Orthopedic Improve Review | Dr Hutaif General Orthopedi -...

Cubitus varus is a common complication of displaced supracondylar humeral fractures that are treated with closed reduction and cast immobilization. Treatment with closed reduction and percutaneous pinning decreases the incidence of this complication. Cubitus varus also can occur in minimally displaced fractures when unrecognized collapse of the medial column of the distal humerus is not corrected with manipulation. This can be detected on physical examination of the carrying angle or on radiographs measuring Baumann’s angle, both in comparison to the opposite side. Cubitus varus may result in unacceptable cosmesis and may predispose the patient to fractures of the lateral condyle. The lateral radiograph demonstrates the crescent sign from overlap of the distal humerus with the olecranon seen in patients with cubitus varus. Patients with growth arrest to the medial trochlear physis would have atrophy of the trochlea on radiographs.
REFERENCES: Flynn JM, Sarwark JF, Waters PM, et al: The surgical management of pediatric fractures of the upper extremity. Instr Course Lect 2003;52:635-45.
Papandrea R, Waters PM: Posttraumatic reconstruction of the elbow in the pediatric patient. Clin Orthop 2000;370:115-126.
Lins RE, Simovitch RW, Waters PM: Pediatric elbow trauma. Orthop Clin North Am 1999;30:119-132.

Symptoms can persist following a rotator cuff repair for a variety of reasons. In the early postoperative period, infection is the primary concern. Stiffness and loss of motion can occur because of postoperative scarring. Complex regional pain syndrome can occur but is rare, and the diagnosis is not made with a plain radiograph. This radiograph shows a superiorly migrated humeral head that articulates with the acromion, indicating that the repair has failed. While large to massive tears may fail more commonly than once thought, the clinical outcome may be satisfactory in many patients.
REFERENCES: Mansat P, Cofield RH, Kersten TE, Rowland CM: Complications of rotator cuff repair. Orthop Clin North Am 1997;28:205-213.
Jost B, Pfirrmann CW, Gerber C, Switzerland Z: Clinical outcome after structural failure of rotator cuff repairs. J Bone Joint Surg Am 2000;82:304-314.

Lateral closing wedge (LCW) and medial opening wedge (MOW) high-tibial osteotomies (HTOs) can both correct varus knee alignment and stabilize the ACL–deficient knee. Increasingly, HTO is being proposed as a singular or concomitant procedure with ACL reconstruction for restoring knee stability and as a more reliable slope correction. LCW HTO demonstrates more reliable slope correction than does MOW HTO. Revision ACL with BTB allograft and meniscal transplant will not help early arthritis in varus alignment. Distal femoral osteotomy is usually considered for valgus knee. Pure sagittal osteotomy _would not help the patient’s medial knee pain, arthritis, and malalignment._

Ice hockey injuries demand a thorough assessment because they have the potential to be significant. In hockey players, bone injuries in the foot and ankle can be missed or improperly diagnosed through routine radiographic imaging. MRI can display bone injuries that are not found radiographically; this is because _some fractures and contusions involve the medial ankle and midfoot bones._

This patient has the classic appearance of a collar button hand abscess. Although antibiotics, soaks, and elevation are important interventions, surgery is required. This infection rarely evolves into a flexor tenosynovitis, so decompression of the flexor tendon sheath is not indicated. Both volar and dorsal incisions often are required to effectively drain the abscess. Amputation is not appropriate as first-line treatment.
RECOMMENDED READINGS
26. McDonald LS, Bavaro MF, Hofmeister EP, Kroonen LT. Hand infections. J Hand Surg Am. 2011 Aug;36(8):1403-12. doi: 10.1016/j.jhsa.2011.05.035. Review. PubMed PMID: 21816297.
27. Osterman M, Draeger R, Stern P. Acute hand infections. J Hand Surg Am. 2014 Aug;39(8):1628-35; quiz 1635. doi: 10.1016/j.jhsa.2014.03.031. Review. PubMed PMID: 25070032.
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Appropriate treatment of an atrophic nonunion of the ulna includes open reduction and internal fixation with autogenous bone grafting. The atrophic nature of the nonunion reveals that biology, and not necessarily stability, is the major issue of the nonunion. The referenced article by Ring et al reviews a case series of these patients and found that even in the face of significant preoperative bone resorption, good clinical outcomes and union rate is possible with open plating and grafting. The article by Street reviews intramedullary nailing/pinning of the forearm, and found a 7% nonunion rate with this technique.

The clinical presentation and imaging studies are consistent with a tibial plateau fracture. Restoration of joint stability has been shown to be the strongest predictor of long term outcomes.
Honkonen reviewed 131 tibial condyle fractures and determined that articular stepoff <3mm and tibial widening <5mm did not negatively effect outcomes. In contrast, 70% of knees with moderate to severe malalignment went on to functionally unacceptable outcomes. They suggested operative fixation for all medial uni and bicondylar fractures, any lateral fractures with >5 degrees of
valgus tilt, >3mm of articular depression, >5mm of condylar widening, or >5 degrees of valgus malalignment.
In the Marsh et al JAAOS symposium review, the authors noted that fractures with up to 10mm of articular depression and joint stability obtained acceptable functional outcomes. They also cited a 20 year follow-up which indicated that articular step-off alone was not a predictor of poor long-term results. More importantly, when instability is present with other factors, including step-off and central depression, poor results followed.
Illustrations A and B show the intraoperative films. Illustration C reviews the Schatzker classification system.

The hallux varus seen in this patient is most likely the result of a combination of causes. Based on the degenerative changes and the significant shortening of the first metatarsal relative to the second metatarsal, a metatarsophalangeal arthrodesis is the treatment of choice. The other surgical approaches are not expected to provide a satisfactory result.
REFERENCES: Coughlin MJ, Mann RA: Adult hallux valgus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby-Year Book, 2000, pp 150-269.
Skalley TC, Myerson MS: The operative treatment of acquired hallux varus. Clin Orthop 1994;306:183-191.

Spontaneous partial reduction will occur when the patient becomes upright, and there is good remodeling potential due to growth.
C losed reduction and abduction cast is not necessary because of the patientâs age, remodeling potential, and range of motion available in the joint.
A formal attempt at closed reduction is not necessary because there is no way of holding it without internal fixation. This process will occur naturally to a large degree when the patient becomes upright.
Open reduction and percutaneous pin fixation poses a risk of pin tract infection because of the large amount of muscle traversed. This procedure is not necessary because of the good results with conservative treatment.

- Arthroscopic evaluation and fixation

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)

The sciatic nerve is the most commonly injured nerve during THA. Reported incidence is approximately 1.5% in large series; common causes include direct trauma, hematoma, and excessive leg lengthening. In the majority of cases, the peroneal division of the sciatic nerve is the portion that is affected. Authors have described an amount that is safe to lengthen the nerve. Some report this measurement in absolute length (centimeters), while other have reported it as a percentage of femur length in an effort to control for a patient’s height. Lengthening the nerve 10% of femur length has been determined to be safe.
RECOMMENDED READINGS
7. [DeHart MM, Riley LH Jr. Nerve injuries in total hip arthroplasty. J Am Acad Orthop Surg. 1999 Mar-Apr;7(2):101-11. Review. PubMed PMID: 10217818. ](http://www.ncbi.nlm.nih.gov/pubmed/10217818)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/10217818)
8. [Nercessian OA, Piccoluga F, Eftekhar NS. Postoperative sciatic and femoral nerve palsy with reference to leg lengthening and medialization/lateralization of the hip joint following total hip arthroplasty. Clin Orthop Relat Res. 1994 Jul;(304):165-71. PubMed PMID: 8020209. ](http://www.ncbi.nlm.nih.gov/pubmed/8020209)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/8020209)
RESPONSES FOR QUESTIONS 96 THROUGH 99
1. Proximal phalangeal osteotomy alone
2. Proximal metatarsal osteotomy with a modified McBride procedure
3. Distal metatarsal osteotomy with a modified McBride procedure
4. First tarsometatarsal fusion with a modified McBride procedure
5. First metatarsophalangeal fusion
Please choose the most appropriate surgical treatment listed above to address each clinical scenario seen in the radiographs below.

A comminuted proximal ulnar fracture is often plated in a shortened position, forcing the radial head into a nonanatomical position. Attempted reduction and pin fixation without addressing the length of the ulna often results in failure, even with a ligament reconstruct. Radial head excision is a salvage procedure. A helpful technique for comminuted proximal ulna fractures is to first pin the radial head in a reduced position and then plate the ulnar out to length.
RECOMMENDED READINGS
15. Heim U. [Combined fractures of the radius and the ulna at the elbow level in the adult. Analysis of 120 cases after more than 1 year]. Rev Chir Orthop Reparatrice Appar Mot. 1998 Apr;84(2):142-53. Review. French. PubMed PMID: 9775058.
16. Morrey BF: Surgical exposures of the elbow. In Morrey BF, ed. The Elbow and its Disorders. 2nd ed. Philadelphia, PA: WB Saunders, 1993:139-166.
17. Ring D, Jupiter JB. Reconstruction of posttraumatic elbow instability. Clin Orthop Relat Res. 2000 Jan;(370):44-56. Review. PubMed PMID: 10660701.
18. Ring D, Jupiter JB, Waters PM. Monteggia fractures in children and adults. J Am Acad Orthop Surg. 1998 Jul-Aug;6(4):215-24. Review. PubMed PMID: 9682084.
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Found in necrotizing fasciitis, Meleneyâs infection is a spreading ulcer rimmed with gangrenous skin. The affected area must be debrided immediately. C ultures are taken at the time of surgery to tailor antibiotic coverage. Amputation is not unusual to control the spread of the gangrenous infection.

The timing of definitive fixation of tibial plateau fractures in patients with fasciotomies has no impact on infection risk.
The incidence of compartment syndrome is high in tibial plateau fractures. In the presence of tense anterior and lateral tibial compartments, combined with pain with passive stretch of involved muscles or unrelenting pain, compartment pressures should be measured and fasciotomies performed when necessary.
Schatzker type V and VI fractures are more likely to have this potential complication. Examination of leg compartments should be repeated at regular intervals because compartment syndrome may occur 24 hours or more after injury.
Zura et al. performed a study to analyze whether there is an association between infection and the timing of definitive fracture fixation in relation to fasciotomy closure or coverage. They found that no statistical difference in the rate of infection when tibial plateau fractures with four-compartment fasciotomies were treated with open reduction and internal fixation before fasciotomy closure, at fasciotomy closure, or after fasciotomy closure. They conclude that timing of definitive fracture treatment can be determined by the medical condition of the patient.
Shah et al. performed a retrospective chart review of all bicondylar tibial plateau fractures that had fixation with two incisions. They reported an infection rate of 13.8% which is lower than historical reports. They concluded that the lower infection rate was due to their treatment algorithm that requires recovery of the soft tissue envelope prior to definitive fixation.
Figure A demonstrates a bicondylar tibial plateau fracture. Figure B demonstrates fixation of a tibial plateau fracture through a dual plating technique.
Incorrect Answers:
Answers 1, 2, 3, and 4 are incorrect as infection risk is unchanged with timing of definitive fracture fixation.

Patients recover the ability to safely operate the brakes of an automobile 9 weeks following operative repair of an ankle fracture. Because this patient is currently 8 weeks out from surgery, his braking time will be expected to return to normal one week from now.
Egol et al studied the time braking ability returns to normal in patients with operatively treated ankle fractures. Patients were studied at 6, 9, and 12 weeks postoperatively and compared to healthy controls. It was determined that total braking time returned to normal by 9 weeks.

DISCUSSION: The radiographs and clinical photographs reveal a child with posteromedial bowing of the tibia. This is a congenital anomaly that is associated with a calcaneal valgus foot. It is a relatively benign condition. The severity of the bow diminishes with time; however, the child will be left with a limb-length discrepancy, usually in the range of 4 cm. The residual limb- length discrepancy presents the greatest challenge for orthopaedic management. This, however, can usually be handled with limb- lengthening techniques. Casting can be used for severe cases with unresolving significant contracture; however, gradual spontaneous correction is usually the norm. This condition is quite different from anterior lateral bowing that can be associated with neurofibromatosis and pathologic fracture or pseudoarthrosis of the tibia.
REFERENCES: De Maio F, Corsi A, Roggini M, et al: Congenital unilateral posteromedial bowing of the tibia and fibula: Insights regarding pathogenesis from prenatal pathology. A case report. J Bone Joint Surg Am 2005;87:1601-1605.
Schoenecker PL, Rich MM: The lower extremity in pediatric orthopaedics, in Morrissy RT, Weinstein SL (eds): Love**l** and Winter’s Pediatric Orthopaedics, ed 6. Philadelphia, PA, Lippincott, Wi**l** iams and Wilkins, 2006, pp 1198-1200.

46 • American Academy of Orthopaedic Surgeons
Figure 54a Figure 54b

This patient's history and physical findings are concerning for deep infection. Inflammatory markers, including ESR and CRP, should be obtained first. If the levels are elevated, knee aspiration should be performed for the synovial cell count and culture. A bone scan is not indicated in an initial investigation for deep infection; it is rarely helpful and is not cost effective. CT to assess implant rotation is an appropriate investigation for knee pain when the clinical scenario is not suspicious for a deep infection
and when infection has been excluded.

These are important concepts when balancing the knee following total knee replacement.
The distal femoral cut only effects the extension gap.
The proximal tibia cut effects the flexion and extension gaps. The posterior femoral condyle cut effects the flexion only.
Attention to these principles is very important to prevent both contractures and flexion instability. Correct Answer: The distal femoral cut only effects the extension gap.

There are a number of risk factors for stress fractures:
A. Menstrual irregularity in women is perhaps the most significant risk factor.
1/. Remember the terrible triad in female patients:
a. Menstrual irregularity b. Eating disorders
c. Low bone mass
B. Increase in frequency and intensity of athletic training or activity
C . C hanges in athletic training are noted in 80% of athletes surveyed who have stress fractures. D. Decreased tibial width (smaller bone size)
E. Factors that have not been found to be statistically significant include:
1/. Testosterone levels in male athletes
2/. Age
a. Location by age is significant, but not etiology
3/. Training surfaces
4/. Flexibility
5/. Low calcium intake
C orrect Answer: Increase in frequency and intensity of training

DISCUSSION: There is legal precedent for banning a scholarship athlete from participation in college

athletics if the physician feels that it presents a significant physical risk to the athlete. The courts have decided that the athlete has no constitutional right to participate in NCAA sports, and as a team physician you must advise your athlete and the school as to the best course of action. The athlete must be allowed to keep his or her college scholarship.
REFERENCES: Klossner D: NCAA Sports Medicine Handbook, ed 18. Indianapolis, IN, National Collegiate Athletic Association, 2007.
Pearsall AW IV, Kovaleski JE, Madanagopal SG: Medicolegal issues affecting sports medicine practitioners. Clin Orthop Relat Res 2005;433:50-57.

The results of elbow dislocations with associated radial head and coronoid fractures are often poor because of recurrent instability and/or stiffness from prolonged immobilization. Therefore radial head replacement and open reduction internal fixation of the coronoid is the most appropriate treatment.
Pugh et al reported their experiences with this difficult population. Their protocol consisted of ORIF or replacement of the radial head, ORIF of the coronoid fracture, repair of the LCL and capsule, and repair of the MCL and/or hinged external fixation. Of the 36 cases, the outcome was graded as 28 excellent to good, 7 fair, and 1 poor. 8 cases required re-operation. The authors concluded that their surgical protocol restored sufficient elbow stability to allow early motion post-op, thereby enhancing the functional outcome. In fracture dislocation of the elbow with radial head and coronoid fracture, the radial head must be fixed or replaced to restore stability. The ORIF of coronoid fracture and radial head restores some valgus stability therefore MCL repair may not be needed. However, the varus stability must be restored by LCL repair.

Radial deficiencies are often seen in the later association. which may include cardiac,renal,anorectal and tracheoesphogeal abnormalities.

Chronic opioid consumption prior to total joint arthroplasty has been associated with increased pain after surgery, increased opioid requirements, a slower recovery and longer hospital stay, and higher 90-day postoperative complications compared with patients not on chronic opioids preoperatively. Based on this information, Nguyen and associates performed a study in three patient groups that included 1) chronic opioid users who underwent no preoperative intervention, 2) chronic opioid users who were weaned down to 50% of their prior opioid regimen, and 3) patients who were not chronic opioid users. The authors found that the reduction of preoperative opioid use improved postoperative function, pain, and recovery and that the weaned group performed more like the opioid naive group than the chronic opioid user
group. Increasing opioid use prior to surgery in this patient would make it more difficult to control pain after surgery. Stopping all of his opioids just prior to surgery would place the patient at substantial risk for opioid withdrawal and is not recommended. Avoiding the use of all narcotics and using only acetaminophen postoperatively is very unlikely to provide appropriate pain relief in a chronic opioid user. The recommendation based on the provided literature is to decrease the patient's narcotic use prior to
surgery.

Several studies have reported an increased incidence of stress fractures in female athletes, including fractures of the foot and ankle in runners. The
female athlete triad describes a condition involving decreased bone density, anorexia, and amenorrhea. In addition to asking about this woman's exercise routine, the orthopaedic surgeon should obtain a comprehensive menstrual and dietary history in the context of multiple stress fractures. A review of genetics, rheumatology, and cardiovascular disorders is less likely to generate an etiology.
RECOMMENDED READINGS
Kasser JR, ed. Orthopaedic Knowledge Update 5: Home Study Syllabus. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1996:96-99.
Arendt EA. Osteoporosis in the athletic female: Amenorrhea and amenorrheic osteoporosis. In: Pearl AJ, ed. AOSSM: The Athletic Female. Champaign, IL: Human Kinetics; 1993:41-59. Brukner PD, Khan KM. Clinical Sports Medicine. Sydney: McGraw-Hill; 1991:17.
RESPONSES FOR QUESTIONS 10 THROUGH 13
1. Ankle replacement
2. Ankle fusion
3. Tibiotalocalcaneal fusion
4. Total contact cast
5. Intra-articular steroid injection
Match the appropriate treatment listed above with the patient scenario described below.

Criteria for spinal instability have been outlined by the Spine Oncology Study Group, which developed the Spinal Instability Neoplastic Score (SINS) criteria. Factors associated with lower risk for instability/fracture are location outside of a junctional level (the SINS criteria use C7-T2 as the junctional level),
blastic metastases, and no evidence of vertebral collapse (even with more than 50% involvement). Radiation has been associated with risk for pathologic fracture, and stereotactic radiation has been associated with risk for a spinal fracture.
RECOMMENDED READINGS
Fisher CG, DiPaola CP, Ryken TC, Bilsky MH, Shaffrey CI, Berven SH, Harrop JS, Fehlings MG, Boriani S, Chou D, Schmidt MH, Polly DW, Biagini R, Burch S, Dekutoski MB, Ganju A, Gerszten PC, Gokaslan ZL, Groff MW, Liebsch NJ, Mendel E, Okuno SH, Patel S, Rhines LD, Rose PS, Sciubba DM, Sundaresan N, Tomita K, Varga PP, Vialle LR, Vrionis FD, Yamada Y, Fourney DR. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976). 2010 Oct 15;35(22):E1221-9. doi: 10.1097/BRS.0b013e3181e16ae2. Review. PubMed
[PMID:20562730. ](http://www.ncbi.nlm.nih.gov/pubmed/20562730)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/20562730)
[Fourney DR, Frangou EM, Ryken TC, Dipaola CP, Shaffrey CI, Berven SH, Bilsky MH, Harrop JS, Fehlings MG, Boriani S, Chou D, Schmidt MH, Polly DW, Biagini R, Burch S, Dekutoski MB, Ganju A, Gerszten PC, Gokaslan ZL, Groff MW, Liebsch NJ, Mendel E, Okuno SH, Patel S, Rhines LD, Rose PS, Sciubba DM, Sundaresan N, Tomita K, Varga PP, Vialle LR, Vrionis FD, Yamada Y, Fisher CG. Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group. J Clin Oncol. 2011 Aug 1;29(22):3072-7. doi:10.1200/JCO.2010.34.3897. Epub 2011 Jun 27. PubMed PMID: 21709187. ](http://www.ncbi.nlm.nih.gov/pubmed/21709187)[View Abstract](http://www.ncbi.nlm.nih.gov/pubmed/21709187)[ ](http://www.ncbi.nlm.nih.gov/pubmed/21709187)[at ](http://www.ncbi.nlm.nih.gov/pubmed/21709187)[PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21709187)
Rose PS, Laufer I, Boland PJ, Hanover A, Bilsky MH, Yamada J, Lis E. Risk of fracture after single fraction image-guided intensity-modulated radiation therapy to spinal metastases. J Clin Oncol. 2009 Oct 20;27(30):5075-9. doi: 10.1200/JCO.2008.19.3508. Epub 2009 Sep 8.
[PubMed PMID: 19738130 ](http://www.ncbi.nlm.nih.gov/pubmed/19738130)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19738130)

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Osteoclasts are derived from cells of the monocyte/macrophage lineage. They are multinucleated and develop by fusion of mononuclear precursors, a process that requires receptor activator for nuclear factor kappa-B ligand (RANKL) and macrophage-colony stimulating factor (M-CSF). RANKL is secreted by osteoblasts in response to inflammatory signals and is a key component of inflammation-mediated osteolysis. OPG binds to and sequesters RANKL, thus inhibiting osteoclast differentiation and activity.
BMP and IGF-1 are potent regulators of osteoblast differentiation and activation. TNF is a cytokine secreted by macrophages and degranulating platelets infiltrated in the fracture site and impacts a variety of cells, not osteoclasts.

Proximal tibial osteotomy is the most appropriate intervention to correct varus malalignment and to reduce stress on the ACL. In some cases, proximal tibial osteotomy alone may address both pain and instability, but if instability persists, particularly in the setting in which instability can be dangerous, subsequent ACL reconstruction can further stabilize the knee with less stress on the graft after the correction of malalignment.
29
Varus alignment places increased stress on the native or reconstructed ACL. ACL reconstruction should be performed only at the same time as or following proximal tibial osteotomy to correct alignment in the setting of varus malalignment. It is not appropriate to perform ACL reconstruction prior to proximal tibial osteotomy in this setting. Distal femoral osteotomy is not indicated to correct varus malalignment. Varus alignment places increased stress on the native or reconstructed ACL, and ACL reconstruction alone is not indicated for this patient.
A patient has pain 2 years after undergoing a metal-on-metal (MOM) left total hip arthroplasty (THA). Which test(s) best correlate with prognosis in the setting of reaction to metal debris?
A. Erythrocyte sedimentation rate, C-reactive protein, and white blood cell count
B. Serum cobalt and chromium ion levels
C. MRI with metal artifact reduction sequence (MARS)
D. CT of pelvis
Painful MOM THA and taper corrosion can cause substantial damage to a patient's hip if left untreated. In this case, the workup for a painful MOM THA starts the same as a workup for a painful metal-on-polyethylene bearing couple. Infection must be ruled out in every case with a set of inflammatory markers. If these markers are remotely elevated, this is an indication for joint aspiration. In patients with metal debris, the pathology report often indicates too many cells to count or cellular debris. Metal ion levels do not seem to correlate with prognosis. There are well-functioning patients with high ion levels and poor-functioning patients with low ion levels. Advanced imaging with MARS MRI to evaluate for peritrochanteric fluid collection, a soft-tissue mass, or synovial/capsular hypertrophy will reveal signs of a metal reaction that indicate the need for a revision discussion. A CT scan can show more advanced bony destruction as an indicator of poor prognosis. These films can be used to determine the need for a structural graft or augments for reconstruction of bone loss attributable to metal debris.
Correct answer : C
30

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.

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Complication rates for percutaneous interventional procedures are low (1-2%). Potential risks for epidural injections include dural injury, cerebrospinal fluid leak, infection, nerve puncture, intrathecal injection, and intravascular injection. Furman and associates reported 8% incidence of inadvertent vascular puncture from lumbar transforaminal injection. In this patient, there was injection into an L2 radiculomedullary artery, which ultimately caused catastrophic spinal cord ischemia and infarction. The dominant radiculomedullary artery, artery of Adamkiewicz, is the major blood supply for the anterior cord. Adamkiewicz enters the cord on the left from T9 to L2 level in 85% of people. The MRI scan shown, taken 48 hours after injury, indicates classic cord infarction with hyperintense cord signal on sagittal film. The axial image also shows hyperintense signal, predominantly in the gray matter with "owl's eye" pattern. Epidural hematoma would show a high T2 signal extradural compressive lesion on MRI. Intravenous injections are rarely dangerous. L2 nerve injury from a puncture would cause unilateral L2 nerve pain (dysesthesia), hypoesthesia, and/or palsy.

Prevalence of flexor tendon rupture after distal radius fracture is between 2% and 12%. The FPL tendon is the most common flexor tendon rupture associated with volar plating. It is usually seen with plates that are distal to the watershed line (W) and with plates extending volar to the critical line (C) (Figure below). The watershed line (W) is the location of the origin of the volar carpal ligaments and the bone prominence

---

at which flexor tendons are most closely opposed to the distal radius (Figure 4). In this scenario, the lateral radiograph shows that the plate is not distal to the watershed line (W) and is between the critical line (C) and the line parallel to the volar cortex of the radius (R). This is the optimal position for the plate. Placement of a volar locking plate distal to the watershed line of the distal radius and excessive plate prominence has been associated with FPL tendon rupture. This patient is only 2 weeks past surgery and there is some FPL function. FPL weakness after volar distal radius plating is common and has been seen in as many as 50% of patients. This usually recovers spontaneously by 2 months, and no treatment is needed. A nerve conduction study would be indicated if an anterior interosseous nerve compression were considered, but it is too early for this test. A CT scan could be obtained to judge the alignment of the fracture fragment and position of the screws, but it is not indicated in this case. Exploration could be performed if an FPL rupture were considered, but, because it is only 2 weeks after surgery, there is some FPL function, the plate is proximal to the watershed line, and immediate exploration is not indicated. If this does not improve after 2 to 3 months, further investigation with ultrasound or MRI would be indicated.

The complication rate after routine wrist arthroscopy is between 2% and 5%.

Normal lactate levels or base excess indicate adequate tissue perfusion.
Hypovolemic shock leads to poor tissue perfusion due to inadequate flow or oxygenation. If a patient is in compensated shock (i.e. normal vital signs), there may be ongoing inadequate perfusion of some end-organs. Elevated lactate or a base deficit are markers of poor end-organ perfusion, thus when normalized indicate appropriate end-organ perfusion even if vital sign derangements persist.
Rossaint et al. wrote a comprehensive review article in 2006 in which they discuss principles of fluid management, coagulopathy, hypothermia and tissue oxygenation in hypovolemic shock. In addition to prolonged elevated lactate levels correlating to mortality, lactate levels (or base deficits) can be used to evaluate for compensated shock in the setting of normal hemodynamic status.
Illustration A shows the classification of hypovolemic shock. Note the percent of blood loss required for vital sign abnormalities.
Incorrect Answers:
Answer 1: While an arterial line is often helpful in the setting of
uncompensated hemodynamic shock, it would not be as important as measures of adequate tissue perfusion for ruling out compensated shock. Answer 2: The hematocrit is expected to stay normal for a short time even in the setting of massive blood loss. The hematocrit only changes once the patient has physiologic or iatrogenic fluid shifts in response to the blood loss. Answer 3: Vital sign derangements indicate uncompensated shock, but do not directly measure tissue perfusion or end-organ damage
Answer 5: Though uncommon, bleeding from isolated femur fractures can lead to Class II shock (blood loss 15-30%)

Measurements of compartment pressures in patients with tibial fractures and compartment syndrome reveal that the highest tissue pressures are recorded at the level of the fracture or within 5 cm of the fracture. Tissue pressures show a statistically significant decrease when they are recorded at increasing distances proximal and distal to the site of the highest pressure recorded. To reliably determine the location of the highest tissue pressure in patients with tibial fractures, measurements should be obtained, at a minimum, in both the anterior and deep posterior compartments at the level of the fracture, as well as at locations proximal and distal. The highest tissue pressure recorded should serve as a basis for determining the need for fasciotomy.
REFERENCES: Heckman MM, Whitesides TE Jr, Grewe SR, Rooks MD: Compartment pressure in association with closed tibial fractures: The relationship between tissue pressure, compartment, and the distance from the site of the fracture. J Bone Joint Surg Am 1994;76:1285-1292.
Whitesides TE Jr, Heckman MM: Acute compartment syndrome: Update on diagnosis and treatment. J Am Acad Orthop Surg 1996;4:209-218.

In multiple studies, femoral intramedullary reaming debris has been shown to have similar biochemical characteristics as iliac crest autograft. Intramedullary reaming products have osteogenic potential with viable cells while BMP's are osteoinductive cytokines.
Hoegel et al found that the reamings had alkaline phospatase activity, indicating living osteoblasts. The amount of activity was independent of the reamer sizes and reamer design.
Frolke et al concluded that reaming debris supports callus building (healing) as much as conventional iliac crest bone grafting in an animal fracture gap model.
The video shows a retrograde femoral autograft harvest using the RIA system.

The PA view of the wrist shows a pisiform fracture. Pisiform fractures constitute 1% to 3% of all carpal bone fractures. This fracture can be further evaluated with a carpal tunnel view or a supination oblique view of the wrist. Initial management should consist of immobilization with a short arm cast. If nonsurgical measures fail, bony excision is warranted.
REFERENCES: Failla JM, Amadio PC: Recognition and treatment of uncommon carpal fractures. Hand Clin 1988;4:469-476.
Botte MJ, Gelberman RH: Fractures of the carpus, excluding the scaphoid. Hand Clin 1987;3:149-161.

Controversy persists over what exactly is the best approach to managing patients with metal-on-metal (MOM) hip arthroplasties. All patients with painful MOM hip arthroplasties should be examined for fixation loosening, wear/osteolysis, and infection—no differently than patients without MOM hip arthroplasties. It is recommended to obtain serum trace element levels. If the levels are high, cross- sectional imaging should be obtained to determine whether any pseudotumor or tissue necrosis is present around the hip arthroplasty. Hip aspiration should be considered if concern for infection exists. Adverse tissue reaction has been identified to occur around MOM hip arthroplasties. The predominant histologic
feature is tissue necrosis with infiltration of lymphocytes and plasma cells.

DISCUSSION: The patient has a large valgus deformity and flexion contracture that places her at increased risk for peroneal nerve injury. The peroneal nerve is tethered at the fibular head and correction of her valgus deformity and flexion contracture at the time of total knee arthroplasty can stretch the nerve, leading to peroneal nerve palsy.

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 147155.
Asp JP, Rand JA: Peroneal nerve palsy after total knee arthroplasty. Clin Orthop Relat Res 1990;261:233- 237. Schinsky MF, Macaulay W, Parks ML, et al: Nerve injury after primary total knee arthroplasty. J Arthroplasty 2001; 16:1048-1054.

Figure 33a Figure 33b

Traditionally, recurrence rates associated with open stabilization procedures have been lower than rates associated with arthroscopic repair. Recent studies show that for patients without significant bone loss, however, the recurrence rate is the same for open and arthroscopic surgeries.

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DISCUSSION:
Some authors have reported the incidence of lateral femoral cutaneous nerve neuropraxia following hip arthroplasty with the direct anterior approach to be near 80%, but resolution of the sensory deficits has been observed in most patients over time. Femoral nerve palsy has been reported to occur in .64% to 2.3% direct lateral (Hardinge) and anterolateral (Watson-Jones) approaches, and the superior gluteal nerve may be injured with proximal extension of the abductor muscular dissection. The posterior approach has been reported to be associated with sciatic nerve injury, especially in cases of dysplasia. Pudendal nerve injury has not been reported with the anterior, anterolateral, direct lateral, or posterior approaches to hip
arthroplasty. It has been reported following hip arthroscopy and the use of a traction table, however.

Intervertebral disk degeneration has been associated with a progressive decrease in proteoglycan content of nucleus pulposus. The potential application of gene therapy for prevention of disk degeneration is to increase or maintain the proteoglycan content of nucleus pulposus. Thompson and colleagues reported that addition of TGF-Ã1 to canine disk tissue in culture stimulated in vitro proteoglycan synthesis

The recognized treatment for a proximal periprosthetic fracture is to first identify the extent and then optimize the correction of the fracture. Several studies indicate that proximal cerclage wiring is adequate to create "barrel hoop" stability of the proximal femur. Braided cables offer superior stability compared with twisted wires or Luque wires. Finally, the appropriate postoperative treatment is protected
weight bearing for 6 weeks, with periodic radiographs taken at 2-week intervals. Other options such as
cementing the femoral stem and using a revision arthroplasty device are indicated for unstable fractures.

Salter Harris III and IV fractures of the medial malleolus often contain a large cartilaginous portion, larger than the apparent ossified fragment seen on radiographs. Consequently, articular incongruity is common. As such, open reduction and internal fixation is often required. Growth disturbance and angular deformity are also common complications of Salter Harris III and IV fractures of the distal tibia.
REFERENCES: Flynn JM, Skaggs DL, Sponseller PD, et al: The surgical management of pediatric fractures of the lower extremity. Instr Course Lect 2003;52:647-659.
Kay RM, Matthys GA: Pediatric ankle fractures: Evaluation and treatment. J Am Acad Orthop Surg 2001;9:268-278.

DISCUSSION: Noninvasive cardiac testing is recommended in the presence of the three or more of the following risk factors in a sedentary patient: history of coronary artery disease or myocardial infarction, history of heart failure, prior cerebrovascular accident, and diabetes mellitus or chronic renal disease. Preoperative stress testing is not recommended if patients can perform moderate activities such as climbing a flight of stairs.

REFERENCES: Bushnell BD, Horton JK, McDonald MF, et al: Perioperative medical comorbidities in the orthopaedic patient. J Am Acad Orthop Surg 2008;16:216-227.
Auerback A, Goldman L: Assessing and reducing the cardiac risk of noncardiac surgery. Circulation 2006;113:1361-1376.
Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, pp 105-113.

Figure 28

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._

Anterior dislocation is the most common type of sternoclavicular dislocation. The medial end of the clavicle is displaced anterior or anterosuperior to the anterior margin of the sternum. In a study by Omer, 31% of athletic injuries have been known to cause a dislocation of the sternoclavicular joint. The serendipity view can show this dislocation, as will CT of the chest. This view requires the x-ray beam to be aimed at the manubrium with 40 degrees of cephalic tilt. An anterior sternoclavicular joint dislocation will appear superiorly displaced, while a posterior sternoclavicular joint dislocation is inferiorly displaced on the serendipity view.
REFERENCES: Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, pp 566-572.
Omer GE Jr: Osteotomy of the clavicle in surgical reduction of anterior sternoclavicular dislocation. J Trauma 1967;7:584-590.

Prompt tick removal is recommended because Lyme disease is more likely if the tick is attached for more than 24 hours. Immediate antibiotic administration is not recommended because the incidence of Lyme disease is low after any single tick bite and treatment is equally effective once the disease is diagnosed. Doxycycline is not recommended in children younger than 8
years old because of dental discoloration. Immediate testing for antibodies (ELISA) is not useful because antibodies do not rise for at least several weeks. Steroids are not recommended in this setting.

DISCUSSION: Tension forces in the healthy, as well as the reconstructed, anterior cruciate ligament were measured and found to be highest with the knee in full extension and decreased as the flexion increased.

Scientific References

: Markolf KL, Burchfield DM, Shapiro MM, et al: Biomechanical consequences of replacement of the anterior cruciate ligament with a patellar ligament allograft. Part II: Forces in the graft compared with forces in the intact ligament. J Bone Joint Surg Am 1996;78:1728-1734.
Beynnon BD, Johnson RJ, Fleming BC, et al: The measurement of elongation of anterior cruciate-ligament grafts in vivo. J Bone Joint Surg Am 1994;76:520-531.
83/. Compared to eumenorrheic athletes, amenorrheic athletes have more frequent occurrences of

A significant malunion of the distal tibia has important consequences for patient outcome, including pain, gait changes, and cosmesis.
The first referenced article by Milner et al looked at long-term outcomes of tibial malunions and noted that varus malunion led to increased ankle/subtalar stiffness and pain regardless of the amount of radiographic degenerative changes.
The second referenced article by Puno et al reinforced the concept of decreased functional outcomes of the ankle with tibial malunions, and noted
that other lower extremity joints (ipsilateral and contralateral) do not have increased rates of degeneration from such a malunion.

The radiographic and clinical findings suggest a scapulothoracic dissociation with a widely displaced clavicular fracture and a laterally displaced scapula. These injuries have a high association with neurovascular injuries to the brachial plexus and subclavian artery. Emergent vascular evaluation with arteriography and possible vascular repair are indicated. This repair can be combined with open reduction and internal fixation of the clavicle to improve stability. Delay in treatment of these vascular injuries can be devastating.
REFERENCES: Iannotti JP, Williams GR (eds): Disorders of the Shoulder. Philadelphia, PA, Lippincott, 1999, pp 632-635.
Ebraheim NA, An HS, Jackson WT, et al: Scapulothoracic dissociation. J Bone Joint Surg Am 1988;70:428-432.