Anatomic Risk Factors Research Articles

Poster 254: Improvements in Kujala at Minimum Two-Years Following Medial Patellofemoral Ligament Reconstruction are Correlated with Intraoperative Instability Measurements: A Multivariate Analysis of Risk Factors

Objectives: Isolated medial patellofemoral ligament reconstruction (MPFLR) is an effective treatment for those suffering from patellofemoral instability. Currently, many concomitant procedures are associated with MPFLR that address underlying pathologic anatomy. The indication and need for such procedures are currently not well understood and often involve the use of more invasive techniques. We aim to identify patients who may be more vulnerable to worse outcomes. The purpose of this study is to correlate demographic, anatomical, and clinical risk factors to minimum two-year outcomes following isolated MPFLR. Methods: A retrospective review of patients undergoing isolated MPFLR for recurrent patellar instability at a single institution between December 2015-June 2021 was performed. Patients with concomitant osseous procedures beyond chondroplasty and any ligamentous procedure were excluded. Included patients completed patient reported outcome (PRO) surveys preoperatively then at a minimum of 2 years postoperatively. Demographic, radiographic, surgical, and clinical data was collected. Univariate correlations to minimum 2-year delta-PRO scores were calculated, then those reaching significance were included in a multivariable linear regression analysis. Results: One hundred and thirteen MPFLR patients were included (77 female, 36 male; age: 21.6 ± 9.1 years). Final Kujala score was 88.44 ± 14.12 at 2.97 ± 1.11 years postoperatively. On univariate testing, final Kujala score was significantly correlated with age at time of surgery ( P=0.035; r=0.218), body mass index (P=0.035; r=-0.204), and the degree of knee flexion at which the patella can no longer be manually dislocated laterally during an examination under anesthesia (Instability Resolution Angle — IRA; P=0.010; r=-0.318). The delta final Kujala score (mean score 30.72 ± 19.68) was significantly correlated with age at time of surgery (P=0.032; r=-0.207), age at time of first patellar instability event (P=0.001; r=0.364), Caton-Deschamps Index (CDI; P=0.026; r=-0.235), trochlear width (P=0.016; r=0.251), the percentage of trochlear-patellar overlap on sagittal MRI (P=0.031; r=0.227), and the depth of the central trochlear trough from the lateral trochlear peak (P=0.035; r=0.221)(Table 1). On multivariable linear regression analysis, a larger IRA remained significantly correlated with worse final Kujala scores ( P= 0.018) and delta final Kujala ( P= 0.04). Conclusions: A larger IRA on examination under anesthesia is independently correlated with worse final and delta final Kujala scores at a minimum of two-years after isolated MPFLR. This finding can help guide surgeons in their decision to do an isolated MPFLR or add in larger, more invasive procedures that address underlying anatomic pathologies.

Poster 153: Decreased Coracoid Index in Patients with Recurrent Instability after an Arthroscopic Bankart Procedure: A Retrospective Analysis with a Mean Follow-Up of 12.9 Years

Objectives: Traumatic anterior shoulder instability is a common sports medicine pathology, disproportionally affecting competitive, contact athletic and military populations. Currently, arthroscopic Bankart repair is the gold standard for managing patients with anterior instability and associated labral injury with subcritical bone loss. However, recurrent instability remains common after the index operation, with rates between 5% and 20% reported in the literature. Multiple prognostic calculators and scoring indices have been developed in attempts to proactively determine which cohorts may benefit from a bony (Latarjet or free bone graft) or soft tissue (Remplissage) augmentation procedure to further stabilize the joint and decrease the risk of recurrence. Importantly, there has been a growing appreciation for the effects of coracoid process morphology on shoulder pathology, including subcoracoid impingement and subscapularis tears. However, there is a paucity of literature exploring the effect of coracoid morphology on anterior shoulder instability. Therefore, the purpose of this study was to compare known osseous risk factors for recurrent instability, as well as the coracoid index, between patients with and without recurrent instability after an arthroscopic Bankart repair, and to compare long-term outcomes between the 2 cohorts. Methods: Following institutional review board approval, a retrospective cohort comparison of patients with anterior glenohumeral instability treated at a single academic military medical facility was performed. After identifying the initial cohort, patients were invited to complete Western Ontario Shoulder Instability Index (WOSI) and Single Assessment Numeric Evaluation (SANE) surveys. Inclusion criteria included symptomatic anterior shoulder instability, surgical treatment with arthroscopic Bankart repair, and survey completion. Preoperative MRIs were obtained, and glenoid bone loss, Hill-Sachs interval, and coracoid index were quantified. Patients with recurrent instability at last follow up were age-matched in a 1:2 ratio for comparison with those without recurrent instability. Subsequently, unpaired two-tailed t tests were used to compare anatomic morphologies and patient-reported outcome measures (PROMs) between the 2 cohorts. Finally, linear regression was used to evaluate the relationship between the anatomic measurements and PROMs. Results: At a mean of 12.9 years follow-up, 12 patients were confirmed to have recurrent shoulder instability by survey and chart review and were age-matched to 24 patients without recurrent instability (n = 36; mean age 26.0 ± 5.2 years). Patients with recurrent instability after arthroscopic Bankart repair had lower coracoid indices (by 3.28 ± 1.55 mm; p = .0412), greater glenoid bone loss (by 6.67 ± 1.62%; p = .0002), and larger Hill-Sachs Intervals (by 5.88 ± 2.30 mm; p = .0153) on preoperative MRI. The cohort with recurrent instability had lower SANE scores (by 38.0 ± 9.1; p = .0002), and higher WOSI scores (by 692 ± 174; p = .0003) at final follow-up. Coracoid index, glenoid bone loss and Hill-Sachs interval were not correlated with PROMs at latest follow-up (p > 0.05). Conclusions: To our knowledge, this is the first study to assess coracoid morphology in a cohort of patients with symptomatic shoulder instability. The current study findings suggest that a more laterally-projecting coracoid may be protective against recurrent shoulder instability after an arthroscopic Bankart repair. In accordance with recent literature, the recurrent instability cohort had greater glenoid bone loss and larger Hill-Sachs lesions on their index pre-operative MRI and had worse subjective outcomes at latest follow-up. As the shoulder is a complex joint with static and dynamic stabilizers, it is important to understand the effects of anatomic variation on pathoanatomy, as well as patient symptomatology. These preliminary findings highlight the need for further large cohort studies investigating the role of coracoid morphology on shoulder stability. A clearer understanding of the anatomic risk factors for recurrent instability will improve surgical planning and decision making, as well as minimizing time missed from athletic activities or military service.

Paper 01: Clinical Outcomes Following ACL Reconstruction with Slope Reducing High-Tibial Osteotomy: A Matched Case-Control Study

Objectives: Despite recent efforts, the reinjury rate following anterior cruciate ligament (ACL) reconstruction remains high, with documented reports of up to 30%. According to retrospective evidence, high posterior tibial slope (≥12°) has been identified as an anatomic risk factor contributing increased graft reinjury rates. Surgeons are therefore exploring the effectiveness of slope reducing high tibial osteotomy (SRO) as a means of modifying this potential risk factor. While cadaveric models suggest that this surgical procedure decreases the forces across the ACL graft, there are few clinical trials examining its’ safety and clinical effectiveness in patient samples. Therefore, the purpose of this study is to compare functional performance and graft reinjury rates between patients undergoing ACL reconstruction surgery with SRO versus matched controls undergoing isolated ACL reconstruction. We hypothesized that patients undergoing ACL reconstruction with SRO would exhibit similar performance outcomes with a low failure rate when compared to their matched counterparts. Methods: A retrospective matched-case control study was conducted in accordance with the ‘Strengthening the Reporting of Observational Studies in Epidemiology’ guidelines for patients undergoing ACL reconstruction (Figure 1), utilizing a single surgeon database (n=1978). The experimental group (ACL+SRO) consisted of patients ages 18-50 years old that were at least 24-months out of ACL reconstruction with a concomitant SRO. Patients were age, sex, and revision-matched to a cohort of individuals undergoing isolated ACL reconstruction. Exclusion criteria consisted of contralateral knee injury (<24 months prior to surgery), isolated coronal-plane high tibial osteotomy, and multiligamentous knee injury. Patient demographics and surgical data were obtained, including pre/postoperative posterior tibial slope (o) for the ACL+SRO group and presurgery activity levels. Data were gathered at return to sports and included knee range of motion, single-leg balance, single-leg hop testing, and self-reported International Knee Documentation Committee and ACL-Return to Sports After Injury (ACL-RSI) scores. Complications and injury surveillance was conducted throughout the postoperative follow-up period. Primary outcome measures included the Single Assessment Numeric Scale (SANE), and graft failure rates at two-years. Secondary outcomes included return to sport rate and level of participation, and postoperative complications (infection, loss of motion, deep vein thrombosis, etc). Generalized Linear Models and chi-square analyses were conducted using SPSS (IBM, Chicago IL) to compare groups with an a-priori alpha level of .05. Results: Of the 1978 patients in the ACL registry, 48 met the study criteria and were included in the analyses (ACL+SRO group, n=24; Isolated ACL group, n=24). Baseline comparisons revealed that the ACL+SRO group had a higher bodyweight (200.9 ±35.1 vs 179.7 ±33.9, P <.001) and subsequent higher body mass index (29.7 ±4.6 vs 26.7 ±5.0, P = .044), Table 1. Additional baseline differences included ACL graft type, and staged procedures ( P < .05, Table 2). The mean preoperative posterior tibial slope was 17.0° ±2.7° and 7.0° ±2.2° following SRO (mean diff: -10.0°, P <.001). Table 3 depicts the comparisons at return to sport, with the ACL+SRO group demonstrating longer time to return ( P < .001) and lower ACL-RSI scores ( P = .027). At 2 years, there were no statistical differences in SANE score (85.3 ±7.3 vs 88.2 ±9.7, P = .349), graft reinjury rate (0.0% vs 0.0%, P = 1.000), rate of return to sports (85.7% vs 91.7%, P = .844), or level of return to sports between groups with 45.8% (n=11) of the ACL+SRO group returning to a level I or II cutting and pivoting sport versus 54.2% (n=13) in the Isolated ACL group ( P = .656). There were no reported postoperative infections or deep vein thromboses in either group (P > .05). Conclusions: The current study suggests that SRO in the setting of ACL reconstruction for large posterior tibial slope deformities is effective at correcting malalignment, restoring objective and self-reported function, and avoiding graft failure out to 2 years. This procedure also holds promise to allow a majority of patients to return to various levels of sporting activities. To our knowledge, this is the first comparative study examining the return to sports and 2-year outcomes of this population to a matched isolated ACL cohort. While these data do provide evidence for ongoing investigation, we recommend the performance of larger clinical trials to confirm these results. [Figure: see text][Figure: see text][Figure: see text][Figure: see text]

Poster 257: Assessing the Likelihood of Symptomatic Patellar Instability via the Two-Image Lateral Trochlear Inclination Angle as a Measurement of Trochlear Dysplasia

Objectives: Trochlear dysplasia is the most common anatomic risk factor for patellar instability (PI) and it is present in roughly 90% of patients with recurrent PI. Qualitative descriptions/categorizations of dysplasia include the Dejour and Oswestry-Bristol classifications. Quantitative measurements include the sulcus angle and the lateral trochlear inclination angle (LTI). The LTI has shown utility given that it is a numeric representation of dysplasia at the most proximal aspect of the trochlea where dysplasia is most severe. Recently, the two-image LTI has been described as a more accurate and reliable method to quantitate dysplasia compared to the original one-image LTI with high inter and intrarater reliability. However, since the advent of the two-image LTI, no analysis has been done to determine the likelihood of developing (PI) once the LTI reaches a certain value. A prior analysis of the single image LTI showed a value of 11° as a threshold value between patients with and without PI. The purpose of this study is to determine a two-image LTI threshold value at or below which a patient is likely to develop recurrent PI. Methods: Ninety-nine patients with PI and 91 age and sex matched control patients were identified. All patients had available magnetic resonance imaging (MRI) and any patients with unreadable imaging, questionable diagnosis or neuromuscular or arthritic conditions were excluded. Trochlear dysplasia was measured via the two-image LTI (Figure 1). In the study group, any negative LTI values (patients with dysplasia so severe that the trochlea is convex), were excluded from analysis. This left 64 study patients. Means and standard deviations were calculated, and an independent t-test determined significant differences between groups. A receiver-operating characteristic (ROC) curve was plotted to determine the area under the curve (AUC) and a threshold value was determined to best discriminate between study and control patients. Results: The mean two-image LTI in the study group was 9.4 ± 5.2 and 17.3 ± 6.77 in the control group (p < 0.001). Intrarater reliability of 15 randomly selected study patients and 15 randomly selected control patients was excellent (Intraclass Correlation Coefficient: 0.963, 0.924-0.982). ROC AUC was 0.825 (95% CI: 0.758-0.891) as depicted in Figure 2. A threshold value of 14.5° (Table 1) was chosen as the best demarcating value between controls and PI patients with a sensitivity of 0.828 (53/64), specificity of .769 (70/91), and an accuracy of .793 (123/155). Conclusions: In comparison to the single image LTI, the two image LTI had a higher threshold value in discriminating between patients with and without PI (11° vs 14.5°). This is very likely due to the difference in measurement techniques. This information is valuable for risk stratification of patients with PI as one would expect patients with an LTI below 14.5° to have recurrent PI and those patients with a single dislocation with an LTI higher than 14.5° to be more likely to stabilize with conservative management. Given the reliability and representative nature of the two image LTI in assessing trochlear dysplasia, symptomatic trochlear dysplasia (that which results in patellar instability) can be defined for most people as dysplasia with a two image LTI £ 14.5°. [Figure: see text]

Outcomes of heart transplantation in children with previously palliated hypoplastic left heart syndrome.

Paediatric heart transplantation in children who fail multistage palliation for hypoplastic left heart syndrome is associated with challenges related to immune, clinical or anatomic risk factors. We review current outcomes and risk factors for survival following heart transplantation in this challenging patient population. The United Network for Organ Sharing transplantation database was merged with Paediatric Health Information System database to identify children who received heart transplantation following prior palliation for hypoplastic left heart syndrome. Multivariable Cox analysis of outcomes and factors affecting survival was performed. Our cohort included 849 children between 2009 and 2021. The median age was 1044 days (interquartile range 108-3535), and the median weight was 13 kg (interquartile range 7-26). Overall survival at 10 years following heart transplantation was 71%, with most of the death being perioperative. On multivariable analysis, risk factors for survival included Black race (hazard ratio = 1.630, P = 0.0253), blood type other than B (hazard ratio = 2.564, P = 0.0052) and male donor gender (hazard ratio = 1.367, P = 0.0483). Recipient age, the use of ventricular assist device or extracorporeal membrane oxygenation were not significantly associated with survival. Twenty-four patients underwent retransplantation, and 10-year freedom from retransplantation was 98%. Rejection before hospital discharge and within 1 year from transplantation was 20% and 24%, respectively, with infants having lower rejection rates. Compared with existing literature, the number of children with prior hypoplastic left heart syndrome palliation who receive heart transplantation has increased in the current era. Survival following transplantation in this patient population is acceptable. Most of the death is perioperative. Efforts to properly support these patients before transplantation might decrease early mortality and improve overall survival.

Differential impacts of clinical, anatomical, and procedural factors on early and late mortality following open thoracoabdominal aortic repair: a retrospective observational study

BackgroundThe operative outcomes of thoracoabdominal aortic aneurysms (TAAAs) are challenged by high operative mortality and disabling complications. This study aimed to explore the baseline clinical, anatomical, and procedural risk factors that impact early and late outcomes following open repair of TAAAs.MethodsWe reviewed the medical records of 290 patients who underwent open repair of TAAAs between 1992 and 2020 at a tertiary referral center. Determinants of early mortality (within 30 days or in hospital) were analyzed using multivariable logistic regression models, while those of overall follow-up mortality were explored using multivariable Cox proportional hazards models and landmark analyses.ResultsThe rates of early mortality and spinal cord deficits were 13.1% and 11.0%, respectively, with Crawford extent II showing the highest rates. In the logistic regression models, older age (P < 0.001), high cardiopulmonary bypass (CPB) time (P < 0.001), and low surgical volume of the surgeon (P < 0.001) emerged as independent factors significantly associated with early mortality. During follow-up (median, 5.0 years; interquartile range, 1.1–7.6 years), 82 late deaths occurred (5.7%/patient-year). Cox proportional hazards models demonstrated that older age (P < 0.001) and low hemoglobin level (P = 0.032) were significant risk factors of overall mortality, while the landmark analyses revealed that the significant impacts of low surgical volume (P = 0.017), high CPB time (P = 0.002), and Crawford extent II (P = 0.017) on mortality only remained in the early postoperative period, without significant late impacts (all P > 0.05).ConclusionThere were differential temporal impacts of perioperative risk variables on mortality in open repair of TAAAs, with older age and low hemoglobin level having significant impacts throughout the postoperative period, and low surgical volume, high CPB time, and Crawford extent II having impacts in the early postoperative phase.

A Predictive Model for Intraoperative Cerebrospinal Fluid Leak During Endonasal Pituitary Adenoma Resection Using a Convolutional Neural Network

Cerebrospinal fluid (CSF) leak during endoscopic endonasal transsphenoidal surgery can lead to postoperative complications. The clinical and anatomic risk factors of intraoperative CSF leak are not well defined. We applied a two-dimensional (2D) convolutional neural network (CNN) machine learning model to identify risk factors from preoperative magnetic resonance imaging. All adults who underwent endoscopic endonasal transsphenoidal surgery at our institution from January 2007 to March 2023 who had accessible preoperative stereotactic magnetic resonance imaging were included. A retrospective classic statistical analysis was performed to identify demographic, clinical, and anatomic risk factors of intraoperative CSF leak. Stereotactic T2-weighted brain magnetic resonance imaging scans were used to train and test a 2D CNN model. Of 220 included patients, 81 (36.8%) experienced intraoperative CSF leak. Among all preoperative variables, visual disturbance was the only statistically significant identified risk factor (P= 0.008). The trained 2D CNN model predicted CSF leak with 92% accuracy and area under receiver operating characteristic curve of 0.90 (sensitivity of 86% and specificity of 93%). Class activation mapping of this model revealed that anatomic regions of CSF flow were most important in predicting CSF leak. Further review of the class activation mapping gradients revealed regions of the diaphragma sellae, clinoid processes, temporal horns, and optic nerves to have anatomic correlation to intraoperative CSF leak risk. Additionally, visual disturbances from anatomic compression of the optic chiasm were the only identified clinical risk factor. Our 2D CNN model can help a treating team to better anticipate and prepare for intraoperative CSF leak.

Maculopapillary Bundle Degeneration in Optic Neuropathies.

Degeneration of the maculopapillary bundle (MPB) is a prominent feature in a spectrum of optic neuropathies. MPB-selective degeneration is seen in specific conditions, such as nutritional and toxic optic neuropathies, Leber hereditary optic neuropathy (LHON), and dominant optic atrophy (DOA). Despite their distinct etiologies and clinical presentations, which encompass variations in age of incidence and monocular or binocular onset, these disorders share a core molecular mechanism: compromised mitochondrial homeostasis. This disruption is characterized by dysfunctions in mitochondrial metabolism, biogenesis, and protein synthesis. This article provides a comprehensive understanding of the MPB's role in optic neuropathies, emphasizing the importance of mitochondrial mechanisms in the pathogenesis of these conditions. Optical coherence tomography studies have characterized the retinal nerve fiber layer changes accompanying mitochondrial-affiliated optic neuropathies. Selective thinning of the temporal optic nerve head is preceded by thickening in early stages of these disorders which correlates with reductions in macular ganglion cell layer thinning and vascular atrophy. A recently proposed mechanism underpinning the selective atrophy of the MPB involves the positive feedback of reactive oxygen species generation as a common consequence of mitochondrial dysfunction. Additionally, new research has revealed that the MPB can undergo degeneration in the early stages of glaucoma, challenging the historically held belief that this area was not involved in this common optic neuropathy. A variety of anatomical risk factors influence the propensity of glaucomatous MPB degeneration, and cases present distinct patterns of ganglion cell degeneration that are distinct from those observed in mitochondria-associated diseases. This review synthesizes clinical and molecular research on primary MPB disorders, highlighting the commonalities and differences in their pathogenesis. 1.Temporal degeneration of optic nerve fibers accompanied by cecocentral scotoma is a hallmark of maculopapillary bundle (MPB) degeneration. 2.Mechanisms of MPB degeneration commonly implicate mitochondrial dysfunction. 3.Recent research challenges the traditional belief that the MPB is uninvolved in glaucoma by showing degeneration in the early stages of this common optic neuropathy, yet with features distinct from other MPB-selective neuropathies. 4.Reactive oxygen species generation is a mechanism linking mitochondrial mechanisms of MPB-selective optic neuropathies, but in-vivo and in-vitro studies are needed to validate this hypothesis.

Investigation of the anatomic risk factors in acute anterior cruciate ligament ruptures to develop ramp lesions of the medial meniscus by quantitative MRI

ObjectiveTo investigate the anatomic risk factors of knee in patients with acute non-contact anterior cruciate ligament (aACL) ruptures to develop ramp lesions.MethodsA total of 202 subjects were retrospectively divided into three groups: (1) aACL ruptures combined with ramp lesions group (n = 76); (2) isolated ACL ruptures group (n = 56) and (3) normal controls group (n = 70). Quantitative morphological parameters on MRI were measured including: diameter of medial femoral condyle (MFC), anterior-posterior length and depth of medial tibial plateau (MTP AP length and depth), lateral posterior tibial slope (LPTS) and medial posterior tibial slope (MTPS), asymmetry of LPTS and MPTS (LMPTS), lateral meniscal slope (LMS), and medial meniscal slope (MMS).ResultsThe MTP AP length, MTP AP length/MFC diameter ratio, MTP depth, LPTS and the asymmetry of LMPTS showed significant differences among the three groups (p < 0.001). The risk factors associated with the ramp lesions including a longer MTP AP length (OR 1.17, 95% CI 1.00–1.44, p = 0.044), increased MTP depth (OR 1.91, 95% CI 1.22–3.00, p = 0.005) and lager ratio (OR 1.11, 95% CI 1.01–1.22, p = 0.036). The highest AUC was the MTP AP length/MFC diameter ratio (0.74; 95% CI, 0.66–0.82). The combination model increased higher accuracy (0.80; 95% CI, 0.72–0.88).ConclusionSeveral bony anatomic characteristics of the knee, especially the morphology of medial tibia plateau, are additional risk factors for aACL ruptures to develop ramp lesions.Critical relevance statementPredictive anatomic risk factors of the knee for patients with acute non-contact anterior cruciate ligament (aACL) ruptures to develop ramp lesions, especially the morphology of medial tibia plateau, are detectable by MRI.Key PointsRamp lesion development can complicate aACL ruptures and requires specific treatment.Longer AP length and increased MTP depth are risk factors for concurrent ramp lesions.Identification of ramp lesions allows for the most appropriate treatment.Graphical

Trochlea Dysplasia as the Major Anatomic Risk Factors for Patellofemoral Joint Instability: An Infographic as a Visual Learning Tool.

Patellofemoral instability (PFI) is a common condition in children and adolescents, ranging from mild discomfort and mal-tracking to lateral patellar dislocation [1]. A number of anatomical risk factors have been described in the literature, such as trochlear dysplasia, patella alta, excessive tibial tuberosity to trochlear groove (TT-TG) distance, patellar tilt and soft tissue alterations [2]. Among them, TD has been identified as the main anatomical risk factor with the strongest association with PFI [1, 2]. In the study by Dejour et al. [2] radiographically observed TD was identified in 96% of patients with a history of patellofemoral dislocation [1, 2]. Patients with Dejour Type D dysplasia are characterized by a prominent and convex lateral facet with a vertical connection to a hypoplastic medial facet (Figure 1), which provides inadequate tracking of the patella in the trochlea during flexion leading to patella subluxation [2]. Non-operative treatment of lateral patellar dislocation presents a rate of re-dislocation up to 70% within 24 months of the first episode [3]. Sulcus deepening trochleoplasty is indicated for Type B and D dysplasia, in order to improve patella tracking, reduce the rate of re-dislocation and achieve good functional outcomes [2, 4]. Trochlea dysplasia is defined as a shallow or flattened groove with decreased resistance to lateral patellar translation. TD can be assessed on computed tomography (CT) and magnetic resonance imaging (MRI) with the use of overlapping axial images and are able to show perfectly the global shape of the femoral trochlea [2]. The thresholds for identifying trochlear dysplasia are established based on the sulcus angle ≥ 145°, medial/lateral trochlea facet asymmetry < 40%, trochlear depth < 3 mm and lateral trochlear inclination ≤ 11° and therefore it can be used in young adolescents [4, 5]. A deep knowledge of anatomic variations and abnormalities of the patellofemoral joint, which may predispose to PFI, is crucial in order to choose the appropriate treatment for each patient.

Operative Treatment of Patellofemoral Instability: Osteotomies for Torsional and Coronal Malalignment

Patellofemoral instability (PFI) is a prevalent orthopedic issue that leads to significant morbidity and functional limitation. It has a notable incidence, specifically higher amongst adolescent females, and a recurrence rate ranging from 17% to 33%. Recurrent PFI significantly increases the risk of degenerative changes and early-onset osteoarthritis. Patients with multiple risk factors increase recurrence rates significantly, and thus identifying and managing anatomical risk factors is an effective strategy for patients. These include: trochlear dysplasia, patella alta, increased tibial tubercle-to-trochlear groove (TT-TG) distance, increased femoral anteversion, external tibial torsion and valgus limb alignment.This study outlines a comprehensive evaluation and surgical approach focusing on PFI associated with torsional or coronal malalignments. The evaluation includes a detailed patient history, clinical examination, and diagnostic imaging. Surgical interventions are selected based on an algorithmic approach tailored to the specific pathoanatomy of the instability, focusing on both bony and soft-tissue procedures.Surgical techniques for addressing PFI in the presence of malalignment include proximal and distal bony procedures. Specific techniques detailed in this study include femoral torsional osteotomy over an intramedullary nail, distal femur opening and closing wedge osteotomies, and torsional tibial osteotomies fixed with an intramedullary nail or plate.

Effect of the extrahepatic bile duct anatomy on choledocholithiasis and its clinical significance.

A comprehensive understanding of the extrahepatic bile duct anatomy is vital to guide surgical procedures and perform endoscopic retrograde cholangiography. Anatomical irregularities within the extrahepatic bile duct may increase susceptibility to bile duct stones. To investigate the anatomical risk factors associated with extrahepatic bile ducts in patients diagnosed with choledocholithiasis, with a specific focus on preventing stone recurrence after surgical intervention and endoscopic lithotomy. We retrospectively analyzed the medical records of 124 patients without choledocholithiasis and 108 with confirmed choledocholithiasis who underwent magnetic resonance cholangiopancreatography examinations at our center between January 2022 and October 2022. Logistic regression analyses were conducted to identify the anatomical risk factors influencing the incidence of common bile duct stones. Multivariate logistic regression analysis revealed that several factors independently contributed to choledocholithiasis risk. Significant independent risk factors for choledocholithiasis were diameter of the common hepatic [adjusted odds ratio (aOR) = 1.43, 95% confidence interval (CI): 1.07-1.92, adjusted P value = 0.016] and common bile (aOR = 1.68, 95%CI: 1.27-2.23, adjusted P value < 0.001) ducts, length of the common hepatic duct (aOR = 0.92, 95%CI: 0.84-0.99, adjusted P value = 0.034), and angle of the common bile duct (aOR = 0.92, 95%CI: 0.89-0.95, adjusted P value < 0.001). The anatomical features of the extrahepatic bile duct were directly associated with choledocholithiasis risk. Key risk factors include an enlarged diameter of the common hepatic and bile ducts, a shorter length of the common hepatic duct, and a reduced angle of the common bile duct.

Surgery for Active Infective Endocarditis on Mitral Valve: Anatomical, Surgical, and Disease Factors as Long-Term Outcome Modifiers.

Background and Objectives: Determinants of long-term outcomes after surgery for native mitral valve endocarditis have not been thoroughly investigated. The aim of this study was to assess anatomical, disease, and surgical risk factors for long-term mortality and need of reintervention, in patients undergoing mitral valve surgery for active endocarditis. Materials and Methods: Patients who underwent surgery for active native mitral valve endocarditis at three academic centres, between 2000 and 2022, were analysed. The primary outcome was long-term survival. The secondary outcome was the freedom from mitral reoperation. Survival curves were constructed with Kaplan-Meier methodology. Multivariable Cox regression was used to identify demographic, anatomical, disease, and surgical factors associated with late mortality and reoperation. Results: 335 consecutive patients with active mitral endocarditis were analysed. Two hundred and one patients (70.5%) had infection confined to the valve cusp whereas 89 (25.6%) had invasive disease extended to the annulus and surrounding tissues. Preoperative neurological events occurred at the diagnosis in 52 cases. Streptococci were the most common causative organisms followed by Staphylococcus aureus, Coagulase-negative Staphylococcus, and Enterococcus. Valve repair was performed in 108 patients (32.2%). Survival at 5 and 10 years was 70.1% and 59.2%, respectively. Staphylococcus emerged as an independent predictor of late mortality, along with age, chronic obstructive pulmonary disease, and previous cardiac surgery. Survival was considerably reduced in patients with S. aureus compared with those without (log rank p < 0.001). The type of surgery (repair vs. replacement) did not emerge as a risk factor for late mortality and reoperation. Seventeen patients underwent mitral reoperation during the follow-up. The 5- and 10-year freedom from reoperation was 94.7% and 91.8%, respectively. Conclusions: Active mitral valve endocarditis remains a life-threatening disease with impaired survival. While lesion characteristics influenced surgical decision-making and intraoperative management, their impact on long-term survival and freedom from reintervention appears to be moderated by other factors such as infecting pathogens and patient comorbidities.

Management of a Retinal Arterial Macroaneurysm

While patients with RAMs are often asymptomatic, providers must be able to clinically differentiate them from other retinal conditions so they can manage and counsel patients appropriately. This case report reviews the anatomical features, risk factors, clinical course, pathophysiology, and treatment options for potential sequelae of a RAM.

Lacrimal Obstruction in Craniosynostosis: Anatomical and Genetic Risk Factors.

To investigate whether patients with craniosynostosis exhibit higher rates of nasolacrimal duct obstruction (NLDO) and to explore potential risk factors. Retrospective review including all craniosynostosis patients treated at both the Divisions of Ophthalmology and Plastic, Reconstructive, and Oral Surgery at The Children's Hospital of Philadelphia between 2009 and 2020 was conducted. Synostosis characteristics, lacrimal disorders, and genetic data were collected. Main outcome measures were the rate of NLDO and associations with anatomical and syndromic/genetic risk factors. The total of 767 participants had a mean age of 2.8 ± 3.8 years, 465 (60.6%) were males, 485 (63.2%) had no syndromic association; 631 (82.3%) had one major suture involved, 128 (17%) had involvement of 2 to 4 major sutures, and 429 (55.9%) underwent craniofacial surgery. Forty-eight (6.2%) patients had NLDO, which more prevalent in the genetic/syndromic group (11.0% vs. 3.5%, respectively, p < 0.001), with the highest prevalence observed in patients with Apert syndrome (n = 4, 30.8%). The genetic variants most associated with NLDO were EFNB1 (n = 1, 100%) and FGFR2 (n = 6, 19.4%). There was no association between NLDO and the number or types of sutures involved or a history of craniofacial surgery. Nasolacrimal duct obstruction is more common in patients with craniosynostosis compared to the general population. Having a putative syndrome or a putative genetic variant and female sex were risk factors for NLDO. Ophthalmic evaluations for all craniosynostosis patients and careful assessments of any symptoms of tearing are recommended.

Assessing the prophylactic use of the superficial inferior epigastric vessels (SIEV) for the super – Drainage of deep inferior epigastric perforator flaps (DIEPS), correlated to patient demographic, anatomical and operative risk factors

Assessing the prophylactic use of the superficial inferior epigastric vessels (SIEV) for the super – Drainage of deep inferior epigastric perforator flaps (DIEPS), correlated to patient demographic, anatomical and operative risk factors

Nasal Septum Deviation in Patients with Acute Invasive Fungal Rhinosinusitis in a Tertiary Care Hospital: A Cross-Sectional Study.

This is a retrospective study exploring the demographics and the role of nasal septum deviation in acute invasive fungal rhinosinusitis (AIFS); and if this deviation contributes to the laterality predilection of this opportunistic infection. Fifty-six craniofacial CT scans were evaluated by two radiologists blinded to the clinical data and outcome for laterality of the disease; and nasal septal deviation (NSD). NSD was graded based on the measured septal angle of deviation into mild, moderate, and severe and furtherly classified into one of seven types based on Mladina's classification. High prevalence of remarkable nasal septum deviation existed in our population with AIFS, with type 7 Mldina NSD represented the most prevalent in this population. We found no significant statistical relation between the side of deviation and the initial side of the fungal disease. We recommend screening for early manifestations of AIFS in similar debilitated patients; with high degrees of nasal septum deviation for considering it as an anatomical risk factor.

Gender differences in the impact of anatomical factors on non-contact anterior cruciate ligament injuries: a magnetic resonance study

PurposeTo identify MRI-detected anatomical risk factors for non-contact anterior cruciate ligament (ACL) injuries across genders.MethodsA retrospective analysis was performed on 141 ACL-reconstructed patients (35 females, 106 males) and 142 controls (37 females, 105 males) from January 2020 to April 2022. Inclusion criteria were primary non-contact ACL injuries. The tibial plateau slope, lateral femoral condyle index, Insall-Salvati index, and patellar tendon angle were measured, using binary logistic regression for gender-specific risk evaluation.ResultsIncreased lateral tibial plateau slope, reduced intercondylar notch width index, lateral femoral condyle index, and patellar tendon angle correlated with ACL injuries in both genders. The Insall-Salvati index was a significant risk factor in females but not in males.ConclusionThis study identifies the lateral tibial plateau slope, notch width index, lateral femoral condyle index, and patellar tendon angle at near-extension as risk factors for ACL injuries in both genders, with the Insall-Salvati index also implicated in females.

Tibial spine volume is smaller in ACL-injured athletes compared to healthy athletes.

The aim of this study was to investigate whether the whole tibial spine volume and femoral intercondylar notch volume are risk factors for anterior cruciate ligament (ACL) injury. The hypothesis was that the whole tibial spine volume and femoral notch volume would be smaller in athletes who sustained ACL injury than in athletes with no history of ACL injury. Computed tomography scans of both knees were acquired and three-dimensionalbone models were created using Mimics to measure whole tibial spine volume and femoral notch volume. Tibial spine volume, femoral notch volumeand each of these volumes normalised by tibial plateau area were compared between the ACL-injured andthe ACL-intact group. Fifty-one athletes undergoing unilateral anatomical ACL reconstruction (17 female, 34 male: average age 22.0 ± 7.5) and 19 healthy collegiate athletes with no previous knee injury (eight female, 11 male: average age 20.1 ± 1.3) were included in this study. The whole tibial spine volume in the ACL-injured group(2.1 ± 0.5 cm3) was 20.7% smaller than in the ACL-intact group (2.7 ± 0.7 cm3) (p = 0.005). No differences were observed between the femoral notch volume in the ACL-injured group(9.5 ± 2.1 cm3) and the ACL-intact group (8.7 ± 2.7 cm3) (n.s.). The main finding of this study was that the whole tibial spine volume of the ACL-injured group was smaller than the ACL-intact group. A small tibial spine volume can be added to the list of anatomical risk factors that may predispose athletes to ACL injury. Level Ⅲ.

High Rates of Abnormal Patellofemoral Morphology in Adolescents With Anterior Knee Pain: A Retrospective Review.

Background: Anterior knee pain is a common reason for referral to a pediatric orthopedic surgeon. Although previous studies have found that adults with anatomic risk factors for patellofemoral instability (patella dislocation) are predisposed to anterior knee pain, no studies have elucidated the relationship between anatomic risk factors for patellofemoral instability and anterior knee pain in children. Purpose: We sought to characterize common radiographic findings in adolescent patients with a chief complaint of anterior knee pain and to determine the prevalence of abnormal patellofemoral morphology. Methods: We conducted a retrospective review of patients 13 to 18 years old with anterior knee pain at a single tertiary care metropolitan institution from 2016 to 2021. X-rays and magnetic resonance imaging (MRI) were evaluated in those diagnosed with "chondromalacia patellae," "chondromalacia," "patellofemoral disorders," or "anterior knee pain." Patella alta, tibial tubercle-trochlear groove (TT-TG) distance, tubercle height, Wiberg patella type, patellar tilt, and trochlear dysplasia characterization were recorded. Results: Of the 293 adolescents with anterior knee pain included, 62 had bilateral anterior knee pain. Of the 172 MRIs, 72 (42%) met criteria for patella alta, Caton-Deschamps Index (CDI) >1.3, 35% had a TT-TG distance >15 mm, and 32% had lateral patellar tilt >15°. Magnetic resonance imaging findings included infrapatellar fat pad signal hyperintensity (41%) and patellofemoral dysplasia (23%). Of all 293 adolescents, 74% had images showing abnormal patellofemoral morphology, of which 30% had a history of 1 or more patellar dislocation. Overall, 40% of the adolescents had surgery, most commonly medial patellofemoral ligament (MPFL) reconstruction (18%). Conclusions: In this retrospective review, nearly 3/4 of adolescents with anterior knee pain had images showing abnormal patellofemoral morphology, including patella alta, increased TT-TG distance, trochlear dysplasia, or abnormal lateral patellar tilt; only 18% had MPFL surgery. These findings suggest that primary care providers might consider obtaining X-rays and/or MRIs to evaluate for pathology that warrants orthopedic evaluation.