2011 Annual Meeting San Diego, California

ORTHOPAEDIC REVIEW COURSE David L. Skaggs, MD

Course Chairman

Friday, February 18, 2011 Hilton Bay Front

Sapphire Ballroom

DISCLAIMER The material presented at this course has been made available by the American Academy of Orthopaedic Surgeons for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed, but rather is intended to present an approach, view, statement or opinion of the faculty, which may be helpful to others who face similar situations. The AAOS disclaims any and all liability for injury or other damages resulting to any individual attending the course and for all claims, which may arise from the use of techniques, demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. No reproductions of any kind, including audiotapes and videotapes, may be made of the presentations at the Academy’s Annual Meeting. The Academy reserves all of its rights to such material, and commercial reproduction is specifically prohibited. FDA STATEMENT Some drugs or medical devices demonstrated at the Annual Meeting have not been cleared by the FDA or have been cleared by the FDA for specific purposes only. The FDA has stated that it is the responsibility of the physician to determine the FDA clearance status of each drug or medical device he or she wishes to use in clinical practice. Academy policy provides that “off label” uses of a device or pharmaceutical may be described in the Academy’s CME activities so long as the “off-label” status of the device or pharmaceutical is also specifically disclosed (i.e. that the FDA has not approved labeling the device for the described purpose). Any device or pharmaceutical is being used “off label” if the described use is not set forth on the product’s approved label. DISCLOSURE Each participant in the Annual Meeting is required to disclose if he or she has received something of value from a commercial company or institution, which relates directly or indirectly to the subject of their presentation: The Academy has identified the options to disclose as follows: The numbers after the name are identified as 3-royalties; 4-speakers bureau/paid presentations; 5a-paid consultant or employee; 5b-unpaid consultant; 7-research or institutional support has been received; 8-stock or stock options; 10-miscellaneous non-income support (e.g. equipment or services); n-no conflicts to disclose. The Academy does not view the existence of these disclosed interests or commitments implying bias or decreasing the value of the author’s participation in the meeting.

American Academy of Orthopaedic Surgeons

ORTHOPAEDIC REVIEW COURSE Friday, February 18, 2011 San Diego Bayfront Hotel

Sapphire Ballroom Course Chairman: David L. Skaggs, MD

8:00-10:00 AM Lower Extremity Moderator: Thomas S. Thornhill, MD 8:00 AM Hip and Knee Reconstruction Thomas S. Thornhill, MD 8:30 AM Sports Knee James P. Bradley, MD 9:00 AM Foot and Ankle Steven L. Haddad, MD 9:30 AM Trauma Donald A. Wiss, MD 10:00-10:15 AM STRETCH BREAK 10:15 AM-12:00 PM Upper Extremity Moderator: Marc Safran, MD 10:15 AM Hand and Wrist Jeffrey A. Greenberg, MD 10:50 AM Forearm and Elbow Rick F. Papandrea, MD 11:25 AM Shoulder and Humerus Marc Safran, MD 12:00-12:50 PM LUNCH (box lunch included) 12:50-2:50 PM Pediatrics Moderator: Lori A. Karol, MD 12:50 PM Hip William C. Warner Jr., MD 1:20 PM Infection, Congenital, Developmental Problems/Miscellaneous Jeffrey R. Sawyer, MD 1:50 PM Fractures of the Upper and Lower Extremities John M. Flynn, MD 2:20 PM Lower Extremity Lori A. Karol, MD

2:50-3:00 PM STRETCH BREAK 3:00-4:30 PM Spine Moderator: David L Skaggs, MD 3:00 PM Trauma Jens R. Chapman, MD 3:30 PM Degenerative Todd J Albert, MD 4:00 PM Pediatric David L Skaggs, MD 4:30-4:40 PM STRETCH BREAK

4:40-5:40 PM Tumors and Metabolic Bone Disease Moderator: Albert J. Aboulafia, MD 4:40 PM Tumors Albert J. Aboulafia, MD 5:10 PM Metabolic Bone Disease Joseph M. Lane, MD 5:45 PM Adjourn

Session: 490A-E

Session Title: Orthopaedic Review Course

Location: Hilton Bayfront

Date and Time: February 15, 8:00 AM

Orthopaedic Review Course - Lower Extremity

NOTE: This output does not display responses to all questions (see footnote) and only looks at data after 3/5/2010 in the new disclosure program).

• James P Bradley, MD: 1 ( Arthrex, Inc);5 (Arthrex, Inc); Submitted on: 05/27/2010 and last confirmed as accurate on 09/24/2010. *

• Steven L Haddad, MD: 2 (Stryker); 3B (Wright Medical Technology, Inc.); 3C (OrthoHelix Surgical Designs); 4 (OrthoHelix Surgical Designs); 5 (Biomimetic); Submitted on: 10/10/2010. *

• Thomas S Thornhill, MD: 1 (DePuy, A Johnson & Johnson Company);3B (DePuy, A Johnson & Johnson Company);3C (Scientific Advisory Board of Conformis);4 (Conformis);7 (Up to Date); Submitted on: 03/14/2010. *

• Donald A Wiss, MD: (n) Submitted on: 09/27/2010 and last confirmed as accurate on 11/29/2010. *

Orthopaedic Review Course - Upper Extremity

• Jeffrey A Greenberg, MD: 3B (Stryker);5 (Acumed, LLC); Submitted on: 10/14/2010. *

• Rick F Papandrea, MD: 2 (Acumed, LLC; Exactech, Inc);3B (Acumed, LLC; Exactech, Inc); Submitted on: 05/26/2010 and last confirmed as accurate on 09/12/2010. *

• Marc Safran, MD: 1 (Stryker);3B (Cool Systems, Inc; Arthrocare);3C (Cool Systems, Inc Cradle Medical, Inc Ferring Pharmaceuticals Biomimedica);4 (Cool Systems, Inc Cradle Medical, Inc Biomimedica);5 (Ferring Pharmaceuticals);7 (Wolters Kluwer Health - Lippincott Williams & Wilkins; Saunders/Mosby-Elsevier); Submitted on: 10/13/2010 and last confirmed as accurate on 12/18/2010. *

Orthopaedic Review Course - Pediatrics

• John M Flynn, MD: 1 (Biomet);7 (Wolters Kluwer Health - Lippincott Williams & Wilkins); Submitted on: 10/21/2010. *

• Lori A Karol, MD: 7 (Journal of the American Academy of Orthopaedic Surgeons; Saunders/Mosby-Elsevier); Submitted on: 09/13/2010. *

• Jeffrey R Sawyer, MD: 3B (Synthes);3C (Medtronic); Submitted on: 09/13/2010. *

• William C Warner Jr, MD: 3C (Medtronic Sofamor Danek);7 (Saunders/Mosby-Elsevier); Submitted on: 06/21/2010 and last confirmed as accurate on 11/05/2010. *

Orthopaedic Review Course - Spine

• Todd J Albert, MD: 1 (DePuy, A Johnson & Johnson Company); 3B (DePuy, A Johnson & Johnson Company); 4 (Bioassets; Biomerix; Breakaway Imaging; Crosstree; Gentis; International Orthopaedic Alliance; Invuity; Paradigm Spine; PIONEER; Reville Consortium; Vertech); 6 (United Healthcare); 7 (Saunders/Mosby-Elsevier; Thieme); Submitted on: 09/01/2010 and last confirmed as accurate on 09/09/2010. *

• Jens R Chapman, MD: 2 (Synthes);5 (Medtronic; Stryker); Submitted on: 09/23/2010. *

• David Lee Skaggs, MD: 2 (Medtronic; Stryker);3B (Medtronic; Stryker);7 (Wolters Kluwer Health - Lippincott Williams & Wilkins); Submitted on: 09/15/2010. *

Orthopaedic Review Course - Tumor/Metabolic Disease

• Albert J Aboulafia, MD: 7 (AAOS); Submitted on: 05/27/2010 and last confirmed as accurate on 09/27/2010. *

• Joseph M Lane, MD: 2 ( Eli Lilly; Harvest Technologies, Inc. Novartis, Weber Chilcott );3B (Amgen Co; Biomimetic; Zimmer, DFine, Inc, Graftys SA, ; Eli Lilly, Bone Therapeutics, Inc. Innovative Clinical Solutions, Zelos, Inc., Kuros, Inc.); Submitted on: 09/28/2010. *

• NOTE: Disclosures do not display responses to questions 8 and 9 (i.e., one of those items may be 'yes,' but is not evaluated or listed).

* Disclosure Items Answered: (n) = Respondent answered 'No' to all items indicating no conflicts. 1= Royalties from a company or supplier; 2= Speakers bureau/paid presentations for a company or supplier; 3A= Paid employee for a company or supplier; 3B= Paid consultant for a company or supplier; 3C= Unpaid consultant for a company or supplier; 4= Stock or stock options in a company or supplier; 5= Research support from a company or supplier as a PI; 6= Other financial or material support from a company or supplier; 7= Royalties, financial or material support from publishers.

AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS ORTHOPAEDIC REVIEW COURSE FACULTY

FRIDAY, FEBRUARY 18, 2010 SAN DIEGO HILTON BAYFRONT, SAPPHIRE BALLROOM

Albert J. Aboulafia, MD Life Bridge Health Lapidus Cancer Institute Medical School: University of Michigan Medical School, Ann Arbor Residency: University of Southern California Medical Center – LAC Fellowship: Washington Hospital Center Todd J. Albert, MD Thomas Jefferson University and Hospital Dr. Todd Albert holds several positions at Jefferson Medical College at Thomas Jefferson University in Philadelphia, PA. He is the Richard H. Rothman Professor and Chairman of Orthopaedic Surgery, and Professor of Neurosurgery. Additionally, he is President of The Rothman Institute at Jefferson Hospital. The American Board of Orthopaedic Surgery certified Dr. Albert in 1995. Dr. Albert interned at Pennsylvania Hospital. During his residency at Thomas Jefferson University Hospital in Orthopaedic Surgery, Dr. Albert was recognized as the Outstanding Chief Resident. His fellowship was at Minnesota Spine Center in Spinal Surgery. He was awarded the John J. Fahey Orthopaedic Association Memorial North American Traveling Fellowship. Dr. Albert is a member of the American Academy of Orthopaedic Surgery, American Medical Association, Cervical Spine Research Society, Scoliosis Research Society, North American Spine Society, American Spinal Injury Association, and the International Society for Study of the Lumbar Spine. Dr. Albert has written four books, contributed more than 40 book chapters and published 200 peer-reviewed and non-peer-reviewed articles. He has received an outstanding paper award from the North American Spine Society and from the Cervical Spine Research Society. Dr. Albert is a guest editor for several academic journals. In addition, Dr. Albert frequently gives presentations at professional meetings. His commitment to education also extends to training residents; he has been recognized with the John J. Gartland Award for Resident Education. For six years running, Dr. Albert participated in the Marine Corps Marathon. James P. Bradley, MD, MS Burke & Bradley Orthopedics UPMC Sports Medicine Specialty: Orthopaedic Surgery Sub Specialty: Sports Medicine Medical School: Georgetown University Academic Affairs, Washington, DC Florida Institute of Technology, Melbourne, FL Residency: University of Pittsburgh Medical School, Pittsburgh, PA Fellowship: Kerlan Jobe Orthopedic Clinic, Los Angeles, CA Jens R. Chapman, MD University of Washington Dr. Chapman is a professor of orthopaedics and sports medicine and director of the Spine Service at Harborview Medical Center. He is an expert in surgery for spinal disorders and in orthopaedic trauma surgery, and is also an adjunct professor in the Department of Neurological Surgery. He earned his medical degree at Munich Technical University, Germany, in 1983 and after an internship there came to the United States for an internship and residency in orthopaedic surgery

at the University of Texas Southwestern Medical Center at Dallas. He came to the UW for a fellowship in traumatology and spine surgery in 1990. His patient care philosophy is “to provide the best possible state-of-the-art spine care. John M. Flynn, MD Attending Surgeon Associate Trauma Director, Orthopaedic Surgery Associate Professor of Orthopaedic Surgery University of Pennsylvania School of Medicine Medical School: University of Pittsburg School of Medicine Residency: Harvard Combined Orthopaedic Residency Program, Children’s Hospital of Boston Fellowship: Pediatric Orthopaedics, A.I. DuPont Hospital for Children, Wilmington, DE Board Certification: Orthopaedic Surgery Special Interests: Scoliosis and other disorders of the spine; Hip disorders; Fractures; Cerebral palsy; Pediatric sports medicine Research Interests: Optimal treatment of pediatric fractures; Evaluation and treatment of children with spinal deformities; Osteochondritis dissecans in athletes with open physes; Early diagnosis and treatment of pediatric bone and joint infections; Hip reconstruction for children with cerebral palsy Jeffrey A. Greenberg, MD The Indiana Hand Center Jeffrey A. Greenberg, M.D., was raised in Brooklyn, NY. Dr. Greenberg received his training in orthopedic surgery at the Syracuse program, prior to being selected to receive his hand surgery training in Indianapolis. He is yet another passionate hand surgeon, bringing a high level of enthusiasm for clinical research and teaching to our practice. Dr. Greenberg is currently the director of our fellowship program and is instrumental in regularly organizing prospective studies and clinical research projects with our fellows. Steve L. Haddad, MD Associate Professor of Clinical Orthopaedic Surgery Department of Orthopaedic Surgery University of Chicago Pritzker School of Medicine Section Head, Foot and Ankle Surgery Department of Orthopaedic Surgery Evanston Northwestern Healthcare Illinois Bone and Joint Institute B.S., University of Michigan, Ann Arbor, Michigan M.D., The Johns Hopkins University, Baltimore, Maryland Internship, General Surgery - Georgetown University, Washington, D.C. Residency, Orthopaedic Surgery - Georgetown University, Washington, D.C. Fellowship, Foot and Ankle Surgery - Union Memorial Hospital, Baltimore, Maryland Certification: Diplomate of the American Board of Orthopaedic Surgery Lori A. Karol, M.D. Texas Scottish Rite Hospital for Children Medical Director of Movement Science Laboratory and Medical Director of Performance Improvement Dr. Lori Karol is a staff orthopaedist and the medical director of performance improvement and the movement science lab at Texas Scottish Rite Hospital for Children. She earned her

undergraduate and medical degrees from the University of Michigan. Dr. Karol completed her general surgery internship and orthopaedic surgery residency at Wayne State University School of Medicine. She also completed the Harrington Fellowship of Pediatric Orthopaedics and Scoliosis at TSRHC. Dr. Karol is a professor in the department of orthopaedic surgery at The University of Texas Southwestern Medical Center at Dallas. She is a member of the American Academy for Cerebral Palsy and Developmental Medicine; the American Medical Association; a member and chairperson of the Communication Counsel of the Pediatric Orthopaedic Society of North America; a member of the American Academy of Orthopaedic Surgeons; the North American Society for Gait and Clinical Movement Analysis; the Scoliosis Research Society; and SICOT. Joseph M. Lane, MD Hospital for Special Surgery Joseph M. Lane, MD, was born in New York City and raised in Great Neck, Long Island. He received his AB degree (Magna Cum Laude) from Columbia College (1961) and his medical degree from Harvard Medical School (1965). General surgical internship and residency were performed at the Hospital of the University of Pennsylvania (1965-67). Dr. Lane performed bone collagen research at the NIDR at NIH (USPHS) from 1967-69 in Bethesda, Maryland, under Karl Piez and Edward Miller. He had a collagen research fellowship under Darwin Prochop at the CCRC University of Pennsylvania (1969-70) and a three-year orthopaedic residency at the Hospital of the University of Pennsylvania during which time he was awarded the Kappa Delta Award (AAOS) for inhibiting scar formation. Dr. Lane was the Elsee Butz Assistant Professor (Orthopaedics) at the Hospital University of Pennsylvania and Children’s Hospital of Philadelphia (1973-75). He was appointed Assistant Professor and Chief of the Metabolic Bone Disease Service at Hospital for Special Surgery at Cornell Medical School in 1975, ultimately attaining full Professorship, Assistant Dean, Director of Clinical Research, and Medical Director of the Metabolic Bone Disease Service and Osteoporosis Prevention (1976-93, 96—present). He was appointed Chief of the Bone Tumor Service (osteogenic sarcoma, Ewing’s sarcoma) at the Memorial Sloan-Kettering Cancer Center (1976-91) and Senior Attending (1991-93). From 1993-96 he was Professor and Chairman of the Department of Orthopaedic Surgery at UCLA. He is currently the Associate Director of the Orthopaedic Trauma Service at New York-Presbyterian Hospital. Dr. Lane has published extensively on bone biology, tissue injury and repair, trauma, bone and soft tissue sarcomas (including osteogenic sarcoma and Ewing’s sarcoma), limb preservation, functional amputations, limb regeneration, and metabolic bone diseases (osteoporosis, Paget’s disease, rickets, osteomalacia, fibrous dysplasia). He has served on numerous committees for the AAOS, including the Board of Directors and Chairman of COMSS, the Chairman Oversight Panel on Women’s Health Issues. He was President of the Orthopaedic Research Society, Musculoskeletal Tumor Society, Chairman of NIH Orthopaedic Study Section, OREF grants review board, ABOS Question Writing Task Force. He is a member of the AAOS, AOA, ABJS, ASBMR, ORS, MSTS, and OTA. He has earned NIH career and R01 grants, OREF grants, and foundation awards. He has been a visiting professor at educational institutes and is on the editorial board of several peer journals. Rick F. Papandrea, MD Vice Chairman, Department of Surgery, Waukesha Memorial Hospital

Assistant Clinical Professor of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee Orthopaedic Associates of Wisconsin Special Interests / Training: Elbow – arthroscopy; joint replacement; total elbow; hemiarthroplasty; fracture/instability reconstruction; ligament reconstruction; contracture treatment; pediatric elbow surgery; Hand – wrist arthroscopy; wrist reconstruction; arthritis reconstruction; post-traumatic reconstruction; fracture reconstruction; tendon/nerve/artery repair; Shoulder – fracture reconstruction; joint replacement; arthroscopy Medical School: University of Wisconsin School of Medicine Residency: The Mount Sinai Medical Center Fellow: Adult Upper Extremity Reconstruction (Shoulder/Elbow) – Mayo Clinic Certification: ABOS Board Certified in Orthopaedic Surgery; ABOS Certified in Hand Surgery; ABOS Board Certified in Sports Medicine Marc Safran, MD Stanford University Medical School: Duke University School of Medicine, NC Residency: UCLA Fellowship: University of Pittsburgh, PA Professor – Med Center Line, Orthopaedic Surgery Clinical Focus: Hip Arthroscopy; Sports Medicine; Arthroscopy Research Interest: Arthroscopic Management of Hip problems; articular cartilage regeneration; shoulder surgery and athletic shoulder and elbow problems.

Jeffrey R. Sawyer, MD Campbell Clinic Dr. Sawyer joined Campbell Clinic in July 2005. He received his college degree at Rochester Institute of Technology and went on to complete medical school at University of Rochester and completed his residency at the Hospital of the University of Pennsylvania with completion of his fellowship at UT – Campbell Clinic. He was certified by the American Board of Orthopaedic Surgeons and has affiliations with the following professional societies - American Academy of Orthopaedic Surgeons; Pediatric Orthopaedic Society of North America; Scoliosis Research Society; American Academy for Cerebral Palsy and Developmental Medicine David L. Skaggs, MD Associate Professor Childrens Hospital Los Angeles Division of Orthopaedic Surgery Medical School: Columbia University College of Physician Residency: Columbia-Presbyterian Medical Center Fellowship: Children’s Hospital Los Angeles, University of Southern California - Pediatric Orthopaedics and Frank E. Stinchfield Orthopaedic Research Fellowship, Columbia University Board Certification: American Board of Orthopaedic Surgery Research Interests: Bone density in children; public policy affecting pediatric orthopaedic care; care of spinal deformities in children; treatment of thoracic insufficiency syndrome with thoracic expansion; pediatric orthopaedic trauma Professional Memberships: Pediatric Orthopaedic Society of North America; American Academy of Orthopaedic Surgeons; American Academy of Pediatrics; Scoliosis Research Society; Orthopaedic Research Society; American Medical Association; California Orthopaedic Association; Los Angeles County Medical Society

Thomas S. Thornhill, MD

Brigham and Women’s Hospital Chairman, Department of Orthopaedic Surgery John B and Buckminster Brown Professor of Orthopaedic Surgery Clinical Specialty: Orthopaedic Surgery – Joint Replacement Medical School: Weill Medical College of Cornell University Residencies: Peter Brent Brigham Hospital – Medicine Harvard Combined Orthopaedic Residency Program – Orthopaedic Surgery Fellowship: Robert Breck Brigham Hospital - Total Joint Certifications in Internal Medicine and Orthopedic Surgery Clinical Interests in joint replacement (hip); joint replacement revision; knee; shoulder and elbow William C. Warner, Jr., MD Campbell Clinic Joined the Campbell Clinic staff in July, 1989 and graduated from Mississippi State University went on to graduate from Tulane University School of Medicine in New Orleans and completed his residency at UT-Campbell Clinic and completed his fellowship in Pediatric Orthopaedic Surgery at Scottish Rite Children’s Hospital in Atlanta. Dr. Warner received his board certification from the American Board of Orthopaedic Surgery and currently has his university appointment as Associate Professor, UT-Campbell Clinic, Department of Orthopaedic Surgery. He is a member of several professional societies including American Academy of Orthopaedic Surgeons; Scoliosis Research Society; Pediatric Ortho. Society of N. America; Chief of Orthopaedics, Mississippi Crippled Children’s Services, Memphis; Orthopaedic Consultant, Muscular Dystrophy Service; Orthopaedic Consultant, Scoliosis and Spina Bifida Clinics; Orthopaedic Consultant Spasticity Clinic; Orthopaedic Consultant St. Jude Hospital

Donald A. Wiss, MD Cedars-Sinai Medical Center Director, Orthopaedic Trauma

Dr. Donald A. Wiss is a board-certified orthopaedic surgeon. His clinical and research focus is on the diagnosis, treatment and rehabilitation of musculo-skeletal injuries and post-traumatic fracture reconstruction. Dr. Wiss has held academic appointments at the Boston University School of Medicine and the University of Southern California, where he was Clinical Professor of Orthopedic Surgery and Director of the Orthopaedic Trauma Service at Los Angeles County/USC Medical Center. For the past 17 years, Dr. Wiss was the Head of the Orthopaedic Trauma at the Southern California Orthopaedic Institute. Dr. Wiss earned his bachelor's degree from Michigan State University and his medical degree from Wayne State University School of Medicine. He completed his internship and one year of general surgery at Cedars-Sinai Medical Center followed by an orthopaedic surgical residency at the University of Pittsburgh. He was awarded the prestigious Girdlestone Scholarship in Orthopaedic Surgery at Oxford University's Nuffield Orthopaedic Center in England, and was a

trauma Fellow both at the AO Fracture Clinic in Tubingen, Germany and a senior trauma Fellow at Boston University, City Hospital.

Lower Extrem

ity

 

 

 

LOWER EXTREMITY  

Moderator: Thomas S. Thornhill, MD 

8:00 AM ‐ Hip and Knee Reconstruction Thomas S. Thornhill, MD 

 8:30 AM – Sports Knee James P. Bradley, MD 

 9:00 AM – Foot and Ankle Steven L. Haddad, MD 

 9:30 AM – Trauma Donald A. Wiss, MD 

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ADULT HIP AND KNEE RECONSTRUCTION AAOS REVIEW COURSE: SAN DIEGO 2011

Thomas S. Thornhill M.D.

John B. and Buckminster Brown Professor of Orthopedic Surgery

Harvard Medical School Chairman, Department of Orthopedics

Brigham and Women's Hospital Boston Massachusetts

1 Introduction A. Presentation Format -core material in handout (pages 1-55) (presented material in bold) -selected annotated references from 2009-2010(pages 55-72) -what's in/what's out -author's preference B. Adult Hip Reconstruction -Osteonecrosis -pathophysiology, treatment options, results -Arthritis (inflammatory, non-inflammatory) -pathophysiology

-treatment options (osteotomy,arthrodesis, hemiarthroplasty, arthroplasty, revision) -results, complications, future directions C. Adult Knee Reconstruction -Surgical options in non-inflammatory arthritis

-arthroscopy, debridement, cartilage regeneration, osteotomy, uni TKR, TKR -Surgical options in inflammatory arthritis -synovectomy(radiation, arthroscopic, open), TKR -Results of treatment -survivorship analysis,complications, future directions 2 Adult Hip Reconstruction/Osteonecrosis A) Etiology

1) compartment syndrome-ischemia occurs as the pressure in the confined femoral head exceeds filling pressure. 2) direct cellular injury-the initial event leading to osteonecrosis is direct injury to the osteoblast with apoptosis.

B) Staging 1) FICAT I-nl x-ray

2

II-sclerosis, cystic nl contour III-subchondral fracture /collapse, nl joint space IV-acetabular changes, joint space 2) STEINBERG I-nl x-ray; nl scan II-nl x-ray; abn scan III-sclerosis and/or cyst formation, A,B,C IV-crescent sign; no flattening V-flattening; decreased joint space VI-advanced DJD 3) ARCO (ASSOCIATION FOR RESEARCH ON OSSEOUS

CIRCULATION) ARCO News 1992;4:41 0-Bone Biopsy: AVN. All Other Tests Normal I- Scintigraphic or MRI Positive Lesions Subdivided based on Location (medial, central and lateral) and percentage of head involvement Ia-<15% involvement Ib-15-30% involvement Ic->30% involvement II- Radiographs: Osteosclerosis, cystic, osteopenia or

Mottled femoral head without collapse or acetabular involvement Scintigraphy or MRI: Positive Lesions subdivided based on location (medial, central, and lateral) and percentage of involvement of Femoral Head IIa-<15% involvement IIb-15-30% involvement IIc->30% involvement

III- Radiographs: Crescent sign; lesions subdivided based on

location (medial, central and lateral) and percentage involvement of Femoral Head

IIIa-<15% involvement or <2mm depression of head IIIb-15-30% involvement or 2-4mm depression IIIc->30% involvement or>4mm depression IV- Radiographs: Flattened articular Surface, joint space

narrowing, acetabular changes, osteophytosis

3

3) KEY FACTORS ARE 1. Sclerotic vs. cystic 2. Size and Location of Lesion 3. Crescent sign 4. Intact lateral column 5. Synovitis 6. MRI Pattern

C) Diagnosis and surgical options 1) x-ray- plain x-rays are selective but not very sensitive in determining osteonecrosis. Computerized tomography is the best technique to determine the area of bone death. 2) scintigraphy-99Tc-MDP scans are sensitive but there are a surprising number of false positives. Sulfur colloid scans offer no apparent advantage to MRI. Scintigraphy is not very specific.

3) MRI- T1 and T2 weighted MRI is highly sensitive and specific but not good for estimating the extent of the lesion. Diffusion and persusion technical improvements may be beneficial 4)PET scans not clear to Date

Options For Treatment of Osteonecrosis

-Protective Weight Bearing -Provide Mechanical Support -Bonfiglio -Tantulum Rod -Stimulate Bone Formation -Core Decompression -Vascularized Fibular Graft -Trap Door Procedures Allograft Autograft BMP

Mesenchymal Stem Cells (Bone Marrow Derived) -Inhibit Bone Resorption -Bisphosphonates

4

_Osteotomy -Hemiarthroplasty Bipolar Surface Hemiarthroplasty -High Failure Rate -Total Hip Arthroplasty Conventional Resurfacing Bearing Surface metal poly ceramic metal on metal Treatment of Osteonecrosis of the femoral head : Everything’s new.

This review article from a strong proponent of non-arthroplasty options in osteonecrosis points out that improvements in hip arthroplasty have changed surgical indications in this disease. In the author’s opinion core decompression is still indicated in the proper patient but that procedures such as femoral osteotomy and free vascular grafts can no longer be justified Hungerford, D.S. John Hopkins Orthopedics at Good Samaritan Hospital, Baltimore, Maryland. J Arthroplasty. 2007 June;22(4Suppl 1):91-4. D) Surgical Options 1)Protective weight bearing a)Enneking and Steinberg -showed greater than 90% progression b)Morrey (AAOS 1989) - demonstrated progression in treated side of patients with bilateral disease c)Recent data with MRI has suggested the early stages of osteonecrosis may be reversible E) Core Decompression 1) Positive results -Ficat (I,II,III) -Hungerford (I,II,III)

5

-Thornhill (I, IIa sclerotic) -Stulberg (I,II) 2) Negative results -Colwell -Hopson

Bozic, Zurakowski and Thornhill, JBJS Am 1999 Feb;81(2):200-9 Core Decompression

-54 hips in 34 patients ave follow/up 9.5 yrs. -Steroids 37 hips, ETOH 8 hips Idiopathic 7 hips, Misc 2 hips -34 (63%) radiographic failures at ave 25 months -28(52%) clinical failures at ave 40 months -combined failure by Ficat class Stage One 4/13(31%) Stage IIA Sclerotic 0/7 (0%) Stage IIA Sclerocystic 13/16(81%) Stage IIB 9/10(90%) Stage III 8/8 (100%) -predictors of failure by Cox proportional hazards regression model -advanced Ficat Stage -shorter duration of symptoms -steroid use F) Electrical Stimulation -Its role in pre collapse Osteonecrosis is Still Unclear G) Vascularized Fibular Graft -The principle is to provide mechanical support as suggested by Bonfiglio but, in addition, to graft the femoral head, remove necrotic bone and provide a vascularized fibula. -Urbanaik has reported good results with this technique in later stages unsuitable for core decompression . Urbaniak et al JBJS-A. 77(5):681-94, May 1995- Vascularized Fibular Graft for AVN -103 hips/89 patients -ETOH 30%: Steroids 17%: Trauma 13%: Perthes 3%: Idiopathic 38% -minimum 5 year follow/up -31 hips converted to THR Marcus /Enneking classification stage 2- 11% conversion stage 3- 23% conversion stage 4- 29% conversion stage 5- 27% conversion -younger patients did better

6

-results independent of etiology of the osteonecrosis Free vascularized fibular grafting for the treatment of postcollapse osteonecrosis of the femoral head. Surgical technique.

-188 Patients(224 hips) underwent free vascularized fibular grafting between 1989 and 1999 for AVN with collapse but no arthrosis -Ave follow-up was 4.3 years (2-12 years) -Failure defined as Revision to THR -Survival of 67.5% at 2 years and 64.5% at 5 years -Worse results in ETOH, Idiopathic and Post-traumatic

Aldridge JM 3rd, Berend KR, Gunneson EE, Urbaniak JR. J Bone Joint Surg Am. 2004 Mar;86-A Suppl 1:87-101. Histopathologic retrieval analysis of clinically failed porous tantalum osteonecrosis implants.

• 113 porous tantalum osteonecrosis intervention implants were studied • 17 implants(15%) were retrieved at the time of failure which averaged 13.4 months • Subchondral fracture was present in all cases • Bone growth was present in 13 cases with a mean extent of bone growth of 1.9%

Tanzer M, Bobyn JD, Krygier JJ, Karabasz D. JBJS(A). 2008 Jun;90(6):1282-9

H) Osteotomy a)Rotational, angular b)Principle is to deliver or contain the lesion b)Results of Rotational Osteotomy are Variable c)Angular Osteotomy works well if arc of necrotic area is <200 degrees Femoral Osteotomy and Iliac Graft Vascularization for Femoral Head Osteonecrosis Between 1978-1986 41 Patients (52 hips) were Treated with Intertrochanteric Osteotomy and

Pedicled Iliac Bone Block Transfer for Ficat Stage 2 and 3 Disease. 33 Patients (44 hips) available for follow-up at 13.5 years mean 15 (34%) were Converted to THR 6 Patients died. 2 lost At Latest follow-up 31% had Severe Arthritis, 59% Moderate Arthritis, 3 had mild Arthritis. Consider this Operation only in Young Symptomatic patients with Good Preoperative Function

and Ficat Stage 2 Disease

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Fuchs B, Knothe U, Hertel R and Ganz R. Clin Orthop. 2003 Jul; (412): 84-93. I) Bipolar Hemiarthroplasty a)Positive -spares acetabulum -easier revision b)Negative -acetabulum may be involved -late protrusion -significant polyethylene debris Hemi-Surface for AVN -33 hips/25patients -mean follow-up 10.5 year (4-14) -61% good/ excellent -Mean time to failure 60 mos. -successful total hip replacement post failure Hungerford MW, et al J Bone Joint Surg Am 1998 Nov;80(11):1656-64 Femoral head resurfacing for the treatment of osteonecrosis in the young patient. -29 consecutive femoral head resurfacing procedures for AVN -18 male10 female -average age 31.6 years -Harris Hip Score improved from 48.1 to 79.3 points -Overall Survivorship was 75.9% at 3 years -8 hips converted to THR at ave 18 mos. -only 62.5% with satisfaction and good pain relief

Adili A, Trousdale RT. Clin Orthop. 2003 Dec;(417):93-101.

J) Total Hip Arthroplasty

Failure of Femoral Surface Replacement for Femoral Head Avascular Necrosis

8

• 37 surface hemiarthroplasties perform between 1997 and 2003 • failure defined as revision surgery or Harris hip pain score of 20 or less • overall failure rate was 64.8% • revision rate was 40.5%

Squire, M., Fehring et al. J. Arthroplasty 2005 Oct;20: 108-114 Total Hip Arthroplasty in Osteonecrosis is Associated with a Greater Failure Rate due to: -High patient demand -Dislocation -Young Age -High Expectation -? higher response to particulate debris Piston, Engh et al: JBJS, 1994- THR in Patients with AVN -30 patients (35 hips) with Ficat stage III/IV -7.5 years mean follow/up (range 5-10 yrs) -Average patient age (32 years) -Femoral stem osteointegration in 33 hips(94%) -3% femoral revision, 6% acetabular revision -Femoral remodeling (17%), osteolysis (17%) Stulberg et al: 1997– Uncemented THR in AVN -64 pts (98 hips) 87 available -Ave age 41 yrs (21–69) -Ave f/up 7.3 yrs -Steroids 42, ETOH 27 -18 (21%) revised -4 with osteolysis 5) Author's preference Stage 1- establish diagnosis: if certain to be osteonecrosis then consider core decompression in younger patient and observe older patient. Stage 2- core decompression for IIa sclerotic disease in younger patient. Stage 3- core decompression only if on opposite side of patient undergoing surgical procedure on other hip. Osteotomy on younger

9

patient if mechanically correct. Consider vascularized fibula in selected patients. Resurfacing hemiarthroplasty or bipolar hemiarthroplasty if no significant synovitis or effusion. Otherwise THR. Stage 4- Arthrodesis only if absolutely certain that there is not bilateral involvement. Otherwise, THR. Stage / X-ray

Intact Lateral Column

<200°†

>200°

Synovitis ††

I

Normal / +MRI 1,2,3 ††† – – 1,2,3

II

Sclerosis 3 3 3 3

III

Cystic/Sclerocystic 1,4 4,5 4 4

IV

Crescent w/o collapse

1,4 5 6 7

V

Collapse/NL, Acet, Jt. Space

6 6 6 7

VI

Acet Changes / Jt space Ø

7 7 7 7

† arc in degrees of involved area as measured on AP and lat radiograph †† determined by MRI (T2 weighted)* ††† OPT for more conservative option in elderly or minimally symptomatic patients Treatment Options 1 Observation 2 Electrical stimulation 3 Core decompression 4 Vascularized Fibular Graft 5 Angular Osteotomy 6 Hemiarthroplasty 7 Total Hip Arthroplasty WHAT'S IN/WHAT'S OUT - HIP OSTEONECROSIS*

10

WHAT'S IN -MRI for diagnosis -Intertrochanteric osteotomy -Acetabular resurfacing during arthroplasty -Vascularized fibular grafts in limited situations -core decompression only for I or IIa sclerotic disease -Hemi Resurfacing for Hemiarthroplasty -Move towards Arthroplasty WHAT'S OUT -Scintigraphy -Core decompression for beyond Ficat IIa sclerotic -Bipolar hemiarthroplasty -Rotational osteotomies

*WHAT'S IN/WHAT'S OUT reflects trends within the past year and does not specifically indicate the author' preference or the standard of practice.

3. Adult Hip Reconstruction/Osteotomy/Debridement/Impingement 1) Goals a)Decrease unit load b)Decrease muscle forces c)Increase surface area d)Biological events e)Stabilize the unstable joint 2) Unit loading of hip a)contact area 26.7 cm@ b)unit load 23 kg/cm2 3) Types of osteotomy a)Femoral 1 angular 2 displacement b)Pelvic 1 Innominate -Salter-Steel-Sutherland 2 Wagner-Dial 3 Ganz-Periacetabular

11

4) Ideal Candidate for Osteotomy a)Less than 50 yrs b)No obesity c)Evidence of Mechanical overload -Decreased. jt. space by 1/2 -Increased subchondral density -No large cysts 5) Pelvic versus Femoral Osteotomy a) Femoral osteotomy should be used to correct femoral deformity -Osteonecrosis -Slipped capital femoral epiphysis -Legg-Calve-Perthe's disease -Proximal femoral deformities (growth arrests, congenital coxa vara) -Osteochondral defects b) Pelvic osteotomy should be used to correct acetabular deformity -primary hip dysplasia -secondary acetabular dysplasia (LCP) -neuromuscular disorders 6) Preoperative evaluation -Plain radiographs -AP(abd/add)-severe arthritis by 65 yrs if: -lat. center edge angle <16o -fem. head uncovered >1/3 -acetabular roof that does not turn down past horizontal -false profile (standing weight bearing view with patient turned 25o from true lateral. -CT imaging analysis and simulation 7) Pros and Cons of Osteotomy for Osteoarthritis -PROS -conservative -avoids arthroplasty -does not burn bridges -allows greater activity -improves acetabular stock -CONS -more difficult rehabilitation -less pain relief -temporary solution -difficult conversion to THR

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Ganz et al. JBJS-B 79(2) Mar 97 THR After Femoral Osteotomy -74 THAs post osteotomy -74 THAs primary -No difference except -increased OR time -increased troch. osteotomy Perlau, Wilson, Poss. JBJS-A 78(10) Oct 1996- Osteotomy for DDH/OA: 5-10 yr -17 hips DDH -8 satisfied -9 not satisfied -4 THR’s -16 hips OA -6 satisfied -Best results in early OA or less dysplasia Lessons learned from early clinical experience and results of 300 ASR Hip Resurfacing Implantations

• 300 ASR metal on metal resurfacing hip arthroplasty • mean follow-up was 202 days • Harris hip score improved from 44 to 89 • eight revisions, five neck fractures and 3 cup provisions • higher failure in patients with previous proximal femoral surgery • distinct learning curve demonstrated

Siebel et al Proc Inst Mech Eng 2006 Feb;220(2): 345-53 Intertrochanteric Osteotomies Do Not Impair Long-Term Outcome of Subsequent Cemented Total Hip Arthroplasties

• 121 total hip replacements after osteotomy compared to 290 total hip replacements with no prior osteotomy

• there was no difference in survival rate, radiographic findings or clinical findings • higher incidence of intraoperative perforation of the femur in patients following osteotomy

Haverkamp, D, Marti RK et al. CORR 2006 Mar; 444:154-160 8) Authors Preference

13

Femoral, pelvic or combined osteotomy is indicated for the young (biologically and emotionally not chronologically) individual with a mechanical problem that can be corrected. The patient must be educated to understand the rationale of osteotomy over THR. WHAT'S IN/WHAT'S OUT-HIP OSTEOTOMY WHAT'S IN -Preoperative Evaluation -Intertrochanteric osteotomies for femoral deformity -Periacetabular osteotomies for acetabular deformities WHAT'S OUT -Rotational osteotomies -Osteotomy for mod/severe osteoarthrosis Femoral-Acetabular Impingement-Prof Reinhold Ganz -Anterior impingement as cause of hip pain and DJD -limited range of motion -limited internal rotation -anterior overcoverage secondary to (Pistol grip deformity): -acetabular retroversion -coxa profunda -nonspherical head -no anterior head-neck offset -retrotilt of femoral head -coxa vara -femoral neck retroversion

• Developmental alterations of the Hip – Femur - Cam lesion – Acetabulum - Pincer lesion – Malrotation of acetabulum and/or femur

• Secondary Arthritis – Ganz, et al: FAI: a cause of aosteoarthritis of hip. CORR 2003

14

-Surgical Treatment to increase the impingement free hip joint clearance may include hip dislocation and

-acetabular reorientation -trimming of the rim -femoral head shaping

-increase head neck offset -change femoral anteversion

-Arthroscopic Intervention with labral Debridement and Removal of Impingement

Treatment of Femoral Acetabular Impigement with Surgical Dislocation and Debridement in Young Adults.

• 30 hips in 29 patients underwent debridement with anterior dislocation of the femoral head

• Mean age 31 years with mean follow-up of 32 months • Mean Harris hip score improved from 70 to 87 points • no evidence of osteonecrosis • unrecognized severe acetabular damage seen in 18 hips(poor prognostic indicator)

Peters, C. L. and Erickson, JA. JBJS 2006:88(8) 1735-41

• Arthroscopic Treatment – Byrd, J.W., et al: Arthroscopic Femoroplasty for FAI. CORR 2008

• Minimum one year f/u • 200 pts - 83% improvement

– Philippon, et al: Outcome of FAI and Chondrolabral dysfunction. (B) JBJS 2009.

• Prospective study with 112 pts, minimum 2 year f/u • < less than 2 mm joint space narrowing did well • Labral repair did better than debridement • Older patients more likely to undergo THR

4. Adult Hip Reconstruction/Arthrodesis 1) Indications -infection -high activity 2) Contraindications -osteonecrosis

15

-hip, knee, back problems 3) Technique -30 degrees flexion -0-5 degrees ext. rot. -0-10 degrees adduction 4) Author's preference

-arthrodesis if performed more often in conference than in the operating room. It is indicated in the young active patient with limited motion who has oligoarticular disease and wants to return to an active life style.

WHAT'S IN/WHAT'S OUT - HIP ARTHRODESIS WHAT'S IN -Fusion to allow for later THR -Careful patient counselling WHAT' OUT -Cobra plate fixation if trochanter is destroyed -Arthrodesis in patients with good motion 5. Adult Hip Reconstruction/Hemiarthroplasty 1) Indications a)femoral neck fractures -bipolar vs. Moore b)avascular necrosis c)revision hip arthroplasty -acetabular reconstr. -joint stability 2) Long term concerns a)acetabular wear b)protrusion c) polyethylene wear debris

Kim, Rubash J. Arth. 12(1) Jan 1997- Bipolar Hemiarthroplasty -Interface membranes 17 bipolars vs 17 THRs -Bipolars produced more PGE2 (p<.05) -Raised concern of poly wear with bipolars 3) Author's preference

-Hemiarthroplasty is indicated in younger patients with osteonecrosis who are not candidates for core decompression or osteotomy and who have Stage III disease without significant synovitis or effusion. Moreover, it is indicated in

16

femoral neck fractures (? bipolar or unipolar) not amenable to internal fixation (except in the elderly who should be

considered for THR). 6. Adult Hip Reconstruction/Total Hip Arthroplasty(Go to Page 20) I Results of Primary Cemented Total Arthroplasty A. Early Results-cemented -acetabular failure -30-50% at 10-14 years -femoral failure -20-30% at 5 years -30-40% at 10 years B. Improvements in cement technique -improved stem design for cemented application -improved femoral canal preparation -pulsatile lavage -distal plugging -porosity reduction C. Current U.S. Long Term Results-Cemented Mancuso et al. J Arth 12(4) Jun 97-Patient Satisfaction: THR -180 pts 2 yrs post-op (HSS) -89% satisfied -Lower satisfaction if -less preoperative loss -nonessential demands -worse post-op function -50% referred by patient/friend -64% would refer others for surgery Maloney and Harris- 105 hips/93 pts. 10-12.7 yr f/up -femoral loosening- 3 loose/2.8% (24 possibly loose) -acetabular loosening-42% Eftekhar-1009 Charnley LFA THRS. 5-15 yr f/up -over all failure rate of 4.5% -higher incidence of late failure in the acetabulum -poor pressurization, elasticity of pelvis.

17

Bosco- High modulus design (HD2,CAD). 86 hips 6.7 yrs f/up -cement gun, 2nd gen. design, distal plug (1979-82) -19 excellent; 44 good; 15 fair; 11 poor -Survivorship 5 year 10 year Acetabulum 97% 58% Femur 93% 78% Combined 91% 50% Mulroy, Harris: JBJS 77 (12) 1995-Cemented THR Results -Grit blasted stem – HD2 -162 hips (149 pts) -51 patients died (60 hips) -102 hips (90 pts): min. 14 yr F/up -8 (10%) acetabular revision: 42% loose -2% femoral loosening

Twenty-five Year Results after Charnley THR in Patients less than 50 Years old: A Concise Follow-up of a Previous Report. 93 Charnley cemented THRs in 69 patients less than 50 yo at Index Arthroplasty Minimum 25 years follow-up or until death Results on 42 of 43 living Patients (38% deceased) 29 Revised or Removed (31%) 13% Femoral Failure 34% Acetabular Failure 69% of Hips Functioning well at Latest Follow-up or Death 5% Required more than one Revision.

Keener JD, Callaghan JJ, Johnston RC et al. JBJS 2003 Jun. 85-A(6):1066-72

Madey, Callaghan, Johnston et al. JBJS-A 79(1) Jan 1997-Long Term Charnley Results

-357 Charnley LFA (320) pts -2nd generation cement technique -189 pts (214 hips) died/1 lost -130 pts (142 hips) available at 15 yrs -356 hips with follow-up -Acet loosening -12% in whole group(356 hips) -22% at 15 yrs(142 hips) -Femoral loosening -10(3%) in whole group -6 (5%) at 15 years

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II Hybrid Hip Arthroplasty-Cemented Femur; Uncemented Acetabulum A. Rationale Difference in long term results with late socket loosening B. Early Results-Hybrid Wixson et al-131 pts 2-4 yr f/up

uncemented femur in men <70 yrs, women <60 yrs and good bone quality. no clinical difference in cemented, uncemented and hybrid except; -2/65 loose uncemented femurs(one revised) -24% incidence of thigh pain at one yr in the uncemented group -higher incidence of migration and radiolucencies in the cemented sockets Maloney and Harris-25 hybrid /25 uncemented min. 2 yr HHS 96 for hybrid, 84 for cementless (p<0.02) uncemented group had 24% thigh pain, 5 migrated, 4 revised.

Callaghan, Johnston: Clin Orthop 1997-THR in the Young Patient (<50 yo) -93 cemented hips (20 yr f/up) -5% femoral loosening -19% acetabular loosening -45 hybrid hips (5–10 yr f/up) -18% femoral loosening -0% acetabular loosening

-Current technique is hybrid with uncemented acetabulum with Charnley type polished stem.

-Early Cemented Stem Failure -Stem debonding -Surface finish -Stem geometry -Cement mantle

Verdonschot, Huiskes:J. Biomech 1997-Stem Debonding -Finite element analysis -Increases initial stresses -Fourfold increase in failure -Promotes pathway for debris

-Surface Finish -Polished

19

-Matte finish -Bead blasted

-Grit blasted -RA (avg roughness µin)

Stem Geometry -Influence of surface finish on subsidence -1st order effect -tapered stem -2nd order effect -“Charnley stem” Cement Mantle -Increased failure with -Thin mantle -Mantle fracture -Weak perimantle bone

Early Loosening with Precoat Stems -Callaghan -Rubash -Coutts, Santore

Santore, Coutts: Intl Soc Tech Arth 1997-Early Loosening with Precoat Stems -110 THR (101 patients) -4 deaths, 8 lost -90 hips (89 patients) -10 failures (11.4%) at 32.8 mos ave f/up -Prosthesis cement Gruen 1 failure

Early Failure of Cemented Femoral Stems 84 Centralign femurs (76 patients) ave flu 35.8 mos, ave age 48.2 yrs 10 loose (12%) 9 revised (11%) failed by debonding Sylvain, Kassib, Coutts, Santore J Arthroplasty 16(2):141-8 Feb 2001

20

Early Loosening with Precoat Stems -Associated factors Inadequate cement mantle Increased surface finish Stem design Small flexible stems Precoat debonding

Grit Blast vs. Pre-coat In Cemented Total Hip Replacement -Iowa Hip -36 hips (25 pts) bead blasted (0.8um) -45 hips (37 pts) grit blasted pre coated (2.1um) -Average follow up 11.3 years beaded blasted, 8.2 years pre

coated -Revised or radiographically loose 4/36 (11%) bead blasted 11/45 (24%) pre coat (p = .007) Sporer SM, Callaghan JJ., et al J Bone Joint Surg Am 1999 Apr;81(4):481-92 III Results of Uncemented THR Most investigators agree that uncemented femoral stems -have greatly improved -require immediate stability in host bone -transfer load by spot welding at endosteal cortex -have a higher incidence of thigh pain postoperatively. Engh et al. JBJS-A 79(2) Feb 1997- Uncemented THR-AML Long Term

- 223 hips (215 pts) - 55 yr ave age (16-87 yrs) - 21 lost, 27 died (174 hips left) - 11 yr ave f/u (10-13 yr) - 97% stem survival

- 92% cup survival

Results of Porous Coated Anatomic THR without Cement at 15 Years; A Concise Follow-up of a Previous Report. 100 PCAs Implanted between 1983 and 1986.

21

55 Patients alive at 15 Years (ave 15.6 yrs) 17% of and 23% of the living Cohort had Undergone Acetabular Revision and 6% and 7% respectively had Undergone Femoral Revision. Femur was more Durable than the Acetabulum

Bojecsul JA, Callaghan JJ et al. JBJS 2003 Jun; 85-A (6) : 1079-83. Bugbee, Engh et al. JBJS-A 79(7) July 1997- Uncemented THR- AML - 48/207 hips (23%) showed stress shielding - 10 yr minimum f/up - No increase in loosening, pain, lysis in stress shielded stems Capello et al. JBJS-A 79(7) Jul 1997-Uncemented THR-HA -133 pts (152 hips) -6.4 yr mean f/u (5-8.3 yr) -Harris Hip Score 47Æ 93 -2 thigh pain -32% Gruen 1,7 lysis -One distal lysis -All stems osseointegrated Dorr et al. CORR (336) March 1997-THR in patients 65 yrs & older - 89 hips (79 pts.) - 5-9 yr f/up - 22% died, 38% function limiting medical problems - 10% with hip limitation (all cementless implants) IV Summary of Past 25 Years in Hip Arthroplasty(19) Cemented Hips -High Acetabular Failure Hybrid Hip Arthroplasty -Femoral Failure with Some Roughened Surfaces Predominant Use of Uncemented Implants Surgical Decision Points -When to Cement -Surgical Approach -Minimally Invasive Techniques

22

One incision Anterior Anterolateral Posterior Two incision -Modular or Not -Proximal and/or Distal Fixation - Resurfacing -Head Neck Ratio -Altered Anatomy -Women -? High Performance -Bearing Surface -Type of Polyethylene -Metal Poly -Ceramic on Ceramic -Metal on Metal -IDE Ceramic on Metal -Component Orientation Influences Edge Loading - Edge Loading leads Wear, Fracture, Squeaking, ALVAL -Head Size V Author's preference

-There is a role for both cemented and uncemented THR. In virtually every case the acetabular component should be uncemented. . A porous coated, under-reamed cup should be press fit with ancillary screws if necessary. In elderly,sedentary individuals with type C bone, the femoral component should be cemented. There is a trend towards Uncemented Designs in patients with Type C bone. A collared cobalt chrome implant is preferable for cemented situations. In young active people with good bone (Type A or B) the femoral component should be uncemented. A straight, collarless proximally porous titanium stem with proximal fit and distal fill is preferred for uncemented arthroplasty.

V Mechanisms of Failure of THR and Possible Solutions/Questions A. Loosening -Poor patient selection. Current metallurgy, fixation,

and the mechanical/biologic response of the host precludes THR in the young, active individual. As our technology improves will we be able to broaden the patient base for THR?

-

-Generation of wear debris. Can we improve on existing materials or

23

develop new materials? -hydroxyapatite(HA) advantages -osteoconductive -avoids porous coating -potentially stronger bond disadvantages -inflammatory as a particulate -critical parameters for application -questionable bond to substrate -lower frictional resistance -cost issues Comparison of Hydroxyapatite and Porous Coated Stems in THR

No difference in S-ROM ZTT HA or Porous Component in Thigh pain, Bone Reaction or Hip Scores up to 4 years

Park YS et al. Acta Orthop[ Scand. 2003 Jun; 74 (3):259-263. -ceramic heads advantages -lower frictional resistance -scratch resistant -possible less polyethylene wear -potentially less Morse taper wear -newer ceramic materials are promising disadvantages -clip fracture -squeaking microseparation edge loading component specific -stripe wear -taper sizes -cost issues -revision limitations Ceramic Recall Demarquest- switch from batch to tunnel oven processing. Two Eighty-two fractured zirconia heads.

24

No known risk in the Ceramtec 80% aluminun and 20% zirconia heads or ceramic on ceramic bearings

Revision THR Performed after Fracture of a Ceramic Femoral Head. A Multicenter Study 105 Fractured Alumina Ceramic Heads Follow-up post Revision was 3.5 years Cup Loosening in 21%, Femoral Loosening in 21% One or more subsequent Revisions in 31% 5 year Survival rate was 63% Survival Worse if cup not Revised, new head was Stainless Steel, When a Total Synovectomy was not done and if Patient was less than 50 years old.

Allain J, et al. JBJS 2003 May; 85-A: 825-30.

-improved polyethylene advantages -potential less polyethylene wear disadvantages -increased stiffness may increase wear -cost issues Methods of polyethylene sterilization -gamma in air -ethylene oxide -gas plasma -gamma in vacuum with hydrogen retention -gamma in inert gas with heating -highly cross linked ( gamma or electron beam). Variations in -dose and method of irradiation -method of free radical quenching -terminal sterilization -second/third generation highly cross linked polys(goal is to maintain both wear and mechanical characteristics) -antioxidants -sub melt annealed -melt annealed with better resin Are free radicals sbabilized or gone? Increased wear seen in Cross linked poly at 5 years-Malchau Ex Vivo Oxidation seen in retrieved highly cross linked Components. ? Squalines and/or loading-Murtaglou

25

Besong et al. Bio-med Mater & Engr 7(1) 1997- Polyethylene Wear - Wear dramatically increased with shelf life of gamma irradiation polyethylene and femoral head roughness

Collier et al. CORR 342 Sept 1997- Polyethylene Wear

Gamma sterilized poly with less than one year shelf life had less oxidation and better in vivo performance

-Metal on Metal Articulations Promising clinical data but concerns remain: Shanbhag et al. CORR 342 Sept 1997- Wear Debris THR -In vitro monocyte challenge -Metal (Ti) particles more effective than poly particles in stimulating fibrogenesis Brodner et al. JBJS-B 79(2) March 1997- Metal-on-Metal Articulations -27 metal-on-metal CoCr (1yr) serum cobalt 1.1 µg/l -28 ceramic on poly (1 yr) serum cobalt 0.3 µg/l p < .001 -Raised concern of long term toxicity Levels of Metal Ions after Small and Large Diameter Metal on Metal Hip Arthroplasty. 22pts MOM Resurfacing vs. Matched Group With 28mm MOM THR Median Follow-up 16 mos (7-56) Measured serum Cobalt and Chromium (nl 5 nmol/l) levels

Resurfacing MOM- 38 nmol/l cobalt and 53 nmol/l chromium compared to 22 and 19 for 28mm MOM. Both significantly higher than normal.

Clarke MT et al. JBJS Br 2003 Aug;85(6): 913-17.

26

Four Year Study of Cobalt and Chromium Blood Levels in Patients Managed with Two Different Metal-on-Metal THRs

259 Patients with THR 131 with METASUL, 128 with SIKOMET-SM21 THRs Both Prostheses are cobalt-chromium metal-on metal Implants Blood Cobalt and Chromium Measured by Atomic Absorption Spectrophotometry 31 age and gender matched controls No Difference in levels between Implants Both showed Cobalt levels up to 50 times higher and Chromium levels up to 100 times Higher than Controls Lhotka C., Zweymuller et al J Orthop Res. 2003 Mar; 21 (2): 189-95 Metal on Metal Advantages -Lubricity -Good for large diameter heads -No Poly or Ceramic debris -Optimal Bearing for Resurfacing Arthroplasty -Metal ions likely Prosthesis Specific due to carbides and clearance -Larger heads appear to have lower metal ion risk Disadvantages -Patient Selection -Systemic Metal Ion Toxicity -Hard Bearing -Local Delayed Hypersensitivity -ALVAL/Pseudotumor -Recent Recalls/Withdrawels

Neo-capsule tissue reactions in metal-on-metal hip arthroplasty.

• Neo-capsule tissue samples from 46 hips with a modern second-generation metal on metal articulations were examined histopathologically and immunohistochemically

• A distinct lymphocytic infiltrate was found in all cases with in situ times of more than seven months

• This consisted of CD20 positive B Lymphocytes and CD3 positive T lymphocytes • At times there were CD 138 positive plasma cells • This pattern has not been seen in metal on polyethylene or ceramic on polyethylene

replacements Witzleb WC, et al. Acta Orthop. 2007 Apr;78(2):211-20.

27

The blood flow to the femoral head/neck junction during resurfacing arthroplasty: a comparison of two approaches using Laser Doppler flowmetry

• Laser Doppler flowmetry was used to measure the effect on the blood flow to the femoral head during resurfacing arthroplasty

• 24 hips undergoing resurfacing arthroplasty were studied • 12 had a posterior approach and 12 had a trans-trochanteric approach • There was a greater reduction in blood flow with the posterior approach (40%) then with a

trans-trochanteric approach (11%)

Amarasekera HW, Griffin DR. et al. JBJS(B). 2008 Apr;90(4):442-5 Current Controversies In THR

- Use of highly cross linked polyethylene - Which one to use? - How Thick Should Poly be? - Amount of gamma irradiation

As dose increases wear decreases but so do mechanical properties.

-Head size 22,26,28,32,36,38,42 Need 36 head to Increase Stability - Bearing Metal Ceramic Metal on Metal

Technical/ Design ways to decrease wear. DESIGN -avoid titanium bearing -limit modularity -improve acetabular metal/poly couple -improve Morse taper tolerances TECHNIQUE -avoid vertical cup -avoid edge loading -clean Morse taper -clean acetabular surface

28

-avoid scratching of femoral head

B. Infection

-A) The incidence of infection in THR varies from 0.4% to1.5% by use of prophylactic antibiotics and by additional use of laminar flow, UV lights, and exhaust systems. Treatment generally consists of delayed exchange with a treatment period where implant and cement are removed. Will antibiotic

impregnated implants shorten the exchange period? What is the role for immediate exchange? -B) Surgical options -incision and debridement -immediate exchange -delayed exchange -C) Indications for incision and debridement -superficial infection - acute perioperative infection with susceptible organism and adequate host response -D) Indications for immediate exchange

-established deep infection with susceptible organism (non glycocalyx former, adequate antibiotic susceptibility)

-good host response -straight forward revision E) Indications for delayed exchange -majority of patients with established deep infection F) Results of treatment for infected THR -Immediate exchange- Bucholtz (ENDO Clinic)

-77% success (583 patients) using gentamicin impregnated cement. Fifty- 55% recurrence if gram negative infection. Further follow-up by Rottger should 30% failure at 6 years and 50% failure at 11 years. Salvati reported 81% success with immediate exchange in adequate host if bactericidal antibiotic levels >1:8.

-Delayed exchange-Fitzgerald reported 87% success in 83 THRs at 2-13 years. If a patient received 3 weeks of antibiotics, had all cement removed and waited 12 weeks before reimplantation, there was a 97% success rate. Patients with retained cement, less than 28 days of antibiotic treatment, reconstruction less than one year following (p<0.05) increased risk of recrudescent infection.

-Delayed Exchange Protocol Options

29

-interval to reimplantation -beads or Prostalac system -length and type of antibiotic therapy -reported worse results in MRSA and MRSE -If exchange fails: Pagnano, Trousdale, Hanssen CORR 338 May 1997-Septic THR: Reinfection -34 hips reinfected -Avg 2.2 yrs following revision -Resection arthroplasty successful -Reimplantation: 8/11 failed -Consider delayed exchange if same organism C. Dislocation -Incidence- 1-10% -Causes

component malposition. The combination of acetabular forward flexion and femoral anteversion should be 45o. Intraoperatively, the construct should be tested in flexion and internal rotation, extension and external rotation, for any impingement and for abductor tension component impingement. Increased incidence of dislocation using 20o liners and plus 10mm head. You want Maximal Head Neck Ratio.

surgical approach. There is an increased posterior dislocation rate using the posterior approach. surgeon experience sepsis. Late unexplained dislocation should raise the suspicion of indolent sepsis.

patient issues. Senility, alcoholism, ataxia, basal ganglia disorders. revision surgery especially when only a single component is revised severe coxa vara. should consider trochanteric advancement in such cases. You must reproduce the proper offset.

Hedlundh et al. JBJS-B 78(2) Mar 1996-Hip Dislocation -4230 primary THRS -Posterior approach -3% dislocation -Correlated with surgeon experience

30

-with each 10 hips done(up to 30), rate Ø by 50%

Hedlundh et al. JBJS-B 79(3) May 1997-Hip Dislocation: Recurrent -121 primary THA -39 revision THA -All with primary dislocation -Only 35% with no further dislocation or revision -best result with revision if components were found to be malaligned D. Heterotopic ossification(HO) Associated with; -revision surgery -previous HO -ankylosing spondylitis -DISH -neuropathic states -Pagets disease Treatment radiation (700 rads as single dose) preoperatively(4 hrs) or postoperatively (48 hrs) indomethicin 50mg BID x 7days diphosphonates do not work Knelles et al. JBJS-B 79(4) Jul 1997-Heterotopic Ossification -700 rads or 50 mg indocin BID x 7d -More effective than 500 RADS

CRP for Determining Risk of HO -⇑ CRP in early post of period indicates increased risk of HO

Sell S, Schleh T Arch Orthop Trauma Surg 1999;119(3-4):205-7 E. Fracture

As a general rule unstable fractures around THR implants should undergo ORIF. If stability can't be achieved consider revision to a long stemmed implant.

F. Component breakage

31

Not as large a problem as with earlier designs. Most likely occurs with a well fixed implant distally that is loose proximally. There has been a reported incidence of neck fracture with the large size chrome cobalt stem with a plus 10mm head.

G. Osteolysis -One must differentiate between stress shielding in components with distal fixation and osteolysis. Osteolysis is recognized by focal endosteal erosion and is predominantly due to wear debris (polyethylene, metal, and cement). WHAT'S IN/WHAT'S OUT -HIP ARTHROPLASTY WHAT'S IN -Uncemented acetabular components with -minimal holes -good locking mechanisms -full back side contact -Use of screws if necessary -Cemented polyethylene cups for elderly

-Cemented femoral components with limited surface roughness (depends on design)

-Adequate cement mantle, careful cement technique -Increased use of uncemented femoral component (especially type A and B) -Use of Highly Cross Linked Polyethylene

-Consider larger heads for better stability and improved head neck ratio WHAT'S OUT -Gamma irradiated polyethylene in air -Cemented femurs in good bone -Use of cement in cardiac patient -Bipolar hemiarthroplasty -Routine acetabular screw fixation -Threaded acetabular cups -Titanium bearing surfaces -Highly modular systems -Custom components Revision Total Hip Arthroplasty.

A) The first issue is to determine the mechanism of failure and to

32

establish what is missing.

B) Classification of femoral deficiency

1 Segmental -level 1 (to lesser troch) -level 2 (to mid shaft)

-level 3 (distal half) 2 Cavitary -with cortical shell expansion -ectasia 3 Combined 4 Malalignment AAOS HIP COMM., 1993 Proprosky Femoral Bone Loss Classification Type 1

• Metaphysis: Minimal bone loss

• Isthmus: Intact > 5cm

• Diaphyseal cortex: Supportive

Type 2

• Metaphysis: Damaged, calcar, non-supportive

• Isthmus: Intact > 5cm

• Diaphyseal cortex: Supportive

Type IIIA

• Metaphysis: Severely deficient, Non-supportive

• Isthmus: Intact 4-6cm

• Diaphyseal cortex: Supportive distally

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Type IIIB

• Metaphysis: Severely deficient, Non-Supportive

• Isthmus: Intact < 4cm

• Diaphyseal Cortex: Supportive distally Type IV

• Metaphysis: Severely deficient, Non-supportive

• Isthmus: Deficient

• Diaphyseal cortex: “Paper thin” endosteal canal enlarged

C)Classification of Acetabular Deficiency 1 Segmental deficiencies -Peripheral Superior Anterior Posterior -Central (medial wall absent) 2 Cavitary deficiencies

-Peripheral Superior Anterior Posterior Central (medial wall intact)

3 Combined deficiencies 4 Pelvic discontinuity 5 Arthrodesis

AAOS HIP COMM,1989

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Acetabular Classification Proprosky Kohler’s line

Integrity of medial wall and superior anterior column Ischial lysis

Integrity of posterior wall and posterior column

Tear drop Integrity of medial wall and inferior portion of anterior and posterior column

Vertical migration

Integrity of superior dome

DEALING WITH OSTEOLYTIC LESIONS IN THE ACETABULUM Characterize Extent of Lesion Eliminate the Debris Generator Estimate Extent of Viable Host Bone ? Graft the Lytic Lesions ? Choice of Graft Material ? Biological Solution D) Bone loss in revision THR: Surgical Options

Dependent upon four radiographic criteria Kohler’s line Acetabular tear drop Ischial lysis Vertical migration

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1) Acetabular -large hemispherical cup -bone graft -autograft -allograft -morselllized -structural -high hip center -custom component -oblong cup -reinforcement ring -reconstruction ring -trabecular metal augments -cup and cage 2) Femoral -bone graft -autograft -allograft -morsalized -structural -whole bone - cortical struts E) Surgical options for Revision THR

-Cemented revision- the early results suggested that cemented revision THR had a higher failure rate and that uncemented revision was preferable. Recent data has supported the use of cemented revision, with impaction grafting when necessary, in some cases.

-Cemented Options -routine cement with 4th generation technique -impaction grafting Katz, Callaghan, Johnston JBJS-B 79(2) Mar 1997-Cemented Hip Revision -83 cemented revision THA -22% reoperation at 8-10 year -2 (2.5%) sepsis -3 (4%) dislocation

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-13 (16%) loose -5.4% femoral -16.0% acetabular

-Uncemented revision- many investigators feel that uncemented revision are preferable as they obviate the high failure rate reported for cemented

revisions. -Uncemented Options -Acetabulum high hip center jumbo cup oblong cup (bilobed cup) allograft protrusio shell Reinforcement Reconstructive trabecular metal augments Augment, Cage, Cup

The Fate of Cementless Jumbo Cups in Revision THR 43 Porous Jumbo cups used in 42 Patients. Mean age 63 yrs. ( range 25-86)

Morsallized allograft in 27 hips, Bulk Allograft in 8 5 Died; 2 Lost; 36 cases with minimum 10 year follow-up 2 cups Revised for loosening, 2 for Dislocation 92% Kaplan Meier Survival at 10 years.

Patel JV, Masonis JL, Bourne RB and Rorabeck CH. J Arthroplasty. 2003 Feb; 18 (2): 129-33 -Femur Unitized proxmially porous coated Extensively porous coated Modular Allograft Prosthetic composite

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FAILED ACETABULUM

IInnttaacctt AAnntt.. aanndd PPoosstt CCoolluummnnss

YYeess

LLaarrggee HHeemmiisspphheerriiccaall CCuupp

NNoo

PPeellvviicc DDiissccoonnttiinnuuiittyy

NNoo

RReeccoonnssttrruuccttiioonn oorr RReeiinnffoorrcceemmeenntt RRiinngg TTrraabbeeccuullaarr MMeettaall AAuuggmmeennttss CCuupp aanndd CCaaggee

YYeess

OORRIIFF AAPPOO

FAILED FEMUR

Yes

Establish proximal hoop stresses and diaphyseal fit (struts, osteotomy, etc.)

No

Modular implant

Establish diaphyseal fit (4cm x < 16 mm)

yes no

Extensively coated implant

Tapered stem Impaction graft Reduction osteotomy Allograft pros. Composite

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F) Author's preference

-In most revision situations, uncemented revision is preferable. In older patients cemented revision with 4th generation cementing is reasonable .In most revisions a modular implant is used. If proximally bone can not be made to carry hoop stresses, an extensively coated implant is used. Allografts are generally preferrable to custom components but the concerns about long term incorporation and disease transmission must be considered.

WHAT'S IN/WHAT'S OUT -REVISION HIP ARTHROPLASTY WHAT'S IN -Limited modularity -Extensively coated implants -Limited use of cancellous packing/Cemented revision (Impaction

Grafting) -Higher hip centers/protrusio cages/jumbo cups/?trabecular metal -Mechanical cement removal with windows/extended osteotomies -Cortical struts -Implant cost concerns WHAT'S OUT -Unitized prox. coated implants -Massive allografts that bear load -Acetabular allografts -Bipolars for revision -Custom components

II Adult Knee Reconstruction -Surgical options in non-inflammatory arthritis -arthroscopy, debridement, osteotomy, uni TKR, TKR -Surgical options in inflammatory arthritis -synovectomy(radiation, arthroscopic, open), TKR -Results of treatment -survivorship analysis,complications, future directions Adult Knee Reconstruction/Surgical options in non-inflammatory arthritis

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A. Non Arthroplasty Options -arthroscopic debridement -abrasion arthroplasty -osteochondral allograft -autologous chondrocyte implantation/mosaic -osteotomy -arthrodesis B. Arthroplasty Options -Unispacer -Unicompartmental knee arthropolasty (UKA) Fixed Mobile Patient Specific -Duocondylar -Isolated Patellofemoral -Total Knee Arthroplasty (TKA) Adult Knee Reconstruction/arthroscopic debridement,abrasion arthroplasty, open debridement -Bert (Arthroscopy 1989)- 126 patients (follow-up 60 mos. mean) Debridement good to excellent 66% fair 13% poor 21% worsened 15% Abrasion arthroplasty plus debridement good to excellent 51% fair 16% poor 33% worsened 20% - Johnson, L. 1990- results of abrasion arthroplasty (423 knees) asymptomatic 12% painful 66% using pain meds 44% loss of motion 24% limp 36% subsequent surgery 14% - Rand 1991-compared abrasion with debridement

Concluded that abrasion (50% of patients required TKR at 5 years) was no better than debridement (6improvement)

- Salisbury CORR 1985- results of abrasion arthroplasty 32% good or fair if in varus 94% goodor fair if in neutral

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-Magnuson 1941, Insall 1964-results of open debridement- 60 knees successful in 77% at 6.5 years

-Janzen et al. A J Roent. 169(3) Sept 1997-AVN Following Laser Menisectomy -2 cases of arthroscopic menis. with neodymium: yttrium alum. garnet laser leading to osteonecrosis

-MRI showed subchondral tibial & femoral AVN at 5–6 mos. -1 TKR, 1 HTO for continued symptoms - Current indications for specific treatment in non-inflammatory osteoarthritis Arthroscopy- evidence of internal derangement, normal alignment, preservation of joint space.

Arthroscopic debridement -impinging osteophytes (intercondylar, patellofemoral) -sealing techniques(not validated) Be Aware of the Prospective Studies of Arthroscopy in OA -Moseley/VA, Toronto, METEOR Open debridement-limited Marrow stimulation techniques -limited to focal (<1.5 cm.2) areas of eburnated bone in patient with reasonable alignment.

abrasion chondroplasty microfracture drilling

Autologous chondrocyte implantation-not for OA. changes in technique worse results following microfracture Osteochondral grafting-small lesions, suitable donor site OATS, mosaicplasty, COR, SDS Adult Knee Reconstruction/Osteotomy/UKR

Advantages of Osteotomy Compared with UKA/TKA -Biologic solution -Bone sparing

-No concerns of wear debris -Less activity restriction

Concerns With Osteotomy -Higher perioperative complication rate

-Longer Rehabilitation -Less pain relief -Less functional return

-Higher failure rates

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Factors Associated With Failure of Osteotomy -Obesity -High adduction moment -Subluxation -Greater than 50% loss of joint space -Laxity -Limited motion -Technical error -Undercorrection Results of Tibial Osteotomy Satisfactory pooled results of HTO from different centers- 85% at 2 years 75% at 5 years 40-60% at 10 years Pooled complications of HTO from different centers inadequate correction 20% recurrent varus 5-30% nonunion 1-3% infection 1-8% neurologic 1-10% vascular <1%

Increased interest in Opening Wedge HTO and HTO in Combination with Cartilage Repair

SPECIFIC DATA Long term Results(Varus) Coventry, JBJS,1993 -87 valgus HTOs with 3-14 yr. (mean 10 year follow up) -90% survivorship at 5yrs and 65% at 10 years if valgus angulation was 8 degrees or more and patient's weight was 1.32 times ideal weight or less. Otherwise, the survivorship was 38% at 5 years ands 19% at 10 years. Lootvoet et al, 1993 -8 year f/up of 193 valgus osteotomies -71% good results with 7.2% reoperation -statistically better results (p=0.0004) if tibio-femoral space is 50% of normal Yasuda et al, CORR, 1992

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-86 HTOs at 10-15 year follow up -88% 6yr. and 63% 10 year satisfactory results -best if tibiofemoral angle was 164-168 degrees. Odenbring et al, Acta Orthop Scand,1990 -314 HTOs 10-19 year follow up -32% revision in undercorrected knees -5% revision in normal or overcorrected knees -20% revised to TKR; 3% revised to HTO Long term Results (Valgus) Gross et al, JBJS,1988 -24 patients with varus femoral osteotomies for lat. OA -ave follow up of 4 years -22/24 with satisfactory results -best done medially with rigid fixation Edgerton, Mariani, and Morrey,CORR, 1993 -23 patients with varus femoral osteotomies for lat. OA -5-11 year f/up (ave. 8.3 years) -71% good/excellent results -high incidence of failure with staple fixation -13% conversion to TKR

Finkelstein, Gross et al. JBJS-A 78(9): 1348-52, Sept 1996 -1 knees (20 patients) Ave follow/up(97-240) -13 still successful 7 failed 1 died(functional) -survival 64% at 10 years Medial OA and Anterior Instability Lattermann and Jakob. Arthroscopy 4(1):32-38 1996 -30 patients:medial OA and ACL def:3 groups -1, HTO: 2, HTO and ACL: 3, HTO with ACL 6-12 mos later -Post op pain 1, 1/11: 2, 3/8 : 3, 2/8 -Post op pivot shift 1, 2/11: 2, 4/8: 3, 3/8 -Post op complications 1, 4/11: 2, 5/8: 3, 3/8 -High rate of major complications in Group 2 -If over 40 do HTO alone -If less than 40 do HTO and wait

Results compared with UKA Weale and Newman, CORR, 1994 -12-17 yr. f/up of 21 HTOs vs. 15 UKAs

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-42% good result, 12% revision with UKA -21% good result, 40% revision with HTO Broughton JBJS 1986 Results better with uni at 6 years UKR 76% good HTO 42% good Results of Failed HTO Converted to TKR Neyret et al, 1992 -TKR post HTO. -38 patients, mean 8.5 years post HTO -3 year mean follow up -as compared with primary TKR these patients decreased walking distance and less flexion (p< 0.001) - no difference in knee score Results of Unicompartmental Arthroplasty -Thornhill, Clark et al- UKR results 1991 AAOS 307 UKAs in 251 patients mean age 66.2 years;153 female/98 male mean f/up 4.2 years (range 2-9 years) 90% pain relief 13 knees revised (4.5%) wear- 5 knees progression of disease- 5 knees loosening - 2knees synovitis - 1 knee -Advantages of UKR preservation of bone stock, ACL, PCL, PF joint easier rehabilation than HTO and TKR fewer perioperative complications less metabolic demand Potential as an outpatient arthroscopic procedure (Minimally invasive) Cost benefits -Disadvantages of UKR technically demanding difficulty in patient selection -Strict contraindications to UKR inflammatory arthritis

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multicompartment disease severe deformity/subluxation non articular deformity ACL deficiency ? Patellofemoral Disease -Relative contraindications to UKR chondrocalcinosis ? osteonecrosis obesity

Results of Failed HTO Converted to TKR Neyret et al, 1992 -TKR post HTO. -38 patients, mean 8.5 years post HTO -3 year mean follow up -as compared with primary TKR these patients had decreased walking distance and less flexion (p< 0.001) - no difference in knee score Gill, Thornhill et al CORR 321: 10-18, Dec 1995 -Matched group of failed UKRs and HTOs UKRS had more revision problems with bone loss HTOs had more problem with exposure HTOs had better knee and function scores after revision -Results of Failed UKR Converted to TKR Levine, Thornhill et al: J Arthroplasty 11(7):797-801, Oct 1996 29 Patients (31 knees) failed RBBH UKR ave age 72.3 yrs (range(49-88) ave weight 179 lbs (range 112 -242) interval to revision ave 62 months (7-106) ave follow up 45 months (24-104) PCL sparing knees 30: One PCL sub TKR grafted contained defects 7 4 tibial and 2 femoral wedges no structural grafts knee and functional results similar to primary TKR -Current indications for UKR ~8-10% of patients with OA undergoing TKR

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transition patient between HTO and TKR elderly patient (especially with bilateral disease ?role of mobile bearing uni-TKR ?role of patient specific UKR WHAT'S IN/WHAT'S OUT-ARTHROSCOPY/OSTEOTOMY/UNI KNEE WHAT'S IN -Unloader braces/Hyaluronic acid gels -Glucosamine/Chondroitin Sulfate -Debridement, lavage and partial menisectomy -HTO earlier in the disease process -Rigid fixation for HTO -Metaphyseal or dome osteotomy for large corrections -Staging of combined HTO and ACL reconstruction -Minimally invasive unicompartmental arthroplasty WHAT'S OUT -Arthroscopy with primary diagnosis of OA -Abrasion chondroplasty -Osteotomy without rigid fixation -Osteotomy for the elderly Adult Knee Reconstruction/Total Knee Arthroplasty A Cruciate Sacrificing 1. Insall- Total Condylar (1974-1986) 7 yr survivorship (revision defines failure)-93% 10 yr survivorship-90% 2 Ranawat- Total Condylar 8-11 yr (112 TKRs) 11 yr survivorship-94% B Cruciate Substituting 1. Insall- Posterior Stabilized 7 yr survivorship- 97% 10 yr survivorship-97% C Cruciate Sparing

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1 Wright et al- Kinematic (5-9yr) 98% survivorship 88.6% good/excellent 2 Martin, Scott and Thornhill PFC(5-9 yr) J Arth 12 (6): 603-14, 1997 Sept 378 TKRs (290 patients) KSS 28-pre 88-post no loosening failures predominately with metal backed patellae 3 Rotating bearing designs Jordan et al. CORR 338 May 1997- Meniscal Bearing TKR -473 LCS MB TKRS (375 pts) -Avg 5 yr f/up -17 bearing failures -12 fracture/dislocation -5 tibial subluxation 4 High Flex Designs

High incidence of loosening of the femoral component in legacy posterior stabilized-flex total knee replacement

• 72 NexGen legacy posterior stabilized high flexed total knee

replacements in 47 patients were studied • Aseptic loosening was found in 27 (38%) and a mean follow-up of 32

months • 15 knees (21%) required revision at a mean of 23 months • Postoperatively, the mean maximum flexion was 136° in the loosened

group and 125° in the well-fixed group

Han HS, Kang SB, Yoon KS. JBJS(B). 2007 Nov;89(11):1457-61

5 Gender Specific/Patient Specific D Gait Study Comparisons 1 Andriacchi-JBJS 1972- PCL sparing knees better on stairs. 2 Dorr-CORR 1988- PCL sacrificing TKR required more work from Quadriceps, B. Femoris, and Soleus 3 Kelman-CORR 1989- PCL Sparing knees performed like normal contralateral knee.

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E. Prosthetic options Posterior cruciate 1. Cruciate sparing 2. Cruciate augmentation 3. Cruciate sacrifice 4. Cruciate substitution 5. Constrained Bearing configuration flat and fixed conforming and fixed meniscal bearing rotating platform F Fixation Options (Potential concerns) 1 Cemented (bone stock loss, fem. stress distribution) 2 Uncemented (tibial fixation, metal backed patellae) -press fit (fibrous ingrowth) -porous coated (cost, metal toxicity) -screw fixation (screw osteolysis) 3 Hybrid -cemented patellar button - cemented tibia -plateau only (requires uniform and strong proximal tibial bone) -plateau and keel - uncemented femur Minimally Invasive Techniques Quad Sparing Subvastus Midvastus No Patellar Eversion Computer Assisted Techniques Advantages Limits Outliers in Alignment Marketing Suitable for Minimally Invasive Disadvantages Cost Surgical Time Not Ideal for Soft Tissue Balance Microarrays are Invasive and Cumbersome

48

Gender Specific Issues Patient Specific Designs (Pre Operative Navigation) MR or CT based Patient Specific Components/Instruments -Uni, Duo, TKR Disposable Instruments WHAT'S IN/WHAT'S OUT KNEE ARTHROPLASTY WHAT'S IN -Cemented arthroplasty -Patellar resurfacing -Improved contact areas/minimum of 8mm poly -Limited or controlled Modularity -Minimally Invasive Techniques -Computer Assisted Surgery -? Use of Moderately Cross linked Polyethylene WHAT'S OUT -Uncemented tibial fixation -Tibial screw fixation -flat inserts -gamma irradiated polyethylene in air -Metal backed patellas -Titanium bearing surfaces WHAT'S IN/WHAT'S OUT-REVISION KNEE ARTHROPLASTY WHAT'S IN -Press fit stems -Modular systems -Wedges for bony defects -Delayed exchange for infected TKR WHAT'S OUT -Fully uncemented revision -Cemented long stems -Custom implants -Hinge designs Adult Knee Reconstruction/TKR Complications

49

A Malalignment and loosening related to patient selection, design considerations and surgical technique B Soft tissue imbalance related to surgical technique differences between PCL sparing, sacrificing and substitution C Patellofemoral problems fracture loosening wear metal backed concerns subluxation/dislocation avascular necrosis D Infection Incidence-single institution -TKR- Wilson, Kelley, Thornhill JBJS 1990 -1973-1987 -4171 TKRs -67 (1.6%) infections -predominantly late hematogenous infection Risk Factors -Wilson, Kelley, Thornhill JBJS 1990-TKR -significant factors (p< .05) -RA -RA male -Skin breakdown -Prior surgery in OA -associated factors (p> .05) -Obesity -UTI -Steroid use in RA -not associated -Age -Weight (RA) -Prior Surgery (RA) -Non RA medical conditions Diagnosis -Exam -swelling, drainage, erythema, tenderness, warmth -Lab -acute phase reactants, leukocytosis, synovial analysis wound cultures, blood cultures

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-Radiographic -plain films, scintigraphy, arthrograms Prevention -Predominant organisms Emerging organisms -Staph Aureus -Meth. res. Staph aureus(MRSA) -Staph Epi. -Meth. res. Staph epi.(MRSE) -Streptococci -Enterococci -Strep faecium -VREF -Preoperative Screening -Mupirocin Treatment of carriers -Antibiotics in Cement Revisions High Risk Patients ? All TJRs -Systemic antibiotics -Cefazolin 1 GM IV at surgery 1 GM IV q8 hr X 24 hrs. - Cefuroxime 1.5 GM IV at surgery 750 MG IV q8 hr X 24 hrs. -? Vancomycin 1 GM IV (slowly) at surgery 0.5-1 GM IV q12 hr X 24 hrs. - if penicillin anaphylaxis or cephalosporin allergy, use vancomycin as above. -Late Antibiotic Prophylaxis (significant dental, GI, GU) -Amoxycillin 3 GR. PO 1 hr before - Erythromycin 1 GM PO 1 hr before -Indications for late prophylaxis -all patients who tolerate treatment -all high risk patients

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- OR Environment -Ultraviolet lights -2537 A -Vertical laminar flow -Horizontal laminar flow -Exhaust system -Greenhouse - J.P.Nelson Hip Society 1977 There is a significant decrease in infection with IV antibiotics. Addition of vertical laminar flow further reduces infection as does ultraviolet light (UV not significant secondary to low numbers) - Lidwell et al In a conventional OR, IV antibiotics reduces the infection rate from 3.4% to 0.8%. Addition of ultraclean air and exhaust systems further reduces the incidence of infection. - Salvati et al JBJS 64A 1982 horizontal laminar flow reduced the incidence of infection in THR but not TKR. -Planning of skin incision -dissect below deep investing fascia -avoid large skin flaps -honor previous incisions (especially lateral incisions) -Meticulous surgery -avoid dead space -handle tissues carefully -efficient operative time -close quadriceps tendon in two layers -Antibiotic Irrigation

- if a tourniquet is used antibiotics are necessary to provide a local antibiotic environment.

-Antibiotics in Cement -indications -immunosupressed patient -systemic illness -presence of risk factors -revision surgery -usual choices

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-Gentamicin 0.5- 1.0 gm/40 gm -Cephamandole 1.0 gm/40 gm -Tobramycin 600 mg/ 40 gm

- Treatment options (all include the use of intravenous antibiotics) -Prosthesis retention -aspiration alone -debridement -arthroscopic -open -Prosthesis exchange -immediate -intermediate - Delayed -CPM -spacers -prostalic -Salvage -arthrodesis -resection arthroplasty -amputation Long Term Suppression Of Infection in Total Joint Arthroplasty All Patient underwent Debridement, 4-6 Weeks of IV Antibiotics with Prosthesis Retention. At

5 years overall success was 86.2% and 69% for Staph Aureus. This is a Viable Option in Patients not suitable for Prosthesis Removal.

Rao N, Crossett LS et al. Clin Orthop. 2003 Sept; (414); 55-60. - Factors affecting choice of treatment -host factors -delay in diagnosis -type of prosthesis -organism -radiographs

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-skin and soft tissue -response to treatment - Indications/Results for Specific Treatment Option Indication for Aspiration -early detection (<48 hrs.) -penicillin sensitive streptococci -rapid clinical response -decreased effusion, lower synovial WBCs, negative cultures, no systemic toxicity. -no synovial reaction Results of Aspiration

-Wilson, Kelley, Thornhill JBJS 1990 -5 of 12 TKRs free of infection off antibiotics. When above criteria are applied the results have been favorable in a small series.

-Bengston et al Acta Orthop Scand. 1991- 357 infected TKRs. There was only a 15% success rate with aspiration and antibiotics alone.

Indications for Open Debridement -not suitable for aspiration alone -early detection -no radiographic loosening, osteolysis, periosteal reaction -no malalignment -immunocompetent host -sensitive organism Results of Open Debridement

-Borden et al J. Arthroplasty 1987.- 11 infected TKRs. (mean f/up 51 mos.) 6 failures (55%)

-Wilson, Kelley, Thornhill JBJS 1990- 42 infected TKRs. (31 knees>2 yrs.) mean f/up 43 mos. 14 failures (45%). Staph aureus was a poor organism for consideration of prosthesis retention.

-Schoifet, Morrey JBJS 79(2) 1990.-31 infected TKRS (27 patients) mean f/up 8.8 yrs. 77% recurrence Staph aureus was associated with a 58% failure.

-Bengston et al Acta Orthop Scand. 1991- overall 24% success rate with soft tissue surgery

Indication for Early Exchange

The indications for early or immediate exchange are unclear as most series are small. Moreover, newer antibiotics and treatment regimens may increase these indications.

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At present, immediate exchange is considered when there is a loose or malaligned TKR that otherwise fulfills all other criteria for aspiration alone.

Results of Early/Immediate Exchange

-Mayo Clinic 14 acute infected TKRs 6/7 low virulence and 2/7 high virulence were salvaged but overall there was only a 35% satisfactory functional result.

-Bengston et al Acta Orthop Scand. 1991.- overall 75% success rate with revision surgery with no difference between one and two stage procedures

-vonFoerster ENDO Clinic 1991-104 infected TKRs 5-15 yr, f/up 73% cure with single exchange and overall 84% cure with second exchange.

Indication for Delayed Exchange

This is the principle treatment option utilized in most cases. The protocol involves removal of all components and closure over large drains. Cement spacers or prostalac systems impregnated with antibiotics may be used. The interval to reimplantation is variable and determined in conjunction with an infectious disease consult. Reimplantation is by standard techniques using antibiotic impregnated cement.

Results of Delayed Exchange

-Windsor, Insall et al JBJS 1990.-38 infected TKRs (35 pts.) 4 yrs. ave. f/up (2.5-10 yrs) Overall 89.5% success rate.

-Wilson, Kelley, Thornhill JBJS 1990- 24 infected TKRs. Mean f/up 34 mos. Overall 80% success rate.

-Borden et al J. Arthroplasty 1987.- 11 infected TKRs. Mean f/up 2 yrs. Overall 91% success rate.

-Teeny, Dorr et al J Arthroplasty 1990. 9 infected TKRs with 100% success rate with delayed exchange as compared to a 77% failure rate in 21 infected TKRs treated with prosthesis retention.

Indication for Arthrodesis -resistant organisms -immunocompetent host -failure of delayed exchange -inadequate skin or soft tissues Results of Arthrodesis -Bengston et al Acta Orthop Scand. 1991.- overall 88% success rate in 135 infected TKRs Indications for Resection Arthroplasty

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-failure of arthrodesis -non ambulatory patient Results of Resection Arthroplasty

-Falahee, Matthews, Kaufer JBJS 69(A) 1013-1021, 1987- 28 infected TKRs (26 pts) Overall 89% success of controlling local and systemic infection. Six knees required 2o arthrodesis and 3 spontaneously fused.

Indications for Amputation -failure of all other treatment options - life threatening situation

SELECTED ANNOTATED HIP AND KNEE REFERENCES 2010

The posterior approach reduces the risk of thin cement mantles with a straight femoral stem design. Macpherson GJ, Hank C, Schneider M, Trayner M, Elton R, Howie CR, Breusch SJ. Acta Orthop. 2010 Jun;81(3):292-5. Two hundred seventy patients underwent cemented Exeter total hip arthroplasty. 135 stems used the anterolateral approach and 135 stems the posterior approach. All radiographs were graded according to Gruen zones. With a straight femoral stem design, the posterior approach gave a lower risk of a thin cement mantle. Validity of frozen sections for analysis of periprosthetic loosening membranes. Tohtz SW, Müller M, Morawietz L, Winkler T, Perka C. Clin Orthop Relat Res. 2010 Mar;468(3):762-8. Epub 2009 Sep 19. This study analyzes the benefit of frozen section in evaluating 64 patients who underwent exchange for failed total hip replacement. Eighty percent of the sample tested at frozen section correlated with the results found at permanent section. The authors recommend this technique for evaluating hip revision membranes.

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Incidence of lateral femoral cutaneous nerve neuropraxia after anterior approach hip arthroplasty. Goulding K, Beaulé PE, Kim PR, Fazekas A. Clin Orthop Relat Res. 2010 Sep;468(9):2397-404. This study examined the incidence of injury to the lateral femoral cutaneous nerve in 132 patients who underwent an anterior hip approach. Eighty one percent of the patients reported some evidence of neuropraxia. Most patients had a decrease in symptoms over time. Hip resurfacing data from national joint registries: what do they tell us? What do they not tell us? Corten K, MacDonald SJ. Clin Orthop Relat Res. 2010 Feb;468(2):351-7. The authors reviewed the results of hip resurfacing from metal-on-metal hip resurfacing implants. Patients with a diagnosis other than primary osteoarthritis had a higher risk of early revision. Revision of surface replacement had a re-revision rate of 11% at 5 years. The influence of head size and sex on the outcome of Birmingham hip resurfacing. McBryde CW, Theivendran K, Thomas AM, Treacy RB, Pynsent PB J Bone Joint Surg Am. 2010 Jan;92(1):105-12. This study looked at head size and gender on the outcome of hip resurfacing and found that female gender was not in itself a risk factor but that a smaller head size led to greater risk. Histological features of pseudotumor-like tissues from metal-on-metal hips. Campbell P, Ebramzadeh E, Nelson S, Takamura K, De Smet K, Amstutz HC Clin Orthop Relat Res. 2010 Sep;468(9):2321-7. This article reviewed the histological features of pseudotumor and attempted to differentiate between excessive wear and metal hypersensitivity. They reviewed 32 revised hip replacements and found that those patients with suspected high wear had fewer lymphocytes but more macrophages and metal particles than those tissues revised for pain and suspected metal hypersensitivity. Inferior outcome after hip resurfacing arthroplasty than after conventional arthroplasty. Evidence from the Nordic Arthroplasty Register Association (NARA) database, 1995 to 2007.

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Johanson PE, Fenstad AM, Furnes O, Garellick G, Havelin LI, Overgaard S, Pedersen AB, Kärrholm J. Acta Orthop. 2010 Oct;81(5):535-41. This is a review from the Nordic Arthroplasty Registry and compared hip resurfacing with conventional arthroplasty and found that resurfacing had an almost threefold increased revision rate compared to THA. Femoral head size and wear of highly cross-linked polyethylene at 5 to 8 years. Lachiewicz PF, Heckman DS, Soileau ES, Mangla J, Martell JM. Clin Orthop Relat Res. 2009 Dec;467(12):3290-6. Epub 2009 Aug 19. The authors studied 146 hips implanted in 90 patients with a minimum follow up of 5 years. The mean linear wear rate was 0.028 mm per year and the median volumetric weight was 25.6 mm3 per year. There was no association between femoral head size and linear wear rate, but there was an association between a larger head size and volumetric wear. The authors urged caution in using large femoral heads in young and active patients. Risk of complication and revision total hip arthroplasty among Medicare patients with different bearing surfaces. Bozic KJ, Ong K, Lau E, Kurtz SM, Vail TP, Rubash HE, Berry DJ. Clin Orthop Relat Res. 2010 Sep;468(9):2357-62. This study reviewed the Medicare database and found that in Medicare patients a hard on hard bearing had no benefit and, given the higher cost may not be indicated in the Medicare patient. The risk of revision after primary total hip arthroplasty among statin users: a nationwide population-based nested case-control study. Thillemann TM, Pedersen AB, Mehnert F, Johnsen SP, Søballe K. J Bone Joint Surg Am. 2010 May;92(5):1063-72. The authors compared the revision rate in patients taking statin therapy versus those not taking the drug. This review was of 58,000 total hip arthroplasties with a cumulative revision rate of 8.9%. Statin use was associated with a reduced risk of revision due to deep infection, aseptic loosening, dislocation and periprosthetic fracture. No difference in the risk of revision due to pain or implant failure was found.

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Dislocation after total hip arthroplasty with 28 and 32-mm femoral head. Amlie E, Høvik Ø, Reikerås O. J Orthop Traumatol. 2010 Jun;11(2):111-5. Epub 2010 May 27. This retrospective study of 2572 primary total hip arthroplasties compared dislocation rate with 28-mm or 32-mm diameter femoral heads. The authors found that a 32-mm head had a reduced incidence of dislocation, with dislocations occurring in 49 hips with a 28 femoral head and 4 hips with a 32 femoral head. The authors did not compare this with acetabular component size. Delamination of a highly cross-linked polyethylene liner associated with titanium deposits on the cobalt-chromium modular femoral head following dislocation. Patten EW, Atwood SA, Van Citters DW, Jewett BA, Pruitt LA, Ries MD. J Bone Joint Surg Br. 2010 Sep;92(9):1306-11. This is a single case report of a revision of a total hip with highly cross-linked polyethylene that had undergone recurrent dislocation. At revision there were large areas of visible delamination, and the authors concluded that the cobalt chrome modular femoral head had scraped against the titanium shell and had transferred deposits of titanium which led to the delamination. Reduced dislocation rate after hip arthroplasty for femoral neck fractures when changing from posterolateral to anterolateral approach. Sköldenberg O, Ekman A, Salemyr M, Bodén H Acta Orthop. 2010 Oct;81(5):583-7. . This study reaffirms the reduced dislocation rate when total hip arthroplasty was performed for femoral neck fractures. There were 199 fractures in 2007 in which 77% were done through a posterolateral approach. In 2008, 78% were operated on with an anterolateral approach. Switching to the anterolateral approach reduced the dislocation from 8% to 2%. Retrospective analysis of infection rate after early reoperation in total hip arthroplasty. Darwiche H, Barsoum WK, Klika A, Krebs VE, Molloy R. Clin Orthop Relat Res. 2010 Sep;468(9):2392-6. The authors performed a retrospective analysis of 60 patients undergoing revision total hip as an unplanned and unavoidable return to the operating room during the acute recovery phase. This was due to instability, periprosthetic fracture, retained hardware and nerve exploration. The minimum follow-up averaged 3.7 years and the goals were to study the infection rate and implant survivorship.

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The infection rate for the cohort was 33%. Six of these 20 infected hips retained their implants at 2 years. This study underscores the high incidence of complications following early return to the OR. The impact of obesity on weight change and outcomes at 12 months in patients undergoing total hip arthroplasty. Dowsey MM, Liew D, Stoney JD, Choong PF Med J Aust. 2010 Jul 5;193(1):17-21. This study underscores the higher complication rate in obese patient. The authors studied 529 patients undergoing primary total knee arthroplasty using conventional body mass index rates with nonobese less than 30, obese 30-39 and morbidly obese greater than 40. Overall, 60% were obese or morbidly obese. At 12 months, a significant weight loss (5% or greater) had occurred in 21% of patients but a significant gain in 21%. Adverse events occurred in 14.2% of the nonobese patients, 22.6% in the obese group and 35% in the morbidly obese. Perioperative outcomes after unilateral and bilateral total knee arthroplasty. Memtsoudis SG, Ma Y, González Della Valle A, Mazumdar M, Gaber-Baylis LK, MacKenzie CR, Sculco TP Anesthesiology. 2009 Dec;111(6):1206-16. This study from Hospital for Special Surgery, the authors compared their experience with bilateral versus staged total knee arthroplasty. They concluded that staging bilateral knee replacement during the same hospitalization offered no mortality benefit and may even expose patients to increase morbidity. They also stated that bilateral knee replacement even in a selected group of patients had a higher complication rate than a unilateral procedure. They did not, however, add complication rate of a second total knee replacement from a separate hospitalization. Risk of revision for infection in primary total hip and knee arthroplasty in patients with rheumatoid arthritis compared with osteoarthritis: a prospective, population-based study on 108,786 hip and knee joint arthroplasties from the Norwegian Arthroplasty Register. Schrama JC, Espehaug B, Hallan G, Engesaeter LB, Furnes O, Havelin LI, Fevang BT. Arthritis Care Res (Hoboken). 2010 Apr;62(4):473-9. This is a study from the Norwegian Arthroplasty Registry based on the population study of 108 thousand patients and concluded that rheumatoid patients had a 1.6 times higher rate a revision for infection than osteoarthritis patients in total knee, but there was no difference in total hip replacement. The risk of revision for infection as a late hematogenous event was higher in rheumatoid patients as well.

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Total knee replacement in patients with end-stage haemophilic arthropathy: 25-year results. Goddard NJ, Mann HA, Lee CA J Bone Joint Surg Br. 2010 Aug;92(8):1085-9. This is a British study reviewing 70 primary total knee replacements performed in 57 hemophiliac patients between 1983-2007. Six patient had died at, 60 knees were available at 9.2 years followup and 95% had good or excellent results. There was 1 deep infection. Using infection and aseptic loosening as an endpoint, the survival rate at 20 years was calculated to be 94%. Two-stage exchange knee arthroplasty: does resistance of the infecting organism influence the outcome? Kurd MF, Ghanem E, Steinbrecher J, Parvizi J Clin Orthop Relat Res. 2010 Aug;468(8):2060-6. This study reviewed the reinfection rate after 2-stage exchange arthroplasty, calculated risk factors that would predict failure and the variables associated with acquiring a resistant organism. One hundred and two patients with infected total knee underwent a 2-stage procedure, 96 patients had a minimum follow-up of 2 years. Two-stage exchange arthroplasty was successful in 70 patients. Those who failed had a 3.4 times greater likelihood to have a methicillin-resistant organism. Older age, a high BMI and a history of thyroid disease were associated with a higher incidence of resistance organisms. These data suggest that the emergent resistant organisms may decrease the likelihood of a successful 2-stage exchange. Cruciate-retaining TKA using a third-generation system with a four-pegged tibial component: a minimum 10-year followup note. Schwartz AJ, Della Valle CJ, Rosenberg AG, Jacobs JJ, Berger RA, Galante JO. Clin Orthop Relat Res. 2010 Aug;468(8):2160-7. Epub 2010 May 4. This is a follow-up of a third generation cruciate retaining total knee with a 4 peg tibial component. One hundred sixty-one patients underwent 179 total knee replacements. All components were cemented and the patella was resurfaced. Forty patients with 44 knees had died. For the remaining patients mean follow-up was 10 years. Survivorship with revision for any reason was 97.7%. Three knees were revised, 1 for infection, 1 for fracture and 1 for arthrofibrosis. Comparison of a standard and a gender-specific posterior cruciate-substituting high-flexion knee prosthesis: a prospective, randomized, short-term outcome study. Kim YH, Choi Y, Kim JS. J Bone Joint Surg Am. 2010 Aug 18;92(10):1911-20. This is a review of the gender specific high flexion cruciate substituting total knee arthroplasty. Eighty-five patients (170 knees) received a cruciate substituting high flex knee on one

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side and a gender specific cruciate substituting high flex knee in the contralateral knee with a mean duration of follow-up of 2.13 years. All patients were female. Postoperative Knee Society Scores were 95.5 points in the standard group and 96.5 in the gender specific group. There was no difference in the range of motion, the patient's satisfaction or radiographic results. The femoral component in the standard group fit significantly better than in the gender specific group. These authors showed no clinical benefits of the gender specific knee. Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA: a prospective trial. Burnett RS, Aggarwal A, Givens SA, McClure JT, Morgan PM, Barrack RL Clin Orthop Relat Res. 2010 Jan;468(1):127-34. Epub 2009 Aug 11. These authors question whether prophylactic antibiotics should be with held prior to cultures taken at revision total knee arthroplasty. Twenty-five patients with 26 infected total knees with a known preoperative infecting organism were studied. Antibiotic prophylaxis was then given prior to intraoperative cultures. The use of perioperative antibiotics prior to culture did not affect the interoperative culture results. Isolated tibial polyethylene insert exchange outcomes after total knee arthroplasty. Willson SE, Munro ML, Sandwell JC, Ezzet KA, Colwell CW Jr. Clin Orthop Relat Res. 2010 Jan;468(1):96-101. Epub 2009 Aug 12. This study reviewed isolated tibial polyethylene insert exchange after total knee arthroplasty. Forty-two patients were studied at a minimum follow-up of 2 years. The authors found that isolated tibial polyethylene exchange had only a 58% survivorship at 11 years. The group who underwent exchange less than 3 years from index arthroplasty had a higher failure rate. A prospective randomized study of minimally invasive total knee arthroplasty compared with conventional surgery. Wülker N, Lambermont JP, Sacchetti L, Lazaró JG, Nardi J. J Bone Joint Surg Am. 2010 Jul 7;92(7):1584-90. The authors prospectively randomized 134 patients to undergo total knee arthroplasty with either a minimally invasive or standard approach. They found no significant difference in terms of range of motion, Knee Society Scores, pain scores or activities of daily living. The patients with MIS surgery had a longer mean surgical time and less mean blood loss. The authors found no advantage to a minimally invasive approach.

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SELECTED TKR REFERENCES 2009

Range of motion of standard and high-flexion posterior cruciate-retaining total knee prostheses a prospective randomized study. Kim YH, Choi Y, Kim JS J Bone Joint Surg Am. 2009 Aug;91(8):1874-81. 54 patients (mean age 69.7 years) received a standard posterior cruciate retaining total knee on one side and a high flexion posterior cruciate retaining total knee prosthesis on the contralateral side. At a mean three years postoperatively, there were no significant differences in WOMAC, Knee Society or HSS scores. Postoperatively, the mean ranges of motion weightbearing/non wgt bearing was 131 degrees and 115 degrees for the standard prosthesis, and 133 degrees and 118 degrees for the high flex design. There were no significant differences between the two groups. The impact of obesity on the mid-term outcome of cementless total knee replacement. Jackson MP, Sexton SA, Walter WL, Walter WK, Zicat BA. J Bone Joint Surg Br. 2009 Aug;91(8):1044-8. 535 consecutive primary cementless total knee replacements were performed with a mean follow-up of 9.2 years. 153 obese patients (BMI greater than 30) and 382 nonobese patients were studied. There was a significant lower mean improvement and lower postoperative total clinical score in the obese group. There was no difference in rate of radiographic osteolysis or lucent lines, and no difference in alignment. Ten year survivorship was 96.4% in the obese and 98% in the nonobese cohort. While mid term survival is similar in the two groups, obesity appears to have a negative impact on the clinical outcome. The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. Marchant MH Jr, Viens NA, Cook C, Vail TP, Bolognesi MP. J Bone Joint Surg Am. 2009 Jul;91(7):1621-9.

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This study uses the Nationwide Inpatient sample which recorded over one million patients undergoing This total joint replacement. The present study compared 3973 patient with uncontrolled diabetes relative to 105,485 patients with controlled diabetes. Patients with uncontrolled diabetes had significant increased odds of stroke, urinary tract infection, ileus, postoperative hemorrhage, wound infection, hospital length of stay and death. All-polyethylene compared with metal-backed tibial components in total knee arthroplasty at ten years. A prospective, randomized controlled trial. Bettinson KA, Pinder IM, Moran CG, Weir DJ, Lingard EA. J Bone Joint Surg Am. 2009 Jul;91(7):1587-94 This study reviews 510 patients with 566 total knees with the mean patient age of 69.3 years. Ten year survivorship with revision as the end point for both metal back and all polyethylene tibial components was similar. Fifteen-year survival and osteolysis associated with a modular posterior stabilized knee replacement. A concise follow-up of a previous report. Lachiewicz PF, Soileau ES J Bone Joint Surg Am. 2009 Jun;91(6):1419-23. This is a followup report of a group of patients who underwent a modular posterior stabilized total knee replacement with mechanical failure as the endpoint. The 15 years survival was 96.8% with failure defined as reoperation. The 15 years survivorship with failure defined as reoperation was 90.6%. Early recovery after total knee arthroplasty performed with and without patellar eversion and tibial translation. A prospective randomized study. Dalury DF, Mulliken BD, Adams MJ, Lewis C, Sauder RR, Bushey JA J Bone Joint Surg Am. 2009 Jun;91(6):1339-43. This study considers the impact of patellar eversion and tibial translation on the outcome of total knee arthroplasty. Forty patients were prospectively randomized into one of two treatment groups. In group 1, the patellar was everted, and in the group 2 the patella was subluxed but not everted. At six weeks, there were no significant differences with regard to range of motion, quadriceps strength or knee society scores. At 12 weeks and 6 months, there were no differences seen and no difference in the patient preference.

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The effect of an intravenous bolus of tranexamic acid on blood loss in total hip replacement. Rajesparan K, Biant LC, Ahmad M, Field RE. J Bone Joint Surg Br. 2009 Jun;91(6):776-83. This study reviews the effect of tranexamic acid as a fibrinolytic agent to reduce blood loss in total joint surgery. A standard 1 gram intravenous bolus was given at the induction of anesthesia in patients undergoing total hip replacement. 36 patients receiving the drug were compared to 37 standard THRs. Tranexamic acid reduced the early postoperative blood loss and total blood loss, but not the intraoperative blood loss. The tranexamic acid group required fewer transfusions and had no increase in deep venous thrombosis. How often do patients with high-flex total knee arthroplasty use high flexion? Huddleston JI, Scarborough DM, Goldvasser D, Freiberg AA, Malchau H. Clin Orthop Relat Res. 2009 Jul;467(7):1898-906. This study reviews 20 consecutive patients who have high flexion TKA reviewed at two years. The patient wore a validated smart activity monitor to document the prevalence of knee flexion greater than 90 degrees. Activities performed with flexion greater than 90 degrees were, on average, 70% in single leg stance, 12% moving from sitting to standing, 8% walking. 7% moving from standing to reclining, 2% stepping, 1% moving from lying to standing, and 0.1% running. The patients studied in this group rarely used deep flexion. Periprosthetic infection due to resistant staphylococci: serious problems on the horizon. Parvizi J, Azzam K, Ghanem E, Austin MS, Rothman RH. Clin Orthop Relat Res. 2009 Jul;467(7):1732-9. This study reviewed the results of treatment of periprosthetic infection caused by resistant Staphylococcus species. Debridement controlled the infection in only 30% of cases, whereas delayed exchange arthroplasty controlled the infection in 75% of hips and 60% of knees. These data are worse than previously reported indicating increased virulence for these organisms

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Functional outcome and range of motion of high-flexion posterior cruciate-retaining and high-flexion posterior cruciate-substituting total knee prostheses. A prospective, randomized study. Kim YH, Choi Y, Kwon OR, Kim JS. J Bone Joint Surg Am. 2009 Apr;91(4):753-60. This study is similar to the above reported study from the same institution comparing a standard versus high flex cruciate retaining in the present study. Similar observations were made in a standard and high flex cruciate substituting knee. There were no differences in WOMAC score, Knee Society score or HSS score. The mean nonweightbearing and weightbearing range of motion was 133 degrees and 118 degrees in the standard group, and 135 degrees and 122 degrees in high flex design. This study reported no significant differences between the groups. The intra-operative joint gap in cruciate-retaining compared with posterior-stabilised total knee replacement. Matsumoto T, Kuroda R, Kubo S, Muratsu H, Mizuno K, Kurosaka M. J Bone Joint Surg Br. 2009 Apr;91(4):475-80.

This paper reviews the use of a tensor for total knee replacement, which was designed to assist with soft tissue balancing throughout the range of motion. Measurement of the joint gap with a reduced patella in posterior stabilized knees increased from extension to flexion. For cruciate retaining TKRS the gap was similar throughout a full range of motion. The joint gaps at the knee flexion were significantly smaller for both types of prosthetic knee when the patellofemoral joint was reduced. This study underscores the importance of the quadriceps mechanism in determining flexion gap during knee replacement. Analysis of the outcome in male and female patients using a unisex total knee replacement system. Dalury DF, Mason JB, Murphy JA, Adams MJ. J Bone Joint Surg Br. 2009 Mar;91(3):357-60. This report reviews 1970 cruciate retaining knees implanted in 920 women and 592 men with a mean aged 69.7 years. At a mean followup of 7.3 years, there were minimal differences in the outcome between genders. Men had a higher overall Knee Society score and more osteolysis. There were no significant differences between men and women in terms of complications or improvement in

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function, pain score or range of motion. The 10-year survivorship was 97% in women and 98% in men. There were no gender differences seen. Staged revision for knee arthroplasty infection: what is the role of serologic tests before reimplantation? Ghanem E, Azzam K, Seeley M, Joshi A, Parvizi J. Clin Orthop Relat Res. 2009 Jul;467(7):1699-705. This reviewed the diagnostic value of sedimentation rate and C-reactive protein as an indicator to reimplanting an infected implant as a second stage procedure. The authors found that both of these acute phase reactants are poor predictors of reinfection and that other markers should be evaluated. Outcome of a second two-stage reimplantation for periprosthetic knee infection. Azzam K, McHale K, Austin M, Purtill JJ, Parvizi J. Clin Orthop Relat Res. 2009 Jul;467(7):1706-14. This study reviewed 18 patients with failed two-stage total knee arthroplasties treated with a second two-stage reimplantation. Minimal followup was 24 months. Recurrent or persistent infection was diagnosed in 4 of 18 patients, two of whom were successfully treated with a third two-stage arthroplasty. The authors suggest that a repeat two-stage arthroplasty is a reasonable option for treating these patients. Limitations of structural allograft in revision total knee arthroplasty. Bauman RD, Lewallen DG, Hanssen AD. Clin Orthop Relat Res. 2009 Mar;467(3):818-24. This paper reviews the outcome of treatment of major bone defects treated with a structural allograft at the time of knee revision. 74 patients with 79 knees were evaluated at a minimum five years. 65 patients and 70 knees were available for review. 16 patients (22.8%) had failed reconstructions and underwent additional revision surger. 8 of the 16 were secondary to the allograft failure. An additional 3 were secondary to failure of a component not supported by an allograft and 5 became infected. The revision free survivorship in this study was 80.7% at 5 years and 75.9% at 10 years.

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Case reports: Tantalum debris dispersion during revision of a tibial component for TKA. Sanchez Marquez JM, Del Sel N, Leali A, González Della Valle A. Clin Orthop Relat Res. 2009 Apr;467(4):1107-10. This is a case report of tantalum debris seen during revision of a tibial component. The authors revised 3 well fixed tantalum tibial trays. The component was removed with osteotomes and oscillating saws. They state that the removal of the components was laborious and resulted in generation of abundant tantalum debris that seeded the periarticular soft tissues, despite meticulous protection with gauze. The retained debris was visible on postoperative radiographs.

SELECTED HIP REFERENCES 2009 Total hip arthroplasty with shortening subtrochanteric osteotomy in Crowe type-IV developmental dysplasia. Krych AJ, Howard JL, Trousdale RT, Cabanela ME, Berry DJ. J Bone Joint Surg Am. 2009 Sep;91(9):2213-21. Medium-term outcome of periacetabular osteotomy and predictors of conversion to total hip replacement. Troelsen A, Elmengaard B, Søballe K. J Bone Joint Surg Am. 2009 Sep;91(9):2169-79.

Intermediate to long-term results following the Bernese periacetabular osteotomy and predictors of clinical outcome. Matheney T, Kim YJ, Zurakowski D, Matero C, Millis M. J Bone Joint Surg Am. 2009 Sep;91(9):2113-23.

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Fulfillment of patients' expectations for total hip arthroplasty. Mancuso CA, Jout J, Salvati EA, Sculco TP. J Bone Joint Surg Am. 2009 Sep;91(9):2073-8. Acetabular revision with impacted morsellised cancellous bone grafting and a cemented acetabular component: a 20- to 25-year follow-up. Schreurs BW, Keurentjes JC, Gardeniers JW, Verdonschot N, Slooff TJ, Veth RP. J Bone Joint Surg Br. 2009 Sep;91(9):1148-53

Early clinical failure of the Birmingham metal-on-metal hip resurfacing is associated with metallosis and soft-tissue necrosis. Ollivere B, Darrah C, Barker T, Nolan J, Porteous MJ. J Bone Joint Surg Br. 2009 Aug;91(8):1025-30.

Hip resurfacings revised for inflammatory pseudotumour have a poor outcome. Grammatopolous G, Pandit H, Kwon YM, Gundle R, McLardy-Smith P, J Bone Joint Surg Br. 2009 Aug;91(8):1019-24. The epidemiology of bearing surface usage in total hip arthroplasty in the United States. Bozic KJ, Kurtz S, Lau E, Ong K, Chiu V, Vail TP, Rubash HE, Berry DJ. J Bone Joint Surg Am. 2009 Jul;91(7):1614-20

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Acetabular revision using an anti-protrusion (ilio-ischial) cage and trabecular metal acetabular component for severe acetabular bone loss associated with pelvic discontinuity. Kosashvili Y, Backstein D, Safir O, Lakstein D, Gross AE. J Bone Joint Surg Br. 2009 Jul;91(7):870-6.

The squeaking hip: a phenomenon of ceramic-on-ceramic total hip arthroplasty. Jarrett CA, Ranawat AS, Bruzzone M, Blum YC, Rodriguez JA, Ranawat CS. J Bone Joint Surg Am. 2009 Jun;91(6):1344-9. The painful metal-on-metal hip resurfacing. Hart AJ, Sabah S, Henckel J, Lewis A, Cobb J, Sampson B, Mitchell A, Skinner JA. J Bone Joint Surg Br. 2009 Jun;91(6):738-44 Periacetabular osteotomy for acetabular dysplasia in patients older than 40 years: a preliminary study. Millis MB, Kain M, Sierra R, Trousdale R, Taunton MJ, Kim YJ, Rosenfeld SB, Kamath G, Schoenecker P, Clohisy JC. Clin Orthop Relat Res. 2009 Sep;467(9):2228-34.

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Primary total hip arthroplasty with a porous-coated acetabular component. A concise follow-up, at a minimum of twenty years, of previous reports. Della Valle CJ, Mesko NW, Quigley L, Rosenberg AG, Jacobs JJ, Galante JO. J Bone Joint Surg Am. 2009 May;91(5):1130-5. Outcome after primary and secondary replacement for subcapital fracture of the hip in 10 264 patients. Leonardsson O, Rogmark C, Kärrholm J, Akesson K, Garellick G. J Bone Joint Surg Br. 2009 May;91(5):595-600. Outcome of uncemented primary femoral stems for treatment of femoral head osteonecrosis. Hungerford MW, Hungerford DS, Jones LC. Orthop Clin North Am. 2009 Apr;40(2):283-9. Charnley low-frictional torque arthroplasty: follow-up for 30 to 40 years. Wroblewski BM, Siney PD, Fleming PA. J Bone Joint Surg Br. 2009 Apr;91(4):447-50. Clinical comparison of polyethylene wear with zirconia or cobalt-chromium femoral heads. Stilling M, Nielsen KA, Søballe K, Rahbek O. Clin Orthop Relat Res. 2009 Oct;467(10):2644-50.

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Slower recovery after two-incision than mini-posterior-incision total hip arthroplasty. Surgical technique. Pagnano MW, Trousdale RT, Meneghini RM, Hanssen AD. J Bone Joint Surg Am. 2009 Mar 1;91 Suppl 2 Pt 1:50-73. The effect of a single infusion of zoledronic acid on early implant migration in total hip arthroplasty. A randomized, double-blind, controlled trial. Friedl G, Radl R, Stihsen C, Rehak P, Aigner R, Windhager R. J Bone Joint Surg Am. 2009 Feb;91(2):274-81. Femoroacetabular impingement treatment using arthroscopy and anterior approach. Laude F, Sariali E, Nogier A. Clin Orthop Relat Res. 2009 Mar;467(3):747-52. Relationship between perioperative urinary tract infection and deep infection after joint arthroplasty. Koulouvaris P, Sculco P, Finerty E, Sculco T, Sharrock NE Clin Orthop Relat Res. 2009 Jul;467(7):1859-67.

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The use of alendronate in the treatment of avascular necrosis of the femoral head: follow-up to eight years. Agarwala S, Shah S, Joshi VR. J Bone Joint Surg Br. 2009 Aug;91(8):1013-8 Pyrolytic carbon endoprosthetic replacement for osteonecrosis and femoral fracture of the hip: a pilot study. Bernasek TL, Stahl JL, Pupello D. Clin Orthop Relat Res. 2009 Jul;467(7):1826-32

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IItt iiss ccrriittiiccaall ttoo aatttteemmpptt ttoo aacchhiieevvee lliiggaammeenntt ""iissoommeettrryy"" dduurriinngg rreeccoonnssttrruuccttiioonnss,, mmeeaanniinngg tthhee lliiggaammeennttss sshhoouulldd lliiee wwiitthhiinn tthhee fflleexxiioonn aaxxiiss iinn aallll ppoossiittiioonnss ooff kknneeee mmoottiioonn..

KKNNEEEE BBIIOOMMEECCHHAANNIICCSS DDiiaarrtthhrrooddiiaall JJooiinntt,, aalllloowwss ffoorr ssiimmuullttaanneeoouuss rroottaattiioonn aanndd ttrraannssllaattiioonn TThhee rroollee ooff tthhee lliiggaammeennttss ooff tthhee kknneeee iiss ttoo pprroovviiddee ppaassssiivvee rreessttrraaiinnttss ttoo aabbnnoorrmmaall mmoottiioonn..

TThhee hheeiigghhtt ooff tthhee llaatteerraall ffeemmoorraall ccoonnddyyllee iiss ggrreeaatteerr tthhaann tthhaatt ooff tthhee mmeeddiiaall ccoonnddyyllee.. TThhee aalliiggnnmmeenntt ooff tthhee ccoonnddyylleess iiss aallssoo ddiiffffeerreenntt;; tthhee llaatteerraall ccoonnddyyllee iiss rreellaattiivveellyy ssttrraaiigghhtt,, bbuutt tthhee mmeeddiiaall ccoonnddyyllee iiss ccuurrvveedd.. TThhiiss aalllloowwss tthhee mmeeddiiaall ttiibbiiaall ppllaatteeaauu ttoo rroottaattee eexxtteerrnnaallllyy iinn ffuullll eexxtteennssiioonn—— tteerrmmeedd tthhee ""ssccrreeww hhoommee mmeecchhaanniissmm""

66 ddeeggrreeeess ooff ffrreeeeddoomm KKNNEEEE AANNAATTOOMMYY AANNDD BBIIOOMMEECCHHAANNIICCSS:: AACCLL

LLFFCC ==>> TTiibbiiaa ((TThhee ttiibbiiaall iinnsseerrttiioonn iiss aa bbrrooaadd,, iirrrreegguullaarr,, oovvaall--sshhaappeedd aarreeaa jjuusstt aanntteerriioorr ttoo aanndd bbeettwweeeenn tthhee iinntteerrccoonnddyyllaarr eemmiinneenncceess ooff tthhee ttiibbiiaa.. TThhee ffeemmoorraall aattttaacchhmmeenntt iiss aa sseemmiicciirrccuullaarr aarreeaa oonn tthhee ppoosstteerroommeeddiiaall aassppeecctt ooff tthhee llaatteerraall ffeemmoorraall ccoonnddyyllee..))

AAvveerraaggee lleennggtthh aanndd wwiiddtthh 3333 mmmm xx 1111 mmmm 22 BBuunnddlleess:: aanntteerroommeeddiiaall bbuunnddllee tthhaatt iiss ttiigghhtt iinn fflleexxiioonn ppoosstteerroollaatteerraall bbuunnddllee tthhaatt iiss ttiigghhtt iinn eexxtteennssiioonn The intercondylar ridge and bifurcate ridge are bony landmarks on the

medial aspect of the lateral femoral condyle that can be used to help identify the insertion sites of the bundles of the ACL.

MMiiddddllee GGeenniiccuullaattee AA.. iiss tthhee pprriimmaarryy bblloooodd ssuuppppllyy ffoorr bbootthh ccrruucciiaatteess bbuutt tthhee pprriimmaarryy AACCLL bblloooodd ssuuppppllyy iiss vviiaa eeppiilliiggaammeennttoouuss ttiissssuuee nnoott tthhee iinnsseerrttiioonn ssiitteess

11%% ccoommppoosseedd ooff nneerrvvee ttiissssuuee TThhee AACCLL iiss ccoommppoosseedd ooff 9900%% ttyyppee II ccoollllaaggeenn aanndd 1100%% ttyyppee IIIIII ccoollllaaggeenn

KKNNEEEE AANNAATTOOMMYY AANNDD BBIIOOMMEECCHHAANNIICCSS:: PPCCLL

MMFFCC ==>> TTiibbiiaa ssuullccuuss ((TThhee PPoosstteerriioorr ccrruucciiaattee lliiggaammeenntt ((PPCCLL)) oorriiggiinnaatteess ffrroomm aa bbrrooaadd,, ccrreesscceenntt--sshhaappeedd aarreeaa aanntteerroollaatteerraallllyy oonn tthhee mmeeddiiaall ffeemmoorraall ccoonnddyyllee aanndd iinnsseerrttss oonn tthhee ttiibbiiaa iinn aa ssuullccuuss tthhaatt iiss bbeellooww tthhee aarrttiiccuullaarr ssuurrffaaccee..))

AAvveerraaggee lleennggtthh aanndd wwiiddtthh 3388 mmmm xx 1133 mmmm ((ccoommppaarree tthhiiss ttoo AACCLL)) 22 BBuunnddlleess:: aanntteerroollaatteerraall bbuunnddllee tthhaatt iiss ttiigghhtt iinn fflleexxiioonn ppoosstteerroommeeddiiaall bbuunnddllee tthhaatt iiss ttiigghhtt iinn eexxtteennssiioonn

VVaarriiaabbllee mmeenniissccooffeemmoorraall lliiggaammeennttss ((HHuummpphhrryy''ss——aanntteerriioorr;; WWrriissbbeerrgg''ss——ppoosstteerriioorr)) oorriiggiinnaattee ffrroomm tthhee ppoosstteerriioorr hhoorrnn ooff tthhee llaatteerraall mmeenniissccuuss aanndd iinnsseerrtt iinnttoo tthhee ssuubbssttaannccee ooff tthhee PPCCLL..

MMiiddddllee GGeenniiccuullaattee AA.. iiss tthhee pprriimmaarryy bblloooodd ssuuppppllyy ffoorr bbootthh ccrruucciiaatteess

KKNNEEEE AANNAATTOOMMYY AANNDD BBIIOOMMEECCHHAANNIICCSS:: MMCCLL

MMFFCC ==>> TTiibbiiaa SSuuppeerrffiicciiaall TThhee ssuuppeerrffiicciiaall MMCCLL iiss aallssoo kknnoowwnn aass tthhee ttiibbiiaall ccoollllaatteerraall lliiggaammeenntt aanndd lliieess

ddeeeepp ttoo tthhee ggrraacciilliiss aanndd sseemmiitteennddiinnoossiiss tteennddoonnss.. IItt oorriiggiinnaatteess ffrroomm tthhee mmeeddiiaall ffeemmoorraall eeppiiccoonnddyyllee aanndd iinnsseerrttss oonnttoo tthhee ppeerriioosstteeuumm ooff tthhee pprrooxxiimmaall ttiibbiiaa,, ddeeeepp ttoo tthhee ppeess aannsseerriinnuuss..

TThhee aanntteerriioorr ffiibbeerrss ooff tthhee ssuuppeerrffiicciiaall MMCCLL ttiigghhtteenn dduurriinngg tthhee ffiirrsstt 9900°° ooff mmoottiioonn,, wwhhiillee tthhee ppoosstteerriioorr ffiibbeerrss ttiigghhtteenn iinn eexxtteennssiioonn..

DDeeeepp TThhee ddeeeepp ppoorrttiioonn ooff tthhee lliiggaammeenntt iiss aallssoo rreeffeerrrreedd ttoo aass tthhee mmeeddiiaall ccaappssuullaarr

lliiggaammeenntt aanndd iiss aa ccaappssuullaarr tthhiicckkeenniinngg tthhaatt bblleennddss wwiitthh tthhee ssuuppeerrffiicciiaall ffiibbeerrss aanndd iiss iinnttiimmaatteellyy aassssoocciiaatteedd wwiitthh tthhee mmeeddiiaall mmeenniissccuuss bbyy aattttaacchhmmeennttss ttoo tthhee ccoorroonnaarryy lliiggaammeennttss..

KKNNEEEE AANNAATTOOMMYY AANNDD BBIIOOMMEECCHHAANNIICCSS:: LLCCLL

AAllssoo ccaalllleedd tthhee ffiibbuullaarr ccoollllaatteerraall lliiggaammeenntt CCoorrdd--LLiikkee wwhheenn oonn ssttrreettcchh SSiinnccee iitt iiss llooccaatteedd bbeehhiinndd tthhee aaxxiiss ooff kknneeee rroottaattiioonn,, tthhee LLCCLL iiss ttiigghhtt iinn eexxtteennssiioonn aanndd llaaxx iinn fflleexxiioonn..

OOrriiggiinnaatteess oonn tthhee llaatteerraall ffeemmoorraall eeppiiccoonnddyyllee ppoosstteerriioorr aanndd ssuuppeerriioorr ttoo tthhee iinnsseerrttiioonn ooff tthhee ppoopplliitteeuuss tteennddoonn aanndd iinnsseerrttss oonn tthhee llaatteerraall aassppeecctt ooff tthhee ffiibbuullaarr hheeaadd..

KKNNEEEE AANNAATTOOMMYY AANNDD BBIIOOMMEECCHHAANNIICCSS:: TTeennssiillee ssttrreennggtthh ooff LLiiggaammeennttss

AACCLL:: aapppprrooxxiimmaatteellyy 22220000 NN,, aanndd uupp ttoo 22550000 NN iinn yyoouunngg iinnddiivviidduuaallss.. TThhee PPCCLL iiss tthhoouugghh ttoo hhaavvee aa hhiigghheerr tteennssiillee ssttrreennggtthh tthhaann tthhee AACCLL,, bbuutt iittss

vvaalluuee iiss ddiissppuutteedd.. TThhee MMCCLL hhaass aapppprrooxxiimmaatteellyy ttwwiiccee tthhee ssttiiffffnneessss aanndd tteennssiillee ssttrreennggtthh aass tthhee

AACCLL.. LLCCLL iiss aapppprrooxxiimmaatteellyy 775500 NN..

KKNNEEEE AANNAATTOOMMYY AANNDD BBIIOOMMEECCHHAANNIICCSS:: PPoosstteerroommeeddiiaall CCoorrnneerr

SSttrruuccttuurreess ddeeeepp ttoo tthhee MMCCLL IImmppoorrttaanntt ffoorr rroottaarryy ssttaabbiilliittyy.. LLaayyeerr 11:: SSaarrttoorriiuuss LLaayyeerr 22:: SSuupp MMCCLL,, PPOOLL ((oorriiggiinnaatteess oonn tthhee aadddduuccttoorr ttuubbeerrccllee)),, SSMM LLaayyeerr 33:: DDeeeepp MMCCLL,, ccaappssuullee

KKNNEEEE AANNAATTOOMMYY AANNDD BBIIOOMMEECCHHAANNIICCSS:: PPoosstteerroollaatteerraall CCoorrnneerr

TThhee PPoosstteerroollaatteerraall CCoorrnneerr iiss bbeeccoommiinngg iinnccrreeaassiinnggllyy mmoorree iimmppoorrttaanntt iinn ttrreeaattiinngg tthhee mmuullttiippllee lliiggaammeenntt--iinnjjuurreedd kknneeeess.. IItt ccoonnssiissttss ooff ssuuppeerrffiicciiaall aanndd ddeeeepp llaayyeerrss.. PPLLCC:: SSuuppeerrffiicciiaall::

BBiicceeppss,, IITTTT PPLLCC:: DDeeeepp::

LLCCLL ccaappssuullee PPoopplliitteeuuss ((oorriiggiinnaatteess oonn tthhee bbaacckk ooff tthhee ttiibbiiaa aanndd iinnsseerrttss mmeeddiiaall,, aanntteerriioorr,, aanndd ddiissttaall ttoo tthhee LLCCLL)) AArrccuuaattee lliiggaammeenntt ((ccoonnttiigguuoouuss wwiitthh tthhee oobblliiqquuee ppoopplliitteeaall lliiggaammeenntt mmeeddiiaallllyy)) PPoopplliitteeooffiibbuullaarr lliiggaammeenntt ((ffrroomm ppoopplliitteeuuss ttoo ffiibbuullaarr hheeaadd))

KKNNEEEE AANNAATTOOMMYY AANNDD BBIIOOMMEECCHHAANNIICCSS:: PPFF JJOOIINNTT

TThhee ppaatteellllooffeemmoorraall jjooiinntt iiss ccoommppoosseedd ooff tthhee ppaatteellllaa ((wwiitthh vvaarriiaabbllyy ssiizzeedd mmeeddiiaall aanndd llaatteerraall ffaacceettss)) aanndd tthhee ffeemmoorraall ttrroocchhlleeaa..

22 FFaacceettss:: MMeeddiiaall ((PPrrooppeerr && OOdddd))

---- LLaatteerraall ((LLoonnggeerr && WWiiddeerr)) PPaatteellllaa iinnccrreeaasseess mmoommeenntt aarrmm ((QQuuaaddss)) FFuullllyy eennggaaggeedd @@ 2200--4400oo CCaarrttiillaaggee 55 mmmm tthhiicckk ((tthhiicckkeesstt iinn tthhee bbooddyy aanndd ccaann wwiitthhssttaanndd ffoorrcceess

sseevveerraall ttiimmeess bbooddyy wweeiigghhtt ((FFoorrcceess nnoorrmmaallllyy == 33--55 xx BBWW)) TThhee ppaatteellllaa iiss rreessttrraaiinneedd iinn tthhee ttrroocchhlleeaa bbyy tthhee vvaallgguuss aaxxiiss ooff tthhee

qquuaaddrriicceeppss mmeecchhaanniissmm ((QQ aannggllee)),, tthhee oobblliiqquuee ffiibbeerrss ooff tthhee vvaassttuuss mmeeddiiaalliiss aanndd llaatteerraalliiss mmuusscclleess ((aanndd tthheeiirr eexxtteennssiioonnss——tthhee ppaatteellllaa rreettiinnaaccuullaa)),, aanndd tthhee ppaatteellllooffeemmoorraall lliiggaammeennttss..

TThhee mmeeddiiaall ppaatteellllooffeemmoorraall lliiggaammeenntt ((MMPPFFLL)),, oorriiggiinnaatteess ffrroomm tthhee ffeemmuurr 11..99 mmmm aanntteerriioorr aanndd 33..88 mmmm ddiissttaall ttoo tthhee aadddduuccttoorr ttuubbeerrccllee.. IItt iinnsseerrttss oonnttoo tthhee pprrooxxiimmaall 11//33 ooff tthhee mmeeddiiaall bboorrddeerr ooff tthhee ppaatteellllaa aanndd iiss tthhee kkeeyy rreessttrraaiinntt iinn pprreevveennttiinngg llaatteerraall ddiissppllaacceemmeenntt ooff tthhee ppaatteellllaa.. BBiioommeecchhaanniiccaallllyy,, iitt hhaass bbeeeenn sshhoowwnn ttoo aaccccoouunntt ffoorr 5533--6600%% ooff tthhee rreessttrraaiinniinngg ffoorrccee ooff tthhee ppaatteellllaa ttoo llaatteerraall ssuubblluuxxaattiioonn..

When tensioning a MPFL reconstruction, the graft should be tensioned with 2N

at 30 degrees of flexion KKNNEEEE AANNAATTOOMMYY AANNDD BBIIOOMMEECCHHAANNIICCSS:: MMeenniissccuuss

CCrreesscceenntt sshhaappeedd ffiibbrrooccaarrttiillaaggiinnoouuss ssttrruuccttuurreess tthhaatt aarree ttrriiaanngguullaarr iinn ccrroossss--sseeccttiioonn

MMeeddiiaall == CC--sshhaappeedd LLaatteerraall == SSeemmiicciirrccuullaarr TThhee rroollee ooff tthhee mmeenniissccii iiss ttoo ddeeeeppeenn tthhee ttiibbiiaall ssuurrffaaccee,, aacctt aass aa sseeccoonnddaarryy

ssttaabbiilliizzeerr ((tthhee ppoosstteerriioorr hhoorrnn ooff mmeeddiiaall mmeenniissccuuss [[PPHHMMMM]])),, nnuuttrriittiioonn,, aanndd lluubbrriiccaattiioonn

TThhee mmeenniissccii aarree ccoonnnneecctteedd aanntteerriioorrllyy bbyy tthhee ttrraannssvveerrssee ((iinntteerrmmeenniissccaall)) lliiggaammeenntt

TThhee mmeenniissccii aarree aattttaacchheedd ppeerriipphheerraallllyy vviiaa tthhee ccoorroonnaarryy lliiggaammeennttss

MMEENNIISSCCUUSS:: LLOOAADD TTRRAANNSSMMIISSSSIIOONN

5500%% jjooiinntt llooaadd ttrraannssmmiitttteedd iinn ffuullll eexxtt.. 8855%% jjooiinntt llooaadd ttrraannssmmiitttteedd iinn 9900ºº fflleexx.. TToottaall mmeenniisscceeccttoommyy ddeeccrreeaasseess ccoonnttaacctt aarreeaa bbyy 5500%% 1155--3344%% ppaarrttiiaall mmeenniisscceeccttoommyy iinnccrreeaasseess ccoonnttaacctt pprreessssuurree bbyy 335500%%

KKNNEEEE AANNAATTOOMMYY AANNDD BBIIOOMMEECCHHAANNIICCSS:: MMeenniissccuuss

PPeerriimmeenniissccaall ccaappiillllaarryy pplleexxuuss ((mmeedd aanndd llaatt ggeenniiccuullaarr aarrtteerriieess)) pprroovviiddeess bblloooodd ssuuppppllyy ttoo tthhee ppeerriipphheerryy ooff tthhee mmeenniissccii.. TThhee ppeerriipphheerraall 2200––3300%% ooff tthhee mmeeddiiaall mmeenniissccii aanndd 1100--2255%% ooff tthhee llaatteerraall mmeenniissccuuss aarree vvaassccuullaarriizzeedd..

BBlloooodd ssuuppppllyy rreeggrreesssseess wwiitthh aaggee,, wwhhiicchh cchhaannggeess tthhee ddeemmaarrccaattiioonn ooff tthhee rreedd--rreedd,, rreedd--wwhhiittee,, aanndd wwhhiittee--wwhhiittee zzoonneess..

KKNNEEEE AANNAATTOOMMYY AANNDD BBIIOOMMEECCHHAANNIICCSS:: MMeenniissccuuss

TThhee ccoollllaaggeenn ffiibbeerrss ooff tthhee mmeenniissccii aarree aarrrraannggeedd rraaddiiaallllyy aanndd lloonnggiittuuddiinnaallllyy TThhee lloonnggiittuuddiinnaall ffiibbeerrss hheellpp ddiissssiippaattee hhoooopp ssttrreesssseess BBootthh ffiibbeerrss hheellpp tthhee mmeenniissccii eexxppaanndd uunnddeerr ccoommpprreessssiivvee ffoorrccee TTyyppee II ccoollllaaggeenn iiss tthhee pprreeddoommiinnaanntt ccoollllaaggeenn iinn tthhee mmeenniissccii

LLaatteerraall mmeenniissccuuss hhaass 22xx tthhee eexxccuurrssiioonn ooff mmeeddiiaall.. TThhee mmeenniissccii iinnccrreeaassee tthhee ccoonnttaacctt aarreeaa ooff tthhee jjooiinntt ssiiggnniiffiiccaannttllyy.. AACCLL ddeeffiicciieennccyy iinnccrreeaasseess tthhee llooaadd oonn tthhee mmeenniissccii,, ppaarrttiiccuullaarrllyy tthhee

ppoosstteerriioorr hhoorrnn ooff tthhee mmeeddiiaall mmeenniissccii.. AAccuuttee AACCLL tteeaarr >> 5500%% hhaavvee tteeaarrss ooff mmeenniissccii 8833%% aarree llaatteerraall,, hhoowweevveerr iinn cchhrroonniicc AACCLL tteeaarrss mmeeddiiaall mmeenniissccaall tteeaarrss aarree mmoorree ccoommmmoonn

AAttttaacchhmmeenntt @@ hhoorrnnss iiss ccrriittiiccaall:: LLaatteerraall:: NNeeaarr AACCLL MMeeddiiaall:: FFaarr sseeppaarraatteedd ffrroomm tthhee AACCLL

KKNNEEEE AANNAATTOOMMYY AANNDD BBIIOOMMEECCHHAANNIICCSS:: KKeeyy TTeessttaabbllee IItteemmss

FFoouurr--bbaarr lliinnkkaaggee ssyysstteemm SSccrreeww hhoommee mmeecchhaanniissmm WWhheenn aarree tthhee bbuunnddlleess ooff AACCLL//PPCCLL ttiigghhtt//llaaxx ((AAnntt bbuunnddlleess aarree ttiigghhtt iinn

fflleexxiioonn)) IInnsseerrttiioonn ooff LLCCLL iinn rreellaattiioonn ttoo ppoopplliitteeuuss SSuuppeerrffiicciiaall aanndd DDeeeepp CCoommppoonneennttss ooff PPLLCC AAnnaattoommyy // IInnsseerrttiioonn ooff tthhee mmeenniissccii CCoonnttaacctt pprreessssuurree iinnccrreeaasseess wwiitthh mmeenniisseeccttoommyy HHoooopp ssttrreesssseess ooff mmeenniissccii aanndd bblloooodd ssuuppppllyy

KKNNEEEE AANNAATTOOMMYY AANNDD BBIIOOMMEECCHHAANNIICCSS:: RREEFFEERREENNCCEESS AArrnnoocczzkkyy,, SS..PP..:: AAnnaattoommyy ooff tthhee aanntteerriioorr ccrruucciiaattee lliiggaammeenntt.. CClliinn.. OOrrtthhoopp.. 117722::1199––2255,, 11998833..

AArrnnoocczzkkyy,, SS..PP..,, aanndd WWaarrrreenn,, RR..FF..:: MMiiccrroovvaassccuullaattuurree ooff tthhee hhuummaann mmeenniissccuuss.. AAmm.. JJ.. SSppoorrttss MMeedd.. 1100::9900––9955,, 11998822.. BBeecckk PP,, BBrroowwnn NNAA,, GGrreeiiss PPEE,, BBuurrkkss RRTT.. PPaatteellllooffeemmoorraall ccoonnttaacctt pprreessssuurreess aanndd llaatteerraall ppaatteellllaarr ttrraannssllaattiioonn aafftteerr mmeeddiiaall ppaatteellllooffeemmoorraall lliiggaammeenntt rreeccoonnssttrruuccttiioonn.. AAmm JJ SSppoorrttss MMeedd.. 3355((99)):: 11555577--6633,, 22000077.. CChhhhaabbrraa,, AA..,, EElllliioott,, CC..,, MMiilllleerr,, MM..DD..:: NNoorrmmaall AAnnaattoommyy aanndd BBiioommeecchhaanniiccss ooff tthhee KKnneeee.. SSppoorrttss MMeeddiicciinnee aanndd AArrtthhrroossccooppyy RReevviieeww.. 99:: 116666--117777,, 22000022.. CCooooppeerr,, DD..EE..,, DDeenngg,, XX..HH..,, BBuurrnnsstteeiinn,, AA..LL..,, eett aall..:: TThhee ssttrreennggtthh ooff tthhee cceennttrraall tthhiirrdd ppaatteellllaarr tteennddoonn ggrraafftt:: AA bbiioommeecchhaanniiccaall ssttuuddyy.. AAmm.. JJ.. SSppoorrttss MMeedd.. 2211::881188––882244,, 11999933.. DDaanniieell,, DD..MM..,, AAkkeessoonn,, WW..HH..,, aanndd OO''CCoonnnnoorr,, JJ..JJ..,, eeddss..:: KKnneeee LLiiggaammeennttss:: SSttrruuccttuurree,, FFuunnccttiioonn,, IInnjjuurryy,, aanndd RReeppaaiirr.. NNeeww YYoorrkk,, RRaavveenn PPrreessss,, 11999900.. FFeerrrreettttii MM,, EEkkddaahhll MM,, SShheenn WW,, FFuu FFHH.. OOsssseeoouuss LLaannddmmaarrkkss ooff tthhee ffeemmoorraall aattttaacchhmmeenntt ooff tthhee aanntteerriioorr ccrruucciiaattee lliiggaammeenntt:: aann aannaattoommiicc ssttuuddyy.. AArrtthhrroossccooppyy.. 2233((1111)):: 11221188--2255,, 22000077.. FFuu,, FF..HH..,, HHaarrnneerr,, CC..DD..,, JJoohhnnssoonn,, DD..LL..,, eett aall..:: BBiioommeecchhaanniiccss ooff kknneeee lliiggaammeennttss:: BBaassiicc ccoonncceeppttss aanndd cclliinniiccaall aapppplliiccaattiioonn.. JJ.. BBoonnee JJooiinntt SSuurrgg.. 7755::11771166––11772255,, 11999933.. GGiirrggiiss,, FF..GG..,, MMaarrsshhaallll,, JJ..LL..,, aanndd AAll MMoonnaajjeemm,, AA..RR..SS..:: TThhee ccrruucciiaattee lliiggaammeennttss ooff tthhee kknneeee jjooiinntt:: AAnnaattoommiiccaall,, ffuunnccttiioonnaall aanndd eexxppeerriimmeennttaall aannaallyyssiiss.. CClliinn.. OOrrtthhoopp.. 110066::221166––223311,, 11997755.. LLaaPPrraaddee RRFF,, EEnnggeebbrreettsseenn AAHH,, LLyy TTBB,, JJoohhaannsseenn SS,, WWeennttoorrff FFAA,, EEnnggeebbrreettsseenn LL.. TThhee aannaattoommyy ooff tthhee mmeeddiiaall ppaarrtt ooff tthhee kknneeee.. JJ BBoonnee JJooiinntt SSuurrgg [[AAmm]] 8899((99)):: 220000--1100.. NNooyyeess,, FF..RR..,, BBuuttlleerr,, DD..LL..,, GGrroooodd,, EE..SS..,, eett aall..:: BBiioommeecchhaanniiccaall aannaallyyssiiss ooff hhuummaann lliiggaammeenntt ggrraaffttss uusseedd iinn kknneeee--lliiggaammeenntt rreeppaaiirrss aanndd rreeccoonnssttrruuccttiioonnss.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 6666::334444––335522,, 11998844.. SSeeeebbaacchheerr,, JJ..RR..,, IInngglliiss,, AA..EE..,, MMaarrsshhaallll,, JJ..LL..,, eett aall..:: TThhee ssttrruuccttuurree ooff tthhee ppoosstteerroollaatteerraall aassppeecctt ooff tthhee kknneeee.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 6644::553366––554411,, 11998822.. TThhoommppssoonn,, WW..OO..,, TThheeaattee,, FF..LL..,, FFuu,, FF..HH..,, eett aall..:: TTiibbiiaall mmeenniissccaall ddyynnaammiiccss uussiinngg tthhrreeee--ddiimmeennssiioonnaall rreeccoonnssttrruuccttiioonn ooff mmaaggnneettiicc rreessoonnaannccee iimmaaggeess.. AAmm.. JJ.. SSppoorrttss MMeedd.. 1199::221100––221166,, 11999911.. WWaarrrreenn,, LL..FF..,, aanndd MMaarrsshhaallll,, JJ..LL..:: TThhee ssuuppppoorrttiinngg ssttrruuccttuurreess aanndd llaayyeerrss ooff tthhee mmeeddiiaall ssiiddee ooff tthhee kknneeee.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 6611::5566––6622,, 11997799..

WWaarrrreenn,, RR..,, AArrnnoocczzkkyy,, SS..PP..,, aanndd WWiicckkiieewwiicczz,, TT..LL..:: AAnnaattoommyy ooff tthhee kknneeee.. IInn NNiicchhoollaass,, JJ..AA..,, aanndd HHeerrsshhmmaann,, EE..BB..,, eeddss..:: TThhee LLoowweerr EExxttrreemmiittyy aanndd SSppiinnee iinn SSppoorrttss MMeeddiicciinnee,, SStt.. LLoouuiiss:: CCVV MMoossbbyy,, 11998866,, pppp.. 665577––669944..

HHIISSTTOORRYY && PPHHYYSSIICCAALL EEXXAAMM KKNNEEEE:: HHIISSTTOORRYY

AA ccoommpplleettee hhiissttoorryy aanndd ccllaarriiffiiccaattiioonn ooff mmeecchhaanniissmm iiss eesssseennttiiaall.. TThhee aaggee ooff tthhee ppaattiieenntt iiss aallssoo ccrriittiiccaall ((yyoouunnggeerr ppaattiieennttss hhaavvee mmeenniissccaall oorr lliiggaammeennttoouuss iinnjjuurriieess)) ((oollddeerr ppaattiieennttss uussuuaallllyy hhaavvee ddeeggeenneerraattiivvee ccoonnddiittiioonnss))

PPaaiinn wwiitthh ssttaaiirr cclliimmbbiinngg == PPaatteellllooffeemmoorraall eettiioollooggyy MMeecchhaanniiccaall ssyymmppttoommss,, ssqquuaattttiinngg ppaaiinn == mmeenniissccaall tteeaarr NNoonnccoonnttaacctt wwiitthh ppoopp == AACCLL AAnntt bbllooww wwiitthh DDFF ffoooott == ppaatteellllaa AAnntt bbllooww wwiitthh PPFF ffoooott == PPCCLL

PPHHYYSSIICCAALL EEXXAAMM IInnjjuurryy EExxaamm AACCLL LLaacchhmmaann,, PPiivvoott SShhiifftt PPCCLL PPoosstt DDrraawweerr QQuuaadd AAccttiivvee,, ssaagg MMCCLL VVaallgguuss 3300oo LLCCLL VVaarruuss 3300oo PPLLCC EERR AAssyymmmmeettrryy MMeenniissccii JJLLTT,, MMccMMuurrrraayy PPaatteellllaarr AApppprreehheennssiioonn IInnssttaabb PPaatt.. GGrriinndd PPFF ppaatthhoollooggyy KKNNEEEE:: PPHHYYSSIICCAALL EEXXAAMM IInnjjuurryy EExxaamm PPCCLL iinnccrreeaasseedd EERR aatt 9900ºº PPLLCC iinnccrreeaasseedd EERR aatt 3300 ºº PPCCLL//PPLLCC iinnccrreeaasseedd EERR aatt 3300 && 9900 ºº KKNNEEEE:: LLAAXXIITTYY TTEESSTTIINNGG

KKTT 11000000 aanndd 22000000 iiss tthhee aacccceepptteedd ssttaannddaarrddiizzeedd llaaxxiittyy ddeevviiccee AACCLL iiss mmeeaassuurreedd wwiitthh tthhee kknneeee sslliigghhttllyy fflleexxeedd aanndd EERR 2200--3300 ddeeggrreeeess SSiiddee ttoo ssiiddee ccoommppaarriissoonn ((>> 33 mmmm ssiiggnniiffiiccaanntt)) PPCCLL llaaxxiittyy mmeeaassuurreemmeenntt mmuucchh lleessss aaccccuurraattee

HHIISSTTOORRYY && PPHHYYSSIICCAALL EEXXAAMM:: KKeeyy TTeessttaabbllee IItteemmss

NNoonn--ccoonnttaacctt iinnjjuurryy,, ++ ppoopp,, uunnaabbllee ttoo RRTTPP ((AACCLL iinnjjuurryy))

MMoosstt sseennssiittiivvee PPEE tteesstt ffoorr AACCLL ((LLaacchhmmaann)) LLaacchhmmaann AAMM bbuunnddllee,, ppiivvoott PPLL bbuunnddllee

QQuuaadd aaccttiivvee tteesstt ((tthheeyy wwiillll ddeessccrriibbee tthhee tteesstt)) ((ffoorr PPCCLL iinnjjuurryy)) EERR aatt 3300 aanndd 9900 ddeeggrreeeess ttoo ddiissttiinngguuiisshh bbeettwweeeenn PPCCLL aanndd PPLLCC iinnjjuurriieess PPoossiittiioonn ooff ffoooott ffoorr PPCCLL iinnjjuurriieess vvss ppaatteellllaa ffrraaccttuurreess

HHIISSTTOORRYY && PPHHYYSSIICCAALL EEXXAAMM:: RREEFFEERREENNCCEESS FFeettttoo,, JJ..FF..,, aanndd MMaarrsshhaallll,, JJ..LL..:: IInnjjuurryy ttoo tthhee aanntteerriioorr ccrruucciiaattee lliiggaammeenntt pprroodduucciinngg tthhee ppiivvoott sshhiifftt ssiiggnn.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 6611::771100––771144,, 11997799.. FFuullkkeerrssoonn,, JJ..PP..,, KKaalleennaakk,, AA..,, RRoosseennbbeerrgg,, TT..DD..,, eett aall..:: PPaatteellllooffeemmoorraall ppaaiinn.. IInnssttrr.. CCoouurrssee LLeecctt.. 4411::5577––7711,, 11999922.. GGaallwwaayy,, RR..DD..,, BBeeaauupprree,, AA..,, aanndd MMaaccIInnttoosshh,, DD..LL..:: PPiivvoott sshhiifftt.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[BBrr..]] 5544::776633,, 11997722.. HHoosseeaa,, TT..MM..,, aanndd TTrriiaa,, AA..JJ..:: PPhhyyssiiccaall eexxaammiinnaattiioonn ooff tthhee kknneeee:: cclliinniiccaall.. IInn SSccootttt,, WW..NN..,, eedd..:: LLiiggaammeenntt aanndd EExxtteennssoorr MMeecchhaanniissmm IInnjjuurriieess ooff tthhee KKnneeee:: DDiiaaggnnoossiiss aanndd TTrreeaattmmeenntt.. SStt.. LLoouuiiss,, CCVV MMoossbbyy,, 11999911.. RRiittcchhiiee,, JJ..RR..,, MMiilllleerr,, MM..DD..,, aanndd HHaarrnneerr,, CC..DD..:: HHiissttoorryy aanndd pphhyyssiiccaall eexxaammiinnaattiioonn ooff tthhee kknneeee.. IInn FFuu,, FF..HH..,, HHaarrnneerr,, CC..DD..,, aanndd VViinnccee,, KK..GG..,, eeddss..:: KKnneeee SSuurrggeerryy.. BBaallttiimmoorree,, WWiilllliiaammss && WWiillkkiinnss,, 11999944.. SSllooccuumm,, DD..BB..,, aanndd LLaarrssoonn,, RR..LL..:: RRoottaattoorryy iinnssttaabbiilliittyy ooff tthhee kknneeee.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 5500::221111,, 11996688..

IIMMAAGGIINNGG

KKNNEEEE IIMMAAGGIINNGG:: SSTTAANNDDAARRDD RRAADDIIOOGGRRAAPPHHSS

SSttaannddaarrdd RRaaddiiooggrraapphhss.. SSttaannddaarrdd ppllaaiinn ffiillmmss iinncclluuddee aann AAPP vviieeww,, 4455 ddeeggrreeee PPAA VViieeww,, LLaatteerraall VViieeww aanndd aa MMeerrcchhaanntt ((4455 ddeeggrreeeess)) oorr LLaauurriinn VViieeww ((2200 ddeeggrreeeess)) ooff tthhee ppaatteellllaa.. AAddddiittiioonnaall vviieewwss iinncclluuddee lloonngg ccaasssseettttee lloowweerr eexxttrreemmiittyy vviieewwss,, oobblliiqquueess,, aanndd ssttrreessss rraaddiiooggrraapphhss..

KKNNEEEE IIMMAAGGIINNGG:: SSTTRREESSSS RRAADDIIOOGGRRAAPPHHSS

VVaarruuss//VVaallgguuss ffoorr ccoollllaatteerraallss aanndd ppeeddss ggrroowwtthh ppllaattee iinnjjuurriieess:: MMCCLL//LLCCLL PPhhyysseeaall FFrraaccttuurreess

PPoosstteerriioorr:: --PPCCLL MMeeaassuurreemmeenntt

KKNNEEEE IIMMAAGGIINNGG:: NNUUCCLLEEAARR IIMMAAGGIINNGG

SSttrreessss ffrraaccttuurreess

EEaarrllyy DDJJDD RReefflleexx SSyymmppaatthheettiicc DDyyssttrroopphhyy

KKNNEEEE IIMMAAGGIINNGG:: MMRRII

IImmaaggiinngg mmooddaalliittyy ooff cchhooiiccee ffoorr lliiggaammeennttoouuss iinnjjuurriieess,, AAVVNN,, aarrttiiccuullaarr ccaarrttiillaaggee ddeeffeeccttss,, aanndd mmeenniissccaall tteeaarrss

““BBoonnee BBrruuiissee”” iinn AACCLL tteeaass –– OOsstteeoocchhoonnddrraall iinnjjuurryy –– LLFFCC ((MMiidd 11//33)) && LLTTPP ((PPoosstt 11//33)) wwiitthh AACCLL tteeaarrss

OOCCDD:: LLooookk ffoorr fflluuiidd iinntteerrppoossiittiioonn wwhhiicchh ddeetteerrmmiinneess ssttaabbiilliittyy,, aanndd tthhuuss ooppeerraattiivvee vvss.. nnoonn--ooppeerraattiivvee ttrreeaattmmeenntt

Patellar dislocation – bone edema LFC & medial patella Discoid meniscus Displaced lateral meniscal tear

KKNNEEEE IIMMAAGGIINNGG:: CCTT SSCCAANNSS

LLaarrggeellyy rreeppllaacceedd bbyy MMRRII SSttiillll uusseeffuull ffoorr bboonnyy ttuummoorrss oorr ffrraaccttuurreess

IIMMAAGGIINNGG:: KKeeyy TTeessttaabbllee IItteemmss FFaaiirrbbaannkkss cchhaannggeess SSeeggoonndd lleessiioonn iiss aann aavvuullssiioonn ooff wwhhaatt?? WWhhaatt ddooeess iitt iinnddiiccaattee?? BBoonnee bbrruuiissee ppaatttteerrnn ffoorr AACCLL // PPCCLL iinnjjuurriieess,, MMRRII ffiinnddiinnggss iinn ddiissccooiidd mmeenniissccuuss && ppaatteellllaarr ddiissllooccaattiioonnss

SSttrreessss rraaddiiooggrraapphhss ffoorr pphhyysseeaall iinnjjuurriieess IIMMAAGGIINNGG:: RREEFFEERREENNCCEESS BBllaacckkbbuurrnnee,, JJ..SS..,, aanndd PPeeeell,, TT..EE..:: AA nneeww mmeetthhoodd ooff mmeeaassuurriinngg ppaatteellllaarr hheeiigghhtt.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[BBrr..]] 5599::224411––224422,, 11997777.. BBlluummeennssaaaatt,, CC..:: DDiiee llaaggeeaabbwweeiicchhuunnggeerr aanndd vveerrrreennkkuunnggeenn ddeerr kknniieesscchheeiibbee.. EErrggeebb.. CChhiirr.. OOrrtthhoopp.. 3311::114499––222233,, 11993388.. IInnssaallll,, JJ..,, aanndd SSaallvvaattii,, EE..:: PPaatteellllaa ppoossiittiioonn iinn tthhee nnoorrmmaall kknneeee jjooiinntt.. RRaaddiioollooggyy 110011::110011––110044,, 11997711.. JJaacckkssoonn,, DD..WW..,, JJeennnniinnggss,, LL..DD..,, MMaayywwoooodd,, RR..MM..,, eett aall..:: MMaaggnneettiicc rreessoonnaannccee iimmaaggiinngg ooff tthhee kknneeee.. AAmm.. JJ.. SSppoorrttss MMeedd.. 1166::2299––3388,, 11998888.. JJaacckkssoonn,, RR..WW..:: TThhee ppaaiinnffuull kknneeee:: AArrtthhrroossccooppyy oorr MMRR IImmaaggiinngg.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 44::9933––9999,, 11999966.. MMeerrcchhaanntt,, AA..CC..,, MMeerrcceerr,, RR..LL..,, JJaaccoobbsseenn,, RR..HH..,, eett aall..:: RRooeennttggeennooggrraapphhiicc aannaallyyssiiss ooff ppaatteellllooffeemmoorraall ccoonnggrruueennccee.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 5566::11339911––11339966,, 11997744..

NNeewwhhoouussee,, KK..EE..,, aanndd RRoosseennbbeerrgg,, TT..DD..:: BBaassiicc rraaddiiooggrraapphhiicc eexxaammiinnaattiioonn ooff tthhee kknneeee.. IInn FFuu,, FF..HH..,, HHaarrnneerr,, CC..DD..,, aanndd VViinnccee,, KK..GG..,, eeddss..:: KKnneeee SSuurrggeerryy.. BBaallttiimmoorree,, WWiilllliiaammss && WWiillkkiinnss,, 11999944,, pppp.. 331133––332244.. RRoosseennbbeerrgg,, TT..DD..,, PPaauullooss,, LL..EE..,, PPaarrkkeerr,, RR..DD..,, eett aall..:: TThhee ffoorrttyy--ffiivvee ddeeggrreeee ppoosstteerrooaanntteerriioorr fflleexxiioonn wweeiigghhtt--bbeeaarriinngg rraaddiiooggrraapphh ooff tthhee kknneeee.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 7700::11447799––11448833,, 11998888.. TThhaaeettee,, FF..LL..,, aanndd BBrriittttoonn,, CC..AA..:: MMaaggnneettiicc rreessoonnaannccee iimmaaggiinngg.. IInn FFuu,, FF..HH..,, HHaarrnneerr,, CC..DD..,, aanndd VViinnccee,, KK..GG..,, eeddss..:: KKnneeee SSuurrggeerryy.. BBaallttiimmoorree,, WWiilllliiaammss && WWiillkkiinnss,, 11999944..

KKNNEEEE AARRTTHHRROOSSCCOOPPYY

KKNNEEEE AARRTTHHRROOSSCCOOPPYY:: GGEENNEERRAALL CCOONNCCEEPPTTSS

TThhee GGoolldd SSttaannddaarrdd ffoorr ddiiaaggnnoossiiss ooff kknneeee ppaatthhoollooggyy iiss aarrtthhrroossccooppyy.. TThhee bbeenneeffiittss ooff aarrtthhrroossccooppyy iinncclluuddee ssmmaalllleerr iinncciissiioonnss,, iimmpprroovveedd vviissuuaalliizzaattiioonn,, aanndd lleessss rreeccoovveerryy ttiimmee

KKNNEEEE AARRTTHHRROOSSCCOOPPYY:: PPOORRTTAALLSS

SSttaannddaarrdd ppoorrttaallss iinncclluuddee ssuuppeerroommeeddiiaall oorr ssuuppeerroollaatteerraall iinnffllooww ppoorrttaall ((mmaaddee wwiitthh kknneeee iinn eexxtteennssiioonn)),, iinnffeerroollaatteerraall ((aarrtthhrroossccooppee)) aanndd iinnffeerroommeeddiiaall ((iinnssttrruummeennttss)) ppoorrttaallss

AAcccceessssoorryy ppoorrttaallss,, ssoommeettiimmeess hheellppffuull ffoorr vviissuuaalliizziinngg tthhee ppoosstteerriioorr hhoorrnnss ooff tthhee mmeenniissccii aanndd PPCCLL,, iinncclluuddee tthhee ppoosstteerroommeeddiiaall ppoorrttaall ((11 ccmm aabboovvee tthhee jjooiinntt lliinnee bbeehhiinndd tthhee MMCCLL [[aavvooiidd ssaapphheennoouuss nneerrvvee bbrraanncchheess]])) aanndd tthhee ppoosstteerroollaatteerraall ppoorrttaall ((11 ccmm aabboovvee tthhee jjooiinntt lliinnee bbeettwweeeenn tthhee LLCCLL aanndd bbiicceeppss tteennddoonn [[aavvooiiddiinngg tthhee ccoommmmoonn ppeerroonneeaall nneerrvvee]]))..

PPoosstteerriioorr HHoorrnn ooff MMeeddiiaall MMeenniissccii ((PPHHMMMM)):: AALL && PPMM == BBeesstt vviissuuaalliizzaattiioonn PPaatteellllaarr ttrraacckkiinngg:: SSuuppeerriioorr == BBeesstt vviissuuaalliizzaattiioonn

KKNNEEEE AARRTTHHRROOSSCCOOPPYY:: CCOOMMPPLLIICCAATTIIOONNSS

CCoommpplliiccaattiioonnss -- IIaattrrooggeenniicc aarrttiiccuullaarr ccaarrttiillaaggee ddaammaaggee ((mmoosstt ccoommmmoonn)) -- HHeemmaarrtthhrroossiiss -- IInnffeeccttiioonn -- NNeeuurroovvaassccuullaarr iinnjjuurryy -- BBlloooodd cclloottss

KKNNEEEE AARRTTHHRROOSSCCOOPPYY:: KKeeyy TTeessttaabbllee IItteemmss

PPoorrttaallss MMoosstt ccoommmmoonn ccoommpplliiccaattiioonnss PPrroopphhyyllaaxxiiss ffoorr tthhoossee wwiitthh pprriioorr DDVVTT

KKNNEEEE AARRTTHHRROOSSCCOOPPYY:: RREEFFEERREENNCCEESS

DDeeLLeeee,, JJ..CC..:: CCoommpplliiccaattiioonnss ooff aarrtthhrroossccooppyy aanndd aarrtthhrroossccooppiicc ssuurrggeerryy:: RReessuullttss ooff aa nnaattiioonnaall ssuurrvveeyy.. AArrtthhrroossccooppyy 44::221144––222200,, 11998888.. DDiiGGiioovviinnee,, NN..MM..,, aanndd BBrraaddlleeyy,, JJ..PP..:: AArrtthhrroossccooppiicc eeqquuiippmmeenntt aanndd sseett--uupp.. IInn FFuu,, FF..HH..,, HHaarrnneerr,, CC..DD..,, aanndd VViinnccee,, KK..GG..,, eeddss..:: KKnneeee SSuurrggeerryy.. BBaallttiimmoorree,, WWiilllliiaammss && WWiillkkiinnss,, 11999944.. GGiillllqquuiisstt,, JJ..:: AArrtthhrroossccooppyy ooff tthhee ppoosstteerriioorr ccoommppaarrttmmeennttss ooff tthhee kknneeee.. CCoonntteemmpp.. OOrrtthhoopp.. 1100::3399––4455,, 11998855.. JJoohhnnssoonn,, LL..LL..:: AArrtthhrroossccooppiicc SSuurrggeerryy:: PPrriinncciipplleess aanndd PPrraaccttiiccee,, 33rrdd eedd.. SStt.. LLoouuiiss,, CCVV MMoossbbyy,, 11998866.. OO''CCoonnnnoorr,, RR..LL..:: AArrtthhrroossccooppyy iinn tthhee ddiiaaggnnoossiiss aanndd ttrreeaattmmeenntt ooff aaccuuttee lliiggaammeenntt iinnjjuurriieess ooff tthhee kknneeee.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 5566::333333––333377,, 11997744.. RRoosseennbbeerrgg,, TT..DD..,, PPaauullooss,, LL..EE..,, PPaarrkkeerr,, RR..DD..,, eett aall..:: AArrtthhrroossccooppiicc ssuurrggeerryy ooff tthhee kknneeee.. IInn CChhaappmmaann,, MM..WW..,, eedd..:: OOppeerraattiivvee OOrrtthhooppaaeeddiiccss.. PPhhiillaaddeellpphhiiaa,, JJBB LLiippppiinnccootttt,, 11998888,, pppp.. 11558855––11660044.. SSmmaallll,, NN..CC..:: CCoommpplliiccaattiioonnss iinn aarrtthhrroossccooppyy:: TThhee kknneeee aanndd ootthheerr jjooiinnttss.. AArrtthhrroossccooppyy 22::225533––225588,, 11998866.. WWaannttaannaabbee,, MM..,, aanndd TTaakkeeddaa,, SS..:: TThhee nnuummbbeerr 2211 aarrtthhrroossccooppee.. JJ.. JJppnn.. OOrrtthhoopp.. AAssssoocc.. 3344::11004411,, 11996600..

MMEENNIISSCCII MMEENNIISSCCAALL TTEEAARRSS

MMoosstt ccoommmmoonn iinnjjuurryy ttoo tthhee kknneeee tthhaatt rreeqquuiirreess ssuurrggeerryy HHiigghheerr rriisskk iinn AACCLL--ddeeffiicciieenntt kknneeee TThhee mmeeddiiaall mmeenniissccuuss iiss ttoorrnn aapppprrooxxiimmaatteellyy tthhrreeee ttiimmeess mmoorree ffrreeqquueennttllyy

tthhaann tthhee llaatteerraall mmeenniissccuuss dduuee ttoo lleessss eexxccuurrssiioonn ((LLaatt mmeenniissccuuss mmoottiioonn 22XX mmeeddiiaall))

Acute ACL tear Posterior horn of lateral meniscus Chronic ACL deficiency Medial Meniscus tear

YYoouunngg:: TTrraauummaattiicc iinnjjuurryy,, uussuuaallllyy ppeerriipphheerraall,, 6600%% wwiitthh AACCLL tteeaarrss OOllddeerr:: DDeeggeenneerraattiivvee tteeaarrss,, uussuuaallllyy ppoosstteerriioorr hhoorrnn mmeeddiiaall mmeenniissccuuss dduuee ttoo

iinnccrreeaassee ccoonnttaacctt ssttrreesssseess,, uussuuaallllyy iinnssiiddiioouuss oonnsseett MMeenniissccaall tteeaarrss aarree ccllaassssiiffiieedd bbaasseedd oonn tthheeiirr::

LLooccaattiioonn iinn rreellaattiioonn ttoo tthhee vvaassccuullaarr ssuuppppllyy ((aanndd hheeaalliinngg ppootteennttiiaall)) PPoossiittiioonn ((aanntteerriioorr,, mmiiddddllee,, oorr ppoosstteerriioorr tthhiirrdd)) AAppppeeaarraannccee OOrriieennttaattiioonn..

Meniscal root tears are becoming more commonly diagnosed. They are especially problematic for patients because they represent complete disruption

of the longitudinal fibers and are difficult to repair. PPAARRTTIIAALL MMEENNIISSEECCTTOOMMYY

IIss iinnddiiccaatteedd iiff tteeaarr iiss iirrrreeppaarraabbllee CCoommpplleexx// ddeeggeenneerraattiivvee// cceennttrraall// aanndd ssoommeettiimmeess rraaddiiaall MMoottoorriizzeedd sshhaavveerr iiss hheellppffuull iinn ccrreeaattiinngg aa ssmmooootthh ttrraannssiittiioonn zzoonnee LLaasseerrss aanndd RRaaddiiooffrreeqquueennccyy ((RRFF)) aarree nnoott tthhee aannsswweerr bbeeccaauussee ooff iiaattrrooggeenniicc

cchhoonnddrraall rriisskk MMiinniimmaall rreemmoovvaall wwhhiillee ggiivviinngg ssmmooootthh aanndd ssttaabbllee rriimm DDJJDD RRiisskk pprrooppoorrttiioonnaall ttoo aammoouunntt rreemmoovveedd

MMEENNIISSCCAALL RREEPPAAIIRR

IInnddiiccaattiioonnss PPeerriipphheerraall lloonnggiittuuddiinnaall tteeaarrss YYoouunngg ppaattiieennttss WWiitthh AACCLL RReeccoonnssttrruuccttiioonn

CCoonnttrraaiinnddiiccaattiioonn:: AACCLL DDeeffiicciieennccyy IImmpprroovveedd hheeaalliinngg wwiitthh ccoommbbiinneedd AACCLL rreeccoonnssttrruuccttiioonn ((9900%%)) 8800--9900%% ssuucccceessss rraattee wwiitthh aapppprroopprriiaattee iinnddiiccaattiioonnss HHeeaalliinngg bbyy iinnffllaammmmaattoorryy cceellll iinnffiillttrraattiioonn TTeecchhnniiqquueess:: OOppeenn,, OOuuttssiiddee--iinn,, AAllll iinnssiiddee,, IInnssiiddee--oouutt AAuuggmmeennttaattiioonn tteecchhnniiqquueess,, iinncclluuddiinngg ffiibbrriinn cclloott,, ttrreepphhiinniizzaattiioonn,, aanndd rraassppiinngg ccaann eexxtteenndd tthhee iinnddiiccaattiioonnss ffoorr rreeppaaiirr

TThhee ggoolldd ssttaannddaarrdd ffoorr mmeenniissccaall rreeppaaiirr iiss tthhee iinnssiiddee--oouutt tteecchhnniiqquuee wwiitthh vveerrttiiccaall mmaattttrreessss ssuuttuurreess.. ((IIff tthhiiss iiss aann ooppttiioonn,, iitt iiss tthhee aannsswweerr))

NNeewweerr tteecchhnniiqquueess ffoorr aallll--iinnssiiddee rreeppaaiirrss ((aarrrroowwss,, ddaarrttss,, ssttaapplleess,, ssccrreewwss,, eettcc..)) aarree eeaassyy ttoo uussee,, bbuutt nnoott pprroovveenn ttoo bbee ssuuppeerriioorr ttoo vveerrttiiccaall mmaattttrreessss ssuuttuurreess..

RRiisskkss ooff nneeww aallll iinnssiiddee ddeevviicceess iinncclluuddee BBrreeaakkaaggee,, MMiiggrraattiioonn,, SSyynnoovviittiiss,, CChhoonnddrraall IInnjjuurryy,, aanndd DDeeccrreeaasseedd ssttrreennggtthh

MMEENNIISSCCAALL RREEPPAAIIRR RRIISSKKSS

MMeeddiiaall:: SSaapphheennoouuss NN//VV PPoopplliitteeaall vveesssseellss

LLaatteerraall:: PPeerroonneeaall NNeerrvvee PPoopplliitteeaall vveesssseellss Common Peroneal Nerve can be found posterior and medial to biceps femoris long head tendon MMEENNIISSCCUUSS TTRRAANNSSPPLLAANNTTAATTIIOONN

IInnddiiccaattiioonnss aarree ccoonnttrroovveerrssiiaall IInnddiiccaatteedd iinn yyoouunngg aaccttiivvee ppaattiieennttss wwiitthh ppaaiinn wwhhoo hhaavvee hhaadd aa nneeaarr ttoottaall

mmeenniisseeccttoommyy ggoooodd aaxxiiaall aalliiggnnmmeenntt aanndd oonnllyy eeaarrllyy cchhoonnddrroossiiss ((uupp ttoo GGrraaddee IIII CChhoonnddrroossiiss))

AAvvooiidd iinn ppaattiieennttss wwiitthh GGrraaddee IIIIII oorr IIVV CChhoonnddrroossiiss NNeeeedd nneeaarr nnoorrmmaall mmeecchhaanniiccaall aalliiggnnmmeenntt ttoo hhaavvee ssuucccceessss TTeecchhnniiccaallllyy DDiiffffiiccuulltt May require concomitant realignment procedure (HTO) ?? LLoonngg--tteerrmm RReessuullttss SShhrriinnkkaaggee//DDeeggeenneerraattiioonn

TTeecchhnniiqquuee iiss eevvoollvviinngg,, bbuutt ggeenneerraallllyy,, iiss aarrtthhrroossccooppiicc wwiitthh tthhee mmeenniissccii iinnttrroodduucceedd tthhrroouugghh tthhee ccoonnttrraallaatteerraall ppoorrttaall

MMeeddiiaall:: UUssuuaallllyy uussee BBoonnee PPlluuggss LLaatteerraall:: UUssuuaallllyy uussee BBoonnee BBrriiddggee PPeerriipphheerraall SSuuttuurreess ffoorr bbootthh mmeeddiiaall aanndd llaatteerraall

PPrrootteeooggllyyccaannss ddeeccrreeaasseedd aanndd WWaatteerr ccoonntteenntt iinnccrreeaasseedd aatt 66 mmoonntthhss Question is do they function MMEENNIISSCCAALL CCYYSSTTSS

MMoosstt ccoommmmoonnllyy aassssoocciiaatteedd wwiitthh LLMM hhoorriizzoonnttaall cclleeaavvaaggee tteeaarrss CCyysstt fflluuiidd iiss ggeell--lliikkee aanndd ssiimmiillaarr iinn ccoonntteenntt ttoo ssyynnoovviiaall fflluuiidd PPaarrttiiaall mmeenniisscceeccttoommyy aanndd aarrtthhrroossccooppiicc ddeeccoommpprreessssiioonn ((ssoommeettiimmeess

iinncclluuddiinngg nneeeeddlliinngg tthhee ccyysstt)) PPoopplliitteeaall ccyyssttss aarree aallssoo rreellaatteedd ttoo mmeenniissccaall ddiissoorrddeerr aanndd wwiillll uussuuaallllyy

rreessoollvvee wwiitthh ttrreeaattmmeenntt.. TThheeiirr ccllaassssiicc llooccaattiioonn iiss bbeettwweeeenn tthhee sseemmiimmeemmbbrraannoossuuss aanndd mmeeddiiaall hheeaadd ooff tthhee ggaassttrrooccnneemmiiuuss.. TThheeyy wwiillll aasskk tthhee aannaattoommiicc llaannddmmaarrkkss ooff tthhiiss ssppaaccee

DDIISSCCOOIIDD MMEENNIISSCCII

OOfftteenn ccaalllleedd ““PPooppppiinngg kknneeee ssyynnddrroommee”” CClliinniiccaall ffiinnddiinnggss iinncclluuddee mmeecchhaanniiccaall ssyymmppttoommss oorr ppooppppiinngg aass tthhee kknneeee

rreeaacchheess eexxtteennssiioonn XX--RRaayy ffiinnddiinnggss

jjooiinntt ssppaaccee wwiiddeenniinngg ssqquuaarriinngg ooff llaatteerraall ttiibbiiaall ppllaatteeaauu hhyyppooppllaassttiicc llaatteerraall ssppiinnee

MMRRII ccaann hheellpp iinn ddiiaaggnnoossiiss aanndd ttoo ffiinndd aa tteeaarr ((33 sseeqquueennttiiaall ccuuttss ffoorr ddiiaaggnnoossiiss ooff mmeenniissccaall tteeaarr))

CCllaassssiiffiiccaattiioonn TTyyppee II -- IInnccoommpplleettee TTyyppee IIII -- CCoommpplleettee TTyyppee IIIIII-- WWrriissbbeerrgg ((ppeerriipphheerraall ddeettaacchhmmeenntt))

TTrreeaattmmeenntt:: SSaauucceerriizzaattiioonn ooff tteeaarrss MMeenniissccaall rreeppaaiirr ooff ppoosstteerriioorr ddeettaacchhmmeennttss ((WWrriissbbeerrgg’’ss vvaarriiaanntt)) OObbsseerrvvaattiioonn iiff AAssyymmppttoommaattiicc

MMEENNIISSCCII:: KKeeyy TTeessttaabbllee IItteemmss

MMeeddiiaall >> LLaatteerraall tteeaarrss MMoosstt ccoommmmoonn llooccaattiioonn ooff ddeeggeenneerraattiivvee tteeaarrss GGoolldd ssttaannddaarrdd ffoorr mmeenniiccaall rreeppaaiirrss

RRiisskkss ffoorr mmeeddiiaall aanndd llaatteerraall mmeenniissccaall rreeppaaiirrss MMeenniissccaall ccyyssttss aarree aassssoocciiaatteedd wwiitthh wwhhaatt ttyyppee ooff mmeenniissccaall tteeaarrss?? LLooccaattiioonn ooff PPoopplliitteeaall ccyyssttss CCllaassssiiffiiccaattiioonn//MMRRII//TTrreeaattmmeenntt ooff DDiissccooiidd MMeenniissccii

MMEENNIISSCCII:: RREEFFEERREENNCCEESS AArrnnoocczzkkyy,, SS..PP..,, WWaarrrreenn,, RR..FF..,, aanndd SSppiivvaakk,, JJ..MM..:: MMeenniissccaall rreeppaaiirr uussiinngg aann eexxooggeennoouuss ffiibbrriinn cclloott——AAnn eexxppeerriimmeennttaall ssttuuddyy iinn ddooggss.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 7700::11220099––11222200,, 11998888.. BBaarraattzz,, MM..EE..,, FFuu,, FF..HH..,, aanndd MMeennggaattoo,, RR..:: MMeenniissccaall tteeaarrss:: TThhee eeffffeecctt ooff mmeenniisscceeccttoommyy aanndd ooff rreeppaaiirr oonn iinnttrraa--aarrttiiccuullaarr ccoonnttaacctt aarreeaass aanndd ssttrreesssseess iinn tthhee hhuummaann kknneeee.. AAmm.. JJ.. SSppoorrttss MMeedd.. 1144::227700––227755,, 11998866.. BBeellzzeerr JJ..PP..,, aanndd CCaannnnoonn WW..DD.. MMeenniissccuuss tteeaarrss:: TTrreeaattmmeenntt iinn tthhee ssttaabbllee aanndd uunnssttaabbllee kknneeee.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 11::4411––4477,, 11999933.. BBooeenniisscchh,, UU..WW..,, FFaabbeerr,, KK..JJ..,, eett.. aall..:: PPuullll oouutt ssttrreennggtthh aanndd ssttiiffffnneessss ooff mmeenniissccaall rreeppaaiirr uussiinngg aabbssoorrbbaabbllee aarrrroowwss oorr TTii--ccrroonn vveerrttiiccaall aanndd hhoorriizzoonnttaall lloooopp ssuuttuurreess.. AAmm JJ SSppoorrttss MMeedd,, 2277:: 662266--663311,, 11999999.. CCaarrtteerr,, TT..RR..:: MMeenniissccaall aallllooggrraafftt ttrraannssppllaannttaattiioonn.. SSppoorrttss MMeedd AArrtthhrroosscc RReevv,, 77:: 5511--6622,, 11999999.. CCaannnnoonn,, WW..DD..,, aanndd VViittttoorrii,, JJ..MM..:: TThhee iinncciiddeennccee ooff hheeaalliinngg iinn aarrtthhrroossccooppiicc mmeenniissccaall rreeppaaiirrss iinn aanntteerriioorr ccrruucciiaattee lliiggaammeenntt rreeccoonnssttrruucctteedd kknneeeess vveerrssuuss ssttaabbllee kknneeeess.. AAmm.. JJ.. SSppoorrttss MMeedd.. 2200::117766––118811,, 11999922.. DDeeHHaavveenn,, KK..EE..,, BBllaacckk,, KK..PP..,, aanndd GGrriiffffiitthhss,, HH..JJ..:: OOppeenn mmeenniissccuuss rreeppaaiirr:: TTeecchhnniiqquuee aanndd ttwwoo ttoo nniinnee yyeeaarr rreessuullttss.. AAmm.. JJ.. SSppoorrttss MMeedd.. 1177::778888––779955,, 11998899.. DDeeHHaavveenn,, KK..EE..:: MMeenniissccuuss RReeppaaiirr.. AAmm.. JJ.. SSppoorrttss MMeedd,, 2277:: 224422--225500,, 11999999.. DDiicckkhhaauutt,, SS..CC..,, aanndd DDeeLLeeee,, JJ..CC..:: TThhee ddiissccooiidd llaatteerraall mmeenniissccuuss ssyynnddrroommee.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 6644::11006688––11007733,, 11998822.. FFaaiirrbbaannkk,, TT..JJ..:: KKnneeee jjooiinntt cchhaannggeess aafftteerr mmeenniisscceeccttoommyy.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[BBrr..]] 3300::666644––667700,, 11994488.. HHeennnniinngg,, CC..EE..,, LLyynncchh,, MM..AA..,, YYeeaarroouutt,, KK..MM..,, eett aall..:: AArrtthhrroossccooppiicc mmeenniissccaall rreeppaaiirr uussiinngg aann eexxooggeennoouuss ffiibbrriinn cclloott.. CClliinn.. OOrrtthhoopp.. 225522::6644,, 11999900.. JJoorrddaann MM..RR..,, LLaatteerraall mmeenniissccaall vvaarriiaannttss:: EEvvaalluuaattiioonn aanndd ttrreeaattmmeenntt.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 44::119911––220000,, 11999966.. MMiilllleerr,, MM..DD..,, RRiittcchhiiee,, JJ..RR..,, RRooyysstteerr,, RR..MM..,, eett aall..:: MMeenniissccaall rreeppaaiirr:: AAnn eexxppeerriimmeennttaall ssttuuddyy iinn tthhee ggooaatt.. AAmm.. JJ.. SSppoorrttss MMeedd.. 2233((11))::112244––112288,, 11999955..

MMiilllleerr,, MM..DD..,, WWaarrnneerr,, JJ..JJ..PP..,, aanndd HHaarrnneerr,, CC..DD..:: MMeennssiiccaall rreeppaaiirr.. IInn FFuu,, FF..HH..,, HHaarrnneerr,, CC..DD..,, aanndd VViinnccee,, KK..GG..,, eeddss..:: KKnneeee SSuurrggeerryy.. BBaallttiimmoorree,, WWiilllliiaammss && WWiillkkiinnss,, 11999944.. NNeeuusscchhwwaannddeerr,, DD..CC..,, DDrreezz,, DD..,, aanndd FFiinnnneeyy,, TT..PP..:: LLaatteerraall mmeenniissccaall vvaarriiaanntt wwiitthh aabbsseennccee ooff tthhee ppoosstteerriioorr ccoorroonnaarryy lliiggaammeenntt.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 7744::11118866––11119900,, 11999922.. PPaarriissiieenn,, JJ..SS..:: AArrtthhrroossccooppiicc ttrreeaattmmeenntt ooff ccyyssttss ooff tthhee mmeenniissccii:: AA pprreelliimmiinnaarryy rreeppoorrtt.. CClliinn.. OOrrtthhoopp.. 225577::115544––115588,, 11999900.. WWaarrrreenn,, RR..FF..:: MMeenniisscceeccttoommyy aanndd rreeppaaiirr iinn tthhee aanntteerriioorr ccrruucciiaattee lliiggaammeenntt––ddeeffiicciieenntt ppaattiieenntt.. CClliinn.. OOrrtthhoopp.. 225522::5555––6633,, 11999900..

OOSSTTEEOOCCHHOONNDDRRAALL IINNJJUURRIIEESS OOSSTTEEOOCCHHOONNDDRRAALL LLEESSIIOONNSS:: OOCCDD

IInnvvoollvveess ssuubbcchhoonnddrraall bboonnee aanndd oovveerrllyyiinngg ccaarrttiillaaggee sseeppaarraattiioonn,, mmoosstt lliikkeellyy aass aa rreessuulltt ooff ooccccuulltt ttrraauummaa..

MMoosstt oofftteenn iinnvvoollvveess tthhee llaatteerraall aassppeecctt ooff tthhee mmeeddiiaall ffeemmoorraall ccoonnddyyllee.. JJuuvveenniillee ffoorrmm

–– ooppeenn pphhyysseess –– MMaajjoorriittyy hheeaall ssppoonnttaanneeoouussllyy –– LLeessss rriisskk ooff DDJJDD –– GGoooodd pprrooggnnoossiiss

AAdduulltt FFoorrmm –– MMFFCC ((8855%%));; LLFFCC ((1155%%)) –– uussuuaallllyy ssyymmppttoommaattiicc –– PPoosstteerroollaatteerraall aassppeecctt ooff MMFFCC ((7700%%)) –– PPaatthhoollooggiiccaall cchhaannggeess bbeeggiinn iinn ssuubbcchhoonnddrraall bboonnee –– WWoorrssee pprrooggnnoossiiss bbeeccaauussee lleeaaddss ttoo DDJJDD –– OOppeerraattiivvee ttrreeaattmmeenntt iinn mmoosstt lloooossee,, ssyymmppttoommaattiicc,, aanndd aadduulltt ffoorrmmss

OOSSTTEEOOCCHHOONNDDRRAALL LLEESSIIOONNSS:: TTrreeaattmmeenntt

Initial treatment for stable fragment is 6 weeks of activity modification and restricted weightbearing.

CCaarrttiillaaggee ssoofftt bbuutt iinnttaacctt ww//oo sseeppaarraattiioonn –– RReettrrooggrraaddee ddrriilllliinngg

CCaarrttiillaaggee ssoofftt bbuutt iinnttaacctt ww// eeaarrllyy sseeppaarraattiioonn –– RReettrrooggrraaddee ddrriilllliinngg ++ ffiixxaattiioonn

CCaarrttiillaaggee ppaarrttiiaallllyy ddeettaacchheedd –– DDeebbrriiddee bbaassee,, rreedduuccee ++ ffiixxaattiioonn

LLoooossee bbooddyy // CCrraatteerr ((NNWWBB aarreeaa)) –– DDeebbrriiddee aanndd mmiiccrrooffrraaccttuurree

LLoooossee bbooddyy // CCrraatteerr ((WWBB aarreeaa))

–– DDeebbrriiddee ++ mmiiccrrooffrraaccttuurree ((<<22ccmm)) –– OOAATTSS vvss.. AAuuttoollooggoouuss CChhoonnddrrooccyyttee IImmppllaanntt ((llaarrggeerr lleessiioonn))

–– BBeesstt hhaarrvveesstt llooccaattiioonn == mmeeddiiaall ffeemmoorraall ttrroocchhlleeaa –– OOsstteeoottoommyy oorr aarrtthhrrooppllaassttyy ((llaarrggee))

MMiiccrrooffrraaccttuurree ((PPrroodduucceess TTyyppee II CCoollllaaggeenn ““ffiibbrrooccaarrttiillaaggee”” NNoott ttyyppee IIII

ccoollllaaggeenn)) ssmmaallll ((<<22ccmm)) ffooccaall lleessiioonnss

OOSSTTEEOONNEECCRROOSSIISS AAttrraauummaattiicc OONN

SSaammee rriisskkss aass hhiipp OONN RRiisskk ffaaccttoorrss aarree tthhee ssaammee aass ffoorr hhiipp AAVVNN CCoommmmoonn iinn eellddeerrllyy ffeemmaalleess OOfftteenn iiss wweeddggee sshhaappeedd bbyy MMRRII CCoorree ddeeccoommpprreessssiioonn iiss ttrreeaattmmeenntt iiff ccaauugghhtt eeaarrllyy eennoouugghh.. IInn llaatteerr ssttaaggeess,,

aarrtthhrrooppllaassttyy iiss ttrreeaattmmeenntt ooff cchhooiiccee SSOONNKK ((SSppoonnttaanneeoouuss OOsstteeoonneeccrroossiiss ooff tthhee KKnneeee))

SSuubbcchhoonnddrraall IInnssuuffffiicciieennccyy FFrraaccttuurree MMaayy ffoollllooww aarrtthhrroossccooppyy iinn oollddeerr ppaattiieennttss DDiiaaggnnoossiiss iiss bbyy MMRRII OOfftteenn iiss aa sseellff--lliimmiittiinngg ccoonnddiittiioonn

Intra-articular use of lidocaine

Recent work has shown that lidocaine is cytotoxic to chondrocytes of articular cartilage in a dose- and time-dependent manner.

Post-operative intra-articular lidocaine catheters are no longer recommended. OOSSTTEEOOCCHHOONNDDRRAALL LLEESSIIOONNSS:: KKeeyy TTeessttaabbllee IItteemmss

MMoosstt iimmppoorrttaanntt pprrooggnnoossttiicc ffaaccttoorr ffoorr OOCCDD lleessiioonnss MMoosstt ccoommmmoonn llooccaattiioonnss ooff OOCCDD WWhheenn iiss ooppeerraattiivvee ttrreeaattmmeenntt iinnddiiccaatteedd iinn OOCCDD lleessiioonnss BBaassiicc sscciieennccee ooff mmiiccrrooffrraaccttuurree tteecchhnniiqquuee RReeccooggnniizzee SSOONNKK ffoolllloowwiinngg ssccooppee,, ttrreeaatt ccoonnsseerrvvaattiivveellyy

OOSSTTEEOOCCHHOONNDDRRAALL LLEESSIIOONNSS:: RREEFFEERREENNCCEESS BBaauueerr,, MM..,, aanndd JJaacckkssoonn,, RR..WW..:: CChhoonnddrraall lleessiioonnss ooff tthhee ffeemmoorraall ccoonnddyylleess:: AA ssyysstteemm ooff aarrtthhrroossccooppiicc ccllaassssiiffiiccaattiioonn.. AArrtthhrroossccooppyy 44::9977––110022,, 11998888.. BBuucckkwwaalltteerr,, JJ..AA..,, RReessttoorraattiioonn ooff iinnjjuurreedd oorr ddeeggeenneerraatteedd aarrttiiccuullaarr ccaarrttiillaaggee.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 22::119922––220011,, 11999944.. BBuucckkwwaalltteerr,, JJ..AA..,, aanndd MMaannkkiinn,, HH..JJ..,, AArrttiiccuullaarr ccaarrttiillaaggee ((ppaarrttss II&&IIII)).. IInnssttrruuccttiioonnaall CCoouurrssee LLeeccttuurreess.. JJ.. BBoonnee JJooiinntt SSuurrgg.. 7799AA::660000––663322,, 11999977..

BBuuggbbeeee,, WW..DD..,, CCoonnvveerryy,, FF..RR..:: OOsstteeoocchhoonnddrraall aallllooggrraafftt ttrraannssppllaannttaattiioonn.. CClliinn SSppoorrttss MMeedd,, 1188:: 6677--7755,, 11999999.. CCaahhiillll,, BB..RR..:: OOsstteeoocchhoonnddrriittiiss ddiisssseeccaannss ooff tthhee kknneeee:: TTrreeaattmmeenntt ooff jjuuvveenniillee aanndd aadduulltt ffoorrmmss.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 33::223377––224477,, 11999955.. EEcckkeerr,, MM..LL..,, aanndd LLoottkkee,, PP..AA..:: SSppoonnttaanneeoouuss oosstteeoonneeccrroossiiss ooff tthhee kknneeee.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 22::117733––117788,, 11999944.. GGuuhhll,, JJ..:: AArrtthhrroossccooppiicc ttrreeaattmmeenntt ooff oosstteeoocchhoonnddrriittiiss ddiisssseeccaannss.. CClliinn.. OOrrtthhoopp.. 116677::6655––7744,, 11998822.. KKaarrppiiee JJCC,, CChhuu CCRR.. LLiiddooccaaiinnee eexxhhiibbiiss ddoossee-- aanndd ttiimmee--ddeeppeennddeenntt ccyyttoottooxxiicc eeffffeeccttss oonn bboovviiee aarrttiiccuullaarr cchhoonnddrrooccyytteess iinn vviittrroo.. AAmm JJ SSppoorrttss MMeedd.. 3355((1100)):: 11662211--77,, 22000077.. MMaannddeellbbaauumm,, BB..RR..,, BBrroowwnnee,, JJ..EE..,, FFuu,, FF..HH..,, eett aall..:: AArrttiiccuullaarr ccaarrttiillaaggee lleessiioonnss ooff tthhee kknneeee:: CCuurrrreenntt ccoonncceeppttss.. AAmm.. JJ.. SSppoorrttss MMeedd.. 2266::885533––886611,, 11999988.. MMeenncchhee,, DD..SS..,, VVaannggssnneessss,, CC..TT..,, PPiittmmaann,, MM,, eett aall..:: TThhee ttrreeaattmmeenntt ooff iissoollaatteedd aarrttiiccuullaarr ccaarrttiillaaggee lleessiioonnss iinn tthhee yyoouunngg iinnddiivviidduuaall.. AAAAOOSS IInnssttrr.. CCoouurrssee LLeecctt.. 4477::550055––551155,, 11999988.. MMuurrrraayy,, PP..BB..,, aanndd RRaanndd,, JJ..AA..:: SSyymmppttoommaattiicc vvaallgguuss kknneeee:: TThhee ssuurrggiiccaall ooppttiioonnss.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 11::11––99,, 11999933.. NNeewwmmaann,, AA..PP..:: AArrttiiccuullaarr ccaarrttiillaaggee rreeppaaiirr:: CCuurrrreenntt ccoonncceeppttss.. AAmm.. JJ.. SSppoorrttss MMeedd.. 2266::330099––332244,, 11999988.. OO''DDrriissccoollll,, SS..WW..:: CCuurrrreenntt ccoonncceeppttss rreevviieeww:: TThhee hheeaalliinngg aanndd rreeggeenneerraattiioonn ooff aarrttiiccuullaarr ccaarrttiillaaggee.. JJ.. BBoonnee JJooiinntt SSuurrgg.. 8800AA::11779955––11881122,, 11999988.. SScchheenncckk,, RR..CC..,, aanndd GGooooddnniigghhtt,, JJ..MM..:: CCuurrrreenntt ccoonncceeppttss rreevviieeww:: OOsstteeoocchhoonnddrriittiiss ddiisssseeccaannss.. JJ.. BBoonnee JJooiinntt SSuurrgg.. 7788AA::443399––445566,, 11999966..

SSYYNNOOVVIIAALL PPAATTHHOOLLOOGGYY SSYYNNOOVVIIAALL LLEESSIIOONNSS

PPiiggmmeenntteedd VViilllloonnoodduullaarr SSyynnoovviittiiss ((PPVVNNSS)) PPaattiieennttss pprreesseenntt wwiitthh ppaaiinn aanndd sswweelllliinngg aanndd mmaayy hhaavvee aa ppaallppaabbllee mmaassss.. SSyynnoovveeccttoommyy iiss eeffffeeccttiivvee,, bbuutt tthheerree iiss aa hhiigghh rreeccuurrrreennccee rraattee.. AArrtthhrroossccooppiicc tteecchhnniiqquueess aarree jjuusstt aass eeffffeeccttiivvee aass ttrraaddiittiioonnaall ooppeenn

pprroocceedduurreess.. TThheeyy wwiillll ggiivvee yyoouu aa bbrroowwnniisshh ssyynnoovviiuumm aanndd aa hheemmoorrrrhhaaggiicc aassppiirraattee iinn tthhee qquueessttiioonn

RReeccooggnniizzee ggrroossss hhiissttoollooggiiccaall ssppeecciimmeenn SSyynnoovviiaall CChhoonnddrroommaattoossiiss

TThhiiss pprroolliiffeerraattiivvee ddiisseeaassee ooff tthhee ssyynnoovviiuumm iiss aassssoocciiaatteedd wwiitthh ccaarrttiillaaggiinnoouuss mmeettaappllaassiiaa,, rreessuullttiinngg iinn mmuullttiippllee iinnttrraa--aarrttiiccuullaarr lloooossee bbooddiieess..

SSyynnoovveeccttoommyy iiss ttrreeaattmmeenntt ooff cchhooiiccee SSYYNNOOVVIIAALL LLEESSIIOONNSS:: TTrreeaattmmeenntt

SSyynnoovveeccttoommyy iiss eeffffeeccttiivvee ttrreeaattmmeenntt aanndd ttrreeaattmmeenntt ooff cchhooiiccee ffoorr:: –– PPaauucciiaarrttiiccuullaarr JJRRAA –– HHeemmoopphhiilliiaa –– RRhheeuummaattooiidd AArrtthhrriittiiss ((ffoolllloowwiinngg ffaaiilleedd mmeeddiiccaall mmaannaaggeemmeenntt)) –– CChhoonnddrroommaattoossiiss –– PPVVNNSS

AAddddiittiioonnaall aarrtthhrroossccooppiicc ppoorrttaallss aarree rreeqquuiirreedd ffoorr ccoommpplleettee ssyynnoovveeccttoommyy Intra-articular instillation of radioactive isotopes and extermal beam

radiotherapy have been used to augment synovectomy in cases of synovial lesions SSYYNNOOVVIIAALL LLEESSIIOONNSS:: PPlliiccaa

SSyynnoovviiaall ffoollddss tthhaatt aarree eemmbbrryyoollooggiicc rreemmnnaannttss PPlliiccaa SSyynnddrroommee iinncclluuddeess ppaatthhoollooggiicc pplliiccaa MMeeddiiaall PPlliiccaaee mmoosstt ccoommmmoonn CCaauusseess aabbrraassiioonn ttoo tthhee MMFFCC TThheerree iiss oofftteenn aa hhiissttoorryy ooff bblluunntt ttrraauummaa OOfftteenn pprreesseennttss wwiitthh cchhrroonniicc aanntteerroommeeddiiaall kknneeee ppaaiinn oorr ssuubbppaatteellllaarr

ttiigghhttnneessss wwiitthh ssqquuaattttiinngg TTrreeaattmmeenntt aarrtthhrroossccooppiicc rreesseeccttiioonn DDiiaaggnnoossiiss iiss oovveerruusseedd

SSYYNNOOVVIIAALL PPAATTHHOOLLOOGGYY:: KKeeyy TTeessttaabbllee IItteemmss

RReeccooggnniizzee ggrroossss hhiissttoollooggyy ooff PPVVNNSS aanndd SSyynnoovviiaall CChhoonnddrroommaattoossiiss OOppeenn ssyynnoovveeccttoommyy iiff mmuullttiippllee aarrtthhrroossccooppiicc ffaaiilluurreess PPlliiccaa iiss aa ddiiaaggnnoossiiss ooff eexxcclluussiioonn,, bbuutt iiss rraarreellyy tthhee aannsswweerr oonn bbooaarrddss

SSYYNNOOVVIIAALL PPAATTHHOOLLOOGGYY:: RREEFFEERREENNCCEESS CCuurrll,, WW..WW..:: PPoopplliitteeaall ccyyssttss:: HHiissttoorriiccaall bbaacckkggrroouunndd aanndd ccuurrrreenntt kknnoowwlleeddggee.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 44::112299––113333,, 11999966.. EEwwiinngg,, JJ..WW..:: PPlliiccaa:: PPaatthhoollooggiicc oorr nnoott?? JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 11::111177––112211,, 11999933.. FFllaannddrryy,, FF..,, aanndd HHuugghhssttoonn,, JJ..CC..:: CCuurrrreenntt ccoonncceeppttss rreevviieeww:: PPiiggmmeenntteedd vviilllloonnoodduullaarr ssyynnoovviittiiss.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 6699::994422,, 11998877.. Mendenhall WM, Mendenhall CM, Reith JD, Scarborough MT, Gibbs CP, Mendenhall NP. Pigmented villonodular synovitis. Am J Clin Oncol. 29(6): 548-50, 2006.

LLIIGGAAMMEENNTTOOUUSS KKNNEEEE IINNJJUURRIIEESS

LLIIGGAAMMEENNTTOOUUSS KKNNEEEE IINNJJUURRIIEESS:: AACCLL

NNoonn--ccoonnttaacctt ppiivvoottiinngg iinnjjuurryy HHeeaarr oorr ffeeeell aa ““PPoopp”” // wwiitthh eeffffuussiioonn ((7700%%++ AACCLL rruuppttuurree rraattee)) MMoosstt aarree uunnaabbllee ttoo RReettuurrnn ttoo ppllaayy PPaattiieennttss ddeemmoonnssttrraaccee aa qquuaaddrriicceeppss aavvooiiddaannccee ggaaiitt TThhee nnaattuurraall hhiissttoorryy ooff cchhrroonniicc AACCLL ddeeffiicciieennccyy iiss aa hhiigghheerr iinncciiddeennccee ooff ccoommpplleexx mmeenniissccaall tteeaarrss nnoott aammeennaabbllee ttoo rreeppaaiirr aanndd cchhoonnddrraall iinnjjuurriieess ((uussuuaallllyy ppoosstteerriioorr mmeeddiiaall ttiibbiiaall ppllaatteeaauu)) oovveerr ttiimmee

BBoonnee bbrruuiisseess ((ttrraabbeeccuullaarr mmiiccrrooffrraaccttuurreess)) ooccccuurr iinn oovveerr hhaallff ooff aaccuuttee AACCLL iinnjjuurriieess aanndd aarree ttyyppiiccaallllyy llooccaatteedd nneeaarr tthhee ssuullccuuss tteerrmmiinnaalliiss oonn tthhee llaatteerraall ffeemmoorraall ccoonnddyyllee aanndd tthhee ppoosstteerroollaatteerraall aassppeecctt ooff tthhee ttiibbiiaa

TTrreeaattmmeenntt ddeecciissiioonnss sshhoouulldd bbee iinnddiivviidduuaalliizzeedd bbaasseedd oonn aaggee,, aaccttiivviittyy lleevveell,, iinnssttaabbiilliittyy,, aassssoocciiaatteedd iinnjjuurriieess,, aanndd ootthheerr ffaaccttoorrss

TThhee ddeevveellooppmmeenntt ooff llaattee aarrtthhrriittiiss iinn AACCLL--ddeeffiicciieenntt vveerrssuuss rreeccoonnssttrruucctteedd kknneeeess iiss ccoonnttrroovveerrssiiaall

AACCLL iinnjjuurriieess ccoommmmoonnllyy aassssoocciiaatteedd wwiitthh llaatteerraall mmeenniissccaall tteeaarrss –– EEssppeecciiaallllyy iinn sskkiieerrss –– MMeedd mmeenniissccaall tteeaarrss aarree mmoorree ccoommmmoonn iinn cchhrroonniicc AACCLL tteeaarrss

FFeemmaallee aatthhlleettee 22--88XX iinnccrreeaasseedd iinncciiddeennccee ooff AACCLL tteeaarrss wwhheenn ccoommppaarreedd ttoo mmaalleess dduuee ttoo:: –– SSmmaalllleerr nnoottcchh wwiiddtthh iinnddeexx ttoo ssiizzee ooff AACCLL lliiggaammeenntt –– IInnccrreeaasseedd vvaallgguuss llaannddiinngg jjuummppss ((ddiiffffeerreenntt llaannddiinngg

bbiioommeecchhaanniiccss)) –– HHoorrmmoonnaall iinnfflluueenncceess –– TTrraaiinniinngg ((qquuaaddss >> hhaammssttrriinnggss)) –– NNeeuurroommuussccuullaarr CCoonnttrrooll IImmbbaallaanncceess –– IInnccrreeaasseedd jjooiinntt llaaxxiittyy

AACCLL:: PPHHYYSSIICCAALL EEXXAAMM

LLaacchhmmaann tteesstt ((3300 ddeeggrreeeess)) iiss tthhee mmoosstt sseennssiittiivvee eexxaammiinnaattiioonn ffoorr aaccuuttee AACCLL iinnjjuurriieess

AAnntteerriioorr DDrraawweerr ((9900 ddeeggrreeeess)) PPiivvoott SShhiifftt oorr JJeerrkk TTeesstt iiss oofftteenn hheellppffuull dduurriinngg tthhee eexxaamm uunnddeerr aannaaeesstthheessiiaa KKTT--11000000 oorr 22000000 iiss uusseeffuull iinn qquuaannttiiffyyiinngg llaaxxiittyy

AACCLL TTRREEAATTMMEENNTT

NNoonnooppeerraattiivvee ttrreeaattmmeenntt iiss rreeccoommmmeennddeedd iinn:: –– LLooww--ddeemmaanndd ppaattiieennttss wwiitthh lleessss llaaxxiittyy

OOppeerraattiivvee ttrreeaattmmeenntt iiss rreeccoommmmeennddeedd iinn:: –– HHiigghheerr ddeemmaanndd,, aaccttiivvee ppaattiieennttss –– BBeeccaauussee iitt rreedduucceess tthhee iinncciiddeennccee ooff cchhoonnddrraall aanndd mmeenniissccaall iinnjjuurryy –– IInnttrraa--aarrttiiccuullaarr rreeccoonnssttrruuccttiioonn iiss ccuurrrreennttllyy ffaavvoorreedd ffoorr ppaattiieennttss wwhhoo mmeeeett tthhee

ccrriitteerriiaa

–– PPrriimmaarryy rreeppaaiirr ooff AACCLL tteeaarrss iiss nnoott ccuurrrreennttllyy rreeccoommmmeennddeedd –– OOvveerr tthhee ttoopp ffeemmoorraall ttuunnnneellss aarree uusseedd pprriimmaarriillyy iinn rreevviissiioonn ssiittuuaattiioonnss aanndd iinn

cchhiillddrreenn GGrraafftt cchhooiicceess aarree ddeeppeennddeenntt oonn ppaattiieenntt ffaaccttoorrss aanndd ssuurrggeeoonn pprreeffeerreennccee

BBoonnee PPaatteellllaarr TTeennddoonn BBoonnee:: ggoolldd ssttaannddaarrdd HHaammssttrriinnggss ggrraaffttss hhaavvee bbeeeenn sshhoowwnn ttoo bbee ffiixxaattiioonn ddeeppeennddeenntt HHiigghheesstt SSttrreennggtthh && SSttiiffffnneessss iinn bbiioommeecchhaanniiccaall ssttuuddiieess QQuuaaddrriicceeppss rraarreellyy uusseedd AAllllooggrraafftt bbeeccoommiinngg mmoorree ppooppuullaarr

HHIIVV RRiisskk 11::11..77 MMiilllliioonn HHeeppaattiittiiss RRiisskk 11::770000,,000000

DB ACL reconstruction is becoming more popular. It is thought to better reproduce normal knee kinematics when compared to single bundle ACL reconstruction. Long term clinical studies are required to show a significant benefit for patients.

AACCLL GGRRAAFFTTSS PPrreeccoonnddiittiioonniinngg ooff ggrraaffttss ccaann rreedduuccee ssttrreessss rreellaaxxaattiioonn uupp ttoo 5500%% GGrraafftt HHeeaalliinngg:: iinnffllaammmmaattiioonn aanndd nneeccrroossiiss,, rreevvaassccuullaarriizzaattiioonn ((ssyynnoovviiuumm

iimmppoorrttaanntt)),, rreeppooppuullaattiioonn ((~~44wwkkss)),, ggrraadduuaall rreemmooddeelliinngg 66 mmoonntthhss nneecceessssaarryy bbeeffoorree rreettuurrnn ttoo ppllaayy ffoorr ggrraafftt ttuunnnneell ffiixxaattiioonn

AACCLL AALLLLOOGGRRAAFFTTSS

RRaaddiiaattiioonn ((ddoossee ccoonnttrroovveerrssiiaall)) rreeqquuiirreedd ttoo kkiillll HHIIVV AAffffeeccttss ssttrruuccttuurraall aanndd mmeecchhaanniiccaall pprrooppeerrttiieess ooff tthhee ggrraafftt.. TTeecchhnniiqquueess aarree

ssttiillll bbeeiinngg ddeevveellooppeedd RRiisskk ooff bbaacctteerriiaall iinnffeeccttiioonn ttrraannssmmiissssiioonn CClloossttrriiddiiuumm mmoosstt ccoommmmoonn FFrreeeezziinngg ddeessttrrooyyss cceellllss DDooeessnn’’tt aaddvveerrsseellyy aaffffeecctt ggrraaffttss DDeellaayyeedd IInnccoorrppoorraattiioonn iinn AAnniimmaall SSttuuddiieess LLoossss ooff cceelllluullaarr DDNNAA bbyy 44 wweeeekkss SSiimmiillaarr pprroocceessss aass aauuttooggrraafftt,, jjuusstt ddeellaayyeedd HIV transmission risk = 1: 1.5-1.7 million Hepatitis C Risk = 1: 600,000

AACCLL:: PPOOSSTT--OOPP RREEHHAABB

RROOMM ((ffuullll eexxtteennssiioonn)) iiss ggooaall iinn eeaarrllyy rreehhaabb pphhaassee –– BBeewwaarree wwiitthh mmeeddiiaall ssiiddeedd ssuurrggeerryy ((TThhiiss wwiillll ssllooww ddoowwnn rreehhaabb aanndd rreeqquuiirree

lloonnggeerr bbrraaccee wweeaarr)) AAvvooiidd iissookkiinneettiicc qquuaadd ssttrreennggtthheenniinngg ((1155--3300oo)) eeaarrllyy bbeeccaauussee ccaann ccaauussee iinnccrreeaasseedd ggrraafftt llaaxxiittyy

CClloosseedd cchhaaiinn eexxeerrcciisseess aarree eemmpphhaassiizzeedd bbeeccaauussee iitt eennccoouurraaggeess pphhyyssiioollooggiicc ccoo--ccoonnttrraaccttiioonn ooff kknneeee mmuussccuullaattuurree

IImmmmeeddiiaattee wweeiigghhtt--bbeeaarriinngg hhaass bbeeeenn sshhoowwnn ttoo rreedduuccee ppaatteellllooffeemmoorraall ppaaiinn AACCLL RREECCOONNSSTTRRUUCCTTIIOONN:: CCOOMMPPLLIICCAATTIIOONNSS

AAbbeerrrraanntt ttuunnnneell ppllaacceemmeenntt iiss mmoosstt ccoommmmoonn ccaauussee ooff llaattee ((>> 66 wweeeekkss)) AACCLL ffaaiilluurree

IIff ttuunnnneellss aarree ttoooo aanntteerriioorr,, ttiigghhtt iinn fflleexxiioonn IIff ttuunnnneellss aarree ttoooo ppoosstteerriioorr,, ttiigghhtt iinn eexxtteennssiioonn If femoral tunnel is vertical (12 o’clock) lachman is stable, but positive pivot shift

IIff ttiibbiiaall ttuunnnneell iiss ttoooo vveerrttiiccaall,, tthheerree iiss aann iinnccrreeaasseedd lloossss ooff fflleexxiioonn aanndd aa llaattee iinnccrreeaasseedd aanntteerriioorr ttrraannssllaattiioonn aass tthhee ggrraafftt ssttrreettcchheess oouutt

FFeemmoorraall TTuunnnneell aatt 1100::3300--1111 ((rriigghhtt)) oorr 11--11::3300 ((lleefftt)) hhaass bbeeeenn sshhoowwnn ttoo iinnccrreeaassee rroottaattiioonnaall ccoonnttrrooll

AArrtthhrrooffiibbrroossiiss mmoosstt ccoommmmoonn ccoommpplliiccaattiioonn iinn AACCLL ssuurrggeerryy –– IInncciiddeennccee iinnccrreeaasseedd wwiitthh PPaatteellllaa BBaajjaa aanndd AAccuuttee AACCLL RReeccoonnssttrruuccttiioonn iiff pprree--

oopp mmoottiioonn nnoott rreettuurrnneedd HHaarrddwwaarree // FFiixxaattiioonn ooff GGrraafftt

–– MMoosstt ccoommmmoonn ccaauussee ooff eeaarrllyy ffaaiilluurree ((<< 66 wweeeekkss)) -- DDoouubbllee tthhee tteennddoonn iinn ttuunnnneellss wwiitthh ssoofftt ttiissssuuee ggrraaffttss rreessuullttss iinn >>5500%% iinnccrreeaasseess iinn ssttrreennggtthh aatt ssiixx wweeeekkss ((GGrreeiiss AAJJSSMM 22000011))

FFrraaccttuurreess ((uussuuaallllyy ooccccuurr 88--1122 wweeeekkss ppoosstt--oopp)) RReedduuccee iinncciiddeennccee ffoorr PPaatteellllaa oorr TTiibbiiaall FFrraaccttuurreess bbyy::

SSmmaalllleerr SSaaww BBllaaddee CCuuttttiinngg UUnnddeerrssuurrffaaccee DDrriillll hhoolleess aatt ccoorrnneerrss LLeessss RReeccttaanngguullaarr ggrraafftt BBoonnee ggrraafftt ddeeffeeccttss

CCyyccllooppss –– FFiibbrroopprroolliiffeerraattiivvee ttiissssuuee bblloocckkss eexxtteennssiioonn –– ““CClliicckk”” aatt tteerrmmiinnaall eexxtteennssiioonn

MMiisssseedd ccoonnccuurrrreenntt iinnjjuurriieess ((ppoosstteerroollaatteerraall ccoorrnneerr iinnjjuurryy)),, wwhhiicchh mmaayy ccaauussee ggrraafftt ffaaiilluurree

BBoonnee TTuunnnneell WWiiddeenniinngg ((OOsstteeoollyyssiiss)) MMoorree ccoommmmoonn wwiitthh hhaammssttrriinngg ggrraaffttss CCaauussee uunnkknnoowwnn IImmpplliiccaattiioonnss uunnkknnoowwnn

AACCLL CCOOMMPPLLIICCAATTIIOONNSS——LLoossss ooff MMoottiioonn

CCaann bbee dduuee ttoo PPrree--oopp,, IInnttrraa--oopp,, oorr PPoosstt--oopp CCaauusseess PPrree--oopp CCaauusseess DDeeccrreeaasseedd RROOMM,, EEffffuussiioonn,, DDeeccrreeaasseedd QQuuaadd ttoonnee,, AAbbnnoorrmmaall GGaaiitt MMCCLL//MMPPFFLL IInnjjuurryy IInnttrraa--oopp TTuunnnneellss && TTeennssiioonn iinnaaddeeqquuaattee PPoosstt--oopp HHeemmaarrtthhrroossiiss ((TTrreeaatt wwiitthh iiccee)) RRSSDD ((CCoommpplleexx RReeggiioonnaall PPaaiinn SSyynnddrroommee [[CCRRPPSS]])) EEaarrllyy LLOOMM ((EExxtteennssiioonn iiss kkeeyy))

LLyyssiiss ooff AAddhheessiioonnss ((LLOOAA)) // MMaanniippuullaattiioonn UUnnddeerr AAnnaaeesstthheessiiaa ((MMUUAA)) aafftteerr 66--1122 wweeeekkss iiff PPTT aanndd sseerriiaall eexxtteennssiioonn sspplliinnttiinngg ffaaiillss

AACCLL ““SSHHRRIINNKKAAGGEE””

RRaaddiiooffrreeqquueennccyy ““ttrreeaattmmeenntt”” ooff 1188 CCaanniinnee AACCLL’’ss rreessuulltteedd iinn 110000%% AACCLL rruuppttuurree @@ 88 wweeeekkss ppoosstt--ttxx!! ((LLooppeezz aanndd MMaarrkkeell AAJJSSMM 22000033))

NNeevveerr tthhee bbooaarrdd aannsswweerr!! AACCLL IINNJJUURRYY PPRREEVVEENNTTIIOONN

–– SSkkiieerr ((PPrroopprriioocceeppttiivvee)) TTrraaiinniinngg iinn VVeerrmmoonntt BBeenneeffiicciiaall ffoorr EElliittee SSkkiieerrss,, nnoott nnoovviicceess

–– FFeemmaallee AAtthhlleettee NNeeuurroommuussccuullaarr ttrraaiinniinngg // ppllyyoommeettrriiccss aarree bbeenneeffiicciiaall

–– AACCLL BBrraacciinngg——oonnllyy bbeenneeffiicciiaall iinn sskkiieerrss NNoott eeffffeeccttiivvee iinn ttrraannssiittiioonn ffrroomm NNWWBB ttoo WWBB

LLIIGGAAMMEENNTTOOUUSS IINNJJUURRIIEESS:: PPCCLL

MMeecchhaanniissmm ooff IInnjjuurryy IInncclluuddeess:: AAnntteerriioorr bbllooww ttoo ttiibbiiaa ((ddaasshhbbooaarrdd iinnjjuurryy)) FFoorrcceeffuull llaannddiinngg oonn aa hhyyppeerrfflleexxeedd kknneeee && ppllaannttaarrfflleexxeedd ffoooott HHyyppeerreexxtteennssiioonn iinnjjuurriieess ccaann aallssoo rreessuulltt iinn PPCCLL rruuppttuurreess HHiissttoorryy:: AAccuuttee IInnjjuurriieess:: mmeecchhaanniissmm ooff iinnjjuurryy aanndd ffeeeelliinngg ooff iinnssttaabbiilliittyy CChhrroonniicc PPCCLL ddeeffiicciieenntt ppaattiieennttss ccoommppllaaiinn ooff ppaaiinn wwiitthh ssttaaiirrss aanndd iinniittiiaattiinngg

sspprriinntt CChhrroonniicc PPCCLL ddeeffiicciieennccyy ccaann rreessuulltt iinn llaattee cchhoonnddrroossiiss ooff tthhee ppaatteellllooffeemmoorraall

ccoommppaarrttmmeenntt aanndd//oorr mmeeddiiaall ffeemmoorraall ccoonnddyyllee.. PPCCLL:: PPhhyyssiiccaall EExxaamm

AAccuuttee iinnjjuurriieess mmaayy nnoott hhaavvee aa ssiiggnniiffiiccaanntt eeffffuussiioonn ((ddiissttiinngguuiisshh tthhiiss ffrroomm aann AACCLL iinnjjuurryy))

QQuuaaddrriicceeppss AAccttiivvee TTeesstt ((RReedduuccttiioonn ooff ppoosstteerriioorr ssuubblluuxxaattiioonn wwiitthh qquuaadd ffiirriinngg)) tthheeyy hhaavvee ddeessccrriibbeedd tthhiiss tteesstt tthhee llaasstt 22 yyeeaarrss oonn tthhee bbooaarrddss..

PPoosstteerriioorr DDrraawweerr iiss tthhee kkeeyy eexxaamm tteesstt wwiitthh aann aabbsseenntt oorr ppoosstteerriioorrllyy ddiirreecctteedd ttiibbiiaall sstteepp ooffff ((NNoorrmmaall SStteepp--ooffff iiss 11 ccmm,, ii..ee.. tthhee ttiibbiiaall ppllaatteeaauu iiss 11 ccmm aanntteerriioorr ttoo tthhee ccoonnddyylleess aatt 9900 ddeeggrreeeess ooff fflleexxiioonn))

RReevveerrssee PPiivvoott SShhiifftt // DDyynnaammiicc ppoosstteerriioorr sshhiifftt aarree vvaalluuaabbllee ffoorr hhiigghh ggrraaddee PPCCLL iinnjjuurriieess oorr cchhrroonniicc iinnjjuurriieess

PPoosstteerriioorr SSaagg tteesstt iiss aallssoo kknnoowwnn aass ““GGooddffrreeyy’’ss”” tteesstt IInnccrreeaasseedd eexxtteerrnnaall rroottaattiioonn aatt 9900 ddeeggrreeeess oonnllyy

PPCCLL:: AASSSSOOCCIIAATTEEDD IINNJJUURRIIEESS

AAccuuttee iissoollaatteedd PPCCLL iinnjjuurriieess aarree lleessss ccoommmmoonn tthhaann aaccuuttee iissoollaatteedd AACCLL iinnjjuurriieess PPLLCC ((iinncclluuddiinngg LLCCLL)) aanndd MMCCLL aarree sseeccoonnddaarryy rreessttrraaiinnttss ttoo ppoosstteerriioorr ttiibbiiaall ttrraannssllaattiioonn

IIff PPCCLL ttoorrnn,, tthheerree iiss aann iinnccrreeaasseedd ssttrraaiinn oonn tthhee sseeccoonnddaarryy rreessttrraaiinnttss AAllssoo,, iiff PPLLCC iinnjjuurryy,, tthheerree iiss iinnccrreeaasseedd ssttrraaiinn oonn PPCCLL bbeeccaauussee tthhee PPCCLL iiss aa sseeccoonnddaarryy rreessttrraaiinntt ttoo eexxtteerrnnaall ttiibbiiaall ttrraannssllaattiioonn

WWiitthh PPCCLL iinnjjuurriieess,, bboonnee bbrruuiisseess aanndd mmeenniissccaall tteeaass aarree lleessss ccoommmmoonn tthhaann wwiitthh AACCLL tteeaarrss bbeeccaauussee ooff ddeeccrreeaasseedd llooaaddiinngg oonn tthhee ppoosstteerriioorr mmeenniissccaall hhoorrnnss wwiitthh ppoosstteerriioorr ttiibbiiaall ttrraannssllaattiioonn

PPCCLL:: TTRREEAATTMMEENNTT

TTrreeaattmmeenntt iiss ccoonnttrroovveerrssiiaall,, aalltthhoouugghh rreeppoorrttss ssuuggggeesstt tthhaatt nnoonnooppeerraattiivvee mmaannaaggeemmeenntt mmaayy rreessuulltt iinn llaattee ppaatteellllaarr aanndd mmeeddiiaall ffeemmoorraall ccoonnddyyllee cchhoonnddrroossiiss..

PPrriimmaarryy rreeppaaiirr ((aass wwiitthh AACCLL’’ss)),, hhaass nnoott bbeeeenn ssuucccceessssffuull,, uunnlleessss iitt iiss aa bboonnyy aavvuullssiioonn..

BBoonnyy AAvvuullssiioonn OORRIIFF aaccuutteellyy wwiitthh ggoooodd rreessuullttss IIssoollaatteedd PPCCLL iinnjjuurryy:: TThhee aannsswweerr iiss iinniittiiaall nnoonnooppeerraattiivvee

ttrreeaattmmeenntt oonn tthhee bbooaarrddss.. NNaattuurraall hhiissttoorryy == RRTTPP aatt pprreevviioouuss lleevveell ddeessppiittee iinnccrreeaasseedd ppoosstteerriioorr KKTT

vvaalluueess FFaavvoorreedd bbyy ssoommee ssuurrggeeoonnss iiff PPoosstteerriioorr DDrraawweerr iimmpprroovveess wwiitthh IInntteerrnnaall

RRoottaattiioonn ((bbeeccaauussee tthhiiss iinnddiiccaatteess tthhaatt tthhee PPLLCC iiss iinnttaacctt)) QQuuaaddrriicceeppss RReehhaabb ttoo pprreevveenntt ppoosstteerriioorr ssuubblluuxxaattiioonn iiss tthhee ttrreeaattmmeenntt ooff

cchhooiiccee EExxtteennssiioonn BBrraaccee ffoorr 22--44 wwkkss ffoorr GGrraaddee IIIIII iinnjjuurriieess LLaattee CChhoonnddrroossiiss ((MMFFCC aanndd PPaatteellllaa))

In the case of varus deformity and chronic PCL tear if a

high tibial osteotomy is done. you must remember that you can also change the tibial slope which can address the PCL.. By increasing the slope the posterior aspect of the tibia is elevated & this will decrease posterior tibial translation

CCoommbbiinneedd IInnjjuurriieess RReeccoonnssttrruuccttiioonn iiss rreeccoommmmeennddeedd.. TTiimmiinngg aanndd tteecchhnniiqquuee aarree

ccoonnttrroovveerrssiiaall,, ssoo wwiillll nnoott bbee aasskkeedd.. PPCCLL:: RREECCOONNSSTTRRUUCCTTIIOONN

AArrtthhrroossccooppiicc ((TTrraannssttiibbiiaall)) rreeccoonnssttrruuccttiioonn:: OOfftteenn tteecchhnniiccaallllyy ddiiffffiiccuulltt bbeeccaauussee ooff iinn ppaassssiinngg tthhee ggrraafftt.. ((TThhee ““kkiilllleerr ttuurrnn”” aarroouunndd tthhee ttiibbiiaa))

TTiibbiiaall IInnllaayy:: UUsseess aa bboonnee pplluugg tthhrroouugghh aa ppoosstteerriioorr aapppprrooaacchh.. PPuuttss ppoosstteerriioorr ssttrruuccttuurreess aatt rriisskk ffoorr iinnjjuurryy..

DDoouubbllee--bbuunnddllee PPCCLL rreeccoonnssttrruuccttiioonnss aarree oofftteenn uusseedd ffoorr cchhrroonniicc rreeccoonnssttrruuccttiioonnss

–– AAnntteerroollaatteerraall ggrraafftt iiss tteennssiioonneedd iinn 9900oo,, wwhhiillee tthhee ppoosstteerroommeeddiiaall bbuunnddllee iiss tteennssiioonneedd iinn 3300oo ooff fflleexxiioonn

SSiinnggllee BBuunnddllee PPCCLL rreeccoonnssttrruuccttiioonnss rreeccrreeaattee tthhee aanntteerroollaatteerraall bbuunnddllee PPCCLL RREECCOONNSSTTRRUUCCTTIIOONN:: OOUUTTCCOOMMEESS

SSiinnggllee bbuunnddllee PPCCLL ((aarrtthhrroossccooppiicc)) pprroovviiddeess ssaattiissffaaccttoorryy rreettuurrnn ttoo ffuunnccttiioonn TTwwoo--bbuunnddllee tteecchhnniiqquuee rreessuullttss iinn ddeeccrreeaasseedd ppoosstteerriioorr ttiibbiiaall ttrraannssllaattiioonn iinn bbiioommeecchhaanniiccaall ssttuuddiieess..

TTiibbiiaall IInnllaayy:: –– CCaann bbee ddoonnee aass aa ssiinnggllee oorr ddoouubbllee bbuunnddllee –– SSuuppeerriioorriittyy nnoott pprroovveenn cclliinniiccaallllyy oorr bbiioommeecchhaanniiccaallllyy yyeett

PPCCLL RREECCOONNSSTTRRUUCCTTIIOONN:: RREEHHAABB PPrree--oopp::

–– FFiixxeedd ((cchhrroonniicc PPCCLL)) ppoosstteerriioorr ttiibbiiaall ttrraannssllaattiioonn mmuusstt bbee ccoorrrreecctteedd pprree--oopp wwiitthh ppoosstteerriioorr ttiibbiiaall ssuuppppoorrtt bbrraaccee

PPoosstt--oopp:: –– IImmmmoobbiilliizzee iinn eexxtteennssiioonn ((TThhiiss qquueessttiioonn hhaass bbeeeenn aasskkeedd)) –– pprrootteecctt aaggaaiinnsstt ggrraavviittyy ((aa ppoosstteerriioorr ssaagg iiss pprreesseenntt wwhheenn rreeccuummbbeenntt)) –– QQuuaadd rreehhaabbiilliittaattiioonn

AAvvooiidd ooppeenn cchhaaiinn hhaammssttrriinnggss ((ccrriittiiccaall)) –– RReettuurrnn ttoo PPllaayy iiss ttyyppiiccaallllyy 99--1122 mmoonntthhss

PPCCLL RREECCOONNSSTTRRUUCCTTIIOONN:: CCOOMMPPLLIICCAATTIIOONNSS

MMoosstt CCoommmmoonn:: –– RReessiidduuaall llaaxxiittyy oovveerr ttiimmee

MMoosstt SSeerriioouuss:: –– NNeeuurroovvaassccuullaarr iinnjjuurryy:: PPoopplliitteeaall AArrtteerryy dduurriinngg ttiibbiiaall ttuunnnneell pprreeppaarraattiioonn

((PPoossssiibbllee wwiitthh aarrtthhrroossccooppiicc oorr ttiibbiiaall iinnllaayy)) OOtthheerr ccoommpplliiccaattiioonnss iinncclluuddee::

–– LLoossss ooff MMoottiioonn –– IInnffeeccttiioonn –– MMFFCC oosstteeoonneeccrroossiiss dduuee ttoo ttuunnnneell//ttuunnnneellss iinn tthhee MMFFCC aanndd ssiinnggllee vveesssseell

bblloooodd ssuuppppllyy –– AAnntteerriioorr KKnneeee ppaaiinn ((dduuee ttoo mmuussccllee aattrroopphhyy))

KKNNEEEE LLIIGGAAMMEENNTTOOUUSS IINNJJUURRIIEESS:: PPLLCC

TThheessee iinnjjuurriieess ooccccuurr rraarreellyy aass iissoollaatteedd iinnjjuurriieess bbuutt mmoorree ccoommmmoonnllyy aarree aassssoocciiaatteedd wwiitthh ootthheerr lliiggaammeennttoouuss iinnjjuurriieess ((eessppeecciiaallllyy tthhee PPCCLL >> tthhaann tthhee AACCLL))..

BBeeccaauussee ooff ppoooorr rreessuullttss wwiitthh cchhrroonniicc rreeccoonnssttrruuccttiioonnss,, aaccuuttee rreeppaaiirr iiss aaddvvooccaatteedd..

MMeecchhaanniissmm ooff IInnjjuurryy:: RRoottaattiioonnaall iinnjjuurryy IIff PPLLCC iinnjjuurryy mmiisssseedd,, mmaayy bbee llaattee ccaauussee ooff ffaaiilluurree ooff AACCLL oorr PPCCLL rreeccoonnssttrruuccttiioonn

PPEE:: –– EERR AAssyymmmmeettrryy ((mmoosstt sseennssiittiivvee aanndd ssppeecciiffiicc tteesstt))

IInnccrreeaasseedd aatt 3300oo oonnllyy == IIssoollaatteedd PPLLCC IInnccrreeaasseedd aatt 3300oo && 9900oo == PPCCLL//PPLLCC IInnccrreeaasseedd aatt 9900oo oonnllyy == iissoollaatteedd PPCCLL

–– EERR RReeccuurrvvaattuumm TTeesstt –– PPoosstteerroollaatteerraall DDrraawweerr –– RReevveerrssee PPiivvoott SShhiifftt ((tthhiiss hhaass bbeeeenn aasskkeedd oonn tteesstt))

KKNNEEEE LLIIGGAAMMEENNTTOOUUSS IINNJJUURRIIEESS:: PPLLCC

AAccuuttee TTrreeaattmmeenntt:: PPrriimmaarryy rreeppaaiirr ++//-- aauuggmmeennttaattiioonn vvss rreeccoonnssttrruuccttiioonn iiss oofftteenn ssuucccceessssffuull

wwiitthhiinn 22--33 wweeeekkss FFoorr cchhrroonniicc ttrreeaattmmeenntt,, tthhee bbeesstt tteecchhnniiqquuee iiss ccoonnttrroovveerrssiiaall,, ssoo wwiillll nnoott bbee

aasskkeedd.. PPrroocceedduurreess rreeccoommmmeennddeedd iinncclluuddee ppoosstteerroollaatteerraall ccoorrnneerr aaddvvaanncceemmeenntt,,

ppoopplliitteeuuss bbyyppaassss,, ttwwoo aanndd tthhrreeee ttaaiilleedd rreeccoonnssttrruuccttiioonn,, bbiicceeppss tteennooddeessiiss aanndd,, ""sspplliitt"" ggrraaffttss,, wwhhiicchh aarree uusseedd ttoo rreeccoonnssttrruucctt bbootthh tthhee LLCCLL aanndd tthhee ppoopplliitteeuuss//ppoosstteerroollaatteerraall ccoorrnneerr,,.. MMoorree rreecceennttllyy,, tthheerree hhaass bbeeeenn aa ffooccuuss ttoo rreeccoonnssttrruucctt tthhee ppoopplliitteeooffiibbuullaarr lliiggaammeenntt..

KKNNEEEE LLIIGGAAMMEENNTTOOUUSS IINNJJUURRIIEESS:: MMCCLL

MMeecchhaanniissmm ooff IInnjjuurryy:: VVaallgguuss ccoonnttaacctt ssttrreessss ttoo tthhee kknneeee PPaattiieennttss ccoommppllaaiinn ooff ppaaiinn aanndd iinnssttaabbiilliittyy PPEE:: VVaallgguuss ooppeenniinngg aatt 3300oo iiss ddiiaaggnnoossttiicc ffoorr iissoollaatteedd MMCCLL iinnjjuurriieess.. IIff tthheerree

iiss iinnccrreeaasseedd ooppeenniinngg aatt 00oo,, tthheerree iiss ccoommbbiinneedd lliiggaammeennttoouuss iinnjjuurryy ((eeiitthheerr AACCLL//MMCCLL [[mmoorree ccoommmmoonn]] oorr PPCCLL//MMCCLL))

IInnjjuurriieess mmoosstt ccoommmmoonnllyy ooccccuurr aatt tthhee ffeemmoorraall iinnsseerrttiioonn ooff tthhee lliiggaammeenntt,, aanndd tthheessee hheeaall mmoorree pprreeddiiccttaabbllyy tthhaann ttiibbiiaall ssiiddeedd iinnjjuurriieess..

PPrroopphhyyllaaccttiicc bbrraacciinngg mmaayy bbee hheellppffuull ffoorr ffoooottbbaallll ppllaayyeerrss ((iinntteerriioorr lliinneemmeenn oonnllyy))..

DDeellaayy AACCLL rreeccoonnssttrruuccttiioonn iinn ccoommbbiinneedd AACCLL--MMCCLL IInnjjuurriieess uunnttiill mmeeddiiaall ssiiddeedd ssttaabbiilliittyy iiss iimmpprroovveedd

CChhrroonniicc iinnjjuurriieess mmaayy hhaavvee ccaallcciiffiiccaattiioonn aatt tthhee mmeeddiiaall ffeemmoorraall ccoonnddyyllee iinnsseerrttiioonn ((PPeelllleeggrriinnii--SSttiieeddaa ssiiggnn))..

TTrreeaattmmeenntt HHiinnggeedd kknneeee bbrraaccee ffoorr 66--88 wweeeekkss IInniittiiaall TTxx ooff ggrraaddee IIII MMCCLL -- WWtt.. bbeeaarriinngg aass ttoolleerraatteedd wwiitthh

ccrruuttcchheess SSoommeettiimmeess,, aaddvvaanncceemmeenntt aanndd rreeiinnffoorrcceemmeenntt ooff tthhee lliiggaammeenntt aarree nneecceessssaarryy

ffoorr cchhrroonniicc iinnjjuurriieess tthhaatt ddoo nnoott rreessppoonndd ttoo ccoonnsseerrvvaattiivvee ttrreeaattmmeenntt..

KKNNEEEE LLIIGGAAMMEENNTTOOUUSS IINNJJUURRIIEESS:: LLCCLL MMeecchhaanniissmm ooff IInnjjuurryy:: VVaarruuss ccoonnttaacctt ssttrreessss ttoo kknneeee PPEE:: VVaarruuss ooppeenniinngg aatt 3300oo iiss iinnddiiccaattiivvee ooff aann iissoollaatteedd LLCCLL iinnjjuurryy.. IIff tthheerree iiss vvaarruuss ooppeenniinngg aatt 00oo,, tthheerree iiss aa ccoommbbiinneedd lliiggaammeennttoouuss ((eeiitthheerr AACCLL oorr PPCCLL))..

TTrreeaattmmeenntt –– IIssoollaatteedd ((rraarree)) –– BBrraaccee aanndd RReehhaabb –– CCoommbbiinneedd iinnjjuurriieess –– RReeppaaiirr oorr RReeccoonnssttrruuccttiioonn.. TTeecchhnniiqquueess aarree vvaarriieedd

aanndd wwiillll nnoott bbee aasskkeedd.. MMUULLTTIIPPLLEE LLIIGGAAMMEENNTT IINNJJUURRIIEESS:: DDIISSLLOOCCAATTIIOONN

CCoommbbiinneedd lliiggaammeennttoouuss iinnjjuurriieess ((eessppeecciiaallllyy AACCLL//PPCCLL iinnjjuurriieess)) ccaann bbee aa rreessuulltt ooff aa kknneeee ddiissllooccaattiioonn,, aanndd nneeuurroovvaassccuullaarr iinnjjuurryy mmuusstt bbee ssuussppeecctteedd.. TThhee iinncciiddeennccee ooff vvaassccuullaarr iinnjjuurryy ffoolllloowwiinngg aanntteerriioorr kknneeee ddiissllooccaattiioonn iiss 3300 ttoo 5500%%.. PPeerroonneeaall AArrtteerryy VVaassccuullaarr eexxaamm bbeeffoorree aanndd aafftteerr rreedduuccttiioonn iimmppeerraattiivvee

IIff ppuullsseelleessss aafftteerr rreedduuccttiioonn:: AArrtteerriiooggrraamm iinn OORR -- rreeppaaiirr // eexx--ffiixx HHaavvee aa llooww tthhrreesshhoolldd ffoorr ffaasscciioottoommiieess HHaavvee aa llooww tthhrreesshhoolldd ffoorr pprriimmaarryy ccoollllaatteerraall rreeppaaiirrss

IIff ddiimmiinniisshheedd aafftteerr rreedduuccttiioonn:: SSttaatt aannggiiooggrraapphhyy

IIff nnoorrmmaall aafftteerr rreedduuccttiioonn:: •• SSeerriiaall AABBIIss vvss.. aannggiiooggrraapphhyy

ABI < 0.9 end systolic vascular injury RReemmeemmbbeerr aa nnoorrmmaall ppuullssee ddooeess nnoott rruullee oouutt aann iinnttiimmaall tteeaarr..

MMUULLTTIIPPLLEE LLIIGGAAMMEENNTT IINNJJUURRIIEESS:: CCLLAASSSSIIFFIICCAATTIIOONN

NNaammeedd bbyy ddiirreeccttiioonn ooff ttiibbiiaall ddiissppllaacceemmeenntt AAnntteerriioorr DDiissllooccaattiioonn>>PPoosstteerriioorr DDiissllooccaattiioonn >>LLaatteerraall DDiissllooccaattiioonn

MULTIPLE LIGAMENT INJURIES: TREATMENT

RReedduuccttiioonn iinniittiiaallllyy RReeccoonnssttrruuccttiioonn vvss RReeppaaiirr ooff aallll ttoorrnn ssttrruuccttuurreess EEmmeerrggeenntt ssuurrggiiccaall iinnddiiccaattiioonnss iinncclluuddee ppoopplliitteeaall aarrtteerryy iinnjjuurryy,, ooppeenn ddiissllooccaattiioonnss,, aanndd iirrrreedduucciibbllee ddiissllooccaattiioonnss..

TTiimmiinngg ooff lliiggaammeennttoouuss rreeppaaiirrss ccoonnttrroovveerrssiiaall mmoosstt ssuurrggeeoonnss rreeccoommmmeenndd ddeellaayyiinngg ssuurrggeerryy 55––1122 ddaayyss ttoo eennssuurree tthhaatt tthheerree iiss nnoo vvaassccuullaarr iinnjjuurryy..

HHiigghh eenneerrggyy iinnjjuurriieess wwiitthh iinnccrreeaasseedd ssoofftt ttiissssuuee ddaammaaggee,, tteemmppoorraarryy ssppaannnniinngg eexx--ffiixx,, tthheenn MMUUAA,, tthheenn lliiggaammeennttoouuss rreeccoonnssttrruuccttiioonnss..

CCaappssuullee mmuusstt hheeaall pprriioorr ttoo aarrtthhrroossccooppyy,, eessppeecciiaallllyy wwiitthh aa ppuummpp,, ttoo ddeeccrreeaassee rriisskk ooff fflluuiidd eexxttrraavvaassaattiioonn aanndd ccoommppaarrttmmeenntt ssyynnddrroommee..

MMUULLTTIIPPLLEE LLIIGGAAMMEENNTT IINNJJUURRIIEESS:: PPRROOGGNNOOSSIISS

IImmpprroovveedd pprrooggnnoossiiss –– FFuunnccttiioonnaall rreehhaabbiilliittaattiioonn aanndd eeaarrllyy mmoottiioonn iiss ccrriittiiccaall ttoo aavvooiidd aa hhiigghh

iinncciiddeennccee ooff aa ssttiiffff kknneeee aafftteerr tthheessee ccoommbbiinneedd pprroocceedduurreess.. –– CCrruucciiaattee rreeccoonnssttrruuccttiioonn // ssttaabbllee kknneeee nneeeeddeedd ffoorr rreehhaabb

WWoorrssee pprrooggnnoossiiss –– PPeerroonneeaall iinnjjuurryy oonn iinniittiiaall aasssseessssmmeenntt –– DDeellaayy iinn ddiiaaggnnoossiiss ooff vvaassccuullaarr iinnjjuurryy

–– UUnnssttaabbllee kknneeee PPRROOXXIIMMAALL TTIIBB--FFIIBB DDIISSLLOOCCAATTIIOONN

MMeecchhaanniissmm ooff IInnjjuurryy:: FFaallll oonn fflleexxeedd aadddduucctteedd kknneeee ((ccoommmmoonn iinn eeqquueessttrriiaannss oorr sskkyy ddiivveerrss))

AAnntteerroollaatteerraall ddiissllooccaattiioonn mmoosstt ccoommmmoonn CClloosseedd rreedduuccttiioonn iiss ppeerrffoorrmmeedd wwiitthh fflleexxiioonn ––aanndd pprreessssuurree oonnttoo tthhee ffiibbuullaarr

hheeaadd PPoosstt--ooppeerraattiivvee,, iimmmmoobbiilliizzee iinn eexxtteennssiioonn FFoorr CChhrroonniicc//RReeccuurrrreenntt ccaasseess,, RReeccoonnssttrruuccttiioonn lliiggaammeennttss oorr ffiibbuullaarr hheeaadd

rreesseeccttiioonn iiss ttrreeaattmmeenntt ((ccoonnttrroovveerrssiiaall)) LLIIGGAAMMEENNTTOOUUSS KKNNEEEE IINNJJUURRIIEESS:: KKeeyy TTeessttaabbllee IItteemmss

MMeecchhaanniissmmss ooff iinnjjuurryy ooff aallll lliiggaammeennttss FFeemmaallee vvss mmaallee AACCLL iinnjjuurryy rraattee NNaattuurraall hhiissttoorryy ooff AACCLL ddeeffiicciieenntt kknneeee GGaaiitt ppaatttteerrnn wwiitthh AACCLL iinnjjuurryy HHIIVV //HHeeppaattiittiiss rriisskk wwiitthh aallllooggrraafftt AACCLL IImmpprrooppeerr ttuunnnneell ppllaacceemmeenntt oonn xxrraayyss FFoorr AACCLL wwiitthh lloossss ooff mmoottiioonn ((LLOOMM)),, nnoo MMaanniippuullaattiioonn uunnddeerr AAnnaaeesstthheessiiaa ((MMUUAA)) oorr LLyyssiiss ooff AAddhheessiioonnss ((LLOOAA)) uunnttiill 88 wweeeekkss

LLIIGGAAMMEENNTTOOUUSS KKNNEEEE IINNJJUURRIIEESS:: KKeeyy TTeessttaabbllee IItteemmss

RReeccooggnniizzee ccyyccllooppss lleessiioonn aarrtthhrroossccooppiiccaallllyy ((lloossee eexxtteennssiioonn)) SShhrriinnkkaaggee iiss nneevveerr tthhee rriigghhtt aannsswweerr TTrreeaatt iissoollaatteedd PPCCLL’’ss nnoonn--ooppeerraattiivveellyy iinniittiiaallllyy RRiisskk dduurriinngg PPCCLL rreeccoonnssttrruuccttiioonn DDiiaaggnnoossiiss ooff vvaassccuullaarr iinnjjuurriieess aafftteerr kknneeee ddiissllooccaattiioonnss MMOOII aanndd ttrreeaattmmeenntt ooff pprrooxxiimmaall ttiibb--ffiibb ddiissllooccaattiioonnss

LLIIGGAAMMEENNTTOOUUSS KKNNEEEE IINNJJUURRIIEESS:: RREEFFEERREENNCCEESS AAllmmeekkiinnddeerrss,, LL..CC..,, aanndd DDeeddmmoonndd,, BB..TT..:: OOuuttccoommeess ooff OOppeerraattiivveellyy ttrreeaatteedd kknneeee ddiissllooccaattiioonnss.. CClliinn SSppoorrttss MMeedd,, 1199::550033--551188,, 22000000.. AAllbbrriigghhtt,, JJ..PP..,, aanndd BBrroowwnn,, AA..WW..:: MMaannaaggeemmeenntt ooff cchhrroonniicc ppoosstteerroollaatteerraall rroottaattoorryy iinnssttaabbiilliittyy ooff tthhee kknneeee:: SSuurrggiiccaall tteecchhnniiqquuee ffoorr tthhee ppoosstteerroollaatteerraall ccoorrnneerr sslliinngg pprroocceedduurree.. AAAAOOSS IInnssttrr.. CCoouurrssee LLeecctt.. 4477::336699––337788,, 11999988.. CCaarrssoonn,, EE..WW..,, SSiimmoonniiaann,, PP..TT..,, WWiicckkiieewwiicczz,, TT..LL..,, eett aall:: RReevviissiioonn aanntteerriioorr ccrruucciiaattee lliiggaammeenntt rreeccoonnssttrruuccttiioonn.. AAAAOOSS IInnssttrr.. CCoouurrssee LLeecctt.. 4477::336611––336688,, 11999988.. CChheenn,, FF..SS..,, RRookkiittoo,, AA..SS..,, aanndd PPiiuuttmmaann,, MM..II..:: AAccuuttee aanndd CChhrroonniicc ppoosstteerroollaatteerraall rroottaarryy iinnssttaabbiilliittyy ooff tthhee kknneeee.. JJ AAmm AAccaadd OOrrtthhoopp SSuurrgg 88:: 9977--111100,, 22000000..

CCllaannccyy,, WW..GG..,, RRaayy,, JJ..MM..,, aanndd ZZoollttaann,, DD..JJ..:: AAccuuttee tteeaarrss ooff tthhee aanntteerriioorr ccrruucciiaattee lliiggaammeenntt:: SSuurrggiiccaall vveerrssuuss ccoonnsseerrvvaattiivvee ttrreeaattmmeenntt.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 7700::11448833––11448888,, 11998888.. CCooooppeerr,, DD..EE..,, WWaarrrreenn,, RR..FF..,, aanndd WWaarrnneerr,, JJ..JJ..PP..:: TThhee ppoosstteerriioorr ccrruucciiaattee lliiggaammeenntt aanndd ppoosstteerroollaatteerraall ssttrruuccttuurreess ooff tthhee kknneeee:: AAnnaattoommyy,, ffuunnccttiioonn,, aanndd ppaatttteerrnnss ooff iinnjjuurryy.. IInnssttrr.. CCoouurrssee LLeecctt.. 4400::224499––227700,, 11999911.. DDyyee,, SS..FF..,, WWoojjttyyss,, EE..MM..,, FFuu,, FF..HH..,, eett aall..:: FFaaccttoorrss ccoonnttrriibbuuttiinngg ttoo ffuunnccttiioonn ooff tthhee kknneeee jjooiinntt aafftteerr iinnjjuurryy oorr rreeccoonnssttrruuccttiioonn ooff tthhee aanntteerriioorr ccrruucciiaattee lliiggaammeenntt.. JJ.. BBoonnee JJooiinntt SSuurrgg.. 8800AA::11338800––11339933,, 11999988.. FFoowwlleerr,, PP..JJ..,, aanndd MMeessssiieehh,, SS..SS..:: IIssoollaatteedd ppoosstteerriioorr ccrruucciiaattee lliiggaammeenntt iinnjjuurriieess iinn aatthhlleetteess.. AAmm.. JJ.. SSppoorrttss MMeedd.. 1155::555533––555577,, 11998877.. FFrraannccee,, EE..PP..,, aanndd PPaauullooss,, LL..EE..:: KKnneeee bbrraacciinngg.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 22::228811––228877,, 11999944.. FFrraannkk,, CC..BB..:: LLiiggaammeenntt hheeaalliinngg:: CCuurrrreenntt kknnoowwlleeddggee aanndd cclliinniiccaall aapppplliiccaattiioonnss.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 44::7744––8833,, 11999966.. FFrraannkk,, CC..BB..,, aanndd JJaacckkssoonn,, DD..WW..:: CCuurrrreenntt ccoonncceeppttss rreevviieeww:: TThhee sscciieennccee ooff rreeccoonnssttrruuccttiioonn ooff tthhee aanntteerriioorr ccrruucciiaattee lliiggaammeenntt.. JJ.. BBoonnee JJooiinntt SSuurrgg.. 7799AA::11555566––11557766,, 11999977.. FFrraassssiiccaa,, FF..JJ..,, SSiimm,, FF..HH..,, SSttaaeehheellii,, JJ..WW..,, eett aall..:: DDiissllooccaattiioonn ooff tthhee kknneeee.. CClliinn.. OOrrtthhoopp.. 226633::220000––220055,, 11999911.. FFuu,, FF..HH..,, BBeennnneetttt,, CC..HH..,, eett.. aall..:: CCuurrrreenntt ttrreennddss iinn aanntteerriioorr ccrruucciiaattee lliiggaammeenntt rreeccoonnssttrruuccttiioonn,, PPaarrtt II.. AAmm JJ SSppoorrttss MMeedd 2277:: 882211--883300,, 11999999.. FFuu,, FF..HH..,, BBeennnneetttt,, CC..HH..,, eett.. aall..:: CCuurrrreenntt ttrreennddss iinn aanntteerriioorr ccrruucciiaattee lliiggaammeenntt rreeccoonnssttrruuccttiioonn,, PPaarrtt IIII.. AAmm JJ SSppoorrttss MMeedd 2288:: 112244--113300,, 22000000.. GGoooodd,, LL..,, aanndd JJoohhnnssoonn,, RR..JJ..:: TThhee ddiissllooccaatteedd kknneeee.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 33::228844––229922,, 11999955.. HHaarrnneerr,, CC..DD..,, aanndd HHoohheerr,, JJ..:: EEvvaalluuaattiioonn aanndd ttrreeaattmmeenntt ooff ppoosstteerriioorr ccrruucciiaattee lliiggaammeenntt iinnjjuurriieess:: CCuurrrreenntt ccoonncceeppttss.. AAmm.. JJ.. SSppoorrttss MMeedd.. 2266::447711––448822,, 11999988.. HHaarrnneerr,, CC..DD..,, IIrrrrggaanngg,, JJ..JJ..,, PPaauull,, JJ..,, eett aall..:: LLoossss ooff mmoottiioonn ffoolllloowwiinngg aanntteerriioorr ccrruucciiaattee lliiggaammeenntt rreeccoonnssttrruuccttiioonn.. AAmm.. JJ.. SSppoorrttss MMeedd.. 2200::550077––551155,, 11999922.. HHoowweellll,, SS..MM..,, aanndd TTaayylloorr,, MM..AA..:: FFaaiilluurree ooff rreeccoonnssttrruuccttiioonn ooff tthhee aanntteerriioorr ccrruucciiaattee lliiggaammeenntt dduuee ttoo iimmppiinnggeemmeenntt bbyy tthhee iinntteerrccoonnddyyllaarr rrooooff.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 7755::11004444––11005555,, 11999933..

IInnddeelliiccaattoo,, PP..AA..,, IIssoollaatteedd mmeeddiiaall ccoollllaatteerraall lliiggaammeenntt iinnjjuurriieess iinn tthhee kknneeee.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 33::99––1144,, 11999955.. IInnddeelliiccaattoo,, PP..AA..,, HHeerrmmaannssddoorrffeerr,, JJ..,, aanndd HHuueeggeell,, MM..:: NNoonnooppeerraattiivvee mmaannaaggeemmeenntt ooff ccoommpplleettee tteeaarrss ooff tthhee mmeeddiiaall ccoollllaatteerraall lliiggaammeenntt ooff tthhee kknneeee iinn iinntteerrccoolllleeggiiaattee ffoooottbbaallll ppllaayyeerrss.. CClliinn.. OOrrtthhoopp.. 225566::117744––117777,, 11999900.. LLaarrssoonn,, RR..LL..,, aanndd TTaaiilllloonn,, MM..:: AAnntteerriioorr ccrruucciiaattee lliiggaammeenntt iinnssuuffffiicciieennccyy:: PPrriinncciipplleess ooff ttrreeaattmmeenntt.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 22::2266––3355,, 11999944.. MMiilllleerr,, MM..DD..,, BBeerrggffeelldd,, JJ..AA..,, eett aall..:: TThhee ppoosstteerriioorr ccrruucciiaattee lliiggaammeenntt iinnjjuurreedd kknneeee:: PPrriinncciipplleess ooff eevvaalluuaattiioonn aanndd ttrreeaattmmeenntt,, AAAAOOSS IInnssttrr CCoouurrssee LLeeccttuurree.. 4488:: 119999--220077,, 11999999.. MMiilllleerr,, MM..DD..,, OOssbboouurrnnee,, JJ..RR..,, eett.. aall..:: TThhee nnaattuurraall hhiissttoorriieess ooff bboonnee bbrruuiisseess.. AAmm JJ SSppoorrttss MMeedd.. 2266:: 1155--1199,, 11999988.. MMyyeerrss,, MM..HH..,, aanndd HHaarrvveeyy,, JJ..PP..:: TTrraauummaattiicc ddiissllooccaattiioonn ooff tthhee kknneeee jjooiinntt:: AA ssttuuddyy ooff eeiigghhtteeeenn ccaasseess.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 5533::1166––2299,, 11997711.. NNooyyeess,, FF..RR..,, BBaarrbbeerr--WWeessttiinn,, SS..DD..,, BBuuttlleerr,, DD..LL..,, eett aall..:: TThhee rroollee ooff aallllooggrraaffttss iinn rreeppaaiirr aanndd rreeccoonnssttrruuccttiioonn ooff kknneeee jjooiinntt lliiggaammeennttss aanndd mmeenniissccii.. AAAAOOSS IInnssttrr.. CCoouurrssee LLeecctt.. 4477::337799––339966,, 11999988.. OO''BBrriieenn,, SS..JJ..,, WWaarrrreenn,, RR..FF..,, PPaavvlloovv,, HH..,, eett aall..:: RReeccoonnssttrruuccttiioonn ooff tthhee cchhrroonniiccaallllyy iinnssuuffffiicciieenntt aanntteerriioorr ccrruucciiaattee lliiggaammeenntt wwiitthh tthhee cceennttrraall tthhiirrdd ooff tthhee ppaatteellllaarr lliiggaammeenntt.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 7733::227788––228866,, 11999911.. PPaauullooss,, LL..EE..,, RRoosseennbbeerrgg,, TT..DD..,, DDrraawwbbeerrtt,, JJ..,, eett aall..:: IInnffrraappaatteellllaarr ccoonnttrraaccttuurree ssyynnddrroommee:: AAnn uunnrreeccooggnniizzeedd ccaauussee ooff kknneeee ssttiiffffnneessss wwiitthh ppaatteellllaarr eennttrraappmmeenntt aanndd ppaatteellllaa iinnffeerraa.. AAmm.. JJ.. SSppoorrttss MMeedd.. 1155::333311––334411,, 11998877.. SShheellbboouurrnnee,, KK..DD..,, aanndd NNiittzz,, PP..:: AAcccceelleerraatteedd rreehhaabbiilliittaattiioonn aafftteerr aanntteerriioorr ccrruucciiaattee lliiggaammeenntt rreeccoonnssttrruuccttiioonn.. AAmm.. JJ.. SSppoorrttss MMeedd.. 1188::229922––229999,, 11999900.. SShheellttoonn,, WW..RR..,, TTrreeaaccyy,, SS..HH..,, DDuukkeess,, AA..DD..,, eett aall..:: UUssee ooff aallllooggrraaffttss iinn kknneeee rreeccoonnssttrruuccttiioonn.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 66::116655––117755,, 11999988.. SSiissttoo,, DD..JJ..,, aanndd WWaarrrreenn,, RR..FF..:: CCoommpplleettee kknneeee ddiissllooccaattiioonn:: AA ffoollllooww--uupp ssttuuddyy ooff ooppeerraattiivvee ttrreeaattmmeenntt.. CClliinn.. OOrrtthhoopp.. 119988::9944––110011,, 11998855.. SSiittlleerr,, MM..,, RRyyaann,, JJ..,, HHooppkkiinnssoonn,, WW..,, eett aall..:: TThhee eeffffiiccaaccyy ooff aa pprroopphhyyllaaccttiicc kknneeee bbrraaccee ttoo rreedduuccee kknneeee iinnjjuurriieess iinn ffoooottbbaallll:: AA pprroossppeeccttiivvee,, rraannddoommiizzeedd ssttuuddyy aatt WWeesstt PPooiinntt.. AAmm.. JJ.. SSppoorrttss MMeedd.. 1188::331100––331155,, 11999900.. VVeellttrrii,, DD..MM..,, aanndd WWaarrrreenn,, RR..FF..:: IIssoollaatteedd aanndd ccoommbbiinneedd ppoosstteerriioorr ccrruucciiaattee lliiggaammeenntt iinnjjuurriieess.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 11::6677––7755,, 11999933..

OOVVEERRUUSSEE IINNJJUURRIIEESS KKNNEEEE OOVVEERRUUSSEE IINNJJUURRIIEESS

PPaatteellllaa tteennddiinniittiiss AAllssoo ccaalllleedd JJuummppeerr''ss KKnneeee MMoosstt ccoommmmoonn iinn bbaasskkeettbbaallll aanndd vvoolllleeyybbaallll PPaattiieennttss ccoommppllaaiinn ooff ppaaiinn aanndd tteennddeerrnneessss nneeaarr tthhee iinnffeerriioorr bboorrddeerr ooff tthhee

ppaatteellllaa ((wwoorrssee iinn eexxtteennssiioonn tthhaann fflleexxiioonn)) TTrreeaattmmeenntt iinncclluuddeess nnoonnsstteerrooiiddaall aannttii--iinnffllaammmmaattoorryy ddrruuggss ((NNSSAAIIDDss)),,

pphhyyssiiccaall tthheerraappyy ((ssttrreennggtthheenniinngg aanndd uullttrraassoouunndd)),, aanndd oorrtthhoottiiccss RRaarreellyy ssuurrggeerryy iiss iinnddiiccaatteedd,, bbuutt wwhheenn ddoonnee,, eexxcciissee nneeccrroottiicc tteennddoonn ffiibbeerrss

ssiiggnniiffiiccaanntt ppaarrttiiaall tteeaarr eexxcciissee aanndd rreeppaaiirr QQuuaaddrriicceeppss TTeennddoonniittiiss LLeessss ccoommmmoonn ttaann ppaatteellllaarr tteennddoonniittiiss bbuutt jjuusstt aass ppaaiinnffuull PPaattiieennttss mmaayy nnoottee ppaaiinnffuull cclliicckkiinngg aanndd llooccaalliizzeedd ppaaiinn ssuuppeerriioorrllyy SSyymmppttoommaattiicc ttrreeaattmmeenntt OOppeerraattiivvee ttrreeaattmmeenntt iiss ooccccaassiioonnaallllyy nneecceessssaarryy PPrreeppaatteellllaarr bbuurrssiittiiss AAllssoo ccaalllleedd HHoouusseemmaaiidd''ss KKnneeee TThhee mmoosstt ccoommmmoonn ffoorrmm ooff bbuurrssiittiiss ooff tthhee kknneeee ((EExxttrraa--aarrttiiccuullaarr)) AAssssoocciiaatteedd wwiitthh aa hhiissttoorryy ooff pprroolloonnggeedd kknneeeelliinngg oorr ddiirreecctt bbllooww SSuuppppoorrttiivvee ttrreeaattmmeenntt ((kknneeee ppaaddss,, ooccccaassiioonnaall sstteerrooiidd iinnjjeeccttiioonnss)) aarree uussuuaallllyy

eennoouugghh RRaarreellyy,, bbuurrssaall eexxcciissiioonn iiss rreeccoommmmeennddeedd ffoorr rreeffrraaccttoorryy ccaasseess AAssppiirraattee iinn WWrreessttlleerrss

IITTBB SSYYNNDDRROOMMEE

HHiissttoorryy:: rruunnnneerrss ((eessppeecciiaallllyy rruunnnniinngg hhiillllss)) aanndd ccyycclliissttss TThhee rreessuulltt ooff aabbrraassiioonn bbeettwweeeenn tthhee iilliioottiibbiiaall bbaanndd aanndd tthhee llaatteerraall ffeemmoorraall

ccoonnddyyllee PPhhyyssiiccaall EExxaamm:: LLooccaalliizzeedd tteennddeerrnneessss,, wwoorrssee wwiitthh tthhee kknneeee fflleexxeedd 3300

ddeeggrreeeess aanndd aa ppoossiittiivvee OObbeerr TTeesstt –– PPaattiieenntt oonn ssiiddee wwiitthh ssyymmppttoommaattiicc lleegg uupp ((AABBDD--EExxtt--AADDDD)) –– PPaattiieenntt lliieess iinn aa llaatteerraall ddeeccuubbiittuuss ppoossiittiioonn aanndd aabbdduuccttiioonn aanndd

hhyyppeerreexxtteennssiioonn ooff tthhee hhiipp ddeemmoonnssttrraattee ttiigghhttnneessss ooff tthhee iilliioottiibbiiaall bbaanndd TTrreeaattmmeenntt::

–– SSttrreettcchh // SSttrreennggtthheenniinngg –– RRaarreellyy SSuurrggiiccaall EExxcciissiioonn ((rreemmoovvee aann eelllliippssee ooff tthhee iilliioottiibbiiaall bbaanndd )) ffoorr

rreeffrraaccttoorryy ccaasseess EEXXTTEENNSSOORR MMEECCHHAANNIISSMM IINNJJUURRIIEESS

QQuuaaddrriicceeppss rruuppttuurree MMoorree ccoommmmoonn tthhaann ppaatteellllaarr tteennddoonn rruuppttuurreess MMoosstt ccoommmmoonnllyy iinn ppaattiieennttss >>4400 yyeeaarrss oolldd wwiitthh iinnddiirreecctt ttrraauummaa Diabetic history AA ppaallppaabbllee ddeeffeecctt aanndd iinnaabbiilliittyy ttoo eexxtteenndd tthhee kknneeee aarree ddiiaaggnnoossttiicc

Delay in surgical repair of the extensor mechanism is the factor that most significantly diminishes results of surgical Tx

PPaatteellllaa tteennddoonn rruuppttuurree UUssuuaallllyy iinn ppaattiieennttss << 4400 yyoo MMeecchhaanniissmm wwiitthh ddiirreecctt oorr iinnddiirreecctt ttrraauummaa AA ppaallppaabbllee ddeeffeecctt aanndd iinnaabbiilliittyy ttoo eexxtteenndd tthhee kknneeee aarree ddiiaaggnnoossttiicc PPaatteellllaa ffrraaccttuurree OORRIIFF iiff ddiissppllaacceedd aanndd lloossss ooff eexxtteennssoorr mmeecchhaanniissmm

OOVVEERRUUSSEE IINNJJUURRIIEESS:: KKeeyy TTeessttaabbllee IItteemmss

TTrreeaatt ccoonnsseerrvvaattiivveellyy iinniittiiaallllyy PPEE ffiinnddiinnggss ffoorr IITTBB SSyynnddrroommee DDoonn’’tt ffoorrggeett aabboouutt ssttrreessss ffrraaccttuurreess iinn rruunnnneerrss OObbeerr tteesstt

OOVVEERRUUSSEE IINNJJUURRIIEESS:: RREEFFEERREENNCCEESS BBuucckkwwaalltteerr,, JJ..AA..,, EEiinnhhoorrnn,, TT..AA..,, aanndd SSiimmoonn,, SS..RR.. ((eeddss))..:: OOrrtthhooppaaeeddiicc BBaassiicc SScciieennccee,, BBiioollooggyy aanndd BBiioommeecchhaanniiccss ooff tthhee MMuussccuulloosskkeelleettaall SSyysstteemm,, 22nndd eedd.. AAmmeerriiccaann AAccaaddeemmyy ooff OOrrtthhooppaaeeddiicc,, 22000000.. GGaarrrriicckk,, JJ..GG.. ((eedd..)) OOrrtthhooppaaeeddiicc KKnnoowwlleeddggee UUppddaattee,, SSppoorrttss MMeeddiicciinnee 33,, AAmmeerriiccaann AAccaaddeemmyy ooff OOrrtthhooppaaeeddiicc SSuurrggeeoonnss,, 22000044 KKoovvaall,, KK..JJ.. ((eedd)).. OOrrtthhooppaaeeddiicc KKnnoowwlleeddggee UUppddaattee 77.. AAmmeerriiccaann AAccaaddeemmyy ooff OOrrtthhooppaaeeddiicc SSuurrggeeoonnss,, 22000022..

PPAATTEELLLLOOFFEEMMOORRAALL DDIISSOORRDDEERRSS

PPAATTEELLLLOOFFEEMMOORRAALL DDIISSOORRDDEERRSS:: PPHHYYSSIICCAALL EEXXAAMM SSttaannddiinngg:: AAlliiggnnmmeenntt @@ ppeellvviiss,, kknneeee aanndd aannkkllee // hhiinnddffoooott LLooookk ffoorr aanntteevveerrtteedd hhiipp,, vvaallgguuss kknneeee,, eexxtteerrnnaallllyy rroottaatteedd ttiibbiiaa,, hhiinnddffoooott

vvaallgguuss,, oorr pprroonnaatteedd ffoooott AAsssseessss ffoorr ttiigghhtt hhaammssttrriinnggss ((AAnntteerriioorr ppoopplliitteeaall aannggllee)) QQuuaadd ttiigghhttnneessss SSeeaatteedd// kknneeee fflleexxeedd @@ 9900ºº:: PPaatteellllaa aallttaa ““JJ”” ssiiggnn ((ttrraacckkiinngg ooff ppaatteellllaa)) TTuubbeerrccllee SSuullccuuss AAnnggllee ((SSeeaatteedd QQ aannggllee)) SSuuppiinnee:: PPaatteellllaarr ttrraannssllaattiioonn // ?? AApppprreehheennssiioonn PPaatteellllaarr ttiilltt QQ aannggllee ((<<1100ºº iinn mmeenn,, <<1155ºº iinn wwoommeenn))

FFeemmoorraall aanndd ttiibbiiaall vveerrssiioonn// ttoorrssiioonn QQuuaadd ttiigghhttnneessss

PPAATTEELLLLOOFFEEMMOORRAALL DDIISSOORRDDEERRSS:: RRAADDIIOOGGRRAAPPHHIICC AANNAALLYYSSIISS

AAPP// LLaatt IInnssaallll--SSaallvvaattii RRaattiioo ((lleennggtthh ooff ppaatteellllaa ttoo lleennggtthh ooff ppaatteellllaarr tteennddoonn)) ((nnoorrmmaall

rraannggee iiss 00..88 –– 11..22)) BBllaacckkbbuurrnnee--PPeeeell RRaattiioo ((rraattiioo ooff tthhee aarrttiiccuullaarr lleennggtthh ooff tthhee ppaatteellllaa ttoo tthhee

hheeiigghhtt ooff tthhee lloowweerr ppoollee ooff tthhee aarrttiiccuullaarr ccaarrttiillaaggee aabboovvee tthhee ttiibbiiaall ppllaatteeaauu ((nnoorrmmaall rraannggee iiss bbeettwweeeenn ..5544 aanndd 11..0066;; ppaatteellllaa aallttaa rraattiioo iiss ggrreeaatteerr tthhaann 11..00))

TTrroocchhlleeaarr ddeepptthh oonn llaatteerraall ffiillmm MMeerrcchhaanntt TTrroocchhlleeaa hhyyppooppllaassiiaa CCoonnggrruueennccee aannggllee ((AA lliinnee bbiisseeccttiinngg tthhee llaatteerraall rriiddggee ooff tthhee ffeemmuurr,, tthhee

ddeeeeppeesstt ppoorrttiioonn ooff tthhee ttrroocchhlleeaarr ggrroooovvee aanndd tthhee mmeeddiiaall rriiddggee ooff tthhee ffeemmuurr iiss ddrraawwnn.. AA sseeccoonndd lliinnee ffrroomm tthhee ddeeeeppeesstt ppoorrttiioonn ooff tthhee ttrroocchhlleeaarr ggrroovvee ttoo tthhee lloowweesstt ppooiinntt oonn tthhee mmeeddiiaall rriiddggee ooff tthhee ppaatteellllaa iiss ddrraawwnn.. IIff tthhiiss aannggllee iiss ttoo tthhee rriigghhtt ooff tthhee bbiisseeccttoorr,, tthhee vvaalluuee iiss nneeggaattiivvee ((mmeeddiiaall)),, iiff iitt iiss ttoo tthhee lleefftt,, tthhee vvaalluuee iiss ppoossiittiivvee ((llaatteerraall)).. TThhee nnoorrmmaall rraannggee ffoorr tthhee ccoonnggrruueennccee aannggllee iiss ––88 ++ 66 ddeeggrreeeess..))

MMeeaassuurree ppaatteellllaarr ttiilltt OOAA CCTT ssccaann wwiitthh mmiidd--ppaatteellllaarr ccuuttss aatt 00,, 1100,, 2200,, aanndd 3300 ddeeggrreeeess ooff fflleexxiioonn

• Tibial Tubercle/ Trochlear Groove Index • Normal < 20mm on overlayed axial cut CT

•• MMRRII AAccuuttee ppaatteellllaarr ddiissllooccaattiioonn ttoo llooookk ffoorr MMPPFFLL tteeaarr aanndd mmeeddiiaall ffaacceett cchhoonnddrraall

sshheeaarr ffrraaccttuurree wwiitthh lloooossee bbooddyy PPAATTEELLLLOOFFEEMMOORRAALL DDIISSOORRDDEERRSS:: GGEENNEERRAALL

PPaaiinn // NNoorrmmaall aalliiggnnmmeenntt –– RRiisskk FFaaccttoorrss ffoorr PPFF ppaaiinn •• SShhoorrtteenneedd qquuaadd mmuussccllee •• AAbbnnoorrmmaall vvaassttuuss mmeeddiiuuss oobblliiqquuuuss mmuussccllee rreefflleexx rreessppoonnssee ttiimmee •• DDeeccrreeaasseedd eexxpplloossiivvee ssttrreennggtthh •• HHyyppeerrmmoobbiillee ppaatteellllaa •• PPaaiinn // aabbnnoorrmmaall aalliiggnnmmeenntt::

PPaatteellllaarr ttiilltt // llaatteerraall ppaatteellllaarr ccoommpprreessssiioonn ((TThhiiss pprroobblleemm iiss aassssoocciiaatteedd wwiitthh aa ttiigghhtt llaatteerraall rreettiinnaaccuulluumm aanndd eexxcceessssiivvee llaatteerraall ttiilltt wwiitthhoouutt eexxcceessssiivvee ppaatteellllaarr mmoobbiilliittyy))

MMccCCoonnnneellll ttaappiinngg iinniittiiaallllyy RReehhaabb -- ssttrreettcchh llaatteerraall RReettiinnaaccuulluumm aanndd ssttrreennggtthheenn qquuaadd // VVMMOO LLaatteerraall RReelleeaassee oonnllyy iiff llaatteerraall RReettiinnaaccuulluumm ttiigghhtt aanndd nnoo llaatt qquuaadd vveeccttoorr ffoorrccee ((ii..ee.. ttiilltt oonnllyy,, nnoott ssuubblluuxxaattiioonn oorr jjuusstt ppaaiinn))

-- TThhee bbeesstt ccaannddiiddaatteess ffoorr llaatteerraall rreelleeaassee hhaavvee aa nneeuuttrraall oorr nneeggaattiivvee ttiilltt aanndd mmeeddiiaall ppaatteellllaarr gglliiddee lleessss tthhaann oonnee qquuaaddrraanntt wwiitthh aa llaatteerraall ppaatteellllaarr gglliiddee lleessss tthhaann tthhrreeee qquuaaddrraannttss

-- FFoorr aann aaddeeqquuaattee llaatteerraall rreelleeaassee,, ppaatteellllaa sshhoouulldd bbee aabbllee ttoo bbee ppaassssiivveellyy ttiilltteedd 8800 ddeeggrreeeess

MMeeddiiaall ttiibbiiaall ttuubbeerroossiittyy ttrraannssffeerr IIff llaatteerraall QQuuaadd vveeccttoorr aanndd nnoo cchhoonnddrroossiiss AAnntteerroommeedd ttiibbiiaall ttuubbeerrccllee ttrraannssffeerr iiff aarrtthhrroossiiss iinn llaatteerraall ffaacceett

PPAATTEELLLLOOFFEEMMOORRAALL DDIISSOORRDDEERRSS:: SSUUBBLLUUXXAATTIIOONN

•• RReeccuurrrreenntt ssuubblluuxxaattiioonn // ddiissllooccaattiioonn ooff tthhee ppaatteellllaa ccaann bbee cchhaarraacctteerriizzeedd bbyy llaatteerraall ddiissppllaacceemmeenntt ooff tthhee ppaatteellllaa,, aa sshhaallllooww iinntteerrccoonnddyyllaarr ssuullccuuss,, oorr ppaatteellllaarr iinnccoonnggrruueennccee

•• RRiisskk FFaaccttoorrss iinncclluuddee:: LLaatt.. TTuubbeerroossiittyy IInnccrreeaasseedd QQ aannggllee PPaatteellllaa aallttaa IInnccrreeaasseedd vvaallgguuss aatt kknneeee ((ggeennuu vvaallgguuss)) TTrroocchhlleeaarr ddyyssppllaassiiaa PPrroonnaatteedd ffeeeett DDeeccrreeaasseedd qquuaadd ffuunnccttiioonn

•• TTrreeaattmmeenntt:: RReehhaabb // bbrraacciinngg iiss oofftteenn eennoouugghh AAnntteerroommeeddiiaalliizzaattiioonn ooff ttiibbiiaall ttuubbeerrccllee MMPPFFLL rreeppaaiirr // rreeeeffiinngg

PPAATTEELLLLOOFFEEMMOORRAALL DDIISSOORRDDEERRSS:: AACCUUTTEE DDIISSLLOOCCAATTIIOONN

•• PPaatthhoollooggyy MMPPFF lliiggaammeenntt tteeaarr ((ffrroomm ffeemmoorraall ssiiddee)) AAllssoo hhaavvee mmeeddiiaall rreettiinnaaccuulluumm tteeaarr ++//--VVMMOO tteeaarr 4400%% OOsstteeoocchhoonnddrraall ddeeffeecctt nnoott sseeeenn oonn xx--rraayy MMRRII ttoo eevvaalluuaattee llooccaattiioonn ooff MMPPFFLL tteeaarr aanndd lloooossee bbooddyy Most common sites of osteochondral injury are medial inferior patellar

facet and lateral femoral condyle. •• RReehhaabbiilliittaattiioonn

5500%% rreeccuurrrreennccee rraattee ii OOff tthhoossee ww//oo rreeccuurrrreenntt ddiissllooccaattiioonnss,, 5588%% lliimmiitteedd ssppoorrttss ppeerrffoorrmmaannccee aatt 66

mmoonntthhss •• SSuurrggiiccaall rreeppaaiirr

<<1100%% rreeccuurrrreennccee PPAATTEELLLLOOFFEEMMOORRAALL DDIISSOORRDDEERRSS:: RREECCUURRRREENNTT DDIISSLLOOCCAATTIIOONN

•• EExxaamm::

UUssuuaallllyy hhaavvee mmaall--aalliiggnnmmeenntt ooff tthhee eexxtteennssoorr mmeecchhaanniissmm AApppprreehheennssiioonn tteesstt ppoossiittiivvee

•• RRaaddiiooggrraapphhss SSuullccuuss,, IInnccoonnggrruueennccee ooff ppaatteellllaa PPaatteellllaa AAllttaa TTrroocchhlleeaarr ddyyssppllaassiiaa

•• TTrreeaattmmeenntt RReehhaabbiilliittaattiioonn PPrrooxxiimmaall // DDiissttaall RReeaalliiggnnmmeenntt

MMoosstt ssiiggnniiffiiccaanntt rriisskk ffaaccttoorrss ffoorr rreeccuurrrreennccee iiss pprriioorr iinnssttaabbiilliittyy eeppiissooddee aanndd eeaarrllyy aaggee aatt ffiirrsstt ddiissllooccaattiioonn..

SSuuppeerroommeeddiiaall aarrtthhrroossiiss ooff tthhee ppaatteellllaa iiss aa ccoonnttrraaiinnddiiccaattiioonn ffoorr aa ddiissttaall bboonnyy rreeaalliiggnnmmeenntt pprroocceedduurree

PPAATTEELLLLAARR CCHHOONNDDRROOSSIISS

•• IInnjjuurryy aanndd mmaallaalliiggnnmmeenntt ccaann ccoonnttrriibbuuttee ttoo ppaatteellllaarr ddeeggeenneerraattiivvee jjooiinntt ddiisseeaassee

•• LLaatteerraall rreelleeaassee mmaayy bbee bbeenneeffiicciiaall eeaarrllyy;; hhoowweevveerr,, ootthheerr pprroocceedduurreess mmaayy bbee rreeqquuiirreedd ffoorr aaddvvaanncceedd ppaatteellllaarr aarrtthhrriittiiss

•• EExxaamm:: •• CCoommpprreessssiioonn aanndd ccrreeppiittaattiioonn •• RRaaddiiooggrraapphhss •• MMeerrcchhaanntt vviieeww mmoosstt hheellppffuull •• TTrreeaattmmeenntt •• RReehhaabbiilliittaattiioonn •• TTuubbeerrccllee EElleevvaattiioonn

CCoonnttrraaiinnddiiccaatteedd wwiitthh ssuuppeerroommeeddiiaall ppaatteellllaarr aarrtthhrroossiiss •• PPaatteelllleeccttoommyy ffoorr eexxttrreemmee ccaasseess ((nneevveerr tthhee aannsswweerr oonn tthhee

bbooaarrddss)) PPaatteellllooffeemmoorraall DDiissoorrddeerrss:: KKeeyy TTeessttaabbllee IItteemmss

PPaatteellllaa BBaajjaa vvss.. AAllttaa mmeeaassuurreemmeennttss EEsssseennttiiaall ssttrruuccttuurree ttoo rreeppaaiirr wwiitthh ssuubblluuxxiinngg // ddiissllooccaattiinngg ppaatteellllaa SSuuppeerroommeeddiiaall ppaatteellllaarr aarrtthhrroossiiss iiss ccoonnttrraaiinnddiiccaattiioonn ffoorr bboonnyy ddiissttaall rreeaalliiggnnmmeenntt

PATELLOFEMORAL DISORDERS: REFERENCES BBooddeenn,, BB..PP..,, PPeeaarrssaallll,, AA..WW..,, GGaarrrreetttt,, WW..EE..,, eett aall..:: PPaatteellllooffeemmoorraall iinnssttaabbiilliittyy::

EEvvaalluuaattiioonn aanndd mmaannaaggeemmeenntt.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 55::4477––5577,, 11999977.. CCooooppeerr,, DD..EE..,, aanndd DDeeLLeeee,, JJ..CC..:: RReefflleexx ssyymmppaatthheettiicc ddyyssttrroopphhyy ooff tthhee kknneeee.. JJ.. AAmm..

AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 22::7799––8866,, 11999944.. CCrraammeerr,, KK..EE..,, aanndd MMooeedd,, BB..RR..:: PPaatteellllaarr ffrraaccttuurreess:: CCoonntteemmppoorraarryy aapppprrooaacchh ttoo

ttrreeaattmmeenntt.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 55::332233––333311,, 11999977..

FFuullkkeerrssoonn,, JJ..PP..:: AAnntteerroommeeddiiaalliizzaattiioonn ooff tthhee ttiibbiiaall ttuubbeerroossiittyy ffoorr ppaatteellllooffeemmoorraall

mmaallaalliiggnnmmeenntt.. CClliinn.. OOrrtthhoopp.. 117777::117766––118811,, 11998833.. FFuullkkeerrssoonn,, JJ..PP..:: PPaatteellllooffeemmoorraall ppaaiinn ddiissoorrddeerrss:: EEvvaalluuaattiioonn aanndd mmaannaaggeemmeenntt.. JJ..

AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 22::112244––113322,, 11999944.. FFuullkkeerrssoonn,, JJ..PP..,, aanndd SShheeaa,, KK..PP..:: DDiissoorrddeerrss ooff ppaatteellllooffeemmoorraall aalliiggnnmmeenntt:: CCuurrrreenntt

ccoonncceeppttss rreevviieeww.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 7722::11442244––11442299,, 11999900.. GGaammbbaarrddeellllaa,, RR..AA..:: TTeecchhnniiccaall ppiittffaallllss ooff ppaatteellllooffeemmoorraall ssuurrggeerryy.. CClliinn SSppoorrttss MMeedd..

1188:: 889977--990033,, 11999999.. JJaammeess,, SS..LL..:: RRuunnnniinngg iinnjjuurriieess ttoo tthhee kknneeee.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 33::330099––

331188,, 11999955.. KKeellllyy,, MM..AA..:: AAllggoorriitthhmm ffoorr aanntteerriioorr kknneeee ppaaiinn.. AAAAOOSS IInnssttrr.. CCoouurrssee LLeecctt.. 4477::333399––

334433,, 11999988.. KKiilloowwiicchh,, PP..,, PPaauullooss,, LL..,, RRoosseennbbeerrgg,, TT..,, eett aall..:: LLaatteerraall rreelleeaassee ooff tthhee ppaatteellllaa::

IInnddiiccaattiioonnss aanndd ccoonnttrraaiinnddiiccaattiioonnss.. AAmm.. JJ.. SSppoorrttss MMeedd.. 1188::336611,, 11999900.. LLaarrssoonn,, RR..LL..,, CCaabbaauudd,, HH..EE..,, SSllooccuumm,, DD..BB..,, eett aall..:: TThhee ppaatteellllaarr ccoommpprreessssiioonn

ssyynnddrroommee:: SSuurrggiiccaall ttrreeaattmmeenntt bbyy llaatteerraall rreettiinnaaccuullaarr rreelleeaassee.. CClliinn.. OOrrtthhoopp.. 113344::115588––116677,, 11997788..

MMaattaavvaa,, MM..JJ..:: PPaatteellllaarr tteennddoonn rruuppttuurreess.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 44::228877––229966,,

11999966.. MMeerrcchhaanntt,, AA..:: CCllaassssiiffiiccaattiioonn ooff ppaatteellllooffeemmoorraall ddiissoorrddeerrss.. AArrtthhrroossccooppyy 44::223355––224400,,

11998888.. MMeerrcchhaanntt,, AA..CC..,, MMeerrcceerr,, RR..LL..,, JJaaccoobbsseenn,, RR..JJ..,, eett aall..:: RRooeennttggeennooggrraapphhiicc aannaallyyssiiss

ooff ppaatteellllooffeemmoorraall ccoonnggrruueennccee.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 5566::11339911––11339966,, 11997744.. PPoosstt,, WW..RR..:: CClliinniiccaall eevvaalluuaattiioonn ooff ppaattiieennttss wwiitthh ppaatteellllooffeemmoorraall ddiissoorrddeerrss..

AArrtthhrroossccooppyy,, 1155:: 884411--885511,, 11999999..

PPEEDDIIAATTRRIICC KKNNEEEE DDIISSOORRDDEERRSS PPEEDDIIAATTRRIICC KKNNEEEE DDIISSOORRDDEERRSS:: TTRRAACCTTIIOONN AAPPOOPPHHYYSSIITTIISS

•• OOssggoooodd--SScchhllaatttteerrss •• TTiibbiiaall TTuubbeerrccllee •• SSiinnddiinngg--LLaarrsseenn--JJoohhaannssssoonn •• IInnffeerriioorr ppaatteellllaa •• TTrreeaattmmeenntt

•• UUssuuaallllyy ttrreeaatteedd wwiitthh RReesstt aanndd aaccttiivviittyy mmooddiiffiiccaattiioonn,, NNSSAAIIDDss,, aanndd QQuuaaddrriicceeppss SSttrreettcchh

•• OOccccaassiioonnaallllyy,, pprroocceedduurreess ssuucchh aass oossssiiccllee eexxcciissiioonn aarree iinnddiiccaatteedd ffoorr rreeffrraaccttoorryy ccaasseess

PEDIATRIC KNEE DISORDERS: PHYSEAL INJURIES

•• MMoosstt ccoommmmoonnllyy iinnvvoollvvee SSaalltteerr--HHaarrrriiss IIII ffrraaccttuurreess ooff tthhee ddiissttaall ffeemmoorraall pphhyyssiiss.. KKnnooww tthhee SSaalltteerr HHaarrrriiss CCllaassssiiffiiccaattiioonn ((iinn ppeeddss aanndd ttrraauummaa sseeccttiioonn))

•• PPEE:: PPaaiinn,, sswweelllliinngg,, aanndd iinnaabbiilliittyy ttoo aammbbuullaattee •• SSttrreessss rraaddiiooggrraapphhss aarree oofftteenn nneecceessssaarryy ttoo mmaakkee ddiiaaggnnoossiiss •• OORRIIFF ffoorr SSaalltteerr--HHaarrrriiss IIIIII aanndd IIVV ffrraaccttuurreess aanndd SSaalltteerr--HHaarrrriiss II aanndd IIII

ffrraaccttuurreess tthhaatt ccaannnnoott bbee aaddeeqquuaatteellyy rreedduucceedd •• CCrroossssppiinn ddiissttaall ffeemmoorraall ffrraaccttuurreess iiss tthhee ffiixxaattiioonn ooff cchhooiiccee •• LLaattee eeffffeeccttss oofftteenn ccaarrrryy aa wwoorrssee pprrooggnnoossiiss dduuee ttoo aanngguullaarr ggrroowwtthh

ddeeffoorrmmiittiieess PPEEDDIIAATTRRIICC KKNNEEEE DDIISSOORRDDEERRSS:: AACCLL

•• MMiiddssuubbssttaannccee AACCLL iinnjjuurriieess iinn sskkeelleettaallllyy iimmmmaattuurree iinnddiivviidduuaallss rreemmaaiinn aa ssuubbjjeecctt ooff ddeebbaattee..

•• PPaattiieennttss wwhhoo hhaavvee AACCLL tteeaarrss hhaavvee aa hhiigghheerr rriisskk ooff mmeenniissccaall aanndd cchhoonnddrraall ddaammaaggee iiff ttrreeaatteedd nnoonn--ooppeerraattiivveellyy..

•• MMoosstt lliiggaammeenntt iinnjjuurriieess aarree ttrreeaatteedd lliikkee tthhoossee iinn aadduullttss eexxcceepptt uussee aa pphhyysseeaall ssppaarriinngg tteecchhnniiqquuee ((eesspp.. tthhee ffeemmuurr)) aann oovveerr tthhee ttoopp ffeemmoorraall ttuunnnneell iiss uusseedd ttoo nnoott vviioollaattee tthhee uunndduullaattiinngg ggrroowwtthh ppllaattee ooff tthhee ffeemmuurr.. UUssee aa ssoofftt ttiissssuuee ggrraafftt ffoorr TTaannnneerr SSttaaggee 11 oorr 22

•• DDiissppllaacceedd aavvuullssiioonn ffrraaccttuurreess •• UUssuuaallllyy iinnvvoollvvee tthhee MMeeddiiaall TTiibbiiaall EEmmiinneennccee •• OORRIIFF iiss tthhee ttrreeaattmmeenntt ooff cchhooiiccee •• LLaatteerraall MMeenniissccuuss//IInntteerr--mmeenniissccaall lliiggaammeenntt mmaayy bblloocckk rreedduuccttiioonn •• DDoonn’’tt ffoorrggeett ttoo llooookk ffoorr iinntteerrssttiittiiaall iinnjjuurryy aallssoo

PPEEDDIIAATTRRIICC KKNNEEEE DDIISSOORRDDEERRSS:: PPAATTEELLLLAA SSLLEEEEVVEE FFRRAACCTTUURREE

•• HHiigghh iinnddeexx ooff ssuussppiicciioonn rreeqquuiirreedd •• MMaayy hhaavvee nnoo aassssoocciiaatteedd ffrraaccttuurree •• OObbttaaiinn MMRRII iiff ppaattiieenntt iiss uunnaabbllee ttoo ppeerrffoorrmm aa ssttrraaiigghhtt lleegg rraaiissee

PPEEDDIIAATTRRIICC KKNNEEEE DDIISSOORRDDEERRSS:: OOTTHHEERR PPRROOBBLLEEMMSS

•• PPoopplliitteeaall ccyysstt •• UUssuuaallllyy ssppoonnttaanneeoouussllyy rreessoollvveess •• BBiippaarrttiittee PPaatteellllaa •• MMaallee >>>> FFeemmaallee •• BBiillaatteerraalliittyy uunnccoommmmoonn ((rreeppoorrtteedd rraannggeess bbeettwweeeenn 00..22%% ttoo 99%%)) •• OObbsseerrvvee •• BBoonnee SSccaann iiff AAccuuttee •• RRoollee ffoorr llaatteerraall rreelleeaassee ddeebbaatteedd

PPEEDDIIAATTRRIICC KKNNEEEE DDIISSOORRDDEERRSS:: KKeeyy TTeessttaabbllee IItteemmss

NNaattuurraall CCoouurrssee ooff OOssggoooodd--SScchhllaatttteerr’’ss TTrreeaattmmeenntt ooff PPeeddiiaattrriicc AACCLL iinnjjuurriieess ((pphhyysseeaall ggrroowwtthh ddiissttuurrbbaanncceess wwiitthh ttuunnnneellss)) RReeccooggnniizzee ppaatteellllaa sslleeeevvee ffrraaccttuurreess RReeccooggnniizzee BBiippaarrttiittee ppaatteellllaa

PPEEDDIIAATTRRIICC KKNNEEEE DDIISSOORRDDEERRSS:: RREEFFEERREENNCCEESS AAnnddrriisshh,, JJ..TT..:: MMeenniissccaall iinnjjuurriieess iinn cchhiillddrreenn aanndd aaddoolleesscceennttss:: DDiiaaggnnoossiiss aanndd mmaannaaggeemmeenntt.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 55::223311––223377,, 11999966.. AArroonnoowwiittzz,, EE..RR..,, GGaannlleeyy,, TT..JJ.. eett aall..:: AAnntteerriioorr ccrruucciiaattee lliiggaammeenntt rreeccoonnssttrruuccttiioonn iinn aaddoolleeccsscceennttss wwiitthh ooppeenn pphhyysseess.. AAmm JJ SSppoorrttss MMeedd.. 2288:: 116688--117755,, 22000000.. BBaaxxtteerr,, MM..PP..,, aanndd WWiilleeyy,, JJ..JJ..:: FFrraaccttuurreess ooff tthhee ttiibbiiaall ssppiinnee iinn cchhiillddrreenn:: AAnn eevvaalluuaattiioonn ooff kknneeee ssttaabbiilliittyy.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[BBrr..]] 7700::222288––223300,, 11998888.. EEddwwaarrddss,, PP..HH..,, aanndd GGrraannaa,, WW..AA..:: PPhhyysseeaall ffrraaccttuurreess aabboouutt tthhee kknneeee.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 33::6633––6699,, 11999955.. LLoo,, II..KK..YY..,, BBeellll,, DD..MM..,, aanndd FFoowwlleerr,, PP..JJ..:: AAnntteerriioorr ccrruucciiaattee lliiggaammeenntt iinnjjuurriieess iinn tthhee sskkeelleettaallllyy iimmmmaattuurree ppaattiieenntt.. AAAAOOSS IInnssttrr.. CCoouurrssee LLeecctt.. 4477::335511––335599,, 11999988.. MMccCCaarrrroollll,, JJ..RR..,, RReettttiigg,, AA..CC..,, aanndd SShheellbboouurrnnee,, KK..DD..:: AAnntteerriioorr ccrruucciiaattee lliiggaammeenntt iinnjjuurriieess iinn tthhee yyoouunngg aatthhlleettee wwiitthh ooppeenn pphhyysseess.. AAmm.. JJ.. SSppoorrttss MMeedd.. 1166::4444––4477,, 11998888.. MMeeyyeerrss,, MM..HH..,, aanndd MMccKKeeeevveerr,, FF..MM..:: FFrraaccttuurreess ooff tthhee iinntteerrccoonnddyyllaarr eemmiinneennccee ooff tthhee ttiibbiiaa.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 4411::220099––222222,, 11995599.. MMiicchheellii,, LL..JJ..,, aanndd FFoosstteerr,, TT..EE..:: AAccuuttee kknneeee iinnjjuurriieess iinn tthhee iimmmmaattuurree aatthhlleettee.. IInnssttrr.. CCoouurrssee LLeecctt.. 4422::447733––448811,, 11999933.. OOggddeenn,, JJ..AA..,, TTrroossss,, RR..BB..,, aanndd MMuurrpphhyy,, MM..JJ..:: FFrraaccttuurreess ooff tthhee ttiibbiiaall ttuubbeerroossiittyy iinn aaddoolleesscceennttss.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 6622::220055––221155,, 11998800.. PPaarrkkeerr,, AA..WW..,, DDrreezz,, DD..,, aanndd CCooooppeerr,, JJ..LL..:: AAnntteerriioorr ccrruucciiaattee lliiggaammeenntt iinnjjuurriieess iinn ppaattiieennttss wwiitthh ooppeenn pphhyysseess.. AAmm.. JJ.. SSppoorrttss MMeedd.. 2222::4444––4477,, 11999944.. RRiisseebboorroouugghh,, EE..JJ..,, BBaarrrreetttt,, II..RR..,, aanndd SShhaappiirroo,, FF..:: GGrroowwtthh ddiissttuurrbbaanncceess ffoolllloowwiinngg ddiissttaall ffeemmoorraall pphhyysseeaall ffrraaccttuurree--sseeppaarraattiioonnss.. JJ.. BBoonnee JJooiinntt SSuurrgg.. [[AAmm..]] 6655::888855––889933,, 11998833.. SSttaanniittsskkii,, CC..LL..:: AAnntteerriioorr ccrruucciiaattee lliiggaammeenntt iinnjjuurryy iinn tthhee sskkeelleettaallllyy iimmmmaattuurree ppaattiieenntt:: DDiiaaggnnoossiiss aanndd ttrreeaattmmeenntt.. JJ.. AAmm.. AAccaadd.. OOrrtthhoopp.. SSuurrgg.. 33::114466––115588,, 11999955..

SSttaanniittsskkii,, CC..LL..:: PPaatteellllaarr iinnssttaabbiilliittyy iinn tthhee sscchhooooll aaggee aatthhlleettee.. AAAAOOSS IInnssttrr.. CCoouurrssee LLeecctt.. 4477::334455––335500,, 11999988..

KKNNEEEE QQUUEESSTTIIOONNSS

““WWrroonngg”” aannsswweerrss:: –– IInnddiissccrriimmiinnaattee oorrddeerriinngg ooff MMRRII’’ss –– SStteerrooiidd iinnjjeeccttiioonnss –– TThheerrmmaall SShhrriinnkkaaggee –– ““DDiiaaggnnoossttiicc”” aarrtthhrroossccooppyy –– AACCLL ““rreeppaaiirr”” ffoorr AAccuuttee AACCLL rreeccoonnssttrruuccttiioonn –– IInniittiiaall ooppeerraattiivvee ttrreeaattmmeenntt ooff PPCCLL iinnjjuurriieess –– IInniittiiaall ooppeerraattiivvee ttrreeaattmmeenntt ooff PPFF//oovveerruussee pprroobblleemmss

QQUUEESSTTIIOONN 11:: WWhhiicchh ooff tthhee ffoolllloowwiinngg ssttaatteemmeennttss bbeesstt ddeessccrriibbeess tthhee tteennssiioonn iinn tthhee ddiiffffeerreenntt ccoommppoonneennttss ooff tthhee ppoosstteerriioorr ccrruucciiaattee lliiggaammeenntt wwhheenn tthhee kknneeee iiss ttaakkeenn ffrroomm ffuullll eexxtteennssiioonn ttoo 9900 ddeeggrreeeess ooff fflleexxiioonn?? 11-- BBootthh tthhee AALL aanndd PPMM bbaannddss aarree iissoommeettrriicc aanndd ddoo nnoott cchhaannggee 22-- AALL bbaanndd iiss llaaxx aanndd bbeeccoommeess ttiigghhtt;; PPMM iiss ttiigghhtt aanndd bbeeccoommeess llaaxx 33-- AALL iiss ttiigghhtt aanndd bbeeccoommeess llaaxx;; PPMM iiss llaaxx aanndd bbeeccoommeess ttiigghhtt 44-- BBootthh tthhee AALL aanndd PPMM bbaannddss aarree llaaxx aanndd bbeeccoommee ttiigghhtt 55-- BBootthh tthhee AALL aanndd PPMM bbaannddss aarree ttiigghhtt aanndd bbeeccoommee llaaxx

QQUUEESSTTIIOONN 22:: WWhhiicchh ooff tthhee ffoolllloowwiinngg lliiggaammeennttss pprroovviiddeess tthhee mmaajjoorr ssttaattiicc rreessttrraaiinntt ttoo llaatteerraall ppaatteellllaarr ddiissppllaacceemmeenntt?? 11-- MMeeddiiaall ppaatteelllloottiibbiiaall 22-- MMeeddiiaall ppaatteellllooffeemmoorraall 33-- MMeeddiiaall ppaatteelllloommeenniissccaall 44-- LLaatteerraall ppaatteellllooffeemmoorraall 55-- LLaatteerraall ppaatteelllloottiibbiiaall

QQUUEESSTTIIOONN 33:: AA ccoolllleeggee ffoooottbbaallll ppllaayyeerr ttwwiissttss hhiiss kknneeee wwhheenn hhee aatttteemmppttss ttoo ttaacckkllee aann oonnccoommiinngg ppllaayyeerr.. EExxaammiinnaattiioonn rreevveeaallss nnoo mmeeddiiaall llaatteerraall llaaxxiittyy oorr jjooiinnttlliinnee tteennddeerrnneessss.. TThhee aanntteerriioorr aanndd ppoosstteerriioorr ddrraawweerr tteessttss aanndd ppiivvoott sshhiifftt rreessuullttss aarree nneeggaattiivvee;; hhoowweevveerr,, tthhee LLaacchhmmaann tteesstt rreessuulltt iiss ppoossiittiivvee.. WWhhaatt iiss tthhee mmoosstt lliikkeellyy ddiiaaggnnoossiiss?? 11-- MMiinnoorr kknneeee sspprraaiinn

22-- MMeeddiiaall ccoollllaatteerraall lliiggaammeenntt iinnjjuurryy 33-- LLaatteerraall ccoollllaatteerraall lliiggaammeenntt iinnjjuurryy 44-- AAnntteerriioorr ccrruucciiaattee lliiggaammeenntt iinnjjuurryy 55-- PPoosstteerriioorr ccrruucciiaattee lliiggaammeenntt iinnjjuurryy

QQUUEESSTTIIOONN 44:: TThhee llaatteerraall ffrraaggmmeenntt ooff bboonnee ((SSeeggoonndd ffrraaccttuurree)) aassssoocciiaatteedd wwiitthh aann iinnjjuurryy ooff tthhee aanntteerriioorr ccrruucciiaattee lliiggaammeenntt iiss tthhee rreessuulltt ooff aann aavvuullssiioonn ooff tthhee 11-- oobblliiqquuee ppoopplliitteeaall lliiggaammeenntt 22-- llaatteerraall ccaappssuullee 33-- ppoopplliitteeaall tteennddoonn 44-- ffiibbuullaarr ccoollllaatteerraall lliiggaammeenntt 55-- ppoosstteerriioorr oobblliiqquuee lliiggaammeenntt

QQUUEESSTTIIOONN 55:: AA 1133--yyeeaarr--oolldd qquuaarrtteerrbbaacckk ffeeeellss aa ““ppoopp”” iinn hhiiss kknneeee wwhhiillee bbeeiinngg ttaacckklleedd.. RRaaddiiooggrraapphhss ooff tthhee kknneeee aanndd rreessuullttss ooff aa LLaacchhmmaann’’ss tteesstt aarree nnoorrmmaall.. EExxaammiinnaattiioonn rreevveeaallss tteennddeerrnneessss oovveerr tthhee ddiissttaall ffeemmoorraall pphhyyssiiss.. TToo hheellpp ccoonnffiirrmm tthhee ddiiaaggnnoossiiss,, mmaannaaggeemmeenntt sshhoouulldd ffiirrsstt iinncclluuddee 11-- aann MMRRII ssccaann 22-- aarrtthhrroossccooppiicc eexxaammiinnaattiioonn 33-- AAPP aanndd ffrroogg--lleegg rraaddiiooggrraapphhss ooff tthhee ppeellvviiss aanndd hhiippss 44-- vvaarruuss aanndd vvaallgguuss ssttrreessss rraaddiiooggrraapphhss ooff tthhee kknneeee 55-- pphhyyssiiccaall eexxaammiinnaattiioonn ooff tthhee kknneeee uunnddeerr aanneesstthheessiiaa

QQUUEESSTTIIOONN 66:: AA ppaattiieenntt ssuussttaaiinnss aa tteeaarr ooff tthhee AACCLL,, aanndd aann MMRRII rreevveeaallss aa bboonnee ccoonnttuussiioonn.. SSiiggnnaall cchhaannggeess aass tthhee rreessuulltt ooff tthhiiss iinnjjuurryy wwoouulldd mmoosstt lliikkeellyy bbee llooccaatteedd aatt tthhee 11-- ppoosstteerriioorr 11//33 ooff tthhee LLFFCC aanndd mmiiddddllee 11//33 ooff tthhee LLTTPP 22-- ppoosstteerriioorr 11//33 ooff tthhee LLFFCC aanndd aanntteerriioorr 11//33 ooff tthhee LLTTPP 33-- aanntteerriioorr 11//33 ooff tthhee LLFFCC aanndd ppoosstteerriioorr 11//33 ooff tthhee MMTTPP 44-- mmiiddddllee 11//33 ooff tthhee MMFFCC aanndd ppoosstteerriioorr 11//33 ooff tthhee MMTTPP 55-- mmiiddddllee 11//33 ooff tthhee LLFFCC aanndd ppoosstteerriioorr 11//33 ooff tthhee LLTTPP

QQUUEESSTTIIOONN 77:: WWhhaatt ppaarrtt ooff tthhee mmeenniissccuuss hhaass tthhee hhiigghheesstt iinncciiddeennccee ooff ddeeggeenneerraattiivvee tteeaarrss?? 11-- AAnntteerriioorr hhoorrnn ooff tthhee mmeeddiiaall mmeenniissccuuss 22-- AAnntteerriioorr hhoorrnn ooff tthhee llaatteerraall mmeenniissccuuss 33-- PPoosstteerriioorr hhoorrnn ooff tthhee llaatteerraall mmeenniissccuuss 44-- PPoosstteerriioorr hhoorrnn ooff tthhee mmeeddiiaall mmeenniissccuuss 55-- MMiiddddllee aanndd ppoosstteerriioorr hhoorrnnss ooff tthhee llaatteerraall mmeenniissccuuss

QQUUEESSTTIIOONN 88:: SSuucccceessssffuull hheeaalliinngg ooff aa mmeenniissccaall rreeppaaiirr iiss mmoosstt lliikkeellyy aassssoocciiaatteedd wwiitthh wwhhiicchh ooff tthhee ffoolllloowwiinngg tteeaarr ppaatttteerrnnss?? 11-- RRaaddiiaall tteeaarr 22-- PPaarrrroott--bbeeaakk tteeaarr 33-- VVeerrttiiccaall tteeaarr iinn tthhee ““rreedd--rreedd”” zzoonnee 44-- VVeerrttiiccaall tteeaarr iinn tthhee ““rreedd--wwhhiittee”” zzoonnee 55-- VVeerrttiiccaall tteeaarr iinn tthhee ““wwhhiittee--wwhhiittee”” zzoonnee

QQUUEESSTTIIOONN 99:: PPaallppaabbllee jjooiinnttlliinnee ccyyssttss iinn tthhee kknneeee aarree mmoosstt ccoommmmoonnllyy aassssoocciiaatteedd wwiitthh 11-- BBaakkeerr’’ss ccyysstt 22-- mmeeddiiaall mmeenniissccuuss tteeaarrss 33-- llaatteerraall mmeenniissccuuss tteeaarrss 44-- ccoonnggeenniittaall ddiissccooiidd llaatteerraall mmeenniissccuuss 55-- aanntteerriioorr ccrruucciiaattee lliiggaammeenntt aanndd mmeenniissccaall tteeaarrss

QQUUEESSTTIIOONN 1100:: OOsstteeoocchhoonnddrriittiiss ddiisssseeccaannss ooff tthhee kknneeee mmoosstt ccoommmmoonnllyy iinnvvoollvveess wwhhaatt ssttrruuccttuurree?? 11-- MMeeddiiaall ttiibbiiaall ppllaatteeaauu 22-- LLaatteerraall ttiibbiiaall ppllaatteeaauu 33-- PPaatteellllaa 44-- MMeeddiiaall ffeemmoorraall ccoonnddyyllee 55-- LLaatteerraall ffeemmoorraall ccoonnddyyllee

QQUUEESSTTIIOONN 1111:: AA 1133--yyeeaarr--oolldd bbooyy ccoommppllaaiinnss ooff kknneeee ppaaiinn aanndd sswweelllliinngg ffoolllloowwiinngg ttrraaiinniinngg lleessssoonnss ffoorr sskkii rraacciinngg ffoorr tthhee ppaasstt ssiixx mmoonntthhss.. MMRRII ddeemmoonnssttrraatteess aann OOCCDD lleessiioonn wwiitthh ooppeenn pphhyysseess.. TThhee oonnllyy aabbnnoorrmmaall ffiinnddiinngg oonn pphhyyssiiccaall eexxaammiinnaattiioonn iiss aann eeffffuussiioonn.. MMaannaaggeemmeenntt sshhoouulldd ccoonnssiisstt ooff 11-- ccaasstt iimmmmoobbiilliizzaattiioonn ffoorr 66 wweeeekkss 22-- aaccttiivviittyy mmooddiiffiiccaattiioonn aanndd rree--eevvaalluuaattiioonn iinn 22 mmoonntthhss 33-- iinntteerrnnaall ffiixxaattiioonn wwiitthh oorr wwiitthhoouutt bboonnee ggrraaffttiinngg 44-- rreettrrooggrraaddee ddrriilllliinngg ooff tthhee ddeeffeecctt wwiitthhoouutt aarrttiiccuullaarr ccaarrttiillaaggee ppeenneettrraattiioonn 55-- ddrriilllliinngg ooff tthhee ddeeffeecctt ddiirreeccttllyy tthhrroouugghh tthhee aarrttiiccuullaarr ccaarrttiillaaggee

QQUUEESSTTIIOONN 1122:: AA 2200--yyeeaarr--oolldd ffoooottbbaallll ppllaayyeerr rreeppoorrttss hheeaarriinngg aa ““ppoopp”” iinn hhiiss kknneeee aass aa rreessuulltt ooff aa nnoonnccoonnttaacctt ddeecceelleerraattiioonn iinnjjuurryy.. EExxaammiinnaattiioonn 2244 hhoouurrss llaatteerr rreevveeaallss aa llaarrggee eeffffuussiioonn.. TThhee iinncciiddeennccee ooff aa rruuppttuurree ooff tthhee aanntteerriioorr ccrruucciiaattee lliiggaammeenntt iinn tthhiiss ssiittuuaattiioonn iiss cclloosseesstt ttoo 11--1155%% 22--3300%% 33--7700%% 44--9900%% 55--9955%%

QQUUEESSTTIIOONN 1133:: WWhhaatt ttyyppee ooff ggaaiitt ppaatttteerrnn cchhaarraacctteerriizzeess tthhee ppaattiieenntt wwiitthh aann aanntteerriioorr ccrruucciiaattee lliiggaammeenntt--ddeeffiicciieenntt kknneeee?? 11-- NNoorrmmaall bbiipphhaassiicc fflleexxiioonn--eexxtteennssiioonn mmoommeenntt 22-- QQuuaaddrriicceeppss aavvooiiddaannccee ggaaiitt 33-- HHaammssttrriinngg aavvooiiddaannccee ggaaiitt 44-- PPrroolloonnggeedd ssttaannccee pphhaassee oonn tthhee iinnvvoollvveedd lleegg 55-- PPrroolloonnggeedd sswwiinngg pphhaassee oonn tthhee iinnvvoollvveedd lleegg

QQUUEESSTTIIOONN 1144:: AAnn 1188--yyeeaarr--oolldd hhiigghh sscchhooooll ffoooottbbaallll ppllaayyeerr iinnjjuurreess hhiiss kknneeee wwhhiillee ddeecceelleerraattiinngg aanndd ppiivvoottiinngg ttoo tthhrrooww aa bbaallll.. HHeemmaarrtthhrroossiiss ddeevveellooppss iimmmmeeddiiaatteellyy aafftteerr tthhee iinnjjuurryy.. EExxaammiinnaattiioonn sshhoowwss aa llaarrggee eeffffuussiioonn,, aa 1155-- ttoo 9900--ddeeggrreeee rraannggee ooff mmoottiioonn,, aa 22++ LLaacchhmmaann tteesstt rreessuulltt,, aanndd nnoo jjooiinnttlliinnee tteennddeerrnneessss.. TTrreeaattmmeenntt sshhoouulldd ccoonnssiisstt ooff 11-- aaccuuttee AACCLL rreeppaaiirr 22-- aaccuuttee AACCLL rreeccoonnssttrruuccttiioonn uussiinngg aauuttooggeennoouuss ggrraafftt 33-- aaccuuttee AACCLL rreeccoonnssttrruuccttiioonn uussiinngg aauuttooggeennoouuss ggrraafftt aanndd aa LLAADD 44-- AACCLL rreeppaaiirr wwhheenn RROOMM hhaass rreettuurrnneedd ttoo nnoorrmmaall 55-- AACCLL rreeccoonnssttrruuccttiioonn wwiitthh aauuttooggeennoouuss ggrraafftt wwhheenn RROOMM hhaass rreettuurrnneedd ttoo nnoorrmmaall

QQUUEESSTTIIOONN 1155:: PPhhyyssiiccaall eexxaammiinnaattiioonn ooff aa hhiigghh sscchhooooll ssoocccceerr ppllaayyeerr wwhhoo ssuussttaaiinnss aa kknneeee lliiggaammeenntt iinnjjuurryy rreevveeaallss ggrraaddee IIIIII tteeaarrss ooff tthhee aanntteerriioorr ccrruucciiaattee aanndd mmeeddiiaall ccoollllaatteerraall lliiggaammeennttss.. IInn aaddddiittiioonn,, aa MMRRII ssccaann rreevveeaallss aa llaatteerraall mmeenniissccaall iinnjjuurryy.. DDeellaayyiinngg aanntteerriioorr ccrruucciiaattee lliiggaammeenntt ssuurrggeerryy uunnttiill tthhee ppaattiieenntt hhaass ffuullll,, ppaaiinn--ffrreeee rraannggee ooff mmoottiioonn wwiillll ddeeccrreeaassee tthhee rriisskk ooff:: 11-- ppaatteellllaarr cchhoonnddrroommaallaacciiaa 22--ffaaiilluurree ooff mmeenniissccuuss rreeppaaiirr 33--aarrtthhrrooffiibbrroossiiss 44--vvaarruuss--vvaallgguuss iinnssttaabbiilliittyy 55--aanntteerrooppoosstteerriioorr iinnssttaabbiilliittyy

QQUUEESSTTIIOONN 1166:: WWhhiicchh ooff tthhee ffoolllloowwiinngg mmeecchhaanniissmmss iiss mmoosstt lliikkeellyy ttoo rreessuulltt iinn ggrraafftt ffaaiilluurree 44 wweeeekkss aafftteerr aanntteerriioorr ccrruucciiaattee lliiggaammeenntt rreeccoonnssttrruuccttiioonn wwiitthh aa ppaatteellllaarr tteennddoonn ggrraafftt?? 11-- LLoossss ooff ffiixxaattiioonn 22-- MMiiddssuubbssttaannccee ggrraafftt rruuppttuurree 33-- NNoottcchh iimmppiinnggeemmeenntt 44-- SSttrreettcchhiinngg ooff tthhee ggrraafftt 55-- TTeeaarr aatt tthhee bboonnee--tteennddoonn iinntteerrffaaccee

QQUUEESSTTIIOONN 1177:: AA 2233--yyeeaarr--oolldd ffoooottbbaallll ppllaayyeerr ssuussttaaiinnss aa hhyyppeerrfflleexxiioonn iinnjjuurryy ttoo tthhee kknneeee,, rreeppoorrttss ffeeeelliinngg aa ““ppoopp,,”” aanndd iiss tthheenn uunnaabbllee ttoo bbeeaarr wweeiigghhtt.. AA ttrraaccee hheemmaarrtthhrroossiiss ddeevveellooppss wwiitthhiinn 11 ddaayy.. WWhhiicchh ooff tthhee ffoolllloowwiinngg lliiggaammeennttss hhaass mmoosstt lliikkeellyy bbeeeenn ddaammaaggeedd?? 11-- MMeeddiiaall ccoollllaatteerraall 22-- PPoosstteerroollaatteerraall ccoommpplleexx 33-- PPoosstteerriioorr ccrruucciiaattee 44-- AAnntteerriioorr ccrruucciiaattee 55-- AAnntteerriioorr aanndd ppoosstteerriioorr ccrruucciiaattee

QQUUEESSTTIIOONN 1188:: PPoosstteerriioorr ccrruucciiaattee iinnssuuffffiicciieennccyy ddiiaaggnnoosseedd uussiinngg tthhee qquuaaddrriicceeppss aaccttiivvee tteesstt iiss ccoonnffiirrmmeedd wwiitthh ttiibbiiaall ttrraannssllaattiioonn 11-- aanntteerriioorrllyy aatt 2200 ttoo 3300 ddeeggrreeeess ooff fflleexxiioonn 22-- aanntteerriioorrllyy aatt 7700 ttoo 9900 ddeeggrreeeess ooff fflleexxiioonn 33-- ppoosstteerriioorrllyy aatt 2200 ttoo 3300 ddeeggrreeeess ooff fflleexxiioonn 44-- ppoosstteerriioorrllyy aatt 7700 ttoo 9900 ddeeggrreeeess ooff fflleexxiioonn 55-- aanntteerriioorrllyy wwiitthh tthhee kknneeee iinn ffuullll eexxtteennssiioonn

QQUUEESSTTIIOONN 1199:: WWhhiicchh ooff tthhee ffoolllloowwiinngg bbeesstt ddeessccrriibbeess tthhee rreellaattiioonnsshhiipp ooff tthhee ttiibbiiaa ttoo tthhee ffeemmuurr dduurriinngg aa ppoossiittiivvee rreevveerrssee ppiivvoott sshhiifftt?? 11-- TTiibbiiaa rreedduucceedd wwiitthh fflleexxiioonn aanndd ssuubblluuxxaatteess ppoosstteerriioorrllyy iinn eexxtteennssiioonn 22-- TTiibbiiaa rreedduucceedd wwiitthh fflleexxiioonn aanndd ssuubblluuxxaatteess aanntteerriioorrllyy iinn eexxtteennssiioonn 33-- TTiibbiiaa rreedduucceedd wwiitthh fflleexxiioonn aanndd ffiibbuullaa ssuubblluuxxaatteess ppoosstteerriioorrllyy iinn kknneeee eexxtteennssiioonn 44-- TTiibbiiaa ssuubblluuxxaatteedd ppoosstteerriioorrllyy wwiitthh fflleexxiioonn aanndd rreedduucceess iinn eexxtteennssiioonn 55-- TTiibbiiaa ssuubblluuxxaatteedd aanntteerriioorrllyy wwiitthh fflleexxiioonn aanndd rreedduucceess iinn eexxtteennssiioonn

QQUUEESSTTIIOONN 2200:: EExxaammiinnaattiioonn ooff aa 2255--yyeeaarr--oolldd mmaann wwhhoo hhaass kknneeee ppaaiinn aafftteerr aa mmoottoorrccyyccllee aacccciiddeenntt rreevveeaallss aann eeffffuussiioonn,, nnoorrmmaall ssttaabbiilliittyy ttoo vvaarruuss// vvaallgguuss ssttrreessss,, aa nneeggaattiivvee LLaacchhmmaann tteesstt,, aanndd aa ggrraaddee IIIIII ppoosstteerriioorr ddrraawweerr.. RRaaddiiooggrraapphhss ddeemmoonnssttrraattee aa bboonnyy ppiieeccee ooffff tthhee ppoosstteerriioorr aassppeecctt ooff tthhee ttiibbiiaa.. TTrreeaattmmeenntt sshhoouulldd ccoonnssiisstt ooff

11-- RReeppaaiirr ooff tthhee iinnjjuurreedd ssttrruuccttuurreess 22-- PPoosstteerriioorr ccrruucciiaattee rreeccoonnssttrruuccttiioonn wwiitthh ppaatteellllaarr tteennddoonn ggrraafftt 33-- IImmmmoobbiilliizzaattiioonn ffoorr 44 wweeeekkss 44-- PPhhyyssiiccaall tthheerraappyy ffooccuusseedd oonn qquuaaddrriicceeppss ssttrreennggtthheenniinngg aanndd RROOMM 55-- DDiiaaggnnoossttiicc aarrtthhrroossccooppyy ffoolllloowweedd bbyy rreehhaabbiilliittaattiioonn QQUUEESSTTIIOONN 2211:: AA 3322--yyeeaarr--oolldd mmaann hhaass sswweelllliinngg ooff tthhee kknneeee aass aa rreessuulltt ooff ffaalllliinngg wwiitthh tthhee kknneeee fflleexxeedd aanndd hhiiss ffoooott iinn ppllaannttaarr fflleexxiioonn.. AA LLaacchhmmaann’’ss tteesstt rreevveeaallss aann aappppaarreenntt iinnccrreeaassee iinn aanntteerriioorr ttrraannssllaattiioonn.. PPaassssiivvee eexxtteerrnnaall ttiibbiiaall rroottaattiioonn aatt 3300 ddeeggrreeeess aanndd 9900 ddeeggrreeeess iiss eeqquuaall ttoo tthhee ccoonnttrraallaatteerraall ssiiddee,, aanndd tthhee qquuaaddrriicceeppss aaccttiivvee tteesstt iiss ppoossiittiivvee oonn tthhee aaffffeecctteedd ssiiddee.. TThhee nneeuurroovvaassccuullaarr eexxaamm iiss nnoorrmmaall.. TTrreeaattmmeenntt sshhoouulldd ccoonnssiisstt ooff 11-- aann aanntteerriioorr ccrruucciiaattee ffuunnccttiioonnaall kknneeee bbrraaccee 22-- aa pphhyyssiiccaall tthheerraappyy pprrooggrraamm 33-- rreeccoonnssttrruuccttiioonn ooff tthhee PPCCLL aanndd ppoosstteerroollaatteerraall ccoorrnneerr 44-- rreeccoonnssttrruuccttiioonn ooff tthhee PPCCLL 55-- rreeccoonnssttrruuccttiioonn ooff tthhee AACCLL

QQUUEESSTTIIOONN 2222:: EExxaammiinnaattiioonn ooff aa 2277--yyeeaarr--oolldd mmaann wwhhoo iinnjjuurreedd hhiiss kknneeee ppllaayyiinngg ssoocccceerr sshhoowwss ffuullll rraannggee ooff mmoottiioonn,, nnoo jjooiinnttlliinnee tteennddeerrnneessss,, nneeggaattiivvee LLaacchhmmaann aanndd aanntteerriioorr ddrraawweerr tteessttss,, bbuutt aa ppoossiittiivvee ggrraaddee II ppoosstteerriioorr ddrraawweerr tteesstt rreessuulltt.. RRaaddiiooggrraapphhss aanndd ssiiggnnss ooff ppoosstteerroollaatteerraall iinnssttaabbiilliittyy aarree nneeggaattiivvee.. IInniittiiaall mmaannaaggeemmeenntt sshhoouulldd ccoonnssiisstt ooff 11-- pprriimmaarryy ppoosstteerriioorr ccrruucciiaattee lliiggaammeenntt rreeppaaiirr 22-- rreehhaabbiilliittaattiioonn,, wwiitthh eemmpphhaassiiss oonn qquuaaddrriicceeppss ssttrreennggtthheenniinngg 33-- rreehhaabbiilliittaattiioonn,, wwiitthh eemmpphhaassiiss oonn hhaammssttrriinngg ssttrreennggtthheenniinngg 44-- rreeccoonnssttrruuccttiioonn ooff tthhee PPCCLL uussiinngg aann aauuttooggeennoouuss ppaatteellllaarr tteennddoonn 55-- rreeccoonnssttrruuccttiioonn ooff tthhee PPCCLL uussiinngg aann aauuttooggeennoouuss hhaammssttrriinngg tteennddoonn QQUUEESSTTIIOONN 2233:: CCaaddaavveerr ssttuuddiieess sshhooww tthhaatt aalltteerraattiioonn iinn jjooiinntt kkiinneemmaattiiccss ffoolllloowwiinngg ppoosstteerriioorr ccrruucciiaattee lliiggaammeenntt sseeccttiioonniinngg lleeaaddss ttoo 11-- iinnccrreeaasseedd ccoonnttaacctt pprreessssuurreess iinn aallll tthhrreeee ccoommppaarrttmmeennttss ooff tthhee kknneeee 22-- iinnccrreeaasseedd ccoonnttaacctt pprreessssuurreess iinn tthhee mmeeddiiaall aanndd ppaatteellllooffeemmoorraall ccoommppaarrttmmeennttss 33-- iinnccrreeaasseedd ccoonnttaacctt pprreessssuurreess iinn tthhee llaatteerraall aanndd ppaatteellllooffeemmoorraall ccoommppaarrttmmeennttss 44-- ddeeccrreeaasseedd ccoonnttaacctt pprreessssuurree iinn tthhee ppaatteellllooffeemmoorraall ccoommppaarrttmmeenntt,, bbuutt iinnccrreeaasseedd ccoonnttaacctt pprreessssuurreess iinn tthhee mmeeddiiaall ccoommppaarrttmmeenntt 55-- ddeeccrreeaasseedd ccoonnttaacctt pprreessssuurree iinn tthhee ppaatteellllooffeemmoorraall ccoommppaarrttmmeenntt,, bbuutt iinnccrreeaasseedd ccoonnttaacctt pprreessssuurree iinn tthhee llaatteerraall ccoommppaarrttmmeenntt

QQUUEESSTTIIOONN 2244:: TTrreeaattmmeenntt ttoo mmiinniimmiizzee ppoosstteerriioorr ssaagg ffoolllloowwiinngg ppoosstteerriioorr ccrruucciiaattee lliiggaammeenntt rreeccoonnssttrruuccttiioonn ccoonnssiissttss ooff iimmmmoobbiilliizzaattiioonn aatt wwhhiicchh ooff tthhee ffoolllloowwiinngg fflleexxiioonn aanngglleess?? 11-- 00 ddeeggrreeeess 22-- 3300 ddeeggrreeeess 33-- 4455 ddeeggrreeeess 44-- 7700 ddeeggrreeeess 55-- 9900 ddeeggrreeeess QQUUEESSTTIIOONN 2255:: WWhhiicchh ooff tthhee ffoolllloowwiinngg ffiinnddiinnggss oonn pphhyyssiiccaall eexxaammiinnaattiioonn bbeesstt iinnddiiccaatteess iissoollaatteedd ppoosstteerroollaatteerraall iinnssttaabbiilliittyy ooff tthhee kknneeee?? 11-- RReevveerrssee ppiivvoott sshhiifftt 22-- PPoossiittiivvee LLaacchhmmaann tteesstt rreessuulltt 33-- PPoossiittiivvee qquuaaddrriicceeppss aaccttiivvee tteesstt rreessuulltt 44-- IInnccrreeaasseedd eexxtteerrnnaall rroottaattiioonn ooff tthhee ffoooott rreellaattiivvee ttoo tthhee ccoonnttrraallaatteerraall ssiiddee aatt 3300 ddeeggrreeeess ooff kknneeee fflleexxiioonn oonnllyy 55-- IInnccrreeaasseedd eexxtteerrnnaall rroottaattiioonn ooff tthhee ffoooott rreellaattiivvee ttoo tthhee ccoonnttrraallaatteerraall ssiiddee aatt bbootthh 3300 aanndd 9900 ddeeggrreeeess ooff kknneeee fflleexxiioonn QQUUEESSTTIIOONN 2266:: AA 2255--yyeeaarr--oolldd wwoommaann wwhhoo ssuussttaaiinnss aa ddiirreecctt bbllooww ttoo tthhee aanntteerroommeeddiiaall aassppeecctt ooff hheerr lleegg wwhhiillee ppllaayyiinngg bbaasskkeettbbaallll hhaass iimmmmeeddiiaattee ppaaiinn aanndd ccaannnnoott wwaallkk.. EExxaammiinnaattiioonn ooff tthhee kknneeee rreevveeaallss aann iinnccrreeaassee iinn ppoosstteerriioorr ttrraannssllaattiioonn aanndd eexxtteerrnnaall rroottaattiioonn aatt 9900 ddeeggrreeeess ooff fflleexxiioonn.. AAtt 3300 ddeeggrreeeess ooff fflleexxiioonn,, ppoosstteerriioorr ttrraannssllaattiioonn aanndd eexxtteerrnnaall rroottaattiioonn aarree ssyymmmmeettrriiccaall ttoo tthhee uunnaaffffeecctteedd ssiiddee.. RRaaddiiooggrraapphhss aarree nnoorrmmaall.. WWhhiicchh ooff tthhee ffoolllloowwiinngg ssttrruuccttuurreess aarree iinnjjuurreedd?? 11-- PPoosstteerroollaatteerraall ccoommpplleexx 22-- PPoosstteerriioorr ccrruucciiaattee lliiggaammeenntt 33-- LLaatteerraall ccoollllaatteerraall lliiggaammeenntt 44-- PPoosstteerriioorr ccrruucciiaattee lliiggaammeenntt aanndd ppoosstteerroollaatteerraall ccoommpplleexx 55-- PPoosstteerriioorr ccrruucciiaattee lliiggaammeenntt aanndd mmeeddiiaall ccoollllaatteerraall lliiggaammeenntt

QQUUEESSTTIIOONN 2277:: AA 2255--yyeeaarr--oolldd mmaann iiss ssttrruucckk bbyy aa mmoottoorr vveehhiiccllee aanndd ssuussttaaiinnss aann iinnjjuurryy ttoo tthhee rriigghhtt lloowweerr eexxttrreemmiittyy.. RRaaddiiooggrraapphhss sshhooww aa ppoosstteerriioorr ddiissllooccaattiioonn ooff tthhee kknneeee;; hhoowweevveerr,, eexxaammiinnaattiioonn rreevveeaallss tthhaatt tthhee lliimmbb iiss nneeuurroollooggiiccaallllyy iinnttaacctt.. IInniittiiaall mmaannaaggeemmeenntt ooff tthhee lliimmbb sshhoouulldd iinncclluuddee 11-- aapppplliiccaattiioonn ooff aann aabboovvee--kknneeee sspplliinntt 22-- aapppplliiccaattiioonn ooff aann eexxtteerrnnaall ffiixxaattoorr 33-- aann aarrtteerriiooggrraamm 44-- cclloosseedd rreedduuccttiioonn ooff tthhee kknneeee ddiissllooccaattiioonn 55-- ooppeenn rreedduuccttiioonn ooff tthhee kknneeee ddiissllooccaattiioonn

QQUUEESSTTIIOONN 2288:: TThhee iinncciiddeennccee ooff vvaassccuullaarr iinnjjuurryy aafftteerr aann aanntteerriioorr kknneeee ddiissllooccaattiioonn iiss 11-- lleessss tthhaann 55%% 22-- 1100 ttoo 2255%% 33-- 3300 ttoo 5500%% 44-- 6600 ttoo 8800%% 55-- ggrreeaatteerr tthhaann 9955%%

QQUUEESSTTIIOONN 2299:: AA 2266--yyeeaarr--oolldd mmaarraatthhoonn rruunnnneerr rreeppoorrttss llaatteerraall kknneeee ppaaiinn aafftteerr hhiillll ttrraaiinniinngg.. EExxaammiinnaattiioonn rreevveeaallss nnoo eeffffuussiioonn;; aanndd rreessuullttss ooff OObbeerr’’ss tteesstt aarree ppoossiittiivvee.. WWhhaatt iiss tthhee mmoosstt lliikkeellyy ddiiaaggnnoossiiss?? 11-- LLaatteerraall mmeenniissccaall tteeaarr 22-- PPoopplliitteeuuss tteennoossyynnoovviittiiss 33-- IIlliioottiibbiiaall bbaanndd ffrriiccttiioonn ssyynnddrroommee 44-- PPeerroonneeaall nneerrvvee eennttrraappmmeenntt 55-- BBiicceeppss tteennddiinniittiiss

QQUUEESSTTIIOONN 3300:: AA mmiiddddllee--aaggeedd wwoommaann wwhhoo rruunnss aabboouutt 3300 mmiilleess wweeeekkllyy oonn hhiillllyy tteerrrraaiinn iiss eevvaalluuaatteedd ffoorr aa sseevveerraall mmoonntthhss’’ hhiissttoorryy ooff llaatteerraall kknneeee ppaaiinn tthhaatt hhaass pprrooggrreessssiivveellyy wwoorrsseenneedd.. SShhee hhaass ppaaiinn wwiitthh wweeiigghhttbbeeaarriinngg oonn hheerr fflleexxeedd kknneeee aanndd ccoommppllaaiinnss ooff ddeeeepp llaatteerraall kknneeee ppaaiinn wwiitthh ttiibbiiaall rroottaattiioonn.. EExxaamm ccoonnffiirrmmss ddiiffffuussee llaatteerraall ppaaiinn aanndd nnoo lliiggaammeennttoouuss iinnssttaabbiilliittyy.. RRaaddiiooggrraapphhss aarree nnoorrmmaall.. TThhee pphhyyssiicciiaann sshhoouulldd rreeccoommmmeenndd 11-- aa llaatteerraall hheeeell wweeddggee 22-- aarrtthhrroossccooppyy 33-- nneeuuttrraall mmoolldd rruunnnniinngg oorrtthhoottiiccss 44-- iinnjjeeccttiioonn ooff sstteerrooiidd iinnttoo tthhee iilliioottiibbiiaall bbaanndd 55-- aa ssttrreettcchhiinngg aanndd ssttrreennggtthheenniinngg pprrooggrraamm

QQUUEESSTTIIOONN 3311:: WWhhaatt iiss tthhee mmoosstt ccoommmmoonn cclliinniiccaall iinnddiiccaattoorr ooff rreefflleexx ssyymmppaatthheettiicc ddyyssttrroopphhyy ooff tthhee kknneeee?? 11-- EEffffuussiioonn 22-- MMuussccllee aattrroopphhyy 33-- AAttrroopphhiicc hhaaiirr cchhaannggeess 44-- DDiisspprrooppoorrttiioonnaattee ppaaiinn 55-- DDeeccrreeaasseedd rraannggee ooff mmoottiioonn

QQUUEESSTTIIOONN 3322:: AA 3388--yyeeaarr--oolldd wwoommaann wwaass ttrreeaatteedd ssuurrggiiccaallllyy ffoorr aa ttrraannssvveerrssee ppaatteellllaarr ffrraaccttuurree 44 mmoonntthhss aaggoo.. TThhee ffrraaccttuurree iiss hheeaalleedd aanndd tthhee hhaarrddwwaarree iiss iinnttaacctt;; hhoowweevveerr,, sshhee nnooww rreeppoorrttss sseevveerree ddiiffffuussee ppaaiinn.. AAlltthhoouugghh sshhee hhaass ggaaiinneedd 6600oo ooff

fflleexxiioonn ssoooonn aafftteerr ssuurrggeerryy,, aanndd hheerr ppaaiinn wwaass iinniittiiaallllyy ttoolleerraabbllee,, sshhee nnooww hhaass ccoonnttiinnuuoouuss aanndd sseevveerree sseeaarriinngg ppaaiinn.. EExxaamm rreevveeaallss tthhaatt tthhee kknneeee iiss ccooooll ttoo ttoouucchh wwiitthh aa ssmmaallll eeffffuussiioonn.. RRaaddiiooggrraapphhss sshhooww oosstteeooppeenniiaa.. MMaannaaggeemmeenntt sshhoouulldd ccoonnssiisstt ooff 11-- aarrtthhrroossccooppiicc llyyssiiss ooff aaddhheessiioonnss 22-- aarrtthhrroossccooppiicc iirrrriiggaattiioonn aanndd ddeebbrriiddeemmeenntt 33-- iioonnoopphhoorreessiiss 44-- aa ssyymmppaatthheettiicc bblloocckk 55-- nneeuurroommaa rreesseeccttiioonn

QQUUEESSTTIIOONN 3333:: WWhhaatt iiss tthhee mmoosstt aapppprroopprriiaattee iinnddiiccaattiioonn ffoorr llaatteerraall rreettiinnaaccuullaarr rreelleeaassee iinn tthhee kknneeee?? 11-- DDiiffffuussee kknneeee ppaaiinn ffoolllloowwiinngg aarrtthhrroossccooppyy 22-- AAnntteerriioorr kknneeee ppaaiinn ffoolllloowwiinngg pphhyyssiiootthheerraappyy 33-- AAccuuttee ppaatteellllaarr ddiissllooccaattiioonn aassssoocciiaatteedd wwiitthh aann iinnccrreeaasseedd QQ aannggllee 44-- LLaatteerraall ppaatteellllaarr ccoommpprreessssiioonn ssyynnddrroommee ffoolllloowwiinngg pphhyyssiiootthheerraappyy aanndd aassssoocciiaatteedd llaatteerraall ppaatteellllaarr ssuubblluuxxaattiioonn 55-- LLaatteerraall ppaatteellllaarr ccoommpprreessssiioonn ssyynnddrroommee ffoolllloowwiinngg pphhyyssiiootthheerraappyy aanndd aassssoocciiaatteedd llaatteerraall ppaatteellllaarr ttiilltt

QQUUEESSTTIIOONN 3344:: AA 2211--yyeeaarr--oolldd wwoommaann hhaass hhaadd aanntteerriioorr kknneeee ppaaiinn ffoorr tthhee ppaasstt 44 wweeeekkss tthhaatt wwoorrsseennss wwhheenn sshhee ddeesscceennddss ssttaaiirrss aanndd ssqquuaattss.. EExxaammiinnaattiioonn sshhoowwss ppaatteellllaarr aapppprreehheennssiioonn aanndd mmeeddiiaall ffaacceett tteennddeerrnneessss;; hhoowweevveerr,, tthheerree iiss mmiinniimmaall eeffffuussiioonn,, ffuullll rraannggee ooff mmoottiioonn,, nnoo jjooiinnttlliinnee tteennddeerrnneessss,, aanndd ssttaabbllee lliiggaammeennttss.. TTrreeaattmmeenntt sshhoouulldd iinncclluuddee 11-- llaatteerraall rreettiinnaaccuullaarr rreelleeaassee 22-- ppaatteellllaarr tteennddoonn rreeaalliiggnnmmeenntt 33-- aarrtthhrroossccooppiicc ddeebbrriiddeemmeenntt ooff cchhoonnddrroommaallaacciiaa 44-- sshhoorrtt aarrcc ooppeenn cchhaaiinn qquuaaddrriicceeppss eexxeerrcciisseess 55-- sshhoorrtt aarrcc cclloosseedd cchhaaiinn qquuaaddrriicceeppss eexxeerrcciisseess

QQUUEESSTTIIOONN 3355:: AA 66--yyeeaarr--oolldd ggiirrll hhaass aann aarreeaa ooff ppaaiinnlleessss sswweelllliinngg iinn tthhee mmeeddiiaall ppoopplliitteeaall ffoossssaa tthhaatt iiss 44 ccmm iinn ddiiaammeetteerr.. AAssppiirraattiioonn rreevveeaallss tthhee sswweelllliinngg ttoo bbee ccoonnssiisstteenntt wwiitthh aa ppoopplliitteeaall BBaakkeerr’’ss ccyysstt,, aanndd tthhee ccyysstt ddiissaappppeeaarrss ffoolllloowwiinngg aassppiirraattiioonn.. TThhrreeee mmoonntthhss llaatteerr tthhee ccyysstt rreeccuurrss bbuutt iiss ssttiillll ppaaiinnlleessss.. WWhhaatt iiss tthhee aapppprroopprriiaattee ttrreeaattmmeenntt aatt tthhiiss ttiimmee?? 11-- EExxcciissiioonn 22-- OObbsseerrvvaattiioonn 33-- RReeppeeaatt aassppiirraattiioonn 44-- AAssppiirraattiioonn aanndd sstteerrooiidd iinnjjeeccttiioonn 55-- AAssppiirraattiioonn aanndd pphheennooll iinnjjeeccttiioonn

QQuueessttiioonn 3366:: AAnn 1188--yyeeaarr--oolldd ccoolllleeggiiaattee ffoooottbbaallll ppllaayyeerr ssuussttaaiinnss aa vvaarruuss ccoonnttaacctt iinnjjuurryy ttoo hhiiss rriigghhtt kknneeee.. HHiiss kknneeee wwaass ddiissllooccaatteedd aanndd rreedduucceedd oonn tthhee ffiieelldd.. HHiiss pphhyyssiiccaall eexxaammiinnaattiioonn rreevveeaalleedd aa ggrroossssllyy uunnssttaabbllee kknneeee wwiitthh lloossss ooff ppeerroonneeaall nneerrvvee ffuunnccttiioonn aanndd aa ddiimmiinniisshheedd ppuullssee.. WWhhaatt iiss tthhee mmoosstt aapppprroopprriiaattee nneexxtt sstteepp iinn mmaannaaggeemmeenntt ooff tthhiiss ppaattiieenntt?? 11.. AAddmmiissssiioonn ttoo tthhee hhoossppiittaall wwiitthh sseerriiaall nneeuurroovvaassccuullaarr cchheecckkss 22.. IIccee,, eelleevvaattiioonn,, bbrraaccee aanndd ffoollllooww--uupp aatt tthhee nneexxtt aavvaaiillaabbllee cclliinniicc 33.. EEmmeerrggeenntt vvaassccuullaarr ccoonnssuullttaattiioonn aanndd aannggiiooggrraamm 44.. MMRRII ttoo eevvaalluuaattee tthhee iinnjjuurryy 55.. IImmmmeeddiiaattee ssuurrggiiccaall rreeppaaiirr ooff ttoorrnn lliiggaammeennttss QQuueessttiioonn 3377:: AA 3322--yyeeaarr--oolldd rreeccrreeaattiioonnaall tteennnniiss ppllaayyeerr ccoommppllaaiinnss ooff cchhrroonniicc aanntteerriioorr kknneeee ppaaiinn.. PPhhyyssiiccaall eexxaammiinnaattiioonn sshhoowwss ppaatteellllooffeemmoorraall ccrreeppiitteennccee aanndd aa ssmmaallll eeffffuussiioonn.. MMeeddiiaall ppaatteellllaarr gglliiddee iiss 11++ aanndd tthheerree iiss aa ppoossiittiivvee JJ ssiiggnn dduurriinngg aaccttiivvee kknneeee eexxtteennssiioonn.. IImmaaggiinngg ssttuuddiieess ddeemmoonnssttrraattee llaatteerraall ppaatteellllooffeemmoorraall aarrtthhrroossiiss.. WWhhiicchh pprroocceedduurree iiss mmoosstt aapppprroopprriiaattee ffoorr mmaannaaggeemmeenntt ooff tthhiiss ppaattiieenntt?? 11.. LLaatteerraall rreelleeaassee aanndd ddiissttaall ttiibbiiaall ttuubbeerrccllee ttrraannssffeerr 22.. LLaatteerraall rreelleeaassee aanndd mmeeddiiaall ccaappssuullaarr sshhrriinnkkaaggee 33.. LLaatteerraall rreelleeaassee aanndd aanntteerroommeeddiiaall ttrraannssffeerr ooff tthhee ttiibbiiaall ttuubbeerrccllee 44.. LLaatteerraall rreelleeaassee 55.. LLaatteerraall rreelleeaassee aanndd mmeeddiiaall ppaatteellllooffeemmoorraall lliiggaammeenntt rreeccoonnssttrruuccttiioonn QQuueessttiioonn 3388:: AA 2222--yyeeaarr--oolldd pprrooffeessssiioonnaall ffoooottbbaallll ppllaayyeerr ssuussttaaiinnss aa bbllooww ttoo hhiiss aanntteerriioorr ttiibbiiaa.. PPhhyyssiiccaall eexxaammiinnaattiioonn sshhoowwss aa nneeggaattiivvee LLaacchhmmaann,, 22++ ppoosstteerriioorr ddrraawweerr,, aanndd nnoo iinnssttaabbiilliittyy ttoo vvaarruuss oorr vvaallgguuss ssttrreessss aatt 00 oorr 3300 ddeeggrreeeess.. TThheerree iiss nnoo iinnccrreeaassee iinn eexxtteerrnnaall rroottaattiioonn aatt 3300 ddeeggrreeeess.. WWhhaatt iiss tthhee mmoosstt aapppprroopprriiaattee ttrreeaattmmeenntt?? 11.. PPhhyyssiiccaall tthheerraappyy aanndd ddeellaayyeedd PPCCLL rreeccoonnssttrruuccttiioonn 22.. PPhhyyssiiccaall tthheerraappyy ffooccuussiinngg oonn hhaammssttrriinngg ssttrreennggtthheenniinngg aanndd nnoonn--ooppeerraattiivvee ttrreeaattmmeenntt 33.. IImmmmeeddiiaattee PPCCLL rreeccoonnssttrruuccttiioonn 44.. PPhhyyssiiccaall tthheerraappyy ffooccuussiinngg oonn qquuaaddrriicceeppss ssttrreennggtthheenniinngg aanndd nnoonn--ooppeerraattiivvee ttrreeaattmmeenntt

55.. AArrtthhrroossccooppiicc ddeebbrriiddeemmeenntt QQuueessttiioonn 3399:: aa 1177 yyeeaarr oolldd hhiigghh sscchhooooll ffoooottbbaallll ppllaayyeerr ssuussttaaiinneedd aa ccoonnttaacctt iinnjjuurryy aanndd llaannddeedd oonn aa fflleexxeedd kknneeee.. EExxaammiinnaattiioonn rreevveeaalleedd aa nneeggaattiivvee LLaacchhmmaann tteesstt.. HHee hhaadd iinnccrreeaasseedd eexxtteerrnnaall rroottaattiioonn,, vvaarruuss aanndd ppoosstteerriioorr ttrraannssllaattiioonn aatt 3300 ddeeggrreeeess tthhaatt ddeeccrreeaasseedd aatt 9900 ddeeggrreeeess fflleexxiioonn.. WWhhaatt iiss tthhee ssttrruuccttuurree mmoosstt lliikkeellyy iinnjjuurreedd?? 11.. PPoosstteerriioorr ccrruucciiaattee lliiggaammeenntt 22.. AAnntteerriioorr ccrruucciiaattee lliiggaammeenntt aanndd ppoosstteerriioorr ccrruucciiaattee lliiggaammeenntt 33.. PPoosstteerroollaatteerraall lliiggaammeenntt ccoommpplleexx 44.. PPoosstteerriioorr ccrruucciiaattee lliiggaammeenntt aanndd ppoosstteerroollaatteerraall lliiggaammeenntt ccoommpplleexx 55.. AAnntteerriioorr ccrruucciiaattee lliiggaammeenntt QQuueessttiioonn 4400:: WWhhiicchh ooff tthhee ffoolllloowwiinngg iiss aa ccoonnttrraaiinnddiiccaattiioonn ttoo iissoollaatteedd mmeenniissccaall rreeppaaiirr?? 11.. TTeeaarr oollddeerr tthhaann 66 wweeeekkss 22.. DDiissppllaacceedd bbuucckkeett hhaannddllee tteeaarr 33.. AAggee ggrreeaatteerr tthhaann 3300 44.. TTeeaarr lleennggtthh ggrreeaatteerr tthhaann 2200 mmmm 55.. AACCLL ddeeffiicciieennccyy QQuueessttiioonn 4411:: YYoouu aarree ddeevveellooppiinngg aa pprrooggrraamm ttoo ppootteennttiiaallllyy ddeeccrreeaassee rriisskk ooff AACCLL iinnjjuurriieess iinn yyoouurr ffeemmaallee ee ccoolllleeggee ssoocccceerr ppllaayyeerrss.. IIddeennttiiffyy aa ssttrraatteeggyy ttoo bbeesstt aacchhiieevvee tthhiiss ggooaall.. 11.. NNeeuurroommuussccuullaarr ttrraaiinniinngg pprrooggrraamm 22.. FFiitt ppllaayyeerrss wwiitthh pprroopphhyyllaaccttiicc kknneeee bbrraacceess 33.. OObbttaaiinn rraaddiiooggrraapphhiicc eevvaalluuaattiioonn ttoo aasssseessss ccrroossss--sseeccttiioonnaall aarreeaa ooff tthhee iinntteerrccoonnddyyllaarr nnoottcchh 44.. LLiimmiitt ppllaayy dduurriinngg lluutteeaall pphhaassee ooff mmeennssttrruuaall ccyyccllee 55.. IInnssttiittuuttee aaggggrreessssiivvee qquuaaddrriicceeppss ssttrreennggtthheenniinngg pprrooggrraamm QQuueessttiioonn 4422:: AA 2222--yyeeaarr--oolldd wwrreessttlleerr ssuussttaaiinnss aa ffiirrsstt--ttiimmee ppaatteellllaarr ddiissllooccaattiioonn.. EExxaammiinnaattiioonn rreevveeaallss tthhaatt sshhee hhaass aa 4400 cccc ttrraauummaattiicc hheemmaarrtthhrroossiiss.. WWhhaatt iiss tthhee mmoosstt ccoommmmoonn llooccaattiioonn ffoorr oosstteeoocchhoonnddrraall iinnjjuurryy dduuee ttoo aann aaccuuttee llaatteerraall ppaatteellllaarr ddiissllooccaattiioonn?? 11.. LLaatteerraall ppaatteellllaarr ffaacceett 22.. MMeeddiiaall ttrroocchhlleeaa 33.. LLaatteerraall ttrroocchhlleeaa 44.. CCeennttrraall ppaatteellllaarr rriiddggee 55.. MMeeddiiaall ppaatteellllaarr ffaacceett

QQuueessttiioonn 4433:: HHiissttoorriiccaallllyy,, tthhee HHaauusseerr pprroocceedduurree,, aa mmeeddiiaall ttiibbiiaall ttuubbeerrccllee ttrraannssffeerr,, wwaass ffrreeqquueennttllyy uusseedd ttoo ssuurrggiiccaallllyy ttrreeaatt ppaatteellllooffeemmoorraall ppaaiinn aanndd iinnssttaabbiilliittyy.. WWhhaatt rriisskk hhaass ccaauusseedd tthhiiss pprroocceedduurree ttoo bbee llaarrggeellyy aabbaannddoonneedd?? 11.. WWoouunndd hheeaalliinngg pprroobblleemmss 22.. PPoopplliitteeaall aarrtteerryy llaacceerraattiioonn 33.. CCoommppaarrttmmeenntt ssyynnddrroommee 44.. RReefflleexx ssyymmppaatthheettiicc ddyyssttrroopphhyy 55.. IInnccrreeaasseedd ppaatteellllooffeemmoorraall ccoonnttaacctt ffoorrccee QQuueessttiioonn 4444:: AA 1166--yyeeaarr--oolldd hhiigghh sscchhooooll ssoocccceerr ppllaayyeerr iinnjjuurreess hhiiss kknneeee wwhhiillee ppllaayyiinngg.. HHee ssttaatteess tthhaatt hhee ppllaanntteedd oonn hhiiss rriigghhtt kknneeee aanndd ccuutt ttoo hhiiss lleefftt,, aanndd ffeelltt aa ppoopp aanndd ddeevveellooppeedd mmeeddiiaall kknneeee ppaaiinn.. HHee ssttaatteess tthhaatt hhee hhaass nneevveerr iinnjjuurreedd tthhiiss kknneeee bbeeffoorree.. PPhhyyssiiccaall eexxaammiinnaattiioonn sseevveerraall hhoouurrss llaatteerr sshhoowwss aa mmooddeerraattee eeffffuussiioonn aanndd mmeeddiiaall kknneeee tteennddeerrnneessss.. TThhee ppaattiieenntt hhaass ffuullll kknneeee eexxtteennssiioonn,, bbuutt fflleexxeess oonnllyy ttoo 2200.. FFuurrtthheerr eexxaammiinnaattiioonn iiss ccoommpprroommiisseedd bbyy ppaaiinn,, aapppprreehheennssiioonn aanndd gguuaarrddiinngg;; LLaacchhmmaann tteesstt iiss eeqquuiivvooccaall.. TThheerree iiss nnoo vvaarruuss oorr vvaallgguuss llaaxxiittyy,, bbuutt ddiiffffuussee ppaaiinn oovveerr tthhee mmeeddiiaall ssiiddee ooff tthhee kknneeee.. AAssppiirraattiioonn iiss ddoonnee aanndd rreevveeaallss 3300 cccc ooff bbllooooddyy eeffffuussiioonn wwiitthhoouutt ffaatt ddrroopplleettss,, bbuutt ffuurrtthheerr eexxaammiinnaattiioonn rreemmaaiinnss ccoommpprroommiisseedd bbyy ppaaiinn aanndd gguuaarrddiinngg.. XX--rraayyss aarree nnoorrmmaall.. WWhhaatt iiss tthhee mmoosstt lliikkeellyy ddiiaaggnnoossiiss?? 11.. OOsstteeoocchhoonnddrraall ffrraaccttuurree 22.. RRuuppttuurree ooff tthhee MMPPFFLL 33.. AACCLL rruuppttuurree 44.. PPCCLL rruuppttuurree 55.. MMCCLL iinnjjuurryy QQuueessttiioonn 4455:: AA 2299 yyeeaarr oolldd mmaallee ssuussttaaiinnss ccoommpplleettee AACCLL tteeaarr ppllaayyiinngg rreeccrreeaattiioonnaall bbaasskkeettbbaallll.. AAtt tthhee ttiimmee ooff rreeccoonnssttrruuccttiioonnss uussiinngg ppaatteellllaarr tteennddoonn bboonnee aauuttooggrraafftt,, aa llaatteerraall ffeemmoorraall ccoonnddyyllee ffuullll tthhiicckknneessss cchhoonnddrraall lleessiioonn mmeeaassuurriinngg 11..55 ccmm bbyy 11..55 ccmm iiss iiddeennttiiffiieedd.. HHee hhaass iinnttaacctt mmeenniissccii aanndd tthhee ccaarrttiillaaggee lleessiioonn iiss nnoott ttrreeaatteedd.. YYoouu sseeee tthhee ppaattiieenntt 88 yyeeaarrss llaatteerr.. CCoommppaarreedd ttoo aa ssiimmiillaarr AACCLL rreeccoonnssttrruucctteedd ppaattiieenntt wwiitthhoouutt cchhoonnddrraall iinnjjuurryy,, wwhhaatt wwoouulldd yyoouu eexxppeecctt ffoorr yyoouurr ppaattiieenntt.. 11.. BBee aabbllee ttoo ppeerrffoorrmm tthhee ssaammee aaccttiivviittiieess wwiitthh mmiinniimmaallllyy mmoorree ssyymmppttoommss 22.. HHaavvee aa hhiigghheerr rriisskk ooff rreeccuurrrreenntt kknneeee iinnssttaabbiilliittyy

33.. BBee aa ccaannddiiddaattee ffoorr rreeaalliiggnnmmeenntt//rreeccoonnssttrruuccttiivvee ssuurrggeerryy ((oosstteeoottoommyy oorr ttoottaall kknneeee rreeppllaacceemmeenntt)) 44.. RReemmaaiinn tthhee ssaammee wwiitthh aann iinnccrreeaasseedd rriisskk ooff aa ssuubbsseeqquueenntt mmeenniissccaall tteeaarr 55.. BBee mmuucchh mmoorree ssyymmppttoommaattiicc wwiitthh lliimmiittaattiioonn iinn ddaaiillyy aaccttiivviittiieess QQuueessttiioonn 4466:: YYoouu aarree ppeerrffoorrmmiinngg aa PPCCLL rreeccoonnssttrruuccttiivvee ssuurrggeerryy oonn aa hhiigghh sscchhooooll ffoooottbbaallll ppllaayyeerr uussiinngg aa ssiinnggllee bbuunnddllee tteecchhnniiqquuee.. WWhhaatt iiss tthhee bbeesstt ppoossiittiioonn ttoo tteennssiioonn tthhee PPCCLL ggrraafftt wwhheenn rreeccoonnssttrruuccttiinngg tthhee aanntteerroollaatteerraall bbuunnddllee?? 11.. 4455 ddeeggrreeeess ooff fflleexxiioonn 22.. ffuullll fflleexxiioonn 33.. ffuullll eexxtteennssiioonn 44.. 3300 ddeeggrreeeess ooff fflleexxiioonn 55.. 9900 ddeeggrreeeess ooff fflleexxiioonn QQuueessttiioonn 4477:: AA 3300 yyeeaarr oolldd tteeaacchheerr iiss sseeeenn ffoorr rreeccuurrrreenntt ppaatteellllaarr iinnssttaabbiilliittyy.. AAfftteerr ccaarreeffuull hhiissttoorryy,, yyoouu pprroocceeeedd ttoo pphhyyssiiccaall eexxaammiinnaattiioonn.. WWhhaatt iiss tthhee ssiiggnniiffiiccaannccee ooff tthhee ““TTuubbeerrccllee SSuullccuuss AAnnggllee”” ((aallssoo kknnoowwnn aass SSeeaatteedd QQ aannggllee))?? 11.. IItt iiss aa mmeeaassuurree ooff llaatteerraall ddiissppllaacceemmeenntt ooff tthhee ttiibbiiaall ttuubbeerrccllee wwiitthh rreeffeerreennccee ttoo tthhee ffeemmoorraall ssuullccuuss 22.. IItt iiss aa mmeeaassuurree ooff tthhee mmeecchhaanniiccaall aaxxiiss ooff tthhee lloowweerr eexxttrreemmiittyy 33.. IItt iiss aa mmeeaassuurree ooff llaatteerraall ppaatteellllaarr ttiilltt 44.. IItt iiss aa mmeeaassuurree ooff ppaatteellllaarr hheeiigghhtt 55.. IItt iiss aa mmeeaassuurree ooff ffeemmoorraall aanntteevveerrssiioonn QQuueessttiioonn 4488:: AA hhiigghh sscchhooooll ffoorr wwhhiicchh yyoouu aarree tthhee tteeaamm pphhyyssiicciiaann iiss ssttaarrttiinngg uupp aann iinntteerrsscchhoollaassttiicc ffoooottbbaallll pprrooggrraamm.. TThhee hheeaadd aatthhlleettiicc ttrraaiinneerr ccoommeess ttoo yyoouu ffoorr yyoouurr ooppiinniioonn oonn pprroopphhyyllaaccttiicc kknneeee bbrraaccee uussee iinn tthhee ppllaayyeerrss.. WWhhaatt aaddvviiccee wwoouulldd yyoouu ggiivvee ttoo tthhee ttrraaiinneerr.. 11.. PPrroopphhyyllaaccttiicc kknneeee bbrraacceess mmaayy bbee hheellppffuull ffoorr iinntteerriioorr lliinneemmaann aanndd lliinneebbaacckkeerrss,, aalltthhoouugghh ssiiggnniiffiiccaanntt ccoonnttrroovveerrssyy eexxiissttss rreeggaarrddiinngg iittss eeffffiiccaaccyy 22.. PPrroopphhyyllaaccttiicc kknneeee bbrraacceess aarree ddeeffiinniitteellyy nnoott hheellppffuull iinn rreedduucciinngg tthhee rriisskk ooff kknneeee iinnjjuurriieess aanndd mmaayy eevveenn bbee hhaarrmmffuull ttoo tthhee ppllaayyeerrss..

33.. PPrroopphhyyllaaccttiicc kknneeee bbrraacceess mmaayy bbee hheellppffuull ffoorr aallll ooff tthhee ppllaayyeerrss ttoo ddeeccrreeaassee tthhee rriisskk ooff kknneeee iinnjjuurryy,, ppaarrttiiccuullaarrllyy ttoo tthhee mmeeddiiaall ccoollllaatteerraall lliiggaammeenntt 44.. PPrroopphhyyllaaccttiicc kknneeee bbrraacceess aarree ppaarrttiiccuullaarrllyy uusseeffuull ffoorr rruunnnniinngg bbaacckkss aanndd lliinneebbaacckkeerrss,, wwhhoossee kknneeeess aarree oofftteenn ttaarrggeettss ffoorr ttaacckklliinngg aanndd cchhoopp bblloocckkiinngg 55.. PPrroopphhyyllaaccttiicc kknneeee bbrraacceess sshhoouulldd bbee uusseedd ffoorr aallll iinntteerriioorr lliinneemmaann,, aass ddeeffiinniittiivvee eevviiddeennccee iinn wweellll ddeessiiggnneedd cclliinniiccaall ssttuuddiieess rreeccoommmmeennddss tthheeiirr uussee QQuueessttiioonn 4499:: AA 1166 yyeeaarr oolldd cchheeeerrlleeaaddeerr ssuussttaaiinnss aa ppaatteellllaarr ddiissllooccaattiioonn.. AA ddiissccuussssiioonn iiss ccaarrrriieedd oouutt wwiitthh tthhee ppaarreennttss rreeggaarrddiinngg tthhee pprrooggnnoossiiss.. WWhhaatt iiss tthhee ssiinnggllee mmoosstt ssiiggnniiffiiccaanntt ffaaccttoorr pprreeddiiccttiinngg rriisskk ooff rreeccuurrrreenntt ppaatteellllaarr iinnssttaabbiilliittyy aafftteerr aa ttrraauummaattiicc ppaatteellllaarr ddiissllooccaattiioonn?? 11.. MMRRII eevviiddeennccee ooff MMPPFFLL iinnjjuurryy 22.. AAggee 33.. GGeennddeerr 44.. EElleevvaatteedd QQ aannggllee 55.. PPrreevviioouuss ppaatteellllooffeemmoorraall iinnssttaabbiilliittyy eeppiissooddeess QQuueessttiioonn 5500:: AA 2222 yyeeaarr oolldd ffeemmaallee sskkiieerr hhaass sseevveerree aanntteerriioorr kknneeee ppaaiinn ooff oonnee yyeeaarr dduurraattiioonn wwhhiicchh hhaass ffaaiilleedd nnoonn--ooppeerraattiivvee ttrreeaattmmeenntt.. WWhhaatt iiss tthhee bbeesstt iinnddiiccaattiioonn ffoorr llaatteerraall rreettiinnaaccuullaarr rreelleeaassee?? 11.. PPaatteellllaarr ssuubblluuxxaattiioonn 22.. RReeccuurrrreenntt ppaatteellllaarr ddiissllooccaattiioonn 33.. MMeeddiiaall ppaatteellllaarr cchhoonnddrraall lleessiioonn 44.. PPaaiinnffuull iinnffrraappaatteellllaarr ccoonnttrraaccttuurree 55.. PPaaiinnffuull ppaatteellllaarr ttiilltt QQuueessttiioonn 5511:: AA 1177 yyeeaarr oolldd qquuaarrtteerrbbaacckk ssuussttaaiinneedd aa lleefftt kknneeee iinnjjuurryy aafftteerr bbeeiinngg ttaacckklleedd ffiivvee ddaayyss aaggoo.. YYoouu ssuussppeecctt aa ppoosstteerroollaatteerraall ccoorrnneerr iinnjjuurryy.. WWhhaatt iiss tthhee mmoosstt aaccccuurraattee pphhyyssiiccaall eexxaammiinnaattiioonn tteesstt ttoo ccoonnffiirrmm yyoouurr ddiiaaggnnoossiiss.. 11.. IInnccrreeaasseedd ppoosstteerriioorr ttiibbiiaall ttrraannssllaattiioonn aatt 9900 ddeeggrreeeess ooff kknneeee fflleexxiioonn 22.. PPoossiittiivvee ppiivvoott sshhiifftt tteesstt 33.. AAssyymmmmeettrriiccaall ttiibbiiaall eexxtteerrnnaall rroottaattiioonn aatt 3300 ddeeggrreeeess ooff kknneeee fflleexxiioonn 44.. AAssyymmmmeettrriiccaall ttiibbiiaall iinntteerrnnaall rroottaattiioonn aatt 3300 ddeeggrreeeess ooff kknneeee fflleexxiioonn 55.. EExxcceessssiivvee vvaallgguuss llaaxxiittyy aatt 3300 ddeeggrreeeess ooff kknneeee fflleexxiioonn QQuueessttiioonn 5522:: AA 3355 yyeeaarr oolldd rruunnnneerr ssuussttaaiinneedd aa PPCCLL iinnjjuurryy 1155 yyeeaarrss aaggoo wwhhiicchh wwaass ttrreeaatteedd nnoonn--ooppeerraattiivveellyy.. TThhee aatthhlleettee nnooww pprreesseennttss wwiitthh kknneeee ppaaiinn.. WWhheerree iinn tthhee kknneeee wwoouulldd yyoouu mmoosstt lliikkeellyy ffiinndd ddeeggeenneerraattiivvee cchhaannggeess?? 11.. PPaatteellllooffeemmoorraall aanndd mmeeddiiaall ccoommppaarrttmmeennttss 22.. MMeeddiiaall ccoommppaarrttmmeenntt 33.. LLaatteerraall ccoommppaarrttmmeenntt 44.. PPaatteellllooffeemmoorraall aanndd llaatteerraall ccoommppaarrttmmeennttss

55.. MMeeddiiaall aanndd llaatteerraall ccoommppaarrttmmeennttss QQuueessttiioonn 5533:: OOsstteeoocchhoonnddrraall aauuttooggrraafftt ttrraannssppllaannttaattiioonn hhaass bbeeccoommee aa ttrreeaattmmeenntt ooppttiioonn ffoorr ssoommee ssyymmppttoommaattiicc iissoollaatteedd cchhoonnddrraall iinnjjuurriieess iinn tthhee kknneeee.. IInn aann eeffffoorrtt ttoo ddiimmiinniisshh ddoonnoorr ssiittee mmoorrbbiiddiittyy,, yyoouu wwoouulldd lliikkee ttoo hhaarrvveesstt ccaarrttiillaaggee ffrroomm tthhee aarreeaa ooff lloowweesstt ccoonnttaacctt pprreessssuurree.. WWhhaatt iiss tthhee aarreeaa wwiitthh tthhee lloowweesstt ccoonnttaacctt pprreessssuurree.. 11.. IInnffeerroollaatteerraall ttrroocchhlleeaa 22.. SSuuppeerriioorr aassppeecctt ooff tthhee iinntteerrccoonnddyyllaarr nnoottcchh 33.. SSuuppeerriioorr mmaarrggiinn ooff tthhee ffeemmoorraall ttrroocchhlleeaa 44.. MMeeddiiaall ffeemmoorraall ttrroocchhlleeaa 55.. SSuuppeerroollaatteerraall ttrroocchhlleeaa QQuueessttiioonn 5544:: YYoouu aarree ppeerrffoorrmmiinngg aa rreevviissiioonn AACCLL rreeccoonnssttrruuccttiioonn iinn aa 1177 yyeeaarr oolldd ffeemmaallee bbaasskkeettbbaallll ppllaayyeerr.. WWhhaatt iiss tthhee mmoosstt ccoommmmoonn tteecchhnniiccaall eerrrroorr aassssoocciiaatteedd wwiitthh AACCLL ggrraafftt ffaaiilluurree?? 11.. IInnssuuffffiicciieenntt ggrraafftt mmaatteerriiaall 22.. IInnaaddeeqquuaattee ggrraafftt ffiixxaattiioonn 33.. IInnaaddeeqquuaattee nnoottcchhppllaassttyy 44.. NNoonnaannaattoommiicc ttuunnnneell ppllaacceemmeenntt 55.. IImmpprrooppeerr ggrraafftt tteennssiioonn QQuueessttiioonn 5555:: AA sskkeelleettaallllyy iimmmmaattuurree 1133 yyeeaarr oolldd ddeevveellooppeedd aa hheemmaarrtthhrroossiiss aanndd nneeww oonnsseett ooff kknneeee ppaaiinn oonnee wweeeekk aaggoo ffrroomm aa ffoooottbbaallll iinnjjuurryy.. RRaaddiiooggrraapphhss rreevveeaall aa lloooossee bbooddyy aanndd pprroobbaabbllee oosstteeoocchhoonnddrraall lleessiioonn ooff tthhee llaatteerraall ffeemmoorraall ccoonnddyyllee.. DDuurriinngg aarrtthhrroossccooppiicc eevvaalluuaattiioonn aa 11..55 xx 22 ccmm oosstteeoocchhoonnddrraall ddeeffeecctt iiss iiddeennttiiffiieedd aatt tthhee llaatteerraall ffeemmoorraall ccoonnddyyllee.. TThhee lloooossee bbooddyy ccoonnttaaiinnss aarrttiiccuullaarr ccaarrttiillaaggee aanndd ssuubbcchhoonnddrraall bboonnee.. WWhhaatt iiss tthhee pprrooppeerr ttrreeaattmmeenntt?? 11.. PPeerrffoorrmm rreettrrooggrraaddee ddrriilllliinngg aatt tthhee bbaassee ooff tthhee oosstteeoocchhoonnddrraall lleessiioonn 22.. RReemmoovvee tthhee lloooossee bbooddyy aanndd hhaarrvveesstt aarrttiiccuullaarr ccaarrttiillaaggee ffoorr llaatteerr ccaarrttiillaaggee ttrraannssppllaannttaattiioonn 33.. RReemmoovvee tthhee lloooossee bbooddyy aanndd ddeebbrriiddee tthhee bbaassee ooff tthhee lleessiioonn 44.. PPeerrffoorrmm aannaattoommiicc rreedduuccttiioonn aanndd iinntteerrnnaall ffiixxaattiioonn ooff ffrraaggmmeenntt iinn tthhee ddeeffeecctt 55.. PPeerrffoorrmm aanntteerrooggrraaddee ddrriilllliinngg aatt tthhee bbaassee ooff tthhee lleessiioonn QQuueessttiioonn 5566:: AArrtthhrroossccooppiicc llaatteerraall rreelleeaassee iiss oofftteenn ppeerrffoorrmmeedd aass ttrreeaattmmeenntt ffoorr tthhee ppaaiinnffuull oorr uunnssttaabbllee ppaatteellllooffeemmoorraall jjooiinntt,, eeiitthheerr aass aann iissoollaatteedd pprroocceedduurree oorr aass ppaarrtt ooff aa llaarrggeerr ooppeerraattiioonn.. CCuuttttiinngg tthhee rreettiinnaaccuulluumm ttoooo ssuuppeerriioorrllyy mmaayy bbee aassssoocciiaatteedd wwiitthh wwhhaatt ccoonnddiittiioonn?? 11.. IInnjjuurryy ttoo tthhee llaatteerraall ssuuppeerriioorr ggeenniiccuullaattee aarrtteerryy 22.. RReeccuurrrreenntt llaatteerraall ppaatteellllaarr ssuubblluuxxaattiioonn 33.. PPaatteellllaa bbaajjaa 44.. LLoossss ooff kknneeee mmoottiioonn

55.. MMeeddiiaall ssuubblluuxxaattiioonn ooff tthhee ppaatteellllaa QQuueessttiioonn 5577:: AA 2299 yyeeaarr oolldd mmoottoorrccyycclliisstt ssuussttaaiinnss aann iissoollaatteedd aavvuullssiioonn ffrraaccttuurree ooff tthhee PPCCLL ttiibbiiaall iinnsseerrttiioonn.. YYoouu ppllaann aann ooppeenn ppoosstteerroommeeddiiaall aapppprrooaacchh.. HHooww ddooeess tthhee ssuurrggeeoonn pprrootteecctt tthhee ppoosstteerriioorr nneeuurroovvaassccuullaarr bbuunnddllee?? 11.. DDiirreecctt vviissuuaalliizzaattiioonn aanndd ggeennttllee rreettrraaccttiioonn mmeeddiiaallllyy 22.. DDiirreecctt vviissuuaalliizzaattiioonn aanndd ggeennttllee rreettrraaccttiioonn llaatteerraallllyy 33.. RReettrraaccttiioonn ooff tthhee mmeeddiiaall hheeaadd ooff tthhee ggaassttrrooccnneemmiiuuss mmuussccllee mmeeddiiaallllyy 44.. RReettrraaccttiioonn ooff tthhee sseemmiimmeemmbbrraannoossuuss mmuussccllee mmeeddiiaallllyy 55.. RReettrraaccttiioonn ooff tthhee mmeeddiiaall hheeaadd ooff tthhee ggaassttrrooccnneemmiiuuss mmuussccllee llaatteerraallllyy QQuueessttiioonn 5588:: AA 2299 yyeeaarr oolldd mmaallee pprreesseennttss ttoo yyoouurr ooffffiiccee ccoommppllaaiinniinngg ooff rreeccuurrrreenntt kknneeee iinnssttaabbiilliittyy ffoolllloowwiinngg hhaammssttrriinngg AACCLL rreeccoonnssttrruuccttiioonn ddoonnee 22 yyeeaarrss pprreevviioouussllyy.. HHee hhaass nnoott bbeeeenn aabbllee ttoo rreettuurrnn ttoo ssppoorrttss,, aanndd nnootteess iinnssttaabbiilliittyy eevveenn wwiitthh wwaallkkiinngg.. HHee nnootteess nnoo hhiissttoorryy ooff ttrraauummaa ssiinnccee hhiiss iinniittiiaall rreeccoonnssttrruuccttiioonn.. PPhhyyssiiccaall eexxaammiinnaattiioonn rreevveeaallss aa 33++ LLaacchhmmaann wwiitthh aa ssoofftt eennddppooiinntt,, aa 22++ ppiivvoott sshhiifftt wwiitthh gguuaarrddiinngg,, 33++ rreevveerrssee ppiivvoott sshhiifftt,, aanndd nnoo iinnssttaabbiilliittyy wwiitthh vvaarruuss oorr vvaallgguuss ssttrreessss tteessttiinngg.. DDiiaall tteessttiinngg rreevveeaallss 1100 ddeeggrreeeess ooff iinnccrreeaasseedd eexxtteerrnnaall rroottaattiioonn aatt 3300 ddeeggrreeeess tthhaatt iimmpprroovveess aatt 9900 ddeeggrreeeess.. GGaaiitt rreevveeaallss aa vvaarruuss tthhrruusstt.. LLoonngg lleegg aalliiggnnmmeenntt ffiillmmss rreevveeaallss 44 ddeeggrreeeess ooff vvaarruuss mmeecchhaanniiccaall aalliiggnnmmeenntt ssyymmmmeettrriiccaall ttoo hhiiss ccoonnttrraallaatteerraall,, uunniinnvvoollvveedd lliimmbb.. WWhhaatt iiss tthhee mmoosstt aapppprroopprriiaattee mmaannaaggeemmeenntt ffoorr tthhiiss ppaattiieenntt.. 11.. PPoosstteerroollaatteerraall ccoorrnneerr rreeccoonnssttrruuccttiioonn 22.. HHiigghh ttiibbiiaall oosstteeoottoommyy 33.. RReevviissiioonn AACCLL rreeccoonnssttrruuccttiioonn 44.. PPoosstteerroollaatteerraall ccoorrnneerr rreeppaaiirr 55.. PPCCLL rreeccoonnssttrruuccttiioonn

QQuueessttiioonn 5599:: AA 3300 yyeeaarr oolldd jjoocckkeeyy ffaaiilleedd mmiiccrrooffrraaccttuurree tteecchhnniiqquuee ffoorr aa 33xx 44 ccmm bbaarr bboonnee aarrttiiccuullaarr ccaarrttiillaaggee lleessiioonn ooff tthhee mmeeddiiaall ffeemmoorraall ccoonnddyyllee.. SSuurrggiiccaall ttrreeaattmmeenntt iiss ppllaannnneedd.. WWhhaatt wwoouulldd bbee tthhee mmoosstt aapppprroopprriiaattee ttrreeaattmmeenntt ffoorr tthhiiss lleessiioonn?? 11.. OOsstteeoocchhoonnddrraall aallllooggrraafftt 22.. OOsstteeoocchhoonnddrraall aauuttooggrraafftt 33.. LLaavvaaggee aanndd ddeebbrriiddeemmeenntt 44.. AAbbrraassiioonn cchhoonnddrrooppllaassttyy 55.. RReeppeeaatt mmiiccrrooffrraaccttuurree QQuueessttiioonn 6600:: AA 3322 yyeeaarr oolldd bbeeaacchh vvoolllleeyybbaallll ppllaayyeerr hhaass aann aarrttiiccuullaarr ccaarrttiillaaggee lleessiioonn ooff bbaarree bboonnee mmeeaassuurriinngg 11ccmm22 aatt kknneeee aarrtthhrroossccooppyy.. TThhee ddeecciissiioonn iiss mmaaddee ttoo ppeerrffoorrmm aa mmiiccrrooffrraaccttuurree tteecchhnniiqquuee.. WWhhaatt iiss tthhee mmoosstt iimmppoorrttaanntt tteecchhnniiccaall sstteepp iinn tthhiiss tteecchhnniiqquuee?? 11.. TThhee ccaallcciiffiieedd ccaarrttiillaaggee llaayyeerr mmuusstt bbee rreemmoovveedd 22.. TThhee aapppprroopprriiaattee hhoollee ddeepptthh iiss ggrreeaatteerr tthhaann 44 mmmm 33.. TThhee hhoolleess sshhoouulldd bbee mmaaddee lleessss tthhaann 22 mmmm aappaarrtt 44.. FFaatt ddrroopplleettss sshhoouulldd nnoott bbee sseeeenn ccoommiinngg ffrroomm tthhee aawwll hhoolleess 55.. TThhee pprroocceedduurree mmuusstt bbee ddoonnee wwiitthhoouutt aa ttoouurrnniiqquueett QQuueessttiioonn 6611:: AAnn 1111 yyeeaarr oolldd bbooyy ffaallllss ooffff hhiiss bbiikkee ssuussttaaiinniinngg tthhee iinnjjuurryy ddeeppiicctteedd iinn tthhee ffiigguurreess.. FFiigguurree 11:: LLaatteerraall KKnneeee XXrraayy:: PPhhyysseess ooppeenn.. DDiissppllaacceedd aanntteerriioorr ttiibbiiaall ssppiinnee ffrraaccttuurree,, aanngglleedd 4455 ddeeggrreeeess uuppwwaarrddss.. FFiigguurree 22:: AAPP KKnneeee XXrraayy:: TTiibbiiaall ssppiinnee ffrraaccttuurree,, wwiitthh eelleevvaattiioonn aapppprrooxxiimmaatteellyy 8800%% ooff hheeiigghhtt ooff ttiibbiiaall ssppiinnee.. 11.. AArrtthhrroossccooppiicc AACCLL RReeccoonnssttrruuccttiioonn 22.. RReedduuccttiioonn aanndd ffiixxaattiioonn ooff tthhee ffrraaccttuurree 33.. CCaasstt,, nnoonn wweeiigghhtt bbeeaarriinngg ffoorr ssiixx wweeeekkss 44.. CCyylliinnddeerr wweeiigghhtt bbeeaarriinngg ccaasstt ffoorr ttwwoo wweeeekkss 55.. BBrraaccee,, wweeiigghhtt bbeeaarriinngg aass ttoolleerraatteedd ffoorr ssiixx wweeeekkss QQuueessttiioonn 6622:: AA 3399 yyeeaarr oolldd ffeemmaallee vvoolllleeyybbaallll ppllaayyeerr ccoommppllaaiinnss ooff aaccuuttee eexxaacceerrbbaattiioonn ooff cchhrroonniicc aanntteerriioorr kknneeee ppaaiinn aafftteerr aa rreecceenntt ttoouurrnnaammeenntt.. FFiigguurree 11:: TT22 MMRRII,, ffaatt ssaatt,, SSaaggiittttaall ccuutt ooff kknneeee ddeemmoonnssttrraatteess eeddeemmaa wwiitthhiinn tthhee iinnffeerriioorr ppoollee ooff tthhee ppaatteellllaa aanndd pprrooxxiimmaall ppaatteellllaarr tteennddoonn.. FFiigguurree 22:: TT22 MMRRII,, ffaatt ssaatt,, SSaaggiittttaall ccuutt ooff kknneeee ddeemmoonnssttrraatteess ffooccaall eeddeemmaa wwiitthhiinn tthhee pprrooxxiimmaall,, ppoosstteerriioorr 5500%% ooff tthhee ppaatteellllaarr tteennddoonn.. MMiilldd ffaatt ppaadd eeddeemmaa..

FFiigguurree 33:: TT22 MMRRII,, ffaatt ssaatt,, AAxxiiaall ccuutt ooff kknneeee ddeemmoonnssttrraatteess ffooccaall ssiiggnnaall cchhaannggee ooff tthhee cceennttrraall 2255%% ooff tthhee ppaatteellllaarr tteennddoonn.. WWiitthh wwhhiicchh ppaatthhoopphhyyssiioollooggiicc ffiinnddiinngg ddoo tthhee MMRRIIss sshhoowwnn ccoorrrreellaattee bbeesstt?? 11.. TThhee iinnjjuurreedd ttiissssuuee mmaaiinnttaaiinnss iittss nnoorrmmaall rreefflleeccttiivvee aappppeeaarraannccee uunnddeerr ppoollaarriizzeedd lliigghhtt.. 22.. TThhee llooccaattiioonn ooff tthhee pprroocceessss iiss ttyyppiiccaallllyy iinn tthhee aanntteerriioorr ppoorrttiioonn ooff tthhee ppaatteellllaarr tteennddoonn aaddjjaacceenntt ttoo iinnsseerrttiioonn oonn tthhee ttiibbiiaa.. 33.. TThhee uunnddeerrllyyiinngg ppaatthhoollooggiicc pprroocceessss ooff tthhiiss ccoonnddiittiioonn iiss pprriimmaarriillyy ddeeggeenneerraattiivvee iinn nnaattuurree.. 44.. AAvvaassccuullaarr hhyyppoocceelllluullaarriittyy iiss aa ccoonnssiisstteenntt ffiinnddiinngg wwiitthh tthhiiss pprroocceessss.. 55.. TThhee uunnddeerrllyyiinngg ppaatthhoollooggiicc pprroocceessss ooff tthhiiss ccoonnddiittiioonn iiss pprriimmaarriillyy iinnffllaammmmaattoorryy iinn nnaattuurree.. QQuueessttiioonn 6633:: AA 2200 yyeeaarr oolldd ffeemmaallee ccrroossss ccoouunnttrryy rruunnnneerr iiss sseeeenn iinn cclliinniicc ffoorr ppaaiinn oovveerr tthhee mmeeddiiaall ssiiddee ooff hheerr rriigghhtt kknneeee tthhaatt iinnccrreeaasseess wwiitthh aaccttiivviittyy.. TThhiiss 55’’55””,, 111166 ppoouunndd rruunnnneerr ccoommppllaaiinnss ooff ppaaiinn iinn hheerr rriigghhtt kknneeee wwiitthh wwaallkkiinngg.. TThheerree iiss ppaaiinn ttoo ppaallppaattiioonn oovveerr tthhee mmeeddiiaall aassppeecctt ooff hheerr kknneeee.. SShhee hhaass nnoo kknneeee eeffffuussiioonn.. RRaaddiiooggrraapphhss aarree sshhoowwnn.. FFiigguurree 11:: AAPP XXRR ooff tthhee kknneeee sshhoowwss nnoo eevviiddeennccee ooff ffrraaccttuurree.. OOssttooppeenniiaa ccaann nnoott bbee rruulleedd oouutt.. FFiigguurree 22:: LLaatteerraall XXRR ooff tthhee kknneeee sshhoowwss nnoo eevviiddeennccee ooff ffrraaccttuurree.. NNoo ppaatteellllaa aallttaa oorr bbaajjaa.. WWhhaatt wwoouulldd yyoouu aaddvviissee?? 11.. IInnjjeeccttiioonn ooff tthhee ppeess aannsseerriinnee bbuurrssaa.. 22.. MMRRII pprriioorr ttoo rreessuummiinngg aaccttiivviittyy.. 33.. SSppoorrttss ccrreeaamm aapppplliieedd ttoo tthhee aarreeaa,, ssttrreettcchheess aanndd ppllyyoommeettrriicc eexxeerrcciisseess.. 44.. DDoouubbllee uupprriigghhtt bbrraaccee,, oorrtthhoottiiccss,, aanndd aannttii--iinnffllaammmmaattoorryy.. 55.. DDoouubbllee ccoonnttrraasstt aarrtthhrrooggrraamm.. QQuueessttiioonn 6644:: AAfftteerr tthhee ppoosstteerriioorr ccrruucciiaattee lliiggaammeenntt iiss ccoommpplleetteellyy sseeccttiioonneedd iinn tthhee ccaaddaavveerriicc kknneeee,, wwhhaatt aabbnnoorrmmaall mmoottiioonn hhaass bbeeeenn ddeessccrriibbeedd?? 11.. PPoosstteerriioorr ttiibbiiaall ttrraannssllaattiioonn iiss iinnddeeppeennddeenntt ooff ootthheerr sseeccttiioonneedd lliiggaammeennttss.. 22.. PPoosstteerriioorrii ttiibbiiaall ttrraannssllaattiioonn iiss iinnddeeppeennddeenntt ooff fflleexxiioonn aannggllee.. 33.. PPoosstteerriioorr ttiibbiiaall ttrraannssllaattiioonn iiss ggrreeaatteesstt aatt hhiigghh fflleexxiioonn aanngglleess.. 44.. PPoosstteerriioorr ttiibbiiaall ttrraannssllaattiioonn iiss ggrreeaatteesstt nneeaarr ffuullll eexxtteennssiioonn.. 55.. TToottaall aanntteerriioorr aanndd ppoosstteerriioorr ttiibbiiaall ttrraannssllaattiioonn iiss iinnccrreeaasseedd nneeaarr ffuullll eexxtteennssiioonn..

QQuueessttiioonn 6655:: AA 1166 yyeeaarr oolldd,, 66 fftt,, 116600 llbb ffeemmaallee bbaasskkeettbbaallll ppllaayyeerr ssccoorreess aa ggrreeaatt sshhoott aanndd ddooeess aa jjuummppiinngg bbeellllyy bbuummpp wwiitthh aa ffeellllooww ppllaayyeerr ttoo cceelleebbrraattee.. WWhheenn sshhee llaannddss aawwkkwwaarrddllyy,, sshhee hhaass ppaaiinn iinn hheerr rriigghhtt kknneeee.. WWhheenn sshhee rreettuurrnnss ttoo ppllaayy aa wweeeekk llaatteerr,, sshhee ppiivvoottss ooffff hheerr iinnjjuurreedd ffoooott,, eexxppeerriieenncceess ssuuddddeenn ppaaiinn aanndd hhaass ddiiffffiiccuullttyy bbeeaarriinngg wweeiigghhtt.. EExxaammiinnaattiioonn rreevveeaallss ddiiffffuussee rriigghhtt kknneeee ppaaiinn wwiitthh eeffffuussiioonn aanndd llaacckk ooff ffuullll rraannggee ooff mmoottiioonn.. XX--RRaayyss aarree nnoorrmmaall.. MMRRII iiss sshhoowwnn iinn tthhee ffiigguurreess.. FFiigguurree 11:: TT11 MMRRII,, ssaaggiittttaall ccuutt ddeemmoonnssttrraatteess ddiissppllaacceemmeenntt ooff tthhee llaatteerraall mmeenniissccuuss,, aanndd ffeemmoorroo--ttiibbiiaall bboonnee bbrruuiissee ppaatttteerrnn ccoonnssiisstteenntt wwiitthh aanntteerriioorr ttrraannssllaattiioonn ooff tthhee ttiibbiiaa.. FFiigguurree 22:: TT11 MMRRII,, ssaaggiiiittaall ccuutt ddeemmoonnssttrraatteess llaarrggee kknneeee eeffffuussiioonn FFiigguurree 33:: TT11 MMRRII,, ssaaggiittttaall ccuutt ddeemmoonnttssttrraatteess iinnttaacctt PPCCLL,, ddiissppllaacceedd mmeenniissccuuss aaddjjaacceenntt ttoo tthhee PPCCLL.. WWhhaatt wwoouulldd yyoouu aaddvviissee?? 11.. AA ppaatteellllaa ssttaabbiilliizziinngg bbrraaccee wwiitthh pphhyyssiiccaall tthheerraappyy 22.. FFuurrtthheerr eevvaalluuaattiioonn wwiitthh aa bboonnee ssccaann 33.. PPhhyyssiiccaall tthheerraappyy ttoo rreessttoorree mmoottiioonn pprriioorr ttoo ssuurrggeerryy 44.. TTooee ttoouucchh wweeiigghhtt--bbeeaarriinngg aanndd ssuurrggeerryy wwiitthhiinn sseevveerraall ddaayyss 55.. GGeenneettiicc tteessttiinngg wwiitthh aapppprroopprriiaattee ccoouunnsseelliinngg QQuueessttiioonn 6666:: AA 1199 yyeeaarr oolldd ffoooottbbaallll ppllaayyeerr hhaass aa vvaallgguuss ccoonnttaacctt iinnjjuurryy.. EExxaammiinnaattiioonn rreevveeaallss aann eeffffuussiioonn,, 55mmmm ooff ooppeenniinngg ttoo vvaallgguuss ssttrreessss aatt 3300 ddeeggrreeeess ooff kknneeee fflleexxiioonn,, aa nnoorrmmaall LLaacchhmmaann aanndd nnoorrmmaall ppoosstteerriioorr ddrraawweerr.. TThheerree iiss tteennddeerrnneessss oovveerr tthhee mmeeddiiaall eeppiiccoonnddyyllee aanndd rraaddiiooggrraapphhss aarree nnoorrmmaall.. IInn aaddddiittiioonn ttoo rreehhaabbiilliittaattiioonn,, wwhhaatt iiss tthhee nneexxtt aapppprroopprriiaattee sstteepp iinn mmaannaaggeemmeenntt?? 11.. AAssppiirraattiioonn aanndd iinnjjeeccttiioonn ooff ccoorrttiiccoosstteerrooiidd.. 22.. CCaasstt iimmmmoobbiilliizzaattiioonn ffoorr 22 wweeeekkss 33.. AA ffuunnccttiioonnaall kknneeee bbrraaccee,, wweeiigghhtt bbeeaarriinngg aass ttoolleerraatteedd 44.. OOppeenn ssuurrggiiccaall rreeppaaiirr ooff mmeeddiiaall ssttrruuccttuurreess 55.. AArrtthhrroossccooppiicc eevvaalluuaattiioonn aanndd ttrreeaattmmeenntt QQuueessttiioonn 6677:: TThhee qquuaaddrriicceeppss tteennddoonn hhaass bbeeeenn uusseedd aass aauuttooggrraafftt ttiissssuuee ffoorr mmaannyy ddiiffffeerreenntt lliiggaammeennttoouuss rreeccoonnssttrruuccttiivvee pprroocceedduurreess aabboouutt tthhee kknneeee.. WWhhaatt cchhaarraacctteerriissttiiccss ooff tthhee qquuaaddrriicceeppss tteennddoonn mmaakkee iitt aa ffaavvoorraabbllee cchhooiiccee aass aa ggrraafftt?? 11.. IItt hhaass aa bbrrooaadd aarreeaa ooff iinnsseerrttiioonn oonn tthhee ppaatteellllaa aanndd iiss jjuuxxttaappoosseedd ttoo tthhee aarrttiiccuullaarr ccaarrttiillaaggee.. 22.. IItt iiss 11..88 ttiimmeess aass tthhiicckk aass tthhee ppaatteellllaarr tteennddoonn aanndd iiss rreeaaddiillyy aacccceessssiibbllee.. 33.. IItt rreeaaddiillyy rreeppllaacceess iittsseellff aanndd ccaann bbee hhaarrvveesstteedd,, iinn ppaarrtt,, aarrtthhrroossccooppiiccaallllyy.. 44.. IItt iiss ssyymmmmeettrriicc aanndd rreedduunnddaanntt tthhrroouugghhoouutt iittss lleennggtthh.. 55.. IItt iiss hhaarrvveesstteedd wwiitthh aa ffuullll tthhiicckknneessss bboonnee pplluugg,, aanndd aann iinnttaacctt ssyynnoovviiaall sshheeaatthh iiss rreeccoommmmeennddeedd wwiitthh tthhee qquuaaddrriicceeppss tteennddoonn..

QQuueessttiioonn 6688:: AA 5566 yyeeaarr oolldd ggoollffeerr rreeppoorrttss rriigghhtt kknneeee sswweelllliinngg ffoorr ffiivvee ddaayyss wwiitthhoouutt aa hhiissttoorryy ooff iinnjjuurryy.. HHee lleeaavveess ffoorr aa ggoollff ttrriipp iinn SSccoottllaanndd iinn ttwwoo ddaayyss.. CClliinniiccaall eexxaammiinnaattiioonn sshhoowwss aann eeffffuussiioonn aanndd ppaaiinn oovveerr tthhee mmeeddiiaall jjooiinntt lliinnee ooff hhiiss rriigghhtt kknneeee.. KKnneeee rraaddiiooggrraapphhss aarree iinn tthhee ffiigguurreess.. FFiigguurree 11:: AAPP XXRRaayy ooff kknneeee sshhoowwss mmiilldd ttoo mmooddeerraattee mmeeddiiaall jjooiinntt ssppaaccee nnaarrrroowwiinngg,, oosstteeoopphhyyttee ffoorrmmaattiioonn,, aanndd pprreesseerrvvaattiioonn ooff jjooiinntt ssppaaccee llaatteerraallllyy.. FFiigguurree 22:: LLaatteerraall XXRRaayy ooff kknneeee sshhoowwss mmiinniimmaall ppaatteellllaarr oosstteeoopphhyyttee ffoorrmmaattiioonn,, wwiitthh pprreesseerrvvaattiioonn ooff ppaatteelllloo--ffeemmoorraall jjooiinntt ssppaaccee.. WWhhaatt wwoouulldd yyoouu aaddvviissee?? 11.. IImmmmeeddiiaattee ddiiaaggnnoossttiicc aarrtthhrroossccooppyy 22.. AAnn oorraall aannttii--iinnffllaammmmaattoorryy,, aa kknneeee ccoommpprreessssiioonn sslleeeevvee aanndd ssttrreennggtthheenniinngg eexxeerrcciisseess 33.. MMeenniissccaall aallllooggrraafftt iiff XXrraayyss ooff hhiiss ootthheerr kknneeee sshhooww ssiimmiillaarr ffiinnddiinnggss 44.. AA bboonnee ssccaann pprriioorr ttoo aaddvviissiinngg hhiimm rreeggaarrddiinngg hhiiss ttrriipp 55.. CCoonnssiiddeerraattiioonn ooff jjooiinntt rreeppllaacceemmeenntt oonn hhiiss rreettuurrnn ffrroomm tthhee ttrriipp QQuueessttiioonn 6699:: AA 3300 yyeeaarr oolldd mmaallee pprreesseennttss wwiitthh rreeccuurrrreenntt lleefftt kknneeee iinnssttaabbiilliittyy.. HHee uunnddeerrwweenntt aa hhaammssttrriinngg AACCLL rreeccoonnssttrruuccttiioonn 55 yyeeaarrss aaggoo.. EExxaammiinnaattiioonn aafftteerr hhiiss iinnddeexx ssuurrggeerryy sshhoowweedd aa nnoorrmmaall LLaacchhmmaann aanndd nnoo ppiivvoott sshhiifftt.. NNooww hhiiss eexxaammiinnaattiioonn rreevveeaallss aa ppoossiittiivvee LLaacchhmmaann tteesstt,, ppoossiittiivvee ppiivvoott sshhiifftt,, nnoorrmmaall vvaarruuss aanndd vvaallgguuss ssttrreessss aanndd nneeggaattiivvee ppoosstteerriioorr ddrraawweerr.. HHee hhaass iinnccrreeaasseedd eexxtteerrnnaall rroottaattiioonn aatt 3300 ddeeggrreeeess.. RRaaddiiooggrraapphhss sshhooww eexxcceelllleenntt ttuunnnneell ppllaacceemmeenntt.. WWhhaatt iiss tthhee mmoosstt lliikkeellyy ccaauussee ooff tthhee AACCLL ffaaiilluurree?? 11.. LLaatteerraall ccoollllaatteerraall lliiggaammeenntt iinnjjuurryy 22.. PPoooorr rreehhaabbiilliittaattiioonn ooff tthhee hhaammssttrriinnggss 33.. IInnaaddeeqquuaattee ssoofftt ttiissssuuee ggrraafftt ffiixxaattiioonn 44.. UUnnttrreeaatteedd iinnjjuurryy ttoo ppoosstteerriioorr llaatteerraall ccoorrnneerr 55.. UUnnttrreeaatteedd oorr uunnrreeccooggnniizzeedd mmeenniissccuuss iinnjjuurryy QQuueessttiioonn 7700:: AA 1155 yyeeaarr oolldd ccrroossss ccoouunnttrryy sskkiieerr ccoommppllaaiinnss ooff aanntteerriioorr kknneeee ppaaiinn ssiinnccee bbeeggiinnnniinngg ssqquuaattss aanndd lluunnggeess aass ppaarrtt ooff hheerr ccoonnddiittiioonniinngg pprrooggrraamm.. OOnn eexxaammiinnaattiioonn,, sshhee hhaass ppaaiinn ttoo ppaallppaattiioonn aabboouutt tthhee ppaatteellllaa,, aa mmiilldd vvaallgguuss aannggllee ttoo hheerr kknneeee aanndd ffoooott pprroonnaattiioonn.. SShhee hhaass nnoo mmeeddiiaall oorr llaatteerraall jjooiinntt lliinnee tteennddeerrnneessss aanndd nnoo kknneeee iinnssttaabbiilliittyy.. MMRRII iimmaaggeess aarree sshhoowwnn.. FFiigguurree 11:: TT22 MMRRII,, ssaaggiittttaall ccuuttss ddeemmoonnssttrraattee iinnttaacctt llaatteerraall mmeenniissccuuss wwiitthh rreeccttaanngguullaarr aappppeeaarraannccee oonn 33 ccoonnsseeccuuttiivvee iimmaaggeess.. FFiigguurree 22:: TT22 MMRRII,, ffaatt ssaatt,, ssaaggiittttaall ccuuttss ddeemmoonnssttrraattee iinnttaacctt llaatteerraall mmeenniissccuuss wwiitthh rreeccttaanngguullaarr aappppeeaarraannccee oonn 33 ccoonnsseeccuuttiivvee iimmaaggeess.. FFiigguurree 33:: IInnttaacctt AACCLL,, PPCCLL

WWhhaatt wwoouulldd yyoouu aaddvviissee?? 11.. AAvvooiiddaannccee ooff aallll pphhyyssiiccaall aaccttiivviittiieess ffoorr 33 mmoonntthhss wwiitthh rreeppeeaatt MMRRII aatt tthhaatt ttiimmee 22.. OOrrtthhoottiiccss,, kknneeee bbrraaccee aanndd eexxeerrcciisseess ttoo iimmpprroovvee ppaatteellllaa ttrraacckkiinngg 33.. AArrtthhrroossccooppyy ttoo aaddddrreessss aabbnnoorrmmaalliittiieess sseeeenn oonn MMRRII 44.. AA bboonnee mmiinneerraall ddeennssiittyy ssttuuddyy aanndd aa ccoommpplleettee mmeettaabboolliicc wwoorrkk--uupp 55.. FFuurrtthheerr eevvaalluuaattiioonn wwiitthh aann MMRRII wwiitthh ccoonnttrraasstt QQuueessttiioonn 7711:: AAnn aaccttiivvee 2222 yyeeaarr oolldd mmaallee pprreesseennttss wwiitthh aa ssiiggnniiffiiccaanntt ppaaiinn aanndd rraaddiiooggrraapphhiicc jjooiinntt ssppaaccee nnaarrrroowwiinngg ffiivvee yyeeaarrss aafftteerr aa ssuubbttoottaall mmeeddiiaall mmeenniisscceeccttoommyy.. WWhhiicchh ooff tthhee ffoolllloowwiinngg ffaaccttoorrss aarree mmoosstt ccoonnssiisstteenntt wwiitthh aa ssuucccceessssffuull mmeenniissccaall aallllooggrraafftt?? 11.. KKnneeee jjooiinntt lliiggaammeenntt iinnssttaabbiilliittyy 22.. AAddvvaanncceedd aarrttiiccuullaarr ccaarrttiillaaggee ddeeggeenneerraattiioonn 33.. PPaaiinn aanndd sswweelllliinngg wwiitthh mmeecchhaanniiccaall ssyymmppttoommss 44.. AAxxiiaall mmaallaalliiggnnmmeenntt 55.. FFllaatttteenniinngg ooff tthhee mmeeddiiaall ffeemmoorraall ccoonnddyyllee QQuueessttiioonn 7722:: YYoouu ddiiaaggnnoossee aa ppaarrttiiaall AACCLL tteeaarr iinn aa ccoolllleeggiiaattee llaaccrroossssee ppllaayyeerr.. AA rreehhaabbiilliittaattiioonn pprrooggrraamm iiss iinniittiiaatteedd.. AAllpphhaa ssmmooootthh mmuussccllee aaccttiinn iiss aaccttiivvee aafftteerr AACCLL iinnjjuurryy.. WWhhiicchh ssttaatteemmeenntt bbeellooww bbeesstt ddeessccrriibbeess iittss rroollee iinn tthhee hheeaalliinngg ooff tthhiiss lliiggaammeenntt.. 11.. IItt pprroodduucceess cceellllss tthhaatt rreettrraacctt tthhee ttoorrnn lliiggmmaanneett eennddss.. 22.. IItt pprroodduucceess aa ssyynnoovviiaall cceellll llaayyeerr tthhaatt bbrriiddggeess tthhee iinnjjuurryy ssiittee.. 33.. IItt pprroodduucceess ssyynnoovviiaall fflluuiidd,, iinndduucciinngg iinnffllaammmmaattiioonn.. 44.. IItt pprroodduucceess eeppiilliiggaammeennttoouuss ttiissssuuee tthhaatt iinndduucceess hheeaalliinngg.. 55.. IItt pprroodduucceess ccyyttookkiinneess tthhaatt ccaauussee iinnffllaammmmaattiioonn,, lleeaaddiinngg ttoo pprroolliiffeerraattiioonn,, rreemmooddeelliinngg,, aanndd mmaattuurraattiioonn.. QQuueessttiioonn 7733:: TThhee aanntteerriioorr ccrruucciiaattee lliiggaammeenntt mmaayy bbee rreeccoonnssttrruucctteedd wwiitthh aa ddoouubbllee bbuunnddllee tteecchhnniiqquuee ssuucchh tthhaatt tthhee ccoonnssttrruucctt iiss ppllaacceedd iinn ttwwoo ttuunnnneellss tthhrroouugghh tthhee ffeemmuurr aanndd ttwwoo ttuunnnneellss tthhrroouugghh tthhee ttiibbiiaa.. WWhhiicchh ooff tthhee ffoolllloowwiinngg cchhaarraacctteerriissttiiccss aarree sshhoowwnn iinn bbiioommeecchhaanniiccaall ssttuuddiieess ccoommppaarriinngg tthhee ssiinnggllee aanndd ddoouubbllee bbuunnddllee tteecchhnniiqquueess uussiinngg hhuummaann ccaaddaavveerriicc kknneeeess?? 11.. TThhee ggrraafftt ccoonnssttrruucctt ccaann bbeetttteerr wwiitthhssttaanndd iinntteerrnnaall rroottaattiioonn ffoorrcceess bbuutt nnoott vvaallgguuss ttoouurrqquuee,, ccoommppaarreedd ttoo tthhee ssiinnggllee bbuunnddllee tteecchhnniiqquuee.. 22.. TThhee iinn ssiittuu llooaaddss ffoorr aanntteerriioorr ttrraannssllaattiioonn ffoorr tthhee ssiinnggllee bbuunnddllee aanndd ddoouubbllee bbuunnddllee rreeccoonnssttrruuccttiioonnss wweerree tthhee ssaammee aanndd ssiimmiillaarrllyy cclloossee ttoo tthhee iinnttaacctt AACCLL.. 33.. TThhee iinn ssiittuu llooaaddss ffoorr aanntteerriioorr ttrraannssllaattiioonn aanndd rroottaattiioonn ffoorr tthhee ddoouubbllee bbuunnddllee rreeccoonnssttrruuccttiioonn wweerree cclloosseerr ttoo tthhee iinnttaacctt AACCLL..

44.. TThhee ttwwoo ggrraafftt lliimmbbss aarree cclloossee ttoo tthhee cceennttrraall aaxxiiss ooff tthhee ttiibbiiaa aanndd ffeemmuurr,, mmaakkiinngg tthheemm bbeetttteerr aabbllee ttoo rreessiisstt rroottaattiioonnaall llooaaddss.. 55.. TThhee ggrraafftt lliimmbbss oonn tthhee ffeemmoorraall ssiiddee aarree bbeesstt ppoossiittiioonneedd aatt tthhee ppoosstteerroollaatteerraall aanndd tthhee aanntteerroommeeddiiaall ssiittee.. QQuueessttiioonn 7744:: AA 1166 yyeeaarr oolldd aatthhlleettee hhaass aa mmeenniissccuuss tteeaarr aanndd iiss uunnddeerrggooiinngg aarrtthhrroossccooppiicc ttrreeaattmmeenntt.. WWhhaatt ssttaatteemmeenntt iiss mmoosstt ttrruuee rreeggaarrddiinngg tthhee vvaassccuullaarr aannaattoommyy ooff tthhee mmeenniissccuuss?? 11.. TThhee ppeerriipphheerraall 1100%% ooff tthhee mmeeddiiaall mmeenniissccuuss aanndd tthhee ppeerriipphheerraall 1100%% ooff tthhee llaatteerraall mmeenniissccuuss ccoonnttaaiinnss bblloooodd vveesssseellss.. 22.. TThhee ppeerriipphheerraall 1100--2200%% ooff tthhee mmeeddiiaall mmeenniissccuuss aanndd tthhee ppeerriipphheerraall 2255--5500%% ooff tthhee llaatteerraall mmeenniissccuuss ccoonnttaaiinnss bblloooodd vveesssseellss.. 33.. TThhee ppeerriipphheerraall 2200--3300%% ooff tthhee mmeeddiiaall mmeenniissccuuss aanndd tthhee ppeerriipphheerraall 1100--2255%% ooff tthhee llaatteerraall mmeenniissccuuss ccoonnttaaiinnss bblloooodd vveesssseellss.. 44.. TThhee ppeerriipphheerraall 3300--6600%% ooff tthhee mmeeddiiaall mmeenniissccuuss aanndd tthhee ppeerriipphheerraall 2255--5500%% ooff tthhee llaatteerraall mmeenniissccuuss ccoonnttaaiinnss bblloooodd vveesssseellss.. 55.. TThhee ppeerriipphheerraall 5500%% ooff tthhee mmeeddiiaall mmeenniissccuuss aanndd tthhee ppeerriipphheerraall 5500%% ooff tthhee llaatteerraall mmeenniissccuuss ccoonnttaaiinnss bblloooodd vveesssseellss.. QQuueessttiioonn 7755:: AA 1100 yyeeaarr oolldd iiss uunnddeerrggooiinngg kknneeee aarrtthhrroossccooppyy ffoorr rreemmoovvaall ooff aa ffoorreeiiggnn bbooddyy.. PPrriioorr ttoo tthhee ffoorreeiiggnn bbooddyy hhee hhaadd nnoo kknneeee ssyymmppttoommss.. IInn aaddddiittiioonn ttoo tthhee ffoorreeiiggnn bbooddyy,, aann iinnccoommpplleettee ddiissccooiidd llaatteerraall mmeenniissccuuss iiss ffoouunndd.. WWhhaatt iiss tthhee mmoosstt aapppprroopprriiaattee ttrreeaattmmeenntt ooff tthhee ddiissccooiidd llaatteerraall mmeenniissccuuss?? 11.. NNoo ttrreeaattmmeenntt iiss rreeqquuiirreedd 22.. AArrtthhrroossccooppiicc ssaauucceerriizzaattiioonn sshhoouulldd bbee ppeerrffoorrmmeedd.. 33.. MMeenniissccuuss aallllooggrraafftt sshhoouulldd bbee ppeerrffoorrmmeedd 44.. TToottaall mmeennssiicceeccttoommyy sshhoouulldd bbee ppeerrffoorrmmeedd 55.. SSuuttuurree rreeppaaiirr sshhoouulldd bbee ppeerrffoorrmmeedd QQuueessttiioonn 7766:: AA 2255 yyeeaarr oolldd ffeemmaallee rruunnnneerr ttrriippss oonn aann uunneevveenn ppaavveemmeenntt wwhhiillee rruunnnniinngg.. SShhee hheeaarrss aa ppoopp aanndd hhaass iimmmmeeddiiaattee kknneeee ppaaiinn,, bbuutt iiss aabbllee ttoo lliimmpp hhoommee.. TThhee ffoolllloowwiinngg ddaayy iinn yyoouurr ooffffiiccee,, hheerr kknneeee iiss ddiiffffuusseellyy tteennddeerr aanndd sswwoolllleenn.. SShhee iiss aabbllee ttoo ppeerrffoorrmm aa ssttrraaiigghhtt lleegg rraaiissee.. PPaaiinn lliimmiittss ffuurrtthheerr eexxaammiinnaattiioonn.. XX--rraayyss aarree uunnrreemmaarrkkaabbllee.. AAnn MMRRII iiss oorrddeerreedd aanndd tthhee rreessuullttss aarree sshhoowwnn iinn tthhee ffiigguurreess.. FFiigguurree 11:: TT11 MMRRII,, ssaaggggiittaall ccuutt tthhrroouugghhtt tthhee nnoottcchh ddeemmoonnssttrraatteess aann iinnttaacctt AACCLL FFiigguurree 22:: TT22 MMRRII,, ffaatt--ssaatt,, ccoorroonnaall ccuutt ddeemmoonnssttrraatteess bboonnee bbrruuiissiinngg ooff tthhee ttrroocchhlleeaa aanndd llaatteerraall ffeemmoorraall ccoonnddyyllee.. FFiigguurree 33:: TT22 MMRRII,, ffaatt--ssaatt,, aaxxiiaall ccuutt ddeemmoonnssttrraatteess bboonnee bbrruuiissiinngg ooff tthhee mmeeddiiaall ppaatteellllaarr ffaacceett,, aanndd llaatteerraall ffeemmoorraall ccoonnddyyllee.. WWhhaatt wwoouulldd yyoouu aaddvviissee??

11.. AA ttoottaall bbooddyy bboonnee ssccaann,, CCBBCC wwiitthh ddiiffff,, CCRRPP,, aanndd sseedd rraattee.. 22.. CCoonnssiiddeerraattiioonn ooff ssuurrggiiccaall ccoorrrreeccttiioonn ooff hheerr iinnjjuurryy wwiitthhiinn tthhee nneexxtt 55--77 ddaayyss.. 33.. SSlloowwllyy iinnccrreeaassee wweeiigghhtt bbeeaarriinngg aass ppaaiinn ppeerrmmiittss,, aa bbrraaccee ffoorr pprrootteeccttiioonn aanndd pphhyyssiiccaall tthheerraappyy.. 44.. PPhhyyssiiccaall tthheerraappyy ttoo ddeeccrreeaassee sswweelllliinngg,, iimmpprroovvee rraannggee ooff mmoottiioonn aanndd ssttrreennggtthh,, ffoolllloowweedd bbyy ggrraaffttiinngg ttoo ccoorrrreecctt hheerr ppaatthhoollooggyy.. 55.. AA CCAATT ssccaann ttoo bbeetttteerr ddeeffiinnee ppaatthhoollooggyy pprriioorr ttoo aaddvviissiinngg ssppeecciiffiicc ttrreeaattmmeenntt.. QQuueessttiioonn 7777:: DDuurriinngg AACCLL RReeccoonnssttrruuccttiioonn,, tthhee tteennssiioonn iinn tthhee ggrraafftt aafftteerr ffeemmoorraall ffiixxaattiioonn nneeeeddss ttoo bbee ddeetteerrmmiinneedd uussiinngg aa tteennssiioommeetteerr.. TThhee ffoorrccee ttrraassdduucceerr iinn tthhee tteennssiioommeetteerr iiss ccaalliibbrraatteedd bbyy hhaannggiinngg vvaarriioouuss mmaasssseess oonn tthhee ttrraannssdduucceerr aanndd mmeeaassuurriinngg tthhee oouuttppuutt vvoollttaaggee.. AA lliinneeaarr rreellaattiioonnsshhiipp wwaass ffoouunndd bbeettwweeeenn tthhee iinnddeeppeennddeenntt vvaarriiaabbllee ((mmaassss)) aanndd tthhee ddeeppeennddeenntt vvaarriiaabbllee ((vvoollttaaggee..)) WWhhaatt ssttaattiissttiiccaall tteesstt wwaass mmoosstt lliikkeellyy uusseedd ttoo ddeetteerrmmiinnee tthhiiss ccoonncclluussiioonn?? 11.. AAnnaallyyssiiss ooff ccoovvaarriiaannccee ((AANNCCOOVVAA)) 22.. SSiimmppllee RReeggrreessssiioonn 33.. PPooiissssoonn RReeggrreessssiioonn 44.. AAnnaallyyssiiss ooff vvaarriiaannccee ((AANNOOVVAA)) 55.. LLooggiissttiicc rreeggrreessssiioonn QQuueessttiioonn 7788:: AA 3300 yyeeaarr oolldd mmaallee pprreesseennttss ttoo yyoouurr ooffffiiccee oonn ppoosstt ooppeerraattiivvee ddaayy 1144 aafftteerr aann uunnccoommpplliiccaatteedd rriigghhtt aanntteerriioorr ccrruucciiaattee lliiggaammeenntt rreeccoonnssttrruuccttiioonn wwiitthh aann aauuttoollooggoouuss qquuaaddrruupplleedd sseemmiitteennddiinnoouuss aanndd ggrraacciilliiss ggrraafftt.. HHee ccoommppllaaiinnss ooff iinnccrreeaassiinngg ppaaiinn,, ppeerrssiisstteenntt sswweelllliinngg,, aanndd uunnrreessoollvviinngg rreeddnneessss aatt tthhee iinncciissiioonn ssiitteess.. HHiiss oorraall tteemmppeerraattuurree iiss 9988..99 ddeeggrreeeess FF.. HHee hhaass ppaaiinn wwiitthh wweeiigghhtt bbeeaarriinngg.. TThheerree iiss mmooddeerraattee eeffffuussiioonn,, eerryytthheemmaa aanndd wwaarrmmtthh aarroouunndd tthhee iinncciissiioonnss,, aanndd nnoo ddrraaiinnaaggee.. AAccttiivvee rraannggee ooff mmoottiioonn iiss 2255 ttoo 6600 ddeeggrreeeess aanndd ppaaiinnffuull.. TThhee ccaallff iiss nnoonn--tteennddeerr.. WWhhaatt iiss tthhee mmoosstt aapppprroopprriiaattee ccoouurrssee ooff aaccttiioonn?? 11.. OObbttaaiinn aa jjooiinntt aassppiirraattee wwiitthh GGrraamm ssttaaiinn,, fflluuiidd aannaallyyssiiss,, aaeerroobbiicc aanndd aannaaeerroobbiicc ccuullttuurreess 22.. OObbttaaiinn aa rreeppeeaatt pphhyyssiiccaall eexxaammiinnaattiioonn iinn 33 ttoo 55 ddaayyss aass ppaarrtt ooff aa sseerriiaall kknneeee eevvaalluuaattiioonn 33.. OObbttaaiinn AAPP aanndd llaatteerraall rraaddiiooggrraapphhss ttoo eevvaalluuaattee ttuunnnneell aanndd ffiixxaattiioonn ppllaacceemmeenntt 44.. OObbttaaiinn aa pphhyyssiiccaall tthheerraappyy ccoonnssuullttaattiioonn ffoorr aaggggrreessssiivvee rraannggee ooff mmoottiioonn 55.. OObbttaaiinn aa CCBBCC wwiitthh aa ddiiffffeerreennttiiaall,, CC rreeaaccttiivvee pprrootteeiinn,, aanndd eerryytthhrrooccyyttee sseeddiimmeennttaattiioonn rraattee QQuueessttiioonn 7799:: AA 2299 yyeeaarr oolldd mmaallee iiss uunnddeerrggooiinngg aa mmaarrrrooww ssttiimmuullaattiioonn pprroocceedduurree ffoorr aa ggrraaddee IIVV ccaarrttiillaaggee ddeeffeecctt oonn tthhee MMFFCC.. WWhhaatt iiss tthhee pprreeddoommiinnaanntt ttyyppee ooff ccoollllaaggeenn tthhaatt rreessuullttss ffrroomm tthhiiss pprroocceedduurree?? 11.. TTyyppee XX

22.. TTyyppee IIII 33.. TTyyppee VV 44.. TTyyppee II 55.. TTyyppee VVII QQuueessttiioonn 8800:: AAnn 1111 yyeeaarr--oolldd ssoocccceerr ppllaayyeerr ccoommppllaaiinnss ooff kknneeee ppaaiinn,, wwhhiicchh iinnccrreeaasseedd wwiitthh aaccttiivviittyy aanndd iimmpprroovveess wwiitthh rreesstt.. HHee llooccaalliizzeess hhiiss ppaaiinn ttoo tthhee ffrroonntt ooff hhiiss kknneeee.. TThhee ppaaiinn iiss sseevveerree aanndd aaccuuttee.. AA rraaddiiooggrraapphh sshhoowwss OOssggoooodd--SScchhllaatttteerr lleessiioonn aatt tthhee ttiibbiiaall ttuubbeerrccllee.. WWhhaatt iiss tthhee aapppprroopprriiaattee nneexxtt sstteepp?? 11.. AAppppllyy aa lloonngg lleegg ccyylliinnddeerr ccaasstt ffoorr 44 wweeeekkss,, tthheenn rreeppeeaatt rraaddiiooggrraapphhss.. 22.. AAppppllyy aa bbrraaccee aanndd rreeccoommmmeenndd nnoonn--wweeiigghhtt bbeeaarriinngg aammbbuullaattiioonn 33.. OOrrddeerr aann iimmmmeeddiiaattee bboonnee ssccaann 44.. CCeessssaattiioonn ooff aaccttiivviittyy uunnttiill tthhee ppaaiinn rreessoollvveess 55.. OOrrddeerr aa CCTT wwiitthh tthhiinn sslliicceedd iimmaaggiinngg QQuueessttiioonn 8811:: AA 1122 yyeeaarr--oolldd bbooyy hhaass hhaadd aa kknneeee eeffffuussiioonn aanndd ppaaiinnffuull ccaattcchhiinngg ffoorr 66 wweeeekkss.. RRaaddiiooggrraapphhss rreevveeaall aa wweellll--cciirrccuummssccrriibbeedd,, ccrreesscceenntt ––sshhaappeedd bboonnyy ffrraaggmmeenntt ooff ssuubbcchhoonnddrraall bboonnee.. IItt iiss ssuurrrroouunnddeedd bbyy aa rraaddiioolluucceenntt rriimm.. WWhhaatt iiss tthhee mmoosstt ccoommmmoonn llooccaattiioonn ffoorr tthhiiss lleessiioonn iinn tthhee kknneeee?? 11.. PPoosstteerroollaatteerraall aassppeecctt ooff mmeeddiiaall ffeemmoorraall ccoonnddyyllee 22.. AAnntteerroommeeddiiaall aassppeecctt ooff llaatteerraall ffeemmoorraall ccoonnddyyllee 33.. SSuuppeerroollaatteerraall ppaatteellllaa 44.. IInnffeerroommeeddiiaall ppaatteellllaa 55.. PPoosstteerroommeeddiiaall aassppeecctt ooff llaatteerraall ffeemmoorraall ccoonnddyyllee QQuueessttiioonn 8822:: AA 2222 yyeeaarr--oolldd ccoolllleeggiiaattee bbaasskkeettbbaallll ppllaayyeerr ddeevveellooppeedd aanntteerriioorr kknneeee ppaaiinn 88 mmoonntthhss aaggoo.. TThhee ppaaiinn hhaass ppeerrssiisstteedd ddeessppiittee rreesstt aanndd iibbuupprrooffeenn.. AAnn MMRRII sshhoowwss aann OOCCDD lleessiioonn ooff tthhee ttrroocchhlleeaa.. WWhhaatt ddoo yyoouu rreeccoommmmeenndd iinn tthhee nneexxtt sstteepp iinn mmaannaaggeemmeenntt?? 11.. DDoouubbllee uupprriigghhtt bbrraaccee wwiitthh ppaatteellllaarr ssttaabbiilliizziinngg ppaadd 22.. GGlluuccoossaammiinnee aanndd cchhoonnddrrooiittiinn ssuullffaattee 33.. AArrtthhrroossccooppiicc eevvaalluuaattiioonn aanndd ttrreeaattmmeenntt 44.. PPoossiittrroonn eemmiissssiioonn ttoommooggrraapphhyy ssccaann 55.. RReeffeerrrraall ttoo aann eennddooccrriinnoollooggiisstt QQuueessttiioonn 8833:: AA 3333 yyeeaarr--oolldd ffeemmaallee sseemmii--pprrooffeessssiioonnaall bbeeaacchh vvoolllleeyybbaallll ppllaayyeerr pprreesseennttss ccoommppllaaiinniinngg ooff aa ssiixx mmoonntthh hhiissttoorryy ooff vvaagguuee iinntteerriioorr kknneeee ppaaiinn aanndd ooccccaassiioonnaall ccaattcchhiinngg.. SShhee ddeenniieess aannyy iinnssttaabbiilliittyy oorr ggiivviinngg wwaayy,, bbuutt hhaass aann eeffffuussiioonn aanndd iiss nnooww uunnaabbllee ttoo ppllaayy ffoorr aann eexxtteennddeedd ppeerriioodd ooff ttiimmee.. MMRRII ssuuppppoorrttss aa ddiiaaggnnoossiiss ooff llooccaalliizzeedd ppiiggmmeenntteedd vviilllloonnoodduullaarr ssyynnoovviittiiss.. WWhhaatt iiss tthhee mmoosstt aapppprroopprriiaattee ttrreeaattmmeenntt?? 11.. IInnttrraa--aarrttiiccuullaarr cchheemmootthheerraappyy 22.. RRaaddiiooaaccttiivvee ssyynnoovveeccttoommyy 33.. OOppeenn ddeebbrriiddeemmeenntt

44.. AArrtthhrroossccooppiicc ttoottaall ssyynnoovveeccttoommyy 55.. AArrtthhrroossccooppiicc eexxcciissiioonn ooff tthhee ffooccaall lleessiioonn QQuueessttiioonn 8844:: AA 1133 yyeeaarr--oolldd ffeemmaallee ppaattiieenntt ssuussttaaiinnss aa ppaatteellllaa ddiissllooccaattiioonn wwhhiicchh iiss rreedduucceedd bbyy tthhee ppaattiieenntt’’ss uunnccllee wwhhoo iiss aa pphhyyssiicciiaann.. SShhee oobbttaaiinnss aann MMRRII tthhee nneexxtt ddaayy aanndd pprreesseennttss ttoo tthhee ooffffiiccee wwiitthhiinn 2244 hhoouurrss aafftteerr tthhee iinnjjuurryy.. MMRRII sshhoowwss aa ddiissppllaacceedd oosstteeoocchhoonnddrraall ffrraaggmmeenntt ffrroomm tthhee llaatteerraall ffeemmoorraall ccoonnddyyllee.. WWhhaatt iiss tthhee mmoosstt aapppprroopprriiaattee ttrreeaattmmeenntt ooppttiioonn ffoorr tthhiiss ppaattiieenntt?? 11.. OORRIIFF llaatteerraall ffeemmoorraall ccoonnddyyllee aarrttiiccuullaarr ccaarrttiillaaggee ffrraaggmmeenntt 22.. TTiibbiiaall ttuubbeerrccllee oosstteeoottoommyy 33.. LLaatteerraall mmeenniissccaall rreeppaaiirr 44.. LLaatteerraall rreettiinnaaccuullaarr rreelleeaassee 55.. AArrtthhrroossccooppiicc mmeeddiiaall rreettiinnaaccuullaarr pplliiccaattiioonn QQuueessttiioonn 8855:: TThhee ssttrruuccttuurree ooff ccaarrttiillaaggee pprrootteeooggllyyccaannss ccaann bbee ddeessccrriibbeedd aass:: 11.. MMuullttiippllee hhyyaalluurroonnaattee mmoolleeccuulleess bboouunndd ttoo aa ccoorree pprrootteeiinn,, wwhhiicchh iiss ssuubbsseeqquueennttllyy bboouunndd ttoo ggllyyccoossaammiinnooggllyyccaann cchhaaiinn 22.. MMuullttiippllee ggllyyccoossaammiinnooggllyyccaann cchhaaiinnss bboouunndd ttoo hhyyaalluurroonnaattee,, wwhhiicchh iiss ssuubbsseeqquueennttllyy bboouunndd ttoo ccoorree pprrootteeiinn 33.. MMuullttiippllee ggllyyccoossaammiinnooggllyyccaannss bboouunndd ttoo ccoorree pprrootteeiinn,, wwhhiicchh iiss ssuubbsseeqquueennttllyy bboouunndd ttoo hhyyaalluurroonnaattee vviiaa aa lliinnkk pprrootteeiinn 44.. MMuullttiippllee lliinnkk pprrootteeiinnss bboouunndd ttoo aa ccoorree pprrootteeiinn,, wwhhiicchh iiss ssuubbsseeqquueennttllyy bboouunndd ttoo ggllyyccoossaammiinnooggllyyccaann 55.. MMuullttiippllee hhyyaalluurroonnaattee cchhaaiinnss bboouunndd ttoo lliinnkk pprrootteeiinn,, wwhhiicchh iiss ssuubbsseeqquueennttllyy bboouunndd ttoo ggllyyccoossaammiinnooggllyyccaann QQuueessttiioonn 8866:: PPrreessssuurriizzaattiioonn ooff iinntteerrssttiittiiaall fflluuiidd iiss oonnee mmeecchhaanniissmm ooff llooaadd ssuuppppoorrtt iinn aarrttiiccuullaarr ccaarrttiillaaggee.. FFlluuiidd wwiitthhiinn aa ccaarrttiillaaggee llaayyeerr iiss pprreessssuurriizzeedd uunnddeerr ddyynnaammiicc jjooiinntt mmoottiioonn bbeeccaauussee ooff wwhhaatt ffaaccttoorr?? 11.. LLooww hhyyddrraauulliicc ppeerrmmeeaabbiilliittyy ooff tthhee ttiissssuuee 22.. NNoonnppoorroouuss ssttrruuccttuurree ooff ccaarrttiillaaggee 33.. HHiigghh tteennssiillee ssttrreennggtthh ooff tthhee ccoollllaaggeenn ffiibbrriillss 44.. VViissccooeellaassttiicc sshheeaarr ffoorrcceess ooff tthhee mmaattrriixx 55.. LLooww ccooeeffffiicciieenntt ooff ffrriiccttiioonn aatt tthhee ccaarrttiillaaggee QQuueessttiioonn 8877:: WWhhaatt ffaaccttoorr hhaass bbeeeenn aassssoocciiaatteedd wwiitthh bbeetttteerr oouuttccoommee aafftteerr ccaarrttiillaaggee rreeppaaiirr aafftteerr ssuurrggeerryy?? 11.. OOllddeerr aaggee 22.. HHiigghheerr BBMMII 33.. LLoonnggeerr dduurraattiioonn ooff ssyymmppttoommss 44.. SSmmaalllleerr lleessiioonn ssiizzee 55.. HHiigghheerr ppaattiieenntt aaccttiivviittyy QQuueessttiioonn 8888:: WWhhiicchh ffaaccttoorr iiss nnoott aassssoocciiaatteedd wwiitthh tthhee lliimmiitteedd ccaappaacciittyy ooff ccaarrttiillaaggee ttoo hheeaall ffoolllloowwiinngg iinnjjuurryy?? 11.. LLaacckk ooff bblloooodd ssuuppppllyy

22.. IInnhhiibbiittiioonn ooff cceellll mmiiggrraattiioonn 33.. NNoo iinniittiiaall rreessppoonnssee bbyy cchhoonnddrrooccyytteess ttoo iinnjjuurryy 44.. EExxttrraacceelllluullaarr mmaattrriixx 55.. LLiimmiitteedd iinnffllaammmmaattoorryy rreessppoonnssee QQuueessttiioonn 8899:: WWhhaatt iiss tthhee rreellaattiioonnsshhiipp ooff tthhee iinnsseerrttiioonnss ooff tthhee LLCCLL aanndd tthhee ppoopplliitteeuuss tteennddoonn oonn tthhee ffeemmuurr?? 11.. TThhee ppoopplliitteeuuss iinnsseerrttiioonn iiss mmoorree ddiissttaall,, aanntteerriioorr aanndd ddeeeepp 22.. TThhee ppoopplliitteeuuss iinnsseerrttiioonn iiss mmoorree pprrooxxiimmaall,, aanntteerriioorr aanndd ddeeeepp 33.. TThhee ppoopplliitteeuuss iinnsseerrttiioonn iiss mmoorree ddiissttaall,, iinnffeerriioorr aanndd ddeeeepp 44.. TThhee ppoopplliitteeuuss iinnsseerrttiioonn iiss mmoorree pprrooxxiimmaall,, iinnffeerriioorr aanndd ddeeeepp 55.. TThhee ppoopplliitteeuuss iinnsseerrttiioonn iiss mmoorree ddiissttaall,, aanntteerriioorr aanndd ssuuppeerrffiicciiaall QQuueessttiioonn 9900:: LLiisstt tthhee ffoouurr kknneeee lliiggaammeennttss iinn oorrddeerr ooff bbiioommeecchhaanniiccaall ssttrreennggtthh ((llooaadd ttoo ffaaiilluurree)) ffrroomm wweeaakkeesstt ttoo ssttrroonnggeesstt:: 11.. AACCLL,, PPCCLL,, LLCCLL,, MMCCLL 22.. LLCCLL,, MMCCLL,, AACCLL,, PPCCLL 33.. LLCCLL,, AACCLL PPCCLL,, MMCCLL 44.. MMCCLL,, AACCLL,, PPCCLL,, LLCCLL 55.. PPCCLL,, AACCLL,, LLCCLL,, MMCCLL QQuueessttiioonn 9911:: What is the most common reason for failure of anterior cruciate ligament reconstruction? 1- Malposition of the bone tunnels 2- Medial meniscus deficiency 3- Lateral meniscus deficiency 4- Improper graft selection 5- Articular surface damage Question 92: What is the central concept in rehabilitating an athlete during nonsurgical care of an isolated grade II posterior cruciate ligament tear? 1- The knee should be splinted in full extension for 6 weeks. 2- Early range of motion and quadriceps strengthening should start as soon as pain permits. 3- Open chain hamstring strengthening exercises should be initiated early. 4- Functional braces have a high rate of success in patients with persistent symptoms. 5- Patients should not return to sport until hamstring strength equals the contralateral side. Question 93: What anatomic structure inserts most anteriorly on the proximal fibula? 1- Sartorius 2- Iliotibial band 3- Biceps femoris 4- Popliteofibular ligament

5- Lateral collateral ligament Question 94: A 12-year-old boy has had pain in the right knee for the past 6 weeks. He has had two episodes of giving way but no locking. He denies any history of injury. Examination reveals no effusion, ligaments are stable, range of motion is full, and there is no localized tenderness. Plain radiographs and MRI scans show a non-displaced OCD lesion of the medial femoral condyle. What is the most appropriate management? 1- Excision of the lesion 2- Retrograde drilling of the lesion 3- Antegrade drilling of the lesion 4- Arthroscopic reduction and fixation 5- Observation and limitation of activities Question 95: Without a history of a significant reinjury, a 22-year-old student reports recurrent instability 1 year after undergoing autologous patellar tendon anterior cruciate ligament reconstruction. What is the most likely cause of the instability? 1- Varus alignment 2- Tunnel malposition 3- Failure of biological graft ingrowth 4- Failure of bone healing in the tunnels 5- Unrecognized posterolateral corner injury Question 96: Plain x-rays of 30-year-old individual who sustained a noncontact knee injury while playing soccer 2 days ago show a capsular avulsion fracture of the anterolateral tibial plateau. What physical examination test is most likely to be abnormal? 1- McMurray 2- Lachman 3- Posterior drawer 4- Varus laxity at 30° 5- Patellar apprehension Question 97: A 25-year-old man injured his knee in a motor vehicle collision. Abnormal examination findings include 10° increased external tibial rotation at 30° and 90° knee flexion. What additional examination finding is expected? 1- Increased opening to valgus stress at 30° of knee flexion 2- Increased varus opening at 0° of knee flexion 3- Positive apprehension sign with lateral patellar translation 4- Positive pivot shift test 5- Medial tibial plateau rests 10 mm anterior to the medial femoral condyle Question 98: Current ACL injury prevention strategies for femal athletes have focused on which of the following strategies? 1 – Weight loss

2 – Avoidance of at-risk activities during certain phases of the menstrual cycle 3 – Neuromuscular control 4 – Year-round strength training 5 – Intercondylar notch widening Question 99: When Performing a single-bundle posterior cruciate ligament reconstruction, the graft should be tensioned when the knee is in what position? 1- Full extension 2- Full Flexion 3- 30° of flexion 4- 45° of flexion 5- 90° of flexion Question 100: What area of articular cartilage is most likely injured with patellar dislocation?

1- Medial trochlea 2- Odd facet of the patella 3- Medial facet of the patella 4- Lateral facet of the patella 5- Keel of the patella

Knee-Answers 1) 2 2) 2 3) 4 4) 2 5) 4 6) 5 7) 4 8) 3 9) 3 10) 4 11) 2 12) 3 13) 2 14) 5 15) 3 16) 1 17) 3 18) 2 19) 4 20) 1 21) 2 22) 2 23) 2 24) 1 25) 4 26) 2 27) 4 28) 3 29) 3

30) 5 31) 4 32) 4 33) 5 34) 5 35) 2 36) 3 37) 3 38) 4 39) 3 40) 5 41) 1 42) 5 43) 5 44) 2 45) 1 46) 5 47) 1 48) 5 49) 5 50) 5 51) 3 52) 1 53) 4 54) 4 55) 4 56) 5 57) 5 58) 2

59) 1 60) 1 61) 2 62) 3 63) 2 64) 3 65) 4 66) 3 67) 2 68) 2 69) 4 70) 2 71) 3 72) 1 73) 3 74) 3 75) 1 76) 3 77) 2 78) 1 79) 4 80) 4 81) 1 82) 3 83) 5 84) 1 85) 3 86) 1 87) 4 88) 3 89) 1 90) 3 91) 1 92) 2 93) 5 94) 5 95) 2 96) 2 97) 2 98) 3 99) 5 100) 3

AAOS Orthopaedic Review Course

Foot and Ankle Disorders

Steven L. Haddad, M.D.Associate Professor of Clinical Orthopaedic Surgery

University of Chicago Pritzker School of Medicine

Frequency of QuestionsOITE 

• Bunions & HV (11%) • Hallux rigidus (11%) • Other forefoot arthritis (6%) • Diabetic foot (5%) • Tendon disorders (3%) • Heel pain (3%) • Lesser toe deformities (2%) • Sesamoid disorders (2%) • Bunionette (1%) • Other - Morton’s neuroma, anatomy & problems, lesser MP joint synovitis/instability, sprains, ankle osteochondral lesions, ankle

Overview

Forefoot Midfoot Hindfoot Ankle Diseases

BunionsHallux RigidusHallux VarusHammertoesClawtoesMallet toesMTP InstabilitySesamoiditisBunionette

Arthritis Painful Flatfoot

Achilles tendonitis

Plantar heel pain

Just plantar fasciitis

InstabilityOCDArthritis

DiabetesRheumatoid

Arthritis

Bunions

BunionsTreatment

Conservative management is the best option

Find a shoe that fits the foot: wider toe box shoes, extra-depth toe box shoesShoe stretchingOrthotics have value in those with pes planus and hypermobility

BunionsTreatment

Conservative management is the best option

Find a shoe that fits the foot: wider toe box shoes, extra-depth toe box shoesShoe stretchingOrthotics have value in those with pes planus and hypermobility

BunionsSurgery

Angles of Measurement

Intermetatarsal angle

Normal<9°

BunionsSurgery

Angles of Measurement

Hallux valgus angle

Normal<15°

BunionsSurgery

Angles of Measurement

Distal metatarsal articular angle

Normal<6°

BunionsSurgery

Angles of Measurement

Hallux interphalangealangle

Normal<10°

BunionsHallux Valgus

Congruent Incongruent Degenerative

BunionsHallux Valgus

Congruent Incongruent Degenerative

Biplanar Akin and DoubleChevron Exostectomy Osteotomy

Bunion DeformitiesCongruent

Biplanar Chevron Osteotomy

Bunion DeformitiesCongruent

Akin OsteotomyHallux valgusinterphalangeus 3mm

Bunion DeformitiesCongruent

Double OsteotomyFor those with larger intermetatarsal angles (>15°):

Bunion Deformities Incongruent Joints

IM<15°; HV< 30° Distal Osteotomy (Chevron)*

*May add an Akin (double osteotomy)

IM>15°; HV< 40° Prox. Osteotomy (Crescentic, Oblique, Scarf)and distal soft tissue release*

IM>20°; HV>40° Proximal Osteotomy anddistal soft tissue release* or MTP arthrodesis

*May add an Akin (double osteotomy)

Bunion Deformities Incongruent Joints

Bunion Deformities Incongruent Joints

TMT Hyper mobility TMT arthrodesis (Lapidus) and DSTR

*May add an Akin (double osteotomy)

Bunion DeformitiesDegenerativeHallux Valgus

Congruent Incongruent Degenerative

FusionImplant

KellerResection Arthroplasty

Note auto-correctionOf IMA

Bunion DeformitiesDegenerative Hallux Valgus

Congruent Incongruent Degenerative

FusionImplant

KellerResection Arthroplasty

Shortening isn’tThe only problem

Bunion DeformitiesDegenerative Hallux Valgus

Congruent Incongruent Degenerative

FusionImplant

KellerResection Arthroplasty

Shortening isn’tThe only problem

Bunion Complications

Chevron OsteotomyAvascular necrosis

Kenzora (1985): Suggested 20% in distal osteotomies

40% of this group had lateral releaseVery low N

Resch (1992): Defined blood supply and determined not at risk with careful dissectionRichardson (1994): 0% in 80 cases with lateral release

2.5cm

Bunion Complications

First metatarsophalangealjoint arthrodesis

MalunionFollow guidelines:

15 to 20 degrees of dorsiflexion with respect to 1st metatarsalNeutral rotation10° to 15° degrees of valgus

Bunion Complications

Hallux varusBy definition: medial deviation of great toeObserved after:

Lateral collateral ligament disruptionOvercorrectionExtreme ligament laxity (ieEhlers Danlos)

Conservative managementTape

Bunion Complications

Hallux varusSurgery

Passively correctible with no arthritis

EHB tendon transfer vs. split EHL tendon transfer

Bunion Complications

Hallux varusSurgery

Rigid deformity, arthritis1st MTP fusion

Hallux Rigidus

Hallux RigidusSecond most common pathology affecting 1st

metatarsophalangeal jointVariations of osteoarthritis

Grade 1: Mild periarticularosteophytes, no joint space collapse, stiff ROM

Hallux RigidusSecond most common pathology affecting 1st

metatarsophalangeal jointVariations of osteoarthritis

Grade 2: Significant osteophytes, joint space visible but narrowed

Hallux RigidusSecond most common pathology affecting 1st

metatarsophalangeal jointVariations of osteoarthritis

Grade 3: Severe osteophytes, joint space completely collapsed

Hallux Rigidus

Conservative managementExtra depth shoes to accommodate bumpSteel shank placed in shoe sole v. carbon fiber footplate with Morton’s extension to protect 1st MTP motionRocker bottom sole to shoe

Hallux Rigidus

Conservative managementRocker bottom sole to shoe

Hallux RigidusSurgery

Cheilectomy (Grade 1,2)Allows shaving of up to 30% of metatarsal headMann (1988)

90% with pain relief38% with Grade 3 dissatisfied

Moberg osteotomy (1979)Goal is to achieve 25°dorsiflexionSmith (1999)

96% satisfaction v. 76% with cheilectomy alone

Hallux RigidusSurgery

Type 3: first metatarsophalangeal joint arthrodesis

Must prepare surfaces carefully

Keller arthroplasty, Implant arthroplasty

Limited indications (elderly, low demand ONLY)

Lesser Toes

Lesser Toe Deformities

HammertoeExtension MTPFlexion IPExtension DIP

Silipos SleeveShoe StretchMetatarsal pad Budin splint

Conservative Care

Lesser Toe Deformities

ClawtoeExtension MTP Flexion PIPFlexion DIP

Toe CrestSilipos Sleeve

Conservative Care

Lesser Toe Deformities

Mallet toeFlexion DIP

Toe Tip Silipos

Conservative Care

Lesser Toe DeformitiesFixed Flexible

Hammertoe Proximal interphalangeal joint resection arthroplastyEDL lengthening MTP capsulotomy and collateral ligament release

FDL to EDL transfer (Girdlestone-Taylor)

* Address EACH joint Deformity, think flexible or fixed

Lesser Toe DeformitiesFixed Flexible

Clawtoe PIP joint resection arthroplastyDistal interphalangeal joint resection arthroplastyFDL tenotomy

FDL tenotomy

* Address EACH joint Deformity, think flexible or fixed

Lesser Toe DeformitiesFixed Flexible

Mallet toe Distal interphalangeal joint resection arthroplasty

FDL tenotomy

* Address EACH joint Deformity, think flexible or fixed

Metatarsophalangeal Joint Instability2nd metatarsophalangeal jointStability of the joint compromised through

Laxity of volar plate (stretch or rupture)Subsequent rupture of lateral collateral ligament

Dorsal subluxation, dislocation of MTP joints

Weil OsteotomyDistal metatarsal osteotomy

Useful for dislocated 2nd MTP jointWeil-Barouk (1994)

“axial decompression resolving the hammer toe/MP subluxation that increases metatarsalgia”

Weil OsteotomyDistal metatarsal osteotomy

Vandeputte (FA Int, 2000)Excellent or good in 86%95% had reduction in callus

Sesamoid Disorders

Sesamoid DisordersHistory

Pain under plantar 1st

metatarsal (sesamoid)Acute dorsiflexion event

Heard “pop”

RadiographsStanding foot films

Medial bipartite 10%Lateral rarely bipartitieBilateral bipartite 25%

Sesamoid viewOsteochondritisDegenerative between sesamoid at MT head

Sesamoid DisordersMRI better than bone scan, more helpful in difficult cases

Avascular necrosis, non-union, acute fracture

Bone scan – obtain when xrays normal & pain persists

Results may be obscured if there are degenerative changes in the MTPJCollimation will help Increased activity reported in up to 30% of asymptomatic people especially elite athletes

Sesamoid Disorders

Acute Fracture Cast 6 weeks NWB

Alter biomechanicsAlter trainingOrthotics

Non-union Bone graftCastPartial or Total

Sesamoidectomy

Alter biomechanics

Disorder Management Permanent Issues

Sesamoid DisordersTreating altered biomechanics

Utilize off-loading orthoticCarbon-fiber with sesamoid welled-outUtilize plastazote if patient cannot tolerate carbon-fiber

Sesamoid ProblemsSynchondrosisPain

Bipartite80% tibial25% bilateral

Partial sesamoidectomy

Arthritis Total Sesamoidectomy

AVN;Osteochondritis

Partial or Total Sesamoidectomy

IPK Risk of disruption FHB

Plantar Shaving

Sesamoid ComplicationsMedial sesamoidectomy

Inadequate repair FHB: Hallux ValgusMedial plantar nerve at risk

Sesamoid ComplicationsLateral sesamoidectomy

Inadequate repair FHB: Hallux VarusLateral plantar nerve at risk

Sesamoid ComplicationsBoth sesamoids removed

Cock-up toe

Bunionette BunionetteDavies: Initial Description (1949)

pressure over lateral condyle 5th metatarsal head

bursa irritation

Bunionette ClassificationType 1

Enlarged 5th metatarsal head

true hypertrophyexostosis

Bunionette ClassificationType 2

Bowing of the diaphysis laterally

congenital

Bunionette ClassificationType 3

Widened 4th—5th

intermetatarsal angle

Bunionette Surgical ManagementType 1

Isolated metatarsal head shaving

Fallen out of favorKitaoka (1991)

Disruption lateral capsule creates increased valgus of 5th

toeChevron osteotomy with lateral capsule release

1mm shift reduces 4th—5th IM angle by 1 degreeUsual displacement 3 to 4mmLimitation imposed by width of metatarsal neck

Type 2 and 3Both treated similar due to wide IMAOblique diaphyseal 5th

metatarsal osteotomy described by Mann (1986)May be uniplanar or biplanar

Adds advantage of correcting plantar AND lateral keratosesMedial capsule release may be added to improve correction of 5th toe

Bunionette Surgical Management Bunionette Correction

Proximal osteotomiesAvoided in the 5th

metatarsal shaft due to potential violation of blood supply

High rate of nonunion

Midfoot Disorders Midfoot ArthritisComprises tarsometatarsal and naviculocuneiform arthritic conditions

AnatomyBone

Three separate columnsBased on Stability, Structural Rigidity, Movement

Medial: 1st MT + medial cuneiform3.5mm dorsal/plantar movement

Middle: 2nd/3rd MT + middle/lateral cuneiform

0.6mm dorsal/plantar movementLateral: 4th/5th MT + cuboid

13mm dorsal/plantar movementpronation and supination

Midfoot ArthritisPhysical Exam

Painful, swollen midfoot

2nd TMT most common

“Piano Key” testFlatfoot deformity

Standing Foot Films

Midfoot Arthritis

Conservative careStiff sole shoe with Vibram® solePlastazote insert

Support, don’t correct deformityDo not use rigid orthotics

Cortisone injectionsMay require fluoroscopy

Midfoot ArthritisSurgery

Hansen (1990)Accuracy of reduction of deformity correlates directly with patient satisfactionDo not fuse in situ

Midfoot ArthritisSurgery

Hansen (1990)Accuracy of reduction of deformity correlates directly with patient satisfactionDo not fuse in situ

Midfoot ArthritisSurgery

Mann (1996)If joint has questionable arthritis, fuse it at index procedure

Do not fuse lateral columnMaintain mobility through joint arthroplasty

Hindfoot Tarsal Coalition

FactsResults from failure of differentiation → lack of joint formationIncidence debated between <1% to 12%

Bilateral in 20 – 60%Talocalcaneal & calcaneonavicular more common than talonavicularPresentation freq after trauma i.e. sprained ankle

Tarsal Coalition

Physical ExaminationFlatfoot deformity of variable rigidityTalocalcaneal

no calcaneal inversion w/ heel rise; medial pain over middle facet

Calcaneonavicularfraction of inversion compared to contralateral side, TT motion limited

Occasional bony prominenceStressing coalition may elicit pain

Tarsal Coalition

ImagingXray – WB AP, lateral, oblique

Look for distortion of normal bone anatomyLateral – talar beaking

Tarsal CoalitionImaging

Calcaneonavicular coalition:

Internal oblique xray as union or extension of ant neck of calc to navicular

Tarsal Coalition

ImagingTalocalcaneal

Visualized as narrowing of post subtalar joint, loss of middle facet, flattening of talar neck

Tarsal CoalitionImagingCT – limited ability to assess fibrous coalition, MRI better

Tarsal Coalition

TreatmentConservative

NSAIDsActivity modificationSLC immobilizationOrthoses

OperativeSymptomatic & <14 yrs resection +/- interposition grafting/bone waxOlder, more severe involvement, degenerative changes → fusion

Also, if greater than 50% of the TOTAL talocalcaneal joint involved=fusion

Tarsal Coalition Adult Acquired Flatfoot

Adult Acquired FlatfootPrimary offender

Posterior tibial tendon insufficiency

Anatomy2 cm excursionWatershed zone of vascularity

Between Medial Malleolus and Navicular

Ultimate failure: Spring Ligament

Joins calcaneus to navicular

Acts as a sling supporting talonavicular joint

FunctionInvert hindfoot, adduct forefootProduced rigid lever for toe off

Adult Acquired FlatfootPrimary offender

Posterior tibial tendon insufficiency

Anatomy2 cm excursionWatershed zone of vascularity

Between Medial Malleolus and Navicular

Ultimate failure: Spring Ligament

Joins calcaneus to navicular

Acts as a sling supporting talonavicular joint

FunctionInvert hindfoot, adduct forefootProduced rigid lever for toe off

Adult Acquired FlatfootPrimary offender

Posterior tibial tendon insufficiency

Anatomy2 cm excursionWatershed zone of vascularity

Between Medial Malleolus and Navicular

FunctionInvert hindfoot, adduct forefootProduced rigid lever for toe off

Adult Acquired Flatfoot

Thus, when it goes bad:

Hindfoot valgus

Forefoot Abduction

Adult Acquired FlatfootRadiographs

Standing Foot seriesTalonavicular incongruency Subluxation subtalar jointArthritis

Adult Acquired FlatfootRadiographs

Standing Foot seriesTalonavicular incongruency Subluxation subtalar jointArthritis

Adult Acquired FlatfootRadiographs

Standing A/P ankleTalar tiltFibula fracture

Adult Acquired FlatfootRadiographs

+/- MRI

Adult Acquired FlatfootNon-operative treatment

Medial heel and sole wedge orthosis

Adult Acquired FlatfootNon-operative treatment

UCBL orthosisCustom molded lace up ankle braceAFO

StagingDisease is on a continuum, but artificially staged

Stage 1: tenosynovitis

StagingDisease is on a continuum, but artificially staged

Stage 2: rupture, passively correctable

StagingDisease is on a continuum, but artificially staged

Stage 3: rupture, rigid deformity

As If We Didn’t Have Enough Stages

Stage 4 (Myerson): ankle arthritis

valgus angulation of talus

Adult Acquired Flatfoot Stages

Stage 1 Stage 2 Stage 3

PTT Peritendonitis Elongation AbsentHindfoot Mobile, normal Mobile/valgus Rigid

Pain Medial/focal Medial Medial/Lateral

SLHR Negative Positive Positive“Too…” Negative Positive Positive

Path Synovial Prolif Degeneration Degeneration

Adult Acquired Flatfoot Surgery

Stage I (after 3-6 months)TenosynovectomyEvaluate carefully for deformity

Stage IITendon and Bone work +/-TAL/Strayer

FDL to PTT transfer AND (one or more…)

Medial displacement calcaneal osteotomyLateral column lengthening (abduction)Spring ligament repair

Adult Acquired Flatfoot Surgery

Stage I (after 3-6 months)TenosynovectomyEvaluate carefully for deformity

Stage IITendon and Bone work +/-TAL/Strayer

FDL to PTT transfer AND (one or more…)

Medial displacement calcaneal osteotomyLateral column lengthening (abduction)Spring ligament repair

Adult Acquired Flatfoot Surgery

Stage IIITriple arthrodesis with deformity correctionTAL/Strayer

Stage IVTriple arthrodesis with deltoid reconstruction

Most longstanding hindfoot valguspatients have an isolated contracture of the gastrocnemius

Test ankle flexibility with the knee in full extension and full flexion

Notice improved dorsiflexion with the need flexed (relaxing gastroc)

Requires Strayer procedure

Cavovarus Deformities Cavus FootAbnormal elevation of the medial arch in weightbearing = cavus

Forefoot equinusrelative to the hindfootForefoot pronationfrom plantarflexion of the first MT relative to the hindfootEquinus and calcaneus describe position of the hindfoot

Cavus Foot

Wide spectrum of disease

Mild elevation of the longitudinal archRigid deformities

Secondary arthritisStress fracturesProfound weaknessLigamentousinsufficiency

Etiology

Often underlying spinal cord or neuromuscular etiology

Common factor is a muscle imbalance that disturbs the synergy between intrinsic and extrinsic muscles

EtiologyPotential progressiveneurological disorders

2/3 with high arch have underlying progressive neurological condition

Hereditary Sensory Motor Neuropathies

1/2 of these have Charcot-Marie-Tooth

Inherited degenerative disorder of the central and peripheral nervous system

Muscle atrophyLoss of proprioception

Bilateral Condition

EtiologyUnilateral involvement: static condition

PoliomyelitisSpina Bifida

Lesions below 2nd sacral segment

Loss of intrinsic muscles to the foot

TraumaDeep posterior compartment syndromeCrush injuries to the foot with intrinsic muscle ischemia

Pathophysiology

Progressive conditionsCaused by overpull of one muscle relative to weak antagonist

Initially flexible, becomes rigid deformityProgressive means NOT static: muscles will continue to weaken, creating further deformity

May affect an initially excellent surgical correction

Physical ExaminationPosterior v. Anterior

Anterior Pes CavusCalcaneal shape and orientation normal

Gastrocnemius-soleus LASTmuscle group affected

Origin of cavus from MIDFOOT, with plantarflexion of metatarsalsRadiographically:

arch high, plantar angulationoriginates at or between the transverse tarsal and tarsometatarsal jointscalcaneal pitch angle less than 30 degrees

20°

Physical ExaminationPosterior v. Anterior

Anterior Pes Cavus: HSMN

Evaluate valgus of forefoot with patient prone

Physical ExaminationPosterior v. Anterior

Anterior Pes Cavus: HSMNColeman lateral block test evaluates rigidity of the hindfoot in the deformity

Block placed under heel and lateral forefootAllows first ray to drop to floorIf hindfoot corrects, this is a flexible hindfootdeformity

Physical ExaminationPosterior v. Anterior

Anterior Pes Cavus: HSMNMuscle weakness:

Anterior Tibial Tendon: becomes weak earlyPeroneus Brevis: becomes weak earlyPeroneus Longus: remains strong, pulling the 1st ray into plantarflexionwithout opposition (ATT)Posterior Tibial Tendon: remains strong, aggravates hindfoot varuswithout opposition (PB)Intrinsics: becomes weak earlyExtensor Digitorum Longus: remains strong, creating clawtoecontractures without opposition (Intrinsics)

Treatment: Anterior Pes CavusGlobal Metatarsus Equinus

ConservativeUsually function well, no calcaneal varusProblems with metatarsalgia, clawtoesOrthosis made with thermal moldable cork transfers weight to metatarsal shafts

PPT to cushion the metatarsal heads

Deep toe box for clawtoes

Treatment: Anterior Pes Cavus

Global Metatarsus Equinus

SurgicalMultiple basal metatarsal dorsiflexion osteotomies

May result in “bayonet”shaped foot

Plantar fascia release to allow closure of osteotomies

Treatment: Anterior Pes Cavus

Treatment: Anterior Pes Cavus

HindfootLateral displacement calcaneal osteotomy

Add closing wedge to eliminate deforming force

Treatment: Anterior Pes Cavus

Forefoot valgusSurgical: Hindfoot varusrigid

Peroneus longus to peroneus brevistendon transfer

Eliminated longus as deforming force plantarflexion 1st rayAssists weakened peroneus brevis in active eversion and ankle stability

Results

Combination of procedures required, thus results for any particular procedure absent in literature

Most studies agree that joint preserving operations leave higher patient satisfaction than triple arthrodesis

Wetmore and Drennan (1989): 24% good to excellent results with triple for cavusMann and Hsu (1992): 42% with plantigrade foot following triple for cavus

Plantar Heel Pain

Plantar Heel PainDifferential Diagnosis

Proximal Plantar FasciitisTarsal Tunnel SyndromeCalcaneal Stress FractureHeel Pad Atrophy

Plantar Heel PainEvaluation

Localized painQuality of painMechanical vs. neuritis painPast history (cortisone ruptures PF)Systemic symptoms (spondyloarthropathies)

Plantar Heel PainProximal Plantar Fasciitis

Plantar medial heel painWorst in am with first few steps or after sitting (mechanical)

Plantar Heel PainProximal Plantar Fasciitis

Plantar medial heel painHeel spur (attachment of EHB) irrelevant

Only 50% have spurs

Plantar Heel PainProximal Plantar Fasciitis

Plantar medial heel painNon-op treatment 6-9 months

Stretching PF and AchillesNSAIDShock absorbing soles and orthosesPhysical therapyCortisone injectionNight splints (50-80% successful)

Plantar Heel PainProximal Plantar Fasciitis

Plantar medial heel painNon-op treatment 6-9 months

Stretching PF and AchillesNSAIDShock absorbing soles and orthosesPhysical therapyCortisone injectionNight splints (50-80% successful)

Plantar Heel PainProximal Plantar Fasciitis

Plantar medial heel painNon-op treatment 6-9 months

Stretching PF and AchillesNSAIDShock absorbing soles and orthosesPhysical therapyCortisone injectionNight splints (50-80% successful)

Plantar Heel PainProximal PF

Operative treatmentLAST RESORT

6 months of failed conservative careEndoscopic vs open release

Partial release (medial and central slips)Release first branch to lateral plantar nerve (Baxter’s nerve)Complete release leads to dorso-lateral foot pain

Plantar Heel PainProximal PF

Operative treatmentLAST RESORT

Extracorporeal Shock Wave RxHigh Energy

Single treatment of 1000-impulse, anesthesia required

Low Energy20 minutes session, no anesthesia

Literature suggests 80% success rate

History of increased activityTenderness with medial and lateral compression heelPain may be present with or without weightbearingFracture line is perpendicular to trabecularboneTreatment

SLC NWB for 6-8 weeksAlter training or biomechanics

Plantar Heel PainCalcaneal Stress Fracture

Achilles Tendinosis/Chronic Rupture

Achilles Bursitis Retrocalcaneal

Achilles ParatendonitisThickened paratenon, normal tendon

Achilles TendinosisFocal degeneration within tendon

Posterior Heel PainAchilles Tendon Disorders

Mean Age 24-30 years; range 16-52Etiology

OverusePoor training conditionsFoot architecture

Varus hindfootPoor vascularity

Watershed area 4 to 6cm proximal to insertion

Systemic disease (Reiter’s Syndrome, HLA-B27)Tendon narrowest 4cm proximal to insertion

Posterior Heel PainChronic Achilles Tendinosis

RadiographsStanding ankle series

Calcifications in Achilles (intrasubstance or insertion)Soft tissue swellingHaglund’s Deformity

Prominence of posterior calcaneus

MRIPreop for OR

Posterior Heel PainChronic Achilles Tendinosis

Haglund’s

Posterior Heel PainChronic Achilles Tendinosis

SurgeryParatendonitis (after 6 months conservative)

Brisement (injections)Excision of paratenon

Intrasubstance tendinosisAggressive debridement

Excision of entire diseased segment if full thickness

Posterior Heel PainChronic Achilles Tendinosis

SurgeryIntrasubstance tendinosis

VY advancement/ turndown to fill void

Posterior Heel PainChronic Achilles Tendinosis

SurgeryFlexor hallucis longus tendon transfer required if more than 50% of tendon removed

Pulvertaft tendon weave

Posterior Heel PainInsertional Achilles Tendinosis

SurgeryHaglunds with insertionalcalcifications

Central splitting approachRemove entire exostosis

Debride Achilles insertion

Posterior Heel PainInsertional Achilles Tendinosis

SurgeryHaglunds with insertionalcalcifications

Flexor hallucis longus tendon transfer to calcaneus through posterior incision

Posterior Heel PainInsertional Achilles Tendinosis

SurgeryHaglunds with insertionalcalcifications

Repair limbs of Achilles to calcaneus

Ankle Instability Ankle InstabilityInstability = Pain

Osteochondritis dessicans talusPeroneal Tendonitis (Peroneus Brevis)Occult fracture (anterior process calcaneus, lateral process talus, posterolateral tubercle talus; 5th MT) Peroneal tendon subluxation/dislocationAnkle arthritis

AnatomyATFL 66%ATFL and CFL 25%PTFL rarely injured

Ankle InstabilityAcute lateral ankle sprain

85-95% improved with Functional Rehab

RICEAnkle BraceAnkle ROM, Peronealstrengthening, proprioception15-20% residual instability episodesNO ACUTE REPAIR

Ankle Instability

Ankle instabilityMechanical (demonstrate on stress x-rays)Functional (“feelings of giving way”)

BOTH treated the same wayFunctional rehab initially 6-8 weeks

If recurrent instability then Modified Brostrom lateral lig repair

Tendon weave procedures reserved for Large Athletes and hypermobilitysyndromes (Chrisman-Snook)

Surgery is 90-95% successfulBrostrom has lower complication rate

less nerve damageno loss of subtalar motion (inversion)modification

inferior extensor retinaculumaugmentation provides subtalar stability

Beware of Hindfoot VarusMay need calcaneal osteotomy

Ankle InstabilitySurgery is 90-95% successfulBrostrom has lower complication rate

less nerve damageno loss of subtalar motion (inversion)modification

inferior extensor retinaculumaugmentation provides subtalar stability

Beware of isolated subtalarinstablity

difficult to diagnosetreatment with standard ligament reconstruction

Ankle Instability

Osteochondritis Dissicans Talus Osteochondritis DissicansPosteromedial

Avascular lesionCongenital

AnterolateralTrauma induced

Talus OCD

ConservativeNon WBCortisone injection

OperativeDebridement, microfracture, drilling

70 to 90% good to excellent results

OATS, Mosaicplasty, CarticelSalvage procedures (p 493, OKU8)88 to 94% good to excellent results

Ankle ligament repair simultaneously

Systemic Conditions

Rheumatoid ArthritisInflammatory Arthropathies

Rheumatoid Arthritis

17% RA begins in feetMTP< talonavicular<subtalar<calcaneal cuboidAnkle and Midfoot arthritis occur

commonly do not require treatment

89% RA patients have foot involvementHLA-DRW4

Inflammatory ArthropathiesRheumatoid Arthritis

Forefoot deformityHallux valgus with joint changesDorsolateral MTP subluxation/dislocation

Synovitis of MTP jointsIncompetency of plantar plateDistal migration of the plantar fat pad“uncovering” of MTH

Symptoms“Walking on marbles”; occasional ulcerationDifficulty fitting into shoesJoint pain

Rheumatoid ArthritisForefoot

Conservative treatmentTotal contact orthosesExtra depth shoe/shoe stretchingMaximize medical management

OperativeSynovectomy if early (after 3-6 months non-operative management)1st MTP arthrodesis and metatarsal head resections 2nd

through 5th (Hoffman)

Rheumatoid ArthritisForefoot

Conservative treatmentTotal contact orthosesExtra depth shoe/shoe stretchingMaximize medical management

OperativeSynovectomy if early (after 3-6 months non-operative management)1st MTP arthrodesis and metatarsal head resections 2nd

through 5th (Hoffman)

Rheumatoid ArthritisHindfoot

TreatmentConservative

UCBL orthosis or custom lace up ankle braceMaximize medical management

OperativeTenosynovectomy (joint or posterior tibial tendon)Arthrodesis of affected joints

Rheumatoid ArthritisHindfoot

Subtalar Arthrodesis5° valgus hindfoot alignment

Chopart’s joints (talonavicular/ calcaneocuboid)

Neutral abduction/adductionNeutral varus/valgus

Rheumatoid ArthritisAnkle

ConservativeSolid ankle AFOMaximize medical management

OperativeArthrodesis…GOLD STANDARD

5-10° External rotation0-5° Dorsiflexion5-10° Valgus

Distraction ArthroplastyAnkle Replacement

Rheumatoid ArthritisAnkle

ConservativeSolid ankle AFOMaximize medical management

OperativeArthrodesis…GOLD STANDARD

5-10° External rotation0-5° Dorsiflexion5-10° Valgus

Ankle Replacement

Diabetes

The Diabetic FootNeuropathy

Autonomic neuropathy develops from injury to the nerves

Apocrine/endocrine sourcedue to poorly controlled glucose balance

Pre-arteriole Vascular Controldue to decreased blood flow to the nervesless likely, as blood flow is initially increased

Diabetic Foot

The ProblemsNeuropathy

SensoryPolyneuropathySemmes-Weinstein monofilament 5.07

MotorMost commonly common peronealFoot drop and intrinsic clawtoes

AutonomicDry, scaly, fissuring skin leads to loss of skin integrity

Diabetic FootPeripheral vascular disease

Small and Large vessel diseaseNon-palpable pulses get non-invasive vascular studiesABI >0.45 for healing (diabetics)Absolute toe pressures >0.40 mm Hg

Calcifications in vessels lead to falsely pressures

Tc0² toe > 30-40 mmHg

Hypomobility SyndromeGlycosolated tissue leads to soft tissue contractures

Achilles tendonClawtoes

Diabetic FootImmune system impairment

Altered chemotaxisPoor phagocytosisPoor cytotoxic environment ( sugars)

Metabolic deficiencyAlbumin < 2.5 g/dLWBC < 1500 Total protein < 6.0

Diabetic UlcersUlcers (Painless)

Due to increased pressure (bone prominence) and neuropathyClassified by depth, location, infection

Wagner 1-5 (0 = at risk)

Heel is worst

1 Superficial ulcer

2 Deep ulcer

3 Abscess

4 Forefoot gangrene

5 Full foot gangrene

Conservative Ulcer Management

Total Contact CastBrand developed in 1950Cast must be changed weeklyContraindications

Active infectionVascular diseaseNoncompliant

Diabetic Ulcers

May require supplementary procedures to lessen deforming forces

HokeStrayer

Diabetic FootUlcers Treatment

Wagner 1,2 Total contact cast or brace until healedTotal contact insert, appropriate shoes and/or bracewearSurgery for ostectomy or osteotomy to improve alignment if reoccurrenceTAL

Wagner 3,4,5Surgical debridement or amputation +/- TALTotal contact cast until healedAppropriate inserts/shoes/brace

Diabetic FootInfection

PolymicrobialCulture of ulcer NOT helpfulProbe to bone 67% sensitive for infectionIntra-op cultures at time of surgery

InjectablesPiperacillin/TazobactamAmpicillin/SulbactamTicarcillin disodium/Clavulanatepotassium

Ciprofloxacin hydrochloride (good for staph, pseudomonas poor for anaerobes, strep

Contraindicated in children, pregnancyIsolated Tc scan not helpful (TC/IND)

+ with charcot arthropathyAdd tagged WBC scan

MRI may be helpful

Diabetic FootCharcot Arthropathy

Neuropathic OsteoarthropathyDestructive bone fractures and joint dislocations associated with peripheral neuropathyErythema, Warmth Swelling (skin intact)Staged: Eichenholtz 1,2,3

IF acute fracture (Stage 1) and unstable

fix the fracture and cast 2-3 times longer than normalAnkle needs to be braced with AFO for 1 year

Diabetic FootCharcot Arthropathy

Stage 2 FracturesCast until swelling, erythema, warmth resolves (Stage 3) then OR if unbraceable

Stage 3 CharcotBrace if no complicationsOR for Plantigrade Foot

Charcot ArthropathyStage 1Frag.

Red, hot and warm

Rads normal or fragmenting; demineralized

Stage 2Coales.

Red hot and warm but less so

Rads show less acute fragments and joint disruption

Stage 3Consol.

Temp normal; no swelling; may have deformity

Bone healing

Don’t operate on WET WOOD

Thank You

35 yo woman underwent a distal chevron osteotomy for a hallux valgus deformity complicated by a post operative

infection 2 years ago. The patient now has a painful limited hallux MTP motion without drainage. Surgical

management should consist of a

1. Silastic implant

2. 1st MTP arthrodesis

3. Resection arthroplasty (Keller)

4. First Ray amputation

5. Fascial arthroplasty

37 yo woman with seronegative RA underwent a bunionectomy without complications 1 year ago. Now has

a recurrence of pain and difficulty with accommodative shoe wear. Examination demonstrates a recurrent bunion

and pain at the MTP joint. Which is the best course of treatment?

1. Modified Lapidus procedure

2. MTP arthrodesis

3. Proximal first MT osteotomy and DSTR

4. Akin Osteotomy

5. Resection arthroplasty of the Hallux-MT joint

The figure below shows the radiograph of an 82 yo male with a hammertoe deformity of the 2nd toe and a bunion deformity associated with a painful callosity under the

Hallux IP joint. The patient has type II DM which is well controlled with oral meds. Surgical treatment should

consist of

1. A distal Chevron bunionectomy

2. A proximal 1st MT osteotomy and DSTR

3. Resection arthroplasty of the 1st MTP joint (Keller)

4. Arthrodesis of the 1st MTP joint

5. Silicone arthroplasty

57 yo woman with pain from shoe abutment on the halluxand difficulty fitting into shoes 4 years after a bunion

procedure (radiograph below). Exam reveals a flexible 1st

MTP and IP joints. Surgical treatment consists of

1. 1st MTP arthrodesis

2. FHL transfer with IP arthrodesis and medial soft tissue reconstruction

3. Reconstruction with the EHL or EHB tendon transfer

4. Closing wedge osteotomy hallux proximal phalanx

5. A Keller bunionectomy with medial soft tissue reconstruction

Which is the best orthotic prescription for treatment of the symptomatic condition shown below?

1. Longitudinal metatarsal arch support

2. Soft liner

3. Full-length rigid orthosis

4. UCBL orthosis

5. Bunion splint

The clinical picture below is of a 26 yo patient 1 year after a crush injury to the foot. The patient has symptomatic lesser toe deformities with MTP ext, a stiff flexed toe at the PIP joint and a flexible DIP joint. Ankle DF does not affect toe motion.

Surgical management includes1. Intrinsic muscle stripping of the affected toes on

the plantar foot.

2. Excision of the contracted intrinsic muscles of the plantar foot.

3. Lengthening of the EDL, resection of the DPPP and FDL tenotomy.

4. PIP joint resection arthroplasty and a Flex to Ext transfer

5. FDL and EDL tenotomies of the affected toes

A 56 yo woman has a discreet, painful hyperkeratotic lesion under the plantar medial aspect of the 1st MTH.

Conservative management has failed, treatment should now consist of

1. Shaving of the tibial sesamoid

2. Shaving of the tibial and fibular sesamoids

3. Excision of both the tibial and fibular sesamoids

4. Dorsiflexion MT osteotomy

5. 1st MTP arthrodesis

47 yo woman with a symptomatic bunion refractory to non-op methods and pain over a prominent 5th MTH. In

addition to the bunion correction treatment should include

1. Pressure relief on the fifth MTH

2. Proximal midshaft osteotomy of the 5th MT

3. Resection of the lateral exostosis of the 5th MTH

4. Resection of the 5th MTH

5. Resection of both the 5th proximal phalanx and the lateral condyle of the 5th MTH

16 year old boy with an asymptomatic flatfoot

1. OBSERVATION

2. OBSERVATION

3. OBSERVATION

4. OBSERVATION

5. OBSERVATION

2. 16 year old boy with a symptomatic fixed flatfoot, non-op treatment failed

Dx: Tarsal coalition; CT scan to evaluate for excision or Arthrodesis

3. 55 year old man with NIDDM and painless flatfoot

Dx: Charcot arthropathy; Tx Bracewear and Custom orthoses

53 yo female with diffuse swelling and pain in the right ankleFor 1 month. She is unable to perform a single limb heelrise due to pain but can initiate a double heel rise. No injury Was sustained and no prior treatment has been rendered. Examination reveals tenderness and fullness along the posteriorTibial tendon. Standing examination demonstrates a planovalgusFoot deformity. Treatment should consist of:

1. A short leg walking cast then bracewear2. A custom-molded shoe3. A corticosteroid injection into the posterior tibial tendon

sheath4. Physical therapy for ROM and Strengthening 5. Surgical reconstruction

The diagnosis and treatment of tarsal tunnel syndromeShould be primarily based on

1. Clinical symptoms and physical findings2. Radiographic studies3. MRI studies4. Electrodiagnostic studies5. Response to corticosteriod injection

30 yo male with posterior heel pain which began 9 monthsearlier after playing soccer. No history of trauma. MRI demonstrates a fusiform swelling of focal degeneration of the Achilles 3 cm proximal to insertion. Treatment to date has included heel lifts, NSAIDS, PT without success.the patient has been unable to play soccer due to this pain.Management should now include:

1. Surgical debridement of the paratenon2. Surgical debridement of the involved area of the Achilles3. Resection of the involved Achilles tendon with a flexor

hallucis longus tendon transfer4. Injection of cortisone into the involved area of the Achilles5. Gastrocnemius recession with paratenolysis

A 53 yo male sustains a spontaneous non-traumatic ruptureOf the Achilles tendon. This condition may be associated With the use of what class of antibiotics?

1. Penicillins2. Aminoglycosides3. Antifungals4. Fluoroquinolones5. Cephalosporins

34 yo man with no history of trauma has has bilateral posteriorHeel pain for the past 15 months and a painful swollen fourth Toe for the past 6 weeks. Examination reveals retrocalcanealTenderness at the Achilles insertion and bursa, and a chronicMaculopapular rash over both tibial tubercles. ESR is 45 and HLA-B27 are positive. Plain radiographs show a large posteriorAnd plantar calcaneal exostosis. The most likely diagnosis is:

1. Gout2. Lupus erythematosus3. Rheumatoid arthritis4. Lymes Disease5. Psoriatic arthritis

A 72 yo man who has type II DM for the past 20 years reportsa painful ulcer on the tip of the great toe of the right foot for thepast 3 weeks. Examination reveals multiple mild claw toe deformities with decreased sensitivity to light touch. Which ofThe following studies will best confirm the diagnosis?

1. Electromyography and nerve conduction velocity studies2. Trancutaneous oxygen pressure measurement3. Ankle-brachial index by arterial doppler4. Plain radiograph5. Indium-111 WBC scan

A 47 yo female with no history of trauma has a progressive deformity of the ankle managed with an AFO. Medical history is significant for type 1 DM and a contralateral BKA.examination reveals a rigid deformity of the ankle and hindfootand diffuse loss of sensation. Pedal pulses are normal. radiographs demonstrate severe malalignment of ankle andHindfoot into valgus with loss of joint space. Mild lateral skin breakdown from bracewear is occurring. The next step in management is:

1. Symes amputation2. Transtibial amputation3. Fibulectomy4. Brace modification to a PTB with a medial T-strap5. Realignment tibiocalcaneal arthrodesis

56 yo woman with type 1 DM for the past 10 years has multipleClawtoes and a palpable dorsalis pedis pulse. She denies anyHistory of foot problems other than callosities at the toe tips.Which of the following screening tools is most appropriate for This patient?

1. 5.07 (10 g) Semmes-Weinstein monofilament2. 125-MHz tuning fork3. Transcutaneous oxygen pressure measurement4. Doppler ultrasound5. Water displacement test

Hallux Valgus Questions

Which of the following is considered the primary indication for surgery for patients with halluxvalgus?

1-Cosmetic appearance2-Split-size shoe requirements3-An intermetatarsal angle of greater than 15°

between the first and second metatarsals4-Symptoms that persist despite nonsurgical

management5-Arthritic changes in the first metatarsophalangeal

joint

OITE 1999

Which of the following is considered the primary indication for surgery for patients with halluxvalgus?

1-Cosmetic appearance2-Split-size shoe requirements3-An intermetatarsal angle of greater than 15°

between the first and second metatarsals4-Symptoms that persist despite nonsurgical

management5-Arthritic changes in the first metatarsophalangeal

joint

OITE 1999

Hallux Rigidus Questions

A 42-year-old laborer has significant, limiting pain around the first metatarsophalangeal joint despite undergoing a dorsal cheilectomy 2 years ago. Radiographs show progression of arthritis in the joint. What is the next most appropriate step in treatment?

1- Resection of the first metatarsal head2- Resection of the proximal phalanx3- Proximal phalangeal closing wedge osteotomy4- Arthrodesis of the first metatarsophalangeal joint5- Silastic implant arthroplasty

OITE 2005

A 42-year-old laborer has significant, limiting pain around the first metatarsophalangeal joint despite undergoing a dorsal cheilectomy 2 years ago. Radiographs show progression of arthritis in the joint. What is the next most appropriate step in treatment?

1- Resection of the first metatarsal head2- Resection of the proximal phalanx3- Proximal phalangeal closing wedge osteotomy4- Arthrodesis of the first metatarsophalangeal joint5- Silastic implant arthroplasty

OITE 2005

The radiographs shown are of a 44-year old woman who has had great toe pain for the past 5 years. What is the most likely diagnosis?

1- Lupus arthritis2- Rheumatoid arthritis3- Gouty arthritis4- Psoriatic arthritis5- Hallux rigidus

OITE 2003

The radiographs shown are of a 44-year old woman who has had great toe pain for the past 5 years. What is the most likely diagnosis?

1- Lupus arthritis2- Rheumatoid arthritis3- Gouty arthritis4- Psoriatic arthritis5- Hallux rigidus

OITE 2003

The figures below are radiographs of a 61-year-old man who has had chronic pain in the right great toe. Nonsteriodal anti-inflammatory drugs and shoe modifications have failed to provide relief. Treatment should now consist of1- interphalangeal joint fusion.2- cheilectomy.3- implant arthroplasty of the metatarsophalangeal joint.4- proximal phalangeal osteotomy. 5- metatarsophalangeal joint fusion

OITE 2004

The figures below are radiographs of a 61-year-old man who has had chronic pain in the right great toe. Nonsteriodal anti-inflammatory drugs and shoe modifications have failed to provide relief. Treatment should now consist of1- interphalangeal joint fusion.2- cheilectomy.3- implant arthroplasty of the metatarsophalangeal joint.4- proximal phalangeal osteotomy. 5- metatarsophalangeal joint fusion

OITE 2004

A 36-year-old runner presents with increasing pain in his great toe with running. A change of shoes and adding orthotics did not improve his discomfort nor did oral anti inflamatories. His toe does not swell, and he has had no known injury. On physical examination the foot and toe are not swollen. He is neurovascularly intact in the extremity. He has no calf tenderness. He does have pain and decreased range of motion of the MTP joint of the great toe. His radiographs follow. The next most appropriate treatment is:1- injection of corticosteroids.2- metatarsophalangeal fusion.3- short-leg walking cast.4- injection of hyaluronic acid and activity modification.5- a SACH shoe and oral nonsteroidal anti inflammatory drugs.

AOSSM 2006

A 36-year-old runner presents with increasing pain in his great toe with running. A change of shoes and adding orthotics did not improve his discomfort nor did oral anti inflamatories. His toe does not swell, and he has had no known injury. On physical examination the foot and toe are not swollen. He is neurovascularly intact in the extremity. He has no calf tenderness. He does have pain and decreased range of motion of the MTP joint of the great toe. His radiographs follow. The next most appropriate treatment is:1- injection of corticosteroids.2- metatarsophalangeal fusion.3- short-leg walking cast.4- injection of hyaluronic acid and activity modification.5- a SACH shoe and oral nonsteroidal anti inflammatory drugs.

AOSSM 2006

When evaluating a patient with hallux rigidus, what is the most important clinical factor indicating the need for an arthrodesis as opposed to cheilectomy?

1- Dorsal foot pain with shoe wear2- Pronounced limited motion in the first MTPJ3- Pain at the midrange of motion in the first MTPJ4- Large dorsal osteophytes clinically and radiographically5- Flattened first metatarsal head with periarticularsclerosis

F&A Self Assessment 2006

When evaluating a patient with hallux rigidus, what is the most important clinical factor indicating the need for an arthrodesis as opposed to cheilectomy?

1- Dorsal foot pain with shoe wear2- Pronounced limited motion in the first MTPJ3- Pain at the midrange of motion in the first MTPJ4- Large dorsal osteophytes clinically and radiographically5- Flattened first metatarsal head with periarticularsclerosis

F&A Self Assessment 2006

Which of the following orthotic features best reduces pain in patients with hallux rigidus?

1- Plastazote layer to absorb shock2- Medial posting to offload the medial forefoot3- Rigid shank or forefoot rocker4- Metatarsal bar to offload the first metatarsal head5- Full length as opposed to three-quarter length

F&A Self Assessment 2006

Which of the following orthotic features best reduces pain in patients with hallux rigidus?

1- Plastazote layer to absorb shock2- Medial posting to offload the medial forefoot3- Rigid shank or forefoot rocker4- Metatarsal bar to offload the first metatarsal head5- Full length as opposed to three-quarter length

F&A Self Assessment 2006

A 40-year-old woman has had pain and swelling in the metatarsophalangeal (MTP) joint of the second toe for the past 5 months. Dorsal-plantar stress of the MTP joint reproduces the pain. The remainder of the foot examination and radiographs is normal.

Shoe modification, steroid injections, and anti-inflammatory drugs have failed to provide relief. The next most appropriate step in management should consist of

1- arthrodesis of the second MTP joint.2- MTP synovectomy and reconstruction of the MTP joint capsule.3- dorsiflexion osteotomy of the second metatarsal.4- resection of the second metatarsal head (resection arthroplasty).5- resection of the base of the proximal phalanx.

OITE 2002

A 40-year-old woman has had pain and swelling in the metatarsophalangeal (MTP) joint of the second toe for the past 5 months. Dorsal-plantar stress of the MTP joint reproduces the pain. The remainder of the foot examination and radiographs is normal.

Shoe modification, steroid injections, and anti-inflammatory drugs have failed to provide relief. The next most appropriate step in management should consist of

1- arthrodesis of the second MTP joint.2- MTP synovectomy and reconstruction of the MTP joint capsule.3- dorsiflexion osteotomy of the second metatarsal.4- resection of the second metatarsal head (resection arthroplasty).5- resection of the base of the proximal phalanx.

OITE 2002

A 36-year-old man has pain in the metatarsophalangeal (MTP) joint of the great toe with all weight-bearing activities, and management consisting of shoe modification and an insert has failed to provide relief. Examination reveals a painful 100 arc of motion. Radiographs show degenerative changes with dorsal and medial osteophytes and joint narrowing. Treatment should now consist of

1-excision of the osteophytes and the dorsal third of the metatarsal head.

2-a dorsiflexion osteotomy of the metatarsal head. 3-resection arthroplasty of the MTP joint.4-a Silastic implant of the MTP joint. 5-arthrodesis of the MTP joint.

OITE 2001

A 36-year-old man has pain in the metatarsophalangeal (MTP) joint of the great toe with all weight-bearing activities, and management consisting of shoe modification and an insert has failed to provide relief. Examination reveals a painful 100 arc of motion. Radiographs show degenerative changes with dorsal and medial osteophytes and joint narrowing. Treatment should now consist of

1-excision of the osteophytes and the dorsal third of the metatarsal head.

2-a dorsiflexion osteotomy of the metatarsal head. 3-resection arthroplasty of the MTP joint.4-a Silastic implant of the MTP joint. 5-arthrodesis of the MTP joint.

OITE 2001

A 40-year-old man has limited, painful motion in dorsiflexion at the metatarsophalangeal (MTP) joint of the right great toe, despite nonsurgical treatment. Radiographs show dorsal and medial osteophytes and minimal narrowing of the articular space. Treatment should consist of

1- arthrodesis of the MTP joint.2- a Silastic implant of the MTP joint.3- resection arthroplasty of the MTP joint.4- cheilectomy of the MTP joint.5- osteotomy of the base of the proximal phalanx.

OITE 1998

A 40-year-old man has limited, painful motion in dorsiflexion at the metatarsophalangeal (MTP) joint of the right great toe, despite nonsurgical treatment. Radiographs show dorsal and medial osteophytes and minimal narrowing of the articular space. Treatment should consist of

1- arthrodesis of the MTP joint.2- a Silastic implant of the MTP joint.3- resection arthroplasty of the MTP joint.4- cheilectomy of the MTP joint.5- osteotomy of the base of the proximal phalanx.

OITE 1998

TURF TOE & SESAMOID QUESTIONS

A professional football player sustains a hyperextension injury to his great toe during practice. He is diagnosed with a “turf toe”. You explain to him that “turf toe” is:

1- an interphalangeal joint contusion of the great toe.2- a sprain of the first metatarsophalangealjoint.3- flexor hallucis longus tenosynovitis.4- sesamoid bursitis of the great toe.5- plantar fasciitis.

AOSSM 2006

A professional football player sustains a hyperextension injury to his great toe during practice. He is diagnosed with a “turf toe”. You explain to him that “turf toe” is:

1- an interphalangeal joint contusion of the great toe.2- a sprain of the first metatarsophalangealjoint.3- flexor hallucis longus tenosynovitis.4- sesamoid bursitis of the great toe.5- plantar fasciitis.

AOSSM 2006

A 24-year-old professional lacrosse player has severe pain in his great toe at the first metatarsalphalangeal joint. The most likely reason for his symptoms would be:

1- bipartite sesamoid.2- first metatarsal stress fracture.3- forced hyperextension injury.4- bunion deformity.5- chronic sesamoiditis

AOSSM 2007

A 24-year-old professional lacrosse player has severe pain in his great toe at the first metatarsalphalangeal joint. The most likely reason for his symptoms would be:

1- bipartite sesamoid.2- first metatarsal stress fracture.3- forced hyperextension injury.4- bunion deformity.5- chronic sesamoiditis

AOSSM 2007

A 21-year-old collegiate track athlete increased her training 4 months ago in anticipation of starting the season. Two months into her training program, she reported pain followed by a 1-month history of diffuse pain in the first MTPJ that was aggravated by weight bearing. A removable walker boot partially relieved the pain, and she was able to complete the season. Her pain has now returned; however, she denies any history of injury. Examination reveals tenderness over the medial sesamoid but no deformities. Images follow on next slide. What is the best treatment option at this time?

1- Cast immobilization and no weight bearing for 4 to 8 weeks2- Immobilization in a walking cast for 4 to 8 weeks3- Hard soled shoe for 4 to 8 weeks4- Sesamoid bone grafting5- Medial sesamoidectomy

F&A Self Assessment 2006

A 21-year-old collegiate track athlete increased her training 4 months ago in anticipation of starting the season. Two months into her training program, she reported pain followed by a 1-month history of diffuse pain in the first MTPJ that was aggravated by weight bearing. A removable walker boot partially relieved the pain, and she was able to complete the season. Her pain has now returned; however, she denies any history of injury. Examination reveals tenderness over the medial sesamoid but no deformities. Images follow on next slide. What is the best treatment option at this time?

1- Cast immobilization and no weight bearing for 4 to 8 weeks2- Immobilization in a walking cast for 4 to 8 weeks3- Hard soled shoe for 4 to 8 weeks4- Sesamoid bone grafting5- Medial sesamoidectomy

F&A Self Assessment 2006

A hyperextension injury to the metatarsophalangeal joint of the great toe most commonly results in a tear of the

1- intersesamoid ligament.2- insertion of the plantar plate on the proximal

phalanx.3- adductor hallucis tendon.4- medial and accessory collateral ligaments.5- flexor hallucis brevis insertion on the proximal phalanx.

OITE 1999

A hyperextension injury to the metatarsophalangeal joint of the great toe most commonly results in a tear of the

1- intersesamoid ligament.2- insertion of the plantar plate on the proximal

phalanx.3- adductor hallucis tendon.4- medial and accessory collateral ligaments.5- flexor hallucis brevis insertion on the proximal phalanx.

OITE 1999

MORTON’S NEUROMA QUESTIONS

A 50-year-old woman reports a burning sensation on the plantar aspect of her left forefoot, distal to the metatarsal heads between her third and fourth digits. Palpation of the third web space recreates her symptoms. Which of the following will most accurately aid in confirming a diagnosis?

1- History and physical examination2- Ultrasonography3- MRI4- Radiographs5- Nerve conduction velocity studies

F&A Self Assessment 2006

A 50-year-old woman reports a burning sensation on the plantar aspect of her left forefoot, distal to the metatarsal heads between her third and fourth digits. Palpation of the third web space recreates her symptoms. Which of the following will most accurately aid in confirming a diagnosis?

1- History and physical examination2- Ultrasonography3- MRI4- Radiographs5- Nerve conduction velocity studies

F&A Self Assessment 2006

BUNIONETTE QUESTIONS

The radiograph below is of a 38-year-old man who reports persistent pain laterally and plantarly about the fifth metatarsal head. Examination reveals calluses dorsolaterally and plantarly about the fifth metatarsal head. Nonsurgical management has failed to provide relief. Surgical treatment should include1- simple lateral eminence resection.2- distal chevron osteotomy of the fifth metatarsal.3- oblique mid-diaphyseal osteotomy of the fifth metatarsal.4- proximal diaphyseal osteotomy of the fifth metatarsal.5- excision of the fifth metatarsal head.

F&A Self Assessment 2006

The radiograph below is of a 38-year-old man who reports persistent pain laterally and plantarly about the fifth metatarsal head. Examination reveals calluses dorsolaterally and plantarly about the fifth metatarsal head. Nonsurgical management has failed to provide relief. Surgical treatment should include1- simple lateral eminence resection.2- distal chevron osteotomy of the fifth metatarsal.3- oblique mid-diaphyseal osteotomy of the fifth metatarsal.4- proximal diaphyseal osteotomy of the fifth metatarsal.5- excision of the fifth metatarsal head.

F&A Self Assessment 2006

In treatment of all magnitudes of bunionette deformities, what is the most common complication associated with lateral condylectomy of the fifth metatarsal head?

1- Metatarsophalangeal arthrosis2- Transfer metatarsalgia3- Recurrent deformity4- Overcorrection of the deformity5- Dislocation of the metatarsophalangeal joint

In treatment of all magnitudes of bunionette deformities, what is the most common complication associated with lateral condylectomy of the fifth metatarsal head?

1- Metatarsophalangeal arthrosis2- Transfer metatarsalgia3- Recurrent deformity4- Overcorrection of the deformity5- Dislocation of the metatarsophalangeal joint

LISFRANC QUESTIONS

A 16-year-old male athlete presents one week after an injury with a swollen right foot and an inability to bear weight. On AP standing radiographs, there is widening of the first and second metatarsal spaces, and the medial border of the second metatarsal is not aligned with the medial border of the middle cuneiform. What is the optimal management of this injury?

1- Closed reduction and non-weight-bearing cast2- Non-weight-bearing cast immobilization3- Primary tarsometatarsal fusion4- Rest, ice, compression, and elevation5- Reduction and internal fixation

AOSSM 2006

A 16-year-old male athlete presents one week after an injury with a swollen right foot and an inability to bear weight. On AP standing radiographs, there is widening of the first and second metatarsal spaces, and the medial border of the second metatarsal is not aligned with the medial border of the middle cuneiform. What is the optimal management of this injury?

1- Closed reduction and non-weight-bearing cast2- Non-weight-bearing cast immobilization3- Primary tarsometatarsal fusion4- Rest, ice, compression, and elevation5- Reduction and internal fixation

AOSSM 2006

A 32-year-old man who sustained a tarsometatarsal (Lisfranc) injury 3 years ago now reports increasing pain in the left foot. Orthotics, nonsteroidal anti-inflammatory drugs, and injections have provided only temporary relief. Examination reveals swelling and tenderness over the tarsometatarsal joints. Radiographs show advanced arthrosis of the first and second tarsometatarsal joints. Management should now include

1- midfoot arthrodesis.2- a rocker sole show with orthotic inserts.3- shock wave or orthotripsy.4- an ankle-foot orthoses.5- triple arthrodesis

F&A Self Assessment 2006

A 32-year-old man who sustained a tarsometatarsal (Lisfranc) injury 3 years ago now reports increasing pain in the left foot. Orthotics, nonsteroidal anti-inflammatory drugs, and injections have provided only temporary relief. Examination reveals swelling and tenderness over the tarsometatarsal joints. Radiographs show advanced arthrosis of the first and second tarsometatarsal joints. Management should now include

1- midfoot arthrodesis.2- a rocker sole show with orthotic inserts.3- shock wave or orthotripsy.4- an ankle-foot orthoses.5- triple arthrodesis

F&A Self Assessment 2006

The Lisfranc ligament connects the base of the

1- first metatarsal and the medial cuneiform.2- first metatarsal and the base of the second metatarsal.3- first metatarsal and the middle cuneiform.4- second metatarsal and the medial cuneiform.5- second metatarsal and the middle cuneiform.

F&A Self Assessment 2006

The Lisfranc ligament connects the base of the

1- first metatarsal and the medial cuneiform.2- first metatarsal and the base of the second metatarsal.3- first metatarsal and the middle cuneiform.4- second metatarsal and the medial cuneiform.5- second metatarsal and the middle cuneiform.

F&A Self Assessment 2006

Figure 11 shows the radiograph of an otherwise healthy 22-year-old man who sustained a midfoot injury in a motor vehicle accident 9 days ago. Treatment should consist of

1- open reduction and internal fixation.2- a short leg weight-bearing cast.3- a short leg non-weight-bearing cast.4- first tarsometatarsal fusion.5- functional brace application and early range of motion.

F&A Self Assessment 2006

Figure 11 shows the radiograph of an otherwise healthy 22-year-old man who sustained a midfoot injury in a motor vehicle accident 9 days ago. Treatment should consist of

1- open reduction and internal fixation.2- a short leg weight-bearing cast.3- a short leg non-weight-bearing cast.4- first tarsometatarsal fusion.5- functional brace application and early range of motion.

F&A Self Assessment 2006

A 23-year-old football player was injured when another player fell on his flexed and planted foot. He reports severe pain in the midfoot with a feeling of numbness on the dorsum of the foot, and he is unable to bear weight on the limb. Examination reveals mild swelling. Xrays are shown on the next slide. Management should consist of

1- casting.2- closed reduction, casting, and no weight bearing for 6 weeks.3- open reduction and internal fixation.4- closed reduction and percutaneous K-wire fixation.5- closed reduction and percutaneous screw fixation.

F&A Self Assessment 2006

A 23-year-old football player was injured when another player fell on his flexed and planted foot. He reports severe pain in the midfoot with a feeling of numbness on the dorsum of the foot, and he is unable to bear weight on the limb. Examination reveals mild swelling. Xrays are shown on the next slide. Management should consist of

1- casting.2- closed reduction, casting, and no weight bearing for 6 weeks.3- open reduction and internal fixation.4- closed reduction and percutaneous K-wire fixation.5- closed reduction and percutaneous screw fixation.

F&A Self Assessment 2006

JONES FRACTURE QUESTIONS

Intramedullary screw fixation of a Jones fracture has a statistically higher failure rate in

1- elite athletes.2- female patients.3- patients who did not undergo bone grafting.4- patients younger than age 40 years.5- fractures that have been fixed with screws larger than 4.5mm in diameter.

OITE 2003

Intramedullary screw fixation of a Jones fracture has a statistically higher failure rate in

1- elite athletes.2- female patients.3- patients who did not undergo bone grafting.4- patients younger than age 40 years.5- fractures that have been fixed with screws larger than 4.5mm in diameter.

OITE 2003

A 21-year-old elite college football player has ecchymosis, swelling, and pain on the lateral side of his foot after a game. Radiographs are shown below. Management should consist of

1- open reduction and internal fixation with a plate and screws.2- open treatment with calcaneal bone graft.3- percutaneous screw fixation with a 4.5 mm screw.4- weight-bearing cast for 8 weeks.5- spanning external fixation.

F&A Self Assessment 2006

A 21-year-old elite college football player has ecchymosis, swelling, and pain on the lateral side of his foot after a game. Radiographs are shown below. Management should consist of

1- open reduction and internal fixation with a plate and screws.2- open treatment with calcaneal bone graft.3- percutaneous screw fixation with a 4.5 mm screw.4- weight-bearing cast for 8 weeks.5- spanning external fixation.

F&A Self Assessment 2006

An 18-year-old collegiate basketball player sees you for increasing pain on the lateral side of his left foot. The pain has increased over the last eight weeks to the point where now he is limping. On clinical examination, the foot is tender to palpation at the base of the fifth metatarsal. Peroneal tendons are intact and not swollen. Radiographs of his foot are shown. You would advise:1- intramedullary screw fixation.2- a walking boot for six weeks.3- surgical repair using a tension band wire technique.4- crutches and a cast with instructions to not bear weight upon the foot.5- custom made orthoses followed by physical therapy for ROM and strengthening exercise.

AOSSM 2007

An 18-year-old collegiate basketball player sees you for increasing pain on the lateral side of his left foot. The pain has increased over the last eight weeks to the point where now he is limping. On clinical examination, the foot is tender to palpation at the base of the fifth metatarsal. Peroneal tendons are intact and not swollen. Radiographs of his foot are shown. You would advise:1- intramedullary screw fixation.2- a walking boot for six weeks.3- surgical repair using a tension band wire technique.4- crutches and a cast with instructions to not bear weight upon the foot.5- custom made orthoses followed by physical therapy for ROM and strengthening exercise.

AOSSM 2007

A 20-year-old collegiate football player notes the sudden onset of lateral foot pain after a cutting maneuver. Based on the radiographic findings shown in the figures below, what is the best surgical option?

1- Single intramedullary screw2- Crossed Kirschner wires3- Crossed absorbable pins4- Crossed cannulated screws5- Compression plate

OITE 2005

A 20-year-old collegiate football player notes the sudden onset of lateral foot pain after a cutting maneuver. Based on the radiographic findings shown in the figures below, what is the best surgical option?

1- Single intramedullary screw2- Crossed Kirschner wires3- Crossed absorbable pins4- Crossed cannulated screws5- Compression plate

OITE 2005

Figure 19 shows the radiograph of an 18-year-old recreational soccer player who has had pain in the lateral foot for the past 4 weeks. He reports no specific injury and has not undergone any treatment. Initial management should consist of

1- an orthosis.2- observation.3- electrical stimulation.4- open reduction and internal fixation.5- application of a nonweightbearing short leg cast. OITE 1998

Figure 19 shows the radiograph of an 18-year-old recreational soccer player who has had pain in the lateral foot for the past 4 weeks. He reports no specific injury and has not undergone any treatment. Initial management should consist of

1- an orthosis.2- observation.3- electrical stimulation.4- open reduction and internal fixation.5- application of a nonweightbearing short leg cast. OITE 1998

ACCESSORY NAVICULAR QUESTIONS

A 12-year-old boy has pain in the medial arch of his left foot with weight-bearing activities. Nonsurgical management has failed to provide relief. Radiographs show an Ogden type II accessory navicular (accessory ossicle joined to the prominence of the navicular by a synchondrosis). Treatment should consist of

1- arthodesis of the ossicle to the navicular.2- excision of the ossicle and the navicular prominence.3- talonavicular arthodesis, with elevation of the medial arch.4- calcaneal neck lengthening by opening wedge osteotomy and bone graft.5- subtalar joint arthrodesis.

OITE 2003

A 12-year-old boy has pain in the medial arch of his left foot with weight-bearing activities. Nonsurgical management has failed to provide relief. Radiographs show an Ogden type II accessory navicular (accessory ossicle joined to the prominence of the navicular by a synchondrosis). Treatment should consist of

1- arthodesis of the ossicle to the navicular.2- excision of the ossicle and the navicular prominence.3- talonavicular arthodesis, with elevation of the medial arch.4- calcaneal neck lengthening by opening wedge osteotomy and bone graft.5- subtalar joint arthrodesis.

OITE 2003

An 11-year-old girl has had pain in the medial arch of her foot for the past 3 months. She reports that pain is present even with daily activities such as walking to class at school, and ibuprofen provides some relief. She denies and history of trauma. Examination reveals a flexible pes planus with focal tenderness over a prominent tarsal navicular tuberosity. Radiographs show a prominent accessory navicular. Management should consist of

1- cast immobilization for 4 to 6 weeks.2- posterior tibial tendon advancement and repair (Kidner procedure)3- corticosteroid injection of the PTT insertion.4- triple arthodesis.5- needle biopsy of the trochar

F&A Self Assessment 2006

An 11-year-old girl has had pain in the medial arch of her foot for the past 3 months. She reports that pain is present even with daily activities such as walking to class at school, and ibuprofen provides some relief. She denies and history of trauma. Examination reveals a flexible pes planus with focal tenderness over a prominent tarsal navicular tuberosity. Radiographs show a prominent accessory navicular. Management should consist of

1- cast immobilization for 4 to 6 weeks.2- posterior tibial tendon advancement and repair (Kidner procedure)3- corticosteroid injection of the PTT insertion.4- triple arthodesis.5- needle biopsy of the trochar

F&A Self Assessment 2006

The figure below shows a radiograph of a 12-year-old boy who has medial midfoot pain with activity. The pain persists despite activity modifications and trials of orthotics and cast immobilization. Management should now consist of

1- an external bone growth stimulator2- autogenous bone grafting to the nonunion3- excision of the medial prominence of the

navicular, including the synchondrosis4- internal fixation with a compression screw5- injection of bone morphogenetic protein

into the synchondrosis

OITE 2005

The figure below shows a radiograph of a 12-year-old boy who has medial midfoot pain with activity. The pain persists despite activity modifications and trials of orthotics and cast immobilization. Management should now consist of

1- an external bone growth stimulator2- autogenous bone grafting to the nonunion3- excision of the medial prominence of the

navicular, including the synchondrosis4- internal fixation with a compression screw5- injection of bone morphogenetic protein

into the synchondrosis

OITE 2005

NAVICULAR STRESS FRACTURE QUESTIONS

Where is the watershed zone for tarsal navicular vascularity?

1- Medial one third2- Central one third3- Lateral one third4- Tuberosity5- Inferior pole

F&A Self Assessment 2006

Where is the watershed zone for tarsal navicular vascularity?

1- Medial one third2- Central one third3- Lateral one third4- Tuberosity5- Inferior pole

F&A Self Assessment 2006

TARSAL TUNNEL QUESTIONS

A 37-year-old female has had intermittent paresthesias and numbness in the plantar foot for the past 6 months. She reports that the symptoms are worse with activity, and the paresthesias are beginning to awaken her at night. MRI scans are shown in Figures 6a and 6b. What is the most likely diagnosis?

1- Lipoma2- Giant cell tumor of the tendon sheath3- Synovial sarcoma4- Metastatic adenocarcinoma5- Ganglion cyst

F&A Self Assessment 2006

A 37-year-old female has had intermittent paresthesias and numbness in the plantar foot for the past 6 months. She reports that the symptoms are worse with activity, and the paresthesias are beginning to awaken her at night. MRI scans are shown in Figures 6a and 6b. What is the most likely diagnosis?

1- Lipoma2- Giant cell tumor of the tendon sheath3- Synovial sarcoma4- Metastatic adenocarcinoma5- Ganglion cyst

F&A Self Assessment 2006

Patients with tarsal tunnel syndrome are most likely to obtain a favorable outcome from decompression of the posterior tibial nerve if which of the following conditions is present?

1- A space-occupying lesion is compressing the tarsal tunnel,.2- Nerve conduction studies reveal slowing across the medial malleolus.3- The posterior tibial tendon is ruptured.4- The integrity of the posterior tibial tendon is compromised.5- The spring ligament is ruptured, resulting in the development of a dynamic flatfoot.

F&A Self Assessment 2006

Patients with tarsal tunnel syndrome are most likely to obtain a favorable outcome from decompression of the posterior tibial nerve if which of the following conditions is present?

1- A space-occupying lesion is compressing the tarsal tunnel,.2- Nerve conduction studies reveal slowing across the medial malleolus.3- The posterior tibial tendon is ruptured.4- The integrity of the posterior tibial tendon is compromised.5- The spring ligament is ruptured, resulting in the development of a dynamic flatfoot.

F&A Self Assessment 2006

Adequate decompression of the medial and lateral plantar nerves during a tarsal tunnel release requires

1- release of the medial half of the plantar fascia. 2- release of the deep fascia of the abductor hallucis muscle. 3- release of the inferior extensor retinaculum. 4- release of the quadratus plantae fascia. 5- resection of a plantar exostosis of the calcaneus, when present.

OITE 1999

Adequate decompression of the medial and lateral plantar nerves during a tarsal tunnel release requires

1- release of the medial half of the plantar fascia. 2- release of the deep fascia of the abductor hallucis muscle. 3- release of the inferior extensor retinaculum. 4- release of the quadratus plantae fascia. 5- resection of a plantar exostosis of the calcaneus, when present.

OITE 1999

TARSAL COALITION QUESTIONS

A 15-year-old boy has had hindfoot pain and very limited subtalar motion. A CT scan reveals a talocalcaneal coalition involving 40% of the middle facet. He has no degeneration of the posterior subtalar facet. Following failure of nonsurgical management, treatment should consist of

1- resection of the coalition with fat graft interposition.2- Grice extra-articular subtalar arthrodesis.3- subtalar arthroresis.4- intra-articular subtalar fusion.5- medial sliding calcaneal osteotomy.

F&A Self Assessment 2006

A 15-year-old boy has had hindfoot pain and very limited subtalar motion. A CT scan reveals a talocalcaneal coalition involving 40% of the middle facet. He has no degeneration of the posterior subtalar facet. Following failure of nonsurgical management, treatment should consist of

1- resection of the coalition with fat graft interposition.2- Grice extra-articular subtalar arthrodesis.3- subtalar arthroresis.4- intra-articular subtalar fusion.5- medial sliding calcaneal osteotomy.

F&A Self Assessment 2006

A 14-year-old boy has midfoot pain with activity, and nonsurgical management has failed to provide relief. Radiographs and a CT scan are shown in the following figures. Estimated involvement of the subtalar joint includes the entire combined anterior and middle facets and at least 35% of the posterior facet. Treatment should now consist of

1- resection of the coalition and an interposition fat graft.2- Resection of the coalition and a modified Dwyer osteotomy3- Resection of the coalition and extensor brevis interposition4- Triple arthrodesis5- Calcaneocuboid arthrodesis

OITE 2005

A 14-year-old boy has midfoot pain with activity, and nonsurgical management has failed to provide relief. Radiographs and a CT scan are shown in the following figures. Estimated involvement of the subtalar joint includes the entire combined anterior and middle facets and at least 35% of the posterior facet. Treatment should now consist of

1- resection of the coalition and an interposition fat graft.2- Resection of the coalition and a modified Dwyer osteotomy3- Resection of the coalition and extensor brevis interposition4- Triple arthrodesis5- Calcaneocuboid arthrodesis

OITE 2005

A 12-year-old boy has had foot pain for the past 6 months, and immobilization in a cast for 6 weeks has failed to provide relief. CT scans are shown. To optimize his foot biomechanics, the next step in management should consist of

1- triple arthrodesis2- resection of the subtalar coalition3- resection of the calcaneonavicular coalition4- repair of the anterior tibial tendon5- repair of the ruptured posterior tibial tendon

OITE 2005

A 12-year-old boy has had foot pain for the past 6 months, and immobilization in a cast for 6 weeks has failed to provide relief. CT scans are shown. To optimize his foot biomechanics, the next step in management should consist of

1- triple arthrodesis2- resection of the subtalar coalition3- resection of the calcaneonavicular coalition4- repair of the anterior tibial tendon5- repair of the ruptured posterior tibial tendon

OITE 2005

A 16-year-old boy has had pain in the lateral ankle and hindfoot after sustaining a minor ankle sprain 6 months ago. The pain is worse with any twisting activity of the foot. Examination reveals normal alignment of the foot and ankle. An AP radiograph of the ankle and foot is normal. A lateral radiograph is shown in Figure 61. What is the most likely cause of his persistent pain?

1-Fracture of the lateral process of the talus 2- Fracture of the anterior process of the calcaneus 3- Fracture of the tibial plafond 4- Talocalcaneal coalition 5- Stress fracture of the calcaneus

OITE 2001

PLANTAR FASCIITIS QUESTIONS

A patient who underwent an endoscopic plantar fascia release 3 months ago now reports pain in the medial arch with weight bearing and notes progressive flattening of the foot.What is the most likely explanation for this problem?

1- Recurrence of the calcaneal heel spur2- Surgical injury to the medial plantar nerve3- Excessive release of the plantar fascia4- Injury to the posterior tibial tendon5- Injury to the spring (calcaneonavicular)

ligamentOITE 2002

A patient who underwent an endoscopic plantar fascia release 3 months ago now reports pain in the medial arch with weight bearing and notes progressive flattening of the foot.What is the most likely explanation for this problem?

1- Recurrence of the calcaneal heel spur2- Surgical injury to the medial plantar nerve3- Excessive release of the plantar fascia4- Injury to the posterior tibial tendon5- Injury to the spring (calcaneonavicular)

ligamentOITE 2002

A 46-year-old woman has had plantar heel. pain for the past 5 months. She reports that the pain is most severe when she arises out of bed in the morning and when she stands after being seated for a period of time. Initial management should consist of

1- surgical lengthening of the Achilles tendon. 2- surgical release of the plantar fascia. 3- a custom orthosis. 4- a stretching program and a cushioned heel insert. 5- a corticosteroid injection.

OITE 2001

A 46-year-old woman has had plantar heel. pain for the past 5 months. She reports that the pain is most severe when she arises out of bed in the morning and when she stands after being seated for a period of time. Initial management should consist of

1- surgical lengthening of the Achilles tendon. 2- surgical release of the plantar fascia. 3- a custom orthosis. 4- a stretching program and a cushioned heel insert. 5- a corticosteroid injection.

OITE 2001

A patient has proximal plantar fasciitis. To achieve the greatest amount of improvement, initial management should consist of stretching in combination with

1- a silicone insert.2- a felt insert.3- a custom insert.4- a steroid injection.5- strapping of the heel.

OITE 2000

A patient has proximal plantar fasciitis. To achieve the greatest amount of improvement, initial management should consist of stretching in combination with

1- a silicone insert.2- a felt insert.3- a custom insert.4- a steroid injection.5- strapping of the heel.

OITE 2000

The development of plantar fasciitis is frequently associated with which of the following conditions?

1- Equinovarus deformity2- Contracture of the Achilles tendon3- Plantar spur on the calcaneus4- Previous fracture of the calcaneus5- Plantar fibromatosis

OITE 1999

The development of plantar fasciitis is frequently associated with which of the following conditions?

1- Equinovarus deformity2- Contracture of the Achilles tendon3- Plantar spur on the calcaneus4- Previous fracture of the calcaneus5- Plantar fibromatosis

OITE 1999

A 30-year-old patient who underwent an endoscopic plantar fascia release several months ago now reports pain in the medial arch of the foot with weightbearing and progressive flattening of the foot. What is the most likely diagnosis?

1- Surgical injury to the medial plantar nerve2- Excessive release of the plantar fascia3- Degeneration of the posterior tibial tendon4- Inadequate release of the abductor hallucis fascia5- Late rupture of the proximal quadratus plantae

aponeurosis

OITE 1999

A 30-year-old patient who underwent an endoscopic plantar fascia release several months ago now reports pain in the medial arch of the foot with weightbearingand progressive flattening of the foot. What is the most likely diagnosis?

1- Surgical injury to the medial plantar nerve2- Excessive release of the plantar fascia3- Degeneration of the posterior tibial tendon4- Inadequate release of the abductor hallucis fascia5- Late rupture of the proximal quadratus plantae

aponeurosis

OITE 1999

A 33-year-old woman reports a 3-month history of pain in both feet while running. Examination reveals bilateral point tenderness over the plantar fascia at its origin, and the pain is accentuated when the ankle is dorsiflexed. Management should consist of

1- steroid injections.2- stretching of the heel cord.3- surgical release of the plantar fascia.4- application of short leg casts for 6 to 8 weeks.5- wearing dorsiflexion night splints.

OITE 1998

A 33-year-old woman reports a 3-month history of pain in both feet while running. Examination reveals bilateral point tenderness over the plantar fascia at its origin, and the pain is accentuated when the ankle is dorsiflexed. Management should consist of

1- steroid injections.2- stretching of the heel cord.3- surgical release of the plantar fascia.4- application of short leg casts for 6 to 8 weeks.5- wearing dorsiflexion night splints.

OITE 1998

CALCANEAL STRESS FRACTURE QUESTIONS

An 18-year-old female gymnast reports increasing heel pain for the past sixweeks. The pain worsens with activity. She recalls no one particular episode of injury, but has been practicing a new dismount from the uneven bars. She has had no prior history of pain in her ankle or foot. She is healthy with no medical problems. On clinical evaluation, she has pain with palpation and compression of her heel. She has good flexibility of her Achilles tendon and plantar fascia. Her neurovascular exam is normal. Radiographs are shown in the images. The most likely diagnosis is:

1- calcaneal apophysitis.2- calcaneal stress fracture.3- plantar fasciitis.4- plantar osteitis.5- calcnaeal deficiency syndrome

AOSSM 2006

An 18-year-old female gymnast reports increasing heel pain for the past sixweeks. The pain worsens with activity. She recalls no one particular episode of injury, but has been practicing a new dismount from the uneven bars. She has had no prior history of pain in her ankle or foot. She is healthy with no medical problems. On clinical evaluation, she has pain with palpation and compression of her heel. She has good flexibility of her Achilles tendon and plantar fascia. Her neurovascular exam is normal. Radiographs are shown in the images. The most likely diagnosis is:

1- calcaneal apophysitis.2- calcaneal stress fracture.3- plantar fasciitis.4- plantar osteitis.5- calcnaeal deficiency syndrome

AOSSM 2006

Donald A. Wiss, MD Orthopaedic Review Course #390 – AAOS Annual Meeting

February 18, 2011

Timing of Fracture Care – Damage Control Surgery I. HISTORICAL PERSPECTIVE

A. Evolution in Ortho Care Since Mid 1970s 1. Fixation within 2 weeks 2. Fixation within 48 hours 3. Fixation within 24 hours

B. Concurrent Improvements in ICU Care 1. Pulmonary toilet 2. Skin care 3. Nutritional support 4. Sepsis surveillance

II. EARLY FRACTURE STABILIZATION A. Inflammatory Mediators B. Facilitates Early Mobilization C. Permits Upright Chest D. More Rapidly Reduces Pain E. Need for Depressant Narcotics F. Return of Pulmonary & GI Function G. Sub-Group of MIP Managed by

Immediate or Early Internal Fixation of Their Fractures That Are Associated with High Morbidity & Mortality 1. Chest injuries 2. Head injuries 3. Severe open fractures 4. Geriatric trauma 5. High AIS-ISS scores

III. DAMAGE CONTROL ORTHOPEDICS - DEFINITIONS A. Treatment Philosophy & Approach

Which Emphasizes the Stabilization and Control of the Injury Rather Than Primary Repair

IV. HISTORY A. Developed in General Surgery B. Control Hemorrhage & Contamination C. Pack Abdomen Open D. ICU – Resuscitation, Monitoring,

Warming E. Return to OR 24-72 Hours Later for

Repair V. PATHOPHYSIOLOGY

A. Inflammatory Response is a Normal Physiologic Reaction to Injury

B. Amplitude of the Inflammatory Response is Related to the Severity of the Injury

VI. PATHOPHYSIOLOGY A. Traumatic Event – “First Hit”

1. Local tissue damage 2. Systemic inflammation

a) Cytokines

b) Complement c) Proteins d) Neuro-endocrine mediators

B. Consequences of First Hit 1. Endogenous Second Hit:

a) Hypoxia b) Hemorrhage c) Tissue necrosis d) Contamination

2. Exogenous Second Hit a) Massive transfusion b) Ill advised surgery

C. First Hit (Injury) Primes Immune System D. Second Hit (Surgery) Activates Immune

System E. Hyperstimulation of the Inflammatory

System by Either Single or Multiple “Hits” is Considered by Many to be the Key Element in the Pathogenesis of ARDS and MODS

F. Biologic Responses to the First and/or Second Hit Have Now Become the Basis for Our Treatment Algorithm

VII. TIMING OF FRACTURE CARE – ETC VS DCO A. Must Balance the Benefit of Early

Fracture Stabilization Against the Potential Side Effects of an Excessive Surgical Burden

VIII. STAGE 1 – DAMAGE CONTROL SURGERY A. Timing of Fracture Care

1. Stable patient – early fracture care

2. Borderline patient ????? 3. Unstable patient – damage

control 4. Extremis patient – damage

control B. Patient Selection

1. Persistent hypotension 2. Ongoing transfusion requirements 3. Hypothermia, coagulopathy,

acidosis 4. ISS>35 points 5. Head injuries/mental status

change 6. Severe chest injury 7. Abdominal/pelvic trauma with

shock IX. STAGE 2 – DAMAGE CONTROL SURGERY

A. Abdomen – Laporotomy 1. Control hemorrhage 2. Exploration 3. Control contamination

4. Temporary packing 5. Delayed closure

B. Pelvic Ring Injuries 1. Rapid reduction & stabilization 2. Anterior ring – external fixation 3. Posterior ring – C-clamp 4. North America – angiography 5. Europe – pelvic packing

C. Extremity Fractures 1. Rapid I & D open fractures 2. Bridging external fixation 3. Fasciotomy when necessary 4. Amputation – mangled extremity

X. STAGE 3 – DAMAGE CONTROL SURGERY A. ICU Resuscitation

1. Reversal of lethal triad a) Warming b) Coagulopathy correction c) Reversal acidosis

2. Control ICP, vital signs 3. Fluid & electrolyte replacement 4. Blood transfusion

XI. STAGE 4 – DAMAGE CONTROL SURGERY A. 2nd Look – Definitive Surgery

1. Return to OR based on: a) Injury pattern b) Planned operative

procedure c) Response to ICU Rx d) Development of

complications 2. Hemorrhage control – 24 hrs 3. Sepsis control – 48-72 hrs

a) GI tract repair b) Colostomy

4. Pelvic & extremity fixation delayed 4-5 days (avoid 2nd hit)

XII. STAGE 5 – DAMAGE CONTROL SURGERY A. 2o Reconstructive Procedures

1. Complex joint reconstructions 2. Nerve reconstruction 3. Bone grafts 4. Joint replacement

XII. SUMMARY A. ↓Morbidity & Mortality B. Selected Group of Multiply Injured

Patients C. Planned Staged Surgery D. Early Reports Favorable E. Fix the Patient NOT Just the Bone

Pelvic Fractures I. INTRODUCTION

A. 15-30% of High Energy Pelvic Injuries are Hemodynamically Unstable

B. Bleeding Remains the Leading Cause of Death in Patients With Pelvic Fxs

C. Pelvic Anatomy 1. Posterior sacro-iliac ligaments

2. Sacro-spinous 3. Sacro-tuberous

D. 60-80% of Patient With High Energy Pelvic Fractures Have Other Musculoskeletal Injuries 1. 10-15% urologic injuries 2. 8-10% lumbosacral plexus

injuries E. Sustained Shock in Patients With Pelvic

Fxs 1. Mortality 2. Respiratory distress 3. MODS

II. 4 CATEGORIES A. Stable Pelvic Ring Injuries B. Unstable Fracture Hemodynamically

Stable Patient C. Unstable Fracture Hemodynamically

Unstable Patient D. Unstable Fracture Patient in Extremis

III. STABLE INJURIES A. The Pelvis is Able to Withstand the

Physiologic Forces Incurred for Bed to Chair Transfers and Protected Weight Bearing without Abnormal Deformation of the Pelvis Until Bony Union and Soft Tissue Healing Occurs

IV. CLINICAL SIGNS OF INSTABILITY A. Deformity B. Abnormal Motion C. Posterior Bruising D. Open Wounds E. Associated Injuries

V. X-RAY SIGNS OF INSTABILITY A. Posterior Fracture Displacement>1 cm B. Avulsion Sacrospinous Ligament C. Avulsion Transverse Process L-5

VI. UNSTABLE INJURIES A. Unstable Fracture Hemodynamically

Stable Patient B. Definitive Internal Fixation When

Conditions Permit C. MAS(T) Trousers D. Sheet or Pelvic Binder E. Anterior External Fixator F. Pelvic C-Clamp G. Angiographic Embolization H. Pelvic Packing I. Algorithm

1. Bluid & blood ressuscitation 2. Sheet or pelvic binder 3. CT or FAST scan 4. Exp. Laporotomy if indicated 5. Externation fixation or C-clamp 6. Pelvic packing ??? 7. Angiography if unstable

VII. ANGIOGRAPHY A. Indications for Angiography

1. Persistent hypotension after resuscitation & stabilization

2. CT or FAST negative 3. No evidence of coagulopathy

B. Fracture Surfaces C. L-S Venous Plexus D. Pelvic Arterial Injury

1. Internal iliac 2. Superior & inferior gluteal 3. Obturator 4. Lateral sacral

E. Disadvantages of Angiography 1. Time consuming

a) Transport b) Procedure c) 90 minutes

VIII. PATIENT IN EXTREMIS A. BP<60 mm Hg B. Continued Massive Bleeding C. Not Responding to Treatment D. Imminent Threat of Death E. Urgent Life Saving Surgery F. Angiography NOT Helpful G. Pelvic C-Clamp H. Thoracotomy I. Laparotomy J. Aortic Clamping K. Abdominal/Pelvic Packing

IX. TAKE HOME MESSAGE A. Life Threatening Injury B. Unstable Injuries Should be Fixed! C. Refer to Specialist D. Percutaneous Fixation Techniques E. Computer Guided Imaging & Surgery

HIP FRACTURES General I. BURDEN OF DISEASE

A. 300,000 Hip Fxs/Year B. $15 Billion Dollars C. 25% Mortality at 1 Year D. Risk of Second Fracture 3-5%

II. MANAGEMENT A. Not All Hip Fracture Patients

1. Are debilitated 2. Live in a nursing home 3. Have cognitive impairment 4. Are non-ambulatory

III. OUTCOMES A. Patients Functional Expectations Are

Changing B. Healing of the Fracture Alone Should No

Longer Be Defined As Success C. Outcome Failure is the Inability to Restore

Pre-Injury Levels of Activity Femoral Neck Fractures I. NON-DISPLACED GARDEN 1 & 2

A. Nonoperative Treatment B. Displacement 15-18%

C. Recommend ORIF D. In Situ Fixation E. Cannulated Screws

II. DISPLACED GARDEN III & IV A. Younger Patients With Good Bone B. Urgent ORIF 6-8 Hours C. Cannulated Screws D. Capsulotomy? E. Patients <65 Years

1. Good Bone High Function 2. Rapid Medical Evaluation 3. Hemi-Arthroplasty vs. THR 4. ORIF High Complications

F. Patients 65-80 Years 1. Poor Bone Quality 2. Lower Functional Demands 3. Medical Co-Morbidities 4. Arthroplasty NOT ORIF

G. Patients >80 Years 1. Poor Bone Quality 2. Low Demand 3. Chronic Illness 4. Uni-Polar Prosthesis

III. COMPLICATIONS A. Avascular Necrosis B. Fixation Failure C. Nonunion D. Infection E. Heterotopic Bone F. DVT & PE

IV. TAKE HOME MESSAGE A. Urgent Reduction & Fixation in

Physiologically Young Patients B. High Complication Rates Following ORIF

in Garden III & IV Fractures C. Elderly High Function Patient –

Treatment Controversial D. Renewed Interest in Total Hip

Arthroplasty Intertrochanteric Hip Fractures I. CLASSIFICATION

A. Evans B. Kyle-Gustilo C. AO-ASIF D. OTA E. Stable vs. Unstable – Should The

Treatment Be The Same? II. WHAT IS STABILITY?

A. Ability of the Reduced Fracture to Support Physiologic Loads

B. Contact Between the Fragments C. Implant Will Prevent Shortening, Varus,

Medial Displacement III. COMPRESSION HIP SCREW

A. Gold Standard??? B. Controlled Impaction C. Early Mobilization & WB D. Early Weight Bearing E. Complications 4%-12%

F. Familiar to All Surgeons G. Easy Set-up H. Time Honored & Tested I. Ideal: Stable Fracture J. Concerns: Unstable Fractures

IV. COMPLICATIONS CHS A. Screw Cut-out B. Excessive Shortening C. Medialization of Shaft D. Implant Breakage

V. INTRAMEDULLARY HIP SCREW A. Rationale

1. Minimally invasive technique 2. Decreased OR time/Decreased blood

loss 3. Improved biomechanics 4. Greater stability of fixation 5. Earlier patient mobilization 6. Shorter length of stay

VI. ADVANTAGES OF IM FIXATION A. Less Bending Moment B. Less Stress on Implant C. Less Hardware Failure D. Better Sliding Mechanics

VII. WHAT DOES THE LITERATURE SAY? WHAT IS THE EVIDENCE? A. Parker MJ, Handall HH. Cochrane

Database Syst Rev 2005;4:000093 1. 27 Prospective randomized studies 2. N=4588 3. Short nails vs. sliding compression

hip screw 4. Conclusions

a. Sliding compression hip screw resulted in fewer intraop & postop femoral fxs, fewer technical complications & fewer reoperations

b. No difference between the two techniques in terms of cut-out, nonunion, infection, mortality

c. Not enough information regarding OR time, blood loss, would complications, radiation, limb shortening, or functional outcomes

B. Kregor et al. J Orthop Trauma 2005;19:229-233. 1. Meta-analysis 11 studies comparing

CHS vs IM fixation (unstable fxs only)

2. Conclusion – Failure rate associated with IM fixation was significantly lower than with CHS

C. Jones et al. Int Orthop 2006;30:69-78 1. Scientific evidence does NOT

support the superiority of IM nail fixation over SCHS for the

treatment of intertrochanteric hip fxs

D. The Literature Suggests That IM Nail Fixation Is Associated With Higher Complication Rates & No Better Outcomes

E. Anglen, Weinstein. JBJS 2008;90A:700-707 1. 1999-2006 2. 18,720 intertrochanteric fxs 3. 3823 surgeons (6 month Board

collection period) 4. IM fixation

a. 1999 – 3% b. 2006 – 65%

5. Higher rates of fracture & procedure related complications

6. Equivalent pain & deformity scores 7. Conclusions

a. Young surgeons at beginning of career

b. IM nail 2-4 times the cost of SCHS

c. Higher surgeon fees d. No improvement in patient

outcomes e. Theoretical advantages of IM

fixation not realized VIII. INDICATIONS FOR COMPRESSION HIP

SCREW A. Stable Fracture Patterns B. Younger Patients (Spare Abductor

Mechanism) C. Basi-Cervical Fractures D. Ipsilateral Femoral Implants

IX. INDICATIONS FOR IM FIXATION A. Unstable Fractures B. IT-Subtroch C. Reverse Oblique

Subtrochanteric Femur Fractures I. PROBLEMS IN TREATMENT

A. Difficult To Reduce B. High Stress Concentration C. Prolonged Healing Times D. Fixation Failures E. Increased Complications

II. RUSSELL-TAYLOR CLASSIFICATION A. 1A – Lesser Trochanter Intact B. 1B – Lesser Trochanter Fractured C. 2A – Lesser Trochanter Intact; Piriformis

Fossa Compromised D. 2B – Lesser Trochanter Fractured;

Piriformis Fossa Compromised III. TYPE 1A

A. 1st Gen Locked Nail B. Plate

1. Blade plate 2. DCS 3. Locked plate

IV. TYPE 1B A. Intramedullary Nail

1. Reconstruction 2. IMHS or PFN

B. Piriformis vs Trochanteric Entry C. Locking Plate

V. TYPE 2A A. Intramedullary Nail

1. Reconstruction 2. IMHS or PFN

B. Piriformis vs Trochanteric Entry C. Locking Plate

VI. TYPE 2B A. Intramedullary Nail

1. Reconstruction 2. IMHS or PFN

B. Piriformis vs Trochanteric Entry C. Locking Plate

VII. TAKE HOME MESSAGE A. Nail When Possible B. Fracture Table C. Piriformis or Trochanteric Entry D. Outcomes & Implants Improving E. Proximal Femur Locked Plate?

Femoral Shaft Fractures I. EVALUATION

A. Trauma Work-Up B. Resuscitation C. ATLS D. Physical Exam E. High Quality Imaging

II. ASSOCIATED INJURIES A. Femoral Neck Fxs 3-5%

1. 30% missed on plain films 2. CT of abdomen & pelvis should

include the hip B. Patella Fxs Often Overlooked

1. Dashboard injuries 2. Impacts knee function

III. TREATMENT A. Fracture Stabilization Critical B. ORIF “Standard of Care” C. IM Nailing Treatment of 1st Choice D. The Question is Timing!

IV. IMPLANT CHOICES A. External Fixation B. Plate C. Nail

V. EXTERNAL FIXATION INDICATIONS A. Pediatric Femur Fxs B. Damage Control

VI. PLATE FIXATION INDICATIONS A. Neck-Shaft B. Proximal Fxs C. Distal Fxs D. Peds E. Other

VII. IM NAILING INDICATIONS A. Vast Majority Shaft Fractures

1. “Gold Standard” 2. Closed Nailing 3. Load sharing implant 4. Stable fixation 5. Mechanical sound

VIII. WHAT TECHNIQUED IS APPROPRIATE? A. Early vs Delayed B. Antegrade vs. Retrograde C. Fracture Table vs. Jackson Table D. Pririformis Fossa vs Trochanteric Entry E. Reamed vs. Unreamed F. Static vs Dynamic Nailing

IX. ANTEGRADE VS RETROGRADE A. Antegrade Nailing Remains the Most

Commonly Used Technique B. Retrograde Nailing Useful in Selected

Circumstances X. ANTEGRADE NAILING

A. Fracture or Jackson Table B. Supine or Lateral Position C. Closed or Open Fxs D. Majority of Fractures

XI. DISADVANTAGES OF ANTEGRADE NAILING A. Heterotopic Ossification B. Hip Pain & Dysfunction C. Limited in Neck-Shaft Fractures D. Fracture Table Problems E. Pudental Nerve Palsies F. More Difficult in Multiple Trauma

XII. RETROGRADE NAILING A. Viable Alternative to Antegrade Nailing B. Better or Easier?? C. Specific Indications D. Concerns in Open Fractures E. Multiply Injured Patients F. Bilateral Femur Fractures G. Ipsilateral Hip Fracture H. Ipsilateral Pelvis, Acetabular Fracture I. Ipsilateral Tibia or Patella Fracture J. Ipsilateral Vascular Injury K. Morbidly Obese Patient L. Peri-Prosthetic Fracture

XIII. CONTRAINDICATIONS RETROGRADE NAILING A. Subtrochanteric Fxs B. Contaminated Knee Wounds?? C. Grade IIIB Open Fxs ?? D. Open Distal Femoral Epiphysis

XIV. ANTEGRADE VS. RETROGRADE A. No Difference in Outcome With Canal Fill

Nails 1. Time to union 2. Rates of union 3. Alignment

B. Hip Symptoms Antegrade C. Knee Symptoms Retrograde

XV. ENTRY POINT A. Piriformis Fossa – Pros

1. Long track record 2. In line with canal 3. Less hoop stresses 4. Less secondary deformity 5. Less injury to abductor mechanism

B. Piriformis Fossa – Cons 1. Difficult supine 2. Difficult in large patients 3. Damage to short ext rotations 4. risk of AVN in adolescence

C. Trochanteric Entry – Pros 1. Easier to find starting pt 2. Makes supine nailing easier 3. Less OR & fluoro time ??? 4. risk of AVN in adolescence

D. Trochanteric Entry – Cons 1. Secondary deformity with

conventional nails (varus) 2. Damage to abductions 3. Fracture specific implants 4. Easier or better??

XVI. THE ROLE OF REAMING A. Reaming Pros

1. Larger implant 2. Fills canal 3. Less malalignment 4. Fewer mechanical failures 5. Reaming as “bone graft”

B. Reaming Cons 1. Marrow & fat embolism 2. Pulmonary injury 3. IM pressure & temp 4. blood loss 5. Technical issues

C. The Exact Relationship Between Reaming, Fat Embolism & ARDS is Not Fully Understood

XVII. CURRENT CONCEPTS IN REAMING A. Sharp Reamers B. Deep Flutes C. Small Head Size D. Narrow Drive Shaft E. Careful Advancement F. Not Too Much

XVIII. STABLE VS DYNAMIC A. All Nails Should Be Statically Locked B. 1 Locking Screw if >7.5 cm From Fx Site C. 2 Locking Screws if <7.5 cm From Fx

Site XIX. CONCLUSIONS

A. Antegrade Reamed Statically Locked IM Nailing for Both Closed & Open Femur Fxs is Safe & Effective

B. Surgeon’s Choice 1. Supine or lateral position 2. Fx table or Jackson table 3. Piriformis or troch entry

Supracondylar Femur Fractures I. CLASSIFICATION

A. Extraarticular B. Intraarticular C. Unicondylar Fractures

II. GOALS OF SURGICAL TREATMENT A. Restore Joint Congruity B. Anatomic Alignment C. Stable Internal Fixation D. Early ROM Knee

III. SURGICAL TREATMENT A. Plate Osteosynthesis B. IM Nailing

1. Antegrade 2. Retrograde

C. External Fixation IV. INDICATIONS FOR SURGERY

A. Comminuted Fxs B. Severe Soft Tissue Injury C. Multiple Injuries D. Compromised Host E. Prei-Prosthetic Fxs

V. PERI-ARTICULAR LOCKED PLATES A. Minimally Invasive Surgery B. Sub-Muscular Placement C. Multiple Fixed Angle Screws D. Self-Drilling, Self-Tapping E. Unicortical Options

VI. TAKE HOME MESSAGE A. Restore Articular Congruity B. Individualize Treatment C. Avoid Stiffness – Early ROM D. Locking Plates – LISS & Others

Tibial Plateau Fractures I. SCHATZKER CLASSIFICATION

A. I – Split Lateral Condyle B. II – Split Depressed Lateral Plateau C. III – Pure Depression Lateral Plateau D. IV – Medial Plateau Fracture E. V – Bicondylar Plateau Fracture F. VI – Bicondylar Plateau-Diaphyseal Ext.

II. IMAGING STUDIES A. Axial B. Sagittal C. Coronal D. 3D CT Scans E. Preop Plan

III. DECISION MAKING – 3 KEY FACTORS A. Evaluation Soft Tissue B. Evaluation Fracture C. Patient Factors

IV. EVALUATION OF SOFT TISSUE A. Low Energy B. Intermedial Energy C. High Energy

V. EVALUATION OF FRACTURE A. Plain Films B. CT

C. MRI VI. EVALUATION OF LATERAL PLATEAU

A. Split B. Depressed C. Meta-Diaphyseal D. Combinations

VII. TREATMENT OF LATERAL PLATEAU A. Screws Alone B. Conventional Plate C. Locking Plate D. Based On

1. Fracture pattern 2. Bone quality

VIII. MEDIAL PLATEAU A. Two Distinct Fracture Patterns

1. Sagittal 2. Coronal

B. Sagittal Fx Pattern 1. Medial buttress 2. Laterally based locked plate

C. Coronal Fx Pattern 1. Requires a posteromedial plate!

IX. PATIENT FACTORS A. Associated Injuries B. Co-Morbidities C. Functional Demands

X. DECISION MAKING A. The Surgeon Must Have a Clear

Understanding of the Soft Tissue Injury & the Fx Pattern in Order to Determine the Timing of Fixation, The correct Surgical Approach, As Well As the Location and Type of Implants

XI. SURGICAL TECHNIQUES A. Traction B. Distractor C. Ex-Fix D. Tension Device E. Push-Pull F. Plate

XII. INDICATIONS FOR SURGERY A. Displaced Fxs B. Articular Incongruity C. Knee Instability D. Axial Deformity E. Timing of Surgery

XIII. IMMEDIATE SURGERY A. Open Fxs B. Compartment Syndrome C. Neuro-Vasc Compromise

XIV. EARLY DEFINITIVE SURGERY A. Lower Energy Closed Fxs B. Schatzker I, II, III Patterns C. Classic Internal Fixation D. 24-72 Hours Post Injury

XV. DELAYED SURGERY A. Higher Energy Fxs

1. Significant swelling 2. Fx blisters

3. Degloving injuries 4. Open Fxs 5. Multiply injured patients 6. Early internal fixation is contra-

indicated!! XVI. SURGICAL CONTROVERSIES

A. Type of Bone Graft B. External Fixation vs ORIF C. Role of Arthroscopy D. Peds/Open Epiphysis E. Late Presentation

XVII. CONCLUSIONS A. Understand Soft Tissues B. Recognize Fx Pattern C. Correct Surgical Approach D. Correct Choice of Fixation

Tibial Shaft Fractures: Decision Making I. INTRODUCTION

A. Huge Spectrum of Injury B. Isolated Low Energy C. Severe Open Fxs D. Multiply Injuried E. Limb Salvage Decisions

II. DECISION MAKING IN CLOSED FRACTURES A. Isolated or Not B. Compartment & N-V Status C. Condition of Soft Tissues D. Fx Location and Geometry E. Timing of Surgery

III. DECISION MAKING IN OPEN FRACTURES A. Magnitude of Soft Tissue Injury B. Degree of Contamination C. Timing & Type of Stabilization D. Soft Tissue & Bone Reconstruction

IV. CAST TREATMENT A. Low energy injuries B. Closed fractures C. Stable fracture patterns D. Non-multiply injured patients

V. PLATE FIXATION A. 1o for metaphyseal-diaphyseal fractures B. Acceptable soft tissue envelope C. Indirect reduction D. Percutaneous techniques

VI. REAMED NAILS A. Primarily unstable closed fractures B. Selected grade I & II open fractures C. Middle 3/5ths of tibia D. Fracture table or radiolucent table

VII. UNREAMED NAILS A. Primarily open fracture management B. Selected closed fractures with severe

soft tissue injury C. Static interlocking D. Aggressive treatment to achieve union

VIII. EXTERNAL FIXATION A. Grade III open fracture management

B. Closed fractures bad soft tissues C. Spanning frames D. Sick patients – rapid application

IX. TAKE HOME MESSAGE A. Most Common Long Bone Fracture B. Most Problems – Infection, Nonunion,

etc. C. Assessment, Resuscitation, N-V Status,

R/O Compartment Syndrome, Stabilize D. Individualize Treatment E. Staged Reconstruction

Tibial Pilon Fractures I. INTRODUCTION

A. Life Altering Event B. Impacts Work & Recreation C. Full Recovery Rare D. Functional Impairment E. Limb Threatening

II. HISTORICAL PERSPECTIVE A. Poor Understanding of the Soft Tissue

Envelope B. Large Bulky Implants C. High Complication Rates

1. Infection 2. Arthrodesis 3. Amputation

III. CHALLENGES IN TREATMENT A. Soft Tissue Management B. Articular Reduction C. Fx Comminution D. Associated Injuries

IV. FRACTURE PERSONALITY A. Low Energy B. High Energy

V. GOALS IN TREATMENT A. First

1. Assess soft tissues 2. Restore length & alignment 3. Imaging studies

B. Second 1. Articular reduction 2. Stable fixation 3. Early ROM

VI. DECISION MAKING A. Open vs Closed B. Status of Soft Tissues C. Associated Injuries D. Fracture Personality E. Imaging Studies

VII. TIMING OF SURGERY A. Immediate Surgery

1. Open Fxs 2. Compartment syndrome 3. N-V compromise 4. Soft tissue compromise

B. Delayed Definitive Fixation 1. Limb swelling 2. Compromised skin

3. Associated injuries 4. Post-reduction CT scan 5. Special implants

VIII. TREATMENT STRATEGIES A. Timing of Surgery B. Staging of Surgery C. Planning of Surgery D. Surgical Approaches

IX. TIMING OF SURGERY A. Early Internal Fixation of High Energy

Pilon Fxs Associated with Increased Incidence of 1. Wound infection 2. Additional surgeries 3. Poor outcomes 4. Amputations

X. STAGING OF SURGERY A. Planned 2 (or More) Staged

Procedure(s) B. Temporary Bridging External Fixation C. ORIF Fibula D. Delayed ORIF Tibia E. Most Open Fxs F. High Energy Closed Fxs G. Compromised Soft Tissues H. Associated Injuries I. Awkward Time (Night) J. Staged Reconstruction

1. Simple frames 2. Pins outside zone of injury 3. Foot in neutral with pin 4. Soft tissue reconstruction

a. Wound VAC b. STSG c. Free flap

K. Early ORIF of Fibula Helps Control Talus

L. Bi-Columnar Posterior Distraction Centralizes the Talus Between the Tibia

XI. TAKE HOME MESSAGE A. Soft Tissue Assessment Guides Rx B. Good Soft Tissues – Internal Fixation C. Bad Soft Tissues – External Fixation D. Planned Staged Reconstruction

1. Simple spanning external fixator 2. Delayed ORIF with locked plates

Fractures of the Talus I. TALAR NECK FRACTURES

A. High Energy Trauma B. Hyper-Dorsiflexion Injury C. Significant Morbidity D. Complications Frequent

II. HAWKINS CLASSIFICATION 1. Type I - non-displaced 2. Type II - displaced with

disruption of subtalar joints

3. Type III - displaced with disruption of subtalar & tibiotalar joints

4. Type IV - displaced with disruption of subtalar, tibiotalar & talonavicular joints

B. Treatment 1. Type I – cast or cannulated screws 2. Type II, III, IV – ORIF

C. Complications 1. skin necrosis and infection 2. delayed union and nonunion 3. malunion 4. avascular necrosis

Type I 10% Type II 40% Type III 75%

Type IV 95% 5. post-traumatic arthritis

III. TAKE HOME MESSAGE A. Injuries Easily Overlooked B. High Index of Suspicion C. Best Results with ORIF D. Complications Common

Fractures of the Calcaneus I. CONSEQUENCES OF INJURY

A. Shortening of heel B. Widening of heel C. Varus hindfoot D. Subtalar arthrosis E. Fibulo-calcaneal impingement F. Heel pain

II. INDICATIONS FOR SURGERY A. Adequate Soft Tissues B. Fixable Fracture C. Low Profile Implants D. Disruption of the Posterior Facet E. Achilles Tendon Avulsion

III. CONTRAINDICATIONS TO SURGERY A. Compromised Soft Tissues B. Geriatric Pts C. Neuropathic or Occlusive Disease D. Smokers E. Inexperience

IV. TECHNICAL CONSIDERATIONS A. Lateral Decubitus Position B. Image Intensifier C. L-Shaped Incision D. Provisional K-wire Fixation E. Low Profile Implants F. Locked Plates ??? G. Splint to Avoid Equinus H. Early Range of Motion I. Delayed Weight Bearing

V. TAKE HOME MESSAGE A. Fairly Common Injury B. Significant Morbidity/Disability C. Articular Injury to WB Joint

D. Low Profile Peri-Articular Plates E. Fix Them or Refer Them

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89. Ostrum RF: Treatment of floating knee injuries through a single percutaneous approach. Clin Orthop 375:43-50, 2000.

90. Ostrum RF, Agarwal A, Lakatos R, Poka A: Prospective comparison of retrograde and antegrade femoral intramedullary nailing. J Orthop Trauma 14:496-501, 2000.

91. Pallister I, Empson K: The effects of surgical fracture fixation on the systemic inflammatory response to major trauma. J Am Acad Orthop Surg 13:93-100, 2005.

92. Palm H, Jacobsen S, Sonne-Holm S, et al: Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg 89A:470-475, 2007.

93. Pape H-C, Hildebrand F, Pertschy S, et al.: Changes in the management of femoral shaft fractures in polytrauma patients: from early total

care to damage control orthopedic surgery. J Orthop Trauma 18:S13-S23, 2004.

94. Pape H-C, Tornetta P, Tarkin I, Tzioupis C, Sabeson V, Olson S: Timing of fracture fixation in multitrauma patients: The role of early total care and damage control surgery. J AAOS 17:541-549, 2009.

95. Parker MI, Khan RJK, Crawford J, Pryor GA: Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures in the elderly. J Bone Joint Surg 84B:1150-1155, 2002.

96. Parker MI, Pryor G, Gurusamy K: Cemented versus uncemented hemiarthroplasty for intracapsular hip fractures. J Bone Joint Surg 92-B:116-22, 2009.

97. Phisitkul P, Mckinley TO, Nepola JV, Marsh JL: Complications of locking plate fixation in complex proximal tibia injuries. J Orthop Trauma 21:83-91, 2007.

98. Potter MQ, Nunley JA: Long-term functional outcomes after operative treatment for intra-articular fractures of the calcaneus. J Bone Joint Surg Am 91:1854-60, 2009.

99. Probe R, Ward R: Internal fixation of femoral neck fractures. J Am Acad Orthop Surg 14:565-571, 2006.

100. Rademakers MV, Kerkhoffs GMMJ, Sierevelt IN, et al: Operative treatment of 109 tibial plateau fractures: five- to 27-year follow-up results. J Orthop Trauma 21:5-10, 2007.

101. Ratcliff JF, Werner FW, Green JK, Harley BJ: Medial buttress versus lateral locked plating in a cadaver medial tibial plateau fracture model. J Orthop Trauma 21:444-448, 2007.

102. Reid JS, Van Slyke MA, Moulton MJ, Mann TA: Safe placement of proximal tibial transfixation wires with respect to intracapsular penetration. J Orthop Trauma 15:10-17, 2001.

103. Reilly MC, Bono CM, Litkouhi B, Sirkin M, Behrens FF: The effect of sacral fracture malreduction on the safe placement of iliosacral screws. J Orthop Trauma 17:88-94, 2003.

104. Ricci WM, Bellabarba C, Evanoff B, et al.: Retrograde versus antegrade nailing of femoral shaft fractures. J orthop Trauma 22:S31-S38, 2008.

105. Ricci WM, Bolhofner BR, Loftus T, et al: Indirect reduction and plate fixation, without grafting, for periprosthetic femoral shaft fractures about a stable intramedullary implant. J Bone Joint Surg 87A:2240-2245, 2005.

106. Ricci WM, Devinney S, Haidukewych G, Herscovici D, Sanders R: Trochanteric nail insertion for the treatment of femoral shaft fractures. J Orthop Trauma 22:S2-S8, 2008.

107. Ricci WM, O’Boyle M, Borrelli J, Bellabarba C, Sanders R: Fractures of the proximal third of the tibial shaft treated with intramedullary nails

and blocking screws. J Orthop Trauma 22:S39- S45, 2008..

108. Ricci WM, Rudzki JR, Borrelli J Jr.: Treatment of complex proximal tibia fractures with the less invasive skeletal stabilization system. J Orthop Trauma 18:521-527, 2004. 109. Ricci WM, Schwappach J, Tucker M, et al: Trochanteric versus piriformis entry portal for the treatment of femoral shaft fractures. J Orthop Trauma 22:S9-S13, 2008. 110. Roberts CS, Pape H-C, Jones AL, et al.: Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect 54:447-462, 2005. 111. Robinson CM, Houshian S, Khan LAK:

Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma. J Bone Joint Surg 87A:2217-2226, 2005.

112. Rogmark C, Carlsson A, Johnell O, Sernbo I: A prospective randomised trial of internal fixation versus arthroplasty for displaced fractures of the neck of the femur. Functional outcome for 450 patients at two years. J Bone Joint Surg 84B:183-188, 2002.

113. Routt MLC Jr., Nork SE, Mills WJ: Percutaneous fixation of pelvis ring disruptions. Clin Orthop 375:15-29, 2000.

114. Russell TA, Leighton RK: Comparison of autogenous bone graft and endothermic calcium phosphate cement for defect augmentation in tibial plateau fractures. J Bone Joint Surg 90A:2057-2061, 2008.

115. Sagi HC, Militano U, Caron T, Lindvall E: A comprehensive analysis with minimum 1 year follow-up of vertically unstable transforaminal sacral fractures treated with triangular osteosynthesis. J Orthop Trauma 23:313-321, 2009.

116. Saleh KJ, Sherman P, Katkin P, et al.: Total knee arthroplasty after open reduction and internal fixation of fractures of the tibial plateau. A minimum five-year follow-up study. J Bone Joint Surg 83A:1144, 2001.

117. Sarmiento A, Latta LL: Functional fracture bracing. J Am Acad Orthop Surg 7:66-75, 1999.

118. Scalea TM, Boswell SA, Scott JD, et al.: External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Orthop Trauma 18:S2-S12, 2004.

119. Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr.,: A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma 13:78-84, 1999.

120. Smith CS, Nork SE, Sangeorzan BJ: The extruded talus: results of reimplantation. J Bone Joint Surg 88A:2418-2424, 2006.

121. Smith W, Williams A, Agudelo J, et al: Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma 21:31-37, 2007.

122. Stannard JP, Riley RS, McClenney MD, et al.: Mechanical prophylaxis against deep-vein thrombosis after pelvic and acetabular fractures. J Bone Joint Surg 83A:1047-1051, 2001.

123. Starr AJ, Griffin DR, Reinert CM et al.: Pelvic ring disruptions: Prediction of associated injuries, transfusion requirement, pelvic arteriography, complications, and mortality. J Orthop Trauma 16:553-561, 2003.

124. Starr AJ Hay MT, Reinert CM, et al: Cephalomedullary nails in the treatment of high-energy proximal femur fractures in young patients: a prospective, randomized comparison of trochanteric versus piriformis fossa entry portal. J Orthop Trauma 20:240-246, 2006.

125. Stephen DJG, Kreder HJ, Schemitsch EH, et al.: Femoral intramedullary nailing: comparison of fracture-table and manual traction. J Bone Joint Surg 84A:1514-1521, 2002.

126. Stevens DG, Beharry R, McKee MD, Waddell JP, Schemitsch EH: The long-term functional outcome of operative treated tibial plateau fractures. J Orthop Trauma 15:312-320, 2001.

127. Swanson TV, Bray TJ, Holmes GB Jr.,: Fractures of the talar neck. J Bone Joint Surg 74A:544-551, 1992.

128. Tornetta P III, Kain MSH, Creevy WR: Diagnosis of femoral neck fractures in patients with a femoral shaft fracture. J Bone Joint Surg 89A:39-43, 2007.

129. Tornetta P III, Tiburzi D: Antegrade or retrograde reamed femoral nailing. A prospective, randomised trial. J Bone Joint Surg 82B:652-654, 2000.

130. Tornetta P III, Tiburzi D: Reamed versus nonreamed anterograde femoral nailing. J Orthop Trauma 14:15-19, 2000.

131. Trenholm A, Landry S, McLaughlin K, et al.: Comparative fixation of tibial plateau fractures using α-BSMTM, a calcium phosphate cement, versus cancellous bone graft. J Orthop Trauma 19:698-702, 2005.

132. Vallier HA, Nork SE, Barei DP: Talar neck fractures: results and outcomes. J Bone Joint Surg 86A:1616-1624, 2004.

133. Van denBekerom MPJ, Hilverdink EF, Sierevelt IN et al.: A comparison of hemiarthroplasty with total hip replacement for

displaced intracapsular fracture of the femoral neck. J Bone Joint Surg 92-B:1422-8, 2010.

134. Wahnert D, Hoffmeier KL, Dipl-lng et al.: Internal fixation of type-C distal femoral fractures in osteoporotic bone. J Bone Joint Surg 92:1442-52, 2010.

135. Watson JT, Moed BR, Karges DE, Cramer KE: Pilon fractures. Treatment protocol based on severity of soft tissue injury. Clin Orthop 375:78-90, 2000.

136. Weigel DP, Marsh JL: High-energy fractures of the tibial plateau. Knee function after longer follow-up. J Bone Joint Surg 84A:1541-1551,2002.

137. Weiss NG, Parvizi J, Trousdale RT, Bryce RD, Lewallen DG: Total knee arthroplasty in patients with a prior fracture of the tibial plateau. J Bone Joint Surg 85A:218-221, 2003.

138. White TO, Guy P, Cooke CJ, Kennedy SA et al.: The results of early primary open reduction and internal fixation for treatment of OTA 43.C-type tibial pilon fractures: A cohort study. J Orthop Trauma 24:757-763, 2010.

139. Wolinsky P, Tejwani N, Richmond JH, Koval KJ, Egol K, Stephen DJG: Controversies in intramedullary nailing of femoral shaft fractures. J Bone Joint Surg 83A:1404-1415, 2001.

140. Wukich DK, Kline AJ: The management of ankle fractures in patients with diabetes. J Bone Joint Surg 90A:1570-1578, 2008.

141. Yacoubian SV, Nevins RT, Sallis JG, Potter HG, Lorich DG: Impact of MRI on treatment plan and fracture classification of tibial plateau fractures. J Orthop Trauma 16:632-637, 2002.

142. Ziran BH, Smith WR, Towers J, Morgan SJ: Iliosacral screw fixation of the posterior pelvic ring using local anesthesia and computerized tomography. J Bone Joint Surg 85B:411-418, 2003.

Upper Extrem

ity

 

 

UPPER EXTREMITY  

Moderator: Marc Safran, MD 

10:10 AM – Hand and Wrist Jeffrey Greenberg, MD 

 10:50 AM – Forearm and Elbow 

Rick F. Papandrea, MD  

11:25 AM – Shoulder and Humerus Marc Safran, MD

 

Orthopedic Review Course

Hand Surgery Update

AAOS, San Diego, February 2011

Jeffrey A. Greenberg, MD, MS

Indiana Hand to Shoulder Center

Indianapolis, IN

Hand

Flexor Tendon Surgery

Rationale re: Treatment Decisions

Repair Techniques

Evidence

Future Direction

PIP Injuries

Classification

Mechanism/biomechanics

Stability

Treatment options

Rehabilitation

Small Joint Arthroplasty

Surgical options

Implants

Approaches

Evidence

Wrist

Distal Radius Fractures

Evolution in treatment decisions

Rational Approach to Treatment

Treatment Options

Outcomes/Evidence

Ulnar Styloid

Acute

Chronic

Evidence

Distal Radius Malunion

Pathomechanical changes

Rationale for Treatment

Treatment Options

Outcomes

Scaphoid Fractures

Factors affecting treatment decisions

Treatment Options

Outcomes

Nonunion

Carpal Instability

Acute

Subacute

Chronic

Salvage (SLAC, SNAC)

DRUJ

Instability

Pathomechanics

Rationale for Treatment

Treatment Options

Arthroplasty

New evolving concepts

Rationale for Treatment

Indications and Options

Outcomes/Evidence

TFC

Update: Anatomy/Biomechanics

Diagnosis and Classification

Treatment Options/Rationale

Kienbock’s

Classification Schemes

New adjuncts to classification

Classification based Treatments

Outcomes

Thumb CMC Reconstruction

Update on Treatment Options

Evidence

Nerve

Reconstruction: New options for treatment

Conduits

Autogenous

Synthetic

Allograft

Outcomes/Evidence

Rick F. Papandrea, MD Orthopaedic Associates of WI Assistant Clinical Professor, Medical College of WI 

 Elbow 

 1. Intro 

a. Anat mo y i. Collaterals 

1. Isometric points[13] a. Not truly isometric[4] b. Laterally at center of capitellum  c. Medially at inferior epicondyle 

ii. Fossae 1. Coronoid/Olecra

iii. Medial f

non 2. Don’t forget radial head 

ace f 1. Adja en

t o coronoid c t to sublime tubercle a. Attachment of MCL – anterior band 

b. Functional requirements i. ROM 

1. Flex/ext a. 30 to 130 Morrey [5] b. 75 to 120 Vasen [6] 

i. with adjacent joint compensation 2. Supination/pronation 

a. 50 to 50 [5] i. Accommodate loss of pronation 

1. Shoulder abduction c. History 

i. Symptoms 1. Pain 

a. End arc – impingment b. mid arc – incongruity of joint (worse with load) c. rest – synovitis 

d. Imag gin  i. Xrays 

1. laRad l h ts over2. Neu al

ia ead view – limitr  rota on

p from ulna ti  full forearm 

a. Radial bow [7] 

b. Dista  Ri. Loss limits rotation l adioulnar joint 

ess relative ulna length compared to contralateral i. Ass

1. 3D recoii. CT 

nstru tia. Osirix allows post CT reconstrucion [

c on 

i. Surgeon controlled  8] 

iii. MRI 1. Indications 

a. Biceps –  

i. FABS view [9] 1. Flexion, Abduction, Supination 2. Allows visualization from muscle to insertion in same 

image 3. Less sensitive for partial tears[10] 

e. Expo urs e i. Skin 

1. “Un eriv sal” p so terior ng [11] a. nerve spari

b. large la

i. less chance of numbess  f ps i. risk f s o eroma/hematoma/necrosis 

 1. limiting motion for 24‐48 hrs may help

May need multiple incisions depending on pathology 2. Direct 

a. pii. Dee  1. Kocher 

a. Impl aic tions to LCL i. If deep incision is carried in line between anconeus and ECU, the 

UCL will be cut 

a.2. Kaplan 

Limitation‐radial nerve es distal to radial neck, supinator split and Radial i. If dissection go

b. Can extenerve dissected nd up column 

i. Allows increased access to capitellum 3. Lateral “Column” 

a. First described by Hastings/  Morrey 

4. “Ov  th

Cohen[12, 13] b. Named byer e toa. Hot ki

p”, a.k.a. “Medial Column” ch ss 

 Flexor/Pronatoi. Split

r mass ii. Proximal up column rey [5. Bryan‐Mor

6. TRAP [

14] iceps weaknes[a. May be problems with healing and tr

6] a. Trice s

15] 1

p  Reflecting Anconeus Pedicle Morrey combined with muscular portion of Kocher – deep nts left intact 

i. Bryan‐ligame

7. Olecranon osteotomy 8. AFT [17] 

9.  Lat

a. Olecranon osteotomy combined with TRAP eral epicondylar osteotomy a. can a lob. repa  w

l w for increased access to lateral joint ir ith rigid fixation allow for more aggressive rehab   i. can be helpful with radial head replacements, capitellar fractures 

2. Arthroscopy a. Special equipment 

i. Positioning supports ii. Dedicated 30 degree 4mm sleeve 

1. No fenestrations iii. Multiple switching sticks 

b. Positioning i. Prone/lateral decubitus 

1. Arm over bolster/support 2. Must be 90 degrees from body 3. Antecubital region with no pressure 

ii. Supine 1. May be more difficult to work posteriorly 

c. Indications i. OCD ii. Loose body iii. DJD iv. Plica[18, 19] v. Lateral Epicondylitis [20, 21]Risks [22] 

d. Risks i. Mayo data over 470 elbows with no permanent injuries [22] ii. Nerves have been cut 

1. Greatest risk radial? a. Don’t forget Ulnar nerve posteriorly 

3. Stiffness a. Nonoperative management 

i. Bracing 1. Static vs. dynamic 

a. Teaching – dynamic irritates 2. Science – no difference [23] 3.  Protocol? 

a. No science[24] 4. Window of opportunity 

a. 36 months b. no science 

b. Oper tia ve i. Open 

1. Late l ra

a. Column [12, 13] b. Hastings/Cohen (ref) 

Safe, reproducible, simple  access to Ulnar nerve 

c.

2d. Does not allow

. Medial  a. “Over the top” 

Concomit

b.

3

ant Ulnar nerve c. No radial head access 

. Both  a. Start on one side, go to the other if needed 

4. Tardy Ulnar nerve symptoms a. Release or transpose if flexion gained 

i. Absolute numbers? 1. Most surgeons release if flexion only to 90 2. Some surgeons releasing all 

ii. Problems after increased flexion 

1. Tardy Ulnar nerve may present only with loss of  or vague pain motion

ro cop  1. Rele se

ii. Arth s ica  v. Excision of capsule a. Experienced based b. Outcomes unknown for superior tech 

c.  Postoperative management i. No science 

1. CPM [25] 2. Formal therapy 3. Self directed exercises 4. Splints 

4. Stability a. “Primacy of Coronoid” – Morrey 

i. Without adequate coronoid the elbow will be unstable b. Collateral anatomy 

i. LCL critical ii. Non throwers can tolerate MCL insufficiency  

1. If other constrains are in place c. Rad

5. Inst il

ial head – Important secondary [26] i. Critical in persistent instability (failed attempts at ORIF of fx dislocations) [2729] 

ab ity a. Test 

i. Pivot shift  ii. Drawer iii. Push up/off 

b. Simple elbow dislocation i. PLRI – mechanism ii. Recurrent 

1. Reconstruct LCL [30, 31] 2. MCL may be intact and usually does not need to be reconstructed 

c. Fracture dislocation i. Coronoid fracture 

1. Morrey/Regan [32, 33] a. Type I – tip (shear, previously avulsion) b. Type II – less than 50% height c. Type III – More than 50% height 

2. O’Driscoll a. Correlation with injury pattern [34] And therefore treatment recommendations 

1. Tip – PLRI (posterolateral rotatory instability) a. Fix LCL [35] b. Single bundle can work[36] c. Repair or replace Radial Head d. Assess MCL 

a. Most don’t need repair b. Will heal if elbow is stable 

e. Successful published protocol[ 37] f. Now there are questions if all tips needg. Case report of 4 cases treated non‐op[

 to be repaired 38] 

a. Aligned with small frx and no block to motion 2. Medial – VPMRI (Varus posteromedial rotatory instability) 

a. Image b. 3D CT c. Assess LCL 

a. Usually needs repair d. Assess medial coronoid 

a. Usually needs repair 3. Base (transolecranon fxdislocation) 

a. Secure coronoid to ulna a. Easiest access is through olecranon fx 

b. Plate olecraonon c. Fix or replace radial head 

4. EX fix can be considered to support tenuous fixation a. Dynamic or rigid 

a. No science supports one over other b

 

. Dynamic can protect LCL injuries or recon[39] 

 d. Med l cia olla ra

i. Clin al te l ligament ic dx 

p” 1. Loss of velocity, often after “post[40

elin) 2. Moving valgus stress te

rs, jav

] ii. Throwers (pitchers, catcheii ii. Some wrestlers/MMA/gymnast v. Look for ulna n symptoms v. May be repaired with single bundle[41] vi. Docking technique[42] 

e V.  extension overload [algus

f. Rehab 

43] i. Don’t remove more than the osteophyte 

i. Importance f v o arus tr tion a. Forearm teral stress[

 s ess with shoulder abduc position effects on collapination stresses LCL 

resses MCL 

44, 45] i. Su

ii. Acu  siii. Pronation st

te mpl di

e  slocation r early motion 

f static subluxation 1. Immediate o

2. Avo  v

a. Immobilize only iid arus a. Supine exercises 

6. Arth itir s a. Prim rya  

i. Oste pho yte ill ssae 1. “rid ” 

s f ing foge osteophyte  

a. early b. dist

2. Trea me

al olecranon fossae ion c. impinges with extens

t nt a. Remove osteophytes 

i. Open 1. Out brer ide‐Kashiwagi or ulnohumeral arthroplasty[46] 

dial head fossa al bone off ulna 

a. Does not address ra

2. Late l b. Does not remove medial or laterra or medial approach a. May combine with Outerbridge b. Still difficult to remove medial lateral bone from 

olecranon ii. Arthroscopic (OCA – osteocapsular arthroplasty – O’Driscoll) 

b. Address ulnar nerve i. No science 

1. Release v. transpose 2. Only if flexion increased? 3. Only if flexion less than 90? 

b. P ost ac. Infla m

 tr uma 

m atory i. Early syii. Que io

novectomy 

st n role of radial head excision . Classic teaching to remove 

oscopy allows synovectomy with retention 12. Arthr

w rthr pla. Part l r

7. Elbo  A o asty ia eplacement i. “off‐label” use 

1. hemiarthroplasty of distal humerus[47] a. acute fracture b. del

b. Tota El

ayed reconstruction i. salvage 

l  bow rti. History 

 A hroplasty 

[1.

ii.

Current success in low demandlure in other pts[

48] 2. Higher fais 1. Infe io

49]  Risk

ct n a. Abx in PMMA b. Regional Abx[50] 

iii. Linked 1. Term pr

v. Unlinked v. Convertible[

eferred over “semiconstrained” i

51] vi. Hemispherical bearings 

1. Do they matter? vii. Role of radial head (ref?) 

c. Interposition[5254] i. Typically unsuccessful if preoperatively unstable ii. With preoperative stability still a 50:50 surgery 

8. Fusion[55, 56] a. Durabl

9. Tendino

e once fused b. If pt accepts th

pathy a. Medial/lateral 

e disability can provide painless function 

b. N atu alc. Curr t

r  history en  scie ce

n  (there is not much) 

l I evidence that wrist extension splint is superior to forearm strap i. Bracing[57] 

e e 

1. Levii. Shock waviii. Injections 

1. Steroids [58] a.

Short term benefit b.

Longer term detriment 2. Botox 3. Blood 

latelet gel ay weaken tissue (pix) 

4. P5. M

iv. Surgery 1. Debride/release 

a.  epicondyle [No need to tx Rando

us 

59] i. mized double blind study! – LEVEL 1 

b. Percutaneoc. Open 

pe[d. Sco

i. Part l v

60] d. Biceps 

ia . full [61] 1. MR rarely need2. Hook test [

ed 62] 

ii. To fix or n

iii. Techniq

ot to fix[63] 1. 30% loss of 

flexion and 40% loss of supination strength without repair ue 

1. One incision Two incision[64] 

ference screws/tunnels 2.

iv. Rehab 

3. Anchors/buttons/inter

1. Immediate motion[65] e. Tric sep [66] 

i. Rare 

ii. Steroids? i ii. Loo foi

k  r fleck ur in adults and kids Younger with radial head fracture 

v. Can occ1.

v. Repair 10. Frac rtu es 

a. Distal humeral i. Dual plate configuration [67, 68] 

1. “parallel” plates at least as good as “9090” ii. Shortening osteotomy for bone loss[69] iii. Prosthetic for irreparable 

a. Total elbow[70]Must be linked b. Triceps left on  

2. Hemiarthroplasty[47] a. Off label 

b. Olecranon 

c. Coronoid i. See a

d. Radial head bove, under fracture dislocation 

i. ns for ORIF [Indicatioii. ORIF vs. Reiii. Implants 

71]  place? (need references) 

1. overstuffing[7274] a. best assessment is visualizing the lateral UH joint 

i. radiographic “widening” of the joint may be normal, compare to contralatral 

2. spacer v. anatomic[75] a. no comp

3. role f b

aritive data b. most data on o ipolars? a. polyethylene 

 “spacers” 

11. Ulnar nerve 

a. Release v. transposition for Cubital Tunnel[76] 

pitellum   12. Osteochondritis of the Ca

13. Hete ota. Lateral margin should be intact or reconstructed[77] r opic Ossification a. Post op Xray Therapy (700 cGy/Rads) increased non union in ACUTE TRAUMA[78] 

 Forearm 

 I. Ana mto y 

rthrodial joint g separation (IOM) b/t joint “compartments” 

a. Diaon

b. L

II. Monteggia III. Gale zzIV. Both bo

a i nes 

a. Don’t rod both (ref) i.

V.

Malunion ii. nonunion 

x presti a. Recogni

Esse  loze and treat ac

i. Fix or replac

utely   e radial head

h? ii. Stabilize DRUJ 

Pinning enoug IOM surgery 

1. ii

i. ? role of

b. Anconeus [79] 

c. IOM ci. salvage  re onstruction i. Bone‐tendon‐bone [80, 81] i ] t id not work 

i. Pronator teres rerouting[82en ed Monoblock radial heads d

nts – case series[d. Cem

VI.  Mal ii. 8 patie 83] 

un on a. Poor ob. Late  a radius fx years prior 

 r tation  in dolescent, young adult with h/o distal i. Clinically shows up as DRUJ instability 

VII. Hete otr opic ssa. Test g 

 O ification ini. No need for labs i

b. Tim g 

or bone scan ated bone i. Look for well margin

84] os 

in for removal[i. Consensus at 6mi

c. Recu rei. ? 3‐4 mos r ncei. Preo  v

 prevention RT p . post op X

1. Single fraction 2. 700 Rads 

ii. Indocin or other NSAIDs  Bibliog

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Shoulder & Humerus Review Safran, Page 1

SHOULDER & HUMERUS What’s Hot & What’s Not

ORTHOPAEDIC REVIEW COURSE February 18, 2011

San Diego, California

MARC R. SAFRAN, MD

Professor, Orthopaedic Surgery Associate Director, Sports Medicine

Stanford University msafran@stanford.edu

Disclaimers:

(1) This talk is not intended specifically as a board review but rather an update on current, evidenced- and experienced-based practice of shoulder surgery.

(2) This handout is more extensive than the lecture – as 25 minutes

is not enough time to review all the hot topics in the shoulder

1) Clavicle a. Clavicle Fractures

i. What’s HOT 1. Early Plating Of Displaced Midshaft Clavicle Fractures (1)

a. Younger and more active patients b. Poorer outcomes if >1.5cm overlap or increased

comminution, minimal bony contact, segmental fracture or transversely displaced butterfly fragment (2)

c. Increase risk for non union, neurologic injury, cosmetic issues, weakness and endurance deficits

d. Consider ORIF i. Plate – stronger (2, 3)

• Pre contoured • Locked or DCP • Superior surface of clavicle

ii. Hage Pin • Less invasive • Less periosteal stripping • Must remove

NOTES:

Shoulder & Humerus Review Safran, Page 2

ii. What’s NOT

1. Observation of Comminuted and/or shortened midshaft clavicle fractures particularly in young, active patients (1,2)

2. K-wires (2,3) 3. Intramedullary devices for comminution

B. Distal Clavicle Fracture

i. What’s HOT 1. Surgical Plate and Screw Fixation of Type IIB Distal Clavicle

Fractures (4) a. Unstable: High rate of non-union / malunion

ii. What’s NOT 1. Suture Fixation 2. Plating Across AC Joint 3. K Wires / Threaded Steinmann Pin Across AC Joint (5)

a. Infection b. Migration c. AC Arthritis d. Shoulder Stiffness

4. Hook Plate (6) a. Migrate Into Acromion / Acromial Fracture b. Subacromial adhesions / impingement / Stiffness c. Rotator Cuff Injury

2) AC Joint a. AC Separation (7,8)

i. What’s HOT 1. Surgical Repair of CC Ligaments (7) 2. Augmentation or Reconstruction for Type III & V Lesions with

Soft Tissue (7) 3. Semitendinosis Graft (7) 4. Avoiding Anteriorization of Clavicle By Cerclage Fixation

ii. What’s NOT 1. Routine Surgery for Grade III AC Separation (8) 2. Plating Across The AC Joint 3. Non-Anatomic Repairs

a. Weaver Dunn 4. Bosworth Screw

b. AC Osteolysis or Arthritis i. What’s HOT

1. Injection with steroids 2. Distal clavicle resection if symptoms persist

a. Remove only 5 – 10mm ii. What’s NOT

1. Removal of > 1cm of distal clavicle NOTES:

Shoulder & Humerus Review Safran, Page 3

3) Rotator Cuff

a. Impingement i. What’s HOT

1. Secondary Causes a. Scapular Dyskinesis (9) b. Old trauma c. Stiffness

2. Most Always Secondary if < 30 y/o (10) a. Instability b. Stiffness

i. Global vs Posterior Capsule c. Scapular dysfunction d. Os Acromiale e. Overuse

3. Treatment of Impingement (9, 10) a. Rehabilitation

ii. What’s NOT

1. Attribute All Impingement to Acromial Morphology 2. Arthroscopic Subacromial Decompression

a. Though, when needed, results the same as open b. 70 – 95% success c. Spare the Deltoid Insertion

iii. CONTROVERSIAL 1. Role Of Corticosteroid Injections (11)

a. Accuracy (12) b. Efficacy (13)

b. Internal Impingement (14) i. What’s HOT

1. Physiologic 2. Increased with Increased External rotation and hyperabduction 3. Associated with tight Posterior Capsule vs Anterior Laxity (15-19) 4. Associated with SLAP Lesions 5. Treatment (20,21)

a. Stretch posterior capsule b. May require posterior – inferior capsular release

ii. What’s NOT 1. Rotational Osteotomy of Humerus (22) 2. Anterior Shoulder Stabilization

iii. CONTROVERSIAL 1. Posterior Capsular Release for Internal Impingement

NOTES:

Shoulder & Humerus Review Safran, Page 4

c. Partial Thickness Rotator Cuff Tears

i. What’s HOT 1. Primary Repair of PASTA Lesions (23, 24) 2. Repair of Lesions > 50% Thickness

ii. What’s NOT 1. Take down of Partial Tears with Primary Repair 2. Repair Partial Tears < 50% Thickness loss 3. Debridement (25)

d. Full Thickness Rotator Cuff Tears

i. What’s HOT 1. Earlier Repair 2. Arthroscopic Double Row / Transosseous Equivalent

a. Stronger repair vs single row (26) b. Less slippage c. Larger Footprint restoration (27) d. Limitations

i. Effect on Blood Supply ii. Outcomes poor with Massive Tears

3. Arthroscopic repairs approach open and mini-open with regard to symptomatic improvement and clinical rating scales (28-30)

a. Integrity of cuff repair for large / massive tears worse with large / massive tears arthroscopically repaired vs small and vs open.

4. Mason-Allen Stitch or Equivalent (31) 5. Understanding Tear Pattern (32)

a. Allow for Marginal Convergence b. Reduce Stress on Repair

6. Subscapularis tears (33) a. Unique Management – More aggressive

i. Early Surgical Repair b. Chronic cases may require pectoralis major transfer.

ii. What’s NOT 1. Open Repairs

a. Though, Open repair, acromioplasty, cuff mobilization, results = 85-90% good to excellent

b. Mini open repair and arthroscopic repairs results parallel open repair

2. Debridement (34) a. Outcomes deteriorate with time b. Indicated in old, sedentary individuals when involves non-

dominant arm c. Non compliant patients

iii. CONTROVERSIAL 1. Arthroscopic Repair for All Tears vs Small and Medium Size

NOTES:

Shoulder & Humerus Review Safran, Page 5

e. Massive Rotator Cuff Tears

i. What’s HOT 1. Reverse Total Shoulders in Elderly (35,36) 2. Arthroscopic Partial Repairs (37) 3. Tendon transfers (38)

a. Latissimus transfer for irreparable massive (supraspinatus and infraspinatus tears) (39,40)

b. Pectoralis major transfer for irreparable subscapularis tear (41)

4. Rehabilitation of the anterior deltoid and teres minor particularly important (42,43)

ii. What’s NOT 1. Debridement (34) 2. Biceps Tenotomy (44, 45) 3. Allograft or Bridging Soft Tissue Substitute (46)

f. Cuff Arthropathy i. What’s HOT

1. Reverse Total Shoulders in Elderly (35, 36) ii. What’s NOT

1. Debridement (34) 2. Hemiarthroplasty

a. Especially if Cannot Actively Abduct > 90 degrees (47) 3. Reverse Shoulder Arthroplasty in young patients

4) Shoulder Instability

a. Anterior Instability i. What’s HOT

1. Arthroscopic Anterior Stabilization (48) a. Bankart w/ Capsular Tightening b. Success in athletes 89 – 93% (49)

i. 90% of non throwing athletes RTS ii. 68% of throwing athletes RTS

iii. Recurrence rate for contact athletes 9.5% iv. Recurrence rate for non-contact athletes 6%

c. Advantages over open i. Avoid injury / detachment to subscapularis

ii. Less likely loss of external rotation iii. More full assessment of intra-articular pathology

2. Bony Defects (50) a. Glenoid Based Bony Loss

i. > 20 % ii. Latarjet Procedure

b. Humeral / Hill Sachs Lesion i. Engaging Lesion

ii. Osteochondral Allograft iii. Reverse McLaughlin

NOTES:

Shoulder & Humerus Review Safran, Page 6

ii. What’s NOT

1. Arthroscopic Stabilization for Bony defects (50) 2. Thermal Capsular Shrinkage (51)

iii. CONTROVERSIAL 1. Surgery For First time anterior dislocator (52-54) 2. Sling Immobilization in ER

a. MRI – coaptation of Labrum to Glenoid by Subscapularis in ER (55)

b. Benefit clinically – Itoi studies (56, 57) c. Not reproduced in US Studies

b. Posterior instability

i. Not all patients have psychological issues ii. Posterior Dislocation (58)

1. What’s HOT a. Must Get Orthogonal Views

i. Axillary view ii. Velpeau Axillary

b. 3D CT Scan For Full Evaluation of Bony Defects c. Treatment

i. If acute – closed reduction 1. Often associated with Posterior Bankart

Lesion 2. Rehabilitation

a. Strengthen Rotator Cuff b. Strengthen Scapular Stabilizers c. Proprioception training

ii. If Recurrent & failed rehabilitation 1. Open or Arthroscopic posterior Bankart

Repair iii. If subacute or chronic, avoid closed reduction

1. Open reduction iv. If Defect 20 – 45% of head

1. Consider McLaughlin 2. Osteochondral Allograft

v. If Defect 50 – 60% 1. Hemiarthroplasty 2. If young, consider Osteochondral Allograft

vi. If glenoid involvement and old patient, consider TSR

2. What’s NOT a. Early Surgery if not locked b. Thermal Shrinkage

NOTES:

Shoulder & Humerus Review Safran, Page 7

iii. Posterior Subluxation

1. What’s HOT a. Positive jerk test, or load-and-shift test. (59) b. Kim Test c. Kim Lesion (60) d. Arthroscopic Posterior Bankart Repair (61-66)

i. After Failed Rehab ii. Stability restored arthroscopically 88% to 100% of

shoulders and a high rate of return to preinjury sporting activities (67% to 90%)

2. What’s NOT a. Early Surgery b. Open Posterior Capsulolabral repair c. Rotator Interval Closure

iv. Multidirectional instability 1. What’s HOT

a. Rehabilitation is key (65,67) i. Make sure to evaluate scapular mechanics

b. Outcomes of surgery, open or arthroscopic, less optimal as compared with anterior instability, even with newest techniques (65,67)

c. Arthroscopic Capsular Plication (567,68) 2. What’s NOT

a. Thermal Capsular Shrinkage (51,69) b. Rotator Interval Closure (68, 70)

5) Glenohumeral Arthritis

a. Young Patient i. What’s HOT

1. Arthroscopic Debridement (71, 72) 2. Arthroplasty with Short or No Stem (73)

a. Cap b. Non-traditional short stem

3. Hemiarthroplasty with Interposition Graft (74) a. Meniscus b. Allograft / Autograft Fascia Lata c. Allograft Achilles d. “Ream & Run” (75)

NOTES:

Shoulder & Humerus Review Safran, Page 8

i. What’s NOT (76)

1. Resurfacing Glenoid with Cap arthroplasty a. Hard to Ream Concentrically b. Meniscus Allografts Do not Seem To Work well with Cap

2. Hemiarthroplasty a. Erosion of Glenoid Bone Stock b. Incomplete Pain Relief c. TSR Post HA not as good results

3. Total Shoulder Arthroplasty

b. Older Populations i. What’s HOT

1. Total Shoulder (77, 78) a. Glenoid: All-poly, cemented (79) b. Press Fit Stem (80)

2. Prosthetic Infection a. Think Proprionabacter Acnes

i. Slow to grow, keep cultures 14 days 3. Reverse Shoulder Replacement

a. Cuff Arthropathy b. > 70 years old (35, 36, 81)

ii. What’s NOT 1. Hemiarthroplasty (77, 78, 82) 2. Total Shoulder

a. Metal Backed Glenoid (79) b. Cemented Stem

NOTES:

Shoulder & Humerus Review Safran, Page 9

6) Humerus Fractures a. Proximal Humerus

i. What’s HOT 1. CT Scan Evaluation of Fracture Parts and Displacement (83)

a. Radiographs with poor inter & intra-observer reliability 2. Treatment based on age and activity level of patient, co-

morbidities, bone quality and fracture type (84, 85) a. Salvage bone in young, active patients with good bone

quality 3. Greater tuberosity fractures (86)

a. More aggressive for surgical intervention i. Displacement

ii. Secondary Impingement iii. Poorer results with osteotomy for malunion

b. Repair if 5mm displacement / above level of apex of head, subacromial crowding

c. Soft Tissue Fixation (suture through cuff insertion into tuberosity) with or without screw as post in cortical humeral bone

4. 2 and 3 part Fractures (85, 87, 88) a. Locking Plate (87) b. Suture Fixation (85)

5. Getting Greater Tuberosity Fracture To Heal 6. Knowledge of AVN Risk to determine viability of repair

a. Anatomic neck fracture with (89) i. Posteromedial metaphyseal extension < 8 mm

ii. Disruption of the medial hinge 1. Displacement of the humeral shaft > 2 mm

iii. 97% PPV for humeral head ischemia 7. Hemiarthroplasty for 4 part fracture – factors for success (90, 91)

a. Anatomic humeral height i. Humeral prosthetic head should be placed

approximately 3 to 5 mm above the tip of the anatomically reduced greater tuberosity fragment.

b. Anatomic Humeral version i. Forearm is pointed straight ahead in neutral position

and the humeral head is turned to face the glenoid Approximately 20° of retroversion relative to the transepicondylar axis of the elbow

c. Anatomic Tuberosity reconstruction i. Tuberosities rigidly fixed with horizontal cerclage

suture fixation around the medial neck of the prosthetic stem as well as with vertical tension-band suture fixation through drill holes in the humeral shaft

d. Early Surgical Intervention (<4 weeks) (92) NOTES:

Shoulder & Humerus Review Safran, Page 10

ii. What’s NOT

1. Non-operative treatment of Greater Tuberosity Fractures with > 5mm displacement

2. Treatment based solely on fracture pattern 3. Screw fixation of Greater Tuberosity 4. Percutaneous Pinning of proximal humerus fractures in elderly pts

and 4 part fractures(93, 94) 5. Rush Rods 6. Hemiarthroplasty for < 4 part fractures (95, 96) 7. Delayed Surgery

iii. CONTROVERSIAL 1. Closed reduction and Percutaneous Pinning 2. Locked External Fixaiton 3. Intrameduallary Rodding

a. Rotator Cuff complaints and dysfunction 4. Reverse Shoulder Arthroplasty in Elderly (97)

b. Humeral Shaft i. What’s HOT

1. Non-op Treatment (98) a. Most treated in coaptation splint, Velpeau dressing, cuff

and collar or hanging arm cast. b. Convert to functional arm fracture brace c. Alignment considered acceptable (99)

i. 20° of anterior angulation ii. 30° of varus angulation

iii. 3 cm of shortening. 2. If Surgery: Method of choice: Locked Plating (100,101)

a. Less Nerve Risk b. > 95% union

3. Management of Radial Nerve injury (102-104) a. If no radial nerve function from injury, does not affect

management i. Transection of nerve may occur with open fracture

ii. Closed fracture extremely rarely associated with transaction

iii. Primary repair of radial nerve transaction from humeral shaft fracture – no recovery

b. If radial nerve intact and function lost due to manipulation (closed reduction and/or rodding), then need to explore nerve to ensure it is not entrapped.

ii. What’s NOT

1. Intramedullary Rod Fixation (100,101) a. High incidence of shoulder stiffness and rotator cuff

complaints, even after removal of nail NOTES:

Shoulder & Humerus Review Safran, Page 11

7) SLAP Lesions

a. What’s HOT i. Physical Examination (105-107)

1. No 1 Clinical Examination is Diagnostic a. Assess for Glenohumeral Internal Rotation Deficit (GIRD)

(16,17) i. Posterior Capsular Tightness

b. Dynamic Shear Test ii. Mechanism of Injury –

1. Peel Back (16 - 18) 2. Posterior capsular tightness leading to posterosuperior humeral

head migration 3. Degenerative fraying from mechanical contact of labrum and

rotator cuff iii. MRI arthrogram diagnostic tool of choice iv. Treatment of Type II (108-110)

1. Repair to Glenoid if < 40 years old 2. Tenodesis vs Leave Alone if > 40

b. What’s NOT i. Repair of SLAP in Older Patients (109)

1. ? Unrelated to symptoms ii. Need for Thermal Shrinkage Augmentation

c. CONTROVERSIAL i. Type IV –Tenotomy vs biceps repair

ii. Repair of SLAP at same time as Rotator Cuff Repair and/or Subacromial Decompression - Risk Stiffness (109)

8) Biceps

a. What’s HOT i. Arthroscopic Biceps Tenodesis (111 - 113)

ii. Biceps tendon subluxation in to joint = Pathognomonic for Subscapularis tear

b. What’s NOT i. Isolated Biceps Tendinitis as a Primary Pathology (113)

ii. Biceps Tenotomy c. CONTROVERSIAL

i. Role In Shoulder Function

9) Adhesive Capsulitis a. What’s HOT

i. Rehabilitation ii. Focal Capsular Release of Isolated Area of Contraction (114,115)

iii. Brisement b. What’s NOT

i. Thermal Capsulotomy of Inferior Capsule ii. Early Surgery

iii. Expecting Full Range of Motion regardless of treatment (116)

Shoulder & Humerus Review Safran, Page 12

10) Pain Management a. What’s HOT

i. Interscalene Blocks (117 - 119) 1. Indwelling Catheters

b. What’s NOT i. Intra-articular Pain Pumps

1. Marcaine 2. Chondrotoxicity (120, 121)

Shoulder & Humerus Review Safran, Page 13

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Pediatrics

Pediatric Orthopaedics 

Moderator: Lori A. Karol, MD 

 

12:50 PM – Hip Problems in Children  William C. Warner Jr., MD 

 1:20 PM – Infection/Congenital  and 

Developmental Problems/Miscellaneous Jeffrey R. Sawyer, MD 

 1:50 PM – Fractures of the Upper and Lower 

Extremities John M. Flynn, MD 

 2:20 PM – Lower Extremity Problems in  

Children Lori A. Karol, MD 

 

PEDIATRIC HIP REVIEW W. C. WARNER, JR. CAMPBELL CLINIC

DEVELOPMENTAL DYSPLASIA OF THE HIP Definition DDH – is a spectrum of disorders in the developing hip joint. Name changed from CDH to DDH to reflect spectrum of disease Terminology

o Dysplasia – shallow or underdeveloped acetabulum o Subluxation – femoral head can be partially displaced from acetabulum o Dislocatble – femoral head can be displaced from acetabulum with stress but can

be easily relocated o Dislocation – femoral head is completely displaced from acetabulum

o Teratologic dislocation – are dislocated in utero an is not reducible on neonatal

examination. These hip are stiff and have limited range of motion Growth and Development of Hip Acetabulum and proximal femur develops from 1 cartilage 11th week hip joint is formed Proximal femur

o One growth plate that develops into 3 main components 1. Physeal plate of femoral head 2. Growth plate of Greater trochanter 3. Femoral neck isthmus growth plate

Largest determinant of actetabular development – reduced femoral head Neolimbus

o Hypertrophied ridge of acetabular cartilage in the superior, posterior and inferior aspect of the acetabulum

Accessory center of Ossification

o Present in only 2 to 3% of normal hips o Present in 60% of pts treated for DDH

Incidence o Dyspalsia of the hip or some form of instability of the hip – 1 in 100 births o True hip dislocations 1 to 2 in 1000 births o Reported incidence of late dislocations is 4 per 10,000 births

o 2% of all hip dislocations are Teratologic

Risk Factors

1. Breech presentation a. Only 2-4% of deliveries are breech but of DDH cases 17%-20% are

breech presentation b. 1 out of 15 girls with Breech presentation had DDH

2. Female a. 80% of DDH cases female b. Other report a 6:1 ratio of female: male

3. Family History a. + family Hx. In 12% to 33% b. risk of subsequent pregnancies

i. 6% neither parent has DDH ii. 12% when one parent had DDH

iii. 36% when both parents had DDH 4. Ethnic Background

a. Increase in native Americans b. Decrease in African descent

5. First born – increased incidence 6. Oligohydramnios 7. Packing syndrome

a. Torticollis b. Metatarsus adductus

8. Left hip more commonly dislocated a. Due to left hip against sacrum in the most common presentation

Diagnosis CLICK vs., CLUNK Early Diagnosis

1. Ortalani positive 2. Barlow positive

Late Diagnosis 1. Galeazzi positive 2. Adduction contracture 3. Asymmetric skin folds

Diagnostic imaging Ultrasound – 2 methods

1. Morphologic assessment 2. Dynamic assessment

Morphologic assessment – < 4 months of age

1. Alpha angle – measurement of slope of the superior part of the bony acetabulum 2. Beta angle – evaluates the cartilaginous component of the acetabulum 3. % acetabular coverage of the femoral head 4 to 6 weeks of age

alpha angle is ≥ 60 degrees beta angle is < 55 degrees

Dynamic assessment Joint evaluated while being stressed with a Barlow and Ortolani maneuvers Instability is measured by displacement of the femoral head from acetabulum

Clarke found in high-risk infants the use of U/S did not decrease the incidence of late presentation of DDH Plain radiographs

Ossific nucleus does not appear until about 4 - 6 months of age Radiographic measurements

Acetabular index Shenton line Delayed ossification of femoral head Perkins line Center edge angle

Arthrography Useful in assessment of an adequate reduction Medial joint fluid Thorn sign Cartilaginous coverage

CT Scan

Role in assessment of reduction post op Define anatomy of acetabular dysplasia

MRI – role still evolving Obstacles to Reduction

1. Muscle a. Psoas muscle b. Adductor longus muscle

2. Ligamentum teres 3. Transverse acetabular ligament 4. Constricted joint capsule 5. ? inverted labrum – more likely the Neolimbus

Natural History

Newborn – variable but tendency to stabilize o Barlow – reported that 1- 60 unstable o 60% stabilize in 1 week o 88% stabilize in 1 - 2 months

Adult o If false acetabulum present – 24% have good result o If no false acetabulum - >50% good results

Treatment Pavlik Harness

95% effective in Ortolani positive hips if worn for 6 weeks Incidence of osteonecrosis is <5% Contraindications

o Neuromuscular o Teratologic

Effectiveness decreases with age Harness is not effective in children > 6 months of age Risk factors for adverse outcome of the harness

o Ortaloni negative o Bilateral o Age > 7 weeks start of treatment o U/S with less that 20% coverage will not have a successful outcome with

harness 2-3 % treated successfully in harness will have residual acetabular dysplasia Pavlik harness disease

o Failure of harness after 6 weeks Proper application of harness

o Ant straps o Posterior straps o Chest straps

Complication of harness o Inferior dislocation o Femoral nerve palsy o Brachial plexus palsy o Skin problems

Closed reduction Traction

? of benefit o Gage and Winter o Schoenecker o Kutil

Closed reduction

Safe Zone o Is 15 degrees less that the limits of motion defined as the stable zone

Adequacy of reduction by arthrogram o Less than 5 mm of medial contrast o No interposed limbus

Cast immobilization for 12 weeks Open reduction – 6month to 2 years of age

AVN and presence of ossific nucleus o Pro o Con

Anterior approach Ferguson approach

o Between adductor brevis and adductor magnus Anterior Medial approach

o Between femoral neurovascular bundle and pectineus muscle Pros and Cons of different approaches Potential for acetabular remodeling is up to 4 to 8 years of age

Open reduction - > 2 years of age

2 to 3 years is grey area for need of femoral shortening > 3years of age will need a femoral shortening ? When an acetabular procedure should be done

Proximal femoral osteotomies

Role of proximal femoral osteotomy o Must be <4 years to expect acetabular remodeling

Pelvic Osteotomy

For rotational osteotomy 1. Concentric reduction 2. Release of muscle contractures 3. Congruous hip joint 4. Good range of motion

4 types of osteotomies o Redirectional osteotomy

Salter Most likely to succed if CE angle > 10 degrees

Sutherland Tonis/Steele Ganz Wagner/Eppright

o Acetabularplasties Pemberton Dega

o Reconstructive by placing Bone over hip joint capsule Chiari Shelf

o Hybrid Salter + shelf

SLIPPED CAPITAL FEMORAL EPIPHPYSIS Definition – Displacement of the femoral head relative to the femoral neck and shaft Epidemiology-

Male > female 1.4 :1 or 2:1 male:female ratio Annual incidence is 2 to 13 per 100,000 Risk

o Male is 1 per 1000 to 1 per 2000 o Female is 1 per 2000 to 1per 3000

Increased incidence with higher mean body weight Most SCFE occur in the peripubertal period

o Male 13.5 years of age o Female 12 years of age

Obesity is reported in 51% to 77% of SCFE o 50% will be > 90th percentile in wt. o 70% will be > 80th percentile in body wt.

Etiology – mechanical insufficiency of the proximal femoral physis to resist the load across it

Lab studies o Testosterone – weaken physis o Estrogen – Strengthens physis

Endocrinopathies account for 5-8% of SCFE Most common causes of Endocrinopathies

o Hypothyroidism o Panhypopituitarism o Growth Hormone abnormalities o Hypogonadism

Increased prevalence of hypothyroidism in Downs Syndrome patients explains increased risk of SCFE in Downs’s pts.

Indications for endocrine work-up in SCFE o <10 years of age o > 15 years of age o < 10th percentile for height (short stature)

Other systemic disease o Radiation therapy o Renal Osteodystrophy

Have a six fold to eightfold increased risk of SCFE Highest in patients on dialysis and receiving GH Due to secondary hyperparathyroidism Often will slip through metaphysis and not the physis

Immunology o ? Findings o ? Association with chondrolysis

Genetics o 3 to 7% of cases have a second member of family affected

Mechanical factors o Possible association with decreased femoral anteversion or femoral

retroversion o Chung reported the mechanical forces across the femoral head during gait

can be 6.5 time body and that such forces may be enough to cause a SCFE in an obese patient with a normal physis

Classification – two classification systems

Based on time o Acute

Symptoms less than 3 week o Chronic

Symptoms > 3 weeks o Acute on chronic

Acute exacerbation of symptoms that have been present for > 3 weeks

o Preslip Symptomatic hip with evidence of physiolysis prior to true

movement of the femoral neck to the femoral head o Acute slip – had a AVN rate of 10 -15 %

Based on Stability o Unstable Slip – only 5 to 10% of slips

Unable to bear weight with or without crutches o Stable Slip

Able to bear weight o Unstable slips had a 47% incidence of AVN o Stable slip had a 0% incidence of AVN

Presentation

Pain o Groin pain o Often referred pain to knee or distal thigh – 23 to 46% of cases

Limp o Antalgic limp

o Trendelenburg gait Decreased range of motion

o Decreased flexion and extension o Decreased abduction o Loss of internal rotation o Obligate external rotation of hip on flexion

Radiographic Evaluation

AP and Lateral views Must always image both hips (20% bilateral) AP view

o Widening and irregularity of physis o Decreased height of the capital femoral epiphysis o Metaphyseal Blanch - increased radiodensity of the proximal metaphysis o Klein’s Line o Cowell noted that displacement may not be evident in 14% of the AP

radiographs Lateral view

o Cross table vs. frog leg later Degree of slip

o Mild – less than 33% o Moderate 33- 50 % o Severe > 50 %

Other Imaging methods o CT scan

Useful to determine if there is physeal closure and anatomy of slip Detection of Pin penetration

o Ultrasound – of little benefit o MRI

Pre slip Physeal widening Edema

Evaluation of AVN o Bone scan

Evaluation of AVN Pathoanatomy

Have disorganization of Proliferative and hypertrophies zone o The hypertrophic zone is much larger than usual

80% of the physeal width compared to the normal 15 to 30% of physeal width

SCFE occurs through the proliferative and hypertrophic zones of the physis Once slip is stabilized the pathologic changes seen in the physis will return to

normal architecture

Natural History 20% will have bilateral slips at time of presentation a reported additional 10 to 20% will have a contralateral SCFE after diagnosis of

SCFE The true frequency of Bilateral SCFE at long term follow up appears to be

approximately 60% From this data, then ½ of the 80% of pts. who present with a unilateral SCFE will

ultimately have a contralateral SCFE Contralateral slip occurs it within 18 months of the diagnosis of the first slip. Pts. With endocrinopathies - will have bilateral slips in 61 to 100% of the cases.

Therefore the recommendation to do prophylactic pinning Longer term SCFE puts the hip at significant risk of Osteoarthritis

Treatment Goals of treatment

Early detection Prevention of further slipping Avoidance of complications.

Manipulation

No role for forceful manipulation in the treatment of SCFE A serendipitous reduction with patient positioning does not appear to negatively

affect outcome Spica cast

Associated with high complication rates o Chondrolysis

Reported in 14 to 53% of cases o AVN o Progressive slip

5 to 18% of cases Immobilization was for 3 to 4 months

In Situ Fixation

Goal - to prevent slip progression Fracture table vs. radiolucent table Inadvertent reduction do not appear to cause AVN Unrecognized pin penetration – “blind spot” “Approach withdraw phenomenon” described by Moseley Center-center pins are left 5 go 6 mm from subchondral bone, pins that are not

center-center should be at lest 10 mm from subcondral bone Posterior and superior portion of the femoral neck and head should be avoided

o Risk of compromise of the intraosseous blood supply Single vs. two screws Stable vs. unstable

Physeal closure generally occurs within 6 to 12 months following in situ fixation Complication

o AVN More common in unstable slips Role of aspiration or capsular decompression Treatment within 24 hour

May be beneficial in unstable slips o Chondrolysis

Persistent pin penetration Location above fovea

o Progressive slip o Growing off the screw o Proximal femur fracture o Leg length inequality o Impingement o Osteoarthritis

Screw removal not routinely recommended Bone graft epiphysiodesis

Role of bone graft epiphysiodesis is to hastening the physeal closure Physeal closures occurs at 4 to 6 months Is an alternative to in situ pinning but is not recommended as primary treatment

Proximal Femoral Osteotomy

Early vs. Late Location

o Subcapital o Femoral neck o Intertrochanteric

Subcapital o Gives greatest correction o High rates of AVN

Femoral neck o Less power of correction but also has less AVN o Osteotomy may be intracapsular or extracapsular

Intertrochanteric osteotomy o Southwick

Valgus, flexion and internal rotation o Imhauser

Flexion and internal rotation o Greatest correction but not anatomic

Trantrochanteric rotational osteotomy o Sugioka o High complication rate

Femoral neck Osteoplasty

Indicated for impingement Complications

Long term studies of untreated slips o Carney Weinstein o Ordeberg

Osteoarthritis o Appears to be a universal sequela of both treated an untreated SCFE

because of biomechanical derangement of the hip joint o Hagglund noted that no hip with a mild to moderate slip treated with in

situ pinning developed arthritis before 50 years of age o 2 to 9% of those with end stage OA have been reported to have a history

of SCFE AVN

o Canale paper – long term follow up of AVN in slip 38% had salvage procedures Remaining 42% had osteoarthritis

Chondrolysis o Hip is usually held in abduction o Joint space narrowing o Premature closure of trochanteric apophysis

Decreased bone scan activity in trochanter in 47 % of affected hips Salvage Procedures

Hip arthroplasty Hip arthrodesis

o Back pain 57% o Ipsilateral knee pain 45% -57% o Contralateral hip pain in 17 -27% o Conversion to THA in 13-21%

Redirectional osteotomy

Legg-Calve-Perthes Disease Definition – is osteonecrosis of the femoral head in children Epidemiology

Age ranges 4 to 8 years o Reported cases as young as 2 years of age and in late teenagers

Male: Female ratio o 4:1 to 5:1

Bilateral in 10 to 12% More common in

o Urban areas o ADHD pts o Skeletal age lagged behind chronological age

89% had delayed bone age Average delay in skeletal maturity was 21 months but tended to

catch up in the healing phase o Shorter in stature

Male 1 inch shorter Females 3 inches shorter compared to healthy children

Potential abnormalities with Somatodmedin C insulin like growth factor 1 (IGF1) o Associated with regulation of growth hormone

Etiology

Historical proposed etiologies o Infection

Aseptic TB Viral Rubella

o Trauma o Congenital o Hormonal

Hypothyroid IGF1 deficiency

o Transient Synovitis o Mechanical

Increase femoral neck anterversion Most accepted etiologic theories – vascular embarrassment to the femoral head

o Incomplete anastomotic network between medial and lateral femoral circumflex arteries

o Double infarction theory o Increased blood viscosity o Thrombophilia induced by low levels of protein C or Protein S

Pro Con

Pathogenesis

Data suggest that Perthes disease is a generalized process affecting other epiphyses

o Irregular ossification of other epiphyses o Increased association with Kohlers disease

May be a localized manifestation of a generalized disorder of epiphyseal cartilage in the susceptible child

Radiographic Stages Initial

o Failure of femoral ossific nucleus to increase in size o Widening of the medial joint space o Radiodense ossific nucleus o Physeal plate irregularity

Fragmentation o Crescent sign o Fragmentation with areas of increase radiodensity and increased

radiolucency Reossification

o Radiographic normal bone returns to areas that were previously radiolucent

Healed Patterns of deformity

Coax magna Premature physeal arrest patterns

o Central arrest o Lateral arrest

Irregular femoral head formation Osteochondritis dissecans

o Only 3% incidence Natural history

Caterall – 97 untreated pts using grading system of Sundt o Group 1 and 2 – 92% good results o Group 3 and 4 – 91 % poor results

20 to 30 year follow up o 80 to 85 % pain free o Only 40 to 33% have normal radiographs

40 year follow up o 40% had undergone THA o 10% had disabling OA

Prognostic factors

Residual head deformity and hip joint incongruity - most important prognostic factor

o Stulberg classification Class 1 – normal hip Class 2 – spherical but coax magna Class 3 – Mushroom shaped but not flat Class 4 – flat head and abnormal acetabulum

Class 5 – flat head and normal acetabulum Class 5 deteriorate by 4th decade Class 4 and 3 – deteriorate by 5th and 6th decade

The more out of round the femoral head the greater chance of early DJD

o Catterall classification 90 % good results in Group 1 and 2 90% poor results in group 3 and 4 Takes up to 8 months for hip to be far enough into the

fragmentation phase to show the extent of epiphyseal involvement o Salter and Thompson

Extent of subchondral fracture line Group A < 50% Group B > 50%

o Herring Classification Lateral pillar of femoral head on AP radiographs

Type A – no involvement of lateral pilar Type B - > 50% of lateral pilar preserved Type C - < 50 % of lateral pilar preserved

o Head at risk signs Gages sign – radiolucency in the lateral epiphysis and metaphysis Lateral calcification Metaphyseal lesions Lateral subluxation Horizontal growth plate

o Duration of disease is related to the extent of epiphyseal involvement o Poorer prognosis in girls than boys

Age of onset of the disease is the second most significant factor o Age at healing is probably a more important factor o The more immature the patient at the time of entering the reossification

stage – the greater potential for remodeling Physeal arrest

o 90% have some physeal involvement o 25% have premature physeal closure

33% of hips will show some improvement in anatomical grade Once reossification stage there should not be any further femoral head deformity

Clinical Presentation

Insidious onset of a limp Pain with activity and relieved with rest Pain localized to groin or referred to anterior medial thigh or ant knee

Physical exam Limited hip range of motion

o Abduction o Internal rotation

Trendelenburg test

Limb length inequality Imaging

Plain radiographs o AP and frog lateral

Bone scan MRI Arthrography CT scan

Differential diagnosis Infection Bilateral involvement

o Multiple epiphyseal dysplasia o Hypothyroidism

Meyer dysplasia o Benign self resolving condition in children younger than 4 years of age

Treatment

Treatment is considered only for those patient who have an otherwise known poor prognosis based on prognostic factors

o No treatment needed in pts. With good prognosis Catterall I Salter Thompson type A Lateral pillar type A disease

The two most important prognostic factors are o Deformity of the femoral head o Age of the patient

Cornerstone of treatment is containment o Containment is an attempt to reduce the forces through the hip joint by

actual or relative varus positioning Femoral head represents more than ¾ of the sphere and the

acetabulum only ½ of the sphere First principle of treatment is to restoration of motion

o Bed rest at home o Nonsteroidal anti-inflammatory drugs o Home traction o Abduction cast o Physical therapy o Crutches o Adductor tenotomy

Nonoperative treatment o Braces

? Benefit o Petrie cast

May be used as temporary method to regain motion Surgical treatment - hip must be “containable” (relative full range of motion,

congruent)

o Varus osteotomy Should not exceed a neck shaft angle of less than 110 degree Limb shortening

o Innominate osteotomy Persistent acetabular configuration change in a previously normal

acetabulum Loss of flexion ? Increase pressure on femoral head

o Combined procedure – varus and innominate osteotomy o Shelf arthroplasty o Triple Innominate osteotomy o Arthordiastasis

Treatment of Noncontainable hip and late present pt with deformity o Abduction extension osteotomy o Shelf arthroplasty o Chiari osteotomy o Cheilectomy

Femoral Acetabular Impingement

Source of hip pain with subtle abnormalities on radiographs Abnormal contact between femoral neck and acetabular rim during terminal

motion of the hip Abnormal contact leads to labral pathology and adjacent chondral lesions

2 types of femoral acetabular impingement Cam Type Pincer Type

Cam Type Impingement from abnormal shaped femoral head (ex. Slipped Epiphysis) that

abuts the acetabular rim Have separation of labrum and cartilage in the anterior superior portion of the

acetabulum Pincer Type

Have normal femoral head Have abnormal contact between acetabulum and femoral neck that is due to

overcoverage of the acetabulum (ex Acetabular retroversion) Have lesions in

o Anterior superior labrum o Femoral neck o Countrecoupe lesion – posterior inferior acetabulum

History Intermittent groin pain Pain after physical activity Pain after prolonged sitting

Physical exam Impingement test

o Pain on internal rotation, adduction and flexion of hip Grab sign

Radiographs True AP pelvis

o Coccyx points at symphysis pubis with a distance of 1 to 2 cm between them

o Cross over sign o Femoral head deformity o Cystic changes in femoral neck and acetabulum

Lateral of hip o Evaluate femoral head deformity

MRI –arthrogram with gadolinium Treatment

Nonsurgical treatment usually ineffective Surgical treatment

o Surgical dislocation of hip o Arthroscopy

References DDH 1-20 1. Albinana, J.; Dolan, L. A.; Spratt, K. F.; Morcuende, J.; Meyer, M. D.; and

Weinstein, S. L.: Acetabular dysplasia after treatment for developmental dysplasia of the hip. Implications for secondary procedures. J Bone Joint Surg Br, 86(6): 876-86, 2004.

2. Bohm, P., and Brzuske, A.: Salter innominate osteotomy for the treatment of developmental dysplasia of the hip in children: results of seventy-three consecutive osteotomies after twenty-six to thirty-five years of follow-up. J Bone Joint Surg Am, 84-A(2): 178-86, 2002.

3. Castelein, R. M., and Korte, J.: Limited hip abduction in the infant. J Pediatr Orthop, 21(5): 668-70, 2001.

4. Chmielewski, J., and Albinana, J.: Failures of open reduction in developmental dislocation of the hip. J Pediatr Orthop B, 11(4): 284-9, 2002.

5. Grudziak, J. S., and Ward, W. T.: Dega osteotomy for the treatment of congenital dysplasia of the hip. J Bone Joint Surg Am, 83-A(6): 845-54, 2001.

6. Hedequist, D.; Kasser, J.; and Emans, J.: Use of an abduction brace for developmental dysplasia of the hip after failure of Pavlik harness use. J Pediatr Orthop, 23(2): 175-7, 2003.

7. Ito, H.; Matsuno, T.; and Minami, A.: Chiari pelvic osteotomy for advanced osteoarthritis in patients with hip dysplasia. J Bone Joint Surg Am, 86-A(7): 1439-45, 2004.

8. Lorente Molto, F. J.; Gregori, A. M.; Casas, L. M.; and Perales, V. M.: Three-year prospective study of developmental dysplasia of the hip at birth: should all dislocated or dislocatable hips be treated? J Pediatr Orthop, 22(5): 613-21, 2002.

9. Luhmann, S. J.; Bassett, G. S.; Gordon, J. E.; Schootman, M.; and Schoenecker, P. L.: Reduction of a dislocation of the hip due to developmental dysplasia. Implications for the need for future surgery. J Bone Joint Surg Am, 85-A(2): 239-43, 2003.

10. Mladenov, K.; Dora, C.; Wicart, P.; and Seringe, R.: Natural history of hips with borderline acetabular index and acetabular dysplasia in infants. J Pediatr Orthop, 22(5): 607-12, 2002.

11. Paton, R. W.; Hossain, S.; and Eccles, K.: Eight-year prospective targeted ultrasound screening program for instability and at-risk hip joints in developmental dysplasia of the hip. J Pediatr Orthop, 22(3): 338-41, 2002.

12. Roovers, E. A.; Boere-Boonekamp, M. M.; Mostert, A. K.; Castelein, R. M.; Zielhuis, G. A.; and Kerkhoff, T. H.: The natural history of developmental dysplasia of the hip: sonographic findings in infants of 1-3 months of age. J Pediatr Orthop B, 14(5): 325-30, 2005.

13. Shipman, S. A.; Helfand, M.; Moyer, V. A.; and Yawn, B. P.: Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics, 117(3): e557-76, 2006.

14. Tien, Y. C.; Su, J. Y.; Lin, G. T.; and Lin, S. Y.: Ultrasonographic study of the coexistence of muscular torticollis and dysplasia of the hip. J Pediatr Orthop, 21(3): 343-7, 2001.

15. Vengust, R.; Antolic, V.; and Srakar, F.: Salter osteotomy for treatment of acetabular dysplasia in developmental dysplasia of the hip in patients under 10 years. J Pediatr Orthop B, 10(1): 30-6, 2001.

16. Weinstein, S. L.; Mubarak, S. J.; and Wenger, D. R.: Developmental hip dysplasia and dislocation: Part I. Instr Course Lect, 53: 523-30, 2004.

17. Weinstein, S. L.; Mubarak, S. J.; and Wenger, D. R.: Developmental hip dysplasia and dislocation: Part II. Instr Course Lect, 53: 531-42, 2004.

18. Wenger, D. E.; Kendell, K. R.; Miner, M. R.; and Trousdale, R. T.: Acetabular labral tears rarely occur in the absence of bony abnormalities. Clin Orthop Relat Res, (426): 145-50, 2004.

19. Westberry, D. E.; Davids, J. R.; and Pugh, L. I.: Clubfoot and developmental dysplasia of the hip: value of screening hip radiographs in children with clubfoot. J Pediatr Orthop, 23(4): 503-7, 2003.

20. Wirth, T.; Stratmann, L.; and Hinrichs, F.: Evolution of late presenting developmental dysplasia of the hip and associated surgical procedures after 14 years of neonatal ultrasound screening. J Bone Joint Surg Br, 86(4): 585-9, 2004.

Slipped Capital Femoral Epiphysis

1-25 1. Barrios, C.; Blasco, M. A.; Blasco, M. C.; and Gasco, J.: Posterior sloping

angle of the capital femoral physis: a predictor of bilaterality in slipped capital femoral epiphysis. J Pediatr Orthop, 25(4): 445-9, 2005.

2. Carney, B. T.; Birnbaum, P.; and Minter, C.: Slip progression after in situ single screw fixation for stable slipped capital femoral epiphysis. J Pediatr Orthop, 23(5): 584-9, 2003.

3. Carney, B. T.; Weinstein, S. L.; and Noble, J.: Long-term follow-up of slipped capital femoral epiphysis. J Bone Joint Surg Am, 73(5): 667-74, 1991.

4. Chung, S. M.; Batterman, S. C.; and Brighton, C. T.: Shear strength of the human femoral capital epiphyseal plate. J Bone Joint Surg Am, 58(1): 94-103, 1976.

5. Dewnany, G., and Radford, P.: Prophylactic contralateral fixation in slipped upper femoral epiphysis: is it safe? J Pediatr Orthop B, 14(6): 429-33, 2005.

6. Gordon, J. E.; Abrahams, M. S.; Dobbs, M. B.; Luhmann, S. J.; and Schoenecker, P. L.: Early reduction, arthrotomy, and cannulated screw fixation in unstable slipped capital femoral epiphysis treatment. J Pediatr Orthop, 22(3): 352-8, 2002.

7. Hagglund, G.: The contralateral hip in slipped capital femoral epiphysis. J Pediatr Orthop B, 5(3): 158-61, 1996.

8. Kennedy, J. G.; Hresko, M. T.; Kasser, J. R.; Shrock, K. B.; Zurakowski, D.; Waters, P. M.; and Millis, M. B.: Osteonecrosis of the femoral head associated with slipped capital femoral epiphysis. J Pediatr Orthop, 21(2): 189-93, 2001.

9. Kenny, P.; Higgins, T.; Sedhom, M.; Dowling, F.; Moore, D. P.; and Fogarty, E. E.: Slipped upper femoral epiphysis. A retrospective, clinical and radiological study of fixation with a single screw. J Pediatr Orthop B, 12(2): 97-9, 2003.

10. Kocher, M. S.; Bishop, J. A.; Hresko, M. T.; Millis, M. B.; Kim, Y. J.; and Kasser, J. R.: Prophylactic pinning of the contralateral hip after unilateral slipped capital femoral epiphysis. J Bone Joint Surg Am, 86-A(12): 2658-65, 2004.

11. Kocher, M. S.; Bishop, J. A.; Weed, B.; Hresko, M. T.; Millis, M. B.; Kim, Y. J.; and Kasser, J. R.: Delay in diagnosis of slipped capital femoral epiphysis. Pediatrics, 113(4): e322-5, 2004.

12. Krahn, T. H.; Canale, S. T.; Beaty, J. H.; Warner, W. C.; and Lourenco, P.: Long-term follow-up of patients with avascular necrosis after treatment of slipped capital femoral epiphysis. J Pediatr Orthop, 13(2): 154-8, 1993.

13. Loder, R. T.: Unstable slipped capital femoral epiphysis. J Pediatr Orthop, 21(5): 694-9, 2001.

14. Loder, R. T.; Starnes, T.; and Dikos, G.: Atypical and typical (idiopathic) slipped capital femoral epiphysis. Reconfirmation of the age-weight test and description of the height and age-height tests. J Bone Joint Surg Am, 88(7): 1574-81, 2006.

15. Loder, R. T.; Starnes, T.; and Dikos, G.: The narrow window of bone age in children with slipped capital femoral epiphysis: a reassessment one decade later. J Pediatr Orthop, 26(3): 300-6, 2006.

16. Loder, R. T.; Starnes, T.; Dikos, G.; and Aronsson, D. D.: Demographic predictors of severity of stable slipped capital femoral epiphyses. J Bone Joint Surg Am, 88(1): 97-105, 2006.

17. Maeda, S.; Kita, A.; Funayama, K.; and Kokubun, S.: Vascular supply to slipped capital femoral epiphysis. J Pediatr Orthop, 21(5): 664-7, 2001.

18. Mooney, J. F., 3rd; Sanders, J. O.; Browne, R. H.; Anderson, D. J.; Jofe, M.; Feldman, D.; and Raney, E. M.: Management of unstable/acute slipped capital femoral epiphysis: results of a survey of the POSNA membership. J Pediatr Orthop, 25(2): 162-6, 2005.

19. Ordeberg, G.; Hansson, L. I.; and Sandstrom, S.: Slipped capital femoral epiphysis in southern Sweden. Long-term result with no treatment or symptomatic primary treatment. Clin Orthop Relat Res, (191): 95-104, 1984.

20. Poussa, M.; Schlenzka, D.; and Yrjonen, T.: Body mass index and slipped capital femoral epiphysis. J Pediatr Orthop B, 12(6): 369-71, 2003.

21. Puylaert, D.; Dimeglio, A.; and Bentahar, T.: Staging puberty in slipped capital femoral epiphysis: importance of the triradiate cartilage. J Pediatr Orthop, 24(2): 144-7, 2004.

22. Sanders, J. O.; Smith, W. J.; Stanley, E. A.; Bueche, M. J.; Karol, L. A.; and Chambers, H. G.: Progressive slippage after pinning for slipped capital femoral epiphysis. J Pediatr Orthop, 22(2): 239-43, 2002.

23. Schultz, W. R.; Weinstein, J. N.; Weinstein, S. L.; and Smith, B. G.: Prophylactic pinning of the contralateral hip in slipped capital femoral epiphysis : evaluation of long-term outcome for the contralateral hip with use of decision analysis. J Bone Joint Surg Am, 84-A(8): 1305-14, 2002.

24. Seller, K.; Raab, P.; Wild, A.; and Krauspe, R.: Risk-benefit analysis of prophylactic pinning in slipped capital femoral epiphysis. J Pediatr Orthop B, 10(3): 192-6, 2001.

25. Tokmakova, K. P.; Stanton, R. P.; and Mason, D. E.: Factors influencing the development of osteonecrosis in patients treated for slipped capital femoral epiphysis. J Bone Joint Surg Am, 85-A(5): 798-801, 2003.

Perthes Disease 1-18 1. Aksoy, M. C.; Caglar, O.; Yazici, M.; and Alpaslan, A. M.: Comparison

between braced and non-braced Legg-Calve-Perthes-disease patients: a radiological outcome study. J Pediatr Orthop B, 13(3): 153-7, 2004.

2. Balasa, V. V.; Gruppo, R. A.; Glueck, C. J.; Wang, P.; Roy, D. R.; Wall, E. J.; Mehlman, C. T.; and Crawford, A. H.: Legg-Calve-Perthes disease and thrombophilia. J Bone Joint Surg Am, 86-A(12): 2642-7, 2004.

3. Bennett, J. T.; Stuecker, R.; Smith, E.; Winder, C.; and Rice, J.: Arthrographic findings in Legg-Calve-Perthes disease. J Pediatr Orthop B, 11(2): 110-6, 2002.

4. Carney, B. T., and Minter, C. L.: Nonsurgical treatment to regain hip abduction motion in Perthes disease: a retrospective review. South Med J, 97(5): 485-8, 2004.

5. Catterall, A.: The natural history of Perthes' disease. J Bone Joint Surg Br, 53(1): 37-53, 1971.

6. Gigante, C.; Frizziero, P.; and Turra, S.: Prognostic value of Catterall and Herring classification in Legg-Calve-Perthes disease: follow-up to skeletal maturity of 32 patients. J Pediatr Orthop, 22(3): 345-9, 2002.

7. Guille, J. T.; Lipton, G. E.; Tsirikos, A. I.; and Bowen, J. R.: Bilateral Legg-Calve-Perthes disease: presentation and outcome. J Pediatr Orthop, 22(4): 458-63, 2002.

8. Herring, J. A.; Kim, H. T.; and Browne, R.: Legg-Calve-Perthes disease. Part I: Classification of radiographs with use of the modified lateral pillar and Stulberg classifications. J Bone Joint Surg Am, 86-A(10): 2103-20, 2004.

9. Herring, J. A.; Kim, H. T.; and Browne, R.: Legg-Calve-Perthes disease. Part II: Prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am, 86-A(10): 2121-34, 2004.

10. Herring, J. A.; Neustadt, J. B.; Williams, J. J.; Early, J. S.; and Browne, R. H.: The lateral pillar classification of Legg-Calve-Perthes disease. J Pediatr Orthop, 12(2): 143-50, 1992.

11. Hresko, M. T.; McDougall, P. A.; Gorlin, J. B.; Vamvakas, E. C.; Kasser, J. R.; and Neufeld, E. J.: Prospective reevaluation of the association between thrombotic diathesis and legg-perthes disease. J Bone Joint Surg Am, 84-A(9): 1613-8, 2002.

12. Kitoh, H.; Kitakoji, T.; Katoh, M.; and Takamine, Y.: Delayed ossification of the proximal capital femoral epiphysis in Legg-Calve-Perthes' disease. J Bone Joint Surg Br, 85(1): 121-4, 2003.

13. Lappin, K.; Kealey, D.; and Cosgrove, A.: Herring classification: how useful is the initial radiograph? J Pediatr Orthop, 22(4): 479-82, 2002.

14. Maxwell, S. L.; Lappin, K. J.; Kealey, W. D.; McDowell, B. C.; and Cosgrove, A. P.: Arthrodiastasis in Perthes' disease. Preliminary results. J Bone Joint Surg Br, 86(2): 244-50, 2004.

15. Rowe, S. M.; Chung, J. Y.; Moon, E. S.; Yoon, T. R.; Jung, S. T.; and Lee, K. B.: Computed tomographic findings of osteochondritis dissecans following Legg-Calve-Perthes disease. J Pediatr Orthop, 23(3): 356-62, 2003.

16. Segev, E.; Ezra, E.; Wientroub, S.; and Yaniv, M.: Treatment of severe late onset Perthes' disease with soft tissue release and articulated hip distraction: early results. J Pediatr Orthop B, 13(3): 158-65, 2004.

17. Wiig, O.; Terjesen, T.; and Svenningsen, S.: Inter-observer reliability of radiographic classifications and measurements in the assessment of Perthes' disease. Acta Orthop Scand, 73(5): 523-30, 2002.

18. Yoon, T. R.; Rowe, S. M.; Chung, J. Y.; Song, E. K.; Mulyadi, D.; and Anwar, I. B.: A new innominate osteotomy in Perthes' disease. J Pediatr Orthop, 23(3): 363-7, 2003.

Femoral acetabular impingement 1-10 1. Beaule PE, Allen DJ, Clohisy JC, Schoenecker PL, Leunig M. The young adult with hip impingement: deciding on the optimal intervention. Instr Course Lect 2009;58:213-22. 2. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 2003(417):112-20. 3. Gautier E, Ganz K, Krugel N, Gill T, Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br 2000;82(5):679-83. 4. Guanche CA, Bare AA. Arthroscopic treatment of femoroacetabular impingement. Arthroscopy 2006;22(1):95-106. 5. Keogh MJ, Batt ME. A review of femoroacetabular impingement in athletes. Sports Med 2008;38(10):863-78. 6. Leunig M, Beaule PE, Ganz R. The concept of femoroacetabular impingement: current status and future perspectives. Clin Orthop Relat Res 2009;467(3):616-22. 7. Leunig M, Podeszwa D, Beck M, Werlen S, Ganz R. Magnetic resonance arthrography of labral disorders in hips with dysplasia and impingement. Clin Orthop Relat Res 2004(418):74-80. 8. Parvizi J, Leunig M, Ganz R. Femoroacetabular impingement. J Am Acad Orthop Surg 2007;15(9):561-70. 9. Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am 2003;85-A(2):278-86. 10. Sink EL, Gralla J, Ryba A, Dayton M. Clinical presentation of femoroacetabular impingement in adolescents. J Pediatr Orthop 2008;28(8):806-11.

CHILDHOOD BONE AND JOINT INFECTIONS, CONGENITAL, DEVELOPMENTAL PROBLEMS,

& MISCELLANEOUS

Jeffrey R. Sawyer MD Assistant Professor of Orthopaedics

University of Tennessee-Campbell Clinic Memphis, Tennessee USA

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Basic concepts • Pediatric orthopaedics with many rare and unusual syndromes. • Test questions tend to be on major topics. • Rare diseases/conditions appear.

Genetic/molecular defect known Pathognomonic phenotype (OI) Associated conditions that need to be evaluated for (Wilm’s tumor-hemihypertrophy)

• 2-3 year delay from papers to exam questions. • Mainstream concepts. • Conservative treatment in children “best”

Bone and Joint infections in Children Acute Osteomyelitis

3 routes: hematogenous contiguous direct innoculation

most common type is hematogenous rich blood supply to metaphysis blood supply to epiphysis – end arterioles in metaphysis,

↓ phagocytosis increased trauma in children

Demographics: 2:1 male:female

25% cases < 1 yr old, 50% < 5 years old 68% cases in long bones

Differential diagnosis: trauma, septic arthritis, toxic synovitis, rheumatoid, malignancy

Organisms:

most common: 1 S. aureus 61-89% 2 Group A β-hemolytic strep 10% 3 H. influenza – incidence rapidly ↓due to immunization

other: Kingella kingae underreported-harder to culture – PCR testing previous upper resp infection Salmonella sickle cell Pseudomonas shoe puncture

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Diagnosis: pain, limp, inability to bear weight, swelling, warmth neonates-pseudoparalysis radiographs typically not helpful MRI highly sensitive (97%) bone scan good for multifocal disease needle aspirate-definitive (positive 66% cases) blood cultures-positive 36-65% of cases laboratory ESR and CRP elevated (peak 2-5 after treatment) Follow response with CRP Treatment: antibiotics mainstay first generation cephalosporin consider vancomycin or clindamycin in MRSA endemic areas based on blood/bone cultures follow response with CRP surgical indications failure to improve with antibiotics (48 hrs) gross pus on aspiration abcess on MRI tissue for pathology (“biopsy the culture, culture the biopsy”)

Length of antibiotics controversial 2 weeks of IV then change to PO 6 weeks total continue until CRP normal Chronic Osteomyelitis

occurs in 10-20% of children with acute osteomyelitis most commonly following: open fracture, inadequately treated acute treatment is extensive, repeated debridements

removal sequestrum abcess drainage

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Chronic recurrent multifocal osteomyelitis typically older children (mean age 14) recurrent multifocal episodes of inflammation/remission cultures negative antibiotics not effective symptomatic treatment, no need for surgical treatment Pamidronate may be beneficial

Septic Arthritis

3 routes: hematogenous (trauma) contiguous direct inoculation

most common type is hematogenous Mechanism

transphyseal vessels allow spread into joints

several joints with intra-articular metaphysis hip, elbow, shoulder, ankle

enter due to vascular synovium with no basement membrane

↓ proteolytic enzymes cause cartilage destruction

↓ release of cytokines including TNF, IL-1

↓ loss of proteoglycan (5 days) and cartilage (9 days)

Demographics:

2:1 male:female peak children < 3 years 80% in lower extremity (hip)

Differential diagnosis: trauma, osteomyelits, Lyme disease, toxic synovitis, rheumatoid, malignancy

Organisms: most common: S. Aureus age-related: <12 months S. aureus, Streptococcus 6mo-5 yrs S. aureus, Streptococcus, H. influenza (↓ immunization) Kingella kingae 5-12 years S. aureus 12-18 yrs S. aureus, N. gonorrhoeae

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other: Kingella kingae underreported-harder to culture

prior upper resp infection Salmonella sickle cell

Pseudomonas shoe puncture

Diagnosis: pain, limp, inability to bear weight, swelling, warmth symptoms progress more rapidly than osteomyelitis neonates-pseudoparalysis, pain with diaper change radiographs typically not helpful early widened joint space r/o other causes of limp (SCFE, Perthes, Fracture) ultrasound-useful for detecting and aspirating joint effusions MRI-can detect effusion, associated osteomyelits laboratory WBC > 12,000, 40-60% PMN’s, ESR > 55 mm/hr suggestive Follow response with CRP Strains and PVL status (PVL+ and USA3000 strains ↑ virulence) needle aspirate gold standard Infection: > 50,000 wbc, > 75% PMNs, + gram stain Cultures positive 60% Treatment: antibiotics mainstay first generation cephalosporin consider vancomycin or clindamycin in MRSA endemic areas based on blood/joint cultures follow response with CRP surgical indications surgical emergency arthroscopic drainage effective length of antibiotics controversial – trend is shorter courses 2 weeks of IV then change to PO 6 weeks total continue until CRP normalizes complications: joint stiffness, growth arrest

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Septic arthritis versus toxic synovitis Toxic synovitis Typically following viral illness (GI, URI) Temp, WBC, ESR, CRP not as elevated as septic arthritis Self limiting-NSAIDs helpfu

Kocher criteria: Fever, Inability to bear weight, WBC > 12,000, ESR > 40 4 present: 99.8% predictive of septic arthritis 3 present: 93-95% predictive of septic arthritis 2 present: 33.8-62% predictive of septic arthritis 1 present: 0.1% predictive of septic arthritis CRP added and may increase sensitivity Congenital

General concepts • many with associated features • conservative approach • children with unilateral upper extremity deformities do well w/ no surgery

Spine

Klippel Feil Syndrome low posterior hairline, short neck (↓ROM), congenital vertebral fusion Associated with deafness, cardiopulmonary, limb deficiency, urinary defects patients develop hypermobile segments cranial/caudal to fusion lifestyle modification (no contact sports) cervical fusion for significant instability

Shoulder

Sprengel’s Failure of scapular descent during development 50% with omovertebral bone (connects scapula and spine)

Associated with torticollis, Klippel-Feil, pulmonary and renal disorders Surgical treatment for functional impairment Woodward procedure-detach/advance scapular muscules Cavicular osteotomy for older patients (↓plexus injury)

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Forearm Radial neck dislocation

Appears in late childhood/adolescence Bony prominence, little functional problems May be associated with unrelated trauma

Associated with Klippel-Feil, arthrogryposis, Nail-Patella syndrome Flat capitellum, convex radial head, bowed ulna - dif. from traumatic No role for radial head relocation, radial head excision if painful

Radial deficiency Failure of formation of radial side of forearm, hand, wrist

Associated with TAR(thrombocytopenia-absent radius), Fanconi’s anemia, VACTERRL (used to be VATER)

dx life saving in Fanconi’s and TAR PT/bracing early

Surgery (centralization) ↑recurrence and ↓function not indicated for older children who have adapted to deformity

Hand Syndactyly

Most common congenital hand disorder Associated with Poland (chest wall) and Apert (skull/face) syndromes May be associated with functional loss Surgical resection one digit per procedure to avoid necrosis skin grafting necessary

Polydactyly (tends to show up on exams) Male > Female

Pre-axial(Thumb) Over-expression of sonic hedgehog protein Underexpression Gli3 protein (down regulates sonic hedgehog)

Most common: duplicated proximal phalanges (Wassel IV) duplicated distal phalanges (Wassel IV) Surgical treatment: Simple excision contraindicated except pedunculated Reconstruct radial collateral ligaments, advance thenar m. +/- osteotomies Late deformity common (20%)

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Post-axial(Ulnar side –“6th digit”) Autosomal dominant African American > Caucasian more often syndrome-related in caucasian Surgical treatment – excision

Thumb deficiency May be part of spectrum of radial deficiency Commonly bilateral Associated with Fanconi’s, TAR, VACTERRL Severe deform- thumb ablation and index pollicization indicated Unilateral deformities controversial

Knee

Congenital knee dislocation Females > males, can be unilateral or bilateral

Associated with hip dysplasia (50%), clubfoot, congenital vertical talus, myelomenigocele, arthrogryposis, Larsen syndrome History of “packing disorders” (breech birth, oligohydramnios) Conservative treatment and orthotic (Pavlik) Surgery for fixed dislocation or significant contracture

Patellar dislocation

Rare Irreducible lateral dislocation May have genu valgum +/- flex contracture, hypotrophic/aplastic trochlea Conservative treatment not indicated Surgery-lateral release/VMO advancement, medialization patella

Discoid meniscus Many children asymptomatic (? true incidence) Lateral >> medial, 20% bilateral Treatment based on symptoms, tear, meniscofemoral ligaments Conservative treatment mainstay for asymptomatic children Surgery (saucerization) symptomatic, tears total and near total meniscectomy results poor

Developmental/Aquired

Brachial Plexus Palsy 4:1000 births most common with large babies, shoulder dystocia, forceps, breech, long labor poor prognosis: no return of bicep function at 6 months + Horners root avulsion for spinal cord

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Type Roots Deficit Prognosis Other Erb-Duchenne C5-6 (Upper) Deltoid,biceps,wrist

extensors, hand extensors

Good “Waiter’s tip”

Klumpke C8-T1 (Lower) Wrist flexors, hand intrinsic

Poor Horner’s

Total C5-T1 Flaccid arm, sensory defecits

Bad

Early surgical treatment:

Brachial plexus reconstruction technically challenging, complete plexus w/ no return at 3 months Reconstructive treatment:

Early anterior capsular relesase (can be arthroscopic) prevents glenoid deformity (think DDH of the shoulder) Younger patients-lastissimus/teres transfer Older patients- humeral external rotation osteotomy

Amniotic Bands Amniotic disruption leads to constrictive bands 90% distal to wrist Associated with: clubfoot, cleft palate, craniofacial defects Spectrum: skin dimpling ↔ complete amputation Most patients can acutely be observed (rare vascular insufficiency) Surgery for vascular insufficiency, late reconstruction of amputations

Genetics I. General concepts

Autosomal dominant Heterozygotes manifests condition Normal offspring do NOT transmit disease Usually structural defects Autosomal recessive Heterozygotes do not manifest condition Usually biochemical/enzymatic diseases Sex linked dominant Heterozygotes manifest disease (X’Y or X’X) Sex linked recessive Heterozygote male manifests disease (X’Y) Heterozygote female unaffected (X’X)

*many genetic diseases are due to new mutations and may not follow above patterns II. Questions tend to target:

Common diseases

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Diseases where the gene defect, structural product and phenotype known: Achondroplasia – FGFR3 gene→FGF receptor→Proliferative zone of physis

Molecular Basis of Common Orthopaedic Conditions

Disease Molecular Basis Mode Tissue/Physiologic Orthopaedic Manifestations

Dysplasias Achondroplasia FGF receptor 3 AD Proliferative zone Rhizomelic Dwarfism

Joint instability Spinal stenosis

Multiple epiphyseal dysplasia

Cartilage Oligomeric Protein

AD Epiphysis Short limb Disproportionate

Metabolic

OI Collagen genes AD (I,IV) AR (II,III)

Bony fragility Frequent fractures Scoliosis

Vitamin D-dependent rickets

Renal 25 hydroxylase AR Physis-abnormal ossification

Bony deformity Osteomalacia

Vitamin D resistant rickets

1,25 OH D receptor XD Physis -abnormal ossification

Bony deformity Osteomalacia

Connective Tissue

Marfan Fibrillin gene AD Connective tissue Joint laxity-subluxation Scoliosis

Ehlers-Danlos Col 1A2 gene AD Connective tissue Joint laxity Fibrous Dysplasia G protein (GNAS) AD Bone Fibrous lesions

Muscular Dystrophy

Duchenne’s Dystrophin gene XR Muscle Progressive weakness Scoliosis

Becker’s Dystrophin gene* XR Muscle Weakness Lifespan > Duchenne’s (20’s)

Hematologic

Hemophilia A Factor VIII gene XR Complement cascade Hemarthrosis Hemophilic arthropathy

Sickle cell Hemoglobin S gene AR Hemoglobin Bone pain/infarcts Salmonella osteomyelitis

Chromosomal

Down Syndrome Trisomy 21 N/A Increased joint laxity C spine instability Joint laxity

Clinodactyly Trisomy 8 and 12 N/A ? Finger deformity

Miscellaneous

Malignant Hyperthermia Ryanodine receptor AD Skeletal musclesarcoplasm/Ca++

Halothane/succinylcholine Inc. in neuromuscular pts

Multiple hereditary osteochondromas

EXT genes AD Physis Radial head dislocation Angular deformity-lower ext

TAR (Thrombocytopenia-absent radius)

? AR Radial forearm Radial/thumb deficiency Thrombocytopenia

*Same gene-different mutation location ** For a comprehensive list see Dietz & Mathews JBJS 1996 1583-98.

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Diseases that show up on exams

Achondroplasia Defect in FGF receptor 3 gene-majority are spontaneous mutation Most common type of disproportionate dwarfism Failure of proliferative zone in physis Phenotype: normal trunk/short limbs Frontal bossing Trident hands Thoracic kyphosis-resolves w/ ambulation Lumbar stenosis-most common cause of disability Decreasing intrapedicular distance L1-S1 Radial head subluxation “Champagne glass pelvis” Normal intelligence Treatment: weight loss, bracing Surgical: lumbar decompression and fusion Osteotomies for genu varum Limb lengthening (upper and lower) controversial

Osteogenesis Imperfecta Defect in Type I collagen-abnormal cross-linking leads to easy fracture Phenotype: short stature scoliosis tooth defects (dentinogenesis imperfecta) hearing defects ligamentous laxity classic description of 4 types: now with molecular biology-spectrum fractures common with normal healing, no remodeling Treatment: early bracing to prevent fracture prophylactic intramedullary nailing of long bones no proven medical therapy scoliosis-bracing ineffective, surgery difficult due to osteopenia candidate for gene therapy Duchenne’s Muscular Dystrophy Non-inflammatory disorder of muscle weakness (progressive) Defect in Dystrophin gene Diagnosis: Young male with clumsy walking

↓motor skills Gower’s sign calf hypertrophy (pseudohyertrophy)

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Laboratory: increased CPK, absent dystrophin DNA Biopsy: absent dystrophin Most patients lose independent ambulation by 10 Scoliosis progresses rapidly – fusion for curves 25-30° Death of respiratory complications by 20

Different from Becker’s which is less severe, associated w/ red-green color blindness and lifespan >20 years w/o respiratory support.

Marfan Syndrome Disorder of Fibrillin gene Pheontype: arachnodactyly – long arms, fingers Pectus Scoliosis 50% with heart (valve) and eye (superior lens dislocations) problems Joint laxity treated non-operatively with bracing Scoliosis treated surgically. Bracing ineffective Down Syndrome Trisomy 21- most common chromosomal abnormality Phenotype: characteristic facial features ligamentous laxity hypotonia mental retardation 50% with heart disease, endocrine disorders (hypothyroid, diabetes) common Orthopaedic problems: pes planus C1-C2 instability Scoliosis Hip instability

Asymptomatic children with C1-2 instability should avoid contact sports, diving, gymnastics- Special Olympics

Mucopolysaccharidosis Defect in hydrolase enzyme deficiency in carbohydrate metabolism Phenotype: proportionate dwarfism

Diagnosis: complex sugars in urine diagnostic

Four main types: Morquio’s, Hunter’s, Hurler’s, Sanfilippo’s Classified by inheritance, mental retardation, urine sugar Morquios-commonly on exams Waddling gait, 2 years of age

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Phenotype: Genu valgum thoracic kyphosis wide ribs C1-C2 instability (odontoid hypoplasia)

Syndrome Inheritance Intelligence Urinary Excretion Notes Morquio’s AR Normal Keratin sulfate Most common Hurler’s AR Retardation Dermatan/heparin sulfate Worst Hunter’s XR Retardation Dermatin/heparin sulfate Sanfilippo’s AR Retardation Heparin sulfate Normal until 2yo

Exam tips: very confusing and at most this will be one question Morquio’s-classic disease, most common, only one w/ Keratin and nl intelligence All are recessive transmission Cerebral Palsy Non-progressive to brain before the age of 2 Cause most often is not identifiable Classification: Physiologic: Spastic- most common, best response to surgery Athetoid-associated w/ kernicterus, poor response to surgery Ataxia- wide based gait, poor response to surgery Mixed- spastic and athetoid Anatomic: Hemiplegia-upper and lower same side, almost all walk Diplegia-LE involvement > UE, usually walk (late) Quadriplegia-UE and LE involvement, low IQ, rare to walk Physical examination: Persistence of primitive reflexes Increased spasticity Treatment: Pharmacologic

Baclofen - decrease spasticity Botulinum A toxin (postsynaptic blockade at NM junction)

Bracing early to prevent deformity Soft tissue procedures early before contracture/bony deformity Bony procedures for joint subluxation/dislocation

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Hip:

Stage ROM (abduction) Xrays Treatment Hip at risk < 45 degrees May be normal Adductor tenotomy Hip subluxation < 20 degrees Subluxation (migration

index) Adductor tenotomy +/- VDRO +/- pelvic osteotomy

Hip dislocation None Dislocated Open reduction Femoral shortening Femoral VDRO Pelvic osteotomy

Hip dislocation (late) None Dislocated Degenerative changes

Girdlestone Abduction osteotomy

VDRO = varus derotational osteotomy Pelvic osteotomy = most common is Dega

Exam points: trend is toward not reducing hip unless patient: has pain that limits ADL’s (diapering, transfer)

has significant ambulatory potential Spine: risk for scoliosis is highest in children with severe disease bracing ineffective spinal fusion for progressive curves that interfere with care, sitting. Usually involves fusion to pelvis to control obliquity High complication rate (up to 10x idiopathic scoliosis) Important to assess nutritional status: Albunin < 3.5 g/dL, WBC < 1500 consider g-tube due to ↑ infection Knees: Usually hamstring contractures quadriplegia > diplegia > hemiplegia Bracing Hamstring release helpful +/- rectus femoris transfer (to increase knee flexion) Feet: Diplegia: equinovalgus due to spastic peroneals, tight heelcords Calcaneal lengthening osteotomy for severe deformity Hemiplegia equinovarus feet due to overpull of tib ant and tib. post. Achilles tendon lengthening +/- split tendon transfer (tib ant) Bunions: high rate of failure with standard adult procedures MTP joint fusion best

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Upper extremity: Limited role for UE surgery High functioning children – tendon transfers around wrist to improve hand function Severely involved children- soft tissue release to prevent skin breakdown Myelomeningocele Disorder of incomplete spinal cord closure (spina bifida occulta ↔ rachischisis) Folate deficiency in utero Diagnosed in utero ultrasound increased α-fetoprotein levels Associated with Type II Chiari Malformation, hydrocephalus, tethered cord Pathologic fractures common often confused with DVT, infection fractures heal with abundant callus Ambulation/function dependent on level Above L3 non-ambulator L3-L4 household ambulatory L5-S1 community ambulatory Hip: most common level for dislocation L3-4 L2 and cranial – do not treat hip dislocations-painless, no ambulatory potential L4 and caudal – treat hip dislocations surgically Ankle foot: maintain braceable, plantagrade foot soft tissue releases to maintain balance clubfoot common triple arthrodesis for severe deformity and sensate feet Spine: most patients will develop scoliosis/kyphosis (↑ with cranial spinal level) bracing not effective rapid curve progression – tethered cord fixation to pelvis necessary kyphectomy for severe kyphosis

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References Infection Arnold, S.R., et al., Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus. J Pediatr Orthop, 2006. 26(6): p. 703-8. Caird, M.S., et al., Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am, 2006. 88(6): p. 1251-7. Congenital/Developmental/Genetic Ballock, R.T., Molecular and genetic approaches to musculoskeletal diseases. J Pediatr Orthop, 2003. 23(1): p. 131-7. Common Diseases Avivi, E., et al., Skeletal manifestations of Marfan syndrome. Isr Med Assoc J, 2008. 10(3): p. 186-8. Borges, J.L., et al., Modified Woodward procedure for Sprengel deformity of the shoulder: long-term results. J Pediatr Orthop, 1996. 16(4): p. 508-13. Arnold, S. R., D. Elias, et al. (2006). "Changing patterns of acute hematogenous osteomyelitis and

septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus." J Pediatr Orthop 26(6): 703-8.

Avivi, E., H. Arzi, et al. (2008). "Skeletal manifestations of Marfan syndrome." Isr Med Assoc J 10(3): 186-8.

Ballock, R. T. (2003). "Molecular and genetic approaches to musculoskeletal diseases." J Pediatr Orthop 23(1): 131-7.

Borges, J. L., A. Shah, et al. (1996). "Modified Woodward procedure for Sprengel deformity of the shoulder: long-term results." J Pediatr Orthop 16(4): 508-13.

Caird, M. S., J. M. Flynn, et al. (2006). "Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study." J Bone Joint Surg Am 88(6): 1251-7.

Catalano-Pons, C., A. Comte, et al. (2008). "Clinical outcome in children with chronic recurrent multifocal osteomyelitis." Rheumatology (Oxford) 47(9): 1397-9.

Ceroni, D, Cherkauoi, A, Ferey S, Kaelin, A, Schrenzel, J (2010) Kingella Kingae Osteoarticular Infections in Young Children: Clinical Features and Contributions of a New Specific Real Time PCR assay to the Diagnosis. J. Pediatric Orthop 30(3):301-4.

Chapurlat, R. D. and P. Orcel (2008). "Fibrous dysplasia of bone and McCune-Albright syndrome." Best Pract Res Clin Rheumatol 22(1): 55-69.

Crandall, R. C., R. C. Birkebak, et al. (1989). "The role of hip location and dislocation in the functional status of the myelodysplastic patient. A review of 100 patients." Orthopedics 12(5): 675-84.

Dao, K. D., A. Y. Shin, et al. (2004). "Surgical treatment of congenital syndactyly of the hand." J Am Acad Orthop Surg 12(1): 39-48.

Dietz, F. R. and K. D. Mathews (1996). "Update on the genetic bases of disorders with orthopaedic manifestations." J Bone Joint Surg Am 78(10): 1583-98.

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Dormans, J. P. and D. S. Drummond (1994). "Pediatric Hematogenous Osteomyelitis: New Trends in Presentation, Diagnosis, and Treatment." J Am Acad Orthop Surg 2(6): 333-341.

Drennan, J. C. (1993). "Congenital dislocation of the knee and patella." Instr Course Lect 42: 517-24. Driscoll, S. W. and J. Skinner (2008). "Musculoskeletal complications of neuromuscular disease in

children." Phys Med Rehabil Clin N Am 19(1): 163-94, viii. Girschick, H. J., C. Zimmer, et al. (2007). "Chronic recurrent multifocal osteomyelitis: what is it and

how should it be treated?" Nat Clin Pract Rheumatol 3(12): 733-8. Green, N. E. (1987). "The orthopaedic management of the ankle, foot, and knee in patients with

cerebral palsy." Instr Course Lect 36: 253-65. Greene, W. B. (1999). "Treatment of hip and knee problems in myelomeningocele." Instr Course

Lect 48: 563-74. Herman, M. J. and P. D. Pizzutillo (1999). "Cervical spine disorders in children." Orthop Clin North

Am 30(3): 457-66, ix. Horton, W. A., J. G. Hall, et al. (2007). "Achondroplasia." Lancet 370(9582): 162-72. Karol, L. A. (2004). "Surgical management of the lower extremity in ambulatory children with

cerebral palsy." J Am Acad Orthop Surg 12(3): 196-203. Karol, L. A. (2007). "Scoliosis in patients with Duchenne muscular dystrophy." J Bone Joint Surg Am

89 Suppl 1: 155-62. Klimo, P., Jr., G. Rao, et al. (2007). "Congenital anomalies of the cervical spine." Neurosurg Clin N Am

18(3): 463-78. Kocher, M. S., K. Klingele, et al. (2003). "Meniscal disorders: normal, discoid, and cysts." Orthop Clin

North Am 34(3): 329-40. Kocher, M. S., D. Zurakowski, et al. (1999). "Differentiating between septic arthritis and transient

synovitis of the hip in children: an evidence-based clinical prediction algorithm." J Bone Joint Surg Am 81(12): 1662-70.

Kozin, S. H. (2003). "Upper-extremity congenital anomalies." J Bone Joint Surg Am 85-A(8): 1564-76. Light, T. R. (1992). "Treatment of preaxial polydactyly." Hand Clin 8(1): 161-75. Lourie, G. M. and R. E. Lins (1998). "Radial longitudinal deficiency. A review and update." Hand Clin

14(1): 85-99. Maschke, S. D., W. Seitz, et al. (2007). "Radial longitudinal deficiency." J Am Acad Orthop Surg 15(1):

41-52. McCarthy, J. J., L. P. D'Andrea, et al. (2006). "Scoliosis in the child with cerebral palsy." J Am Acad

Orthop Surg 14(6): 367-75. McCarthy, J. J., J. P. Dormans, et al. (2005). "Musculoskeletal infections in children: basic treatment

principles and recent advancements." Instr Course Lect 54: 515-28. Mellado Santos, J. M. (2006). "Diagnostic imaging of pediatric hematogenous osteomyelitis: lessons

learned from a multi-modality approach." Eur Radiol 16(9): 2109-19. Mik, G., P. A. Gholve, et al. (2008). "Down syndrome: orthopedic issues." Curr Opin Pediatr 20(1):

30-6. Mikles, M. and R. P. Stanton (1997). "A review of Morquio syndrome." Am J Orthop 26(8): 533-40. Moran, S. L., M. Jensen, et al. (2007). "Amniotic band syndrome of the upper extremity: diagnosis

and management." J Am Acad Orthop Surg 15(7): 397-407. Morcuende, J. A. (1993). "Orthopedic aspects of skeletal dysplasia in children." Curr Opin Pediatr

5(3): 363-7.

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Novacheck, T. F. and J. R. Gage (2007). "Orthopedic management of spasticity in cerebral palsy." Childs Nerv Syst 23(9): 1015-31.

Rauch, F. and F. H. Glorieux (2004). "Osteogenesis imperfecta." Lancet 363(9418): 1377-85. Renshaw, T. S., N. E. Green, et al. (1996). "Cerebral palsy: orthopaedic management." Instr Course

Lect 45: 475-90. Richette, P., T. Bardin, et al. (2008). "Achondroplasia: from genotype to phenotype." Joint Bone

Spine 75(2): 125-30. Sachar, K. and A. D. Mih (1998). "Congenital radial head dislocations." Hand Clin 14(1): 39-47. Sarwark, J. F. (1999). "Kyphosis deformity in myelomeningocele." Orthop Clin North Am 30(3): 451-

5, viii-ix. Scott, R. J., M. R. Christofersen, et al. (1990). "Acute osteomyelitis in children: a review of 116

cases." J Pediatr Orthop 10(5): 649-52. Spiegel, D. A. and J. M. Flynn (2006). "Evaluation and treatment of hip dysplasia in cerebral palsy."

Orthop Clin North Am 37(2): 185-96, vi. Stieber, J. R. and J. P. Dormans (2005). "Manifestations of hereditary multiple exostoses." J Am Acad

Orthop Surg 13(2): 110-20. Strombeck, C., L. Krumlinde-Sundholm, et al. (2007). "Long-term follow-up of children with obstetric

brachial plexus palsy I: functional aspects." Dev Med Child Neurol 49(3): 198-203. Tassone, J. C. and A. Duey-Holtz (2008). "Spine concerns in the Special Olympian with Down

syndrome." Sports Med Arthrosc 16(1): 55-60. Tedeschi, E., F. Antoniazzi, et al. (2006). "Osteogenesis imperfecta and its molecular diagnosis by

determination of mutations of type I collagen genes." Pediatr Endocrinol Rev 4(1): 40-6. Vekris, M. D., M. G. Lykissas, et al. (2008). "Management of obstetrical brachial plexus palsy with

early plexus microreconstruction and late muscle transfers." Microsurgery 28(4): 252-61.

Pediatric Upper and Lower Extremity Fractures

John (Jack) M. Flynn, MD Orthopaedic Trauma Director

Associate Chief of Orthopaedics Children’s Hospital of Philadelphia, Associate Professor of Orthopaedics

University of Pennsylvania

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Notes

Essential pediatric fracture principles Remodeling based on: Age (younger = better) Distance from the physis (closer = better) Amount of angulation (more = better) Know where to be aggressive

Late puberty/nearly adult “kids” Elbow, Hip Intra-articular fractures Femur fractures: school age and older

Know where non-operative is usually the best option Almost all distal radius Most diaphyseal forearm (90%) Humeral shaft/proximal humerus Clavicle Femur and tibia in very young Most pediatric pelvic fractures

Compartment syndrome Sentinel finding: increasing pain Often the next day in LE fractures Remove any cast if there is increasing pain Knee and elbow get stiff with intra-articular fractures, esp in older kids Growth arrest risk and problems high: distal femur (25-50%), distal ulna (60%) Growth arrest risk and problems low: distal radius, distal humerus, ankle Don’t forget child abuse Femur fx and “not yet walking” SH II distal humerus in baby Corner fracture

Upper Extremity

Wrist

Know remodeling/natural history: don’t over treat! Acceptable reduction

Bayonet apposition Sagittal plane angulation

up to 30° if > 5 yrs. of growth remaining 5° less for each year less than 5

Frontal plane angulation looks bad, remodels slowly ~ 10-15° if > 5 yrs. of growth remaining

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Indications to pin peds distal radius Unstable distal radius and ipsilateral distal humerus Can’t CR/cast (extremely swollen/skin/compartment syndrome)

Diaphyseal Forearm Principles

Most are rotational injuries “The ulna shows you the angulation; the radius shows you the rotation” Look for a second injury if just one diaphyseal fracture Diaphyseal fractures heal more slowly Malunion can be a problem…be “more aggressive” than distal radius

Acceptable reduction Up to 10-20° angulation in kids < 10 y/o No more than 10° angulation >10 y/o Bayonet apposition 30° malrotation Distal fractures more forgiving than proximal fractures

Treatment pearls Make a good cast Don’t accept a crooked arm OK to reduce or re-reduce in OR (even @ 2-3 weeks post-injury) Avoid re-fracture: splint or cast a couple extra weeks if necessary Use single bone fixation if necessary Fracture site often must be opened for IM nailing Treat older adolescents like adults

Monteggia injuries

Principles Don’t accept forearm images that don’t show the elbow Radiocapitellar line in all views Treatment based on Stability of ulna fracture Monteggia type Age of patient Time from injury to treatment (missed or failed treatment)

Bado types I: radial head anterior Most common type in kids Often CR cast OK; flex to reduce, but cast at 90° K-wire or plate on ulna, depending on stability II: radial head posterior Relatively rare Teens Hard to cast in extension; usually fix these

III: radial head lateral 2nd most common in kids

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Look for associated radial nerve injury Greenstick proximal ulna can be hard to control Ulnar IM k-wire commonly used IV: radial head anterior, radial shaft fracture

Late/Missed Monteggia Management very controversial

Results often poor, even in experienced hands Treatment determined by amount of delay < 2 weeks May still be able to get CR and use cast Fixation often helps 2 weeks to about 6 months Often need ulnar osteoclasis or osteotomy Restore ulnar length May need to open radiocapetellar joint May need to repair/reconstruct annular ligament > 6mo

Results often poor, even in experienced hands Ulnar osteotomy, with plate v. ex fix

Open reduction radiocapetellar joint Repair/reconstruct annular ligament (Bell-tawse)

Proximal radius and ulna Radial head/neck

Unusual—5% peds elbow fx Metaphyseal or physeal Usually valgus injuries Displaced fractures: high rate of poor results in literature

15-30% poor results overall 50% poor results in high energy injuries

Results are worse if there is another fx (esp prox ulna) “Satisfactory CR usually better than anatomic OR” Acceptable reduction criteria 0-20 angulation, no translation: accept as is, LAC for 3 weeks

>20angulation, translation: attempt ER closed reduction Post –reduction

If translation corrected and angulation < 30°, cast If > 30°, try OR reduction Percutaneous manipulation works 95% of time Avoid opening fracture site if at all possible A CR to < 45° will do better than anatomic ORIF

Complications Motion loss—esp. pronation Radial head overgrowth—20-40% Myositis ossificans

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Esp. after surgical treatment: AVN—10-20% Non-union (Waters JPO 2001) Radioulnar synostosis

Olecranon/prox. Ulna Apophyseal (seen in OI tarda)

Metaphyseal Flexion Extension Shear

Treatment Non-displaced/min displaced

cast for 3-4 wks 30 elbow flexion

Operative indications: Unstable fractures Articular step-off Younger kids

Suture tension band Leave wires out to pull in clinic

Older adolescents: treat like adults

Elbow fracture principles Posterior fat pad sign predictive of occult fx (53% Supracondylar) Anterior humeral line should intersect the capitellum Carrying angle ~ 5-7 degrees Baumann’s angle 10-20°(or 70-80°, the official way to measure) Very little remodeling at distal humerus High rate of complications from injury/treatment

Supracondylar humerus 10-20% associated NV injury

Anterior interosseous n. palsy the most common Most nerve palsies recover in 2-4 months 1% brachial artery occlusion

~ 95% extension type, 5% flexion type(ulnar n. can be injured) Lots of low level evidence that fixing the next day is safe (unless NV risk) Beware of medial impaction—can cause cubitus varus malunion Classification and treatment Gartland I: non-displaced, crack in anterior cortex, cast 3 weeks Gartland II: displaced but hinged, most get CR/pins(2pins) & cast for 3 weeks Gartland III: completely displaced, all get CR/pins(3pins) & cast for 3 weeks Open reduction Rarely needed in most centers (< 5%) Indications to open

Something trapped in fracture site Need to address vascular compromise

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Anterior approach generally preferred Vascular compromise Absent pulse, well perfused hand Proceed urgently to OR, CR and pin If pulse returns, usual treatment If pulse does not return Hand well perfused: observe as inpatient, splint Hand not well perfused, vascular team assess and treat Absent pulse, poorly perfused hand Proceed urgently to OR, CR and pin If hand perfusion well restored: observe as inpatient, splint If hand not well perfused, vascular team assess and treat

Lateral condylar humerus Milch 1: SH IV Milch II: SH II (most common, by far) Surgical management usually recommended if > 2 mm of displacement (>60 %) Stages of displacement classification best for determining treatment I: Intact hinge of trochlear cartilage: cast x 6 weeks (watch for progressive displacement!) II: Disrupted hinge, but minimally displaced: cast v. perc pin v. ORIF III: Completely displaced: ORIF Use Kocher approach, stay anterior (blood supply posterior) Non-union Can lead to cubitus valgus Early: ORIF, don’t strip soft tissue to improve reduction Late: Fixation in situ, +/- bone graft, sometimes osteotomy

Distal humeral physeal separation Most before age 6 May occur as birth injury Consider child abuse Diagnosis can be challenging Can look like lateral condyle fracture EUA, +/- arthrogram can be helpful Treatment principles

Manipulative closed reduction if fresh Fresh means a few days after injury CRPP just as for supracondylar 2-3 weeks of immobilization

Splint in situ if late (osteotomy better than risking growth arrest)

Medial epicondyle fractures of humerus Apophyseal injury Peak age 11-12 y/o, boys 4:1 Associated with elbow dislocation (50%) Fragment trapped in the joint (15%) Flexor mass, ligaments attached Evaluate the ulnar nerve carefully Minimally displaced: splint Operative indications

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Incarcerated fragment Ulnar nerve completely out

Controversy: displacement > 5mm Non-operative

Strong support in older literature (1982-2002) Fibrous union likely, but asymptomatic in many

ORIF Currently used at many centers, esp for athletes Screw fixation and early motion

Proximal humerus

< 5% of all peds fx prox humerus physeal < 1% of all peds fx

< 5 y/o: SH I 5-12 y/o: metaphyseal fx predominate > 12 y/o: SH II most common

Extraordinary remodeling potential “universal joint” rapidly growing physis

Immobilization only is treatment for most Operative indications

Open NV injury Intra-articular Unacceptable displacement—very controversial

< 12 y/o: can accept up to 70° and 100% displacement Teenage: controversial. 30-40°, 50% displacement

Clavicle

99%+: treated with sling or figure of 8 Trend towards adult ORIF philosophy extending to teens, esp athletes and re-fractures ORIF also with open fractures, NV injury Sternoclavicular physeal fracture/dislocations

Anterior: closed reduction if very displaced Posterior can threaten mediatstinal structures get CT scan reduce in OR with CT surgery on standby trend towards suture fixation through drill holes

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Lower Extremity

Pelvis Look for associated injury: >50%

Head, abdominal, urologic, other fractures Mortality/morbidity usually from other injuries, not pelvic fx Complications—most are rare

Premature triradiate cartilage closure Leg-length discrepancies Nerve palsy Heterotopic ossification

Femoral Neck Fractures

Classification-Delbet Type I: like acute SCFE (very high AVN risk)

Type II: transcervical (moderate AVN risk) Type III: cervicotrochanteric(low AVN risk) Type IV: intertrochanteric (very low AVN risk)

Treatment principles Displaced Type I-III: relative surgical emergency Some form of capsular decompression recommended Rigid internal fixation (screws, not pins) “If child is too young to fix across physis, use a spica for 4-6 weeks”

Complications AVN

Coxa vara Non-union Growth disturbance/arrest

Traumatic Hip Dislocations Children under age 5: trivial trauma, low risk of problems Older children/teens: significant trauma, more risks:

Be alert for fragements trapped in the joint Avascular Necrosis About 10% of hip dislocations Reduce within 24 hours Risk of AVN is probably related to the severity of initial trauma

AAOS Review Course 2010 Pediatric Fractures

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Femoral Shaft Fractures Management principles

Most heal without long-term sequelae Consider abuse in children who are not yet walking Treatment is age-related Infants: Pavlik harness, +/- splint

Infant to < 6 y/o: early spica cast in most cases Skeletally mature: antegrade IM nail 6 y/o to maturity: many options Elastic nailing Submuscular plating External fixation

Trochanteric-entry nailing Traction/casting

Acceptable Alignment 2-10 y/o 11y/o Varus/valgus 15° 5-10 °

Anterior/posterior 20° 10° Malrotation 30° 30°

Acceptable shortening Under 10 y/o: 1.5-2.0 cm Over 10 y/o: 1.0 cm Treatment options

Casting / Traction & Casting Best option for most kids ≤ 5 y/o; rarely used in children > 8 y/o Traction: + Telescope test (EUA > 25 mm shortening) or child > 6 y/o Complications under appreciated

Risk of leg compartment syndrome Flexible intramedullary nails Good option for length-stable fractures ages 6-12 y/o

TEN poor results increase in kids ≥ 11 y/o, wt ≥ 50 kg Select more stable fracture patterns/protect unstable patterns

External Fixation Best for: severe soft tissue injury, comminuted/spiral/unstable fx pattern

Very distal/proximal fractures Submuscular Plate Fixation

Recent surge in popularity Length unstable fractures Long plate, limited number of screws

Solid antegrade IM nail Trochanteric starting point Avoid piriformis fossa

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Knee Fractures

Distal Femoral Physeal Fractures Look for occult fxs in pediatric “knee sprain” If fracture displaced or unstable:

Use internal fixation if fracture, smooth K-wires across physis for 3 weeks: ok

Peroneal nerve injury: avoid excess stretch through traction or excessive varus Vascular injury reported—carefully check vascular status Knee joint instability: check ligaments when fracture healed Growth arrest:

Very common: 25-50% after displaced fractures MRI at 4-6 months after trauma to detect growth disturbances

Patellar Fractures Principles for patellar fx same as for adult

Strong suture (rather than wire) tension band effective in kids Patellar sleeve fractures Entire injury can be missed—feel for defect, look for patella alta

Usually massive soft tissue injury Be sure fixation allows early motion Loss of flexion, extensor lag possible

Tibial Spine Myers and McKeever’s I: non-displaced

Myers and McKeever’s II: intact posterior hinge Myers and McKeever’s III: completely displaced

Meniscus can be entrapped in the fracture Complications

Late anterior instability in 64% patients, not a functional problem Unrecognized injuries of the collateral ligaments Malunion may cause mechanical impingement Non-union, re-fracture Knee stiffness: warn pre-op, move post-op as soon as it’s safe

Proximal tibial physeal fractures These can be surprisingly unstable: fix if there is any question of instability Joint step-off rare, plateau diastasis more common—fix if >2mm Vascular injury a major risk

Vessels tethered at trifurcation: can injure popliteal artery Compartment syndrome

Physeal arrest Often no leg-length discrepancy if less than 3 years growth remaining Watch for varus/valgus deformity

Tibial Tubercle avulsion Compartment syndrome: ant tibial artery tear Genu recurvatum after growth arrest Loss of knee flexion—extensor mechanism contracture

Proximal tibial metaphyseal fractures Usually 3-6 y/o, heal rapidly

Post-fx genu valgum (Cozen’s fracture) Cause unknown, usually resolves spontaneously

Be certain there is no tissue trapped in fx site

AAOS Review Course 2010 Pediatric Fractures

John M. Flynn, MD

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Diaphyseal Tibia/Fibula Fractures Accept: 5 valgus, 5-10 varus and ant. angulation, 5 post. Angulation

Be vigilant for compartment syndrome Often a “next day” problem in children Earliest sign may be increased narcotic requirements

Malrotation Rotational malalignment of the tibia does not spontaneously correct

More than 10 degrees may produce significant functional impairment Leg length discrepancy Beware of occult physeal injury in diaphyseal tibia fracture

Distal Tibial Physeal Fractures Physis closes central to medial to posterior to anterolateral

Tillaux Ext. rotation injury Anterior tibfib ligament pulls off fragment of anterolateral tibial physis Triplane 2, 3 and 4-part fractures < 2mm joint displacement: CR with IR, LLC > 2mm joint displacement: ORIF vs. percutaneous with interfrag screws

Non-unions rare—reported in SHIII (medial mal. fx) Growth arrest Entrapped periosteum has been implicated

Usually occurs after Salter-Harris types III and IV fractures Varus deformity Leg length discrepancy rarely a problem

Foot fractures AVN in talus fractures—use MRI for early diagnosis, NWB if possible Beware of occult tarsometatarsal injury in children Be vigilant for compartment syndrome—esp. the “run-over” or crushed foot Seymour’s fracture (occult open physeal fx/nailbed injury of the toe) Beware when there is blood under the nail bed Give antibiotics in ED ORIF may be necessary to free entrapped tissue

References Upper Extremity General Principles

1. Kocher MS, Kasser JR: Orthopaedic aspects of child abuse. J Am Acad Orthop Surg 2000;8:10-20. 2. Marsh JL, Buckwalter J, Gelberman R, Dirschl D, Olson S, Brown T, Llinias A: Articular fractures: Does an anatomic reduction really

change the result? J Bone Joint Surg Am. 84-A:1259-1271, 2002. 3. Carey J, Spence L, Blickman H, Eustace S: MRI of pediatric growth plate injury: correlation with plain film radiographs and clinical

outcome. Skeletal Radiol. 27:250-255., 1998. 4. Flynn J, Skaggs D, Sponseller P, et al: The operative management of pediatric lower extremity fracture. Journal of Bone and Joint Surgery

Am. 84:2002. Wrist

5. Cannata G, De Maio F, Mancini F, Ippolito E: Physeal fractures of the distal radius and ulna: Long-term prognosis. J Orthop Trauma 2003;17:172-179.

6. McLauchlan GJ, Cowan B, Annan IH, Robb JE: Management of completely displaced metaphyseal fractures of the distal radius in children: A prospective, randomized controlled trial. J Bone Joint Surg Br 2002;84:413-417.

7. Proctor MT, Moore DJ, Peterson JM: Redisplacement after manipulation of distal radial fractures in children. J Bone Joint Surg Br 1993;75:45:3454.

Forearm 8. Bado JL: The Monteggia Lesion. Clin Orthop Relat Res 1967;50:71-86. 9. Price CT, Scott DS, Jurzner ME, Flynn JC: Malunited forearm fractures in children. J Pediatr Orthop 1990;10:705-712 10. Tarr RR, Garfinkel AI, Sarmiento A: The effects of angular and rotational deformities of both bones of the forearm. J Bone Joine Surg Am

1984;66:65-70. 11. Van der Reis WL, Otsuka NY, Moroz P, Mah J: Intramedullary nailing versus plate fixation for unstable forearm fractures in children. J

Pediatr Orthop 1998;18:9-13. Elbow

12. Skaggs DL, Hale JM, Bassett J, Kaminksy C, Kay RM, Vernon TT: Operative treatment of supracondylar fractures of the humerus in children: The consequence of pin placement. J Bone Joint Surg Am 2001;83:735-740.

13. Archibeck MJ, Scott SM, Peters CL: Briachialis muscle entrapment in displaced supracondylar humerus fractures: A technique of closed reduction and report of initial results. J Pediatr Orthop 1997;17:298-302.

14. Campbell CC, Waters PM, Emans JB, et al: Neurovascular injury and displacement in type III supracondylar humerus fractures. J Pediatr Orthop 1995;15:47-52.

15. Gicquel PH, DeBilly B, Karger CS, Clavert JM: Olecranon fractures in 26 children with mean follow-up of 59 months. J Pediatr Orthop 2001;21:141-147.

16. Mintzer CM, Waters PM, Brown DJ, et al: Percutaneous pinning in the treatment of displaced lateral condyle fractures. J Pediatr Orthop 1994;14:462-465.

17. Flynn JC: Nonunion of slightly displaced fractures of the lateral humeral condyle in children: An update. J Pediatr Orthop 1989;9:691-696. 18. Iyengar SR, Hoffinger SA, Townsend DR: Early versus delayed reduction and pinning of type III displaced supracondylar fractures of the

humerus in children: A comparative study. J Orthop Trauma 1999;13:51-55. 19. Bernstein SM, McKeever P, Bernstein L: Percutaneous reduction of displaced radial neck fractures in children. J Pediatr Orthop

1993;13:85-88. 20. Metaizeau JP, Lascombes P, Lemelle JL, et al: Reduction and fixation of displaced radial neck fractures by closed intramedullary pinning. J

Pediatr Orthop 1993;13:355-360. Clavicle

21. Waters PM, Kadiyala R: Short-term outcomes after surgical treatment of traumatic posterior sternoclavicular fracture-dislocations in children and adolescents. J Pediatr Orthop 2003;23:464-469.

Pelvis and Hip 22. Silber JS, Flynn JM: Changing patterns of pediatric pelvic fractures with skeletal maturation: implications for classification and

management. J Pediatr Orthop. 22:22-26., 2002. 23. Silber JS, Flynn JM, Katz MA, et al: Role of computed tomography in the classification and management of pediatric pelvic fractures. J

Pediatr Orthop. 21:148-151., 2001. 24. Schwarz N, Posch E, Mayr J, al e: Long-term results of unstable pelvic ring fractures in children. Injury. 29:431-433, 1998. 25. Smith WR, Oakley M, Morgan SJ: Pediatric pelvic fractures. J Pediatr Orthop 2004;24:130-135 26. Silber J, Flynn J, Koffler K, Dormans J, Drummond D: An analysis of the cause, classification and associated injuries of 166 consecutive

pediatric pelvic fractures. J Pediatr Orthop. 21:446-450, 2001. 27. Karunakar MA, Goulet JA, Mueller KL, Bedi A, Le TT: Operative treatment of unstable pediatric pelvis and acetabular fractures. J Pediatr

Orthop 2005;25:34-38 28. Flynn JM, Wong KL, Yeh GL, Meyer JS, Davidson RS: Displaced fractures of the hip in children. Management by early operation and

immobilization in a hip spica cast. J Bone Joint Surg Br. 84:108-112., 2002. 29. Hughes LO, Beaty JH: Fractures of the head and neck of the femur in children. J Bone Joint Surg Am. 76:283-292., 1994. 30. Morsy HA: Complications of fracture of the neck of the femur in children: A long-term follow-up study. Injury 2001;32:45-51 31. Song KS, Kim YS, Sohn SW, Ogden JA: Arthrotomy and open reduction of the displaced fracture of the femoral neck in children. J Pediatr

Orthop B 2001;10:205-210 Femur

32. Flynn JM, Schwend RM: Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;12:347-359. 33. Schwend RM, Werth C, Johnston A: Femur shaft fractures in toddlers and young children: Rarely from child abuse. J Pediatr Orthop

2000;20:475-481. 34. Shapiro F: Fractures of the femoral shaft in children: The overgrowth phenomenon. Acta Orthop Scand 1981;52:649-655 35. Podeszwa DA, Mooney JF 3rd, Cramer KE, Mendelow MJ: Comparison of Pavlik harness application and immediate spica casting for

femur fractures in infants. J Pediatr Orthop 2004;24:460-462. 36. Smith NC, Parker D, McNicol D: Supracondylar fractures of the femur in children. J Pediatr Orthop 2001;21:600-603. 37. Hutchins CM, Sponseller PD, Sturm P, Mosquero R: Open femur fractures in children: Treatment, complications, and results. J Pediatr

Orthop 2000;20:183-188. 38. Illgen R II, Rodgers WB, Hresko MT, Walters PM, Zurakowski D, Kasser JR: Femur fractures in children: Treatment with early sitting

spica casting. J Pediatr Orthop 1998;18:481-487. 39. Gordon JE, Khanna N, Luhmann SJ, Dobbs MB, Ortman MR, Schoenecker PL: Intramedullary nailing of femoral fractures in children

through the lateral aspect of the greater trochanter using a modified rigid humeral intramedullary nail: Preliminary results of a new technique in 15 children. J Orthop Trauma 2004;18:416-422.

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40. Kanlic EM, Anglen JO, Smith DG, Morgan SJ, Pesantez RF: Advantages of submuscular bridge plating for complex pediatric femur fractures. Clin Orthop Relat Res 2004;426:244-251.

41. Flynn JM, Luedkte L, Ganley TJ, Dawson J, Davidson, RS, Dormans JP, Ecker ML, Gregg JR, Horn BD, Drummond DS. A prospective cohort study comparing titanium elastic nailing to traction and spica casting for pediatric femur fractures. J Bone Joint Surg Am. 2004 Apr;86-A(4):770-7.

42. Flynn JM, Luedtke L, Ganley TJ, Pill SG: Titanium elastic nails for pediatric femur fractures: lessons from the learning curve. Am J Orthop. 31:71-74., 2002.

43. Moroz, LA, Launay F, Kocher MS, Newton PO, Frick SL, Sponseller PD, Flynn JM. Titanium elastic nailing of fractures of the femur in children: predictors of complications and poor outcome. J Bone Joint Surg Br. 2006 Oct;88-B(10):1361-6.

44. Flynn J, Hresko T, Reynolds R, et al: Titanium elastic nails for pediatric femur fractures: initial results of a U.S. multicenter study. J Pediat Orthop. 21:4-8, 2001.

45. Gregory P, Pevny T, Teague D: Early complications with external fixation of pediatric femoral shaft fractures. J Orthop Trauma. 12:191-198., 1996.

46. Luhmann SJ, Schootman M, Schoenecker PL, Dobbs MB, Gordon JE. Complications of titanium nails for pediatric femoral shaft fractures. J Pediatr Orthop. 23:443-7. 2003.11.

47. Raney EM, Ogden JA, Grogan DP: Premature greater trochanteric epiphysiodesis secondary to intramedullary femoral rodding. J Pediatr Orthop. 13:516-520., 1993.

48. Skaggs DL, Leet AI, Money MD, et al: Secondary fractures associated with external fixation in pediatric femur fractures. J Pediatr Orthop. 19:582-586., 1999.

49. Rohde RS, Mendelson SA, Grudziak JS. Acute synovitis of the knee resulting from intra-articular knee penetration as a complication of flexible intramedullary nailing of pediatric femur fractures: report of two cases. J Pediatr Orthop. 23:635-8. 2003.

50. Large TM, Frick SL. Compartment syndrome of the leg after treatment of a femoral fracture with an early sitting spica cast. A report of two cases. J Bone Joint Surg Am. 2003 Nov;85-A(11):2207-10.

51. O’Malley DE, Mazur JM, Cummings RJ: Femoral head avascular necrosis associated with intramedullary nailing in an adolescent. J Pediatr Orthop 1995;15:21-23.

Knee 52. Zionts LE: Fractures around the knee in children. J Am Acad Orthop Surg 2002;10:345-355. 53. Mosier SM, Stanitski CL: Acute tibial tubercle avulsion fractures. J Pediatr Orthop 2004;24:181-184. 54. Riseborough EJ, Barrett IR, Shapiro F: Growth disturbances following distal femoral physeal fracture-separations. J Bone Joint Surg Am.

65:885-893., 1983. 55. Hunt DM, Somashekar M: A review of sleeve fractures of the patella in children. Knee 2005;12(1):3-7. 56. Hresko MT, Kasser JR: Physeal arrest about the knee associated with non-physeal fractures in the lower extremity. J Bone Joint Surg Am.

71:698-703., 1989. 57. Baxter MP, Wiley JJ: Fractures of the tibial spine in children. An evaluation of knee stability. J Bone Joint Surg Br. 70:228-230., 1988. 58. Burstein DB, Viola A, Fulkerson JP: Entrapment of the medial meniscus in a fracture of the tibial eminence. Arthroscopy. 4:47-50., 1988. 59. Janarv PM, Westblad P, Johansson C, Hirsch G: Long-term follow-up of anterior tibial spine fractures in children. J Pediatr Orthop. 15:63-

68., 1995. 60. McLennan JG: Lessons learned after second-look arthroscopy in type III fractures of the tibial spine. J Pediatr Orthop. 15:59-62., 1995. 61. Pape JM, Goulet JA, Hensinger RN: Compartment syndrome complicating tibial tubercle avulsion. Clin Orthop. 201-204., 1993 62. Willis RB, Blokker C, Stoll TM, et al. Long-term follow-up of anterior tibial eminence fractures. J Pediatr Orthop1993;13::361-364. 63. Wessel LM, Scholz S, Ruch M, et al: Hemarthrosis after trauma to the pediatric knee joint: What is the value of magnetic resonance

imaging in the diagnostic algorithm? J Pediatr Orthop 2001;21:338-342. 64. Kocher MS, Forman ES, Micheli L: Laxity and functional outcome after arthroscopic reduction and internal fixation of displaced tibial

spine fractures in children. Arthroscopy 2003;19:1085-1090. Tibia

65. Morton K, Starr D: Closure of the anterior protion of the upper tibial epiphysis as a complication of tibial-shaft fracture. J Bone Joint Surg Am. 46:570, 1964.

66. Cozen L. Fracture of the proximal portion of the tibia in children followed by valgus deformity. Surg Gyecol Obstet 1953;97:183. 67. Jackson DW, Cozen L: Genu Valgum as a complication of proximal tibial metaphyseal fractures in children. J Bone Joint Surg Am

1971;53(8):1571-1578. 68. McCarthy JJ, Kim DH, Eilert RE: Posttraumatic genu valgum: Operative versus nonoperative treatment. J Pediatr Orthop 1998;18(4):518-

521. 69. Jordan SE, Alonso JE, Cook FF. The etiology of valgus angulation after metaphyseal fractures of the tibia in children. J Pediatr Orthop

1987;7:450. 70. Kubiak EN, Egol K, Scher D, Wasserman B, Feldman D, Koval K: Operative Treatment of tibial fractures in children: Are elastic stable

intramedullary nails an improvement over external fixation? J Bone Joint Surg Am 2005;87(8):1761-1768. 71. Yue JJ, Churchill RS, Cooperman DR, et al: The floating knee in the pediatric patient: Nonoperative versus operative stabilization. Clin

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AM J Roentgenol 2004;183:1489-1495. 74. Buckley SL, Smith G, Sponseller PD, Thompson JD, Griffin PP: Open fractures of the tibia in children. J Bone Joint Surg Am

1990;72(10):1462-1469. Foot and Ankle

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Surg Am. 70:967-976. 1988.

AAOS REVIEW COURSE 2011 PEDIATRIC SECTION: LOWER EXTREMITY Lori A. Karol, M.D. Texas Scottish Rite Hospital Dallas, Texas

I. ANGULAR DEFORMITIES OF LOWER EXTREMITIES

A. Normal development 1. Birth: 10-15 deg varus 2. Age 18-24 months: neutral alignment 3. Age 3-4 years: 8 deg valgus 4. Age 6-7 years: normal adult alignment 6 deg valgus

B. Varus deformity 1. Infantile Blount’s disease

a. Etiology -Growth disturbance to medial proximal tibial physis b. History -Usually present as toddlers -Can be unilateral or bilateral -More prevalent in heavy children and early walkers -More prevalent in black children c. Physical examination -Genu varum -Internal tibial torsion -Lateral thrust during gait d. Radiographs -Long leg standing xray with knee straight ahead -Varus angulation in metaphysic with physeal irregularity -Medial beaking -Langenskiold stages subdivide Blount’s *1= normal xray with genu varum *6=bony bar across medial tibial physis -Metaphyseal diaphyseal angle in borderline cases *difficult to reliably measure * >11 degrees likely to develop blount’s e. Treatment -Observation *appropriate for infants < 2 yr of age *borderline radiographs -Bracing *useful in age 2-3 yo children *best if Langenskiold 3 or less

* 65% success (no surgery) *success better in unilateral cases *KAFO with elastic band to apply valgus force *stop before 4th birthday if unsuccessful -Surgery *Best results if performed prior to age 4 *Proximal tibial and fibular osteotomy *Watch for tibial tubercle and stay distal *Overcorrect 10 degrees *If older, may require bar excision (stage 5 and 6) *Epiphyseal osteotomy with elevation described in extreme cases

2. Adolescent Blount’s disease a. Etiology -Disturbance to medial proximal tibial physis -Usually preexisting mild varus b. History -May be uni or bilateral -Usually painful -Cosmetic complaints c. Physical examination -Usually obese teens -Obvious varus deformity of knee -Thrust during gait d. Radiographs -Varus alignment -Proximal medial tibial physeal widening -Variable physeal changes in distal femur -Scanogram may show LLD -Hand xray for bone age e. Treatment -Hemiephyseodesis Benefit: Small operation in large child Can be performed if skeletally immature Successful in 1/3, improvement in 1/3, fail 1/3 *Temporary: remove when corrected --stapling --growth modulation with plate *Permanent --Phemister technique --may need completion of epiphyseodesis Look at femur to see if there is deformity there too -Osteotomy Benefit: Immediate realignment of extremity Difficult to “make perfect” Internal fixation versus external fixation

Immediate correction versus gradual correction Do NOT overcorrect because valgus unsightly! Risks: loss of fixation, under or overcorrection, compartment syndrome

3. Metabolic bone disease a. Nutritional rickets Suspect black breastfed children Still occurs in USA Due to vitamin D deficiency Radiograph: widened metaphyses, blurry wide physes, metaphyseal cupping b. Vitamin –D resistant rickets Looks like rickets on xray Short stature Family history Labs diagnostic

4. Skeletal dysplasias a. Chondrometaphyseal dysplasias (Schmid) Looks like rickets on xray Labs normal Autosomal dominant b. Achondroplasia

C. Valgus deformity 1. Cozen’s fracture

a. Tibial metaphyseal fracture in young child b. Overgrowth phenomena with max deformity 1yr s/p injury c. Treatment observation d. Warn parents at time of injury e. Tibial osteotomy can lead to recurrent valgus

2. Idiopathic a. Usually bilateral b. Cosmetic problem c. If adolescent, can manipulate growth via

hemiepiphyseodesis 3. Skeletal dysplasia (family hx, see on xray)

a. Multiple epiphyseal dysplasia b. Renal rickets c. Multiple hereditary osteochondromatosis

II. ROTATIONAL DIFFERENCES of LOWER EXTREMITIES A. Intoeing

1. Tibial torsion a. Presents usually between ages of 1 and 3 b. Almost always bilateral c. Bimalleolar angle < 20 degrees external d. Foot-thigh angle internal e. Internal foot progression angle

f. Treatment parental reassurance g. Remodelling until age 5 h. No functional sequellae

2. Femoral anteversion a. Usually presents ages 3-7 years b. Usually bilateral c. Hip internal rotation > external rotation d. Foot-thigh angle normal e. Internal foot progression angle with patellae pointing in f. If unilateral, consider CP (birth hx, PE spasticity) g. Can be measured by CT (but not necessary) h. Treatment parental reassurance i. Remodelling until age 10-12 j. No functional sequellae (?? If also ext tibial torsion)

B. Out-toeing a. Common in babies due to increased hip external rotation b. Also seen in flat feet c. Watch for DDH d. No treatment needed e. Less worrisome to parents

III. LEG LENGTH DISCREPANCY A. History

1. Trauma 2. Infection 3. Age of onset

B. Physical examination 1. Galleazzi test Flex hips with patient supine Can approximate femoral length 2. Allis test Can approximate tibial length 3. Standing pelvic obliquity (use blocks to level) 4. Angular deformity 5. Gait

a. Toe-walking b. Vaulting c. Bend long hip and knee

C. Radiographic study 1. Scanogram-

a. Assess precise amount of discrepancy in each bone b. Calculate % shortening c. Use length and bone age to prognosticate difference at

maturity (1) Green Anderson growth remaining charts (2) Mosely graphs (3) Paley multiplier method

2. Long leg AP radiograph (r/o DDH, coxa vara, hemimelia, congenital short femur, skeletal dysplasia)

3. Hand for bone age 4. Abdominal ultrasound in young children R/O neuroblastoma

D. Treatment 1. Observation

a. Appropriate for small discrepancies <2-2.5 cm b. Young children prior to preferred age for treatment

2. Shoe lift a. When discrepancy begins to disturb gait b. Useful prior to femoral shortening in questionable cases

3. Epiphyseodesis a. Best for discrepancies in 2-5 cm range b. Timed based on “growth remaining” and bone age c. Open vs. percutaneous techniques

4. Acute femoral shortening a. Useful in skeletally mature adolescents b. Can be done via closed IM nail with IM saw c. Usually contraindicated for LLD > 5cm d. Postop quad weakness e. Immediate weight-bearing

5. Gradual lengthening a. Useful for LLD > 5cm or with coexistant angular deformity b. Ring fixator vs. Taylor spatial frame vs. monolateral fixator c. Indications vary between centers d. Usually requires 1 month in frame per centimeter

lengthened e. Difficulties with joint motion and muscle tolerance f. Contractures and dislocations/subluxations possible

especially with femoral lengthening g. Regenerate fracture problematic, intramedullary protection

proposed but controversial IV. KNEE DISORDERS

A. ACL injuries 1. Increasing incidence 2. Nonoperative treatment often results in continued instability 3. Extra-articular augmentations not isometric 4. Usual technique violates the physis 5. Typical ACL reconstruction should be delayed til close to

skeletal maturity 6. Epiphyseal tunnels reported in younger patients to prevent

growth arrest

B. Osteochondritis dissecans 1. Usually lateral side of medial femoral condyle of femur 2. Pathology- avascular necrosis of fragment

3. Presents with nonspecific knee pain aggravated by activity 4. May be tender to palpation 5. Radiographs

a. Tunnel view best b. MRI shows stability of fragment c. Bone scan activity may predict healing potential

6. Treatment a. Activity restrictions -may take months to heal b. Casting c. Arthroscopy -Indications are fail conservative rx or unstable fragment -If intact lesion, drilling can promote healing -If early-separated lesion, can pin plus drill -If separated but bed fresh, can replace fragment -If detached and bed not salvageable, options limited

C. Osgood Schlatter 1. Traction-induced inflammation of patellar tendon and tibial

tubercle 2. Presents in adolescents 3. Pain aggravated by activities, esp jumping 4. Tubercle painful, may be enlarged 5. Xrays show fragmentation or ossicles in area of tibial tubercle 6. Treatment nonoperative

V. LEG DISORDERS A. Posteromedial bow of the tibia

1. Present at birth 2. Associated with calcaneus position of foot 3. Angulation usually resolves with growth til age 2 years 4. Leg length discrepancy will require treatment with

epiphyseodesis or lengthening 5. No increased risk of pseudarthrosis

B. Congenital pseudarthrosis of the tibia 1. Seen in anterolateral bowing of the tibia 2. Associated with neurofibromatosis (55%) 3. Classification

a. Crawford: nondysplastic, failure of tubularization, cystic, and frank pseudarthrosis

b. Broken vs. not broken 4. Clinical features

a. Bowing frequently noted at birth b. Motion at pseudarthrosis c. Shortened leg d. Limp

5. Treatment a. GOAL: to obtain and maintain union

b. PRINCIPLES: maintain alignment, permanent IM fixation c. Bracing to prevent fracture in walking children d. Debridement of pseudarthrosis, intramedullary fixation of

tibia and fibula with bone grafting e. External fixation f. Vascularized fibular graft g. Amputation

6. Outcome a. Refracture or persistant pseudarthrosis very common b. Leg length discrepancy c. Ankle valgus

C. Tibial hemimelia 1. Only familial form of limb deficiency (but usually sporadic) 2. Complete or partial absence of tibia (Jones classification)

a. Type 1 – complete absence (1)1a-complete absence and no cartilaginous prox tibia (2)1b-proximal tibia present but not ossified b. Type 2 – proximal tibia ossified at birth c. Type 3- proximal tiba absent, distal tibia present (rare) d. Type 4 – distal tib/fib diastasis

3. Physical examination a. Inability to extend knee implies absence of proximal tibia b. Varus foot due to lack of malleolus c. Extreme shortening d. Possible polydactyly

4. Treatment a. If no proximal tibia (cannot extend knee)-knee

disarticulation b. If proximal tibia ossified or seen on imaging-proximal

tib/fib synostosis and Symes amputation c. Diastasis of type 4 treated either by Symes or by ankle

reconstruction/fusion + multiple lengthenings D. Fibular hemimelia

1. more common than tibial hemimelia 2. Defined as complete or partial absence or hypoplasia of fibula

a. Can classify based on amount of fibula missing b. Clinically useful classification based on status of foot

(#rays) 3. Physical examination

a. Shortening of limb b. Associated femoral shortening c. Tibial bow with pucker anteriorly d. Possible absence of lateral rays of foot e. Ankle equinovalgus in complete deficiency f. ACL insufficiency

4. Associated Abnormalities

a. congenital short femur b. subtalar tarsal coalition c. ACL insufficiency d. Knee valgus

5. Treatment a. If no fibula and foot unstable with < 3 rays: symes or boyd

amputation b. If foot 3 or more rays and ankle reconstruction possible,

can consider multiple lengthenings VI. FOOT DISORDERS

A. Metatarsus adductus 1. Packaging disorder 2. Differentiated from clubfoot because no equinus, ankle ROM nl 3. Bean-shaped foot 4. R/O DDH 5. Flexibility decides if treatment needed

a. If flexible, stretching b. If moderate, reverse last shoes if desired c. If severe, may require casts d. Surgery not indicated

B. Calcaneovalgus 1. Excessive dorsiflexion of the ankle with limited plantarflexion 2. Packaging disorder 3. R/O DDH 4. Check spine 5. Treatment stretching 6. Resolves spontaneously

C. Clubfoot 1. Etiology 2. Types

a. Idiopathic : 1-2/1000 live births b. Neuromuscular -Spina bifida -Spinal cord abnormalities c. Syndromic/teratologic -Arthrogryposis -Larsen’s syndrome -Diastrophic dwarfism

3. Physical examination a. Forefoot adducted b. Hindfoot in varus c. Cavus d. Ankle equinus-heel pad feels empty e. Smaller foot f. Thinner calf

4. Radiographs

a. Not needed for diagnosis b. Parallelism of calcaneus and talus on lateral c. Equinus of calcaneus on lateral

5. Treatment a. Nonoperative treatment -Begins in newborn period -Casting most prevalent -Ponseti technique -LLC -Perc tenotomy of Achilles at 6 weeks -Denis Browne bar after casts for 3 mos -Night-time DB bar thereafter for 3 years b. Surgical treatment -Posteromedial and lateral release most common -Cincinnati incision -Lengthening of shortened tendons -Transects pathologic ligaments and capsules -Postop problems with stiffness and weakness -Recurrence a problem -Lateral column shortening

6. Complications a. Overcorrection b. Recurrence c. DJD

D. Congenital vertical talus 1. Description

a. Equinus of ankle (1) Contracted tendoachilles b. Fixed dorsal dislocation of navicular on talus

(1) Navicular articulates with dorsal aspect of neck of talus

(2) Spring ligament attenuated (3) Anterior tendons, toe extensors tight

c. Also known as congenital pes valgus 2. Etiology

a. Most often associated with syndrome b. Can be seen in neurologic disorders

3. Radiographs a. Lateral radiograph of foot shows ankle equinus b. Stress plantarflexion lateral shows dorsiflexion of 1st

metatarsal relative to the axis of the talus c. Navicular nonossified d. Talus vertical on lateral view

4. Treatment a. Cast treatment usually ineffective

b. Surgical release via PMR (1) Releases equinus (2) Direct reduction of navicular onto talar head (3) Ant tib transfer to talus (4) Dorsal tendon lengthenings

E. Flatfeet 1. Flexible flatfeet

a. Arch normally flexible in young children b. Reconstitutes with sitting or standing on toes c. Signs of ligamentous laxity throughout child d. Rarely symptomatic e. Treatment unnecessary

2. Rigid flatfeet a. Tarsal Coalition (0.03-1% population)

(1) History -usually present in second decade -pain with activity -usually hurts in area of coalition -often bilateral but symptoms asymmetric -may be familial (2) Physical examination

- Limited hindfoot range of motion - Ankle stiffness - External foot progression angle - Peroneal “spastic flatfoot” - No arch when stand on toes

(3) Radiographs - Plain film oblique for calcaneonavicular

coalition * anteater sign - Harris view for subtalar coalition of limited use - CT scan diagnostic – look for multiple fusions - MRI can show fibrous coalition

(4) Treatment - Conservative treatment with orthotics/cast - Surgical excision of coalition if possible *All calcaneonavicular coalitions -interpose EDB muscle *Subtalar coalitions that are “not massive” i.e. only middle facet or < ½ post facet -interpose fat - Triple arthrodesis if massive or fail

resection

b. Accessory navicular (1) common but rarely symptomatic (2) Ossicle within the insertion site of the post tibialis (3) Seen on oblique or AP foot xrays (4) Treatment unnecessary if asymptomatic (5) Soft pads/orthotics for initial treatment of foot pain (6) Surgical excision of fragment for persisant pain (7) Surgery does not correct pes planus

F. Cavus feet 1. Etiology

a. Usually neurologic- r/o CP, Friedreich’s ataxia, spina bifida, Charcot Marie Tooth, spinal cord pathology

b. Results from muscle imbalance (1) Weak tib ant and peroneus brevis (2) strong post tib and peroneus longus (3) Weak intrinsics of foot

c. Can result from clubfoot d. Sequellae of compartment syndrome

2. Clinical presentation a. Elevated arch b. Hindfoot varus c. Increased pressure over lateral midfoot and 1st MT head d. Usually no ankle equinus e. Clawing of toes f. May complain of ankle sprains g. Foot shortened if unilateral

3. Physical examination a. Calluses b. Neuro exam incl spine c. Leg atrophy d. Flexibility of hindfoot varus **Coleman Block Test**

(1) Put lift beneath the heel and lateral forefoot (2) Let 1st MT head fall medial to lift (3) Look to see if varus corrects

4. Radiographs a. Lateral radiograph shows dorsiflexion of calcaneus b. Calcaneal-1st MT (Meary’s) angle increased on lat xray -Normal Meary’s angle zero c. Parallelism of subtalar joint d. MRI neural axis!

5. Treatment a. Conservative treatment only for very mild b. Surgery for “flexible hindfoot” cavovarus

(1) plantar fascia release (2) 1st metatarsal dorsiflexion osteotomy (3) Poss peroneus longus to brevis transfer

(4) No TAL usually needed c. Surgery for “rigid hindfoot” cavovarus

(1) soft tissue surgery as above (2) Possible metatarsal osteotomies (3) Calcaneal osteotomy (4) OR midfoot dorsiflexion osteotomy (5) Triple arthrodesis if very severe-last resort

VII. TOE DISORDERS A. Hallux valgus (Bunion)

1. Lateral deviation of great toe with apex of deformity 1st MTP joint

2. Girls>>boys 3. Positive family history common 4. c/o pain over bump 5. Xray: may show metatarsus primus varus

a. Intermetatarsal angle should not exceed 10 degrees b. Distal metatarsal articular angle > 15 degrees

6. Treatment a. Conservative treatment emphasized b. Recurrence seen after surgery in up to 33% c. 1st MT crescentic osteotomy with distal realignment d. Double osteotomy 1st Metatarsal e. MTP fusion in neuromuscular patients

B. Polydactyly (1.7/1000 live births) 1. Postaxial (5th toe) >>> preaxial (1st toe) 2. Postaxial genetic 3. Preaxial associated with syndromes 4. Usually remove border digit to enable shoe wear 5. Preop xray to assess metatarsals

Spine

 

 

Spine 

Moderator: David L. Skaggs, MD 

 

3:00 PM – Spine Trauma Jens R. Chapman MD 

 3:30 PM – Degenerative Spine  

Todd J. Albert, MD  

4:00 PM – Pediatric Spine David L. Skaggs, MD 

 

AAOS Board Review Course 2010

New Orleans, LA

SPINE TRAUMA A Comprehensive Review

Jens R. Chapman, M.D.

Professor

Chief of Spine Service

HansJörg Wyss Endowed Chair

Department of Orthopaedic Surgery and Sports Medicine

Joint Professor of Neurological Surgery

Harborview Medical Center,

University of Washington School of Medicine

(206) 744-3466

jenschap@u.washington.edu

CONTENTS NOTES

1. Evaluation and Treatment principles

2. Spinal Cord Injury

3. Cervical Spine (for each injury category)

- Classification

- Management

4. TL - Spine

- Classification

- Management

5. Sacrum

- General overview

6. References

Note: This Handout follows the lecture but offers expanded content in the interest of

providing more comprehensive review of principles of Spine Trauma.

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

Review of Spine Trauma

PAGE 2

1. Evaluation and Treatment principles

1.1 Resuscitation / retrieval

Suspect Spine trauma with:

Focal neurologic deficits

Polytrauma

Head -/ facial injuries

Intoxication and/or sedation

Suspect injury mechanism back pain

Postraumatic spinal deformity with pain

Tenderness to palpation and percussion of posterior midline

Apply ATLS principles !

Follow expanded ABC‟s

Airways

Breathing

Circulation and C-Spine

Initial Immobilization Protocol

Collar +/- sand bags / head taped

Backboard

Children < 6y..: Standard backboard causes C-Spine flexion. Use custom pediatric

backboard or place torso on folded sheets.

Resuscitation: Airway

Intubation under manual traction (MILT), nasotracheal or fiberoptic

Standard oral intubation causes excessive neck extension

Maintain log roll and spinal precautions until spine “cleared”

Trauma C-Spine lateral in ER (with arms pulled down)

(Part of routine ATLS Trauma XR: Chest, Pelvis, C-Spine)

Resuscitation: Neurogenic vs. spinal vs. hemorrhagic shock

a) Neurogenic shock : Caused by disrupted sympathetic cardiac input

Usually injury occurs in T4 – 8 region

Differential diagnosis: Hemorrhagic and spinal shock

Treat with IV Norepinephrine or Dopamine drip

Avoid overinfusion (risk of pulmonary edema, CHF)

b) Spinal shock: Temporary depolarization of neural elements

Duration: Minutes to days

99 % resolution within 48 hours

Return of bulbocavernosus reflex (BCR) indicative of recovery

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

Review of Spine Trauma

PAGE 3

c) Hemorrhagic shock: Loss of intravascular volume

Hypotension

Tachycardia

Oliguria / anuria

Cold, clammy skin

1.2 Physical Examination

Definition Spine Clearance: Spine “clearance” is a combination of clinical assessment

and radiographic studies to be obtained as clinically indicated with the purpose of

establishing spinal stability.

Examination:

Inspection – skull to coccyx

Palpation (log roll: skull to coccyx)

Neurologic Evaluation (ASIA principles)

Motor evaluation

Reflexes (with bulbocavernosus, clonus, Babinski)

Sensory

Pain (pin prick)

Proprioception

Rectal examination:

1. Perianal sensation

2. Perianal wink

3. Spontaneous anal sphincter tone

4. Maximal voluntary anal sphincter contractility

Prerequisites for clinical clearance of C-Spine without radiographs:

NEXUS study group (National Emergency X-Ray utilization study)

No X-R‟s necessary if all of the following 5 points are fulfilled:

Cognitively unimpaired patient

(includes mind-altering meds, drugs etc.)

No midline cervical tenderness

No focal neurologic deficits

Normal alertness

No painful distracting injury

Also suggested:

Differential diagnosis Hemorrhagic shock Neurogenic shock

Blood pressure < 100 mm Hg < 100 mm Hg

Heart rate > 110/ min < 80/min

Urine output decreased normal

Skin color / temp Pale and clammy Pink / warm

Mental status Decreased / agitated unaffected

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

Review of Spine Trauma

PAGE 4

Low velocity, blunt injury mechanism

(i.e.: speed < 35 mph, fall < 10 ft.).

Full ROM C-Spine in all directions

1.3 Radiographic Evaluation

Concept of Spine clearance:

Combination of clinical evaluation and radiographic clearance

Communication and integration of information essential for success

Problems: Cognitively impaired ( i.e. severely head injured patients) with limited

examinability, and normal screening images.

Goal: No missed injuries

Missed injuries Causes of missed injuries:

Failure to order appropriate tests

Failure to interpret clinical or radiographic manifestations

Failure of patient to seek medical assistance

Failure of tests to identify relevant pathology (true exception)

Patients at risk for missed injuries

Cognitively impaired (i.e. head injured, mind altering drugs etc)

High energy polytrauma

o Speed > 35mph

o Fall >10 feet

o Death at scene

o Pelvis or long bone fractures

o Facial fractures

Atypical anatomy

Geriatric patients

Imaging Techniques

Plain radiographs:

Lateral C-spine remains diagnostic for 78 - 85 % of C-spine trauma

Open mouth XR can increase number to 95%

Remember that 50% of TL trauma occurs at TL junction. This may be

inadequately visualized on conventional T-, and L- spine radiographs. Consider

coned-down TL junction radiograph if clinical suspicion warrants.

Easily missed injuries: elderly, osteopenic skeleton, ankylosing disorders, type II

odontoid fractures.

Increasingly, helical CT and reformatted views have replaced conventional

radiographs. However, there remains no substitute for alignment assessment and

flexion-extension stability assessment with plain radiographs.

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

Review of Spine Trauma

PAGE 5

CT:

Spiral CT new imaging standard for patients with any cognitive impairment or

who receive head CT for suspected trauma. CT C-spine to follow head scan.

Assess reformats for transition zones.

Also indicated following myelography.

CT-Angiography: For suspected vertebral artery injury or disruption of transverse

process by 2 mm or more.

MRI:

Indicated for any cervical SCI. Optional for suspected ligament disruption (look

for high signal intensity on fat suppressionT2 weighted image).

Aids in assessment of soft tissues, disc herniation, cord signal changes, presence

of blood and integrity of ligaments (note high sensitivity and much lower

specificity).

Most effective screening tool for infection and tumors

MRAngiography most sensitive tool for vertebral artery injury screening

Bone Scan (TC-99 with SPECT)

Indicated for occult pediatric trauma, unclear fractures.

May need 720 to turn positive

2. Spinal Cord Injury

2.1 Cord anatomy

Medulla oblongata: Foramen magnum - C2

Spinal cord: Occiput - T11/L1 (L3 in peds)

Conus Medullaris T11/L1 (adult)

Cauda equina L2-S3

Cross sectional anatomy

a. Anterior-lateral cortical spinal tracts (motor)

- Laminated so that cervical tracts closer to midline, sacral out lateral,

(central cord syndrome)

- Ipsilateral trajectory

b. Anterior spinal - thalamic tracts - pain/temperature

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

Review of Spine Trauma

PAGE 6

- Laminated as above - sacral sparing

- Decussation (crossover) at around Occ - C2 (crossed fibers)

- Hemiplegia with ipsilateral loss of pinprick suggestive of

hysteria/?brain lesion

c. Posterior column - proprioception, vibration, light touch, deep pain

- Touch - spared in anterior cord syndrome

- Ipsilateral trajectory

2.2 Neural injury response

3 main mechanisms: contusion, compression and distraction

1. Contusion: Initial neural tissue trauma

o Primary irreversible axon and cell deaths

o Secondary Effects

o Lyoszymal enzymes

o Ischemia

o Inflammation/edema

o Toxins

2. Compression: Residual mass effects on neural tissue

o Restriction of cell regeneration

o Restriction of axonal flow

o Restriction of vascular supply

3. Distraction: Highly destructive to neurons

o Actual cord separation very uncommon

o Very poor recovery potential

2.3 Biochemical changes of SCI

1. Accumulation of Na+ within neurons within seconds of injury.

2. Resulting depolarization of neural membranes

3. Further Na+ influx » Ca++ pumped into cells

4. Na+ efflux into extracellular environs

5. Na+/Ca++ exchange enzymes destroyed

6. Phospholipid cell membranes destroyed

2.4 Histopathology of SCI

Zone of primary injury

Region of direct insult and cell destruction

Zone of secondary injury

Posttraumatic propagation of injury through several mechanisms:

o Cell apoptosis

o Membrane unraveling

o Electrolyte imbalance

o Inflammation

o Hypoxia

o Vascular insult

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

Review of Spine Trauma

PAGE 7

Gray matter < nerve cell response > after injury:

Immediate very sensitive injury response

White matter < axon response > after injury:

Delayed compared to gray

Axonal death after 24 hours compression

Timeline neurologic injury

Timelines established for cord contusion models (Tator, Ducker, Bohlmann, Carlson)

Impact: Bioelectrical depolarization

1 0

: Biochemical release

2 0: Alterations in blood flow

3 0: Tissue perfusion changes

4 0: Changes in cells

7-8 0

: Tissue necrosis

PMN infiltration

50 0: Pathologic scarring, syrinx formation

Timelines established for compression and contusion effects in several dog and rat

models. (Delamarter et al ‟95)

Immediate effect:

Wallerian degeneration

% SSEP recovery

One hour:

Isolated necrosis

72 % SSEP recovery

6 hours:

Severe central necrosis, cell loss

29 % SSEP recovery

24 hours – 1 week:

Severe necrosis, cellular disorganization

9 % SSEP recovery

Conclusions: For effective intervention if compression is primary injury mechanism

decompression within 24 hours is desired based upon animal models.

Human correlation is not well established. Cauda equina decompression recommended

within 48 hours based on prevalent clinical data. Cord decompression for incomplete

injuries recommended within 24 hours based on weak clinical evidence.

2.3 Neurologic Injury Types:

Formal classification:

Frankel / ASIA Classification (1996)

A: No motor or sensory function

B: No motor function, but sensory intact

C: Sensory intact, motor present but not useful

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

Review of Spine Trauma

PAGE 8

D: Sensory intact, motor weakened (4/5)

E: Sensory and motor intact

E-R: Sensory and motor intact. Nerve root deficit

ASIA motor score is used for quantification of motor function

100 points maximum, 5 points maximally for each of the 5 key muscle groups of each

extremity

Complete / incomplete / intact

Complete - No preservation of motor and sensory function below level of injury (sensory

level within 3 levels of SLI) , absence of sacral preservation (“sacral sparing”) after 48

hours, completion of spinal shock

True complete injuries have very poor prognosis

Root recovery at level of injury or below possible

Incomplete – any motor or sacral preservation, any sensory function below 3 segments of

skeletal level of injury

Concept of sacral preservation: Sparing of most central motor and sensory fibers in

corticospinal and afferent tracts (sacral elements) may indicate incomplete SCI!

Signs of sacral sparing are:

1. Hallux longus flexors functional

2. Perianal sensory function + S1, S2 dermatomes

3. Anal sphincter tone (spontaneous and resting)

Cord syndromes

o Complete spinal cord injuries

o Incomplete spinal cord injuries

o Central Cord Syndrome

o Anterior Cord Syndrome

o Posterior Cord Syndrome

o Brown-Sequard

o Root injuries

2.4 Incomplete Cord Injury Syndromes

Cervicomedullary syndrome

Complete or incomplete paralysis

Respiratory arrest

Hypotension

Loss of facial sensation

Similar to Bell‟s cruciate paralysis

Mimics central cord syndrome

Greater upper than lower extremity weakness

Proximal weakness more pronounced than distal

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

Review of Spine Trauma

PAGE 9

Variant: Hemiplegia cruciata (Wallenberg)

Ipsilateral arm

Contralateral leg weakness

Central cord syndrome

Usually affects cervical spine

Arms worse than legs

Recovery of ambulation

Poor residual hand function

Common mechanism: hyperextension in cervical spondylosis

Anterior cord syndrome

Posterior column function preserved

Variable loss of motor function, pain sensation

Ischemic mechanism (i.e. occlusion of Spinal artery) hypothesized

Poor prognosis

Posterior cord syndrome

Extremely rare

Motor, pain and light touch preserved

Proprioception lost

Brown Sequard lesion

Hemi cord injury

Penetrating injury mechanism common

Ipsilateral motor loss and pain,

contralateral loss of pain and sensation

Conus medullaris syndrome

Injury around thoracolumbar junction

Areflexic bowel and bladder function

Variable prognosis on recovery

Frequently incomplete SCI

Cauda equina syndrome

Frequently incomplete lesion

Chance for recovery (lower motor neuron)

Return of bowel/bladder control variable

Root injuries

As lower motor neuron injury in general good prognosis with postganglionic injury

Recovery particularly favorable for compressive lesions

Repair of torn roots controversial

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

Review of Spine Trauma

PAGE 10

2.5 Principles of SCI Treatment

Rogers‟s rules (1956)

Avoid additional neurologic damage

Stabilize injury

Reduce deformity

Decompress compressed neural elements

Basic principles (2004)

AIRWAY: Oxygenation

BLOOD: Restore hematocrit

CIRCULATION: Treat hypotension

Implement Rogers’s rules!

Pharmacologic Treatment

High dose I.V. steroids (methylprednisolone) administered within 8 0 from injury are

considered treatment option for acute SCI management, but are neither standard of care,

nor FDA approved for this indication.

Purported benefit:

Stabilization of neural membranes

Decrease of secondary neurologic injury zone

Potential to limit neurologic injury by halting neural membrane

destruction

Risks:

Increased wound infection

Increased GI-bleeding

Diabetogenic

Pulmonary distress

Steroid psychosis

Use of steroids for root injuriesor cauda equina syndrome is not supported by literature.

Use of steroids for penetrating trauma is associated with higher complication rates and

has been shown to have no neurologic benefit.

Suggested dose (Bracken, NASCIS II trials) :

IVPB Methylprednisolone if given within 3 – 8 hours from injury

30mg/kg loading

5.4 mg/kg/hr for 23 hours

Lazaroids (membrane protective) and Gangliosides (nucleoproliferative) are

investigational drugs with unclear efficacy. Current research is aimed at reducing neural

cell apoptosis, neural gliosis and preventing neural regeneration blockade (no-go

inhibitors).

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

Review of Spine Trauma

PAGE 11

Sodium channel blockers stabilize neural membranes and aid in restoring electrolyte

balance. Medications such as Riluzole ®

have been shown to slow disease progression in

amyotrophic lateralsclerosis.

Hypothermia (systemic or local) , Naloxone, anticoagulants, CA-channel blockers are

unproven and therefore not recommended.

Stem cell therapy and nerve cable grafts as well as nano scaffoldings are some of many

experimental undertakings that are being studied in a variety of settings without regular

clinical applications.

2.7 Functional SCI Outcomes

(This section is not part of the lecture due to time constraints, however is included as

courtesy to the audience and for completeness sake)

C 1-4 Level

Mechanical ventilation support (C1-3 “pentaplegia”)

C-4 level commonly can use CPAP or BiPAP.

C1-2 level patient has no headcontrol

Early extubation and upright position may lead to pulmonary deterioration due to

decrease of vital capacity with denervated diaphragm

Mobility:

Power wheelchair with tilt back

Mouthsticks for C3-4 ok

“sip and puff” devices for computer access

24o personal care maintenance necessary

Manual wheelchair for back-up

C 5 Tetraplegia

Minimum 3/5 strength in biceps

Mobility aids:

- Opponens splint for feeding

- Ratchet orthosis for patients with strong shoulder abduction

- “Freehand system” (8-channel implanted stimulator) for grasp

- Not able to transfer

- Can operate power wheelchair with hand control

- Driving modified van can be possible

C 6 Tetraplegia

Minimum 3/5 strength of ECRL and ECRB

Can perform self catheterization, sometimes bowel program

Mobility aids:

- Partial assistance necessary

- Consider for wrist-driven flexor hinge splint (tenodesis splint)

- Writing with static splint possible

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

Review of Spine Trauma

PAGE 12

- Can get dressed in upper body, not lower body

- Independent transfers with sliding board can be achieved

- Manual wheelchair with knobs etc. for short distances

- Power wheelchair for longer distances

- Can be considered for tendon transfers, Freehand system

C 7 and C 8 Tetraplegia

Minimum 3/5 strength in triceps (C 7)

Minimum 3/5 strength in finger flexors (C 8)

Mobility:

- Possible to be independent with ADL‟s, transfers

- Manual wheelchair useable

- Able to live alone

- Tenodesis splints not suitable (limit hand function)

T 1 – T12 Paraplegia

Upper extremities and intercostals functional (T1-5)

Abdominals functional from T6 caudalwards

Mobility:

- With good abdominal control limited ambulation possible

- KAFO (cumbersome, household range)

- IRGO (isocentric reciprocating gait orthosis) less energy consuming

- FES (functional electrical stimulation) can be considered with upper motor neuron

lesions

L 1 – L 3 Paraplegia

Iliopsoas and quadriceps lowest functional motor units

Mobility:

- Manual wheelchair usual mode of transport

- Short distance ambulation with KAFO‟s or IRGO‟s possible

- Bladder / bowel function impaired

L 4 – Sacral levels

Various levels of bowel and bladder control impairment

Management of B/b is independent

Mobility:

- Ambulation with AFO‟s +/- crutches frequently possible

Driving car without hand controls possible

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

Review of Spine Trauma

PAGE 13

3. Cervical Spine Trauma

Anatomically and functionally C-spine consists of 2 regions:

Upper C-spine (Occiput – C2 vertebral body)

Lower C-spine (C2/3 disc – T1 vertebral body)

3.1 Imaging

Basic C-spine radiology skills and norm values

Standard views:

- AP

- Lateral (skull base to upper endplate T-1)

- Open mouth odontoid

- Trauma oblique (left and right)

- Swimmer‟s (if lateral insufficient)

Specialized views:

b. Flexion- extension (nonacute setting only)

c. Pillar view (stable spine only)

C-spine lateral :

Prevertebral soft tissue shadow :

C2-3 < 6mm

C5-7 > 14 mm

Altered by intubation, crying

Dens angulation : Odontoid should be parallel to the atlas. Angulation implies transverse

atlantal ligament (TAL) insufficiency.

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

Review of Spine Trauma

PAGE 14

Wackenheim‟s line : Screening study to assess cranio-cervical proportions. Drawn as

caudal continuation from the clivus. Odontoid tip should be within 1 –2 mm distance of

this line.

C1-3 spinolaminar line : Laminae of the atlas, axis and C-3 segments should form

straight line with < 2 mm deviation. If abnormal consider Hangman‟s fracture or TAL

disruption.

ADI (atlas-dens interval):

Adult < 3 mm

Child < 5 mm

SAC (space available for cord):

Adult > 13mm (Post. dens – ant. lamina)

DBI (dens – basion interval):

Adult < 12 mm in

PAL (posterior axis line):

< 4 mm anterior and < 12 mm posterior to the basion.

Open mouth odontoid:

Visualizes: Occipital condyles – C2-3 facet joints

LADI (lateral atlas – dens interval):

< 2mm deviation left to right.

Joint spaces: C 0-1 and C1-2 should be symmetric

Rule of Spence: No overhang of C-1 lateral masses

> 6,9mm overhang: TAL torn

Odontoid: Helpful in identifying Type I and II fractures

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

Review of Spine Trauma

PAGE 15

C-Spine AP:

Visualizes: C3-T3

Uncovertebral joints: Symmetric

Alignment: straight

Transverse processes: No Fx (Vertebral artery C1-C6)

Lower C-Spine lateral:

Basic principle: AAIA: Adequacy. Alignment, Interval, Angulation,

ALL (anterior longitudinal line): Homogeneous continuity

PVL (Posterior vertebral body line): Translation < 3.5mm

PLL (Posterior laminar line): No splaying or stepoffs

Spinous processes: No interspinous splaying

Facet joints: No unroofing

Inferior vertebral body endplates: Angulation < 11o

Limitations of plain X-rays

-Transition zone injuries (Occipitocervical , cervico-thoracic) most frequently missed!

-Visualize cervico-thoracic junction

(pull-down, swimmer‟s or CT)

-CT with sagittal and coronal reformats for unclear odontoid

-Prefer no flexion/extension XR‟s in ER setting

-Stability exam with F/E in postprimary F/U

CT-Scan (Indications)

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

Review of Spine Trauma

PAGE 16

Any Fx / ligamentous injury

Inability to visualize area of spine radiographically

Unclear anatomy on radiographs

Suspected occipitocervical trauma

Unclear cervico-thoracic junction

Unexplained neuro deficit

Attempt to date injury

Post myelography

SPIRAL CT (aka helical) as screening study

(less definition than conventional CT)

Conventional CT for known fx‟s (1.5 - 2 mm thickness)

MRI (Indications)

For all incomplete deficits

Skeletal level of injury (SLI) different from neurologic injury level (NLI)

Suspected spinal canal mass (i.e. HNP) prior to reduction

Spinal cord injury without radiographic abnormalities (SCIWORA)

Suspected neoplastic or infectious disorder

Prediction of SCI severity (Cotler ‟92)

Assessment of ligament disruption (Cohen ‟94)

TC-99 Bone scan

Rare indication

Pediatric indication most common (i.e. physeal fracture)

Not sensitive before 48 – 72o postinjury

Useful to assess for “occult” fractures

3.2 Upper C-Spine Injuries (Occiput - C2)

Osseous Structures

Occiput

Atlas

Axis / Odontoid

Key Cranio - cervical Ligaments

Tectorial membrane

Alar ligaments

Anterior Occipito-atlantal and atlanto-axial membrane

Transverse atlantal ligament

Joint capsules

Occipital condyle Fx’s

Classification: Anderson and Montesano „90

Type 1: Basilar skull Fx into condyle

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

Review of Spine Trauma

PAGE 17

Type 2: Comminuted impaction fx

Type 3: Avulsion alar ligament

Clinical pointers:

Frequently missed

CT diagnosis on skull CT

Types I, II usually stable

Type III may infer AO dissociation

Treatment

Mostly stable

Halo or brace for Types I or II

Consider occult AOD in Type III avulsions

Atlanto - occipital dissociation

Traynelis '73

Types: Anterior

Posterior

Vertical

Mixed

Clinical pointers:

Frequently not survived

Frequently missed (60 %)

High incidence of 2nd

neuro deficit in case of missed injuries

Look for unusual neurologic injury presentation

Cranial nerve, brainstem lesions

Completely unstable > 1mm displacement

Do not apply traction (Sandbags preferable)

Treatment :

Commonly fatal

Traction contraindicated

Frequently missed

Increasing survival rates at trauma centers

Emergent rigid occipitocervical fusion preferred

Atlas fracture

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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Levine „91

o Isolated bony apophysis fracture

o Isolated posterior arch fracture (stable)

o Isolated anterior arch fracture (stable)

o Comminuted lateral mass fracture

o Burst fracture, three or more fragments (aka “Jefferson”)

o Anterior ring blowout (unstable)

Clinical pointers:

Atlas serves as washer between occiput and axis

TAL insufficient if > 6.9mm lat. mass overhang C1 on C2 (Rule of Spence)

Indicator fracture: If atlas fractured 50% incidence of other spine fx

Treatment:

Isolated anterior or posterior ring Fx‟s are usually stable, can be treated with collar

Remember to look for additional spine trauma (50% incidence, “sentinel Fx”)

Burst Fx ( 3- or 4 part) usually are treated with traction followed by Halo. ORIF or

decompression very rarely, if ever, indicated. If TAL is insufficient (Rule of Spence)

choice is either Halo for 3-4 months followed by F/E XR, or primary C1-2

arthrodesis.

Anterior ring “blow-out” requires C1-2 fusion

Lateral mass Fx‟s commonly are treated nonoperatively. If nondisplaced treat with

brace, if displaced closed reduction with traction followed by Halo. Risk of late pain,

malunion and arthrosis.

Odontoid fracture

Anderson, d‟Alonzo, „73

Type I: Fracture of odontoid tip (Congenital dysplasia vs. trauma)

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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Type II: Waist Fx

(Initial displacement important)

Nonunions up to 75% described with cons. Rx

Type III: Body Fx (cancellous surface)

Clinical pointers:

Type I: potential AOD (alar ligament avulsion)

Type II: Up to 30 % miss rate reported

Always unstable fracture

Without treatment nonunion is expected outcome

Important treatment modulators:

- Initial Fx displacement >5mm (Only consistent factor)

- Fx angulation > 9mm (inconsistent factor)

- Age > 60 y.o. (inconsistent factor)

Treatment:

Type I

Rule out AOD, os odontoideum

True Type I very, very rare.

Nonop Rx for true Type I (brace)

Type II

High nonunion rates with any form of nonop Rx (20 – 85%)

Halo most common nonop modality.

Check recumbent and upright XR for stability

Accept closed reduction only if > 60% Fx site overlap, and no distraction

ROM reduced by 50% or more after successful nonop Rx

Decreased chances of successful nonop Rx with distraction > 5mm

Anterior odontoid screw fixation favored for:

Simple transverse Fx pattern at odontoid waist

Acute Fx (<3 months)

Choice of 1 or 2 screws (Sasso‟97)

Good bone quality

Primary C1-2 fusion favored for:

Comminuted, oblique Fx pattern

Geriatric patients

Highly displaced Fx

Nonunion or delayed union

Type III

If minimally displaced, brace acceptable.

For displaced Fx‟s closed reduction and Halo recommended.

Union rate is high

Surgery rarely indicated (C1-2 fusion).

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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Traumatic spondylolisthesis of the axis ( “Hangman’s” Fx )

(Should be named “Hanged man‟s Fx”)

Effendi,‟73, Levine and Edwards, ‟89

Type I: Nondisplaced fracture of the pars interarticularis

Type II: Displaced fracture of the pars interarticularis

Type II a): Displaced fracture of the pars interarticularis with disruption of the C2/3

discoligamentous complex

Type III: Dislocation of C2-3 facets joints with fractured pars interarticularis

Clinical pointers:

Types IIa and III unstable injury pattern

Neurologic injury risk generally low

Healing rates of Type I and II injury types high

Treatment

Type I and II

Brace or with increasing instability Halo

Type IIa

“Preferred Rx” is controversial

Closed reduction with traction recommended.

Attempted mobilization with Halo versus anterior cervical discectomy and fusion

with instrumentation.

For nonop Rx prolonged recumbency and traction may be necessary.

Secondary neurologic deterioration is rare.

Nonop Rx may lead to C2-3 instability and kyphosis

Type III

Posterior open reduction, internal fixation, C2-3

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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Atlanto-axial Disruption

3 Subtypes based on disruption pattern (rotatory, sagittal and vertical)

Group A: Rotatory atlanto-axial disruption

Fielding and Hawkins „77

A Type I, rotation without translation

B Type II, unilateral lateral mass subluxation of 3 – 5 mm

C Type III, unilateral subluxation of greater than 5 mm

D Type IV, posterior displacement C1-2

Clinical pointers:

Pediatric versus adult patient group

Acute versus chronic timeline

Differential Dx: Trauma versus retropharyngeal infection (“Grisel “ syndrome) versus

habitual or congenital deformity

Integrity of TAL key to treatment

Group B: Transverse atlantal ligament disruption (TAL)

Dickman „96

Type I: Bony avulsion

Type II: Midsubstance ligament tear

Clinical pointers:

Chances for healing of ligamentous tear with nonoperative treatment are poor.

Group C: Distractive atlanto-axial disruption

Vertical or rotatory dissociation

Clinical pointers:

Variant of AOD

Traumatic tear of alar ligaments, atlanto-axial facet capsules, TAL

High degree of associated mortality, high SCI

Treatment:

Group A (rotatory)

If TAL intact closed reduction, inpatient observation, collar and FW XR to rule out

instability.

If TAL torn closed reduction followed by fusion

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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Group B (TAL injury)

Type I injuries (bony avulsion of TAL) can be treated with closed reduction, Halo,

follow-up FE-Xr to assess stability

Type II injuries (midsubstance ligament tears) usually require C1-2 fusion

Group C (atlanto-axial dissociation)

If survived C1-2fusion or Occipitocervical fusion

3.3 Lower C- Spine Injuries (C3-C7)

Classification:

Multiple classification systems, concepts.

No consensus

Low interobserver reliability.

Poor relationship of classification to stability

Skeletal Systems

- Anatomic

Holdsworth „70

Denis „83

Louis „85

- Mechanistic

Allen and Ferguson „82

- Combined

Bohlman „79

AO/ASIF/OTA ‟96

Moore and Anderson „06

SLIC „07

OTA ‟95: Suggested nomenclature / system

Minor fractures and ligament injury

- Spinous process fractures

- Tear drop/extension avulsion

- Undisplaced lateral man. fx

- Isolated lamina fx

- Ligament strain

Facet Injuries

- Perched

Unilateral

Bilateral

- Dislocated

Unilateral

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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Bilateral

- Fx Dislocation

Unilateral

Bilateral

Severe Injuries

- Flexion tear drop

- Severe ligament injury

- Compression fx

- Burst fx

AO/ASIF „97

A: AXIAL LOADING: Compressive lesions

( i.e. compression, burst Fx‟s )

B: BENDING INJURIES: Lesions with posterior distraction or

extension injuries

(i.e. facet dislocations)

C: CIRCUMFERENTIAL INJURIES: Rotational injuries

(i.e. complex fracure dislocations)

Ligamentous Instability

White, Southwick and Panjabi ‟76, „90

Element Point Value

Ant. elements injured 2

Post. element injured 2

Sag. plane translation > 3.5 mm 2

Sag. plane rotation > 110 2

Positive stretch test 2

Medullary cord damage 2

Root damage 1

Abnormal disc narrowing 1

Dangerous loading anticipated 1

Total of 5 points or more = unstable

Three column concept:

Louis, 1985

Anterior column = vertebral body

Posterior left and right column facet joimts with lateral masses either side. Never

validated anatomic model.

Cervical Spinal Column Injury Severity Score (CISS)

Four column concept

Anderson and Moore, 2006, Spine Trauma Study Group (Vacarro 2007)

There are 4 columns, anteriorly vertebral body and disc, left and right pillars and

posteriorly interspinous ligaments and spinous processes. Each of four columns is

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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assigned a severity 0-5 on intuitive basis. Combined (additive score of 10 or more is

unstable injury and will likely require surgical stabilization.

©Moore and Anderson, Spine 2006

Treatment:

Cervical skeletal traction:

Most efficacious initial management for cervical fracture-dislocations, indirect reduction

of spinal canal compression and temporary stabilization of injury.

Indications:

Unilateral or bilateral facet dislocations with or without fracture

Burst fractures

Contraindications:

AOD (see above)

Distractive ligamentous injuries

Patients with temporal or parietal skull fractures

Patients with ankylosing spondylits or DISH

Concern: Neurologic deterioration post reduction due to potential disc herniation

compressing spinal cord.

Disc herniation risk (Grant ‟99):

Unilateral facet dislocation: 23 %

Bilateral facet dislocation: 13 %

Risk of neurologic deterioration: <1%

Success of closed reduction: 92 %

Suggested pathway:

Neuro intact: MRI first (if readily available)

Neuro deficit: Reduce first, then MRI

Neuro unknown: MRI first (if readily available)

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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Technique:

Graphite Gardner Wells Tongs

Use Halo ring for definitive Rx or in pediatric patients (<6 years)

Make sure there is NO skull fracture or distractive spine injury

2.5 kg per level per increment in adults

5-10kg initial traction, after check proceed with 5 kg inreases

Incremental XR and MD neuro check

Total weight < 70% body weight

No manipulation

Early reduction with SCI preferred

MRI prior to reduction in neuro intact suggested

Goal: Decompression of spinal canal (indirect or direct) within 8o of injury or less

Determination for surgical intervention based upon success of reduction

Basic decision making

Primarily ligamentous injuries usually heal poorly with nonop Rx

Fx‟s with large cancellous surfaces usually heal well nonop

Most patients with SCI require surgical stabilization consisting of decompression and

fusion with rigid internal fixation

(except SCIWORA, central cord injuries etc.)

Poor nonop Rx prognosis:

- Fx with ankylosing spondylitis

- Patients with pulmonary disease

- Geriatric patients

- Patients with significant traumatic deformity

- Displaced Type 2 odontoid Fx‟s

- Patients with ligamentous injuries

Soft neck collar

No stability to neck

For stable neck sprains etc.

Neck collar (i.e. Philadelphia, Miami –J, Aspen etc.)

Suitable for postop care, stable, minimally displaced Fx‟s

Cervico-thoracic orthoses (Minerva, SOMI)

Improved cervico-thoracic stability

Halo / vest

- Most rigid external immobilization device

- Stability most influenced by snug vest fit

- Reduces motion of normal C-spine by 98 %

- Snaking and loss of reduction common (48%)

- Pins:

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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Adults:

4 pins, 6 - 8 inch pounds

Retighten once

Children < 8 years:

6-8 pins 2 – 4 inch pounds

- Pin infection:

Retighten once, if unsuccessful exchange

- Complications

Supraorbital nerve injury

Temporal fossa penetration (temporal artery!)

Frontal sinus penetration

Pin tract infection 12 – 42% (Garfin‟)

Surgery:

- Simple principle:

Treat anterior lesions anteriorly

Treat posterior lesions posteriorly

- Laminectomy alone destabilizes C-spine and is ineffective for decompression

(Tencer‟89)

- Surgeon preference

- Multilevel surgery needed: treat posteriorly

- Most unstable lower C-spine trauma can be stabilized anteriorly

- Most unstable upper C-spine trauma is treated posteriorly (exception odontoid

screw)

- Combined anterior and posterior surgery is rarely indicated

Indications for emergent surgery

- Irreducible Fx-Dl with neural compromise

- Residual mass effect on neural tissue with neurologic compromise:

- HNP

- Epidural hematoma

- Depressed lamina Fx

- Low velocity projectile in canal (controversial)

Surgical timing

- Emergent Rx rarely indicated

- Mandatory 72o delay of surgery ( Marshall '86) no longer required

- Safety of early management established (McLain‟99, Mirza‟99)

3.5 General C-spine Injury Treatment Algorithm

General

Classification

Subtype Subclass. Recommended Rx Comment

Occipital condyle Fx Type 1 Brace, Halo If AOD fusion

(Anderson, Montesano)

Type 2 Halo, fusion Traction test?

Type 3 R/o AOD Fusion, Halo Traction test

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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Atlanto-occipital

dissociation (AOD)

Not relevant for treatment Infant Halo + Rotorest, Fusion + Halo

(Traynelis) Not relevant for treatment Adolescent,Adult Fusion +/- Halo Occ - C2 if transarticluar screw

Occ - C3 if no transarticular screw

Atlas fractures Posterior arch Brace, Halo "Sentinel" fracture

Isolated lateral mass Brace, Halo Posttraumatic osteoarthritis

Burst (Jefferson) Fx Transverse lig. Intact

Brace, traction - Halo ? Stability

TAL bony avulsion

Halo Reassess stability after Rx

TAL Ligament tear

C1-2 Fusion Treatment decision often delayed

Anterior arch blowout Atlanto-axial subluxation

C1-2 fusion Variant of atlantoaxial dislocation

Atlanto-axial

dissociation

Subluxation vs. dislocation

C1-2 fusion,Occ-2 fusion

Patient survival

Atlanto-axial

rotatory subluxation

Type 1 Age Brace, NSAID, PT R/o infection, Grisel's syndrome

(Fielding) Type 2 Traction, bracing Delayed diagnosis, nonunion rate

Type 3 Traction, brace, halo, fusion

DDx: dysplasia

Type 4 ORIF+ C1-2 fusion Unreducible if ring fractured

Transverse ligament

tear

ADI within "stable" zone Brace F/E XR's after brace

"Unstable" C1-2 fusion

Odontoid fractures Type 1 Halo, Brace R/o AOD

(Anderson, d'Alonzo) Type 2 Displacement Halo, ORIF with screw(s), C1-2 Fusion,

brace

Osteoporosis

Type 3 Halo, brace, fusion (rare)

Type 2 a (Hadley) C1-2 fusion Differentiate from type III Fx

Traumatic C-2

spondylolisthesis

Type 1 Brace

(Effendi) Type 2 Brace,+/-traction,ORIF,

ACDF C2-3

Type 2 a (Levine) ACDF C2-3 Displaces more with traction

Type 3 ORIF, post fusion C2-3, PCF C1-3

Axis vertebral body

fractures

"Teardrop" Fx R/o occult ligament injury

Brace, Halo R/o hyperextensions Fx

Lateral mass Fx Brace, Halo,+/-traction Posttraumatic osteoarthritis

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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4. THORACOLUMBAR SPINE INJURIES

4.1 Clinical Assessment

See Chapter on C-spine Trauma. Same principles apply.

Note that 50% of TL Trauma occurs at TL – junction

Palpation of posterior midline is important component of assessment. Disruption of

posterior elements is important diagnostic insight in regards to Rx choice.

Remember that cord, conus and cauda equina injuries can have different

consequences in terms of injury severity, management and prognosis

4.2 Radiographic Assessment

Conventional Radiographs Primary radiographic workup and injury screening tool.

Basic views:

AP/Lat T-Spine

AP/Lat L-Spine

Pelvis ap

Specific views:

Transitional zone views:

Swimmer‟s view (increasingly substituted by helical (spiral CT) with reformats

Coned down AP and lateral view T12/L1

L5/S1 lateral

Pelvic views

Pelvic in- and outlet views

Judet projections (left and right)

Sacrum lateral

Computed Tomography (CT)

Indicated in :

- Any trauma!

- Suspected neoplasia, infection

- Post-myelography

- Dating of injury

Obtain with sagittal and, if deemed helpful, coronal reformatted views.

3D CT reformats are rarely helpful.

Myelography

Always together with postmyelography study

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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Suitable for patients requiring neuroimaging study if

MRI contraindicated

MRI unavailable

Magnetic Resonance Imaging

Indicated in:

- Unexplained neuro deficit

- Discongruous skeletal level of injury (SLI) and neurologic

level of injury (NLI)

- Screening tool in ankylosing spondylitis with possible

fracture

- Differential diagnosis trauma, neoplasia, infection

- Assessment of posterior ligament injury (controversial in

TL-Spine)

Not necessary for routine TL Fx workup, even in presence of neuro deficit

4.3 CLASSIFICATION

Concept of Stability

Stable vs. Unstable (Nicoll, „49)

Unclear prognostic characteristics

Definition of Stability:

White and Panjabi ‟77 and „90i:

“.. the loss of the spine under physiologic conditions to maintain relationships between

vertebrae in such a way that there is neither damage nor subsequent irritation to the spinal

cord or nerve root, and in addition, there is no development of incapacitating deformity or

pain from structural changes.” (White AA, Panjabi MM. Clinical Biomechanics of the

Spine. W.B. Saunders, 1982, pp.219-244.

Factors of Instability

Neurologic status

Pain

Deformity

Displacement

Structural defects

Compliance

Prognostic factors

Morphologic Systems: “Column - concept”

(2-columns):Whitesides „77

(3-column): Denis „88

Theory:

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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Anterior column = compression

Posterior column = tension

Middle column= no actual anatomic entity

Injury to 2 or 3 of 3 columns = potential for instability

Three Column concept (Denis)

Two Column system (Whitesides, Holdsworth)

CT based classification system (AAOS preferred)

McAffee „83

Wedge compression

Stable burst

Unstable burst

Chance Fx

Flexion-distraction

Translational

AO/ASIF (similar concept to C-Spine)

Type A: Compressive

Type B: Flexion distraction and extension

Type C: Rotational

Thoracolumbar Injury Classification and Severity Score (TLICS)

(Vaccaro et al. 2005)

Three major variables

1) Injury morphology

(0-4 points)

2) Integrity of posterior ligament complex (PLC)

(0-3 points)

ANTERIOR POSTERIOR

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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3) Neurologic status

(0-3 points)

Add point scores of each entity. Final score suggests treatment:

Nonoperative treatment: 3 or less

Operative Treatment: 5 or more

TLICS 4: equivocal management

4.4 TREATMENT

Modulating Factors

Neurologic status/development

Strict spine precautions until disposition / Rx

Associated injuries/age

Body size (obesity)

Bone mineral health (i.e. osteoporosis)

Preexistant spinal conditions

Anticipated patient compliance

Comorbidity

Compression Fx‟s

T2-10:

single level: observation

multiple levels < 60 degrees CTLSO

> 60 degrees PSIF

T11-L5:

Jewett / TLSO

“Stable” Burst Fx

Ongoing controversy as to definition

Criteria for “stable” injury

< 15° kyphosis, < 50% stenosis, < 40% wedging

Ant/middle column failure

Post. column intact

Neurologically intact

Level of injury

Nonoperative Rx with hyperextension cast, TLSO

Unstable Burst Fx

Presence of any related neurodeficit

Generally accepted characteristics (but not necessarily scientifically validated):

> 50 % canal compromise

> 50 % loss of vertebral body height

> 30 o focal kyphosis

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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Disrupted posterior elements (i.e. facet joint Fx)

Treatment options

Bedrest (Rotorest bed + DVT prophylaxis (6-12 weeks)

Custom hyperextension TLSO (+/- period of bedrest)

Risser cast

Surgery

Alternatives: Posterior, anterior or posterior/ anterior staged

Flexion-distraction Injury

Center of rotation in vertebral body

Frequently misread as compression injuries

Unstable injuries due to failure of posterior elements

Conservative Rx commonly fails

Posterior reduction and short segment fixation successful

30 – 60 % association with GI injuries (look for lap-belt sign)!

Chance Injury

Center of rotation anterior to vertebral body

Lap-belt injury common

Risk of higher level SCI

High incidence of pediatric patients

R/o GI injuries !!!

Assess posterior elements

-Pure ligamentous injury

-Pure bony injury (pedicle, spinous process)

-Mixed

Conservative Rx (Hyoerextension cast):

Neuro intact

No GI injuries

Mainly bony posterior injury

Surgery

If prerequisistes for nonop Rx are not met

Interspinous wire in small children

In older patients posterior spinal instrumentation / fusion

Translational Injury (Shear Fx)

Very unstable

Usually associated with paraplegia

Stable fixation important

(may require anterior and posterior surgical stabilization)

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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4.5 General TL Injury Treatment Principles

Nonoperative measures

Basically stable fractures can be mobilized in external support:

Jewett brace for simple compression fractures

CTLSO for T1-6 compression or burst Fx‟s

Custom-molded TLSO for stable burst fractures (T6-L3)

TLHSO for lower lumbar burst fractures (L4-S1)

Bilateral pantaloon spica for nonop RX of complex sacral Fx‟s (controversial)

Risser hyperextension cast suitable for nonop Rx of some unstable burst fractures,

bony Chance injuries etc.

If more unstable fracture consider prolonged bedrest (i.e. Rotorest bed) of 3-6 weeks

with DVT prophylaxis prior to mobilization into upright

Braces / casts / prolonged Rotorest bed care in general unsuitable for patients with

severe chest injuries, sternal Fx‟s, very obese patients etc.

Basic instrumentation concepts

Goal of surgery: Complete decompression, anatomic realignment

Most TL spine trauma can be initially treated with posterior instrumentation and

fusion +/- neural decompression

Posterior instrumentation options:

- Conventional posterior multisegmental fixation: 3 levels above, 2 below

injury

- Short segment fixation: 1 level above, 1 below injury

- Rod long, fuse short: Fusion extends one segment above, and one below,

instrumentation goes beyond this, but requires removal 1 – 2 years later

- Rod long / fuse short concept largely outdated

- Short segment fixation associated with higher failure rates

- Stable segmental fixation concepts generally preferred (i.e. pedicle screws

or multisegment hook assembly)

Neuromonitoring for patients with unknown neurostatus

Early mobilization

Bracing - TLSO helpful for SCI (trunk control)

Early rehab for SCI

Repeat neuroimaging for incomplete SCI

Anterior surgery

Indications:

- High grade burst fracture

- Insufficient anterior column

- Supplemental fusion for highly unstable fracture (rarely

needed)

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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Concept:

- Anterior decompression

- Strutgrafting (ICBG, Allograft, Cage)

- Stabilization

Pros:

- Possibly better neurologic recovery rates than posterior

surgery alone (inconsistent findings)

- Anterior column reconstruction

Con:

- Higher bloodloss, longer surgery time than posterior

- Less biomechanical stiffness than most posterior constructs

- As stand-alone less suitable for osteopenic conditions

- Approach morbidity

- Multilevel surgery neither feasible nor realistic

Traditional approaches:

- Transthoracic (T4 –T12)

- Thoracolumbar subpleural (T11-L1)

- Retroperitoneal (L1-S1)

- Transperitoneal approaches are NOT recommended for

trauma

Minimally invasive surgery is not “Board Standard”

Posterior surgery:

Indications:

- Most TL-fractures can be treated with posterior procedures

- High grade burst fractures, require either long posterior

instrumentation and fusion or supplemental anterior

decompression and fusion

Concept:

- Short segment fixation for simple bending injuries

- Long segment fixation for highly unstable injuries (burst,

dislocations etc.)

- Posterior decompression:

- Indirect (via distraction, realignment)

- Direct (laminectomy with ventral fragment disimpaction)

Technique:

- Segmental fixation strongly favored

- Pedicle screw systems superior in biomechanics

- Caveat: Suspect trapped nerve roots and dural tear with

displaced lamina fracture

Pros:

- Standard, well tolerated approach

- Multilevel surgery readily possible

- Superior biomechanical stiffness to anterior stand-alone

Con:

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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- Indirect decompression via distraction is insufficient,

destabilizing

- Posterior decompression of anterior canal compression is

incomplete

Combined anterior decompression and posterior stabilization:

Indications:

- High grade burst fracture

- Fracture dislocation

- Corrective osteotomy of posttraumatic kyphosis

Concept:

- Staged surgery

- Same day surgery in trauma impractical, rarely if ever

necessary

- Repeat plain CT

- Anterior surgery on delayed basis

5. Sacral Fractures

(This segment is provided as a courtesy to the audience and is not part of the lecture due

to time constraints)

Classification

Three-Zone system (Denis 1988)

This system correlates with incidence and type as well as frequency of

neurologic injury

Zone I injury: Alar fracture, injury lateral to sacral neuroforamina. L-5

root injury

Zone II injury: Transforaminal fracture

Zone III injury: Any sacral fracture extending into the spinal canal

Sublassification of Denis Zone III sacral fractures by Roy-Camille modified by

Strange-Vognsen

- Type 1: simple flexion deformity of the sacrum

- Type 2: flexion and translational deformity

- Type 3: complete translation of the upper to the

lower sacral elements

- Type 4 (Strange-Vognsen): Segmentally

comminuted S1 vertebral body

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

Review of Spine Trauma

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5.2 Treatment

Goals:

- Optimize chances for patient survival

- Assure pelvic ring and lumbosacral stability

- Protecting neural structures or optimizing their recovery

potential in the presence of deficits.

Nonoperative management

Options:

Activity modification

Bed-rest

Brace or cast immobilization with unilateral or bilateral hip spica extensions

Recumbent skeletal traction

Duration: 8 to 12 weeks

Decompression Techniques

- Direct (fragment removal, laminectomy etc.)

- Indirect (fracture reduction, ventral disimpaction, sacral kyphectomy)

Surgical Stabilization Techniques

- Assess anterior fixation needs first

- Posterior pelvic ring stabilization

- Transiliac threaded compression rods (largely outdated)

- Iliac tension band plates (requires bilateral parasagittal approaches)

- Sacral alar plating (small fragment plates inserted into ala lateral to

posterior neuroforamina) – limited usefulness due to frequent

comminution and limited biomechanical stiffness

- Open or percutaneous sacro-iliac screw fixation (for a wide variety of

mildly and moderately displaced sacral fractures)

- Galveston-type lumbo-iliac fixation techniques (for complex sacral “H”

and “U” type fractures); newer systems allow for segmental screw fixation

to ileum instead of rod placement.

- Segmental lumbo-screw screw/rod fixation for lumbo-sacral dislocation

©Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA

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6. REFERENCES

Spinal cord injury

Anderson PA, Bohlman HH. Anterior decompression and arthrodesis in patients with

traumatic, complete motor cervical spine cord injury. Long term neurologic recovery in

51 patients. Part II. JBJS 74-A: 683-91, 1992.

Bohlman HH, Eismont FJ. Surgical techniques of anterior decompression and fusion for

spinal cord injuries. Clin Orthop 154:57-67, 1981.

Bohlman HH, Anderson PA. Anterior decompression and arthrodesis of the cervical

spine: long term motor improvement. Part I-Improvement in incomplete traumatic

quadriparesis. J Bone Joint surg Am 1992;74:671-82.

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28 (3): 351-368, 1997

Jens R. Chapman, M.D., University of Washington AAOS Board Review Course 2010

Introduction • 30%-60% of adults experience significant neck or radicular pain during lifetime • Point prevalence 5-10% • History of previous trauma to cervical spine increases risk of developing

significant axial neck pain or radiculopathy 1. Axial Neck Pain

• Epidemiology o 30%+ of population has significant neck pain in lifetime o ~15% of population with chronic neck pain of > 6 months o ~5% of population has disabling symptoms

• Pathophysiology o Afferent nociceptors in facet joint synovium and degenerative

intervertebral discs likely responsible for most neck pain o Loss of disc height, facet arthrosis, osteophyte formation, and listhesis can

all contribute to pathological loading of facet joints and intervertebral disc o Fibromyalgia may be perceived as neck pain, often localizes to trapezium,

associated with decreased blood flow, high resting muscle tension and intramuscular metabolic derangement

o Although controversial because of the potential for secondary gain, cervical injury including whiplash as a risk factor for axial neck pain

• Presentation/Diagnosis o Cervical injury may precede onset of neck pain

Significant neck pain after trauma common even in patients who have already settled resulting litigation presumably decreasing secondary gain

o Axial neck pain should not be painful to palpation, and is likely to be worse in extension and/or rotation

o Suboccipital pain suggests involvement of the occiput-C1 or C1-C2 level o Trigger points associated with fibromyalgia in the region of the cervical

spine are located in the: occiput, lateral aspect of low cervical spine, trapezius and medial origin of the supraspinatus

o Directed physical examination Range of motion of cervical spine – often limited by spondylosis Palpation of trigger points as mentioned above to evaluate for

fibromyalgia • Also: lateral condyle, medial knee joint line, greater

trochanter, medial 2nd rib and upper, outer quadrant of buttocks

Complete sensory, strength, gait and reflex evaluation • Although a patient’s pain may be predominantly in the

neck, this does not preclude myelopathy or an unrecognized motor deficit

o Anteroposterior, lateral, and lateral flexion and extension radiographs establish baseline evaluations and may show dynamic instability

o MRI is gold standard for evaluation of disc pathology such as annular injury, disc dessication and facet arthrosis but caution needed because of high prevalence of findings in asymptomatic population

o Cervical discography is controversial but may provide guidance Obtaining negative control in adjacent, normal appearing disc

essential to reliance on positive discogram to indicate surgery Multiple positive controls without a negative control should

discourage surgical intervention, especially in young patients • Treatment options

o Natural History At 15 year follow-up with nonoperative care, 79% of patients had

symptom improvement in comparison to pain level at presentation • 43% were pain-free, 32% had moderate/severe pain • Factors associated with persistent pain: severe pain on

presentation, history of related injury Axial neck pain rarely progresses to myelopathy ~20% of patients presenting with severe pain will still be

significantly disabled at 5 years o Conservative treatment ill-defined but successful given natural history

May include: steroids, NSAIDs, narcotics, muscle-relaxants, PT Traction has not been shown to offer any benefit

o Surgery Axial neck pain is a contraindication to cervical disc replacement Anterior cervical discectomy and fusion is the procedure of choice

for carefully selected patients who fail nonoperative treatment Retrospective studies report good/excellent results in 60-80% with

poor results in 5-20% Similar results extend to treatment of neck pain from cervical

pseudoarthrosis if workup identifies no other pain generator • Complications specific to condition

o Adjacent level disease after cervical fusion may be unrelated to surgery and instead due to the natural history of multilevel cervical spondylosis

2. Cervical Radiculopathy

• Epidemiology o Lifetime prevalence 3.5/1000 o Yearly incidence ~ 8/10,000 o F>M o Incidence peaks in 50s and 60s and then declines

Decline due to dessicated disc, reduced likelihood of herniation? • Pathophysiology

o Mechanical compression of nerve roots can result from several causes: Loss of disc height, facet arthritis, uncovertebral joint osteophytes,

ligamentum flavum hypertrophy and disc herniation o Chemical irritation of nerve roots occurs with exposure to herniated

nucleus pulposus

Mediated by TNF-alpha contained within degenerative disc o Foraminal stenosis and associated instability can cause symptom

worsening with extension or rotation to the ipsilateral side as the neural foramen cross-sectional area decreases in these positions

o Conversely, arm abduction causes relative lengthening of cervical roots and may result in pain relief

• Presentation/Diagnosis o Patients typically present with pain in a dermatomal distribution in upper

extremity o Pain may be burning, sharp or electric, can be accompanied by motor

weakness or sensory changes o Positional changes in foraminal area may lead patients to turn their head to

the opposite side or abduct their arm overhead (shoulder abduction sign) o Neck pain also present in 80% o Directed physical examination

Important to identify dermatomes/myotomes affected through history and physical examination to treat only symptomatic levels

Spurling’s test – exacerbation of pain with extension and rotation of head toward painful side

Complete sensory, strength, gait and reflex evaluation • Patients may present with concomitant myelopathy • Pain, motor and sensory dysfunction can also result from

peripheral nerve entrapment and thoracic outlet syndrome which must be ruled out

o MRI is gold standard for evaluation of nerve compression, pathology must correlate with dermatomal complaints when indicating surgery

o EMG useful to differentiate cervical from peripheral nerve compression, • Treatment options

o Natural History 70-90% of patients have good outcome with nonoperative care Pain typically resolves within 6-12 weeks

o Conservative treatment Early treatment – brief course of narcotics if necessary, brief

immobilization with soft collar, short steroid course may be helpful Later treatment may include: NSAIDs, muscle-relaxants, physical

therapy and stretching o Surgery

Anterior Approach - Fusion • Indicated for soft disc herniation, bilateral symptoms,

significant neck pain, kyphotic cervical alignment • Usually not performed when addressing more than 3 levels

as nonunion rates rise unless posterior instrumentation used • Anterior plating increases stiffness, decreases nonunion

rate, and allows earlier postoperative range of motion without a protective collar

• Intervertebral spacer can be autologous or allograft structural bone graft, PEEK or mesh cages

• Good/excellent results in 70-90% of patients • Worse results in smokers, females, patients with decreased

cervical range of motion or worse preoperative disability Anterior Approach – Cervical Disc Replacement

• FDA approved in 2007 although reimbursement difficult • Surgical approach similar to ACDF • Theoretical benefit of reducing adjacent level disease

o Elimination of increased load seen by motion segment adjacent to fusion, not yet proven clinically

• Motion retained 2 years after surgery • Similar clinical results to ACDF although better studies

necessary Posterior Approach

• Indicated for soft posterolateral HNP, lateral recess or foraminal stenosis, facet arthropathy with posterior compression, > 3 level surgery

• Must have cervical lordosis for decompression to be effective (> 10°)

• Decompression via laminectomy, laminoforaminotomy, or laminoplasty

• Posterior fusion/instrumentation can be performed using lateral mass screws or wiring

o Lateral mass/pedicle screws not FDA approved o Complications specific to anterior approach

Dysphagia – common, usually self limited Esophageal perforation – rare (<0.25%) but high mortality rate,

especially when not recognized at time of surgery Recurrent laryngeal nerve palsy (up to 10% although often

asymptomatic), left sided approach may be safer as nerve protected within tracheoesophageal interval

o Complications specific to posterior approach Neck pain if fusion not performed secondary to spondylosis,

preserved motion Wound complication rates higher than for anterior approach Postoperative kyphosis after laminectomy without instrumentation Nerve root palsy after posterior decompression, C5 most common

3. Cervical Myelopathy

• Epidemiology o Degenerative changes in the cervical spine are ubiquitous with aging o True incidence of cervical myelopathy is unknown and likely higher than

expected because of the insidious and subtle nature of symptoms in early disease

• Pathophysiology

o Myelopathy likely with cord narrowing >40% or banana-shaped cord on axial MRI images

o While degenerative changes often cause myelopathy in older population (most common at C5-6 and C6-7), younger patients may become myelopathic due to untreated HNP

o Congenital stenosis (canal diameter <13mm) predisposes patients to myelopathy

o Gait and bladder disturbances likely secondary to spinothalamic and pyramidal tract compression

• Presentation/Diagnosis o May present with isolated myelopathy or with radicular pain plus signs of

cord compression o Typical history often includes: difficulty writing, trouble with buttons or

zippers, dropping objects, gait disturbances or clumsiness, and falls o Directed physical examination very important in diagnosing myelopathy

Evaluation of gait and balance Repetitive tasks such as rapid tapping of thumb and index finger

pads or slapping thigh alternating between palm and dorsum of hand will be difficult and slow in patients with myelopathy

Complete sensory, strength, and reflex evaluation • May see clonus or hyperactive reflexes • Radicular and myelopathic symptoms often coexist so can

find sensory or motor deficiencies on examination Special signs

• Lhermitte’s sign – electric pain in back of neck on flexion • Babinski’s sign – great toe dorsiflexion on plantar stroke • Hoffman’s reflex – thumb IP flexion with flicking of 3rd or

4th fingernail o Anteroposterior, lateral, and lateral flexion and extension radiographs

Pavlov ratio to screen for congenital stenosis • AP diameter canal/AP diameter body <0.8 is pathologic

o MRI is gold standard for evaluation of neural impingement and may demonstrate cord signal changes with severe compression

Prognostic value of cord signal changes unclear, however • Treatment options

o Natural History Insidious onset of symptoms with long periods of stability without

deterioration These stable periods are punctuated by episodic worsening of

symptoms after which a new functional baseline is established and function rarely regained

~5% have rapid onset of symptoms with no further progression Delay of 1 year in mild cases does not affect surgical outcome

o Conservative treatment possible for elderly patients with minimal symptoms and in patients with severe medical co-morbidities

May include: NSAIDs, physical therapy

Patients with myelopathy should avoid activities that will put them at risk for spinal cord injury given the reduced tolerance for trauma

o Surgery Patients with mild symptoms may not benefit from surgery,

especially in the elderly Indications based around level of disability, degree of pain Milder symptoms may be indication in younger patients, those

with evidence of congenital canal stenosis on imaging Anterior surgical indications (ACDF or corpectomy):

• One to three affected levels • Any number of levels with loss of cervical lordosis • Should not be used for congenital stenosis or posterior-

based cord compression • Significant axial neck pain

Posterior surgical indications (laminectomy or laminoplasty): • More than 3 affected levels with preserved lordosis • Cervical kyphosis with concomitant anterior procedure

Need wide decompression so laminoforaminotomy not indicated Technique and surgical considerations same as for radiculopathy Recovery of function depends on severity of preoperative

myelopathy • Complications specific to condition

o Failure to decompress spinal cord if lordosis not preserved or iatrogenic kyphosis develops

o Nerve root palsy related to posterior decompression, C5 most likely 3. Ossification of the Posterior Longitudinal Ligament (OPLL)

• Epidemiology o Predominantly found in patients of Japanese heritage but has been

described in Caucasian and other Asian populations o Occurs in ~3% of adult Japanese, has been described in as many as 1.3%

of patients in study performed in US o M>F o Incidence highest in sixth decade

• Pathophysiology o Human leukocyte antigen (HLA) haplotype is an important risk factor for

development of OPLL indicating a strong genetic basis of disease o OPLL causes ossification with development of mature lamellar bone, not

calcification as previously thought o No correlation with degenerative disc disease although OPLL can occur

with diffuse idiopathic skeletal hyperostosis o Associated with diabetes mellitus

• Presentation/Diagnosis o Often asymptomatic o Presenting symptoms usually include mylopathic features but

radiculopathy may also be present

o Directed physical examination Evaluation of gait, balance and repetitive tasks Complete sensory, strength, and reflex evaluation

• May see clonus or hyperactive reflexes • Radicular and myelopathic symptoms often coexist

Special signs associated with myelopathy: • Lhermitte’s sign, Babinski’s sign, Hoffman’s reflex

o Anteroposterior, lateral, and lateral flexion and extension radiographs Characteristic radiodense strip along posterior vertebral bodies

with disc space preservation Occupation of >60% by OPLL carries high risk of myelopathy

o CT useful because of bony nature of lesion o MRI is necessary for evaluation of neural impingement although OPLL

itself not always easily distinguished on MRI • Treatment options

o Natural History Degree of spinal compression may not change over long periods of

follow-up Only ~15% of patients with OPLL with become myelopathic

o Conservative treatment often employed for asymptomatic OPLL or with mild symptoms because of slow progression

May include: Cervical orthosis, physical therapy o Surgery

Indicated with significant or progressive myelopathy or in patients in whom OPLL occupies >60% of spinal canal

Anterior surgery with corpectomy for removal or decompression of OPLL, especially with convex-posterior OPLL lesions or kyphosis

Posterior surgery using laminectomy or laminoplasty in patients with involvement of multiple levels or congenital stenosis

• Complications specific to condition o C5 nerve palsy seen in ~10% after anterior or posterior decompression o Iatrogenic kyphosis after laminectomy, laminoplasty to lesser degree

Introduction • >70% of adults in developed countries suffer from back pain at some point in

their lives • Annual incidence 15-45% • M=F; most common 35-55 y/o • Total cost of LBP in US >$100 billion annually including treatment, lost wages • Only 5% of patients develop chronic pain, these patients represent 85% of cost

1. Lumbar Herniated Nucleus Pulposis (HNP)

• Epidemiology o 2% of general population will experience symptomatic HNP o 5% recover in 1 month o 96% fully functioning by 6 months (surgical and nonsurgical) o 19% of patients with sciatica ultimately require surgery

• Pathophysiology o Annulus fibrosis and posterior longitudinal ligament cannot contain NP o 3 potential pain generators:

Mechanical breech/stretch of annulus – innervated by sinu-vertebral nerve of Lushka low back pain at site of HNP

Mechanical compression of nerve root Referred pain into buttocks, down leg

Chemical irritation of nerve root – TNF-α mediated Referred pain into buttocks, down leg

o HNP can be: central, posterolateral, foraminal, extraforaminal • Presentation/Diagnosis

o Low back pain may precede HNP as disc degeneration often present o Referred pain is sharp, lancing pain along dermatomes or myotomes that

classically radiates distally from buttocks o Pain worsens with activities that increase intradiscal pressure (i.e. bending

forward in seated or standing position) o May be accompanied by paresthesias, weakness, bowel/bladder symptoms o HNP can present as cauda equine syndrome – large central herniation o Directed physical examination

Loss of lumbar lordosis Paravertebral muscle spasm Percussion of sciatic notch – may reproduce sciatica Complete sensory, strength, and reflex evaluation to

document/localize abnormalities Straight leg raise or Laseque’s Test – nerve root stretch between

30° and 70°, foot dorsiflexion increases sciatic nerve excursion Contralateral straight leg raise test – highly suggestive of HNP if

positive, may be best test to identify contralateral axillary HNP o MRI is gold standard for imaging, ± gadolinium if previous spinal surgery

• Treatment options o Natural History

70-90% of patients have full recovery within one month

Herniated material decreases in size with time based on long-term imaging studies

o No decline in results after surgery if observe for 3 mo, worse results after 1 year of observation

o Conservative treatment ill-defined but should not include bedrest May include: steroids, NSAIDs, narcotics, muscle-relaxants, PT

o Surgery Decompressive Technique:

• laminectomy vs. laminotomy vs limited exposure laminotomy “microdiscectomy”

Discectomy vs. limited discectomy SPORT HNP Trial

• Patients treated with laminotomy or in nonsurgical arm o Nonsurgical arm: PT, home exercise, NSAIDS o High rates of patient crossover between groups

• As treated analysis: Surgical benefit at 4 years vs. nonsurgical arm for ODI (~13 pt difference) and SF36 scores (~16 pt difference for PF and BP subscores)

o Difference exceeded previously established Minimum Clinically Important Differences (MCID)

• Complications specific to condition o Recurrence common (~10% at same level)

2. Lumbar Stenosis

• Epidemiology o Incidence increases in 5th and 6th decade of life for degenerative stenosis,

most commonly seen in 4th decade for patients with congenital stenosis o M=F o Prevalence in population >50 years old as high as 0.5% o Most common preoperative diagnosis for spine surgery in US

• Pathophysiology o Canal shape influences central canal volume, 3 described normal variants:

Round, Ovoid, Trefoil (least volume – 15% of population) o Degenerative/acquired stenosis most common

Most common at L3-4 and L4-5 Later presentation due to acquired morphologic changes:

• Facet hypertrophy from degenerative joint disease • Ligamentum flavum thickening • Disc bulging/herniation

o Congenital stenosis Pedicles shortened, lamina and facet joints thickened Earlier presentation Common in achondroplasia because of limited physeal growth

o Combination of degenerative and congenital stenosis Patients with short pedicles have less room to “spare” before

degenerative changes cause neural compression

• Presentation/Diagnosis o Asymptomatic patients commonly have radiographic evidence of stenosis

so nature of symptoms critical for diagnosis o Insidious onset of diffuse back pain o Leg pain typically develops later

May present as cramping, sharp pain, burning, pins & needles Pseudoclaudication – walking exacerbates pain, improves with rest Radicular pain – seen with lateral recess stenosis, localizes to

affected nerve roots o Leaning forward classically improves pain by increasing canal diameter o Other less common symptoms: weakness, incontinence, UTI, priapism,

perineal numbness, urinary retention (rare) o Directed physical examination

Forward posture when walking/standing Complete sensory, strength, and reflex evaluation If present, weakness common in L5/S1, sensory changes in L4/L5 Asymmetric reflexes more common in central stenosis patients Often have paucity of physical exam findings

o MRI is gold-standard imaging method to evaluate neural impingement o Radiographs with flexion, extension helpful in evaluating associated

listhesis, instability for treatment decisions • Treatment options

o Natural History At medium-term follow-up, 15-25% of patients worse, 50-70%

unchanged with conservative treatment of mild/moderate stenosis o Pharmacologic therapy: NSAIDs, gabapentin, narcotics (acute pain only) o Epidural steroids have been reported to provide relief at 1 year in 50-60%

of patients with less reliable long-term results o No definitive studies of therapeutic exercise but weight loss helpful o Surgery

Laminectomy Laminotomy SPORT Lumbar Spinal Stenosis Trial

• Patients treated with laminectomy or in nonsurgical arm • High rates of patient crossover between groups • As-treated analysis: benefit to surgery vs. nonsurgical arm

at 2 years, sustained at 4 years for ODI (~9 pt difference) and SF36 scores (~13 pts difference for BP, ~9 pts for PF)

o Differences exceeded MCID • Complications specific to condition

o Instability – preserve as much of facet as possible, fuse if more than 50% of both facets removed or if take one joint entirely during decompression

o Postoperative neurological injury more common with laminotomy vs. laminectomy but uncommon in both types of surgery

3. Lumbar degenerative spondylolisthesis

• Epidemiology o Rarely seen in patients younger than 40 years old, typically in 6th decade o Predominantly occurs in women, ~ 6:1 female to male ratio

• Pathophysiology o Reason for female predominance unclear, proposed explanations:

Ligamentous laxity Hormonal effect

o Facets are more sagittally oriented in patients with degenerative spondylolisthesis

Unclear if this is a primary or secondary effect o Most common at L4-5 (85% of cases) o Anterior translation of one vertebral body on another results in an

effective stenosis as spinal canals no longer line up o Degenerative spondylisthesis rarely progresses beyond Grade I slip which

represents <25% translation of one body on the next • Presentation/Diagnosis

o Symptoms and presentation often identical to that of spinal stenosis o Patients typically have neurogenic claudication or radicular symptoms

with antecedent back pain o Directed Physical Examination – same as for spinal stenosis

When present, weakness and sensory changes most often localize to L4-5 level as this is most common spondylolisthesis level

o MRI valuable to evaluate degree and source of neural element compression

o Radiographs with flexion/extension useful for documenting the amount of listhesis and associated instability to guide treatment options

o Radiographic evidence of listhesis and clinical symptoms often have little correlation - radiographic pathology must match clinical impression

• Treatment options o Natural history

At medium term follow-up, most patients do not deteriorate clinically and most do not have progression of listhesis

o Conservative therapy: NSAIDs, gabapentin, narcotics, PT, steroids o Surgery

Decompression is mainstay of surgical intervention • Laminotomy, laminoforaminotomy, laminectomy

Preoperative imaging will help determine if decompression alone is sufficient or if patient will also require fusion

Factors which may suggest fusion should be performed: • Wide bilateral decompression necessary which may lead to

instability if level not fused • Preoperative instability on flexion/extension films • Severe associated degenerative changes

If necessary, fusion with instrumentation (vs. fusion in situ) is associated with higher fusion rates and better long-term results despite higher early complication rates

SPORT Spondylolisthesis Trial • Patients with single-level spondylolisthesis treated with

laminectomy ± fusion or in nonsurgical arm • Fusion either instrumented or in situ per surgeon’s decision • High rates of patient crossover between groups • As treated analysis: Significant benefit at 4 years for

surgical intervention as measured by ODI (~14 pt difference) and SF36 (~15 pt difference BP, ~19 pt for PF)

o Differences exceeded MCID o Complications specific to condition

Slip progression and clinical deterioration in patients with instability or who undergo wide decompression without fusion

Neurologic deficit in high grade slips (rare) that undergo reduction 4. Degenerative scoliosis

• Epidemiology o Prevalence unknown because often asymptomatic, estimated up to 6% o Mean age >60 years old o M=F for de novo degenerative scoliosis

• Pathophysiology o Adult degenerative scoliosis can be due to:

Untreated AIS with degenerative progression De novo from degenerative disease

• asymmetric disc wear and facet joint incompetence o Associated stenosis common due to degenerative changes:

90% of de novo adult scoliosis patients have stenosis symptoms vs. 30% in adult AIS patients not due to scoliosis alone

• Presentation/Diagnosis o Symptoms are same as for lumbar spinal stenosis – back pain and

claudicatory leg pain, radiculopathy often related to foraminal stenosis on concave side of curve

o With extreme deformity, ribs may abut iliac crest o Sagittal and coronal imbalance create gait difficulty, reliance on cane o Directed Physical Examination

Posture often demonstrates loss of lumbar lordosis Radicular symptoms may be relieved when patient holds their

trunk in straightened position using arms Assess coronal and sagittal balance with plumb line Complete sensory, strength, and reflex evaluation although as for

spinal stenosis, neurologic findings rare o MRI valuable to evaluate degree of neural element compression o Standing full-length spine radiographs with bending/traction films o DEXA scan can be useful in preoperative planning

• Treatment options o Natural History:

Well-studied in untreated AIS • Thoracic curves >50° progress ~1° per year • Thoracolumbar and lumbar curves >50° progress ~0.5° per

year Progress not well characterized for de novo degenerative scoliosis Association between curve magnitude and symptoms controversial

o Decision regarding operative vs. nonoperative treatment should consider: Symptoms/quality of life General health - complication rates very high compared to other

degenerative conditions/surgical intervention o Nonoperative treatment – symptomatic use of NSAIDs, general

conditioning, treatment of osteoporosis, use of brace (symptomatic relief only, will not prevent progression)

o In addition to symptoms, surgical indications may include: cosmesis, and coronal or sagittal imbalance

o Surgical decision making should consider symptoms, curve flexibility, osteoporosis, other degenerative changes at levels adjacent to curve, comorbidities

o Goals in order of priority: correct imbalance, pain relief, reduce risk of subsequent degenerative deformity

o Surgical options: Decompression alone (rarely) Posterior-only fusion (increasingly common with all-pedicle screw

constructs) Anterior-posterior fusion may be necessary with rigid deformity or

when anterior column support is necessary to restore lordosis Consider pelvic fusion

• Complications specific to condition o Medical complication rates high in patients who undergo long fusions

because of magnitude of surgery and relative postoperative immobility during lengthy recovery period

o Adjacent level disease can be prevent by not ending fusion at degenerative disc in middle of thoracic kyphosis if thoracic spine included in fusion

o Nonunion Iliac fixation for fusions to sacrum increases fusion rate, especially

important with a long construct or poor bone quality 5. Discogenic pain

• Epidemiology o As many as 90% of patients 50+ have radiographic evidence of lumbar

disc degeneration but little correlation with symptoms o Degenerative disc disease accounts for ~25% of lumbar fusions in US

• Pathophysiology o Traditionally, environmental factors such as heavy lifting, vibration

exposure and smoking have been implicated as causative factors

o Role of genetics being increasingly recognized, probably provides most of individual susceptibility to disease

o Posterior aspect of intervertebral disc innervated by sinuvertebral nerve, nociceptive nerve ingrowth into normally aneural disc with degeneration

o Intradiscal environment undergoes variety of molecular changes Decreased collagen II, aggrecan production Extracellular matrix degradation due to upregulation of matrix

metalloproteinases Increased cell senescence, apoptosis

o Little capacity for repair because of low disc cellularity and vascularity • Presentation/Diagnosis

o Low back pain with radiation into buttocks, posterior thighs, nondermatomal

o Symptoms may be worse with sitting and prolonged walking, relieved with supine position

o No neurogenic claudication unless concomitant lumbar stenosis o Directed Physical Examination

Range of motion of lumbar spine limited, painful No relief with forward flexion, may exacerbate pain because of

increase in intradiscal pressure in this position Otherwise, physical examination often normal

o MRI will show disc dessication with loss of T2 signal, loss of disc integrity and disc height

These findings are nonspecific, widespread in asymptomatic population especially in age 50+

Endplate changes (Modic) have been associated with painful degeneration but this relationship is not well-established

o Discography controversial but is the only diagnostic modality which helps determine whether a degenerative appearing disc is actually painful

Obtaining negative control in adjacent, normal appearing disc essential to reliance on positive discogram to indicate surgery

Poor instrument in patients with secondary gain because of test subjectivity

• Treatment options o Interventional procedures

Intradiscal electrothremal therapy, intradiscal radiofrequency thermocoagulation

No evidence of significant therapeutic benefit over sham treatment o Lumbar fusion

Meta-analyses comparing fusion with nonoperative treatment for isolated degenerative disc disease have had mixed results, some favoring surgery and some finding no difference

o Lumbar total disc replacement (TDR) Studies comparing lumbar fusion and total disc replacement

including the IDE trials prior to TDR approval found no significant differences in outcome between groups at medium term

Long term results, however, not yet known • Complications specific to condition

o Lack of clinical success Clinical success rates as defined by FDA for the IDE trails of TDR

was achieved by only ~55% of patients, ~45% for fusion group • Success= no device failure, no major complications, no

neurologic deterioration, >25% decrease in ODI for Charite trial, similar for ProDisc trial

Annotated Bibliography

Lumbar Spine:

Herniated Nucleus Pulposus

1. Bozzao A, Galucci M, Masciocchi C et al. Lumbar disk herniation: MR imaging assessment of natural history in patients treated without surgery. Radiology 1992; 185:135–141.

Repeat MRI 11 months after initial MRI in 69 patients treated conservatively for HNP demonstrated >70% HNP resorption in ~48%, 30%-70% resorption in 15%, no change in 29% and increased disc fragment size in 8%.

2. Olmarker K, Rydevik B. Selective inhibition of tumor necrosis factor-alpha prevents nucleus pulposus-induced thrombus formation, intraneural edema, and reduction of nerve conduction velocity: possible implications for future pharmacologic treatment strategies of sciatica. Spine. 2001; 26(8):863-869.

A series of investigations in a porcine model established the role of TNF-alpha as the principle agent in HNP which causes chemical irritation of the nerve roots. TNF-alpha blocking agents were demonstrated to mitigate the effects of HNP on nerve roots.

3. Wang JC, Line E, Brodke DS et al. Epidural injections for the treatment of symptomatic lumbar herniated discs. J Spinal Disord 2002; 15:269-272.

This retrospective study of patients who had failed noninvasive conservative treatment and were amenable to surgical treatment for HNP demonstrated good short-term results of transforaminal steroid injections with 77% of patients avoiding surgery at 1.5 years after enrollment.

4. Weinstein JN, Tosteson TD, Lurie JD et al. Surgical vs. Nonoperative Treatment for Lumbar Disk Herniation The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial. JAMA. 2006; 296(20): 2441-2450.

The initial report from the SPORT HNP trial presents only intention-to-treat analysis which was limited by patient crossover. Significant improvements for primary outcome measures were seen in both operative and non-operative treatment groups, demonstrating non-significant trends toward improved outcomes in the operative group.

5. Weinstein JN, Tosteson TD, Lurie JD et al. Surgical Versus Nonoperative Treatment for Lumbar Disc Herniation: Four-Year Results for the Spine Patient Outcomes Research Trial (SPORT). Spine. 2008; 33(25): 2789–2800.

The as-treated four-year follow-up for the SPORT trial demonstrated significantly improved results in SF36, ODI for the operative group vs. the non-operative group.

Lumbar Stenosis

1. Cuckler JM, Bernini PA, Wiesel SW et al. The use of epidural steroids in the treatment of lumbar radicular pain: A prospective, randomized, double blind study. J Bone Joint Surg Am 1985;67:63-66.

A blinded RCT found equivalent results between epidural steroid injection and placebo injection in patients with lumbar stenosis at follow-up of 1 year with 75% of patients in the steroid group reporting significant residual pain at 1 year follow-up.

2. Johnsson KE, Rosén I, Udén A. The natural course of lumbar spinal stenosis. Clin Orthop Relat Res 1992; 279:82-86.

Patients untreated for lumbar spinal stenosis were followed out to 4 years; ~70% of patients had stable symptoms, ~15% improved and ~15% worsened without intervention.

3. Boden SD, Davis DO, Dina TS et al. Abnormal magnetic-imaging scans of the lumbar spine in asymptomatic subjects: A prospective investigation. J Bone Joint Surg Am 1990; 72:403-408.

This study established the high rate (21%) of asymptomatic subjects older than 60 with evidence of spinal stenosis on MRI emphasizing the importance of history, physical examination and clinical correlation in the diagnosis of spinal stenosis.

4. Weinstein JN, Tosteson TD, Lurie JD et al. Surgical versus Nonsurgical Therapy for Lumbar Spinal Stenosis. N Engl J Med 2008;358:794-810.

The first SPORT lumbar spinal stenosis report demonstrated improved results for surgical treatment in terms of SF-36 bodily pain scores in the intention-to-treat analysis and improved results for both SF-36 and ODI scores in the as-treated analysis at 2 years after surgery.

5. Weinstein JN, Tosteson TD, Lurie JD et al. Surgical Versus Nonoperative Treatment for Lumbar Spinal Stenosis Four-Year Results of the Spine Patient Outcomes Research Trial. Spine 2010; 35(14):1329-1338.

The 4 year SPORT follow-up study found advantages for surgical treatment using as-treated analysis with respect to SF-36 and ODI scores.

Lumbar Degenerative Spondylolisthesis

1. Matsunaga S, Sakou T, Morizono Y et al. Natural history of degenerative spondylolisthesis: Pathogenesis and natural course of the slippage. Spine 1990; 14;1204-1210.

This study reports the natural history of untreated lumbar degenerative spondylolisthesis over follow-up of more than 8 years on average and demonstrates clinical deterioration in only 10% of patients and little slip progression.

2. Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis: A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 1991; 73:802-808.

A prospective study that first established the superior results obtained when patients with spondylolisthesis are treated with fusion as opposed to decompression alone.

3. Kornblum MD, Fischgrund JS, Herkowitz HN et al. Degenerative lumbar spondylolisthesis with spinal stenosis: A prospective long-term study comparing fusion and pseudoarthrosis. Spine 2004; 29:726-733.

Patients treated for spondylolisthesis with posterolateral fusion and developed pseudoarthrosis had inferior results to those achieved solid fusion.

4. Weinstein JN, Tosteson TD, Lurie JD et al. Surgical versus Nonsurgical Treatment for Lumbar Degenerative Spondylolisthesis. N Engl J Med 2007;356:2257-70.

The 2 year follow-up data from the SPORT spondylolisthesis trial found no significant differences between surgical and non-surgical treatment in the intention-to-treat analysis likely due to patient cross but significant advantage to surgical treatment in terms of SF-36 and ODI scores.

5. Weinstein JN, Tosteson TD, Lurie JD et al. Surgical Compared with Nonoperative Treatment for Lumbar Degenerative Spondylolisthesis: Four-Year Results in the Spine Patient Outcomes Research Trial (SPORT) Randomized and Observational Cohorts. J Bone Joint Surg Am. 2009;91:1295-304.

Four years after the SPORT trial began, the as-treated analysis demonstrated maintenance of the benefit to surgery at 4 year follow-up in all primary outcome measures (SF-36, ODI).

Degenerative Scoliosis

1. Kostuik JP, Bentivoglio J: The incidence of low-back pain in adult scoliosis. Spine 6:268–273, 1981.

A correlation between curve magnitude and back pain was established although for the population of patients with curves > 10° on the whole, incidence of back pain is similar to the general population – it becomes more prevalent at higher curve magnitudes.

2. Lenke LG, Bridwell KH, Blanke K, Baldus C: Prospective analysis of nutritional status normalization after spinal reconstructive surgery. Spine 1995; 20:1359–1367.

Adult patients who underwent surgery for spinal deformity at an average of ~6 levels took 6 weeks to return to their baseline nutritional status where patients who underwent surgery at an average of 12 levels took ~13 weeks to return to baseline nutritional status.

3. DeWald CJ, Stanley T: Instrumentation-related complications of multilevel fusions for adult spinal deformity patients over age 65: Surgical considerations and treatment options in patients with poor bone quality. Spine 31:S144–S151, 2006.

Complications in patients older than age 65 who underwent ≥5 level fusions are reviewed. A ~25% rate of junctional kyphosis was reported and >10% of patients suffered early complications related to bone quality including pedicle or compression fractures.

4. Kim YJ, Bridwell KH, Lenke LG et al. Pseudarthrosis in long adult spinal deformity instrumentation and fusion to the sacrum: Prevalence and risk factor analysis of 144 cases. Spine 2006; 31:2329–2336.

Factors identified to be associated with pseudoarthrosis in the adult deformity population included: thoracolumbar kyphosis, osteoarthritis of the hip joint, thoracoabdominal approach, positive sagittal balance ≥ 5 cm at 8 weeks postoperatively, age ≥55 years and incomplete sacropelvic fixation.

5. Schwab F, Farcy JP, Bridwell K et al. A clinical impact classification of scoliosis in the adult. Spine 2006;31:2109–2114.

A classification system for adult-onset scoliosis was created in which scores correlate with measures of disability and rates of surgical intervention. Parameters considered by the classification include curve location (e.g. thoracic, thoracolumbar etc.), degree of lumbar lordosis, lateral vertebral subluxation and sagittal balance.

Discogenic Pain

1. Boden SD, Davis DO, Dina TS et al. Abnormal magnetic-imaging scans of the lumbar spine in asymptomatic subjects: A prospective investigation. J Bone Joint Surg Am 1990; 72:403-408.

35% of asymptomatic patients between 20 and 39 and 100% of asymptomatic patients older than age 60 had signs of disc degeneration on MRI emphasizing the importance of clinical judgement in treating degenerative disc disease in the lumbar spine.

2. Huang RC, Lim MR, Girardi FP, et al. The prevalence of contraindications to total disc replacement in a cohort of lumbar surgical patients. Spine 2004;29(22):2538–41.

This retrospective study demonstrated that very few patients are eligible for lumbar total disc replacement when strict guidelines are applied to potential candidates.

3. Freeman BJ, Fraser RD, Cain CM et al. A Randomized, Double-Blind, Controlled Trial: Intradiscal Electrothermal Therapy Versus Placebo for the Treatment of Chronic Discogenic Low Back Pain. Spine 2005; 30(21): 2369–2377.

This RCT found no difference between IDET and sham procedure at 6 months and no benefit to either treatment over baseline for 5 different validated outcome measures.

4. Freemont AJ. The cellular pathobiology of the degenerate intervertebral disc and discogenic back pain. Rheumatology 2009;48:5–10.

This review article presents the biological basis for disc degeneration and identifies strategies to leverage our knowledge of disc biology in the development of new treatment.

5. van den Eerenbeemt KD, Ostelo RW, van Royen BJ et al. Total disc replacement surgery for symptomatic degenerative lumbar disc disease: a systematic review of the literature. Eur Spine J 2010;19:1262–1280.

Results from 3 RCTs and 16 prospective studies comparing total disc replacement and lumbar fusion are analyzed. Overall, results are similar between TDR and lumbar fusion for degenerative disc disease and have low success rates overall for this challenging disease entity.

Cervical Spine:

Axial Neck Pain 1. Bogduk N, Windsor M, Inglis A. The innervation of the cervical intervertebral discs. Spine 1998; 13:2-8.

Dissection provided insight into the innervation of the disc by the sinuvertebral nerve adjacent to the canal and by the vertebral nerves further laterally. Histologic staining demonstrated innervation of only the outermost 1/3 of the annulus fibrosis.

2. Gore D, Sepic S, Gardner G, Murray P. Neck pain: A long term follow-up of 205 patients. Spine 1987; 21:1-5.

A long-term retrospective study of patients treated conservatively for greater than 10 years after presenting with neck pain demonstrated decrease in pain compared with on presentation in 79%. 32% still had moderate/severe pain and 43% were pain free.

3. MacNab I. Acceleration injuries of the cervical spine. J Bone Joint Surg Am 1964; 46:1707-1799.

This classic article established a high rate of neck pain in post-whiplash patients (45%). Interestingly, this group of patients had all definitively settled litigation related to their accident a minimum of 2 years prior to evaluation, a factor hoped to eliminate secondary gain influences on the reporting of symptoms.

4. Zheng Y, Liew SM, Simmons ED. Value of magnetic resonance imaging and discography in determining the level of cervical discectomy and fusion. Spine 2004; 29(19):2140-5.

MRI was found to have a high rate of false negative and false positive results based on discography. 59% of both discs with HNP and discs with annular tears had positive discography. Use of clinical suspicion, MRI and discography together is recommended.

5. Palit M, Schofferman J, Goldthwaite N, et al. Anterior discectomy and fusion for the management of neck pain. Spine 1999;24:2224-8.

This retrospective study of patients treated for axial neck pain demonstrates 79% of patients were satisfied postoperatively. Although significant improvement in VAS and ODI were reported, ~40% could not work postoperatively - expectations must be tempered in comparison to patients treated for radiulopathy.

6. Zdeblick TA, Hughes SS, Riew KD, Bohlman HH. Failed anterior cervical discectomy and arthrodesis. Analysis and treatment of thirty-five patients. J Bone Joint Surg Am. 1997; 79(4):523-32.

A series of patients undergoing revision ACDF included 23 patients with nonunion and 16 of these with significant neck pain who failed conservative treatment. Results were excellent in 20/23 demonstrating that appropriately indicated patients who failed initial surgical treatment and present with neck pain can do well after revision fusion surgery.

Cervical Radiculopathy 1. Muhle C, Resnick D, Ahn JM et al. In vivo changes in the neuroforaminal size at flexion-extension and axial rotation of the cervical spine in healthy persons examined using kinematic magnetic resonance imaging. Spine 2001; 26: e287-93.

MRI was used to visualize neuroforaminal area increase of 31% with neck flexion, decrease of 20% with neck extension and decreases of 15% and 23% with 20° and 40° of rotation, respectively.

2. Murata Y, Onda A, Rydevik B et al. Changes in pain behavior and histologic changes caused by application of tumor necrosis factor-alpha to the dorsal root ganglion in rats. Spine. 2006;31:530-5.

A series of investigations established the role of TNF-alpha as the principle agent in HNP which causes chemical irritation of the nerve roots demonstrated in this paper by both behavioral and histologic data in rats.

3. Henderson CM, Hennessy RG, Shuey HM, Shakelford EG. Posterior-lateral foraminatomy as an exclusive operative technique for cervical radiculopathy: A review of 846 consecutively operative cases. Neurosurgery 1983; 13:504-512.

In addition to reporting 91% good/excellent results, this large study reports presenting symptoms of cervical radiculopathy as a reminder of the symptom diversity: 99% arm pain, 85% sensory deficit, 80% neck pain, 70% reflex changes, 68% motor weakness, 52% scapular pain, 18% chest pain, 10% headache, 6% anterior chest/arm pain.

4. Robinson R, Walker A, Ferlic D. The results of anterior interbody fusion of the cervical spine. J Bone Joint Surg 1962; 44:1569-1587.

This classic paper is the first large series describing outcomes after ACDF using the technique described by Robinson & Smith and reports 73% good/excellent resultswith 22% fair and 6% poor. These numbers have largely been confirmed in subsequent series.

5. Wang JC, McDonough PW, Endow KK, Delamarter RB. Increased fusion rates with cervical plating for two-level anterior cervical discectomy and fusion.

Use of anterior plates in 2 level ACDF was associated with decreased rate of pseudarthrosis and less graft collapse in comparison to ACDF performed without anterior plating in this retrospective study. A similar conclusion was found in a subsequent paper for 3 level ACDF.

6. Krupp W, Schattke H, Muke R. Clinical results of the formainotomy as described by Frykholm for the treatment of lateral cervical disc herniation. Acta Neurochir 1990; 107:22-29.

Retrospective evaluation of 230 patients demonstrated good results in: 98% of patients treated for soft disc lesions, 91% of patients with mixed hard/soft lesion, and 84% of patients treated for hard disc lesions.

Cervical Myelopathy 1. Lees FT, Turner JW. Natural history and prognosis of cervical spondylosis. BMJ 1963; 2:1607-1610 .

The natural history of 44 patients treated nonoperatively is described. Patients presenting with severe myelopathy remained severely disabled, and the overall natural history was characterized by shorter periods of symptom progression with intervening periods of symptom stability.

2. Hukuda S, Wilson CB. Experimental cervical myelopathy: effects of compression and ischemia on the canine cervical cord. J Neurosurg. 1972; 37: 631-652.

Cervical spinal cords in dogs were compressed to determine the amount of compression which would cause myelopathic-like symptoms – 45%. This study also demonstrated the role that restriction of blood flow during cord compression plays in cord injury.

3. Pavlov H, Torg JS, Robie B, Jahre C. Cervical spinal stenosis: determination with vertebral body ratio method. Radiology. 1987;164:771-5.

Measurement of cervical spine lateral radiographs in athletes who suffered transient neuropraxia established a spinal canal diameter/vertebral body diameter ratio of 1.0 as normal and <0.8 as consistent with cervical spinal stenosis and an elevated injury risk.

4. Emery SE, Bohlman HH, Bolesta MJ, Jones PK. Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy. Two to seventeen-year follow-up. J Bone Joint Surg Am. 1998;80:941-51.

Results after operative treatment are heavily dependent on preoperative function. “The strongest predictive factor for recovery from myelopathy was the severity of the myelopathy before the operative intervention.”

5. Hilibrand AS, Fye MA, Emery SE et al. Increased rate of arthrodesis with strut grafting after multilevel anterior cervical decompression. Spine 2002; 27: 146-151.

A comparison of multi-level ACDF with corpectomy and strut grafting demonstrated higher fusion rates in corpectomy and strut grafting. The authors attributed this to fewer bony interfaces to heal and greater healing/stability with strut recession into a trough.

6. Imagama S, Matsuyama Y, Yukawa Y et al. C5 palsy after cervical laminoplasty: a multicentre study. J Bone Joint Surg Br. 2010; 92(3):393-400.

This study identified factors associated with C5 palsy in a cohort of 43 patients who developed postoperative C5 palsy out of 1858 total patients (2.3%) treated with laminoplasty. Factors identified were smaller C5 neural foramen, larger superior articular process and more postoperative posterior shift of the cord after decompression.

Ossification of the Posterior Longitudinal Ligament 1. Matsunaga S, Sakou T, Taketomi E et al. The natural course of myelopathy caused by ossification of the posterior longitudinal ligament in the cervical spine. Clin Orthop. 1994; 305:158-177.

This study with an average follow-up of greater than 10 years demonstrated 66% of patients remained free of myelopathy and ~40% of patients who were myelopathic on presentation demonstrated symptom progression.

2. Harsh GR 4th, Sypert GW, Weinstein PR et al. Cervical spine stenosis secondary to ossification of the posterior longitudinal ligament. J Neurosurg. 1987; 67(3):349-57.

Although OPLL is often considered an exclusively Japanese disease, this report documents OPLL in 17 non-Asian Americans seen over 3 years at two hospitals in California and Florida, 10% of the myelopathic patients seen during that time period.

3. Ono K, Yonenobu K, Miyamoto S, Okada K. Pathology of ossification of the posterior longitudinal ligament and ligamentum flavum. Clin Orthop Relat Res. 1999;(359):18-26.

A description of the pathophysiology of OPLL is provided and the role of BMP and TGF-β in pathogenesis is discussed.

4. Matsunaga S, Sakou T, Hayashi K et al.Trauma-induced myelopathy in patients with ossification of the posterior longitudinal ligament. J Neurosurg 2002; 97(supp2):172-175.

Out of a cohort of patients with OPLL, the only patients who developed myelopathy without a history of trauma had >60% of their canal occupied by OPLL confirming this amount of compression as a threshold for the development of neurological symptoms.

5. Yamaura I, Kurosa Y, Matsuoka T et al. Anterior floating method for cervical myelopathy caused by ossification of the posterior longitudinal ligament. Clin Orthop 1999; 359:27-34.

This technique paper describes the floating method and reports 71% rate of neurological recovery in a cohort of Japanese patients treated for OPLL.

Pediatric Spine AAOS Review Course

David L. Skaggs, MD, Professor and Chief of Orthopaedic Surgery Childrens Hospital Los Angeles University of Southern California School of Medicine Endowed Chair of Pediatric Spinal Disorders

www.childrensorthopaediccenter.com 4650 Sunset Blvd, #69 Los Angeles, California, 90027 323-361-4658 fax 323-361-1310

I. Idiopathic scoliosis a. Definition = coronal plane deformity of >10 degrees by Cobb method with no known

cause. i. Normal thoracic kyphosis is 20-45 degrees with normal lumbar lordosis of 30-60

degrees. ii. Genetics: autosomal dominance with variable penetrance.

b. Infantile Idiopathic scoliosis = Age 0-2 years at onset i. Males>female

ii. Risk of progression overall 10%. Those curves with apical rib-vertebra angle difference (RVAD) or Mehta angle greater than 20 degrees, and apical rib phase 2 (overlap of the rib head with the apical vertebral body) are at the greatest risk of progression.

iii. Most common curve location is in thoracic spine with 75% of curves being left convex,

iv. 22% of patients with curve >20 degrees have neural axis abnormality, of which approximately 80% will require neurosurgical care.

v. can dramatically impair alveolar growth and thoracic cage development causing significant cardiopulmonary impairment with restrictive lung disease, and possibly cor pulmonale.

vi. AVOID long spine fusion <8years vii. Patients with RVAD >20 degrees and Cobb angle >30 degrees are at high risk of

progression. Bracing or casting should be considered when the Cobb is >20-30 degrees.

viii. Growing implants may help pulmonary function, weight gain, etc

ix. To measure the rib-vertebra angle difference (RVAD), a line is drawn perpendicular to the end plate of the apical vertebrae (a). Next, a line is drawn from the midpoint of the neck of the rib through the midpoint of the head of the rib to the perpendicular on the convex side (b). The resultant angle is calculated. The angle on the concave side is calculated in a similar manner. Concave – convex = RVAD. Mehta MH: The rib-vertebra angle in the early diagnosis between resolving and progressive infantile scoliosis. J Bone Joint SurgBr 1972;54:230-243.)

Spine problems in children David L. Skaggs, MD 2

i. Thoracic insufficiency syndrome (TIS) is defined as the inability of the thorax to support normal respiration or lung growth, and is usually associated with significant scoliosis (idiopathic or congenital), a shortened thorax, rib fusions or rib aplasia, or poor rib growth (Jeunes syndrome) . Jarco-Levin syndrome, extensive congenital fusions of the thoracic spine, is a common cause of TIS, with two important subtypes: spondylothoracic dysplasia (primarily vertebral involvement) and spondylocostal dysplasia (fused or missing ribs). Left untreated TIS can cause significant cardiopulmonary insufficiency or an early demise.

c. Juvenile Idiopathic scoliosis = Age 3-10 years at onset i. 95% of curves will progress. Incidence of neural axis abnormalities is 20-25%;

hence MRI necessary. ii. Bracing is usually started for juveniles with curves >20 degrees, and adolescents

>25 degrees; smaller curves are treated with observation.

d. Adolescent Idiopathic scoliosis i. Polygenetic interaction is suspected

ii. Female:male ratio is 1:1 for small curves, but increases to 10:1 for curves >30 degrees.

1. Risk of progression related to curve size and remaining skeletal growth, 2. Girls at greatest risk for progression are premenarchal, Risser grade 0,

with open triradiate cartilage. 3. Peak height velocity generally occurs prior to Risser 1. Peak height

velocity in adolescence is approximately 10 cm/year and occurs just prior to the onset of menses in females.

iii. Long-term implications of scoliosis is dependent upon the size of curve at skeletal maturity. Thoracic curves >50 degrees and lumbar curves >45 have been shown progress up to a mean of 1 degree/year after skeletal maturity.

iv. Larger curves >60 degrees can have a negative impact on pulmonary function tests but symptomatic cardiopulmonary impact traditionally develops in curves >90 degrees.

v. A mild increase incidence of backpain is likely in significant curves in adulthood

e. Evaluation i. Scoliometer measurement >5 degrees, 2-5% false negative rate of missing curve

>20 degrees and a 50% false positive rate (curve <20 degrees) ii. Physical examination should include detailed neurological examination of lower

extremities (sensory exam, motor exam and reflexes). Skin evaluation should inspect for café-au-lait spots (neurofibromatosis).. Lower extremity evaluation should rule out cavovarus feet (associated with neural axis abnormalities), and document normal strength, gait and coordination. Hairy patches, dimples, nevi, tumors, over the spine or may be indicative of spinal dysraphism. Dimples outside of the gluteal fold are generally benigh. Asymmetrical abdominal reflexes are associated with a syrinx, and an indication for an MRI of the spine.

iii. iv. Plain radiographic evaluations include 36 inch cassettes in the posterioanterior

(PA) and lateral projections in the upright position. Bending or traction films are useful for surgical planning.

v. Indications for MRI of spine to rule out an intraspinal anomalies (tethered cord, syringomyelia, dysraphism, and spinal cord tumor) include atypical curve patterns (e.g. left thoracic curve, short angular curves, absence of apical thoracic lordosis, absence of rotation and congenital scoliosis), patients <10 years of age with a curve >20 degrees, abnormal neurologic finding on examination, abnormal pain, rapid progression of curve (>1 degree/month). Intraspinal anomalies are referred for evaluation by neurosurgeon.

Spine problems in children David L. Skaggs, MD 3

f. Classification 1. Adolescent (>10 years of age): Accounts for 80% of IS. Prevalence is

2-3% for curves 10-20 degreees and 0.3% for curves greater than 30 degrees.

ii. Curve location: cervical (C2-C6), cervicothoracic (C7- T1), thoracic (T2-T11/12 disc), thoracoluumbar (T12-L1) and lumbar (L1-2 disc to L4).

iii. Classification of adolescent idiopathic scoliosis 1. King - not commonly used

2. Lenke classification has 6 major curve types with modifiers for the lumbar curve and amount of thoracic kyphosis (T5-T12).

Spine problems in children David L. Skaggs, MD 4

g. Treatment recommendations are based on the natural history of scoliosis. i. Non-operative

1. Bracing is used for skeletally immature patients (Risser 0, 1 or 2) and recommended for 16-23 hours/day and continued until completion of skeletal growth or curve progresses to greater than 45 degrees (at which point bracing is no longer considered effective). Aim of bracing is to halt progression of curve during growth, not to correct scoliosis. Thoracic hypokyphosis is relative contraindication for bracing. Underarm brace or thoracolumbosacral orthosis (TLSO) is most effective when curve apex at T7 or below. The efficacy of brace treatment is controversial.

ii. Operative 1. Thoracic curves >45-50 degrees. 2. Lumbar Curves > 45 degrees or marked trunk imbalance with curve

>40 degrees (relative) 3. Spine fusion with spinal implants and bone graft is gold standard.

Posterior more common than anterior. 4. Complications

a. Crankshaft phenomena: Progression of spine deformity after a solid posterior fusion due to continued anterior spinal growth. Can be avoided by concomitant anterior spine fusion at the time of posterior fusion.

b. Infections occur in up to 5% of cases. Early infection (<6 months post-op) is treated with irrigation and debridment, and antibiotics, without removal of implants as fusion is assumed to not have occurred. Chronic deep infections of the spinal implants are treated with implant removal and intravenous antibiotics, though progression of deformity over time may occur.

c. Neurologic injury has an incidence of up to 0.7%as a result of compressive, tensile or vascular phenomenon. Current recommendations are for intra-operative spinal cord monitoring of SSEP and NMEPs.

d. Decreased pulmonary function has been reported following anterior fusions and posterior thoracoplasties. Thoracoscopic approaches to the thoracic spine have less negative impact on pulmonary function than open thoracotomy. Similarly open anterior thoracolumbar fusions have less impact than open thoracic fusion.

5. Spinal cord monitoring a. Spinal-cord monitoring is current standard of care utilizing

both somatosensory evoked potentials (SSEP), which will detect many but not all neurologic difficulties, and motor evoked potentials (MEP), which can detect neurologic injury earlier than SSEPs. Monitoring of the upper extremities with SSEPs can identify positional injury to the upper extremity, which is the most likely intraoperative neurologic deficity to be reversible.

b. When spinal cord monitoring suggests neurologic injury: i. suspect technical problems

1. loose electrodes 2. uses inhalational agents

ii. real neurological problems

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1. if changes occurred following deformity correction, reverse or lessen the correction

2. raise blood pressure 3. if hematocrit is low give a blood transfusion 4. give intravenous steroids (i.e. solumedrol

30 mg/kg bolus, and 6.5mg/kg x 23 hours 5. wake-up test 6. if all else fails, remove instrumentation if

spine is stable.

II. Congenital scoliosis a. Overview (Epidemiology)

i. Genetics: No specific inheritance pattern; isolated occurrences. ii. Estimated incidence in general population is 1-4%.

b. Pathoanatomy i. Divided into three categories: failure of formation, failure of segmentation and

mixed. 1. Unilateral unsegmented bar associated with a contralateral

hemivertebra has the worst prognosis for development of scoliosis. 2. Best prognosis are the block vertebra (bilateral failure of segmentation). 3. Presence of congenital vertebral anomaly in thoracolumbar region with

fused ribs have a high risk of progression. 4. Incarcerated hemivertebrae do not cause scoliosis as deficiencies above

and below the hemivertebrae compensate.

ii. Progression of deformity correlates with growth which is rapid the first 3 years

of life.

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c. Evaluation i. Associated systemic abnormalities are present in up to 61% of patients with

vertebral anomalies: congenital heart defects (26%), congenital urogenital defects (21%), limb abnormalities (hip dysplasia, limb hypoplasia, Sprengel’s deformity), anal atresia, hearing deficits, and facial asymmetry. Approximately 38-55% of patients with vertebral anomalies present with a constellation of defects that constitute a syndrome, such as VACTERL (formally called VATER) (vertebral anomalies, anorectal anomalies, cardiac defect, tracheo-esophageal fistula, renal and vascular anomalies, and limb defects) and Goldenhar syndromes (dysplastic or aplastic ears, eye growths or absent eye, asymmetric mouth/chin, usually affecting one side or face). Work-up of patient with congenital scoliosis includes renal evaluation (MRI or ultrasound) and cardiology evaluation.

ii. MRI is indicated for patients with congenital spinal deformity due to the incidence of neural axis abnormality in 20-40% (Chiari type 1 malformation, diastematomyelia, tethered spinal cord, syringomyelia, low conus and intradural lipoma). MRI in young children who would require general anesthesia may be delayed if the curve is not progressive or requiring surgery.

d. Treatment

i. Non-operative: Bracing has no effect on the congenital scoliosis. . ii. Operative

1. Indications: significant progression of scoliosis, or known high risk of progression – such as a unilateral bar opposite a hemi-vertebrae, declining pulmonary function and neurologic deficit.

2. Contraindications to operative intervention includes poor skin at operative site, minimal soft tissue coverage over spine, and significant medical comorbidities.

3. Procedures a. Unilateral unsegmented bars with minimal deformity are best

treated with early in situ arthrodesis, either anterior and posterior or posterior alone., .

b. Progressive fully segmented hemivertebra in children <5 years of age with <40 degree curve without notable spinal imbalance have traditionally been treated with an in situ anterior and/or posterior contralateral hemiepiphyseodesis with hemiarthrodesis.

c. Hemivertebra excision is recommended for patients with progressive curve with marked trunk imbalance caused by a hemivertebra This technique has the best results when patients <6 years of age with flexible curves<40 degrees.

d. Anterior and/or posterior osteotomy/vertebrectomy approaches for more severe, rigid deformities, fixed pelvic obliquity or decompensated deformities that present late.

e. Growing rod constructs may attach to the spine and/or ribs and attempt to control deformity and encourage spinal growth. Better results are reported with lengthening the construct about every 6 months

4. Complications a. Iatrogenic shortening of spinal column due to fusion. Younger

age at surgery and more levels fused creates greater impact on growth. The goal of growth constructs is to optimize spinal growth.

b. Neurologic injury can occur secondary to overdistraction or overcorrection, harvesting of segmental vessels, spinal implant intrusion into the canal

Spine problems in children David L. Skaggs, MD 7

c. Soft-tissue problems over the spinal implants. These children often have minimal subcutaneous tissue volume to safely pad the implants, especially those with pulmonary compromise. Pre-operative nutrition maximization is vital.

5. Pearls and pitfalls. a. Due to the significant number of children with congenital

scoliosis which have concomitant cardiopulmonary, renal and neurological issues a multi-disciplinary approach is commonly necessary – particularly pulmonary.

b. Operative treatment is prone to complications due to multiple factors. Preoperative discussions are essential to convey the complexity of the child’s spinal problem and its treatment.

c. The importance of nutrition in this population can not be over-emphasized.

iii. Klippel-Feil syndrome is characterized by failure of segmentation in the cervical spine with a short, broad neck, torticollis, scoliosis, low hairline posteriorly, high scapula, and jaw anomalies.

1. Sprengel deformity seen in 33% of patients with Klippel-Feil. 2. 70% will develop scoliosis

III. Kyphosis a. Overview (Epidemiology)

i. Most common types are postural, Scheuermann’s and congenital kyphosis. ii. Incidence of Scheuermann’s kyphosis is 1-8% with a male:female ratio between

2:1 and 7:1. iii. Scheuermann’s kyphosis is defined as thoracic hyperkyphosis due to three

consecutive vertebra with >5 degrees of anterior wedging (Sorensen’s criteria). An increased kyphosis with gibbus on clinical exam may be considered diagnostic.

b. Pathoanatomy i. Scheuermann’s kyphosis is believed to be a developmental error in collagen

aggregation leading to disturbance of enchondral ossification of the vertebral end plates. This leads to wedge-shaped vertebra and increased kyphosis. Most common in thoracic spine; less common in lumbar spine. The natural history of Scheuermann’s kyphosis in adults with mild forms of the disease (mean 71 degrees) is more back pain than controls, but the back pain rarely interferes with daily activities or professional careers. More severe deformities (>75 degrees) are more likely cause severe thoracic pain. Genrally pulmonary compromise is not a conern unless kyphois reaches >100 degrees .

ii. Congenital kyphosis divided into failure of formation (type I), failure of segmentation (type II), mixed (type III) and rotatory/congenital dislocation of spine (type IV). Type III (mixed) has worst prognosis for sagittal plane deformity. Rate of progression is 7-9 degrees/year for type I and 5-7 degrees for type II. Greatest risk of neurologic injury in type I (failure of formation) and type III (mixed).

c. Evaluation i. Normal thoracic kyphosis is 20-45 degrees with no kyphosis at thoracolumbar

junction. ii. Presentation is usually due to cosmetic concerns or pain which can be at thoracic

region or in hyperlordotic lumbar spine. Thoracolumbar is typically painful, whereas thoracic is typically not painful. Patients with congenital and Scheuermann’s kyphosis will clincally demonstrate an acute gibbus at the site of pathology.

iii. Patients with postural kyphosis have more gentle, rounded contour (without gibbus) of the back and may have up to 60 degrees of kyphosis.

Spine problems in children David L. Skaggs, MD 8

iv. Classic plain radiographic findings in Scheuermann’s are vertebral endplate abnormalities, loss of disc height, Schmorl’s nodes and wedged vertebra. The lumbar spine needs to be evaluated to rule out concomitant spondylolisthesis.

v. MRI indicated for all congenital kyphosis, which has a 56% incidence of intraspinal anomalies.

vi. MRI may be indicated preoperatively in Scheuermann’s kyphosis to rule potential thoracic disc herniation, epidural cyst or spinal stenosis which may cause neurologic symptoms at the time of deformity correction.

d. Classification. Kyphosis is generally Scheuermann’s may be (thoracic or thoraco lumbar), or congenital. Les commonly, it may be secondary to trauma, infection, or at the junction of spine instrumentation.

e. Treatment i. Non-operative

1. Congenital kyphosis: Bracing is ineffective. 2. Bracing of Scheuermann’s kyphosis can be effective if >1 year of

growth remaining and kyphosis is between 50 and 70 degrees with apex at or below T7. Bracing is continued for minimum of 18 months. Pain can respond to physiotherapy and non-steroidal anti-inflammatory medications. Patient noncompliance with bracing is common.

3. ii. Operative

1. Indications: a. In congenital kyphosis surgery is indicated for most with

failure of segmentation or mixed, especially those with neurologic deficits. For those with failure of formation, an indication for surgery is progressive local kyphosis over 40 degrees or neurologic symptoms..

b. Scheuermann’s kyphosis relative indications for surgery are kyphosis >75 degrees, deformity progression, cosmesis, neurologic deficits, and significant pain unresponsive to nonsurgical management.

2. Procedures a. In congenital kyphosis, children with failure of segmentation

who are < 5 years of age with <55 degrees kyphosis, posterior fusion is recommended to stabilize the kyphosis and permit some correction. Anterior decompression (which may be performed through a posterior approach) is performed for compromised neural structures..

b. Scheuermann’s kyphosis surgery is a posterior spinal fusion with instrumentation. Anterior release has been recommended for deformities which do not correct to >50 degrees on hyperextension lateral radiograph over an apical bolster. Newer thoracic pedicle screw constructs withmulitple posterior osteotomies may obviate need for anterior releases. Traditional recommendations are to limit correction to <50% of deformity to prevent proximal or distal junctional kyphosis or implant pull-out

3. Complications a. Neurologic injury (paralysis, nerve root deficit) can occur due

mechanical impingement or stretch of cord, by spine implants or bony/soft-tissue structure, or vascular. Anterior approaches to the thoracic spine can injure the artery of Adamkiewicz, the main blood supply to the T4-T9 spinal cord, generally arising in the variable position from T8-L2 on the left.

Spine problems in children David L. Skaggs, MD 9

b. Junctional kyphosis occurs in 20-30% of patients, though this is usually not clinically significant

4. Pearls and pitfalls a. do not try to correct more than 50% b. the lower end of the instrumentation should include the first

vertebrae crossed by verticle line from posterior-superior corner of S1

c. winds segmental pedicle screws are used in combination with multiple posterior osteotomies, anterior approaches may generally be avoided

IV. Spondylolysis/Spondylolisthesis

a. Overview (Epidemiology) i. Incidence of spondylolysis is 6% (males > females). Incidence of 53% in

eskimos. Or a ii. 25% of spondylolysis have associated spondylolisthesis.

iii. Primarily effects L5 (in 87% to 95% of patients) and less frequently L4 (in up to 10%) and L3 (in up to 3%).

b. Pathoanatomy i. Spondylolysis is an acquired condition presumed to be a stress fracture through

pars interarticularis. ii. Spondylolisthesis is anterior slippage of one vertebra relative to another and is

most common in lumbar spine. iii. Progression associated with adolescent growth spurt, lumbosacral kyphosis (slip

angle >40 degrees), higher Meyerding grade (>2 or >50% translation), younger age, female gender, dysplastic posterior elements and dome-shaped sacrum.

c. Evaluation i. Back pain is usually localized to the lumbosacral area though may run down the

legs ii. Pain is exacerbated lumbar extension activities and improved with rest.

iii. Physical examination findings include paraspinal muscle spasms, tight hamstring and limited lumbar mobility. High-grade spondylolisthesis can have waddling gait and hyperlordosis of lumbar spine. Most common nerve root affected by a spondylolisthesis at L5-S1 is the L5 nerve root.

iv. Oblique radiographs, in addition to AP and lateral views, may aid in identifying pars defects which has been described as the “Scotty dog sign”, but radiographs may miss up to 50% of spondys. CT is best for assessing bone involvement. Single photon emisssion CT (SPECT) is highly sensitive for active pars defects. MRI is suboptimal for evaluating pars defect, but they have a role in assessing nerve entrapment

Spine problems in children David L. Skaggs, MD 10

Classification v. Wiltse system based on etiology: dysplastic (congenital) (type 1), isthmic

(acquired )(type 2), degenerative, traumatic, pathologic, iatrogenic. Most common in adolescents is the isthmic type (type 2) which occurs 85-95% of time at L5, with 5-15% of time at L4.

vi. Meyerding grade: based on amount of forward slippage of superior vertebra on inferior vertebra and reported in quadrants. Grade 5 is spondyloptosis, or 100% translation anteriorly of the superior vertebra.

d. Treatment

i. Non-operative 1. Asymptomatic patients with spondylolysis and grade 1-2

spondylolisthesis do not require treatment or activity restrictions. 2. Symptomatic patients (spondylolysis and grade 1-2 spondylolisthesis)

are treated with lumbosacral orthoses for up to 4-6 months. a. Return to sports after core strengthening

ii. Operative 1. Indications for surgery include uncontrolled pain (after nonoperative

management), neurologic symptoms (ie. radicular symptoms or cauda equina syndrome), > grade 2 slip or progressive slip to grade 2 (50% slip).

2. Procedures

a. Spondylolysis can be treated with pars repair. If disc dessication present (dark disk) then L5-S1 fusion should be performed.

b. Posterolateral fusion (with or without instrumentation) may be performed for spondylolysis and spondylolisthesis. The deformity in uninstrumented fusions may progress over many years. . Pedicle screw constructs may increase fusion rates and decrease postoperative slip progression.

c. In the presence of neurologic deficit,nerve decompression is generally recommended, though neurological improvement has been demonstrated by in situ fusion alone.

d. Indications for reduction are controversial with no universally-accepted guidelines. Reduction of spondylolistheses of greater than 50% is associated with L5 nerve root stretch and neurological injury!

3. Complications

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a. Drop foot - L5 nerve root injury 4. Pearls and pitfalls

a. 5% of the population has this condition, and most are asymptomatic.

i. Even though a patient has spawned a spondy, continue to look for other causes of back pain if the clinical picture is not typical.

ii. The endpoint of treatment in a slip less than 50% is lack of pain, not necessarily radiographic demonstration of healing

V. C-spine a. Torticollis

i. Congenital Muscular 1. Think hips - 5 % DDH 2. x-ray to look for congenital 3. resolves with PT in first year of life 95% 4. release sternocleidomastoid bipolar if needed.

ii. Acquired torticollis 1. most often muscle strain/spasm and self resolving 2. non-resolving, severe or traumatic often from C1C2 subluxation

a. many causes including trauma (even minor), Grisel's syndrome, ophthalmologic, vestibular, CNS tumor or dysfunction. Its etiology is presumed secondary to compartment syndrome.

b. If a tight sternocleidomastoid is not present, look for other causes

c. Dx: dynamic CT d. Treatment

i. < 1 wk soft collar ii. 1-4 wks traction

iii. >4wks surgical fusion iv. Can be reduced safely with pinless halo with pt

awake b. Trauma

i. 87% C3 and above at <8years - different from adults ii. 33% with neruologic injury

iii. SCIWORA - may be delayed iv. Pseudo subluxation of C2-C3. Swischuk’s line connects the spinolaminar

junction of C1 to C3. As long as the spinolamiar junction of C2 is no more than 1mm anterior to this line the subluxation is physiologic.

v. Anterior soft-tissue welling normal from crying. On a lateral radiograph the retropharyngeal space should be less than 6 mm at C2 and less than 22mm at C6, though these both may be enlarged due to crying, and is not necessarily a sign of underlying injury in children.

vi. Atlanto Dens interval 1. Children <4.5 mm normal 2. Downs Syndrome

a. <10 mm OK if no symptoms b. 25% mortality in two surgical series

vii. Os Odontoidium 1. Very common 2. ? Old trauma? 3. OK if stable

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c. pitfall:Posterior cervical fusions in children have high union rate with iliac crest bone grafting, and nonunions reported with allograft.

VI. Disc Conditions in Children .

a. Endplate fractures i. often missed on MRI - remember disc problems uncommon in

children/adolescents ii. VERY painful

b. Intervertebral disc calcification -most common in cervical spine. i. present with neck pain, fevers, increased ESR and DRP

ii. normal neurologic examination. iii. treated with analgesics. Biopsy and antibiotics not needed. Calcifications

usually resolve over 6 months. c. Discitis

i. ii. Pathoanatomy: Presumed infection likely begins by seeding the vascular

vertebral endplate and then extending into disc space iii. Evaluation

1. Symptoms: fever, back pain, abdominal pain, refusal to ambulate, painful limp and lower extremity discomfort.

2. 25% will be febrile. 3. Laboratory studies of erythrocyte sedimentation rate and C-reactive

protein will be elevated. 4. Radiographs can demonstrate disc space narrowing with vertebral

endplate irregularities. Further imaging generally not needed.

iv. typical organism is Staphylococcus aureus. Must consider histiocytosis X (the “great imitator”)

v. Treatment 1. Non-operative treatment typically parenteral antibiotics (to cover

Staphylococcus aureus) for 7-10 days then switch to oral antibiotics for several more weeks. Failure to respond to antibiotics should undergo biopsy for cultures and pathologic tissue evaluation

2. Think of salmonella in the setting of sickle cell anemia. a.

VII. Back pain i. Overview (Epidemiology): Over 50% of children will experience back pain by

the age of 15 years with 80-90% resolving within 6 weeks. Table 1, JAAOS, vol 13, no6, oct 2005 p373 differential diagnosis

ii. Pathoanatomy 1. in children less than 10 years of age, consider serious underlying

pathology, although standard mechanical back pain is still most common.

2. Older children and adolescents will commonly suffer suffer “adult” low-back pain.

3. Spinal deformities (scoliosis and kyphosis) can cause pain. 4. Consider intra-abdominal pathology such as pyelonephritis,

pancreatitis, and appendicitis. 5. Studies suggest more weight in a backpack is associated with a higher

incidence of backpain. 6.

iii. Evaluation 1. Pain at night traditionally associated with tumors. 2. Visceral pain is not relieved by rest or exacerbated by activity.

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3. Detailed musculoskeletal, abdominal and neurologic exam 4. Imaging studies

a. Plain radiographs b. Technetium bone scan: helpful to localize tumor, infection or

fracture c. CT scan best for bone problems (spondylolysis) d. MRI recommended for any neurologic signs or symptoms.

5. Laboratory studies such as complete blood counts, C-reactive protein, erythrocyte sedimentation rate, peripheral smear are indicated for patients with back pain and constitutional symptoms.

iv. Classification 1. Possible specific causes include discitis, spinal deformity (scoliosis and

kyphosis), neoplasms, spondylolysis/spondylolisthesis, disc herniations and vertebral apophyseal end-plate fracture.

2. Posteriorly, common tumors include osteoid osteoma, osteoblastoma, and aneurysmal bone cyst.. Anteriorly, histiocytosis X has predilection for vertebral body causing vertebrae plana

3. Figs 2,4 &5, JAAOS, vol 13, no6, oct 2005 p374 differential diagnosis note – although this is a lot, these are pics likely to show up on tests.

4. 5. Most common malignant cause of back pain is leukemia.

v. Treatment 1. Non-operative

a. b. Osteoid osteomas are initially treated with NSAIDs and

observation. 2. Operative

a. Indications i. Lumbar disc herniation with neurologic symptoms or

is unresponsive to nonoperative management for minimum of 6 weeks.

ii. Osteoid osteomas: failure of nonoperative pain management. Radioablation is not commonly used in the spine for fear of him? risking neurologic injury

iii. Osteoblastomas do not respond to nonoperative interventions

b. Contraindications c. Procedures

i. Benign bone lesions can be marginally excised. d. Complications e. Pearls and pitfalls-included in the table below f. Table: red flags for pathologic back pain

i. History 1. pain is well localize-positive finger test-

patient points to pain in one location with one finger

2. pain is progressively worsening over time 3. pain not associated with activities, and

present at rest or nighttime 4. bowel or bladder incontinence

ii. physical exam 1. tight hamstrings-popliteal angle over 50° 2. localized bony tenderness 3. neurologic abnormalities

3.

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VIII. Spine trauma Addendum: MORE DETAIL THAN IN TALK - JUST FYI - THIS

SUBJECT FREQUENTLY APPEARS ON TESTS a. Overview (Epidemiology)

i. Cervicall spine accounts for 60% of pediatric spinal injuries. ii. Mortality from cervical injury in pediatric trauma victims is 16-17%.

iii. Overall the most common mechanism of injury are motor vehicle crashes. Toddlers and school-age children are injured most commonly in falls, while adolescents also suffer sports-related injuries.

b. Pathoanatomy: i. Increased risk of cervical spine injuries in children <8 years of agedue to larger

head-to-body ratio, increased ligamentous laxity, relatively horizontal facet joints.

ii. 87% of children <8 years have injuries at C3 or higher and have a higher mortality rate compared to children >8 years of age. Mortality rates range from 17% at C1 to 3.7% at C4.

iii. The immature spinal column can stretch up to 5 cm without rupture; the spinal cord ruptures at 5-6 mm of traction.

iv. 33% of children with cervical spine injury will manifest evidence of neurologic deficit.

v. 42% of children with spinal injury have injuries to other organ systems.

c. Evaluation i. Initial management: Transport on backboard with cutout for occiput or mattress

to elevate body to prevent inadvertent flexion of cervical spine due to disproportionately large head.

ii. Physical examination consists of detailed neurologic examination to include sensation (look for sacral sparing) and motor function, reflexes (absence of anal wink indicates spinal shock). Upper cervical spine injuries should be suspected in young children with facial fractures and head trauma

iii. Imaging starts with plain radiographs of the injured region. iv. Atlantoaxial instability is evaluated with and the ADI (atlanto-dens interval).

ADI should be <5mm in children . When ADI >10mm all ligaments have failed, creating cord compression due to negligible SAC. Instability of the subaxial

cervical spine should be suspected with intervertebral angulation of >11 degrees or translation of >3.5 mm. It is crucial to always visualize the C7-T1 junction on the lateral view. 3-dimensional imaging: CT and MRI help to assess injury

and amount of spinal canal intrusion. v. Atlanto-occipital junction injuries are assessed with Powers ratio, C1-C2:C2-C3

and BAI (Basion-Axial Interval). Powers ratio is determined by the ratio of the line from the basion to the posterior arch of the atlas and a second line from the opisthion to the anterior arch of the atlas. Ratio of >1.0 or less than 0.55 respresents disruption of atlanto-occipital joint. The C1-C2:C2-C3 ratio (interval between the posterior arches) which is <2.5 in normal children. The BAI is the distance from the basion to the tip of the odontoid and should be less than 12 mm in all children.

vi. d. Classification

i. Cervical 1. Atlanto-occipital junction are rare, but commonly fatal injuries which

are highly unstable ligamentous injuries. Common mechanism are motor vehicle crashes and pedestrian-vehicle.

2. Atlas fractures (aka “Jefferson” fractures) are uncommon injuries which are usually due to axial loading. Neurologic dysfunction atypical. Widening of lateral masses of more than 7 mm beyond the

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borders of the axis on the AP view indicates injury to travsverse ligament

3. Atlantoaxial injuries are usually ligamentous injuries to the main stabilizers (transverse ligament) or secondary stabilizers (apical and alar ligaments).

4. Odontoid fractures usually occur through synchondrosis by a flexion moment causing anterior displacement.

5. Hangman’s fractures are usually due to hyperextension causing angulation and anterior subluxation of C2 on C3.

6. Lower (C3-7) cervical spine are more common in adolescents. ii. Thoracolumbar

1. Flexion injuries: result in compression or burst fractures. Compression fractures rarely exceed more than 20% of vertebral body. When loss of vertical height >50% consider burst fracture, and obtain CT scan.

2. Distraction and Shear: highly unstable and usually associated with spinal cord injury.

3. Chance fractures: caused by hyperflexion over automobile lap belt and frequently associated with intra-abdominal injuries.

4. Spinal Cord Injury Without Radiographic Abnormality (SCIWORA): MRI is study of choice, but may be normal in 25%. Is the cause of paralysis in approximately 20-30% of children with injuries of the spinal cord. Approximately 50% have delayed onset of neurologic symptoms or late neurologic deterioration. Children <10 years are more likely to have permanent paralysis than older children.

e. Treatment i. Non-operative:

1. Cervical a. Intervertebral disc calcification treated with rest and NSAIDs b. Atlas fractures: treat with cervical collar or halo

2. Thoracolumbar a. Compression fractures: Bracing for 6 weeks. b. Burst fractures: If stable, then bracing. c. Chance fractures with <20 degrees of segmental kyphosis can

be treated in a hyperextension cast. d. SCIWORA: Immobilization for 6 weeks to prevent further

spinal cord injury. ii. Operative

1. Indications: a. Cervical

i. Craniocervical instability ii. Atlantoaxial instability with ADI >5mm

iii. Odontoid fracture displaced iv. Displaced and angulated hangman’s fracture

b. Thoracolumbar burst fractures with neurologic injury and canal compromise.

c. Distraction and shear injuries with displacement. d. Chance fractures which are purely ligamentous injuries and

bony injuries with >20 degrees kyphosis. 2. Contraindications 3. Procedures

a. Craniocervical instability is treated with an occiput to C2 fusion with halo stabilization, preferably with internal fixation.

b. Atlantoaxial instability requires a C1-C2 posterior fusion with transarticular C1-C2 screw with a Brooks-type posterior fusion or lateral mass screws.

Spine problems in children David L. Skaggs, MD 16

c. Odontoid: Reduction of displacement with extension or hyperextension with halo immobilization for 8 weeks.

d. Hangman’s fractures with minimal angulation and translation can be treated with closed reduction in extension with immobilization in a Minerva cast or halo device for 8 weeks. Fractures with significant angulation or translation requires a posterior fusion or anterior C2-C3 fusion.

e. Halo placement: In toddlers and children <8 years, use multiple pins (8-12 pins) with only finger tightness (2-4 inch-pounts). Anterior pins should be placed lateral enough to avoid the frontal sinus, and supraorbital and supratrochlear nerves. Place pins anterior enough to avoid temoralis muscle. The posterior pins should be placed opposite side of ring from anterior pins.

f. Thoracolumbar burst fractures with canal compromise require canal decompression, fusion and instrumentation. Indirect canal decompression is accomplished by operative distraction of injured level.

g. Distraction and shear injuries are treated with reduction with decompression, instrumentation and arthrodesis.

h. Chance injuries which are purely ligamentous injuries should be surgically stabilized with instrumentation and arthrodesis. Bony injuries with >20 degrees kyphosis or inadequate reduction, are treated with posterior compression instrumentation and arthrodesis.

4. Complications a. Os odontoideum: caused by nonunion of an odontoid fracture

which may have episodic or transient neurologic symptoms. Instability when >8 mm of motion; requires C1-2 fusion.

b. Post-traumatic kyphosis usually does not remodel and may worsen.

c. Pseudarthrosis d. Implant failure

5. Pearls and pitfalls a. Ligament injuries do not heal, and usually require operative

stabilization. b. Boney fractures without significant angulation may be treated

nonoperative flick c. ecchymosis in the distribution of the seatbelt should alert one

to the possibility of a chance fracture and/or inter abdominal injuries

d. children under eight years of age tend to have cervical injuries C3 and above, children under eight tend to have injuries below C3

6.

IX. References

a. Gillingham BL, Fan RA, Akbarnia BA. Early Onset Idiopathic Scoliosis. J Am Assoc Orthop Surg 2006;14:101-112.

b. Hedequist D, Emans J. Congenital Scoliosis. J Am Assoc Orthop Surg 2004;12:266-275.

c. Lenke LG, Betz RR, Harms J, et al. Adolescent idiopathic scoliosis: A new classification to determine extent of spinal arthrodesis. J Bone Joint Surg [Am] 2001;83:1169-1181.

Spine problems in children David L. Skaggs, MD 17

d. Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ, Ponseti IV. Health and function of patients with untreated idiopathic scoliosis: A 50-year natural history study. JAMA 2003;289:559-567.

e. Copley LA, Dormans JP. Cervical spine disorders in infants and children. J Am Assoc Orthop Surg 1998;6:204-214.

f. Wenger DR, Frick SL. Scheuermann’s Kyphosis. Spine 1999;24:2630-2639.

X. Top Testing Facts: a. Idiopathic Scoliosis

i. MRI for atypical pattern or neruo signs/SXS ii. Surgical indications 45-50o

b. Congenital Scoliosis i. Early fusion for hemi-vertebrae opposite unilateral bar

c. Spondylolysis and Spondylolisthesis i. In 5% of population – usually not painful

ii. L5 nerve root at risk with >50% reduction at surgery d. Spine Trauma

i. Atlanto dens interval <5mm OK ii. C2-C3 pseudo-subluxation is normal

Tumors and M

etabolicB

one Disease

 

 

Tumors and Metabolic Bone Disease 

Moderator: Albert J. Aboulafia, MD 

 

4:40 PM – Tumors Albert J. Aboulafia, MD 

 5:10 PM – Metabolic Bone Disease 

Joseph M. Lane, MD  

1

AAOS Board Maintenance of Certification Preparation and Review #490

February 18th 2011 San Diego, California

Albert J. Aboulafia, MD FACS MBA Sinai Hospital of Baltimore

University of Maryland

Tumors

I. General Introduction: a. Benign Bone Tumors b. Malignant Bone Tumors c. Benign Soft Tissue Tumors d. Malignant Soft Tissue Tumors e. Principles of diagnosis (imaging and biopsy) f. Principles of treatment

All primary bone and soft tissue tumors fall into one of the following categories. For the purposes of examinations you must be able to recognize what type of tumor you are presented with and in many cases the appropriate diagnostic evaluation and subsequent treatment.

II. Classification of Benign Bone Tumors (Histology) a. Chondrogenic

i. Osteochondroma 1. hallmark: cortical and medullary continuity of host

and lesion

2

This is a common tumor and shows up on many exams. Radiographic imaging is diagnostic. The primary differential diagnosis includes parosteal osteosarcoma and secondary chondrosarcoma. A CT scan demonstrating cortical and medulary continuity of the lesion with the host bone confirms the diagnosis.

ii. Enchondroma 1. hallmark: stippled calcifications, geographic, no

endosteal scalloping The most common clinical scenario is distinguishing an enchondroma from a chondrosarcoma. A cartilage lesion within the bone that demonstrates aggressiveness (breakthrough cortical bone with a soft tissue component) is malignant and not an enchondroma. Enchondromas can be a source of pain and may be moderately “hot” on bone scan.

iii. Chondromyxoid fibroma 1. hallmark: location, age, lobular

Favored location: Fibula and Tibia

iv. Chondroblastoma 1. hallmark: epiphyseal location

Location, Location, Location. Well defined but may extend into adjacent joint.

b. Osteogenic i. Osteoblastoma

ii. Osteoid Osteoma 1. hallmark: nidus, reactive cortical bone

Radiofrequency Ablation is the less invasive method of treatment and very effective.

c. Fibrogenic i. Non ossifying fibroma

1. hallmark: eccentric, well defined, cortical rim May require prophylactic curettage and bone grafting in cases of impending fracture. If fracture occurs, allow it to heal and then treat as neede.

ii. Osteofibrous dysplasia 1. hallmark: diaphyseal tibia

iii. Fibrous Cortical Defect 1. hallmark: see NOF but cortically based

3

iv. Fibrous Dysplasia 1. hallmark: well defined, “ground glass”, cortical

remodeling, expansion: No perisosteal new bone unless associated with fracture

2. Polyostotic or Monostotic 3. May be associated with endocrine abnormalities 4. ?Role of bisphosphonates for aggressive

conditions

d. Vascular i. Hemangioma

Treatment options include observation, resection or embolization. May be symptomatic (pain). Clinically, look for discoloration of the skin and/or a mass that gets bigger and smaller (especially when in a dependent position).

e. Lipogenic i. Intraosseous lipoma

ii. Liposclerosing myxiod fibrous tumor (LSMFT) On X-ray well defined with sclerotic border. MRI shows all fat. LSMFT favored location-proximal femur

f. Unknown Origin i. Anuerysmal Bone Cyst

ii. Unicameral Bone Cyst iii. Giant Cell Tumor iv. Langehan’s Cell Histiocytosis

These tumors have little in common with respect to their radiographic and clinical presentation or treatment.

III. Classification of Benign Bone Tumors (Enneking)

a. Based on Clinical and Radiographic Criteria b. Arabic numerals (1,2 or 3) c. Treatment based on tumor type and stage

4

IV. Stage 1 Tumors a. Osteochondroma

i. Imaging characteristic/diagnostic ii. DDx includes parosteal osteosarcoma, chondrosarcoma,

exostosis bursata iii. Treatment based on symptoms and clinical behavior

b. Osteoid Osteoma i. Imaging studies and clinical history largely diagnostic

(X-ray, CT, bone scan) ii. DDx includes infection/Brodie’s abscess

iii. Treatment may be medical or surgical (NSAID/open vs. closed surgical i.e. RFA)

V. Stage 2 Tumors a. Enchondroma (may be stage 1 or 2)

i. Must distinguish symptomatic from other causes ii. Distinguish from Grade 1 chondrosarcoma

b. Juxtacortical Chondroma i. Diagnosis largely based on imaging studies

ii. Treatment based on natural history c. Unicameral Bone Cyst

i. 50% present as pathologic fracture ii. Most common location proximal humerus

iii. Remember classic “fallen leaf” sign iv. Allow fracture to heal then treat v. Treatment options vary (no one best answer)

vi. Lesions in proximal femur usually require fixation to prevent path fx.

VI. Stage 2or 3 Tumors

a. CMF, Osteoblastoma, Chondromyxoid Fibroma, ABC, GCT i. All require treatment

ii. Treatment options depend on location, patient’s age, proximity to growth plate

iii. Simple curettage, extended curettage with or without physical/chemical adjuvants, resection

5

VII. Malignant Bone Tumors a. Hematopoietic b. Chondrogenic c. Osteogenic d. Fibrogenic e. Vascular f. Notochordal g. Unknown Origin

VIII. Multiple Myeloma/Plasmacytoma: a. Most common malignant primary bone tumor. b. Biology: cells produce macrophage inflammatory protein 1-

alpha which stimulates osteoclast production. In conjunction with parathyroid hormone related peptide (PTH-rp) and osteoclast activating factors there is increase expression of receptor activating factor of nuclear factor kB (RANKL). Some treatments i.e bisphosponates, RANKL inhibitors etc. target these pathways.

c. Work-up: SPEP/UPEP, CBC, ESR, Ca, renal function and B2 microglobulin, skeletal survey.

d. Treatment: primarily systemic chemo and XRT. Surgery for impending fractures, some established fractures or those that do not respond to chemo/rads.

IX. Staging

a. MSTS (Enneking) i. Low and intermediate and high grade (I=low grade

II=intermediate and high grade) ii. A=intracompartmental; B=extra compartmental C=

metastatic

b. Histologic Grade i. Measure of biologic potential (1-3 or 1-4)

ii. Potential for metastases and/or local recurrence

6

X. Evaluation: Pre op a. X-ray b. CT chest c. MRI d. Bone Scan

XI. Biopsy

a. First stage of limb salvage surgery b. First do no harm c. Open vs. Closed

i. FNA/Core ii. Incisional/Excisional

XII. Limb Sparing Surgery

a. Biopsy b. Resection of Tumor c. Reconstruction of Skeletal Defect d. Soft Tissue Reconstruction

XIII. The Basics a. Osteosarcoma and Ewings Sarcoma

i. Chemotherapy well established ii. Limb Sparing surgery in 90% of patients

iii. Chemo+Surgery (wide resection) iv. Radiation rarely used for primary bone tumors v. Surgery requires WIDE surgical excision (a cuff of

normal tissue completely surrounding the tumor) XIV. Benign Soft Tissue Tumors

a. Histologic Subtypes i. Fibrous

ii. Synovial iii. Vascular iv. Lipomatous v. Neurogenic

vi. Muscular

7

b. Treatment i. Leave alone or take out (once dx established)

ii. MRI is key 1. can diagnose many b9 tumors (Be careful: Don’t

trust reports from someone without experience) if you are going to recommend observation

a. lipoma b. PVNS c. Nerve sheath tumors d. Infection e. Ganglion

iii. Locally aggressive tumors require treatment 1. desmoids tumors/PVNS 2. desmoids tumors are very prone to local

recurrence. Treatment options include surgery with or without pre or post op radiation and even low-dose chemotherapy.

It is difficult to ask questions about the most appropriate treatment for desmoids tumors. You should simply be able to recognize it and know that it is locally aggressive and requires treatment. XV. Malignant Soft Tissue Tumors

a. Histologic Subtypes i. Fibrous

ii. Synovial iii. Lipomatous iv. Neurogenic v. Muscular

vi. Uncertain Origin b. Evaluation

i. Clinical/Radiographic and Histologic correlation ii. MRI characteristics (well defined, heterogeneous)

iii. Any soft tissue mass deep to fascia greater than 5cm (assume sarcoma)

iv. Regional nodes: especially epthelioid sarcoma and synovial sarcoma

8

XVI. Staging STS AJC 1997 a. Low vs. High Grade b. Size > or< 5cm c. Deep vs. Superficial d. Regional nodes + or –

Soft tissue tumors that have a relatively high incidence of nodal metastases include epitheleoid sarcomas and rhabdomyosarcoma. The latter is more common in children and adolescents. Epitheleoid sarcomas are the most common primary soft tissue sarcoma in the hand. XVII. Biopsy

a. Closed i. FNA

ii. Core needle b. Open

i. Incisional ii. Excisonal (small, superficial when wide excision adds no

additional morbidity) So… there are 4 types of biopsy. 2 closed: FNA and Core, and 2 open: incisional and excisional

c. Remember to have tissue available for flow cytometry and genetic studies. Send some tissue fresh. Be familiar with translocations associated with specific tumor types i.e Ewings, Dermatofibrosarcoma protuberans, extraskeletal myxoid chondrosarcoma, myxoid/round cell liposarcoma and synovial sarcoma

Ewings: t(11;22)(q22;q12)or t(11;22)(q24;q12) DFSP: t(17;22)(q22;q13) EMCS: t(9:22)(q22-31;q12) M/RCLS: t(12;16)(q13;p11) Synovial Sarcoma: t(X;18)(p11.2:q11.2)

d. Immunohistochemisty: i. Keratin: stains epithelial markers i.e carcinomas (may

also be present in epitheloid sarcoma, synovial sarcoma and adamantinoma.

9

ii. Desmin: Muscle marker i.e rhabdomyosarcoma, a. skeletal muscle: myogenin (Myo-D) b. smooth muscle: actin (leiomyosarcoma,

desmoid tumors iii. CD31 and CD34: Vascular marker iv. S-100: Neural marker

XVIII. Treatment STS

a. Wide local excision b. Role of chemotherapy not well defined (very controversial so

they can’t ask you that) c. Preop radiation vs. post op radiation

i. Radiation improves local control ii. Preop associated with high incidence of local wound

complications XIX: Metastatic Disease:

a. Lead Kettle (P,B,K,T,L) Prostate, Breast, Kidney, Thyrod (75% or more)

b. Consider first in pt over 40 with destructive bone lesion c. Favored location axial skeleton and proximal long bones. Bone

met may be first presentation in nearly 25% of patients with metastatic disease to bone.

d. Indications for prophylactic fixation. A bit of a moving target. Open segment: 1/3 circumf. of bone decreases rigidity 30%. General principle for long bones-protect the entire bone. (See Mirels H. CORR 1989)

e. Treatment: Depends on extent of bone destruction and anticipated response or prior response to radiation and or chemotherapy. Bisphosphonates play a critical role.

f. Spine Mets: Kostuik system 3+ right and left. 3 or more segments destroyed suggests instability. Indications for surgery-mechanical instability, progressive deficit. Anterior or posterolateral approaches that allow anterior vertebral body reconstruction is preferred to posterior approach alone (Patchell RA et al. Lancet 2005)

10

Parting thoughts: 2 Minute Review (OK maybe 5 minute review) 1. Most common primary malignant bone tumor: Myeloma

Evaluation includes X-ray, labs (CBC, Chem 25, SPEP, UPEP, immunofixation Beta-2 microglobulin) look for anemia, elevated calcium, proteinuria Bone scan may not demonstrate lesions (not reliable). Bone/Skeletal Survey more accurate.

2. Biopsy:

Be careful. If you suspect a malignant bone or soft tissue tumor first choice is to refer it prior to biopsy. If you do biopsy must have all imaging studies completed prior to biopsy Biopsy options include FNA, core, incisional or excisional: Know the advantages and disadvantages of each. Special Studies: FISH (fluorescent in situ hybridization), flow cytomety, electron microscopy) and culture for infection. Need fresh tissue Ewings Sarcoma: look for chromosomal translocation T(11:22)(q24;q12) or T(11;22)q(22;q12) Lymphoma (flow cytometry)

3. Osteosarcoma and Ewings Sarcoma most common primary bone tumor in children and adolescents Treatment includes Chemotherapy and Wide Resection

Same is true for most other primary malignant bone tumors other than myeloma.

11

4. Soft Tissue Sarcomas By definition malignant Suspect any deep tumor greater than 5cm as being malignant MRI characteristics are: Well defined, heterogeneous

Treatment always includes wide excision. Chemo is controversial, therefore they can’t ask you about chemo. Preop radiation improves local control but at the expense of higher wound complications.

5. In a patient over 40 years of age with a malignant appearing bone lesion think mets and myeloma. 6. Benign bone tumors are common in children. Fibrous cortical occur in 30-40% of all children. Therefore: this is fair game.

Know them and how to treat them. Recognize the common ones: FCD, osteochondroma, UBC, osteoid osteoma, etc.

7. Benign aggressive bone tumors have high incidence of local recurrence. GCT are treated with aggressive mechanical curettage, use of a physical adjuvant (phenol, cryo) and cementation or bone grafting). 8. Quick guide to imaging studies:

Purpose: Develop a differential diagnosis, define extent of disease and plan treatment in a cost effective and efficient manner.

A. X-ray 1. The "gold standard" for diagnostic criteria in bone

tumors. Most valuable imaging study (and not expensive). May be useful in soft tissue lesions i.e fat or vascular lesions or identify associated bone pathology. Myxoma and fibrous dysplasia Mazenbraud’s syndrome.

2. Note: A. Location: metaphyseal, diaphyseal or epiphyseal

12

B: Pattern: well defined, ill defined, permeative, destructive, moth eaten...

C. What is the bone doing to the lesion and what is the lesion doing to the bone? Sclerotic border, fading border…presence or absence of periosteal new bone, endosteal scalloping… D. Matrix Is the tumor making a matrix like bone i.e osteogenic

B. CT scan

1. Study of choice to assess presence of pulmonary mets.

2. Identifies areas of mineralization, provides superior imaging of cortical bone (and risk for path fracture), subtle pathologic fracture.

3. Indicated when lesion may be metastatic. CT chest, abdomen and pelvis to identify primary.

4. Use in evaluating soft tissue lesions largely replaced by MRI (except when MRI is contraindicated)

5. May be helpful in evaluating osteochondromas

C. MRI 1. The primary imaging modality for evaluating soft tissue lesions. Extremely valuable:

a. Can identify tissue types, i.e fat, fibrous, pertinacious material, fluid, cystic, “hematoma”, heterogeneity etc.

2. Defines medullary extent and soft tissue extension of bone lesions and skip lesions. More sensitive and specific than bone scan.

3. Used in evaluating primary bone lesions when wide resection is anticipated.

4. Not usually necessary for metastatic lesions 5. REMEMBER: STS are typically: 1.WELL

DEFINED and 2. HETEROGENEOUS

13

D. Radionuclide scan 1. Especially important to identify if patient has a

solitary lesion, possibly a primary bone tumor, or multiple lesions and likely to be metastatic i.e patient with a path fx who is over 40. Must be sure it is not a primary before proceeding with fixation.

2. May identify skip lesions (MRI is better) 9. Surgical Principles: Don’t try to memorize the treatment for each and every tumor. Understand the stage of the tumor and the treatments follow: i.e High grade bone tumors: wide excision. Benign bone tumors: stage 1 observation or local excision. Stage 2. intralesional excision. Stage 3 extended curettage frequently with physical adjuvant

A. Surgical Choices: The surgeon may remove a lesion in one of four ways; 1. by entering the lesion ( intralesional excision),

2. by removal through the reactive pseudocapsule (marginal excision), 3. by removing a cuff of normal tissue beyond the reactive pseudocapsule (wide excision), 4. by removing the entire compartment (radical resection).

B. Intralesional Surgery 1. Appropriate for stage 1 or 2 benign bone lesions though there is some risk of recurrence with stage 2 lesions.

a. Chondroblastoma b. Giant cell tumor c. Osteoid osteoma d. Unicameral bone cyst e. Aneurysmal bone cyst

2. And for Stage 3 lesions (usually with physical and chemical adjuvants

a. GCT extended curettage with phenol/cement/liquid nitrogen

14

B. Marginal (local) Excision (within the reactive pseudocapsule)

1. Appropriate for some benign soft tissue (lipoma) tumors and stage 2 benign bone lesions.

a. Neurilemmoma b. Ganglion c. Osteochondroma

C. Wide Excision (a cuff of normal tissue surrounding the entire tumor and pseudocapsule )

1. Used in cases of low grade malignancy, selected stage 3 benign lesions that can not be treated with marginal procedures

2. High grade bone and soft tissue tumors a. Osteosarcoma following chemotherapy b. Soft tissue sarcomas c. Ewing’s sarcoma following chemotherapy

D. Radical (compartmental) Excision (removes the entire anatomic compartment)

1. Rarely used except in very advanced massive tumors or when there has been extensive contamination from prior surgery.

2. How wide is wide? As much as you can get. At times plane may be 1-2mms. Depends on border i.e fascia or loose areolar tissue.

10. Chemotherapy

A. Chemotherapy for osteosarcoma (A must. Well established. Not controversial)

1. Historical 20% five year survival with surgery alone.

2. Adjuvant (post-op) chemotherapy 40-50% five year survival.

3. Confirmed by controlled randomized studies 1970's.

15

4. Neo-adjuvant (pre surgical) chemotherapy a. Reduced primary tumor size b. Allowed assessment of drug efficacy c. Did not increase mortality rate d. Originally used to buy time to make custom

endoprosthesis 5. Currently

a. Neo-adjuvant chemotherapy allows for limb salvage in 80-90% of patients

b. 60-65% five year disease free survival c. Amputation in <20% (non-responders,

pathologic fracture, certain anatomic sites) d. % necrosis has prognostic significance Huvos index) d. Even patients with pulmonary mets can

have long term survival/cure (20%)

B. Chemotherapy in Ewing's Sarcoma 1. Surgery alone resulted in 5% five year survival 2. Chemotherapy - increased survival

a. With radiation therapy - 34% five year survival

b. With surgery >65% five year survival (+RT)

1

OSTEOPOROSISOSTEOPOROSIS

JOSEPH M. LANE, MDJOSEPH M. LANE, MDJOSEPH M. LANE, MDJOSEPH M. LANE, MD

HOSPITAL FOR SPECIAL SURGERY

NEW YORK, NY

JOSEPH M. LANE, MD

• Does have a financial interest or relationship with the• manufacturers of products or services:

– Consulting Fees: Amgen, Arthrocare, Biomimetics, D’Fine Inno ati e Clinical Sol tions K rosD’Fine, Innovative Clinical Solutions, Kuros Biosurgery AG, Osteotech, Orthovita, Soteira, Zelos, Zimmer

– Speakers’ Bureaus: Eli Lilly, Novartis, Orthovita, Proctor and Gamble, Roche, Sonofi - Aventis

• Presentation will not include discussion of off label or investigational use of products or treatments

GOALSDISCUSS PATHOPHYSIOLOGY

OP FRAGILITY FRACTURES

DIAGNOSIS/RISK FACTORS

TREATMENT

ANTI-RESORPTION

ANABOLIC

OSTEOPOROSIS

DECREASED BONE STRENGTHDECREASED BONE STRENGTHRATHER THAN REDUCED BMD

NIH (2001)

OSTEOPOROSISOSTEOPOROSIS

DECREASED BONE MASS

MICROARCHITECTURALMICROARCHITECTURAL DETERIORATION

ALTERED QUALITY

FRAGILITY FRACTURE

Relevance of Architecture to Structural Strength

Normal Quantity Loss of Loss ofand Architecture Quantity Architecture

2

OSTEOPOROSIS AFFECTS 45% WOMEN AGED 50 OR OLDER

LIFETIME RISK OF FRACTURE OFHIP, WRIST AND SPINE 40%

RISK OF VERTEBRAL FRACTURERISK OF VERTEBRAL FRACTURE

5x GREATER WITH PRIOR VERTEBRAL FRACTURE

VERTEBRALVERTEBRAL FRACTUREFRACTUREVERTEBRALVERTEBRAL FRACTUREFRACTURE

2x RISK OF HIP FRACTURE

(NEVITT 1999)

FRACTUREFRACTURE MORE FRACTURESMORE FRACTURES

OSTEOPOROTIC FRACTURES POSE A LIFETIME RISK OFDEATH COMPARABLE TO

BREAST CANCER

CUMMINGS, Arch. Inter. Med. (1989)

3

High Bone Turnover Leads to Development of Stress Risers and Perforations

Bone

Osteoclasts

Stress RisersPerforations

CALCIUM SOURCECHILDREN - YOUNG ADULTS

INTESTINAL ABSORPTION

ELDER ADULTSBONE RESORPTION

DAILY CALCIUM REQUIREMENTSDAILY CALCIUM REQUIREMENTS

CHILD 700 mgTEEN - YOUNG ADULT 1300 mgADULT 800 mgPREGNANCY 1500 mgLACTATION 2000 mgPOST MENOPAUSAL 1500 mgMAJOR FRACTURE 1500 mg

DRUGS WHICH DECREASE DRUGS WHICH DECREASE CALCIUM RETENTIONCALCIUM RETENTION

ISONIAZIDCORTICOSTEROIDSHEPARINLUPRONTETRACYCLINEFUROSEMIDECAFFEINE?NICOTINEALUMINUM CONTAINING ANTACIDS

4

MECHANICAL EFFECTSMECHANICAL EFFECTS

NO LOAD LOSE BONE

LOW LOAD MAINTAIN BONE

HIGH LOAD REMODEL BONE

VERY HIGH LOAD BONE FAILURE

EXERCISE IN GROWING CHILD 30

BONE MASS AND STRUCTURE

5

EXERCISE IN EXERCISE IN POST MENOPAUSAL WOMENPOST MENOPAUSAL WOMEN

NO CHANGE IN BONE DENSITY

FRACTURESBETTER BONE QUALITYLESS FALLS

1

LOW BONE MASS IS THELOW BONE MASS IS THE

SINGLE MOST ACCURATESINGLE MOST ACCURATE

PREDICTOR OF PREDICTOR OF INCREASEDINCREASED

FRACTURE RISKFRACTURE RISK

WHO CRITERIA FOR OPWHO CRITERIA FOR OPNORMAL ≥ 1 SD

OSTEOPENIA ≤ 1 SD TO 2.4 SDOSTEOPENIA ≤ 1 SD TO 2.4 SD

OSTEOPOROSIS ≤ 2.5 SD

SEVERE OP ≤ 2.5 SD AND Fx

BIOCHEMICAL MARKERSBIOCHEMICAL MARKERS

• BONE RESORPTION : COLLAGENBREAKDOWN PRODUCTS - N -TELO ANDC-TELO PEPTIDES, PYRODINOLINEC TELO PEPTIDES, PYRODINOLINE

• BONE FORMATION : BONE ALKALINEPHOSPHATASE, OSTEOCALCIN,AND PINP

2

OP RISK FACTORSOP RISK FACTORSINDEPENDENT OF BONE MASSINDEPENDENT OF BONE MASS

• LOW BODY WEIGHT (127 pounds)

• RECENT LOSS OF BODY WEIGHT

• PERSONAL HX OF FRAGILITY Fx

• MATERNAL HX OF FRAGILITY Fx

• SMOKING

PREDICTORS OF NONPREDICTORS OF NON--SPINE SPINE FRACTUERS IN ELDERLY MENFRACTUERS IN ELDERLY MEN

• Tricyclic antidepressant use

• Previous fracture

I bilit t lk th• Inability to walk narrow path

• Falls in previous year

• Age ≥ 80 years

• Depressed mood

LEWIS JBMR 2007

Country: US (Caucasian) Name / ID: About the risk factors

Questionnaire: 10. Secondary Osteoporosis No Yes

1. Age (between 40-90 years) or date of birth 11. Alcohol 3 more units per day

Age: Date of birth: 12. Femoral neck BMDY: M: D:

2. Sex Male Female

Select

Clear Calculate

FRAX ™ WHO Fracture Risk Assessment Tool Calculate the ten year probability of fracture with BMD

3. Weight (Kg)

4. Height (cm)

5. Previous fracture No Yes

6. Parent fractured hip No Yes

7. Current smoking No Yes

8. Glucocorticoids No Yes

9. Rheumatoid arthritis No Yes

3

R/O OSTEOMALACIAR/O OSTEOMALACIA

Alkaline PhosphatasePTHCa PO4

25(OH) Vit.D60+% Hip Fracture Patients45% General Orthopaedic HSS

COMMON CAUSES OF OSTEOMALACIACOMMON CAUSES OF OSTEOMALACIA

NUTRITIONAL VITAMIN D DEFECIENCY

DISORDERS OF INTESTINAL ABSORPTION OF

VITAMIN D

DEFECTS OF VITAMIN D METABOLISM

RENAL OSTEODYSTROPHY

RENAL TUBULAR ACIDOSIS

HYPOPHOSPHATEMIC (RENAL TUBULAR)

4

METABOLIC BONE DISEASEMETABOLIC BONE DISEASEWORKUP FOR OSTEOPENIAWORKUP FOR OSTEOPENIA

BONE MARROW CBC OSTEOMALACIA -SED RATE CALCIUM, PHOS,IMMUNOELECTRO- ALK-PTASE PTHIMMUNOELECTRO ALK PTASE, PTH

PHORESIS 25 HYDROXY VIT DENDOCRINOPATHY HYPERTHYROID, HYPER PTH, OSTEOPOROSIS -CUSHINGS, JUVENILE HIGH vs. LOW DIABETES TURNOVER NTX

HIP FRACTUREHIP FRACTURE

IN FALLS FROM STANDING HEIGHT IMPACT FORCES:

EXCEED FEMORA STRENGTHEXCEED FEMORA STRENGTHBY 50% IN ELDERLY

BELOW FEMORA STRENGTHBY 20% IN YOUNG

COURTNEY (JBJS, 1995)

HIP FRACTURESHIP FRACTURESODDS RATIOS

NURSINGAMBULATORY HOME

FALL TO SIDE 5.7 21.7FEMORAL NECKFEMORAL NECK

BONE DENSITY 2.7POTENTIAL ENERGY 2.8 3.3BODY MASS INDEX 2.2 4.2

(GREENSPAN & HAYES)

SYMPTOMATIC VERTEBRAL FRACTUREOVER AGE 6050% FALL20% CONTROLLED ACTIVITY

REACHINGBENDINGLIFTING

MYERS (J Bone Min Res 1996)

REPAIR POTENTIALREPAIR POTENTIAL

BONE QUALITYBONE QUALITY

BONE STRUCTUREBONE STRUCTUREBONE MASSBONE MASS TRAUMATRAUMA

GENERAL HEALTHGENERAL HEALTH

AGEAGE

5

1

FRACTURE PROTECTION CONTINUES UP TO 10 YEARS

1 – 3yrs 3.2% Fracture Rate

7-10yrs 5.0% Fracture Rate7 10yrs 5.0% Fracture Rate

1-5yrs drug 6.6% Fracture Rateno drugs 5-10 after d/c drug

BONE (NEJM 2004)

CONTROVERSIES ON CONTROVERSIES ON BISPHOSPHONATESBISPHOSPHONATES

↓ RISK OF FRACTUREIF TOO SUPPRESSED →IF TOO SUPPRESSED →FATIGUE FRACTURE

(PAK CY)

Subtrochanteric Fracture PROLONGED BISPHOSPHONATES

• TURNOVER • MICROFRACTURE • FROZEN BONE• FROZEN BONE• BRITTLE FRACTURE

(PAK)

Alendronate Fracture ST/S Fracture

83 year old female with no history of alendronate use

60 year old female with no history of alendronate use

2

Alendronate FractureHIP FRACTURE

BISPHOSPHONATE 11%

SUBTROCH FX BISPHOSPHONATE 38%

PAMIDRONATE (IV)PAMIDRONATE (IV)RECLASTRECLAST

IBANDRONATE

COMPARABLECOMPARABLE BONE MASS ACCRETIONFRACTURE DATA - ↓HIP/VERT FRACTUREWHEN ORAL BISPHOSPHONATES CONTRAINDICATEDOSTEONECROSIS JAW↓MORTALITY 20%

LYLES NEJM 2007

BONE MASS CHANGE ACCOUNTS FOR APPROXIMATELY 18% OF FRACTURE RISK PREVENTION

TURNOVER REMAINING“QUALITY” FACTORS

PTH (1PTH (1--34) ANABOLIC AGENT34) ANABOLIC AGENT

BONE MASS

ALL FRACTURESALL FRACTURES

? ENHANCES FRACTURE HEALING

SPINE FUSION

(20 ANIMAL STUDIES)

PTH (1PTH (1--34) INDICATIONS34) INDICATIONS

•BONE MASS DECLINE ON BISPHOSPHONATE

•FRACTURES ON BISPHOSPHONATES

•STEADY STATE < 3 5 SD•STEADY STATE < 3.5 SD

•LOW TURNOVER OSTEOPOROSIS•

•PREMENOPAUSAL WOMEN

•ACTIVE LONG BONE FRACTURE

3

50

100

150

200

250

FORTEO® (teriparatide [rDNA origin] injection)

50

100

150

200

250

Alendronate

PINPNTx

% C

hang

e ±

SE 197

40

Biochemical Markers of Bone Turnover Contrasted Data on Mechanism of Action1

1. Arch Intern Med. 2005;165:1762-1768.

- 70- 68

Months0 1 3 6 12

-100

-50

0

Months0 1 3 6 12

-100

-50

0

Mea

n %

Information regarding mechanisms of action does not provide evidence of comparative fracture protection.

See Boxed Warning and Important Safety Information for FORTEO.See Boxed Warning and Important Safety Information for FORTEO.See full Prescribing Information for FORTEO.See full Prescribing Information for FORTEO.

Fracture Healing: PTH vs. Bisphosphonates

Animal

Bisphosphonate PTH

Callus Size

Maturation

Biomechanics -

Initiate Calcium/Vitamin DHold Bisphosphonate 3 – 6 Weeks

New Osteoporotic Fracture

Consider PTH Depending on Host/Site/Character

PREVENTION OPPREVENTION OPPHYSIOLOGICAL CALCIUM

800-2000 UNITS VITAMIN D

+ / - ESTROGEN (MENOPAUSAL

SYMPTOMS)

EXERCISE

EXERCISEEXERCISEIMPACT

STRENGTHENING

BALANCE (DANCING, TAI CHI)

HIP FRACTURE PREVENTION

USING HIP PROTECTORS

LAUPITZEN 1993 HORADA 2001

4

DXATEST OF CHOICE

NTX

DXA APPARENT BONE MASS

NTX RATE OF BONE TURNOVER

FALLSFALLSMAJOR CAUSE HIP FRACTURES

OSTEOPOROTIC INDIVIDUALS

WAITING TO FALL

TO FRACTURE THEIR HIPS

HAYES (HARVARD)