Orthopedics Hyperguide Review | Dr Hutaif General Ortho -...

DISCUSSION: The extensor carpi radialis brevis is most often cited as the anatomic location of pathology in lateral epicondylitis. Histologic examination demonstrates noninflammatory tissue, primarily
angiofibroblastic tendinosis though normal tendon histology is also present. There is usually no evidence of acute inflammation or chondroblastic tissue, or significant calcium deposition.
REFERENCES: Nirschl RP, Ashman ES: Tennis elbow tendinosis (epicondylitis). Instr Course Lect 2004;53:587-598.
Lo MY, Safran MR: Surgical treatment of lateral epicondylitis: A systematic review. Clin Orthop Relat Res 2007;463:98-106.
Calfee RP, Patel A, DaSilva MF, et al: Management of lateral epicondylitis: Current concepts. J Am Acad Orthop Surg 2008;16:19-29.

The lateral wrist radiograph in Figure A shows significant dorsal angulation of the distal radius with a maintained joint space. The most appropriate surgical treatment for this patient would include corrective osteotomy of the distal radius, as there is no evidence of degenerative changes. If degenerative changes would be present, a salvage procedure such as total wrist arthrodesis would become an option.
The referenced article by Fernandez recommended distal radius corrective osteotomy with bone grafting and internal fixation for the following indications:
1) manually active patients who had a symptomatic extra-articular malunion of the distal end of the radius causing angulation of more than 25 to 30 degrees in either the frontal or sagittal plane without significant degenerative changes in the wrist joint (such as narrowing of the joint space, intra-articular incongruency, subchondral sclerosis, and osteophytic reaction) and in whom it
was thought that the result of either a Darrach procedure or shortening osteotomy of the ulna would be uncertain because the deformity of the radius would not be corrected, and 2) patients who wished to have the deformity corrected even though they had adequate function of the wrist.

Stress fractures are a frequent overuse injury among professional ballet dancers. The most common location is at the proximal metaphyseal-diaphyseal junction of the second metatarsal. Repetitive stress injuries and fractures of the tibial sesamoid, tarsal navicular, and base of the fifth metatarsal occur among other athletes.
RECOMMENDED READINGS
[O'Malley MJ, Hamilton WG, Munyak J, DeFranco MJ. Stress fractures at the base of the second metatarsal in ballet dancers. Foot Ankle Int. 1996 Feb;17(2):89-94. PubMed PMID: 8919407. ](http://www.ncbi.nlm.nih.gov/pubmed/8919407)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/8919407)
[Micheli LJ, Sohn RS, Solomon R. Stress fractures of the second metatarsal involving Lisfranc's joint in ballet dancers. A new overuse injury of the foot. J Bone Joint Surg Am. 1985 Dec;67(9):1372-5. PubMed PMID: 4077907. ](http://www.ncbi.nlm.nih.gov/pubmed/4077907)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/4077907)
[Gehrmann RM, Renard RL. Current concepts review: Stress fractures of the foot. Foot Ankle Int. 2006 Sep;27(9):750-7. Review. PubMed PMID: 17038292. ](http://www.ncbi.nlm.nih.gov/pubmed/17038292)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/17038292)

Immediate repair of the tuberosity and rotator cuff is recommended on identifying the avulsion or nonunion. Revising the humeral component to increase tension and length will overtighten the cuff and increase the chance of tuberosity pull-off. The glenoid is uninvolved and should not be replaced. Attempts to strengthen the rotator cuff will be unsuccessful because the insertions are no longer attached to the humerus when the tuberosities avulse.
REFERENCES: Brown TD, Bigliani LU: Complications with humeral head replacement. Orthop Clin North Am 2000;31:77-90.
Muldoon MP, Cofield RH: Complications of humeral head replacement for proximal humeral fractures. Instr Course Lect 1997;46:15-24.

Neutral abduction is important in preventing back pain.
The flexion should be between 25° and 35°.
Any abduction beyond neutral poses increased risk of back pain. External rotation beyond approximately 5° is not needed.
Arthrodesis often produces some shortening; therefore, intentional shortening is not needed.

The patient has a stress fracture of the olecranon that occurs with repetitive throwing motions. If the fracture is not displaced, the initial treatment of choice is rest and rehabilitation to maintain elbow motion, followed by aggressive strengthening at 6 to 8 weeks. A light throwing program generally can begin at 8 to 12 weeks. Complete recovery may require 3 to 6 months. If the fracture is displaced or if nonsurgical management fails, surgery is indicated for internal fixation of the stress fracture.
REFERENCES: Azar FM, Wilk KE: Nonoperative treatment of the elbow in throwers. Oper Tech Sports Med 1996;4:91-99.
Griffin LY (ed): Orthopaedic Knowledge Uupdate: Sports Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 191-203.

This patient’s radiographs, MR imaging, and histologic examination are diagnostic for low-grade chondrosarcoma, which is treated with surgery alone. In this patient, the tumor is entirely intramedullary. Both wide resection and extended intralesional curettage with intraoperative surgical adjuvant treatment are treatment options. Chemotherapy and radiation are not beneficial in the treatment of low-grade chondrosarcoma.
Endoprosthetic reconstruction using a reverse shoulder arthroplasty may be employed when the rotator cuff is deficient for older patients with neoplasms of the proximal humerus. Allograft-prosthetic composite reverse shoulder arthroplasty also has been used with early success.
RECOMMENDED READINGS
92. [Mermerkaya MU, Bekmez S, Karaaslan F, Danisman M, Kosemehmetoglu K, Gedikoglu G, Ayvaz M, Tokgozoglu AM. Intralesional curettage and cementation for low-grade chondrosarcoma of long bones: retrospective study and literature review. World J Surg Oncol. 2014 Nov 10;12:336. doi: 10.1186/1477-7819-12-336. Review. PubMed PMID: 25382793.](http://www.ncbi.nlm.nih.gov/pubmed/25382793)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/25382793)
93. [Di Giorgio L, Touloupakis G, Vitullo F, Sodano L, Mastantuono M, Villani C. Intralesional curettage, with phenol and cement as adjuvants, for low-grade intramedullary chondrosarcoma of the long bones. Acta Orthop Belg. 2011 Oct;77(5):666-9. PubMed PMID: 22187844. ](http://www.ncbi.nlm.nih.gov/pubmed/22187844)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22187844)
94. [Chalmers PN, Keener JD. Expanding roles for reverse shoulder arthroplasty. Curr Rev Musculoskelet Med. 2016 Mar;9(1):40-8. doi: 10.1007/s12178-016-9316-0. PubMed PMID: 26803609. ](http://www.ncbi.nlm.nih.gov/pubmed/26803609)[View](http://www.ncbi.nlm.nih.gov/pubmed/26803609)
[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/26803609)
95. [King JJ, Nystrom LM, Reimer NB, Gibbs CP Jr, Scarborough MT, Wright TW. Allograft-prosthetic composite reverse total shoulder arthroplasty for reconstruction of proximal humerus tumor resections. J Shoulder Elbow Surg. 2016 Jan;25(1):45-54. doi: 10.1016/j.jse.2015.06.021. Epub 2015 Aug 6. PubMed PMID: 26256013. ](http://www.ncbi.nlm.nih.gov/pubmed/26256013)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/26256013)

Early stabilization of femur fractures in patients with concomitant head injuries has been found to have no increased risk of worsening neurologic outcomes.
Treatment of patients with a closed head injury and a femoral fracture remains controversial but recent data suggests that intramedullary nails done acutely
leads to decreased pulmonary complications, decreased thromboembolic events, improved rehabilitation, decreased length of stay and cost of hospitalization, and improved GCS scores on discharge. However, it is important to note that intraoperative hypotension should be avoided in these patients, as it has been associated with worsening outcomes following acute intramedullary nailing of the femur.
Starr et al. performed a retrospective study to determine if the timing of treatment of femur fractures in patients with an associated head injury had an effect on the risk of pulmonary and CNS complications. They found that delaying fracture stabilization (> 24 hours) made pulmonary complications 45 times more likely, while early fracture stabilization had no effect on the risk of CNS complications.
McKee et al. performed a retrospective case-control study to determine the effect of early intramedullary nailing of femoral shaft fractures on the neurologic outcome of patients with multiple injuries and a concomitant head injury. They found no significant differences between the two groups in terms of early mortality, length of hospital/ICU stay, level of neurologic disability, or results of cognitive testing. Their results support the continued early intramedullary nailing of femoral fractures for patients with a concomitant head injury.
Richards et al. performed a retrospective study evaluating lactate levels before reamed intramedullary nailing (IMN) of femur fractures treated with early fixation (< 24 hours) and its effects on pulmonary complications (defined as mechanical ventilation lasting ≥ 5 days). They found that a median admission lactate of 3.7 mmol/L was associated with duration of mechanical ventilation ≥ 5 days, whereas a median preoperative lactate of 2.8 mmol/L was not.
Figures A and B are radiographs demonstrating a transverse femoral shaft fracture.
Incorrect Answers:
Answer 1: Early stabilization of the patient's femur fracture places him at decreased risk of pulmonary complications.
Answer 2: A concomitant head injury is not a contraindication to early fixation of the patient's femur fracture.
Answer 3: Damage control orthopaedics using external fixation is not indicated in this patient. Intramedullary nailing should be performed instead.
Answer 5: A concomitant chest injury is not a contraindication to early fixation of the patient's femur fracture.

Intravenous antibiotics are critical to prevent infection in open fractures. Delay in administration of intravenous antibiotics has been linked with increased risk of infection.
Open tibia fractures are associated with high rates of infection. Historically,
early debridement (within 6-8 hours) and early flap coverage (typically defined as less than 72 hours) were thought to minimize the risk of infection. Recent evidence has challenged these findings, with multiple studies demonstrating no significant link between the timing of debridement and rates of infection.
Multiple studies from the Lower Extremity Assessment Project (LEAP) found no significant difference in infection or complication with flap coverage more than 72 hours after injury.
Bhattacharyya et al retrospectively evaluated patients with type IIIB tibial fractures treated with extended use of negative pressure wound therapy. The authors found increased rates of infection beyond 7 days despite the use of negative pressure wound therapy.
Lack et al evaluated the timing of antibiotic administration on infection rates for type III tibial fractures. The authors found increased rates of infection with administration of antibiotics beyond 66 minutes. The authors discuss the possibility of pre-hospital intervention as many severely injured patients have delayed arrival at treatment centers.
Pollak et al prospectively analyzed rates of complication with flap coverage as part of the LEAP study. The authors found no increase in complications with flap coverage beyond 72 hours. The only significant risk for complication was the use of rotational flaps in comminuted or segmental (AO/OTA type C) tibial fractures.
Incorrect answers:
Answer 1: Lower rates of complication, including infection, were seen with free flaps in AO/OTA type C fractures in the study by Pollak et al.
Answer 2: Timing of flap coverage is controversial. Early studies demonstrated increased infection with delay beyond 72 hours, however recent studies using more rigorous statistical analysis do not support these findings.
Answer 3: No study has demonstrated lower infection rates with the use of plating versus nailing in open tibial fractures.
Answer 5: The timing of debridement with open fractures has been shown not to effect the rate of infection in multiple recent studies.

The plain radiographs show a destructive lesion in the wrist in the distal radius and at the scaphotrapezial joint. The joint spaces are preserved. The histology shows the features of gout: acellular amorphous tissue, macrophages, and giant cells.
Gout is caused by the deposition of monosodium urate crystals in tissues typically around joints. Common locations include the great toe, heel, ankle, and knee. In approximately 50% of patients, the first attack is in the great toe. Gout commonly occurs inside a joint for two reasons:
The synovial fluid is a poorer solvent than plasma
Lower temperatures (as in peripheral joints) favor crystallization
Neutrophils ingest the crystals and then release potent lysosomal enzymes. Histologically, the tophi have several features: Acellular amorphous material
Macrophages
Foreign body giant cells
The first line of treatment is nonsteroidal anti-inflammatory medications. Correct Answer: Nonsteroidal anti-inflammatory medications

MR images reveal a posterior horn root tear of the medial meniscus. LaPrade and associates found that outcomes after posterior meniscal root repair significantly improved postoperatively and patient satisfaction was high, regardless of age or meniscal laterality. Patients aged <50 years had outcomes similar to those of patients ≥50 years, as did patients who underwent medial versus lateral root repair. In patients undergoing pullout fixation for posterior medial meniscus root tear, Chung and associates (in “Pullout Fixation of Posterior Medial Meniscus Root Tears”) found that patients with decreased meniscus extrusion at postoperative 1 year have more favorable clinical scores and radiographic findings at midterm follow-up than those with increased extrusion at 1 year. Krych and associates found that nonoperative treatment of medial meniscus posterior horn root tears is associated with poor clinical outcome, worsening arthritis, and a relatively high rate of arthroplasty at 5-year follow-up. Reconstruction would have no role _in the setting of a reparable meniscal root tear._

HAGL lesions may be initially treated without surgery. Recurrent instability in the setting of a HAGL lesion may be treated with a soft-tissue repair. A nonengaging or nontracking Hill-Sachs lesion may be treated with an anterior soft-tissue (Bankart) repair. A tracking or engaging lesion may be treated with a bony glenoid procedure or a soft-tissue procedure plus remplissage. An ALPSA lesion may be treated with a soft-tissue procedure unless it is associated with a glenoid bony defect exceeding 25%. A glenoid bony defect exceeding 25% is associated with substantially higher recurrence than defects smaller than 20%, and consideration for bony glenoid reconstruction is advised.
RECOMMENDED READINGS
73. [Beran MC, Donaldson CT, Bishop JY. Treatment of chronic glenoid defects in the setting of recurrent anterior shoulder instability: a systematic review. J Shoulder Elbow Surg. 2010 Jul;19(5):769-80. doi: 10.1016/j.jse.2010.01.011. Epub 2010 Apr 14. Review. PubMed PMID: 20392650. ](http://www.ncbi.nlm.nih.gov/pubmed/20392650)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/20392650)
74. [Boileau P, Villalba M, Héry JY, Balg F, Ahrens P, Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. 2006 Aug;88(8):1755-63. PubMed PMID: 16882898. ](http://www.ncbi.nlm.nih.gov/pubmed/16882898)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16882898)

The triangular fibrocartilage complex is made up of the dorsal and palmar radioulnar ligaments, the meniscal homologue, the articular disk, the ulnolunate, and the ulnotriquetral ligaments. The radiolunate ligament is not part of the complex.

There has been a recent increase in the use of outcome instruments to document and measure effects of treatment of medical conditions, including shoulder disorders. The most important feature of an instrument is whether it actually measures what it purports to measure; this is defined as its validity.
REFERENCES: Leggin BG, Iannotti JP: Shoulder outcome measurement, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams and Wilkins, 1999, p 1027.
Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 47-55.

Given the size of the rotator cuff tear, it is likely to be repaired; therefore, the treatment of choice is a total shoulder replacement with rotator cuff repair. Severe rotator cuff insufficiency can lead to early glenoid failure because of superior instability, and glenoid resurfacing should be avoided in those instances.

Scientific References

: Boyd AD Jr, Thomas WH, Scott RD, Sledge CB, Thornhill TS: Total shoulder arthroplasty versus hemiarthroplasty: Indications for glenoid resurfacing. J Arthroplasty 1990;5:329-336.
Arntz CT, Jackins S, Matsen FA III: Prosthetic replacement of the shoulder for treatment of defects in the rotator cuff and surface of the glenohumeral joint. J Bone Joint Surg Am 1993;75:485-491.

The MR arthrogram shows a rupture of the ulnar collateral ligament (UCL) from the ulnar insertion, with the classic T-sign of contrast extravasation. Medial UCL reconstruction, using either ipsilateral palmaris longus or allograft tendon, is
indicated for UCL injuries that fail nonsurgical management. Primary repair has been shown to be successful in select cases, but appropriate patient selection is essential. An arthroscopic elbow debridement would be indicated for early elbow arthritis or intra-articular loose body, which is not demonstrated here. An ulnar nerve decompression would be indicated in the setting of cubital tunnel syndrome, but this patient has no complaints of paresthesias.
40

**
Patients with reflex sympathetic dystrophy (RSD) have a history of trauma, minor rather than major (eg, Colles fracture), in about 50% to 65% of cases. The condition may also follow a surgical procedure. Patients usually have symptoms and signs of RSD including: pain, described as burning, throbbing, shooting, or aching; hyperalgesia; allodynia; and hyperpathia. There are trophic changes within 10 days of onset of RSD in 30% of the extremities affected, including stiffness and edema and atrophy of hair, nails, and/or skin.
Finally there can be autonomic dysfunction, such as abnormal sweating, either
in excess or anhydrosis, heat and cold insensitivity, or redness or bluish discoloration of the extremities. Shingles, also called herpes zoster or zoster, is a painful skin rash caused by the varicella zoster virus (VZV). VZV is the same virus that causes chickenpox. After a person recovers from chickenpox, the virus stays in the body.
Usually the virus does not cause any problems; however, the virus can reappear years later, causing shingles. Charcot arthropathy is a progressive condition of the musculoskeletal system that is characterized by joint dislocations, pathologic fractures, and debilitating deformities. This disorder results in progressive destruction of bone and soft tissues at weight-bearing joints; in its most severe form, it may cause significant disruption of the bony architecture. In patients with diabetes, the incidence of acute Charcot arthropathy of the foot and ankle ranges from
0.15% to 2.5%. Acute Charcot arthropathy almost always appears with signs of inflammation. Profound unilateral swelling, an increase in local skin temperature (generally, an increase of 3° to 7° above the nonaffected foot's skin temperature),
erythema, joint effusion, and bone resorption in an insensate foot are present. These characteristics, in the presence of intact skin and a loss of protective sensation, are often pathognomonic of acute Charcot arthropathy. Cellulitis is an infection of the skin.
Examination would reveal erythema, edema, and pain. Osteomyelitis is an infection of the bone. Examination may reveal edema, drainage, and pain.

This 86-year-old woman has poor bone quality and osteoarthritis of the left hip. Her lateral radiograph confirms Dorr type C bone quality. A hybrid left THA with a cemented femoral stem would be the treatment of choice.

Recovery of upper extremity motor function after a cerebrovascular accident follows a predictable pattern. The greatest amount of recovery is seen within the first 6 weeks. Return of function proceeds from proximal to distal. Shoulder flexion occurs first, followed by return of flexion to the elbow, wrist, and fingers. Return of forearm supination follows the return of finger flexion.
REFERENCE: Waters RL, Keenan ME: Surgical treatment of the upper extremity after stroke, in Chapman MW (ed): Operative Orthopedics. Philadelphia, PA, JB Lippincott, 1988, vol 2,
pp 1449-1450.

Proper soft-tissue tension is critical to prevent instability of a reverse total shoulder. The arm position implicated in reverse total shoulder instability is extension, adduction, and internal rotation, such as pushing out of a chair. The other positions described do not involve extension of the shoulder.

The first step toward osteoarthritis of the dysplastiChip is fatiguing of the labrum under normal stress. Klaue et al described the different pathomorphologies from a torn labrum to ganglion formation, which has been attributed to acetabular rim syndrome

48
The anterior approach to the mid-humerus courses along the lateral margin of the biceps brachii. This muscle is swept medially allowing exposure of the brachialis. The brachialis has a dual innervation, with the lateral fibers innervated by the radial nerve and the medial fibers innervated by the musculocutaneous nerve. The humerus is exposed by splitting this muscle in its midline. The lateral head of the triceps resides in the posterior compartment of the arm and is not involved in the anterior approach to the humerus. The interval between brachialis and coracobrachialis is not an internervous plane, as both muscles are supplied by the musculocutaneous nerve.

DISCUSSION:
TEA is the best surgical option. McKee and associates published a multicenter randomized controlled trial comparing ORIF with TEA in elderly patients. TEA resulted in better 2-year clinical functional scores and more predictable outcomes compared with ORIF. TEA was also likely to result in a lower resurgical rate; one- quarter of patients with fractures randomized to ORIF could not achieve stable fixation. Further, Frankle and associates reported a comparative study of TEA versus ORIF in 24 elderly women. TEA outcomes were again
superior to ORIF at a minimum of 2 years of follow-up. TEA was especially useful in patients with comorbidities that compromise bone stock, including osteoporosis and oral corticosteroid use. Closed
reduction and percutaneous pinning studies have not been published on the adult population.

This patient has isolated posttraumatic ankle arthritis with significantly decreased ankle range of motion that is best treated with an isolated ankle arthrodesis to eliminate pain. Because this patient is younger than 50 years of age and has limited presurgical range of motion, she is not a candidate for ankle arthroplasty. Additionally, TAA outcomes among patients who have a posttraumatic etiology are worse than for those with osteoarthritis. Tibiotalocalcaneal arthrodesis is suited for patients with associated subtalar
arthritis or rigid hindfoot deformity that necessitates correction. Anterior tibial exostectomy will not resolve the underlying arthritic pain and is not indicated.
RECOMMENDED READINGS
[Easley ME, Adams SB Jr, Hembree WC, DeOrio JK. Results of total ankle arthroplasty. J Bone Joint Surg Am. 2011 Aug 3;93(15):1455-68. doi: 10.2106/JBJS.J.00126. Review. PubMed PMID: 21915552. ](http://www.ncbi.nlm.nih.gov/pubmed/21915552)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21915552)
[Spirt AA, Assal M, Hansen ST Jr. Complications and failure after total ankle arthroplasty. J Bone Joint Surg Am. 2004 Jun;86-A(6):1172-8. PubMed PMID: 15173289. ](http://www.ncbi.nlm.nih.gov/pubmed/15173289)[View Abstract at](http://www.ncbi.nlm.nih.gov/pubmed/15173289)[ ](http://www.ncbi.nlm.nih.gov/pubmed/15173289)[PubMed](http://www.ncbi.nlm.nih.gov/pubmed/15173289)
[Ajis A, Henriquez H, Myerson M. Postoperative range of motion trends following total ankle arthroplasty. Foot Ankle Int. 2013 May;34(5):645-56. doi: 10.1177/1071100713481433. Epub 2013 Mar 11. PubMed PMID: 23478890. ](http://www.ncbi.nlm.nih.gov/pubmed/23478890)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23478890)
[Thomas R, Daniels TR, Parker K. Gait analysis and functional outcomes following ankle arthrodesis for isolated ankle arthritis. J Bone Joint Surg Am. 2006 Mar;88(3):526-35. PubMed PMID: 16510818. ](http://www.ncbi.nlm.nih.gov/pubmed/16510818)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16510818)
[Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001 Feb;83-A(2):219-28. PubMed PMID: 11216683. ](http://www.ncbi.nlm.nih.gov/pubmed/11216683)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11216683)

DISCUSSION: The patient has severe wear and loosening of her cemented, all polyethylene acetabular component with a Paprosky type 2 acetabular defect. Optimal long-term results have been achieved with the use of a cementless, porous-coated acetabular component with adjunctive screw fixation. Cemented, all polyethylene components have been shown to have a high rate of failure when used in the revision setting. Bilobed components and antiprotrusio cages are unnecessary for this straightforward defect and have had mixed results reported in the literature. The use of a bipolar head placed directly into the acetabulum is associated with high rates of persistent pain and progressive acetabular erosion.

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 457474.
Della Valle CJ, Schuaipaj T, Berger RA, et al: Revision of the acetabular component without cement after total hip
arthroplasty: A concise follow-up, at fifteen to nineteen years, of a previous report. J Bone Joint Surg Am 2005;87:1795-1800.
Templeton JE, Callaghan JJ, Goetz DD, et al: Revision of a cemented acetabular component to a cementless acetabular component: A ten to fourteen-year follow-up study. J Bone Joint Surg Am
2001;83:1706-1711.

This patient has a classic presentation of postmeniscectomy medial compartment arthritis. The appropriate diagnostic study is weight-bearing radiographs to confirm the diagnosis. An MRI scan will reveal medial compartment arthritis but will not provide information about alignment. A CT scan would be appropriate to detect an occult fracture; however, this condition is not suspected in this clinical scenario. Ultrasonography can provide information about fluid collection around the knee or a deep vein thrombosis; however, these conditions also are not suspected in this clinical scenario. Because the patient has a correctable deformity (gaps 3 mm with valgus stress), and his symptoms are localized to the involved compartment, a trial of a medial unloader brace is appropriate both diagnostically and therapeutically. If unloading the medial compartment resolves the patient’s symptoms, he would be an excellent candidate for an osteotomy. An MRI scan may be obtained to evaluate ligamentous integrity or to evaluate degenerative involvement of the lateral and patellofemoral compartment for presurgical planning of an osteotomy; however, the integrity of the medial meniscus has no clinical importance in a patient with severe medial compartment arthritis. A repeat corticosteroid injection is not indicated within 1 month of his last injection, and referral to pain management is not appropriate with other options available to help this patient. A VPHTO is the appropriate intervention considering the patient’s young age, high-functional occupation, examination, radiographic findings, and response to medial unloader bracing. A revision knee arthroscopy would be appropriate for a recurrent medial meniscus tear, but not appropriate in a patient with severe medial compartment arthritis. The patient’s young age and high functional requirements are contraindications to TKA. The presence of severe arthritis is a contraindication to medial meniscus transplant. The patient is a candidate for a VPHTO. The technical options include a medial opening-wedge or a lateral closing-wedge osteotomy. Both techniques have advantages and disadvantages; however, a medial opening-wedge osteotomy is contraindicated in a smoker because of concern for nonunion. As a result, current smoking history is the only factor listed that would influence the technique used. The history of prior arthroscopy has no relevance in the decision about which type of osteotomy is appropriate. Normal BMI is between 18.5 and 24.9, so this patient’s BMI is considered normal and would not affect the surgical technique (if this patient were obese, a lateral closing-wedge osteotomy would be considered, but this is controversial). His age of 40 years is an indication for HTO but does not influence technique.

■
CA-MRSA is one of the most common organisms causing severe musculoskeletal infections in children. In contrast to its methicillin-sensitive counterpart, CA-MRSA is associated with a much more severe disease burden, including the need for more operative procedures before it is cleared.
CA-MRSA is more likely to be diagnosed when the C-reactive protein level is >5 mg/dL. Currently, clindamycin and vancomycin are the first-line antibiotics used for treatment of CA-MRSA; linezolid is reserved for severe resistant cases or allergies, as it is not indicated otherwise for use in children. CA-MRSA is much more likely to cause associated deep venous thrombosis and pulmonary thromboembolism than hospital-acquired-MRSA, due to a much higher propensity for the former to carry the Panton-Valentin leukocidin gene.

There are many factors that increase the rigidity of an external fixator, including: Increased pin diameter
Increased pin number Decreased bone-to-rod distance Increased pin group separation Separating half pins by 45°
Increasing the bone-to-rod distance decreases the rigidity of the system. The fracture gap is also important. The fracture gap should be minimized for excellent bone apposition.

The description and radiograph reveal a case of proximal humeral epiphysiolysis, also called Little Leaguer’s shoulder (LLS). This is an overuse condition resulting from chronic repetitive microtraumatic forces imposed on the unossified cartilage of the proximal humeral
physis. Classic radiographic findings include widening of the proximal humeral physis with increased sclerosis and/or mineralization/lucency. Many factors have been studied as possible contributors to the development of LSS, including all options presented. However, no clear relationship between body weight/height or throwing mechanics exist with LSS. It has also been claimed that the use of breaking pitches (e.g. curve balls, sliders) at an early age are a contributing factor, but this has been refuted by a number of recent studies. By far, the most important factors are the numbers of pitches thrown and the frequency of pitching. This is reflected in a number of indicators, including numbers of innings pitched, number of throwing days, numbers of pitches or pitched innings per week, month and year, and playing for multiple teams.

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.

The radiographs reveal a tibial pilon fracture with an extruded and rotated anterior tibial fragment that lies deep to the anterior compartment neurovascular bundle, which contains the deep peroneal nerve. This nerve innervates the anterior compartment muscles and the extensor digitorum brevis and extensor hallucis brevis muscles and provides sensation to the dorsal aspect of the first interspace. An injury to the deep peroneal nerve at this level will only affect the innervation to the extensor digitorum brevis and extensor hallucis brevis muscles and the innervation of the first interspace. The superficial peroneal nerve innervates
the lateral compartment muscles above the level of this injury and innervates the dorsum of the foot. The medial forefoot is innervated by the saphenous nerve and the posterior tibial nerve innervates the posterior compartment muscles above the level of the injury. The sural nerve innervates the lateral foot and has no motor component, and the superficial peroneal nerve innervates the peroneus longus, which plantar flexes the first metatarsal above the level of the injury.
RECOMMENDED READINGS
1. Agur AM, Dalley AF, eds. Grant’s Atlas of Anatomy. 13th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2013:362-370.
2. Hoppenfeld S, de Boer P, Buckley R, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:625-673.

- Figure 51b_

Nonsurgical treatment with activity modification and physical therapy is generally considered the first-line approach for young athletes with multidirectional instability (MDI) of the shoulder. Physical therapy focuses on exercises to strengthen the scapular stabilizers and rotator cuff muscles and restore scapulohumeral rhythm. Although a definitive length of time to assess physical therapy failure is not known, many surgeons believe that a patient with MDI should undergo at least 6 months of physical therapy and activity
36
modification before considering surgery. Although an open inferior capsular shift has historically been considered the gold standard for surgical treatment for MDI, studies have shown good success rates for arthroscopic capsulorrhaphy. Arthroscopy can allow a surgeon to assess all intra-articular structures and address a patient’s particular problem based on arthroscopic findings.

- Adjacent segment degeneration

Total knee replacement is a well-established surgery for diffuse, symptomatic osteoarthritis of the knee joint, and its efficacy has been shown in many studies. According to the 2008 AAOS Clinical Practice Guideline, Treatment of Osteoarthritis of the Knee, arthroscopy in the setting of existing osteoarthritis is efficacious for relieving the signs and symptoms of a torn meniscus but not for osteoarthritis. Likewise, in young and active patients, clinical outcomes show improvement after realignment osteotomy for single- compartment osteoarthritis. Unicondylar knee replacement is not indicated for tricompartmental disease
of the knee.

The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial, open inlay, and arthroscopic inlay techniques, one major difference is the creation of the “killer-turn” during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead to more pronounced attenuation and thinning of the graft during cyclic loading. The scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by the varus thrust and abnormal Dial test finding. A valgus-producing osteotomy may be effective, and, in fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral osteotomy would not be appropriate. Of the remaining responses, an osteotomy that increases tibial slope would also address the PCL deficiency by reducing posterior tibial sag. Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery and may occur regardless of the technique used.
Numerous strategies have been described to reduce the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered (rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and the neurovascular bundle and increases, not lessens, risk for _vascular injury._

Various options exist to treat thumb CMC arthritis: trapezial resection alone, trapezial resection with ligament suspensionplasty or tendon interposition, trapezial resection with both ligament suspensionplasty and tendon interposition, CMC fusion, and CMC replacement. MCP hyperextension can develop in long-standing CMC arthritis, contributing to CMC instability as well as thumb pain and weakness. In patients with concomitant MCP hyperextension that exceeds 30°,
correction of the deformity of the MCP joint must also be addressed and can be done with MCP capsulodesis, extensor pollicis brevis tendon transfer, or MCP fusion. Fusion of both the thumb CMC and MP joints is not recommended as this would result in marked stiffness and dysfunction.

Medial plateau fracture dislocations are rare. Failure to recognize this pattern can lead to poor patient outcomes secondary to poor surgical decision making. Pathognomonic findings on the anteroposterior radiograph include an intact lateral column (lateral articular surface still in continuity with tibial shaft), centrolateral articular impaction, shortening, and condylar widening. The medial femoral condyle stays with the fractured medial tibial plateau segment.
Initial management of axially unstable tibial plateau fractures with soft tissue swelling should consist of spanning external fixation and closed manipulative realignment. This allows for soft tissue recovery with the knee joint provisionally stabilized in reduced station. It also provides time for pre-operative planning, which is typically empowered via a CT scan with reconstructions. If the pattern was initially misdiagnosed as a more typically bicondylar tibial plateau fracture, the CT scan will clarify the misconception and allow for better surgical decision making.
Supine positioning is preferred for definitive fixation, but surgical approaches vary. Attempting to stabilize a medial partial articular pattern in the supine position from a lateral utility approach is fraught with difficulties. Lateral locked plating is not designed for this indication. The lateral utility approach allows for visualization of the centrolateral impaction and lateral meniscal peripheral capsular avulsion repair,
but when used alone leads to biomechanically unsound implant placement. The primary plate should be on the medial side of the tibia rather than the intact lateral column.

**
Specificity refers to the proportion of individuals who are truly free of the designated disorder who are so identified by the test. Sensitivity refers to the proportion of individuals who truly have the disorder who are so identified by the test. Positive predictive value refers to the proportion of individuals with a positive test who have the disorder. Negative predictive value refers to the proportion of individuals with a negative test who are free of the disorder.
Accuracy is the overall ability to identify patients with the disorder (true positives) and without the disorder (true negatives) in the study population.

This is a case of obstetric brachial plexus injury involving the C 8, T1 roots (Klumpke Palsy). Erbâs palsy involves upper roots only. C ombined nerve injuries can present in a similar fashion; however, low ulnar and median nerve lesions will not have weakness of flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS).
History of large baby, shoulder dystocia and clavicle fracture point to a difficult labor. The most common type of brachial plexus injury related to birth is Erbâs palsy, which is usually associated with a breech presentation. Isolated Klumpkeâs palsy is rare, and involvement of C 8, T1 usually occurs as part of global plexus injury.

Fractures of the proximal humerus are now the third-most-common fracture in patients older than 60 years of age. This patient sustained a displaced, commonly described 3-part/4-part proximal humerus fracture. The number of fracture fragments and angulation, as initially described by Codman and then Neer, does not necessarily help to predict risk for subsequent AVN. Although the main blood supply to the humeral head historically was believed to be a branch from the anterior circumflex, adequate perfusion can remain through the posteromedial calcar following trauma. Hertel and associates reported that the most accurate predictor of ischemia was whether the length of the metaphyseal head extension for the calcar segment was shorter than 8 mm.
Locking plates have provided surgical alternatives to many unstable fracture patterns previously considered ominous. Although much enthusiasm remains for this use, a relatively high level of
complications has been reported with their use. A multicenter study reported a 14% incidence of intra-articular screw perforation as the most common complication.
When patients are deemed poor candidates for head preservation treatment, both hemiarthroplasty and rTSA can provide successful results when applied and performed appropriately. An increasing body of evidence appears to support consideration of a reverse prosthesis for older patients. A crucial aspect of hemiarthroplasty success is anatomic healing of the tuberosities around the implant. If the greater tuberosity displaces or reabsorbs, patients experience significant loss of active motion. The level of pain, however, is unpredictable. Although beneficial in a reverse prosthesis, anatomic tuberosity position does not appear to be as crucial. Depending on the definition of “complication,” some researchers have reported a higher complication rate for the reverse prosthesis.
If posttraumatic necrosis develops following head preservation treatment, conversion to an anatomic shoulder arthroplasty can provide good success in motion and function, particularly when the tuberosities heal in a relatively anatomic position. However, several researchers, most recently Moineau and associates, report suboptimal results when the greater tuberosity is positioned in a substantial amount of varus that necessitates osteotomy. In this scenario, rTSA should be considered.
RECOMMENDED READINGS
8. [Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004 Jul-Aug;13(4):427-33. PubMed PMID: 15220884. ](http://www.ncbi.nlm.nih.gov/pubmed/15220884)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/15220884)
9. [Südkamp N, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, Luo C, Plecko M, Wendt K, Köstler W, Konrad G. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am. 2009 Jun;91(6):1320-8. PubMed PMID: 19487508. ](http://www.ncbi.nlm.nih.gov/pubmed/19487508)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19487508)
10. [Anakwenze OA, Zoller S, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for acute proximal humerus fractures: a systematic review. J Shoulder Elbow Surg. 2014 Apr;23(4):e73-80. doi: 10.1016/j.jse.2013.09.012. Epub 2014 Jan 7. Review. ](http://www.ncbi.nlm.nih.gov/pubmed/24406120)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24406120)
11. [Jarrett CD, Brown BT, Schmidt CC. Reverse shoulder arthroplasty. Orthop Clin North Am. 2013 Jul;44(3):389-408, Epub 2013 Apr 29. Review. PubMed PMID: 23827841. ](http://www.ncbi.nlm.nih.gov/pubmed/23827841)[View Abstract ](http://www.ncbi.nlm.nih.gov/pubmed/23827841)[at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23827841)
12. Moineau G, McClelland WB Jr, Trojani C, Rumian A, Walch G, Boileau P. Prognostic factors and limitations of anatomic shoulder arthroplasty for the treatment of posttraumatic cephalic collapse or necrosis (type-1 proximal humeral fracture sequelae). J Bone Joint Surg Am. 2012 Dec 5;94(23):2186-
[94/. doi: 10.2106/JBJS.J.00412. PubMed PMID: 23224389. ](http://www.ncbi.nlm.nih.gov/pubmed/23224389)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23224389)
13. [Namdari S, Horneff JG, Baldwin K. Comparison of hemiarthroplasty and reverse arthroplasty for treatment of proximal humeral fractures: a systematic review. J Bone Joint Surg Am. 2013 Sep 18;95(18):1701-8.. PubMed PMID: 24048558. ](http://www.ncbi.nlm.nih.gov/pubmed/24048558)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24048558)

- 50%_

Osteochondromas are the most common primary benign bony tumors.

Historically, orthopaedic surgeons considered early range-of-motion programs following rotator cuff surgery secondary to concerns about potential postsurgical stiffness. Although this may have been a primary open repair concern, arthroscopic surgery appears to substantially decrease this risk. More recently, investigators are reporting similar results in terms of range of motion, retear rate, and functional outcome scores among patients who undergo early and delayed rehabilitation programs.
RECOMMENDED READINGS
25. [Parsons BO, Gruson KI, Chen DD, Harrison AK, Gladstone J, Flatow EL. Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness? J Shoulder Elbow Surg. 2010 Oct;19(7):1034-9. doi: 10.1016/j.jse.2010.04.006. Epub 2010 Jul 24. ](http://www.ncbi.nlm.nih.gov/pubmed/20655763)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/20655763)
26. [Cuff DJ, Pupello DR. Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol. J Shoulder Elbow Surg. 2012 Nov;21(11):1450-5. doi: 10.1016/j.jse.2012.01.025. Epub 2012 May 2. ](http://www.ncbi.nlm.nih.gov/pubmed/22554876)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22554876)
27. [Jarrett CD, Schmidt CC. Arthroscopic treatment of rotator cuff disease. J Hand Surg Am. 2011 Sep;36(9):1541-52; quiz 1552. doi: 10.1016/j.jhsa.2011.06.026. Epub 2011 Aug 6. Review. PubMed PMID: 21821368. ](http://www.ncbi.nlm.nih.gov/pubmed/21821368)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21821368)
28. [Chan K, MacDermid JC, Hoppe DJ, Ayeni OR, Bhandari M, Foote CJ, Athwal GS. Delayed versus early motion after arthroscopic rotator cuff repair: a meta-analysis. J Shoulder Elbow Surg. 2014 Nov;23(11):1631-9. doi: 10.1016/j.jse.2014.05.021. Epub 2014 Aug 13. ](http://www.ncbi.nlm.nih.gov/pubmed/25127908)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/25127908)

Eighty percent of infantile digital fibromata appear before a child's first birthday. They are exclusive to the fingers and toes and are usually painless. Infantile digital fibromata are often small and the same color as the skin. On histological examination, intracytoplasmic inclusion bodies are present. Although benign, the fibromata are locally aggressive. They do not metastaaize, but recurrences after wide local excision are common. Surgery is indicated when deformity or contracture is imminent.

The following are features of stress fractures:
A. Stress fractures most often occur from changes in an athleteâs training program.
1/. Increases in intensity
2/. Increases in duration
B. In military recruits, the rates are gender dependent.
1/. Men â 4%
2/. Women â 7%
C . Stress fractures occur in normal bone subjected to abnormal stresses.
D. Stress fractures occur in sites of bone resorption subjected to continued loading.
E. Important to know is the definition of insufficiency fractures â fractures in abnormal bone from normal stresses. Correct Answe Stress fractures occur in normal bone subjected to normal stresses.

There is no evidence that early weight bearing enhances ultimate rehabilitation. At the other extreme, weight bearing should not be delayed for a prolonged period of time. In a young, healthy individual, the rigid plaster dressing appears to be the safest method of protecting the wound during the early postoperative period. If the wound appears to be secure, early partial weight bearing can be safely initiated.
REFERENCES: Burgess EM, Romano RL, Zettl JH: The Management of Lower Extremity Amputations. Washington, DC, US Government Printing Office, 1969, also at: www.prs-research.org.
Smith DG, McFarland LV, Sangeorzan BJ, et al: Postoperative dressing and management strategies for transtibial amputations: A critical review. J Rehabil Res Dev 2003;40:213-224.

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Workers’ compensation is a system that provides healthcare and wage-replacement benefits for workers injured in the occupational setting. Back pain is the most common workers compensation claim in the United States, accounting for up to 25% of all claims and one-third of total compensation costs. Numerous studies have reported that workers’ compensation is an independent negative risk factor for unsatisfactory outcomes after surgical procedures.
Keeney and associates published a prospective study looking at which factors were predictive for proceeding to surgery in the workers’ compensation population. Their findings showed that young age (<35 years-old), female gender, and Hispanic ethnicity were negative predictive factors for proceeding with surgical treatment. Which medical professional the work compensation patient sought made a difference; nearly 43% of injured workers whose first visit was to a surgeon eventually underwent a surgical procedure.

- Lateral aspect of left foot

The lateral arm flap is based on the posterior radial collateral artery, a branch of the profunda brachial artery.
REFERENCES: Katsaros J, Tan E, Zoltie N: The use of the lateral arm flap in upper limb surgery. J Hand Surg 1991;16:598-604.
Katsaros J, Schusterman M, Beppu M, et al: The lateral upper arm flap: Anatomy and clinical applications. Ann Plast Surg 1984;12:489-499.