Free Orthopedics Review | Dr Hutaif General Orthopedics -...

Regardless of patient activities, desire for shoe wear, and age, the ankle must be fused in a standard position of neutral dorsiflexion and slight valgus. This is important because any deviation of this position, particularly in equinus, will increase the likelihood of arthritis in the talonavicular and subtalar joint.

- reverse total shoulder arthroplasty (rTSA)._

DISCUSSION: Severe periprosthetic fractures after total hip arthroplasty with a loose implant and progressive bone loss are difficult problems for orthopaedic surgeons, with a high complication rate. Recent literature favors the use of long fluted tapered stems that have a long distal taper that may optimally engage the remaining femoral shaft isthmus. Plating options are problematic because the ability to use screws with the plate is limited by the intramedullary stem. Although not the only solution to this problem (such as allograft-prosthetic composites, impaction grafting, tumor prostheses), long distally fixed stems circumvent this problem by enhancing fracture healing and create a long-term prosthetic solution in these most difficult cases.

Scientific References

: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 475503.
Kwong LM, Miller AJ, Lubinus P: A modular distal fixation option for proximal bone loss in revision total hip
arthroplasty: A 2- to 6-year follow-up study. J Arthroplasty 2003;18:94-97.

Figure 88a Figure 88b

Synovial sarcomas are high grade malignant soft tissue sarcomas, in which metastases can occur years after surgery. Long term followup is necessary. They arise close to joints, tendons or bursa and lymphatic spred is common. Histology reveals spindle and epithelial type cells with menophasic or biphasic pattern. Treatment includes wide resection and radiation, chemotherapy is not usually used.

DISCUSSION: The patient has typical adolescent idiopathic scoliosis with a right thoracic curve. This represents a Lenke-IB curve pattern; therefore, only treatment of the thoracic curve is required. The proximal thoracic and thoracolumbar curves are very flexible. The patient is Risser 1 and has just started her menstrual cycles; therefore, she is at significant risk for further curve progression. Bracing is not appropriate for a curve of this magnitude and will not halt the progression of this curve, nor will vertebral body stapling stop this curve. Vertebral body stapling is sometimes useful in small thoracic curves of less than 35 degrees and skeletally immature patients. Anterior and

**14 • American Academy of Orthopaedic Surgeons**

posterior spinal fusion is not required because the patient has no other risk factors, such as neurofibromatosis nor is she at risk for crankshaft. Anterior fusion is an option, but it is not listed.

REFERENCES: Lenke LG, Betz RR, Harmes J, et al: Adolescent idiopathic scoliosis: Anew classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am 2001;83:1169-1181.
Lenke LG, Betz RR, Haher TR, et al: Multisurgeon assessment of surgical decision making in adolescent idiopathic scoliosis: Curve classification, operative approach, and fusion levels. Spine 2001;26:2347- 2353.

DISCUSSION: The collateral ligaments of the MCP joint of the thumb can be isolated by flexing the joint to 30 degrees. Full extension is best to assess the accessory collaterals and the palmar plate. The ulnar collateral ligament nearly always separates from the base of first phalanx of the thumb; it frequently becomes lodged between adductor pollicis aponeurosis and its normal position (Stener lesion). The creation of a Stener lesion requires significant radial deviation of the phalanx along with combined tears of the proper and accessory collateral ligaments in order for the ligament to be displaced above the adductor aponeurosis.
REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgery, 2002, pp 339-358.
Stener B: Displacement of the ruptured ulnar collateral ligament of the MP joint of the thumb: A clinical and anatomical study. J Bone Joint Surg Br 1962;44:869-879.

33 • American Academy of Orthopaedic Surgeons

The history, examination findings, and studies are consistent with an osteoid osteoma. The CT scan shows a classic “target” lesion, and the bone scan has intense uptake at the site of the osteoid osteoma. The child has had a 2-year history of pain that even wakes her from sleep, so observation and anti-inflammatory drugs is not a preferred treatment. Bracing will not help with the discomfort because the pain is not mechanical in nature. MRI would not be needed in addition to the studies already completed. The osteoid osteoma is close to the spinal cord so radiofrequency ablation is not preferred. Surgical removal and biopsy is the treatment of choice.
REFERENCES: Frassica FJ, Waltrip RL, Sponseller PD, et al: Clinicopathologic features and treatment of osteoid osteoma and osteoblastoma in children and adolescents. Orthop Clin North Am 1996;27:559-
574/. Cantwell CP, Obyme J, Eustace S: Current trends in treatment of osteoid osteoma with an emphasis on radiofrequency ablation. Eur Radiol 2004;14:607-617.

Figure 72

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This patient has classic neurogenic shock, which usually occurs when a cervical or high thoracic cord injury disrupts the autonomic pathways and causes a loss of sympathetic tone. Characteristic hypotension and bradycardia are present due to an unopposed vagal tone. Low cardiac output also is present, along with venous and arterial dilatation. The treatment for neurogenic shock is administration of agents called pressors (phenylephrine, dopamine, dobutamine, and norepinephrine) to improve cardiac contractility and increase peripheral vascular resistance. Atropine is given to increase the heart rate. Pressors are titrated to keep the mean arterial pressure above 80 and maintain spinal cord perfusion.

DISCUSSION: Intersection syndrome is also known as “squeakers wrist,” “oarsmen wrist,” and crossover tendinitis. It occurs where the first and second dorsal wrist compartment structures pass over one another, resulting in fibrosis, muscular changes, and inflammation of the bursa in this area. The structures involved are the abductor pollicis longus and extensor pollicis brevis (first dorsal compartment) that pass across the second compartment structures (extensor carpi radialis brevis and extensor carpi radialis longus). An audible “squeak” is occasional y heard at the intersection point, which is approximately 4 to 5 cm proximal to the proximal dorsal wrist crease.

REFERENCES: Grundberg AB, Reagan DS: Pathologic anatomy of the forearm: Intersection syndrome. J Hand Surg Am 1985; 10:299-302.
Thorson E, Szabo RM: Common tendinitis problems in the hand and forearm. Orthop Clin North Am 1992;23:65-74.
Williams JG: Surgical management of traumatic non-infective tenosynovitis of the wrist extensors. J Bone Joint Surg Br 1977;59:408-410.
Wood MB, Dobyns JH: Sports-related extraarticular wrist syndromes. Clin Orthop Relat Res 1986;202:93-102.

Figure A shows an intertrochanteric fracture treated with a cephalomedullary device. A starting point slightly anterior to the piriformis fossa (starting point for standard antegrade femoral nail) has the benefit of improved placement of screws through the nail and into the femoral head. This is due to the fact that the hip is anteverted and the femoral neck arises from the anterior portion of the proximal femur. Therefore, by moving the nail anterior, that will increase the distance between the head screw and the posterior cortex of the neck and lead to a “straight” shot into the center of the femoral head.
Johnson et al investigated the effect of starting hole position, fracture component length, reamed diameter, and nail type on the potential for femoral bursting and fracture instability. They found the most significant factor in the proximal femoral component was found to be the position of the starting hole.
They found excessive anterior displacement greater than 6 mm from the neutral axis of the medullary canal consistently caused high hoop stresses at the level of the fracture, which can increase the possibility of iatrogenic fracture. Posterior starting points increase the risk of possible distal femur anterior cortex impingement/fracture.
Ostrum et al showed that lateral starting points should be avoided in order to avoid varus reduction when using a trochanteric antegrade nail in subtrochanteric fractures. They recommended a slightly medial starting point.

- Reverse total shoulder arthroplasty (rTSA)_

The patient has a loose acetabular component, which explains her pain and progressive shortening. She has a history of inflammatory arthritis, elevated ESR and C-reactive protein, and has recently been treated for an infection. Thus, the suspicion for infection is high and must be ruled out. A triple phase bone scan can assist in the identification of component loosening but cannot differentiate infection from noninfectious causes. Indium-111 scans have been shown to have limited utility, although a negative scan can be helpful in ruling out infection. The selective preoperative use of aspiration of the hip joint has been shown to be effective and is most likely to identify infection; however, the patient must be off of antibiotics for a minimum of 2 weeks prior to her aspiration to avoid a false negative culture.
REFERENCES: Della Valle CJ, Zuckerman JD, Di Cesare PE: Periprosthetic sepsis. Clin Orthop Relat Res 2004;420:26-31.
Lachiewicz PF, Rogers GD, Thomason HC: Aspiration of the hip joint before revision total hip arthroplasty:
Clinical and laboratory factors influencing attainment of a positive culture. J Bone Joint Surg Am 1996;78:749-754. Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 475-503.

Figure 73

Although all of these responses are known complications related to hip arthroscopy, the symptoms of perineal numbness and pain associated with prolonged traction time indicate a compression injury to the pudendal nerve against the perineal post used to provide counter traction. Perineal numbness usually occurs on the surgical side, with pain in the area of the anus to the penis/clitoris. Pain is predominantly experienced while sitting, but is relieved when sitting on a toilet. Pain can be relieved with a diagnostic pudendal nerve block. This injury is not unique to hip arthroscopy; it also is described in the trauma literature. To prevent compression‐type injuries, a well‐padded post larger than 9 cm in diameter should be positioned against the medial thigh. Traction force should be kept to a minimum and the extremity positioned in slight abduction. Continuous traction time should not exceed 2 hours, with intermittent traction used during prolonged procedures.

Multiple cytokines (inflammatory mediators) are released following trauma, and their levels can be measured in serum. Persistent elevated levels of IL-6 (> 800 pg/mL) indicate an exaggerated systemic inflammatory response to trauma and have been associated with the development of MODS. Recent work has shown that extensive surgical procedures should be avoided when IL-6 levels remain elevated to prevent the precipitation of MODS. In the future, it is likely that this mediator and possibly others will be used to determine timing and techniques of future treatment.
REFERENCES: Patrick DA, Moore FA, Moore EE, et al: Jack A. Barney Resident Research Award winner: The inflammatory profile of interleukin-6, interleukin-8, and soluble intercellular adhesion molecule-1 in postinjury multiple organ failure. Am J Surg 1996;172:425-429.
Pape HC, van Griesven M, Rice J, et al: Major secondary surgery in blunt trauma patients and perioperative cytokine liberation: Determination of the clinical relevance of biochemical markers. J Trauma 2001;50:989-1000.
Giannoudis PV: When is the safest time to undertake secondary definitive fracture stabilization procedures in multiply injured patients who were initially managed using a strategy of primary temporary skeletal fixation. J Trauma 2002;52:811-812.

Transient thigh pain after lateral, transpsoas interbody fusion is common and generally lasts for less than 3 months. Transpsoas interbody fusion with slip reduction can result in indirect spinal decompression and often obviates the need for a laminectomy for most patients. Complications with this approach are comparable to those experienced with open surgery, but the hospital stay is generally shorter.
Use of BMP in interbody devices has also become common. The images above show heterotopic bone growth into the spinal canal causing nerve compression. This complication is more commonly encountered after posterior lumbar interbody fusions.
RECOMMENDED READINGS
Oliveira L, Marchi L, Coutinho E, Pimenta L. A radiographic assessment of the ability of the extreme lateral interbody fusion procedure to indirectly decompress the neural elements.
[Spine (Phila Pa 1976). 2010 Dec 15;35(26 Suppl):S331-7. doi: 10.1097/BRS.0b013e3182022db0. PubMed PMID: 21160397. ](http://www.ncbi.nlm.nih.gov/pubmed/21160397)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21160397) Cummock MD, Vanni S, Levi AD, Yu Y, Wang MY. An analysis of postoperative thigh symptoms after minimally invasive transpsoas lumbar interbody fusion. J Neurosurg Spine. 2011 Jul;15(1):11-8. doi: 10.3171/2011.2.SPINE10374. Epub 2011 Apr 8. PubMed PMID:
[21476801.](http://www.ncbi.nlm.nih.gov/pubmed/21476801)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21476801)
[Rodgers WB, Gerber EJ, Patterson J. Intraoperative and early postoperative complications in extreme lateral interbody fusion: an analysis of 600 cases. Spine (Phila Pa 1976). 2011 Jan 1;36(1):26-32. doi: 10.1097/BRS.0b013e3181e1040a. PubMed PMID: 21192221. ](http://www.ncbi.nlm.nih.gov/pubmed/21192221)[View](http://www.ncbi.nlm.nih.gov/pubmed/21192221)
[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21192221)
[Wong DA, Kumar A, Jatana S, Ghiselli G, Wong K. Neurologic impairment from ectopic bone in the lumbar canal: a potential complication of off-label PLIF/TLIF use of bone morphogenetic protein-2 (BMP-2). Spine J. 2008 Nov-Dec;8(6):1011-8. Epub 2007 Nov 26. PubMed PMID: 18037352.](http://www.ncbi.nlm.nih.gov/pubmed/18037352)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18037352)
[Chen NF, Smith ZA, Stiner E, Armin S, Sheikh H, Khoo LT. Symptomatic ectopic bone formation after off-label use of recombinant human bone morphogenetic protein-2 in transforaminal lumbar interbody fusion. J Neurosurg Spine. 2010 Jan;12(1):40-6. doi: 10.3171/2009.4.SPINE0876. PubMed PMID: 20043763.](http://www.ncbi.nlm.nih.gov/pubmed/%2020043763)[View ](http://www.ncbi.nlm.nih.gov/pubmed/%2020043763)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/%2020043763)
Rouben D, Casnellie M, Ferguson M. Long-term durability of minimal invasive posterior transforaminal lumbar interbody fusion: a clinical and radiographic follow-up. J Spinal Disord Tech. 2011 Jul;24(5):288-96. doi:10.1097/BSD.0b013e3181f9a60a. PubMed PMID:
[20975594.](http://www.ncbi.nlm.nih.gov/pubmed/20975594)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/20975594)

- medial cuneiform to the second metatarsal bone.

All soft tissue sarcomas have the same signal sequence - low on T1 weighted images and high on T2 weighted images. | Tissue | T1 weighted | T2 weighted | |---|---|---| | Fat | High | Moderate | | Tendons | Low | Low | | Ligaments | Low | Low | | Fascial layers | Low | Low | | Cortical bone | Low | Low | | Muscle | Moderate | Moderate | | Normal marrow | High | Moderate | | Soft tissue sarcomas | Low | High | | Fluid (ganglions, effusions) | Low | High | | Pigmented villonodular synovitis* | Very low | Very low |

Because the MRI scan shows a complete rupture of the distal biceps tendon, the preferred treatment is anatomic repair of the tendon to the radial tuberosity either with the use of suture anchors or transosseous sutures through a two-incision technique. Several studies have documented superior results with anatomic repair of the distal biceps tendon when compared with results of nonsurgical management or repair of the tendon by attachment to the brachialis muscle. Patients undergoing anatomic repair of the distal biceps tendon through a two-incision technique typically regain a functional range of motion and nearly normal strength.
REFERENCES: D’Alessandro DF, Shields CL Jr, Tibone JE, Chandler RW: Repair of distal biceps tendon ruptures in athletes. Am J Sports Med 1993;21:114-119.
Boyd JB, Anderson LD: A method for reinsertion of the distal biceps brachii tendon. J Bone Joint Surg Am 1961;43:1041-1043.
Morrey BF, Askew LJ, An KN, Dobyns JH: Rupture of the distal tendon of the biceps brachii: A biomechanical study. J Bone Joint Surg Am 1985;67:418-421.
Failla JM, Amadio PC, Morrey BF, Beckenbaugh RD: Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique: Report of four cases. Clin Orthop 1990;253:133-136.

The catastrophiCfailure of the precoat stem was due to proximal debonding associated with laser etching of the identifying numbers and letters on the stem of the prosthesis. Virtually all reported stem failures occurred in left hips because the laser etching caused a local stress concentration effect on the higher stress anterior surface

**
Empathy during the interview demonstrates compassion and earns the patient's trust; which, in turn, enables the patient to discuss any agenda or concerns he or she may otherwise feel uncomfortable revealing. It is also important to engage the patient to establish a trusting relationship and thus understand all the factors impacting the patient. A formal attitude toward the patient makes it difficult to engage the patient to be "drawn in." An engaged patient is more comfortable, reliable, and thorough when providing a history. Closed-end, yes-no questions do not allow the patient to detail all of the subtle nuances of their condition and its effect on their life. Taking copious notes likewise prevents engagement of the patient and the distraction of taking
notes may cause the physician to miss an important detail. It is better to lean forward in a chair when interviewing a patient because this suggests the physician is genuinely interested, whereas leaning back in a chair suggests the physician is simply waiting for the patient to finish talking. Avoid interrupting the patient when talking.

The widening, bowing, and cupping of the physes indicate some form of metabolic bone disease; therefore, the most likely diagnosis is renal osteodystrophy. The age of onset makes X-linked hypophosphatemic rickets less likely. The ground glass lesions and widening of the medullary canal characteristic of fibrous dysplasia are not present. There are no fractures creating the deformities indicating osteogenesis imperfecta.
There is an asymmetry of the deformities that makes diastrophic dysplasia less likely.
REFERENCES: Goldberg MJ, Yassir W, Sadeghi-Nejad A: Clinical analysis of short stature. J Pediatr Orthop 2002;22:690-696.
Parmar VS, Stanitski DF, Stanitski CL: Interpretation of radiographs in a pediatric limb deformity practice: Do
radiologists contribute? J Pediatr Orthop 1999;19:732-734. Question 4
Patients with slipped capital femoral epiphysis are more likely to experience a delay in definitive diagnosis if they initially present to a physician reporting which of the following problems?
L Limp
1. Hip pain
2. Knee pain
3. Proximal thigh pain
4. Buttock pain
PREFERRED RESPONSE: 3
DISCUSSION: A delay in diagnosis of slipped capital femoral epiphysis (SCFE) can lead to significant worsening of the deformity or even progression from a stable to an unstable SCFE. Those patients that report knee pain as their primary complaint are most likely to experience significant delay. Other variables associated with this delay include Medicaid insurance and stable SCFE.
REFERENCES: Kocher MS, Bishop JA, Weed B, et al: Delay in diagnosis of slipped capital femoral epiphysis.
_AL-Madena Copy_
10 • American Academy of Orthopaedic Surgeons
Pediatrics 2004;113:e322-e325.
Rahme D, Comley A, Foster B, et al: Consequences of diagnostic delays in slipped capital femoral epiphysis. J Pediatr Orthop B 2006;15:93-97.

Fibrous dysplasia is a common benign skeletal lesion that may involve 1 bone (monostotic) or multiple bones (polyostotic) and occurs throughout the skeleton with a predilection for the long bones. The radiographic features of fibrous dysplasia typically illustrate a grayish “ground-glass” pattern that is similar to the density of cancellous bone. The key histologic features of fibrous dysplasia are trabeculae of immature bone, with no osteoblastic rimming, contained within a bland fibrous stroma of dysplastic spindle-shaped cells without any cellular features of malignancy. The etiology of fibrous dysplasia has been linked to an activating mutation in the gene that encodes the a subunit of stimulatory G protein located at 20q13.2-13.3. This leads to a constitutive activation of adenylate cyclase and increased cyclic adenosine monophosphate formation. FGFR3 mutations are associated with achondroplasia. COMP mutations are associated with pseudoachondroplasia and multiple-epiphyseal dysplasia. EXT-1 mutations are associated with multiple hereditary exostosis.
RECOMMENDED READINGS
39. [DiCaprio MR, Enneking WF. Fibrous dysplasia. Pathophysiology, evaluation, and treatment. J Bone Joint Surg Am. 2005 Aug;87(8):1848-64. Review. PubMed PMID: 16085630. ](http://www.ncbi.nlm.nih.gov/pubmed/16085630)[View Abstract at](http://www.ncbi.nlm.nih.gov/pubmed/16085630)[ ](http://www.ncbi.nlm.nih.gov/pubmed/16085630)[PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16085630)
40. [Chapurlat RD, Orcel P. Fibrous dysplasia of bone and McCune-Albright syndrome. Best Pract Res Clin Rheumatol. 2008 Mar;22(1):55-69. doi: 10.1016/j.berh.2007.11.004. Review. PubMed PMID: 18328981. ](http://www.ncbi.nlm.nih.gov/pubmed/18328981)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18328981)
41. Ippolito E, Valentini MB, Lala R, De Maio F, Sorge R, Farsetti P. Changing Pattern of Femoral Deformity During Growth in Polyostotic Fibrous Dysplasia of the Bone: An Analysis of 46 Cases. J Pediatr Orthop. 2016 Jul-Aug;36(5):488-93. doi: 10.1097/BPO.0000000000000473. PubMed PMID:
[25887818/. ](http://www.ncbi.nlm.nih.gov/pubmed/25887818)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/25887818)
42. [Leet AI, Collins MT. Current approach to fibrous dysplasia of bone and McCune-Albright syndrome. J Child Orthop. 2007 Mar;1(1):3-17. doi: 10.1007/s11832-007-0006-8. Epub 2007 Feb 23. PubMed PMID: 19308500. ](http://www.ncbi.nlm.nih.gov/pubmed/19308500)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19308500)

The patient has arthritis and supracondylar nonunion of the elbow. Total elbow replacement has been shown to give almost immediate return of function as it can be performed while leaving the triceps intact and resecting the distal humerus fragment. Attempts at osteosynthesis are indicated in younger individuals with good joint surface. Resection arthroplasty yields poor function and is reserved as a salvage procedure.
REFERENCES: Ramsey ML, Morrey BF: Total elbow arthroplasty for nonunion and dysfunctional instability, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 655-661.
Sim FH, Morrey BF: Nonunion and delayed union of distal humeral fractures, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 655-661.

The figures reveal a fracture-dislocation at L1-2. Proper treatment consists of posterior reduction, stabilization, and fusion 2 levels above and below the level of injury. Short-segment stabilization schemes do not stabilize the injury properly, and longer-segment constructs are not necessary. Anterior treatment is not indicated in fracture-dislocations.
RECOMMENDED READINGS
[Mikles MR, Stchur RP, Graziano GP. Posterior instrumentation for thoracolumbar fractures. J Am Acad Orthop Surg. 2004 Nov-Dec;12(6):424-35. Review. PubMed PMID: 15615508. ](http://www.ncbi.nlm.nih.gov/pubmed/15615508)[View](http://www.ncbi.nlm.nih.gov/pubmed/15615508)[ ](http://www.ncbi.nlm.nih.gov/pubmed/15615508)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/15615508)
Bono CM, Rinaldi MD. Thoracolumbar trauma. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:201-216.

The patient has significant preoperative hyperextension with global instability, despite reasonable appearing preoperative radiographs. She has continued hyperextension with intraoperative trialing. The distal femur has already been augmented to distalize the joint line slightly past the appropriate level. Despite this, with this significant mismatch, the appropriate solution is to convert to a hinged prosthesis, which has a hyperextension stop. Studies have shown good results of hinged devices in appropriate patients. Leaving the patient with severe hyperextension postoperatively is not a good solution. Trialing a thicker polyethylene will not address the mismatch, as the tibial side affects both the flexion and extension spaces. Further augmentation of the distal femur would not be indicated and would impact the joint line.
Figures 1 and 2 are the radiographs of a 32-year-old woman with chronic right greater than left hip pain that she localizes to the groin. She has had pain for 3 years that has gradually worsened over the past 6 months and is now routinely a 7/10 on the pain scale. She has attempted the use of corticosteroid injections, nonsteroidal anti-inflammatory drugs and physical therapy. What is the most appropriate treatment?
57
A. Hip arthroscopy with acetabular rim debridement and labral repair
B. Total hip arthroplasty (THA) with ceramic-on-polyethylene bearing
C. Hip resurfacing arthroplasty with metal-on-metal bearing
D. Small diameter drill bit core decompression with bone marrow autograft
The patient has osteonecrosis of bilateral femoral heads as shown on the AP pelvis radiograph and closer inspection of the groin lateral radiograph of the right hip reveals a large femoral head cyst, collapse of the articular surface and a crescent sign. Arthroscopy is not recommended due to the nature of her pathology arising from osteonecrosis and not from femoroacetabular impingement with no provided evidence supporting a labral tear. Hip resurfacing is a viable option for the treatment of osteonecrosis, but the patient is a young female of childbearing age, relative contraindications to hip resurfacing. She has advanced disease that is classified as Ficat and Arlet stage III, Steinberg stage IVB osteonecrosis with femoral head collapse along with a large femoral head cyst, with overall poor results reported at this stage with hip core decompression. THA was performed with the use of a ceramic- on-polyethylene bearing based on the patient’s age and advanced disease (Figure 3).
correct answer : B
58

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The incidence of surgery is increased in patients 80 years of age and older. Patients aged 80 years and older enrolled in the Spine Patient Outcomes Research Trial and undergoing surgery for lumbar stenosis and spondylolisthesis were compared with patients younger than 80. In the older age group, surgical treatment was associated with statistically significant clinical improvement compared with nonsurgical management. No statistically significant increase was observed in complications or mortality compared with younger patients.

The patient has recurrent instability and is at a high rate of further dislocations due to his young age. Therefore, therapy and bracing are unlikely to decrease his dislocation rate. The radiographs are normal, and there is no Hill-Sachs lesion or bony Bankart lesion. His instability severity index score is 3, and; therefore, a bony procedure such as Latarjet is not necessary. Furthermore, the rate of complication following a Latarjet procedure, especially nerve
injury and hardware problems, exceeds that of arthroscopic Bankart repair.

Synovitis of the second MTP occurs in association with instability of the joint. This can be idiopathic or secondary to an external deforming force (such as a hallux valgus or shoe wear causing a claw toe). The primary stabilizer of the MTP joint for translation in the vertical plane is the plantar plate. The flexor digitorum brevis flexes the MTP joint, and the flexor digitorum longus flexes
all joints of the toe. The collateral ligaments are primary stabilizers in the transverse plane and secondary stabilizers in the sagittal plane.
RECOMMENDED READINGS
[Deland JT, Sung IH. The medial crosssover toe: a cadaveric dissection. Foot Ankle Int. 2000 May;21(5):375-8. PubMed PMID: 10830654.](http://www.ncbi.nlm.nih.gov/pubmed/%2010830654)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/%2010830654)
[Suero EM, Meyers KN, Bohne WH. Stability of the metatarsophalangeal joint of the lesser toes: a cadaveric study. J Orthop Res. 2012 Dec;30(12):1995-8. doi: 10.1002/jor.22173. Epub 2012 Jun 13. PubMed PMID: 22696467. ](http://www.ncbi.nlm.nih.gov/pubmed/22696467)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22696467)
CLINICAL SITUATION FOR QUESTIONS 91 THROUGH 95
Figure 91a is the sagittal plane ultrasound of the second web space of a 48-year-old woman who has noted burning pain in the ball of her right foot for 2 years. The pain intermittently radiates into her second and the third toes. Figure 91b shows the surgical procedure and Figure 91c is the pathologic specimen.
A

B

C

DISCUSSION: The foot shows all the classic signs of a clubfoot with hindfoot equinus, heel varus, supination, and forefoot adduction. The Ponseti method is now well recognized as the best treatment for idiopathic clubfoot. It calls for manipulation of the clubfoot on a weekly basis with the application of long leg cast to slowly achieve correction. A percutaneous heel cord tenotomy is often required, followed by an additional 3-week period of casting and eventual use of a foot abduction orthosis. AFO night splints will not achieve any correction. Anterior tibial tendon transfer is sometimes performed for a clubfoot with recurrence or if there is supination in the swing phase of gait. Short leg casts are not sufficient to achieve full correction of a clubfoot.
REFERENCES: Herzenberg JE, Radler C, Bor N: Ponseti versus traditional methods of casting for idiopathic clubfoot. J Pediatr Orthop 2002;22:517-521.
Morcuende JA, Dolan LA, Dietz FR, et al: Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics 2004; 113:376-380.

The pelvic injury is a severe anterior-posterior compression III or Tile C injury. The vessel most likely injured is the superior gluteal artery, but several arterial bleeding sources are likely. Vertical shear injuries can also injure this vessel, but it is much less common. When arterial injury follows a lateral compression injury, it is usually related to injury of a more anterior vessel like the obturator artery or a branch of the external iliac artery.
REFERENCES: O’Neill PA, Riina J, Sclafani S, et al: Angiographic findings in pelvic fractures. Clin Orthop 1996;329:60-67.
Belley G, Gallix BP, Derossis AM, et al: Profound hypotension in blunt trauma associated with superior gluteal artery rupture without pelvic fracture. J Trauma 1997;43:703-705.

Displaced clavicle fractures are associated with higher rates of nonunion.
Nonunion occurs in roughly 5-6% of clavicle fractures and can result in slower functional return, poor cosmesis and muscle fatigability. Clavicle fractures can be sub-classified using the Allman classification into medial, diaphyseal, and lateral injuries (Illustration A). The Neer classification for diaphyseal injuries describes fractures as "nondisplaced" (less than 100% displacement) and "displaced" (greater than 100% displacement).
Robinson et al. performed a prospective cohort study to identify risk factors for nonunion after nonoperative management of clavicle fractures. The overall nonunion rate was 6.2% and was highest in lateral third fractures (11.5%).
Diaphyseal fractures had the lowest nonunion rate (4.5%). Additionally, the authors found that the risk for nonunion was increased by advancing age, female gender, fracture displacement, and comminution.
Jorgensen et al. performed a systemic review of the literature looking for predictors of non-union and malunion in mid shaft clavicle fractures treated non-operatively. They found fracture comminution, displacement, older age, female gender, and the presence of smoking to be his factors for non-union. Of these, displacement was the most likely factor that can be used to predict nonunion.
Figure A demonstrates a displaced left clavicle diaphyseal fracture. Note that the medial fragment is displaced superiorly by the deforming force of the sternocleidomastoid. Illustration A represents the Allman classification.
Illustration B demonstrates the deforming forces acting on the clavicle.
Incorrect Answers:
Answer 1: Diaphyseal fractures were demonstrated to have the lowest rate of nonunion when compared to lateral third fractures and medial clavicle fractures.
Answer 3: Advancing age was found to be an independent predictor of nonunion.
Answer 4: Female gender was found to be an independent predictor of nonunion.
Answer 5: Injury to the dominant hand was not found to be associated with an increased risk of non-union.

Initial treatment of thoracic outlet syndrome is non-operative. Aggravating activities are modified and shoulder girdle strengthening is initiated. Surgery is considered for patients who have failed conservative therapy and suffer intractable pain, and for those who have significant neurologic or vascular deficits. Operative procedures must be tailored to the presumed pathological anatomy; there is no single best procedure.

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Several physeal sparing and physeal respecting ACL reconstruction techniques have been developed to use in skeletally immature patients to minimize the risk of growth disturbance. Growth disturbance can occur after ACL surgery in skeletally immature athletes and includes tibial recurvatum resulting from tibial tubercle apophyseal arrest, as well as limb length inequality and / or angular deformity, typically femoral valgus resulting from physeal arrest or overgrowth. Procurvatum does not occur. A stable ACL reconstruction will also minimize meniscal injury and chondral injury.

The patient sustained a bimalleolar ankle fracture with a syndesmosis disruption. The initial open reduction and internal fixation did not successfully reduce the distal tibiofibular joint. The patient may need a derotational distraction osteotomy of the fibula to reduce the syndesmosis. The other procedures do not address the primary problem of the fibular malunion and syndesmosis malreduction. There is no radiographic evidence of significant arthritis; therefore, ankle arthrodesis is not indicated.
REFERENCE: Heier KA, Walling AK: Treatment of ankle fractures. Foot Ankle Clin 1999;4:521-534.

Originally, Burkhalter and Strait recommended bony insertion into the proximal phalanx through a drill hole. This procedure does require more surgical dissection and flexes only the MCP joints; thus it cannot extend the PIP joints directly. It does improve clawing in the fingers if the PIPs can extend with preoperative MCP flexion. The ability to extend the PIP joints is evaluated preoperatively using the Bouvier test. With the wrist in neutral position, the examiner holds the MCPs flexed and looks for the ability in that position to actively extend the PIPs. If the patient is able to do so, then the test is considered positive, and this describes "simple" clawing. In such cases, procedures that flex only the MCPs are appropriate. The insertion sites for these procedures include the proximal phalanx, the first annular pulley, and the second annular pulley. If the Bouvier test is negative, then it is best to insert the tendon grafts distally into the lateral bands. This technique has a low chance of leading to hyperextension of the PIP joints, particularly when performed with a wrist extensor motor (which leaves the flexor digitorum superficialis undisturbed) and with no preoperative hyperextensibility of the PIPs.

DISCUSSION: Treatment of patellofemoral instability after total knee arthroplasty (TKA) is directed by its etiology. In instances of component malpositioning, revision of one or both components is indicated.
If the components are determined to be in satisfactory position, soft-tissue procedures can be pursued. Lateral retinacular release is usually the first soft-tissue procedure used to improve patellofemoral mechanics. In this patient, the patellar fracture fragment is so small that it can be excised. Distal realignment is not usually used as the first line of treatment for patellar maltracking following TKA.

REFERENCES: Fehring TK, Christie MJ, Lavemia C, et al: Revision total knee arthroplasty: Planning, management, and controversies. Instr Course Lect 2008;57:341-363.
Patel J, Ries MD, Bozic KJ: Extensor mechanism complications after total knee arthroplasty. Instr Course Lect 2008;57:283-294.

The anterior drawer test is performed with the ankle in 10° of plantar flexion, which results in the greatest amount of translation. The test investigates the integrity of the anterior talofibular ligament with a key distance of translation being 8 to 10 mm. While the patient is sitting and has her knees flexed over the edge of a table or bench, the physician uses one hand to stabilize the distal leg and with the other hand applies an anterior force to the heel in an attempt to gap the talus anteriorly from under the tibia. The anterior talofibular ligament and calcaneofibular ligament are both compromised based on the examination findings. The anterior drawer test result reflects injury to the anterior talofibular ligament and a possible injury to the calcaneofibular ligament. A lateral talar tilt test angle measurement >15° degrees reflects a rupture of both anterior talofibular ligament and calcaneofibular ligaments. The
diagnosis is a severe lateral ligament complex sprain. This is optimally managed with early mobilization and a guided rehabilitation program that emphasizes proprioceptive stability.

Ulnar carpal translocation occurs due to the steep radial articular angulation that occurs due to the tethering effect of a shortened ulna and is already apparent in early stages in the first radiograph. While peroneal palsy is possible due to a proximal fibula lesion, it is less common. Malignant transformation occurs, risk varies with families.

C hildren ages 4 to 8 (40 lbs to 60 lbs) are at risk for airbag injuries and should not be in the front seat. In addition, they require booster seats to allow proper fitting of the shoulder harness on the upper torso. Rear-facing seats are only appropriate for infants. C hildren should not be in the front seat until after age 12 and over 100 lbs.

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Although Staphylococcus aureus is the most common infecting organism in children with septic arthritis, in an otherwise healthy newborn, Streptococcus occurs more commonly. Kingella kingae is becoming a more commonly seen infecting organism, but it is more often seen in the toddler age range. Newborns in the neonatal intensive care unit are at risk for infections with Gram-negative organisms as well. With the introduction of a vaccine against Haemophilus influenzae, this organism is now rarely seen as a causative agent in septic arthritis.

Diaphyseal achalasia, also known as multiple hereditary exostoses, has a risk of malignant degeneration in up to 25% patients. Ollierâs disease and Mafucciâs syndrome are associated with enchondromas. There is no lesion called an osteochondromatosis malignant transformans.

In a skeletally immature patient with OCD and minor symptoms, the lesion can be observed and healing obtained with activity limitations if the cartilage is stable (but this cannot be determined radiographically or clinically). Activity restriction and serial follow-up are appropriate if an MRI reveals a stable lesion. MRI is indicated when there is concern that a lesion may be unstable. Surgical treatment depends on MRI findings.
Observation is recommended for OCD lesions in growing patients for 6 months because healing has been observed. Early surgical procedures, although they may be needed in the future, are not appropriate for patients with well-controlled symptoms.
If symptoms continue for longer than 6 months, arthroscopic drilling is not indicated for unstable OCD. The appropriate treatment is OCD fixation. Debridement is not appropriate with a stable lesion.
Evaluation of the fixation and stability of the lesion with advanced imaging after weight bearing and therapy initiation is the most appropriate option. Manipulating the knee without determining whether the stiffness is attributable to subsidence of the fixation or mechanical block is not appropriate. After 4 months, aspiration of a hematoma (if still present) would not yield much benefit. More therapy is not likely to be useful when a patient is attending therapy regularly and working on a home program.

Figure 37a

Figure 37b

Figure 37c

Chronic anterior knee pain at the insertion site is the most common frequently reported complication of closed nailing of a tibial shaft fracture. A high incidence of knee pain has been associated with IM nailing. The etiology of anterior knee pain remains unclear. It had been previously thought that the incidence of pain is higher when the nail was inserted by a patellar tendon-spliting approach versus a paratendon approach. According to the Keating paper, insertion of the nail through the patella tendon was associated with a higher incidence of knee pain compared to the paratendon site of nail insertion
(77% and 50% respectively). Toivanen et al. investigated this question when the group randomized fifty patients with a tibial shaft fracture requiring intramedullary nailing equally to treatment with paratendinous or transtendinous nailing. Fourteen (67%) of the twenty-one patients treated with transtendinous nailing reported anterior knee pain at the final evaluation. Of these fourteen patients, thirteen were mildly to severely impaired by the pain. Fifteen (71%) of the twenty-one patients treated with paratendinous nailing reported anterior knee pain, and ten of the fifteen were impaired by the pain.
The Lysholm, Tegner, and Iowa knee scoring systems; muscle-strength measurements; and functional tests showed no significant differences between the two groups. Compared with a transpatellar tendon approach, a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment by a clinically relevant amount after intramedullary nailing of a tibial shaft fracture.

C omputed tomography scan of the cervical spine will not show the pseudomeningoceles nor provide any information on brachial plexus. C omputed tomography may be needed in case of a suspected neck injury but does not form part of a brachial plexus work up.

Most “metal allergy” is classified as type IV, or delayed-type hypersensitivity response, which is a cellmediated response. Types I, II, and III are not generally associated with metal hypersensitivity responses.Type I reactions are typically anaphylaxis. Type II reactions are antibody mediated, such as seen in Grave’s disease or hemolytic anemia. Type III reactions are immune complex diseases such as serum sickness or systemic lupus erythematosus.

The Milwaukee brace offers the best chance of controlling this curve.
C harleston bending braces are not effective for curves larger than 35°. Boston overlap braces are not effective for curves with an apex above T8. Lateral electrical spinal stimulation has been proven ineffective for scoliosis. This curve is not large enough to pose a recommend fusion.

DISCUSSION: Closed chain kinetic exercises confer a margin of safety and are protective of healing or repaired tissues by the compressive nature of the applied forces. Closed chain kinetic exercise is associated with decreased shear, translation, and distraction of the joints within the chain. Because of patterns of motion with closed chain kinetic exercises, individual muscles may not be maximally strengthened or all joint motion returned to normal. Closed chain kinetic exercises may be used earlier in the rehabilitation process.
REFERENCES: Kibler WB, Livingston B: Closed-chain rehabilitation for upper and lower extremities. J Am Acad Orthop Surg 2001;9:412-421.
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2004, pp 131-132.

It is critical to withhold active range of motion of the shoulder within the first 6 weeks after arthroplasty for acute fracture to prevent tuberosity avulsion. When radiographic and clinical findings show that the tuberosities are healed, active motion may be instituted, usually at 6 to 8 weeks. Immediate passive range-of-motion exercises, including external rotation with a stick, pendulum, and passive elevation, should begin within the limits of the repair on the day of surgery to prevent stiffness.
REFERENCES: Hartstock LA, Estes WJ, Murray CA, et al: Shoulder hemiarthroplasty for proximal humerus fractures. Orthop Clin North Am 1998;29:467-475.
Hughes M, Neer CS: Glenohumeral joint replacment and postoperative rehabilitation. Phys Ther 1975;55:850-858.

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The patient has radiographic findings compatible with diffuse idiopathic skeletal hyperostosis (DISH) of the cervical spine. Characteristics of DISH include flowing, non-marginal osteophytes at four or more levels. Patients with DISH develop a significant loss of flexibility of the spine. The spine acts more as a long bone with minimal force needed to create unstable fractures. Any minor trauma in patients with DISH should be worked up aggressively to rule out occult fracture. In this patient, radiographs fail to clearly rule out a fracture; therefore, CT of the cervical spine is indicated. Without a suspicion of history of a head injury, admission specifically for a possible intracranial hematoma is not warranted. The more concerning injury in a patient with DISH is occult neck fracture. Treatment with a soft or hard collar is not advised until a fracture is ruled out. Repeat radiographs are unlikely to show any occult fractures, and flexion and extension views would not be advised in a patient with a suspected vertebral fracture.