Micro-Fragmented Adipose Tissue Demonstrates Comparable Clinical Efficacy to Other Orthobiologic Injections in Treating Symptomatic Knee Osteoarthritis: A Systematic Review of Level I to IV Clinical Studies.

PURPOSE: To perform a systematic review of clinical outcomes in patients who underwent treatment with micro-fragmented aspirated tissue for symptoms of knee osteoarthritis. METHODS: Medline, Embase, Scopus, and Google Scholar were screened for studies from 2000 to 2023. Risk of bias (ROB) was assessed using the Cochrane Collaboration's tools and the Risk Of Bias In Non-randomised Studies-of Interventions tool. Study quality was assessed with the modified Coleman Methodology Score and Methodological Index for Non-Randomized Studies score. Heterogeneity was assessed using χ2 and I2 statistics. RESULTS: Twenty-one studies were included. One study had a high ROB, 1 had a critical ROB, 3 had serious ROB, and 16 had a moderate ROB. The mean Coleman score was 58, demonstrating fair study quality; the Methodological Index for Non-Randomized Studies score had a mean value of 13, indicating overall fair quality. Best evidence synthesis revealed moderate evidence. The visual analog scale score improved from 5.2 to 3.2 at 6 and 12 months. Knee injury and Osteoarthritis Outcome Score (KOOS) activities of daily living subscore improved from 58.8 to 70.2 at 6 months and 67.5 at 12 months. KOOS pain subscore improved from 54.3 to 70.2 at 6 months and 72.4 at 12 months. KOOS quality of life subscore improved from 33.1 to 43.6 at 6 months and 42.9 at 12 months. KOOS sports subscore improved from 23.7 to 43.6 at 6 months and 57.4 at 12 months. KOOS symptoms subscore improved from 55.3 to 70.1 at 6 months and 67.9 at 12 months. The Western Ontario and McMaster Universities Osteoarthritis Index score steadily increased from 61.8 at baseline to 78.4 at 12 months. CONCLUSIONS: micro-fragmented aspirated tissue injection therapy for the treatment of symptomatic knee osteoarthritis is effective and improves pain and functional outcomes. Moderate study quality combined with a moderate risk of bias, moderate certainty of evidence, and moderate best synthesis evidence reduces external validity. Therefore, the results should be interpreted with a degree of caution. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.

Feasibility of a Sprague???Dawley Rat Model for Investigating the Effects of Seated Whole-body Vibration.

Vehicular whole-body vibration (WBV) can have long-term adverse effects on human quality of life. Animal models can be used to study pathophysiologic effects of vibration. The goal of this study was to assess animal cooperation and well-being to determine the feasibility of a novel seated rat model for investigating the effects of WBV on biologic systems. Twenty-four male Sprague???Dawley rats were used. The experiment consisted of an acclimation phase, 2 training phases (TrP1 and TrP2), and a testing phase (TeP), including weekly radiographic imaging. During acclimation, rats were housed in pairs in standard cages without vibration. First, experimental (EG; n = 18) and control group 1 (C1; n = 3) rats were placed in a vibration apparatus without vibration, with increasing duration over 5 d during TrP1. EG rats were exposed to vertical random WBV that was increased in magnitude over 5 d during TrP2 until reaching the vibration signal used during TeP (15min, 0.7m??s-2 root mean square, unweighted). C1 rats were placed in the vibration apparatus but received no vibration during any phase. Control group 2 (C2; n = 3) rats remained in the home cages. Cooperation was evaluated with regard to rat-apparatus interactions and position compliance. Behavior, weight, and fecal glucocorticoid metabolite concentrations (fGCM) were used to evaluate animal well-being. We observed good cooperation and no behavioral patterns or weight loss between phases, indicating little or no animal stress. The differences in fGCM concentration between groups indicated that the EG rats had lower stress levels than the control rats in all phases except TrP1. Thus, this model elicited little or no stress in the conscious, unrestrained, seated rats.

A Posteromedial Portal Allows Access to the Posteromedial Knee, While a Posterolateral Portal Risks Common Fibular Nerve Injury: A Cadaveric Analysis.

Purpose: To investigate the safety and accessibility of direct posterior medial and lateral portals into the knee. Methods: This study was a controlled laboratory study that comprised a sample of 95 formalin-embalmed cadaveric knees and 9 fresh-frozen knees. Cannulas were inserted into the knees, 16 mm from the vertical plane between the medial epicondyle of the femur and the medial condyle of the tibia, and 8 (females) and 14 mm (males) from the vertical plane connecting the lateral femoral epicondyle and lateral tibial condyle. Landmarks were identified in full extension, and cannula insertion was completed with the formalin-embalmed knees in full extension and the fresh-frozen knees in 90 degrees of flexion. The posterior aspects of the knees were dissected from superficial to deep to assess potential damage caused by the cannula insertion. Results: The incidence of neurovascular damage was 9.6% (n = 10): 0.96% for the medial cannula and 8.7% for the lateral cannula. The medial cannula damaged 1 small saphenous vein (SSV). The lateral cannula damaged 1 SSV, 7 common fibular nerves (CFNs), and both the CFN and lateral cutaneous sural nerve in 1 specimen. All incidences of damage occurred in formalin-embalmed knees. The posterior horns of the menisci were accessible in all specimens. Conclusions: A direct posterior portal into the knee with reference to the medial bony landmarks of the knee proved safe in 99% of the cadaveric sample and allowed access to the posterior horn of the medial meniscus. A direct posterior portal with reference to the lateral bony landmarks demonstrated a higher risk of neurovascular damage in the embalmed sample but no damage in the fresh-frozen sample. Given the severe consequences of common fibular nerve injury, recommending this approach at this stage is not advisable. Clinical Relevance: Direct posterior arthroscopy portals are understudied but may allow safe visualization of the posterior knee compartments and may also assist to manage repair of ramp lesions and posterior meniscus pathology.

Cadaveric Biomechanical Laboratory Research Can Be Quantitatively Scored for Quality With the Biomechanics Objective Basic Science Quality Assessment Tool: The BOBQAT Score.

PURPOSE: The purpose of this study was to develop a quality appraisal tool for the assessment of cadaveric biomechanical laboratory and other basic science biomechanical studies. METHODS: For item identification and development, a systematic review of the literature was performed. The content validity index (CVI) was used either to include or exclude items. The content validity ratio (CVR) was used to determine content validity. Weighting was performed by each panel member; the final weight was either up- or downgraded to the closest of 5% or 10%. Face validity was scored on a Likert scale ranked from 1 to 7. Test-retest reliability was determined using the Fleiss kappa coefficient. Internal consistency was assessed with Cronbach's alpha. Concurrent criterion validity was assessed against the Quality Appraisal for Cadaveric Studies scale. RESULTS: The final Biomechanics Objective Basic science Quality Assessment Tool (BOBQAT) score included 15 items and was shown to be valid, reliable, and consistent. Five items had a CVI of 1.0; 10 items had a CVI of 0.875. For weighting, 5 items received a weight of 10%, and 10 items a weight of 5%. CVR was 1.0 for 6 items and 0.75 for 9 items. For face validity, all items achieved a score above 5. For test-retest reliability, almost-perfect test-retest reliability was observed for 10 items, substantial agreement for 4 items, and moderate agreement for 1 item. For internal consistency, Cronbach's alpha was calculated to be 0.71. For concurrent criterion validity, Pearson's product-moment correlation was 0.56 (95% confidence interval [CI] = 0.38-0.70, P = .0001). CONCLUSION: Cadaveric biomechanical and laboratory research can be quantitatively scored for quality based on the inclusion of a clear and answerable purpose, demographics, specimen condition, appropriate bone density, reproducible technique, appropriate outcome measures, appropriate loading conditions, appropriate load magnitude, cyclic loading, sample size calculation, proper statistical analysis, results consistent with methods, limitations considered, conclusions based on results, and disclosure of funding and potential conflicts. CLINICAL RELEVANCE: Study quality assessments are important to evaluate internal and external validity and reliability and to identify methodological flaws and misleading conclusions. The BOBQAT score will help not only in the critical appraisal of cadaveric biomechanical studies but also in guiding the designs of such research endeavors.

Creation of 21st century anatomy facilities: designing facilities for integrated preclinical education in the Middle East.

BACKGROUND: The establishment of new anatomy facilities needs to accommodate a combination of modern teaching modalities that best align with evidence-based best teaching practices. This article describes the process in which our state-of-the-art anatomy laboratories were designed and implemented, and how these facilities support aspects of modern anatomy education. METHODS: A list of best practices for anatomy education in a modern medical curriculum was summarized from the literature. To assess student satisfaction, a survey related to student perception of the anatomy facilities (5-point Likert scale) was conducted. RESULTS: Our educational modalities include a broad range of teaching approaches. The Instructional Studio houses prosected and plastinated specimens, and cadaveric dissections are performed. Each of our three Dry Laboratories allow for active learning and interaction between small student groups. The Webinar Room acts as a conference room for departmental and online meetings, discussions with students, and dialogues with affiliated hospitals via the internet. The Imaging Center is equipped with a Sectra® medical educational platform, CAE Vimedix® Virtual Medical Imaging Ultrasound Training System, and Philipps Lumify® Ultrasound devices to train students to conduct and interpret sonographic images. Moreover, the Complete Anatomy® program is made available to all our students. CONCLUSION: The layout of our newly created Anatomy Facilities allows for all aspects of modern medical education mentioned in the literature. These educational modalities and teaching approaches are highly appreciated by our faculty and students. Moreover, these technologies allowed for a smooth transition from on-site anatomy teaching to online education during the COVID pandemic.

The surgical anatomy of the axillary approach for nerve transfer procedures targeting the axillary nerve.

PURPOSE: The exact relational anatomy for the anterior axillary approach, targeting the axillary nerve for nerve transfers/grafts, has not been fully investigated. Therefore, this study aimed to dissect and document the gross anatomy surrounding this approach, specifically regarding the axillary nerve and its branches. METHODS: Fifty-one formalin-fixed cadavers (98 axilla) were bilaterally dissected simulating the axillary approach. Measurements were taken to quantify distances between identifiable anatomical landmarks and relevant neurovascular structures encountered during this approach. The musculo-arterial triangle, described by Bertelli et al., to aid in identification on localization of the axillary nerve, was also assessed. RESULTS: From the origin of the axillary nerve till (1) latissimus dorsi was 62.3 ± 10.7 mm and till (2) its division into anterior and posterior branches was 38.8 ± 9.6 mm. The origin of the teres minor branch along the posterior division of the axillary nerve was recorded as 6.4 ± 2.9 mm in females and 7.4 ± 2.8 mm in males. The musculo-arterial triangle reliably identified the axillary nerve in only 60.2% of the sample. CONCLUSION: The results clearly demonstrate that the axillary nerve and its divisions can be easily identified with this approach. The proximal axillary nerve, however, was situated deep and therefore challenging to expose. The musculo-arterial triangle was relatively successful in localising the axillary nerve, however, more consistent landmarks such as the latissimus dorsi, subscapularis, and quadrangular space have been suggested. The axillary approach may serve as a reliable and safe method to reach the axillary nerve and its divisions, allowing for adequate exposure when considering a nerve transfer or graft.

Thoracolumbar transitional vertebrae: Quantitative differentiation and associated numeric variation in the vertebral column using skeletal remains.

Transitional vertebrae at the thoracolumbar region are called thoracolumbar transitional vertebrae (TLTV) and retain physical features from the thoracic and lumbar regions. Since TLTV were first classified 40 years ago, there has been much discrepancy regarding its features, identification and clinical relevance. Vertebral body levels are used in the medical field as a frame of reference to locate specific organs, vessels, nerves or landmarks. Any numeric variation or deviation in the vertebral column may lead to clinical errors. Previous findings have suggested a high association between numeric variation and the presence of TLTV. Therefore, the aim of this study was to identify the types of TLTV observed and to identify any possible associated numeric variation in the vertebral column. This study also aimed to validate the established technique to quantitatively differentiate TLTV from T12 and L1 at the thoracolumbar junction using skeletal remains from a South African population group. Skeletal remains (n = 187) remains from the Pretoria bone collection were assessed. Measurements were taken of the angle of the superior zygapophyseal processes of the last thoracic vertebra (T12), the first lumbar (L1), and identified TLTV. The results indicate a TLTV prevalence of 35% (n = 66/187). The results show that each vertebral type (T12, L1, TLTV) fall into independent confidence intervals: T12 is 188° ± 9.22 (CI: 187° < µ < 189.6°), 110° ± 7.52 (CI: 109.2° < µ < 111.3°) in L1, and 135° ± 24.51 (CI: 130.4° < µ < 139.1°) in the TLTV. This study observed that 70% of cases with TLTV was associated with numeric variation in the spine, both homeotic and meristic and that TLTV has a 35% prevalence. The results clearly show that quantitative morphometric analysis can effectively differentiate TLTV from other vertebral types at the thoracolumbar junction in skeletal remains.

Transcoracoid Drilling for Coracoclavicular Ligament Reconstructions in Patients With Acromioclavicular Joint Dislocations Result in Eccentric Tunnels.

Purpose: To determine the location of coracoid inferior tunnel exit with superior-based tunnel drilling and coracoid superior tunnel exit with inferior-based tunnel drilling. Methods: Fifty-two cadaveric embalmed shoulders (mean age 79 years, range 58-96 years) were used. A transcoracoid tunnel was drilled at the center of the base. Twenty-six shoulders were used for the superior-to-inferior tunnel drilling approach and 26 shoulders for the inferior-to-superior tunnel drilling approach. The distances to the margins of the coracoid process, from both the entry and exit points of the tunnel, were measured. Paired Student t-tests were used to compare the distance from the center of the tunnel and the medial and lateral coracoid border and the apex. Results: The mean difference for the distances between superior entry and inferior exit from the apex was 3.65 ± 3.51 mm (P = .002); 1.57 ± 2.27 mm for the lateral border (P = .40) and 5.53 ± 3.45 mm for the medial border (P = .001). The mean difference for the distances between inferior entry and superior exit from the apex was 16.95 ± 3.11 mm (P = .0001); 6.51 ± 3.2 mm for the lateral border (P = .40) and 1.03 ± 2.32 mm for the medial border (P = .045). Inferior-to-superior drilling resulted in 4 (15%) cortical breaks. Conclusions: Both superior-to-inferior and inferior-to-superior tunnel drilling directed the tunnel from a more anterior and medial entry to a posterior-lateral exit. Superior-to-inferior drilling resulted in a more posteriorly angled tunnel. When using a 5-mm reamer and inferior-to-superior tunnel drilling, cortical breaks were observed at the inferior and medial margin of the tunnel exit. Clinical Relevance: Arthroscopic-assisted acromioclavicular joint reconstruction using conventional jigs may result in an eccentric coracoid tunnel, possibly introducing stress risers and fractures. To avoid cortical breaks and eccentric tunnel placement, open drilling from superior-to-inferior with a superiorly centered guide pin and arthroscopic visualization of a centered inferior exit should be considered.

Surgical treatment is not superior to nonoperative treatment for displaced proximal humerus fractures: a systematic review and meta-analysis.

BACKGROUND: The purpose of this study was to perform a systematic review and meta-analysis of both randomized controlled and observational studies comparing conservative to surgical treatment of displaced proximal humerus fractures. METHODS: We performed a systematic review of Medline, Embase, Scopus, and Google Scholar articles comparing surgical treatment to conservative treatment, including all level 1-3 studies from 2000 to 2022. Clinical outcome scores, range of motion, and complications were evaluated. Risk of bias was assessed using the Cochrane Collaboration's ROB2 tool and ROBINs-I tool. The GRADE system was used to assess the quality of the body of evidence, and heterogeneity was assessed using χ2 and I2 statistics. Twenty-two studies were incorporated into the analysis. Ten studies had a high risk of bias, and all included studies were of low quality. RESULTS: The pooled estimates failed to identify differences for clinical outcomes (P = .208), abduction (P = .275), forward flexion (P = .447), or external rotation (P = .696). Complication rates between groups were significantly lower (P = .00001) in the conservative group. CONCLUSIONS: This meta-analysis demonstrated that there were no statistically significant differences for either clinical outcomes or range of motion between surgically managed and conservatively treated displaced proximal humerus fractures. The overall complication rate was 3.3 times higher, following surgical treatment. The validity of this result is compromised by the high risk of bias and very low level of certainty of the included studies, and the conclusion must therefore be interpreted with caution.

Surgical treatment of proximal humerus fractures: a systematic review and meta-analysis.

INTRODUCTION: The purpose of this study was to perform a systematic review and meta-analysis of both randomized controlled and observational studies comparing surgical interventions for proximal humerus fractures. METHODS: Systematic review of Medline, Embase, Scopus, and Google Scholar, including all level 1-3 studies from 2000 to 2022 comparing surgical treatment with ORIF, IM nailing, hemiarthroplasty, total and reverse shoulder arthroplasty (RTS) was conducted. Clinical outcome scores, range of motion (ROM), and complications were included. Risk of bias was assessed using the Cochrane Collaboration's ROB2 tool and ROBINs-I tool. The GRADE system was used to assess the overall quality of the body of evidence. Heterogeneity was assessed using χ2 and I2 statistics. RESULTS: Thirty-five studies were included in the analysis. Twenty-five studies had a high risk of bias and were of low and very low quality. Comparisons between ORIF and hemiarthroplasty favored ORIF for clinical outcomes (p = 0.0001), abduction (p = 0.002), flexion (p = 0.001), and external rotation (p = 0.007). Comparisons between ORIF and IM nailing were not significant for clinical outcomes (p = 0.0001) or ROM. Comparisons between ORIF and RTS were not significant for clinical outcomes (p = 0.0001) but favored RTS for flexion (p = 0.02) and external rotation (p = 0.02). Comparisons between hemiarthroplasty and RTS favored RTS for clinical outcomes (p = 0.0001), abduction (p = 0.0001), and flexion (p = 0.0001). Complication rates between groups were not significant for all comparisons. CONCLUSIONS: This meta-analysis for surgical treatment of proximal humerus fractures demonstrated that ORIF is superior to hemiarthroplasty, ORIF is comparable to IM nailing, reverse shoulder arthroplasty is superior to hemiarthroplasty but comparable to ORIF with similar clinical outcomes, ROM, and complication rates. However, the study validity is compromised by high risk of bias and low level of certainty. The results should therefore be interpreted with caution. Ultimately, shared decision making should reflect the fracture characteristics, bone quality, individual surgeon's experience, the patient's functional demands, and patient expectations. LEVEL OF EVIDENCE: Level III; systematic review and meta-analysis.

Emerging Imaging Techniques in Anatomy: For Teaching, Research and Clinical Practice.

Visualisation plays a key role in anatomy, where the depiction of gross anatomical structures is essential in understanding and conceptualising content during research and medical teaching. Technology has allowed us to utilise imaging techniques for the visualisation of anatomical features, pathology and correlating physiological functions in a non-invasive manner which is atypical to traditional forms of anatomical investigation. These imaging methods develop integration between anatomy and clinically oriented medical study as well as biomechanics. The progressive research in anatomy can benefit from the vast field of biomechanics which allows for precise and conclusive results regarding the biomechanical integrity of anatomical structures and allows for intricate planning of procedures. 3D imaging techniques have enhanced the modelling of internal structures which are especially essential when implemented as diagnostic tools. An integration of these modalities into medical training accommodates for a more clinically orientated and immediate visualisation as produced when utilising ultrasound imaging which has the added advantage of 3D modelling and manipulation. Immersive technology has revolutionised teaching and learning particularly during the new age of hybrid education. Visualisation in anatomy has many clinical and educational applications which can optimise research, create interactive learning experiences and aid medical practise.

Congenital malformations in the vertebral column: associations and possible embryologic origins.

Cases of associations between random spinal congenital defects have previously been reported, yet several questions remain unanswered. Firstly, why are associations between what seems to be random combinations of vertebral malformations observed? Secondly, is there a common event or pattern that connects the associated defects? Therefore, this study aimed to identify congenital defects in the vertebral column and also to determine whether any associations, if present, between vertebral malformations exist. This article consequently discusses the possible embryological disruptions that may lead to the formation of various defects in the vertebral column. A random skeletal sample (n=187) was selected from the Pretoria Bone Collection housed in the Department of Anatomy, University of Pretoria (Ethics 678/2018). The sample was evaluated to determine the frequencies of spinal congenital defects in each set of remains. Identifiable congenital malformations were observed in 48.1% (n=90/187) of the sample. The results demonstrated a high probability of association between the different defects observed in the vertebral column. Findings are of value as they provide a reasonable explanation to why seemingly random cases of associations have been reported by several authors. This study is clinically relevant as severe spinal defects have been shown to have high morbidity in patients and mortality in infants.

Vertebrae at the thoracolumbar junction: A quantitative assessment using CT scans.

The thoracolumbar junction is often associated with traumatic injuries, due to its biomechanical instability. Reasons for this instability are currently still under debate; however, contributing factors such as the rapid change in spinal curvature and facet orientation from the thoracic to lumbar transition have been implicated. Normally, the superior facet orientation in the thoracic region is angled in a coronal plane, whereas vertebrae in the lumbar region have facets angled in the sagittal plane. Distinguishing between thoracic, lumbar, and transitional vertebrae at the thoracolumbar junction based on articular facet angles, using quantitative methods on CT scans has, to the authors' knowledge, not yet been reported in the literature. Therefore, this study aimed to evaluate whether quantitative measurements can be clinically applied and used to differentiate vertebrae at the thoracolumbar junction using CT scans and, additionally, to record possible cases of congenital defects or variations observed in the spine. A sample (n = 173) of CT scans representative of the Windhoek population in Namibia was retrospectively assessed using radio-imaging software. Measurements of the angle formed by the superior facets of the vertebrae at the thoracolumbar junction (T11-L1) were recorded. Based on the results of this study, quantitative morphometry of the superior facet of vertebrae can differentiate between thoracic, lumbar,. and transitional vertebrae at the thoracolumbar junction. All individuals with identified thoracolumbar transitional vertebrae (TLTV) in this sample had at least one other congenital anomaly of the spine.

Increased Posterior Slope of the Medial and Lateral Meniscus Posterior Horn Is Associated With Anterior Cruciate Ligament Injuries.

PURPOSE: To measure the slope of the medial and lateral posterior horn of the meniscus and its contribution to the overall resulting posterior tibial slope (bone and meniscus combined slope) in anterior cruciate ligament-intact (ACLI) and -deficient (ACLD) knees. METHODS: Magnetic resonance images of intact menisci in patients 16 to 60 years old were included. Posterior tibial bone slope (PTS) and meniscus slope (MS) were measured 25%, 50%, and 75% from the medial and lateral borders of the tibial plateau. Analysis of variance was used to determine differences in posterior tibial slopes between ACLD and ACLI knees and between sexes for ACLD and ACLI knees. RESULTS: 192 ACLI patients (age 35.2 ± 9.6 years, mean ± standard deviation) and 159 ACLD patients (age 34.2 ± 10.3 years) were included. Medial and lateral PTS in ACLD was significantly (P = .00001) higher at 25%, 50%, and 75%. Medial and lateral MS in ACLD was significantly (P = .00001) lower at 25%, 50%, and 75%. There were no significant sex differences for medial or lateral MS in ACLD or ACLI patients (P = .51). The resultant combined medial and lateral slope in ACLD patients was significantly (P = .00001) lower at 25%, 50%, and 75%. There were no significant sex differences in PTS (P = .68), MS (P = .51), or resultant slope (P = .79) CONCLUSIONS: The results of this study strongly suggest that lower meniscal slopes of both the medial and lateral posterior horns are associated with ACL injuries in both males and females. Although the posterior horns reversed the bone PTS to an anterior inclined slope in both ACLD and ACLI patients, both the meniscus slope and the combined resultant slope were significantly lower and more positive at all 6 measured locations in ACLD knees. LEVEL OF EVIDENCE: III, retrospective cohort study.

Medial and Lateral Posterior Tibial Slope Are Independent Risk Factors for Noncontact ACL Injury in Both Men and Women.

BACKGROUND: Higher posterior tibial slope (PTS) is a risk factor for anterior cruciate ligament (ACL) injury in men and women. The individual contribution of the lateral (LPTS) and medial (MPTS) slope has not yet been investigated. PURPOSE: To determine whether either the LPTS or the MPTS is an independent risk factor for ACL injury, and to determine sex-specific differences between patients with ACL-deficient and ACL-intact knees. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We reviewed knee magnetic resonance (MR) images performed on ACL-deficient and ACL-intact knees between January 2018 and June 2020 at a single institution. Inclusion criteria were isolated ACL injury and noncontact mechanism (ACL-deficient group) and nonspecific knee pain and no history of injury (ACL-intact group). Exclusion criteria for both groups were the following: previous knee surgery; meniscal, collateral ligament, posterior cruciate ligament, or multiligamentous injuries; radiological evidence of osteoarthritis; and chondral damage on the tibia. The MR images were used to establish the posterior bony slope at 25%, 50%, and 75% from the medial and/or lateral border of the tibial plateau with respect to the proximal tibial anatomic axis. One-way analysis of variance (ANOVA) was used to determine differences in PTS at the 25%, 50%, and 75% distances for the medial and lateral tibial plateau between the groups and between the sexes. RESULTS: Overall, 325 images were included (mean age, 36.1 ± 11.1 years; 142 ACL-deficient images [82 men and 60 women]; 183 ACL-intact images [112 men and 71 women]). MPTS and LPTS were significantly higher at 25%, 50%, and 75% in the ACL-deficient group (range, -2.7° to -5.7°) compared with the ACL-intact group (range, -2.1° to 1.5°; P = .00001). Similarly, MPTS and LPTS were significantly different in men versus women (P = .00001). ANOVA revealed that there were no significant differences in PTS between men and women for all measures (MPTS, LPTS, ACL-deficient, ACL-intact; P = .68). CONCLUSION: The study results demonstrated that higher MPTS and LPTS is a potential risk factor for ACL injury in both men and women. However, despite being highly statistically significant, the differences between groups and sexes were small and may not be clinically relevant.

The humeral head: A review of the blood supply and possible link to osteonecrosis following rotator cuff repair.

Trauma, corticosteroid therapy and metabolic diseases are well established aetiologies of humeral head osteonecrosis; however, there is increasing evidence that arthroscopic rotator cuff surgery may be another possible cause. One of the reasons is that there may be inadvertent damage to the arterial blood supply to the humeral head during surgical intervention. The blood supply to the humeral head displays large amounts of variation with regard to origin, course and distribution. Therefore, to shed light on the pathogenesis, the blood supply of the humeral head is reviewed together with a summary of all reported cases of osteonecrosis of the humeral head that occurred following rotator cuff repair. Inconsistencies with regard to terminologies used and contradictions concerning arterial contributions from the anterior circumflex humeral artery and the posterior circumflex humeral artery towards humeral head supply are addressed. Moreover, variations in the course of the anterior circumflex humeral artery and its branches are summarized. The vascular anatomy of the humeral head is clinically relevant due to the close relationship of these blood vessels with the surgical repair sites for rotator cuff surgery and biceps tenotomies or tenodesis procedures. Potential sites of disruption of blood supply following arthroscopic rotator cuff surgery are discussed. Detailed knowledge of the course of the arteries supplying the humeral head may help to minimize the risk of vascular injury and subsequent osteonecrosis. Given the great interindividual variations of vascular anatomy, imaging procedures preceding arthroscopic rotator cuff surgery may be advisable.

Defining the popliteal fossa by bony landmarks and mapping of the courses of the neurovascular structures for application in popliteal fossa surgery.

Surgical access to the posterior knee poses a high-risk for neurovascular damage. The study aimed to define the popliteal fossa by reliable bony landmarks and comprehensively mapping the neurovascular structures for application in posterior knee surgery. Forty-five (20 male, 25 female) embalmed adult cadaveric knees were included. The position of the small saphenous vein (SSV), medial cutaneous sural nerve (MCSN) and lateral cutaneous sural nerv (LCSN), tibial nerve (TN) and common fibular nerve (CFN) nerves, and popliteal vein (PV) and popliteal artery (PA) were determined in relation to either medial (MFE) or lateral (LFE) femoral epicondyles, medial (MTC) and lateral (LTC) tibial condyles and the midpoint between the MFE and MTC and LFEF and LTC. The distance between the MFE and the PA, PV, TN, MCSN, and SSV was 38.4±12.1 mm, 38.4±12.9 mm, 39.4±10.2 mm, 39.2±14.0 mm and 37.6±12.5 mm respectively for males and 34.6±4.9 mm, 32.8±5.6 mm and 38.0±8.1 mm 38.8±10.1 mm and 37.9±8.2 mm respectively for females. The distance between LFE and the CFN and LCSN was 13.4±8.2 mm and 24.9±7.3 mm respectively for males and 8.4±9.1 mm and 18.4±10.4 mm respectively in females. This study defined the popliteal fossa by reliable bony landmarks and provided a comprehensive map of the neurovascular structures and will help to avoid injuries to the important neurovascular structures.

The posterior horn of the medial and lateral meniscus both reduce the effective posterior tibial slope: a radiographic MRI study.

PURPOSE: The purpose of this study was to quantify the posterior horn meniscal slope and determine its contribution to the reduction in posterior tibial slope. METHODS: Patients aged between 16 and 60 years and had intact menisci with no evidence of previous injury or surgery were included. Patients with radiological evidence of osteoarthritis Grade II-IV, any acute or chronic meniscus injuries, fractures, and ligamentous injuries were excluded. The posterior bony slope (PTS) and the meniscus slope (MS) of the posterior horns were measured at 25, 50, and 75% from the medial and lateral borders of the tibial plateau. RESULTS: 325 MR images (mean age 37.1 ± 10.9 years) were included. There were 194 males and 131 females, with 162 left and 163 right knees. The PTS in the medial compartment ranged from (-) 2.8° to 3.7° and from (-) 1.3° to 1.9° in the lateral compartment (p = 0.0001). The MS in the medial compartment ranged from 27.4° to 28.2°, and from 27.8° to 28.7° in the lateral compartment (p > 0.05). The differences between the medial and lateral knee compartment were statistically significant. At the 25% interval the p level was 0.037, at 50% p = 0.00001, and at 75% p = 0.0001. There were no significant between gender differences. CONCLUSIONS: The results of this study demonstrated a significant reduction in posterior tibial bone slope by the posterior horns of both the medial and lateral meniscus, from a mean of (-) 1° to 2° to a more horizontal anterior slope. The posterior bone slope was larger in the medial compartment by 1°, resulting in a smaller slope reduction in the lateral compartment.

A quantitative analysis of the dimensions and content of the vertebral triangle.

PURPOSE: The vertebral triangle (VT) located in the root of the neck most commonly contains the vertebral artery (VA), cervical sympathetic chain and certain roots of the brachial plexus. Although other structures have been reported, few studies have reported on the overall content of this space. Based on the current literature, there is a general paucity of anatomical information pertaining to the dimensional anatomy of the VT and specifically the structures related to it. Therefore, this study aimed to quantitatively analyze the size, position, content, and anatomical structures in relation to the vertebral triangle in a South African sample. METHODS: Forty-three VTs were dissected on bodies donated to science. Measurements taken include the dimensions of the triangle, as well as distances between prominent structures and landmarks of the VT. Observations were made on the presence/absence of the varying neurovascular structures within the VT. RESULTS: Mean height was 30.1 ± 1.51 mm (R) and 32.9 ± 1.78 mm (L). Mean width was 18.3 ± 0.74 mm (R) and 19.3 ± 0.98 mm (L). The C8 spinal nerve was found on average approximately halfway [16.4 ± 0.74 mm (R) and 15.9 ± 0.95 mm (L)] in the VT. The VA was present in the VT in 100% of the sample and the C7 spinal nerve and inferior sympathetic ganglia were present in more than 80% of the sample. CONCLUSION: Understanding the VT and the content is of the utmost importance and of great interest to neurosurgeons, to avoid these important neurovascular structures and prevent iatrogenic complications during surgery.

The anatomical relationship of the common peroneal nerve to the proximal fibula and its clinical significance when performing fibular-based posterolateral reconstructions.

PURPOSE: The common peroneal nerve (CPN) can be injured during fibular-based posterolateral reconstructions due to its close relationship to the neck of the fibula. Therefore, the purpose of this study was to observe the course of the CPN and its branches around the fibular head and neck and quantify the position in relation to relevant bony landmarks and observe the relation between tunnel drilling for posterolateral corner reconstruction and both the tunnel entry and exit at the proximal fibula and the CPN and its branches was observed. METHODS: In 101 (mean age = 70.6 ± 16 years) embalmed cadaver knees, the relationship between bony landmarks (tibial tuberosity, styloid process of fibula (APR)) and the CPN and its branches were established and 8 (M1-M8) distances from these landmarks measured; mean, SD and 95% CI were recorded. In 21 of these knees, a fibula tunnel was drilled as in PLC reconstruction and the association of the CPN and its branches to the tunnel entry and exit were judged by two independent observers. Fisher's exact test of independence was used to determine significant differences between genders. Tunnel intersection was analysed in a binary yes/no fashion and was described in frequencies and percentages. RESULTS: The mean distance from the APR to where the CPN reaches the fibula neck (M1) was 31.4 ± 8.9 mm (CI:29.8-33.0); from the apex of the styloid process (APR) to where the CPN passes posterior to the broadest point of the fibular head (M3) was 21.7 ± 12.6 mm (CI:19.4-24.0); from the apex of the APR to the most proximal point of the CPN/CPN first branch in the midline of the fibular head (M2) was 37.0 ± 6.7 mm (CI: 35.4-37.7). Out of the 21 randomly selected knees for drilling, the first branch of the CPN was damaged at the tunnel entry point in 7 (33%), and in 5 knees (24%), the CPN was damaged at the tunnel exit. In one knee, at both the tunnel entry and exit, the first branch of the CPN and the CPN were intersected, respectively. CONCLUSION: The results of this study strongly suggest that the CPN is at risk when drilling the fibula tunnel performing fibula-based posterolateral corner reconstructions. The total injury rate was 57% with a 33% incidence of injury to the first branch of the nerve at the tunnel entry and 24% to the CPN at the tunnel exit. CLINICAL RELEVANCE: Due to the high incidence of injury, percutaneous placement of guide pins and tunnel drilling is not recommended. The nerve should be visualized and protected by either a traditional open approach or minimally invasive techniques. With a minimally invasive approach, the nerve should be identified at the fibula neck and then followed ante- and retrograde.