A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  R  S  T  U  W 
A

pApeR No. 589  Rajiv Gandhi, MD, Toronto, ON Canada David Salonen, MD, Toronto, ON Canada William H Geerts, MD, Toronto, ON Canada Monica Khanna, MD, London, United Kingdom Sean McSweeney, MD Khalid Syed, MD, Toronto, ON Canada J Rod Davey, MD, Toronto, ON Canada Nizar Mahomed, MD, Toronto, ON Canada

With the advent of newer diagnostic imaging tools, the reported prevalence of acute pulmonary embolism (PE) following total hip (THA) and total knee (TKA) arthroplasty appears to be increasing.

However, the true prevalence and clinical relevance of these events are unclear.

Our study was designed to evaluate the results of routine multi-detector computed tomography (MDCT) in this patient population in the early postoperative period.

We prospectively performed MDCT scans on 48 consecutive THA/TKA patients on the first postoperative day.

Patients underwent routine postoperative care and data were collected regarding the development of symptoms such as tachycardia, fever, chest pain or shortness of breath.

All CT scans were kept blinded until completion of study recruitment and then read by two independent chest radiologists for findings of acute PE.

Our cohort included 27 TKA patients and 21 THA patients.

None of the 48 patients had any symptoms of PE.

Among the TKR patients

11 (41%) of the CT scans were read as positive for an acute PE compared with 1 (5%) of the THR patients (p=0.004).

All of the patients diagnosed with an asymptomatic PE were discharged from hospital without developing any clinical symptoms suggestive of venous thrombosis.

One TKA patient, who had a negative CT scan on the first postoperative day, was diagnosed with symptomatic PE the following day.

The majority of the asymptomatic embolic burden found in our study was in the segmental and sub-segmental arteries of the lung.

Our study demonstrates a high rate of abnormal MDCT early following lower extremity arthroplasty, the clinical significance of which may be benign.

This finding is also important in the interpretation of MDCT obtained after a clinical suspicion of PE in these patients.

Acetabular Fractures Updated 05:15:11 (11:59am) 21 Introduction High energy blunt trauma Fracture pattern determined by force vector position of femoral head at time of injury Associated injuries are common 50% will have injury to another organ system (abdominal, GU, neuro) Imaging Radiographic Lines of the Acetabulum Iliopectineal line (anterior column) Ilioischial line (posterior column) Anterior Wall Posterior Wall Teardrop (important to evaluate for protrusio) Weight bearing dome Judet views obturator oblique shows profile of obturator foramen shows anterior column and posterior wall iliac oblique shows posterior column and anterior wall Roof arc measurements show intact weight bearing dome if > 45 degrees on AP, obturator, and iliac oblique not applicable for both column fracture pattern because no intact portion of the acetabulum to measure CT scan important to determine articular surface involvement identify marginal impaction identify loose bodies determine surgical plan Letournel Classification Illus. AP Obt.Obl. Iliac.Obl. CT Comments & Approaches Simple Posterior wall x • most common • will see "gull sign" on obturator oblique view • posterior approach Posterior column • posterior approach Anterior wall x x • anterior approach Anterior column x x x x • anterior approach Transverse x x x x • CT shows anterior to posterior fx line • posterior or extended iliofemoral Associated/Complex Both Column • characterized by dissociation of the articular surface with intact portion of the ilium • will see "spur sign" on obturator oblique • anterior or extended iliofemoral Post. wall + Transverse x • most common associated fx • CT shows anterior to posterior fx line (transverse component) • posterior approach T Shaped x x • extended ilioinguinal or combined anterior and posterior Ant. column + Post. hemitransverse x x x Post. wall + Post. column x x x x x Treatment NonOperative Treatment Protected weight bearing for 6-8 weeks indications minimally displaced fracture (< 2mm) < 20% posterior wall fractures conguent femoral head with weight bearing dome (out of traction) both column fracture with secondary congruence (out of traction) displaced fracture with roof arcs > 45 degrees in AP and Judet views contraindication to surgery morbid obesity age > 60 yrs open contaminated wound presence of DVT technique protected weight bearing for 6-8 weeks close radiographic follow-up initial skeletal tractionskeletal traction rarely indicated as definitive treatment Operative Treatment Open reduction and internal fixation with acute total hip arthroplasty Indicated for significant osteopenia and/or significant comminution Up to 78% 10-year implant survival noted Worse outcomes in males, patients <50 years old or >80kg, or if a significant acetabular defect remains Open reduction and internal fixation indications displacement of dome (>2mm) posterior wall fracture > 20% marginal impaction loose bodies in joint irreducible fracture-dislocation results clinical outcome correlates with quality of articular reduction earlier operative treatment associated with increased chance of anatomic reduction Operative Techniques Approaches approach depends on fracture pattern. Two approaches can be combined. They include: Approaches Indications Risks Anterior Approach (Ilioinguinal) • anterior wall and anterior column • both column fracture • posterior hemitransverse • lowest incidence of HO • femoral nerve injury • LFCN injury • thrombosis of femoral vessels • laceration of corona mortis in 10-15%. Corona mortis is an anastomosis between the external iliac artery and the obturator artery Posterior Approach (Kocher-Langenbach) • posterior wall and posterior column fx • most transverse and T-shaped • combination of above • moderate HO • sciatic nerve injury (2-10%) • damage to blood supply of femoral head (medial femoral circumflex) Extensile Approach (extended iliofemoral) • only single approach that allows direct visulaization of both columns • associated fracture pattern 21 days after injury • some transverse fxs and T types • some both column fxs (if posterior comminution is present) • massive heterotopic ossification • posterior gluteal muscle necrosis Percutaneous fixation with column screws Anterior column screws Anterograde (from iliac wing to ramus) Obturator oblique best view to rule out joint penetration Outlet view best to determine anteroposterior position of screw Retrograde (from ramus to iliac wing) Posterior column screws Complications Post-traumatic DJD most common complication anatomic reduction essential to prevent treat with hip fusion or THA (results of THA not as good as for OA) Heterotopic Ossification highest incidence with extensile approach treat with indomethacin x 5 weeks post-op low dose XRT (no difference shown in direct comparison) lowest incidence with anterior ilioinguinal approach do not need prophylaxis Osteonecrosis 6-7% of all acetabular fractures 18% of posterior fracture patterns Deep venous thrombosis and pulmonary embolism Infection Bleeding Neurovascular injury Intrarticular hardware placement Abductor muscle weakness RATE CONTENT AVERAGE 4.0 of 2 RATINGS QBank (OBQ10-180) A 35-year-old male sustains a posterior column/posterior wall acetabular fracture. Which of the following is the preferred approach for open treatment of this injury? REVIEW TOPIC 1. Modified Stoppa approach 2. Extended iliofemoral approach 3. Kocher-Langenbach approach 4. Ilioinguinal approach 5. Combined anterior and posterior approach PREFERRED RESPONSE ▼ 3 DISCUSSION: Operative treatment is indicated for most displaced acetabular fractures to allow early ambulatory function and to decrease the chance of post-traumatic arthritis. Among the various surgical approaches, the Kocher-Langenbach allows direct exposure of both the posterior column and posterior wall. Indications for using this exposure include posterior wall fractures, posterior column fractures, combined posterior wall/posterior column fractures, and simple transverse fractures. REFERENCES: 1. OITE10 #180 2. Rout ML. Surgical treatment of acetabular fractures. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C, eds. Skeletal Trauma: Basic Science, Management, and Reconstruction, 4th ed. Philadelphia, PA: WB Saunders; 2009:1171-1218. 3. Smith WR, Ziran BH, Morgan SJ, eds. Fractures of the Pelvis and Acetabulum, 2nd ed. New York, NY: Informa Healthcare Publishers; 2007:362-374. : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments. (OBQ10-203) When placing a percutaneous anterior column screw for fixation of an acetabular fracture, which of the following radiographic views can best ensure that the screw does not exit the posterior superior ramus? REVIEW TOPIC 1. AP pelvis 2. Outlet obturator oblique view 3. Inlet iliac oblique view 4. Outlet iliac oblique view 5. Inlet obturator oblique view PREFERRED RESPONSE ▼ 3 DISCUSSION: As reviewed in the referenced article by Starr et al, when placing an anterior column screw, the pelvic inlet iliac oblique view will best determine the anteroposterior placement of the screw in the pubic ramus. To ensure placement outside of the joint, the outlet obturator oblique is best, but all other views should be incorporated into determination of the position of fixation, as the corridor for this screw placement is quite narrow. REFERENCES: 1. OITE10 #203 2. Riley MC. Fractures of the acetabulum. In: Bucholz RW, Tornetta P, Heckman JD, Koval KJ, Court-Brown CM, eds. Rockwood and Green's Fractures in Adults, 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:1665-1715. 3. Starr AJ, Reinert CM, Jones AL. Percutaneous fixation of the columns of the acetabulum: a new technique. J Orthop Trauma. 1998 Jan;12(1):51-8. PMID:9447519 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS CAUTION ERROR ALERT TAG Please login to view and post comments. (OBQ09-99) During the ilioinguinal approach to the pelvis, the corona mortis artery must be identified and ligated if present. The corona mortis artery joins the external illiac artery with which other major artery? REVIEW TOPIC 1. Pudendal 2. Deep illiac circumflex 3. Hypogastric 4. Obturator 5. Testicular PREFERRED RESPONSE ▼ 4 DISCUSSION: The "corona mortis" (translated as “crown of death”) artery is a vascular variant that joins the external illiac and the obturator artery as it crosses the superior pubic ramus. Tornetta et al did a study where "fifty cadaver halves were dissected to determine the occurrence and location of the corona mortis. Anastomoses between the obturator and external iliac systems occurred in 84% of the specimens. Thirty-four percent had an arterial connection, 70% had a venous connection, and 20% had both. The distance from the symphysis to the anastomotic vessels averaged 6.2 cm (range, 3-9 cm)." The corona mortis can be injured in superior ramus fractures and iatrogenically while plating pelvic ring injuries using the ilioinguinal approach. Illustrations: A REFERENCES: 1. OITE09 #99 2. Tornetta P III, Hochwald N, Levine R: Corona mortis: Incidence and location. Clin Orthop Relat Res 1996;329:97-101 PMID:8769440 (Link to Abstract) 3. Letournel E, Judet R: Fractures of the Acetabulum, ed 2. New York, NY, Springer-Verlag, 1993, pp 375-381 : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments. (OBQ09-112) A 33-year-old male sustains the injury seen in figure A as a result of a high-speed motor vehicle collision. Based on this image, what is the most likely acetabular fracture pattern? REVIEW TOPIC FIGURES: A 1. Both column 2. Anterior column 3. Anterior column posterior hemitransverse 4. Transverse 5. T-type PREFERRED RESPONSE ▼ 4 DISCUSSION: The radiograph in figure A shows a transverse acetabulum fracture. The iliopectineal (anterior column) and ilioischial lines (posterior column) are interrupted, revealing bicolumnar involvement; however, this is different than the both column fracture, as a transverse pattern has articular surface still in continuity with the axial skeleton via the sacroiliac joint. The referenced article by Patel et al showed a wide variation of inter and intra-observer agreement in interpreting radiographs of acetabular fractures, ranging from slight to near perfect agreement. The other referenced article by Letournel is a great review article regarding the initial classification of these fractures as well as a quick summary of his outcomes. REFERENCES: 1. OITE09 #112 2. 2. Letournel E: Acetabulum fractures: Classification and management. Clin Orthop Relat Res 1980;151:81-106 PMID:7418327 (Link to Abstract) 3. Patel V, Day A, Dinah F, et al: The value of specific radiological features in the classification of acetabular fractures. J Bone Joint Surg Br 2007;89:72-76 PMID:17259420 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments. (OBQ09-137) The pelvic spur sign on plain radiography is pathognomonic for which of the following injuries? REVIEW TOPIC 1. Transtectal transverse acetabular fracture 2. Vertical shear pelvic ring injury 3. Displaced H-type sacral fracture 4. Both column acetabular fracture 5. Anterior-posterior type III pelvic ring injury PREFERRED RESPONSE ▼ 4 DISCUSSION: The pelvic spur sign is pathognomonic for a both column acetabular fracture. It is best seen on an AP or obturator oblique x-ray. The spur is the intact portion of the ilium, still attached to the axial skeleton and seen posterosuperior to the displaced acetabulum (typically medially displaced). Illustration A shows the spur sign (arrows). Illustrations: A REFERENCES: 1. OITE09 #137 2. Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Heidelberg, Germany, Springer-Verlag, 1981 3. Vrahas MS, Tile M: Fractures of the acetabulum, in Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 1513-1545 : PENDING FINAL APPROVAL RATE CONTENT 2 RATINGS TAG Please login to view and post comments. (OBQ09-144) A computed tomography (CT) scan has been shown to be indicated for evaluation of all of the following aspects of acetabular fractures, EXCEPT: REVIEW TOPIC 1. Determination of surgical planning 2. Intra-articular loose bodies 3. Marginal impaction 4. Fracture piece size and position 5. Determination of pre-existing degenerative changes PREFERRED RESPONSE ▼ 5 DISCUSSION: CT scanning is indicated in acetabular fractures for determination of surgical approach and techniques, evaluation of marginal impaction and presence of intra-articular loose bodies (especially after hip dislocation), and evaluation of fracture piece sizes and relative positions. Kellam et al reviewed their initial experience with CT scanning and acetabular fractures, and noted a 25% change in surgical planning when CT was utilized versus plain radiographs; they also noted the ability to detect marginal impaction and fracture size/position was improved with CT. REFERENCES: 1. OITE09 #144 2. Kellam JF, Messer A. Evaluation of the role of coronal and sagittal axial CT scan reconstructions for the imaging of acetabular fractures. Clin Orthop Relat Res. 1994 Aug;(305):152-9. PMID:8050224 (Link to Abstract) 3. Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Springer-Verlag, 1993, pp 29-61 : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments. (OBQ09-163) An acetabular fracture involving both columns with no articular surface remaining attached to the intact posterior ilium is defined as what fracture pattern? REVIEW TOPIC 1. Transverse 2. Both column 3. Anterior column posterior hemitransverse 4. Posterior column with posterior wall 5. Anterior column with anterior wall PREFERRED RESPONSE ▼ 2 DISCUSSION: A both column acetabular fracture is defined as an acetabular fracture with no articular surface in continuity with the remaining posterior ilium (and therefore, axial skeleton). The spur sign is a radiological sign seen with these fractures, and is the posterio-inferior aspect of the intact posterior ilium. The spur sign and other radiographic findinds consistent with a both column acetabular fracture can be seen in Illustration A (AP), Illustration B (obturator oblique), and Illustration C (iliac oblique). Illustrations: A B C REFERENCES: 1. OITE09 #163 2. Letournel E, Judet R: Fractures of the Acetabulum. New York, NY, Springer-Verlag, 1993, pp 253-254 3. Vrahas MS, Tile M: Fractures of the acetabulum, in Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 1513-1545 : PENDING FINAL APPROVAL RATE CONTENT 2 RATINGS TAG Please login to view and post comments. (OBQ09-198) A 25-year-old male is involved in a motor vehicle accident and presents with the injury shown in Figure A. Early fixation of this fracture pattern is associated with all of the following EXCEPT? REVIEW TOPIC FIGURES: A 1. Decreased length of hospital stay 2. Improved functional outcome 3. Greater organ dysfunction 4. Highly likelihood of being discharged to home as opposed to a rehab facility 5. Improved fracture reduction PREFERRED RESPONSE ▼ 3 DISCUSSION: Early fixation of acetabular fractures is associated with lesser organ dysfunction, so therefore answer three is not true. Plaisier et al showed the timing of acetabular and pelvic ring fracture fixation greatly impacted patient outcome. Patients who had fixation within 24 hours of injury showed shorter length of stay in the hospital and ICU (decreased number of ventilator days), improved functional outcomes including a highly likelihood of being discharged to home as opposed to a rehabilitation facility, and lesser organ dysfunction. The reference by Matta et al is a classic article that shows that patients fixed within 3 weeks of injury showed both a higher rate of anatomical reduction and lower overall complication rate than patients with similar fracture patterns treated after 3 weeks. REFERENCES: 1. OITE09 #198 2. Baumgaertner MR, Tornetta P III (eds): Orthopaedic Knowledge Update: Trauma 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 271-280 3. Plaisier BR, Meldon SW, Super DM, et al: Improved outcome after early fixation of acetabular fractures. Injury 2000;31:81-84 PMID:10748809 (Link to Abstract) 4. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996 Nov;78(11):1632-45. PMID:8934477 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments. (OBQ09-217) A 22-year-old female is involved in an MVC and sustains the injury shown in figures A through D. According to these images, what is the acetabular fracture classification? REVIEW TOPIC FIGURES: A B C D 1. Anterior column posterior hemitransverse 2. Both column 3. Transverse 4. Transverse with posterior wall 5. Anterior column PREFERRED RESPONSE ▼ 2 DISCUSSION: Figures A through D show a comminuted both column acetabular fracture. In this injury, both columns are involved, with the acetabulum losing all connection to the axial skeleton (sacrum). This differentiates it from all other patterns, in which part of the acetabulum maintains connection to the sacrum. REFERENCES: 1. OITE09 #217 2. Letournel E, Judet R: Associated transverse and posterior wall fractures, in Letournel F, Judet R (eds): Fractures of the Acetabulum, ed 2. Berlin, Heidelberg, Springer-Verlag, 1993, pp 201-221 3. Reilly MC: Fractures of the acetabulum, in Rockwood and Green’s Fractures in Adults, ed 6. Philadelphia, PA, Lippincott Williams & Wilkins, 2006, pp 1665-1714 : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments. (OBQ09-223) A patient wakes up with a foot drop following open reduction internal fixation of a posterior wall/posterior column acetabular fracture. What position of the leg causes the highest intraneural pressure in the sciatic nerve? REVIEW TOPIC 1. hip and knee extension 2. hip flexion to 90, knee extension 3. hip internal rotation, knee flexion to 90 4. hip and knee flexion to 90 5. hip extension, knee flexion to 90 PREFERRED RESPONSE ▼ 2 DISCUSSION: Borrelli et al examined the intraneural pressure of the sciatic nerve with the hip and knee in various different positions. They found that the "sciatic nerve appeared to exceed published critical thresholds for alterations of blood flow and neural function only when the hip was flexed to 90 degrees and the knee was fully extended." As a result, the leg is typically position with the hip in extension (or minimal flexion) and the knee in about 90 degrees of flexion when performing acetabular surgery via a posterior approach. REFERENCES: 1. OITE09 #223 2. Borrelli J Jr, Kantor J, Ungacta F, et al: Intraneural sciatic nerve pressures relative to the position of the hip and knee: A human cadaveric study. J Orthop Trauma 2000;14:255- 258 PMID:10898197 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments. (OBQ08-119) A 42-year-old female sustains the injury seen in the single computed tomography image seen in figure A. According to the Letournel classification, what is the injury pattern shown? REVIEW TOPIC FIGURES: A 1. Protrusio 2. Transverse 3. Anterior column 4. Posterior column 5. Both column PREFERRED RESPONSE ▼ 2 DISCUSSION: The coronal CT cut shown reveals a transverse fracture pattern according to the Letournel classification system. This can be determined by the fact that the articular surface of the acetabulum is attached to the intact portion of the ilium, which is connected to the axial skeleton posteriorly through the sacroiliac joint. This differs from a both-column fracture, in which the articular surface of the acetabulum has no attachments to the axial skeleton due to fracture line(s). The referenced articles review the acetabular radiographic anatomy and are great resources for this material. Illustrations: A REFERENCES: 1. OITE08 #119 2. Durkee NJ, Jacobson J, Jamadar D, Karunakar MA, Morag Y, Hayes C. Classification of common acetabular fractures: radiographic and CT appearances. AJR Am J Roentgenol. 2006 Oct;187(4):915-25. PMID:16985135 (Link to Abstract) 3. Baumgaertner MR, Tronetta P, Orthopedic Knowledge Update: Trauma 3. American Academy of Orthopaedic Surgeons, Rosemont, IL, 2005, pp 259-269 : PENDING FINAL APPROVAL RATE CONTENT 2 RATINGS TAG Please login to view and post comments. (OBQ08-265) Which statement is true with respect to acetabular fracture surgery as the time between injury and surgery increases? REVIEW TOPIC 1. decreased chance of anatomic fracture reduction 2. decreased risk of heterotopic ossification 3. decreased rate of neurologic injury 4. decreased rate of infection 5. decreased rate of multi-organ failure PREFERRED RESPONSE ▼ 1 DISCUSSION: Madhu et al showed time to surgery was a significant predictor of radiological and functional outcome for both elementary and associated displaced fractures of the acetabulum. Both anatomic reduction and functional outcome significantly worsened as time to surgery increased. It was found anatomic reduction was more likely when surgery was within 15 days for elementary fracture and 5 days for associated. Heterotopic ossification showed a trend towards increased odds with increased time to surgery but did not reach significance. Neurologic injury is more associated with the initial injury. Non-union is more frequent in non-anatomic reductions. Multi-organ failure was not commented on, but infection showed a trend towards being more likely with longer time to surgery. REFERENCES: 1. OITE08 #265 2. Madhu R, Kotnis R, et al. Outcome of surgery for reconstruction of fractures of the acetabulum. The time dependent effect of delay. J Bone Joint Surg Br. 2006 Sep;88(9):1197-203. PMID:16943472 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments. (OBQ07-3) During an ilioinguinal approach to the pelvis, the majority of patients will have a corona mortis, which can cause significant bleeding if injured. This anastomosis is between which pair of vessels: REVIEW TOPIC 1. Superior gluteal and cluneal 2. Internal iliac and external iliac 3. Obturator and external iliac 4. Femoral and obturator 5. Deep and superificial femoral PREFERRED RESPONSE ▼ 3 DISCUSSION: Pure anatomy question about the corona mortis (See Illustration A). The important thing to remember is that during the ilioinguinal approach you need to be careful of the corona mortis b/c the vessels can cause significant bleeding especially if they retract into the pelvis. In the Tornetta article fifty cadaver halves were dissected to determine the occurrence and location of the corona mortis. Anastomoses between the obturator and external iliac systems occurred in 84% of the specimens. Thirty-four percent had an arterial connection, 70% had a venous connection, and 20% had both. (Illustration A) The distance from the symphysis laterally to the anastomotic vessels averaged 6.2 cm. The Okcu article showed nearly exact results in 150 cadavers: they found vascular anastomoses between the obturator and external iliac systems in 91 of 150 sides (61%), and anastomotic veins in 78 of 150 exposures (52%). Arterial connections were seen in 29 of the exposures (19%). The mean distance between the anastomotic arteries and the symphysis pubis was 64(45-90)mm, and 56(37-80)mm for the communicating veins. There seemed to be no significant difference between genders in the incidence of corona mortis and the distance between communicating vessels and the symphysis pubis. Illustrations: A REFERENCES: 1. OITE07 #3 2. Okcu et al, Acta Orthop Scand, 75: 2004 3. Tornetta et al, CORR, 329: 1996 : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments. (OBQ07-98) Which of the following associated type acetabular fracture patterns is defined based on the fact that all articular segments are detached from the intact portion of the ilium, which remains attached to the sacrum through the sacroiliac joint? REVIEW TOPIC 1. Posterior wall/ posterior column 2. Transverse 3. T-Type 4. Anterior column/ posterior hemitransverse 5. Both columns PREFERRED RESPONSE ▼ 5 DISCUSSION: There are 5 simple and 5 associated fracture types according to the classification system created by Judet and Letournel. The key feature which distinguishes both column fractures from other associated types is that all articular segments are detached from the intact portion of the ilium, which remains attached to the sacrum through the SI joint. Although the transverse plus posterior wall, T-shaped, and anterior plus posterior hemi-transverse fractures all show involvement of the anterior and posterior columns, they are not “both columns” because a portion of the articular surface remains in its normal position, attached to intact ilium. The intact ilium is responsible for the "spur sign" noted most prominently on the obturator oblique radiograph. Illustrations: A REFERENCES: 1. OITE07 #98 2. Browner BD, Jupiter JB, Levine AM (eds): Skeletal Trauma. Philadelphia, PA, WB Saunders, 1992 3. Kellam and Tile, Fractures of the Pelvis and Acetabulum : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments. (OBQ07-114) A 78-year-old community-ambulating female sustains a comminuted left acetabular fracture as a result of a fall from standing height. A radiograph is shown in Figure A. What is the most appropriate treatment for this patient? REVIEW TOPIC FIGURES: A 1. Skeletal traction 2. Conservative treatment with delayed physical therapy and shoe lifts 3. Open reduction and internal fixation 4. Open reduction and internal fixation with acute total hip arthroplasty 5. Closed reduction and percutaneous fixation PREFERRED RESPONSE ▼ 4 DISCUSSION: The patient described in this question has sustained an insufficiency fracture, with the radiograph showing significant osteopenia with comminution of both columns, the dome and the medial wall. Treatment of this problem should include reduction and fixation of the column(s) and placement of a total hip arthroplasty (THA), with use of flanged and/or custom acetabular components as needed. The first referenced article by Weber et al reviewed delayed THA in acetabular fractures, and reported a 78% 10-year survival rate, with worse outcomes in patients < 50yrs, males, weight >80kg, and patients with large residual segmental acetabular defects. The second referenced article by Jiminez et al reviews the the use of THA after acetabular fractures, either in a delayed or acute fashion. The third referenced article by Mears reviews acute THA in osteopenic acetabular fractures, with presentation of treatment algorithms and techniques. REFERENCES: 1. OITE07 #114 2. Weber M, Berry DJ, Harmsen WS: Total hip arthroplasty after operative treatment of an acetabular fracture. J Bone Joint Surg Am 1998;80:1295-1305 PMID:9759814 (Link to Abstract) 3. Jimenez ML, Tile M, Schenk RS: Total hip replacement after acetabular fracture. Orthop Clin North Am 1997;28:435-446 PMID:9208835 (Link to Abstract) 4. Mears DC. Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone. J Am Acad Orthop Surg. 1999 Mar-Apr;7(2):128-41. PMID:10217820 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments. (OBQ07-230) All of the following have been shown to negatively affect clinical outcomes in treating displaced acetabular fractures, EXCEPT: REVIEW TOPIC 1. Increased age 2. Intraoperative complications 3. Ipsilateral femoral head injury 4. Choice of surgical approach 5. Quality of fracture reduction PREFERRED RESPONSE ▼ 4 DISCUSSION: Negative outcome factors have been shown to include: increasing patient age, time from injury to surgery (>3 weeks), intraoperative complications, femoral head bone or cartilage injury, and fracture reduction > 1-2mm from anatomic. Choice of surgical approach has not been shown to affect patient outcomes. The referenced study by Matta evaluated outcomes of displaced acetabular fractures. The overall clinical result was excellent for 104 hips (40 per cent), good for ninety-five (36 per cent), fair for twenty-one (8 per cent), and poor for forty-two (16 per cent). The clinical result was related closely to the radiographic result. These findings indicate that in many patients who have a complex acetabular fracture the hip joint can be preserved and post-traumatic osteoarthrosis can be avoided if an anatomical reduction is achieved. REFERENCES: 1. OITE07 #230 2. Matta JM: Fractures of the acetabulum: Accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am 1996; 78: 1632-1645 PMID:8934477 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments. (OBQ06-51) A 25-year-old patient presents with a posterior wall/ posterior column acetabular fracture. She is scheduled for open reduction internal fixation through a posterior approach. What position of the leg exerts the least amount of intraneural pressure on the sciatic nerve? REVIEW TOPIC 1. hip flexion, knee extension 2. hip extension, knee extension 3. hip flexion, knee flexion 4. hip extension, knee flexion 5. the pressure does not vary based on position PREFERRED RESPONSE ▼ 4 DISCUSSION: In the cited study, researchers measured tissue fluid pressure within the sciatic nerve in cadaveric specimens using a pressure transducer. The hip and knee were taken through a combination of ranges and found that the clinically relevant increase in pressure happened with the hip flexed at 90 degrees and the knee fully extended. They concluded that increased intraneural pressure was related to excursion of the nerve as linear distance between the greater sciatic notch and the distal leg increase. Hence, according to the question stem, to avoid traction injury, the reverse position should be implemented (hip extension and knee flexion). REFERENCES: 1. OITE06 #51 2. Borrelli J Jr, Kantor J, Ungacta F, et al: Intraneural sciatic nerve pressures relative to the positionof the hip and knee: A human cadaveric study. J Orthop Trauma 2000;14:255-258. PMID:10898197 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments. (OBQ06-166) What acetabular component is best appreciated on an obturator oblique radiograph of the pelvis as seen in Figure A? REVIEW TOPIC FIGURES: A 1. ilioischial line 2. posterior column 3. posterior wall 4. anterior wall 5. sacroiliac joint PREFERRED RESPONSE ▼ 3 DISCUSSION: Letournel and Judet developed a schematic representation of the acetabulum as being contained within asymmetric long anterior and short posterior arms of an inverted “Y”. On the bony pelvis, the ilioischial component becomes that posterior column and the iliopectineal line becomes the anterior column. The Judet-Letournel classification system is based on this scheme. By careful evaluation of landmarks on a standard AP pelvis radiograph, as well as on 45-degree oblique obturator and iliac views, the extent of injury can be determined accurately. The AP view usually demonstrates the six fundamental landmarks relatively well as seen in illustration A. The obturator oblique view reveals additional information about the anterior column and posterior wall(see illustration A(B), B). The iliac oblique view visualizes the posterior column and anterior wall (illustration A(C), C). This view also shows the best detail of the iliac wing. Illustrations: A B C REFERENCES: 1. OITE06 #166 2. Browner BD, Jupiter JB, Levine AM (eds): Skeletal Trauma. Philadelphia, PA, WB Saunders, 1992 : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS CAUTION ERROR ALERT TAG Please login to view and post comments. (OBQ05-8) A 32-year-old male sustains the injury shown in Figure A through D as the result of a high-speed motor vehicle collision. This particular injury is best treated with which of the following approaches? REVIEW TOPIC FIGURES: A B C D 1. Ilioinguinal 2. Hardinge 3. Iliofemoral 4. Watson-Jones 5. Kocher-Langenbach PREFERRED RESPONSE ▼ 3 DISCUSSION: The radiograph and CT images shown in A-D show an acute both column acetabular fracture with segmental posterior column comminution. For difficult fractures with anterior displacement in which access to the entire anterior column is required, the ilioinguinal or Stoppa approach is ideal. These approaches allow access to the anterior column as far as the symphysis and includes the quadrilateral plate. Most both-column fractures can also be managed through these approaches, but only if the posterior fragment is large and in one piece. In this case, the posterior column is in several pieces and requires either two approaches or an extended approach, such as the iliofemoral. The original description of the ilioinguinal approach makes intraarticular visualization of the hip impossible. If visualization of the joint is required, a T extension of the incision just medial to the anterior-superior iliac spine can be made. Most surgeons accept that the joint is reduced when the fracture lines inside the pelvis are reduced, and thus this extension is very rarely used. The extended iliofemoral approach gives excellent visualization of the outer table of the ilium, the superior dome, and the posterior column. The anterior column can be visualized to the iliopectineal eminence. The exposure is similar to that provided by the triradiate approach with the additional benefit of access to the bone above the sciatic notch. The approach can be extended to provide exposure to the iliac fossa; however, this is very rarely necessary and should be avoided. Extending the approach to the inside of the pelvis greatly increases the risk of devascularizing segments of the acetabulum. Percutaneous or limited exposure of the posterior column may also be performed using specialized clamps and instrumentation from other approaches in certain circumstances. REFERENCES: 1. OITE05 #8 2. Letournel E, et al (eds). Fractures of the Acetabulum, ed. 2. 1993 : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments. (OBQ04-52) A 20-year-old man presents to the emergency department after a motor vehicle accident. Subsequent radiographs reveal an acetabular fracture in this otherwise healthy patient. For which fracture pattern would you consider an extensile (extended iliofemoral) approach? REVIEW TOPIC 1. Comminuted posterior wall fracture 2. Posterior wall and posterior column fracture 3. Transtectal transverse fracture with impacted roof 4. Anterior column and posterior hemitransverse fracture 5. Simple posterior wall fracture PREFERRED RESPONSE ▼ 3 DISCUSSION: Operative treatment is indicated for most displaced acetabular fractures to allow early ambulatory function and to decrease the chance of post-traumatic arthritis. Among the various surgical approaches, the extended iliofemoral approach was developed by Emile Letournel as a simultaneous approach to the two columns of the acetabulum. It can be regarded as the lateral approach to the innominate bone that primarily exposes the external aspect of the bone. The internal iliac fossa, however, can also be exposed, and circumferential access to the bone can be obtained by palpating the quadrilateral surface from the pelvic brim to the greater sciatic notch. The incision starts at the posterosuperior iliac spine, follows the iliac crest to the anterosuperior spine, and then turns slightly laterally to parallel the femur on the anterolateral aspect of the thigh. REFERENCES: 1. OITE04 #52 : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments. References Show References Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies) Starr AJ, Reinert CM, Jones AL. Percutaneous fixation of the columns of the acetabulum: a new technique. J Orthop Trauma. 1998 Jan;12(1):51-8. PMID:9447519 (Link to Abstract) Jimenez ML, Tile M, Schenk RS: Total hip replacement after acetabular fracture. Orthop Clin North Am 1997;28:435-446 PMID:9208835 (Link to Abstract) Mears DC. Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone. J Am Acad Orthop Surg. 1999 Mar-Apr;7(2):128-41. PMID:10217820 (Link to Abstract) Textbooks Review of Orthopaedics, 5th Edition, Mark D. Miller (editor), Saunders, an imprint of Elsevier, Philadelphia, Copyright 2008 First Aid for the Orthopaedic Boards, Robert Laminzak, Mark Albritton, Trevor Pickering (Editors), McGraw Hill Medical, Copyright 2009 Orthopaedic Knowledge Update 9, Jeffrey S Fischgrund (Editor). Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2008 Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009 OITE Questions, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2010 Frank H. Netter, John A. Craig. Netter's Concise Atlas of Orthopaedic Anatomy, Icon Learning Systems, Teterboro, NJ, Copyright 2002 Rout ML. Surgical treatment of acetabular fractures. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C, eds. Skeletal Trauma: Basic Science, Management, and Reconstruction, 4th ed. Philadelphia, PA: WB Saunders; 2009:1171-1218. Smith WR, Ziran BH, Morgan SJ, eds. Fractures of the Pelvis and Acetabulum, 2nd ed. New York, NY: Informa Healthcare Publishers; 2007:362-374. Riley MC. Fractures of the acetabulum. In: Bucholz RW, Tornetta P, Heckman JD, Koval KJ, Court-Brown CM, eds. Rockwood and Green's Fractures in Adults, 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:1665-1715. Letournel E, Judet R: Associated transverse and posterior wall fractures, in Letournel F, Judet R (eds): Fractures of the Acetabulum, ed 2. Berlin, Heidelberg, Springer-Verlag, 1993, pp 201-221 Reilly MC: Fractures of the acetabulum, in Rockwood and Green’s Fractures in Adults, ed 6. Philadelphia, PA, Lippincott Williams & Wilkins, 2006, pp 1665-1714 Letournel E, et al (eds). Fractures of the Acetabulum, ed. 2. 1993 Undefined Tornetta P III, Hochwald N, Levine R: Corona mortis: Incidence and location. Clin Orthop Relat Res 1996;329:97-101 PMID:8769440 (Link to Abstract) Letournel E, Judet R: Fractures of the Acetabulum, ed 2. New York, NY, Springer-Verlag, 1993, pp 375-381 2. Letournel E: Acetabulum fractures: Classification and management. Clin Orthop Relat Res 1980;151:81-106 PMID:7418327 (Link to Abstract) Patel V, Day A, Dinah F, et al: The value of specific radiological features in the classification of acetabular fractures. J Bone Joint Surg Br 2007;89:72-76 PMID:17259420 (Link to Abstract) Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Heidelberg, Germany, Springer-Verlag, 1981 Vrahas MS, Tile M: Fractures of the acetabulum, in Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 1513-1545 Kellam JF, Messer A. Evaluation of the role of coronal and sagittal axial CT scan reconstructions for the imaging of acetabular fractures. Clin Orthop Relat Res. 1994 Aug;(305):152-9. PMID:8050224 (Link to Abstract) Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Springer-Verlag, 1993, pp 29-61 Letournel E, Judet R: Fractures of the Acetabulum. New York, NY, Springer-Verlag, 1993, pp 253-254 Vrahas MS, Tile M: Fractures of the acetabulum, in Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 1513-1545 Baumgaertner MR, Tornetta P III (eds): Orthopaedic Knowledge Update: Trauma 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 271-280 Plaisier BR, Meldon SW, Super DM, et al: Improved outcome after early fixation of acetabular fractures. Injury 2000;31:81-84 PMID:10748809 (Link to Abstract) Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996 Nov;78(11):1632-45. PMID:8934477 (Link to Abstract) Borrelli J Jr, Kantor J, Ungacta F, et al: Intraneural sciatic nerve pressures relative to the position of the hip and knee: A human cadaveric study. J Orthop Trauma 2000;14:255- 258 PMID:10898197 (Link to Abstract) Durkee NJ, Jacobson J, Jamadar D, Karunakar MA, Morag Y, Hayes C. Classification of common acetabular fractures: radiographic and CT appearances. AJR Am J Roentgenol. 2006 Oct;187(4):915-25. PMID:16985135 (Link to Abstract) Baumgaertner MR, Tronetta P, Orthopedic Knowledge Update: Trauma 3. American Academy of Orthopaedic Surgeons, Rosemont, IL, 2005, pp 259-269 Madhu R, Kotnis R, et al. Outcome of surgery for reconstruction of fractures of the acetabulum. The time dependent effect of delay. J Bone Joint Surg Br. 2006 Sep;88(9):1197-203. PMID:16943472 (Link to Abstract) Okcu et al, Acta Orthop Scand, 75: 2004 Tornetta et al, CORR, 329: 1996 Browner BD, Jupiter JB, Levine AM (eds): Skeletal Trauma. Philadelphia, PA, WB Saunders, 1992 Kellam and Tile, Fractures of the Pelvis and Acetabulum Weber M, Berry DJ, Harmsen WS: Total hip arthroplasty after operative treatment of an acetabular fracture. J Bone Joint Surg Am 1998;80:1295-1305 PMID:9759814 (Link to Abstract) Matta JM: Fractures of the acetabulum: Accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am 1996; 78: 1632-1645 PMID:8934477 (Link to Abstract) Borrelli J Jr, Kantor J, Ungacta F, et al: Intraneural sciatic nerve pressures relative to the positionof the hip and knee: A human cadaveric study. J Orthop Trauma 2000;14:255-258. PMID:10898197 (Link to Abstract) Browner BD, Jupiter JB, Levine AM (eds): Skeletal Trauma. Philadelphia, PA, WB Saunders, 1992 Visitor Comments for Acetabular Fractures

Introduction

Anatomy

usually occur 2-4 cm above calcaneal insertion

Mechanism

maximum plantarflexion

Diagnosis missed in up to 25%

often thought to be an ankle sprain

Presentation

Physical exam
diagnosis made with Thompson test

Treatment

Treatment must be individualized to patient
Nonoperative
cast imobilization in a position of resting equinus
  • increased risk of rerupture
  • patient will have decreased plantar flexion strength
functional bracing vs. casting
  • greater ankle ROM with functional bracing
Operative : Achilles tendon repair
approach
  • make medial incision to avoid sural nerve
techniques
  • end-to-end Achilles tendon repair
    - indicated if gap < 4cm
  • VY advancement of gastroc
    - indicated for gap of 3-5 cm

FHL transfer +/- VY advancement of gastroc indicated for gap > 5 cm release FHL tendon at the Knot of Henry and transfer through the calcaneus percutaneous repair weaker and not recommended sural nerve at highest risk for injury surgical results advantages decreased re-rupture rate and increase plantar flexion strength disadvantages skin sloughing rehab initially immobilize in 20° of plantar flexion to decrease tension on skin and protect tendon repair complications wound complications risk factors for wound complications included tobacco abuse steroid use diabetes mellitus female sex RATE CONTENT AVERAGE 0.0 of 0 RATINGS

QBank

(OBQ10-36) A 58-year-old golfer fell stepping into a sand trap and ruptured his achilles tendon one year ago. He initially chose non-operative treatment, but became unsatisfied with a tender fullness behind his ankle and ankle weakness noticeable during his tee shots. At the time of surgery, a large disorganized fibrous mass is found at the site of rupture. Following extensive debridement there is a 5 cm gap between viable tissue ends.
Which of the following surgical techniques provides the greatest likelihood of a successful clinical outcome? REVIEW TOPIC

 1. Gastocnemius turndown repair augmented with transfer of the posterior tibial tendon 2. Gastocnemius turndown repair augmented with transfer of the extensor digitorum longus 3. Gastocnemius turndown repair augmented with transfer of the flexor hallicus longus 4. Reconstruction with hamstring autograft 5. Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program PREFERRED RESPONSE ▼ 3 DISCUSSION: Tendon loss is a complication associated with secondary ruptures of a repaired achilles tendon and chronic achilles tendon ruptures. Gastrocnemius turndown utilizes a slip of the central third of the gastrocnemius tendon to bridge the gap. Flexor hallicus longus (FHL) is the preferred tendon transfer to augment tissue loss due to its proximity and vascularity. Answer choice 5 is not a prudent option given the risk of equinus contracture and recurrent rupture. Wapner et al conducted a case review of 7 patients who underwent FHL augmentation for chronic achilles tendon rupture. Results included no surgical complications, a small but functionally insignificant decrease in ankle and great toe range of motion, and clinical satisfaction of all 7 patients. Chiodo et al summarize the AAOS clinical guidelines for evaluation and treatment of acute achilles tendon ruptures predicated upon an extensive review of the literature. REFERENCES: 1. OITE10 #36 2. Praszek AJ. Talus fractures and reconstruction: an overview. In: Pinzur MS, Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:91-102. 3. Wapner KL, Pavlock GS, Hecht PJ, Naselli F, Walther R. Repair of chronic Achilles tendon rupture with flexor hallucis longus tendon transfer. Foot Ankle. 1993 Oct;14(8):443-9. PMID:8253436 (Link to Abstract) 4. Chiodo CP, Glazebrook M, Bluman EM, et al: The Diagnosis and Treatment of Acute Achilles Tendon Rupture: Guideline and Evidence Report. Rosemont, IL, American Academy of Orthopaedic Surgeons, December 4, 2009. PMID:20675643 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS Comment Thread TAG

(OBQ08-269) What is the main advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization? REVIEW TOPIC 1. Lower rate of infection 2. Lower rate of nerve injury 3. Better skin cosmesis 4. Lower rate of dehiscence 5. Lower rate of re-rupture PREFERRED RESPONSE ▼ 5 DISCUSSION: In a pooled statistical analysis of 6 randomized studies, surgical repair significantly reduced the risk of rerupture when compared with surgical treatment, but increases the risk of infection and skin complications. For postoperative splintage, functional bracing has been shown to have a significantly lower rate of complications overall when compared with casting, particularly with regard to adhesion formation. Other complications with casting post-operatively include disturbed sensibility, keloid hypertrophic scarring, and infection. REFERENCES: 1. OITE08 #269 2. Bhandari M, Guyatt GH, Siddiqui F, et al: Treatment of acute Achilles tendon ruptures: A systematic overview and metaanalysis. Clin Orthop Relat Res 2002;400:190-200 PMID:12072762 (Link to Abstract) 3. Khan RJ, Fick D, Keogh A, et al.: Treatment of acute Achilles tendon ruptures: A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am 2005;87:2202-2210 PMID:16203884 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS CAUTION ERROR ALERT Comment Thread TAG

(OBQ07-54) A 38-year-old patient has an acute Achilles tendon rupture. He is active in sports and is deciding between operative and nonoperative treatments. Which of the following statements applies to patients undergoing nonoperative treatment? REVIEW TOPIC 1. They have lower patient satisfaction scores 2. They are less likely to return to sport 3. Their ultimate strength is decreased 4. They have a higher risk for rerupture 5. They have a higher risk of skin problems PREFERRED RESPONSE ▼ 4 DISCUSSION: This is a classic tested topic for which the answer has been a higher risk of rerupture in the nonoperative group. This may no longer be true. Weber et al retrospectively compared the results of nonoperative and operative management of Achilles tendon ruptures. They found that patient satisfaction, return to sports, and ultimate strength was the same for both groups. The complication rate was similar except for reruptures, with more occurring in the nonoperative treated group versus the operatively treated group. Khan et al conducted a meta-analysis of randomized controlled trials and they found that open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared with nonoperative treatment, but operative treatment is associated with a significantly higher risk of other complications. A more recent randomized study by Willits et al showed no statistical difference in rerupture rates, which has created new controversy on this subject. REFERENCES: 1. OITE07 #54 2. Weber M, Niemann M, Lanz R, Müller T. Nonoperative treatment of acute rupture of the achilles tendon: results of a new protocol and comparison with operative treatment. Am J Sports Med. 2003 Sep-Oct;31(5):685-91. PMID:12975187 (Link to Abstract) 3. Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2005 Oct;87(10):2202-10. PMID:16203884 (Link to Abstract) 4. Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation.J Bone Joint Surg Am. 2010 Dec 1;92(17):2767-75. PMID:21037028 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS Comment Thread TAG (OBQ06-270) Which factor increases the chance of wound complications after Achilles tendon repair? REVIEW TOPIC 1. increased body mass index 2. immediate surgery 3. male gender 4. age over 40 years old 5. tobacco use PREFERRED RESPONSE ▼ 5 DISCUSSION: Bruggeman et al anlayzed risk factors for wound complications after Achilles tendon repair. They found that tobacco use, steroid use, and female sex were significant risk factors for development of wound complications. Over 40% of those patients who had one or more of the following risk factors: diabetes, tobacco use, or steroid use had a complication, compared with 6% for those without risk factors present. Timing of surgery was not examined. REFERENCES: 1. OITE06 #270 2. Bruggeman NB, Turner NS, Dahm DL, Voll AE, Hoskin TL, Jacofsky DJ, Haidukewych GJ. Wound complications after open Achilles tendon repair: an analysis of risk factors. Clin Orthop Relat Res. 2004 Oct;(427):63-6. PMID:15552138 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG

(OBQ04-136) A 41-year-old female elects non-operative managment of her acute achilles tendon rupture. What is the disadvantage of casting over functional bracing? REVIEW TOPIC 1. increased wound complications 2. decreased ankle range of motion 3. decreased strength 4. increased re-rupture rate 5. worse functional outcomes PREFERRED RESPONSE ▼ 2 DISCUSSION: Saleh et al followed forty patients with acute complete rupture of the achilles tendon who were allocated to treatment groups using either cast immobilization for eight weeks or cast immobilization for three weeks, followed by functional bracing. Patients treated with functional bracing had improved ankle range of motion compared to the immobilization group (p < 0.001). In addition, patients treated with functional bracing were able to return to normal activities sooner. Recovery of the power of plantar flexion was similar in the two treatment groups, and no patient had excessive lengthening of the tendon. One re-rupture occurred in each group. REFERENCES: 1. OITE04 #136 2. Saleh M, Marshall PD, Senior R, MacFarlane A. The Sheffield splint for controlled early mobilisation after rupture of the calcaneal tendon. A prospective, randomised comparison with plaster treatment. J Bone Joint Surg Br.1992 Mar;74(2):206-9. PMID:1544953 (Link to Abstract) 3. McComis GP, Nawoczenski DA, DeHaven KE. Functional bracing for rupture of the Achilles tendon. Clinical results and analysis of ground-reaction forces and temporal data. J Bone Joint Surg Am. 1997 Dec;79(12):1799-808. PMID:9409793 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS CAUTION ERROR ALERT Comment Thread TAG References Show References Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies) Chiodo CP, Glazebrook M, Bluman EM, et al: The Diagnosis and Treatment of Acute Achilles Tendon Rupture: Guideline and Evidence Report. Rosemont, IL, American Academy of Orthopaedic Surgeons, December 4, 2009. PMID:20675643 (Link to Abstract) Textbooks Review of Orthopaedics, 5th Edition, Mark D. Miller (editor), Saunders, an imprint of Elsevier, Philadelphia, Copyright 2008 First Aid for the Orthopaedic Boards, Robert Laminzak, Mark Albritton, Trevor Pickering (Editors), McGraw Hill Medical, Copyright 2009 Orthopaedic Knowledge Update 9, Jeffrey S Fischgrund (Editor). Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2008 Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009 OITE Questions, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2010 Frank H. Netter, John A. Craig. Netter's Concise Atlas of Orthopaedic Anatomy, Icon Learning Systems, Teterboro, NJ, Copyright 2002 Praszek AJ. Talus fractures and reconstruction: an overview. In: Pinzur MS, Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:91-102. Undefined Wapner KL, Pavlock GS, Hecht PJ, Naselli F, Walther R. Repair of chronic Achilles tendon rupture with flexor hallucis longus tendon transfer. Foot Ankle. 1993 Oct;14(8):443-9. PMID:8253436 (Link to Abstract) Bhandari M, Guyatt GH, Siddiqui F, et al: Treatment of acute Achilles tendon ruptures: A systematic overview and metaanalysis. Clin Orthop Relat Res 2002;400:190-200 PMID:12072762 (Link to Abstract) Khan RJ, Fick D, Keogh A, et al.: Treatment of acute Achilles tendon ruptures: A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am 2005;87:2202-2210 PMID:16203884 (Link to Abstract) Weber M, Niemann M, Lanz R, Müller T. Nonoperative treatment of acute rupture of the achilles tendon: results of a new protocol and comparison with operative treatment. Am J Sports Med. 2003 Sep-Oct;31(5):685-91. PMID:12975187 (Link to Abstract) Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2005 Oct;87(10):2202-10. PMID:16203884 (Link to Abstract) Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation.J Bone Joint Surg Am. 2010 Dec 1;92(17):2767-75. PMID:21037028 (Link to Abstract) Bruggeman NB, Turner NS, Dahm DL, Voll AE, Hoskin TL, Jacofsky DJ, Haidukewych GJ. Wound complications after open Achilles tendon repair: an analysis of risk factors. Clin Orthop Relat Res. 2004 Oct;(427):63-6. PMID:15552138 (Link to Abstract) Saleh M, Marshall PD, Senior R, MacFarlane A. The Sheffield splint for controlled early mobilisation after rupture of the calcaneal tendon. A prospective, randomised comparison with plaster treatment. J Bone Joint Surg Br.1992 Mar;74(2):206-9. PMID:1544953 (Link to Abstract) McComis GP, Nawoczenski DA, DeHaven KE. Functional bracing for rupture of the Achilles tendon. Clinical results and analysis of ground-reaction forces and temporal data. J Bone Joint Surg Am. 1997 Dec;79(12):1799-808. PMID:9409793 (Link to Abstract) Visitor Comments for Achilles Tendon Rupture Please login to post comments Anonymous commented at 12:04PM on 02/19/11 "thanks"

Insertional Achilles tendonitis

Occur in middle ages and elderly patients with a tight heel cord mechanism is repetitive trauma (leads to inflammation followed by catilagenous then bony metaplasia) Treatment nonoperative rest gastroc-soleus stretching night splints small heel lift locked ankle AFO for 6-9 months (if other nonoperative modalities fail) operative debridement of diseased tendon and bony prominence resection indicated in < 50% of Achilles tendon insertion is removed FHL tendon augmentation or suture anchor repair if > 50% of Achilles tendon insertion must be removed

Retrocalcaneal bursitis and Haglund deformity

More common in young patients Physical exam pain can be localized to just anterior Achilles tendon 2-3 cm proximal to insertion Treatment nonoperative management is usually successful and includes rest physical therapy NSAIDS operative retrocalcaneal bursa excision and resection of bony Haglund deformity only indicated in refractory cases Achilles tendonitis Consist of two different conditions achilles tendinosis pathoanatomy of tendon along without acute or chronic inflammatory cells thought to be caused by anaerobic degeneration in portion of tendon with poor blood supply achilles peritendonits involves inflammation of tendong sheath Presentation physical exam tendon thickening and tenderness Imaging MRI can distinguish between peritondonitis and tendonosis based on involvement of the sheath Treatment rest physical therapy emphasize eccentric training in later phases RATE CONTENT AVERAGE 0.0 of 0 RATINGS QBank (OBQ08-153) A 48-year-old male complains of 5 years of heel pain while running. Initially the pain was relieved with achilles tendon stretching, orthotics, and open-backed shoe wear. Over the past year these modalities are no longer helpful and he is beginning to have pain with walking. Clinical photograph and radiograph are provided in figures A and B. Which of the following treatment options is the best choice to relieve pain and improve function? REVIEW TOPIC FIGURES: A B 1. Arizona gauntlet brace 2. Steroid injection 3. Achilles tendon debridement 4. Achilles tendon debridement, calcaneal exostectomy, and FHL transfer 5. Ankle arthrodesis PREFERRED RESPONSE ▼ 4 DISCUSSION: Clinical photograph and radiograph demonstrate Haglund's deformity and calcifications consistent with insertional achilles tendonopathy. Failure of conservative management and loss of function are indications for surgical management. Given the large Haglund's deformity on radiograph, calcaneal exostectomy is preferable to tendon debridement alone. McGarvey reviewed the clinical results of 22 insertional achilles tendonopathy treated surgically finding a clinical satisfaction rate of 82%. Hartog reports on 29 cases of FHL augmentation of chronic achilles tendonosis finding excellent or good results in 26 of 29 and no report of functional deficit or deformity of the hallux. Kolodziej conducted a cadaveric study to evaluate the integrity of the insertion of the achilles tendon. The greatest margin of safety was found to be offered by a superior to inferior resection (better than medial/lateral and oblique) and that as much as 50% of the tendon could be resected without sacrificing significant strength to failure. REFERENCES: 1. OITE08 #153 2. Den Hartog BD. Flexor hallucis longus transfer for chronic Achilles tendonosis. Foot Ankle Int. 2003 Mar;24(3):233-7. PubMed PMID: 12793486. PMID:12793486 (Link to Abstract) 3. Kolodziej P, Glisson RR, Nunley JA. Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendonitis and Haglund's deformity: a biomechanical study. Foot Ankle Int. 1999 Jul;20(7):433-7. PMID:10437926 (Link to Abstract) 4. McGarvey WC, Palumbo RC, Baxter DE, Leibman BD. Insertional Achilles tendinosis: surgical treatment through a central tendon splitting approach. Foot Ankle Int. 2002 Jan;23(1):19-25. PMID:11822688 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG References Show References Textbooks Review of Orthopaedics, 5th Edition, Mark D. Miller (editor), Saunders, an imprint of Elsevier, Philadelphia, Copyright 2008 First Aid for the Orthopaedic Boards, Robert Laminzak, Mark Albritton, Trevor Pickering (Editors), McGraw Hill Medical, Copyright 2009 Orthopaedic Knowledge Update 9, Jeffrey S Fischgrund (Editor). Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2008 Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009 OITE Questions, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2010 Frank H. Netter, John A. Craig. Netter's Concise Atlas of Orthopaedic Anatomy, Icon Learning Systems, Teterboro, NJ, Copyright 2002 Undefined Den Hartog BD. Flexor hallucis longus transfer for chronic Achilles tendonosis. Foot Ankle Int. 2003 Mar;24(3):233-7. PubMed PMID: 12793486. PMID:12793486 (Link to Abstract) Kolodziej P, Glisson RR, Nunley JA. Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendonitis and Haglund's deformity: a biomechanical study. Foot Ankle Int. 1999 Jul;20(7):433-7. PMID:10437926 (Link to Abstract) McGarvey WC, Palumbo RC, Baxter DE, Leibman BD. Insertional Achilles tendinosis: surgical treatment through a central tendon splitting approach. Foot Ankle Int. 2002 Jan;23(1):19-25. PMID:11822688 (Link to Abstract) Visitor Comments for Achilles Tendonitis

Introduction

Also known as classic dwarfism, it is the most common cause of disproportionate dwarfism.
Genetics

autosomal dominant (AD) caused by activation mutation of FGFR3 (fibroblast growth factor recepter 3, on chromosome 4P) leads to abnormal chondroid production by chondroblasts in the proliferative zone during enchondral bone formation at the physis

Spine conditions
short pedicles may lead to early spinal stenosis
thoracolumbar kyphosis may cause neurologic symptoms
foramen magnum stenosis (may cause periods of apnea)
Pseudoachondroplasia

an autosomal dominant condition that is clinically similar to achondroplasia genetics include a defect in the cartilage oligometric matrix protein (COMP) different from achondroplasia in that normal facies on physical exam associated with cervical instability

Presentation

Symptoms

normal intelligence delayed motor milestones be alert for symptoms of spinal stenosis

Physical exam

classic rhizomelic dwarfism dwarfism (adult heigh ~ 50 inches) humerus shorter than forearm and femur shorter than tibia normal trunk frontal bossing and button noses trident hands (inability to approximate extended middle and ring finger) thoracolumbar kyphosis excessive lordosis (due to short pedicles) bowed legs muscular hypotonia

Imaging

Xrays

Achondroplasia

 
 
 
 
 
 
 
 
lumbar spine xrays show short pedicles with decreased interpedicular distance pelvis xrays show champagne glass
Achondroplasia
 
 
 
 
 
 
 
 
 
 
 
pelvis (pelvis is wider than deep)
MRI
may be indicated to evaluate spinal stenosis

Treatment

Nonoperative weight loss, bracing, physical therapy Operative spinal stenosis if neurologic deficits treat with multilevel laminectomy and fusion thoracolumbar kyphosis attempt bracing first if bracing fails, neurologic symptoms present, and xrays show a kyphosis of > 60° by age 5 than proceed with anterior spinal cord decompression anterior strut grafting and fusion posterior laminectomy and fusion foramen magnum compression if symptomatic decompress References Review of Orthopaedics, 4th Edition, Mark D. Miller, W B Saunders Co, March 2004 Orthopaedic Knowledge Update 8: Home study syllabus, Edited by Alexander R. Vaccaro, MD Miller Colorado Review Lecture Series , Mark D. Miller, Stryker, 2005 Handbook of Fractures, Joseph D. Zuckerman, Kenneth J. Koval Surgical Exposures in Orthopaedics: The Anatomic Approach, Stanley Hoppenfeld, Piet DeBoer Netter's Concise Atlas of Orthopaedic Anatomy, Frank H. Netter, John A. Craig, Frank H. Netter, John A. Craig, ICOH Physical Examination of the Spine & Extremities. Stanley Hoppenfeld.Prentice Hall. Copyright 1976 RATE CONTENT AVERAGE 0.0 of 0 RATINGS QBank (OBQ10-161) Dwarfism caused by a defect of fibroblast growth factor receptor-3 (FGFR3) is associated with each of the following traits EXCEPT: REVIEW TOPIC 1. Rhizomelic limb shortening 2. Normal intelligence 3. Frontal bossing 4. Cervical spine instability 5. Spinal stenosis PREFERRED RESPONSE ▼ 4 DISCUSSION: Achondroplasia, caused by a defective FGFR3 affecting the proliferative zone of the physis, is characterized by rhizomelic shortening of the extremities. Inheritance is typically autosomal dominant, although spontaneous mutations are not uncommon. Characteristic findings include frontal bossing, trident hands, thoracolumbar kyphosis, shortened pedicles causing spinal stenosis, genu varum, muscular hypotonia, and normal intelligence. Cervical spine instability is not prevalent in achondroplasia, but is is present in pseudoachondroplasia, a skeletal dysplasia due to cartilage oligometric matrix protein (COMP) gene. A clinical example of achondroplasia is provided in illustration A. Illustrations: A REFERENCES: 1. OITE10 #161 2. Hensinger RN. Standards in Pediatric Orthopaedics: Table, Charts and Graphs Illustrating Growth. New York, NY: Raven Press; 1986:4. 3. Herring JA, Tachdjian's Pediatric Orthopaedics, 4th ed. Philadelphia, PA: WB Saunders; 2008:1683-1695. : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ09-10) Which of the following conditions is associated with a mutation in fibroblast growth factor receptor-3 (FGFR3)? REVIEW TOPIC 1. Marfan's syndrome 2. Gaucher's disease 3. Fibrous dysplasia 4. Achondroplasia 5. Diastrophic dysplasia PREFERRED RESPONSE ▼ 4 DISCUSSION: Achondroplasia results from a mutation in fibroblast growth factor receptor-3. Diastrophic dysplasia most commonly results from a mutation in the SLC26A2 gene. Fibrous dysplasia results from a mutation in cAMP. Gaucher's disease results from a mutation in glucocerebrosidase. Marfan's syndrome is caused by a mutation in the fibrillin gene. REFERENCES: 1. OITE09 #10 2. Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007, pp 3-23 3. Fischgrund JS (ed): Orthopaedic Knowledge Update 9. American Academy of Orthopaedic Surgeons, Rosemont, IL, 2008, pp 773-783 : PENDING FINAL APPROVAL RATE CONTENT 5 RATINGS Comment Thread TAG (OBQ06-139) A clinical photograph of two brothers is shown in figure A. X-rays of the brother on the right are shown in figures B and C. A mutation of what gene caused his condition? REVIEW TOPIC FIGURES: A B C 1. Indian Hedgehog 2. Bone morphogenic protein-2 3. Bone morphogenic protein-6 4. Fibroblast growth factor 5. Fibroblast growth factor receptor-3 PREFERRED RESPONSE ▼ 5 DISCUSSION: The child on the right has the characteristic appearance of an achondroplastic dwarf. In these patients, intelligence is normal, though developmental motor milestones are frequently delayed, with normal coordination achieved in later childhood. Clinical presentation includes: -Short stature with rhizomelic shortening of the limbs -Characteristic facies with frontal bossing and midface hypoplasia -Kyphosis at the thoracolumbar junction in infancy, which improves with ambulation -Ligamentous laxity -Limitations in elbow extension, sometimes with radial head subluxation -Genu varum -Trident hand-extra space between the third and fourth digits Radiographic characteristics include: -Decreased distance between the pedicles of the lumbar vertebra -Vertebral bodies with a scalloped appearance -Foramen magnum, central and foraminal stenosis -Broad, short pelvis with relatively wide iliac wings -Horizontal acetabular margins with well-covered femoral heads -Wide proximal femoral metaphyses and short femoral necks -Short, thick long bones with metaphyseal flaring The key to correctly answering this question is to recognize the characteristic appearance and changes of the pelvis and hand demonstrated by the given films as achondroplasia. Achondroplasia is the most common form of short-limb dwarfism. It is an autosomal-dominant condition, although 2/3 of the cases arise from spontaneous mutations. Interestingly, the risk of mutation increases with increased paternal age. The mutation has been mapped to chromosome 4 and is an activating mis-sense mutation of the FGFR-3 gene. The primary defect is abnormal endochondral bone formation; periosteal and intra-membranous ossifications are normal. The bone morphogenic proteins (BMPs) constitute a novel subfamily of the transforming growth factor type beta (TGF-beta) supergene family and play a critical role in modulating mesenchymal differentiation and inducing the processes of cartilage and bone formation. Recombinant human bone morphogenic protein-2 (rhBMP-2) is an osteoinductive protein that is now available and is used in the treatment of fractures and spinal fusion. Fibroblast growth factors are a family of structurally-related signaling molecules involved in wound healing, endothelia, cell proliferation, angiogenesis and embryonic development. Irregularities in function lead to a range of developmental defects. Indian hedgehog is targeted by BMPs and has an essential role in inducing hematopoietic tissue during embryogenesis. REFERENCES: 1. OITE06 #139 2. Aviezer D, Golembo M, Yayon A. Fibroblast growth factor receptor-3 as a therapeutic target for Achondroplasia-genetic short limbed dwarfism. Curr Drug Targets 2003; 4: 353-365. PMID:12816345 (Link to Abstract) 3. Chen L, Adar R, Yang X, Monsonego EO, Li C, Hauschka PV, Yayon A, Deng CX. Gly369Cys mutation in mouse FGFR3 causes achondroplasia by affecting both chondrogenesis and osteogenesis. J Clin Invest 1999; 104: 1517-25. PMID:10587515 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS CAUTION ERROR ALERT Comment Thread TAG (OBQ06-226) Achondroplasia results from abnormal chondrocyte function due to a defective protein in the physis. What protein is defective and what region of the physis is affected? REVIEW TOPIC 1. FGFR-3, zone of proliferation 2. FGFR-2, zone of proliferation 3. FGFR-3, zone of hypertrophy 4. FGFR-2, zone of hypertrophy 5. COMP, zone of hypertrophy PREFERRED RESPONSE ▼ 1 DISCUSSION: Achondroplasia, is the most common form of dwarfism, and the majority are sporadic mutations. It is caused by an autosomal dominant single nucleotide translocation in the FGF-3 receptor. It has its effects in the proliferative zone of the growth plate (see illustration). It causes rhizomelic shortening (where the proximal ends of bones are more affected than the distal ends). Apert's syndrome is caused by a genetic defect in the FGFR-2 and COMP defects cause pseudo-achondroplasia, multiple epiphyseal dysplasia type I, and McKusik's metaphyseal chondrodysplasia. Illustrations: A REFERENCES: 1. OITE06 #226 2. Buckwalter JA, Einhorn TA, Simmons SR, Orthopaedic Basic Science. Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System. ed 2. Rosemont IL, American Academy of Orthopaedic Surgeon, 2000 : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG References Show References Textbooks Review of Orthopaedics, 5th Edition, Mark D. Miller (editor), Saunders, an imprint of Elsevier, Philadelphia, Copyright 2008 First Aid for the Orthopaedic Boards, Robert Laminzak, Mark Albritton, Trevor Pickering (Editors), McGraw Hill Medical, Copyright 2009 Orthopaedic Knowledge Update 9, Jeffrey S Fischgrund (Editor). Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2008 Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009 OITE Questions, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2010 Frank H. Netter, John A. Craig. Netter's Concise Atlas of Orthopaedic Anatomy, Icon Learning Systems, Teterboro, NJ, Copyright 2002 Hensinger RN. Standards in Pediatric Orthopaedics: Table, Charts and Graphs Illustrating Growth. New York, NY: Raven Press; 1986:4. Herring JA, Tachdjian's Pediatric Orthopaedics, 4th ed. Philadelphia, PA: WB Saunders; 2008:1683-1695. Undefined Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007, pp 3-23 Fischgrund JS (ed): Orthopaedic Knowledge Update 9. American Academy of Orthopaedic Surgeons, Rosemont, IL, 2008, pp 773-783 Aviezer D, Golembo M, Yayon A. Fibroblast growth factor receptor-3 as a therapeutic target for Achondroplasia-genetic short limbed dwarfism. Curr Drug Targets 2003; 4: 353-365. PMID:12816345 (Link to Abstract) Chen L, Adar R, Yang X, Monsonego EO, Li C, Hauschka PV, Yayon A, Deng CX. Gly369Cys mutation in mouse FGFR3 causes achondroplasia by affecting both chondrogenesis and osteogenesis. J Clin Invest 1999; 104: 1517-25. PMID:10587515 (Link to Abstract) Buckwalter JA, Einhorn TA, Simmons SR, Orthopaedic Basic Science. Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System. ed 2. Rosemont IL, American Academy of Orthopaedic Surgeon, 2000 Visitor Comments for Achondroplasia

Introduction

Incidence ~400,000 ACL reconstructions / year
Mechanism is a non-contact pivoting injury
Often associated with a meniscal tear
lateral meniscal tears in up to 50% of acute ACL tears ???
Chronic ACL deficient knees associated with
chondral injuries
complex unrepairable meniscal tears
relation with arthritis is controversial
ACL injury more common in female athletes due to
neuromuscular forces (more quadriceps dominant)
landing biomechanics (conditioning and strength) play biggest role
females land in more extension, higher vaglus moment
smaller notches
smaller ligaments
hormone levels
valgus leg alignment

Anatomy

Function

provides 85% of the stability to prevent anterior translation of the tibia relative to the femur acts as secondary restraint to tibial rotation and varus/valgus rotation

Anatomy

33mm x 11mm in size

goes from LFC to anterior tibia (tibial insertion is broad and irregular and inserts just anterior and between the intercondylar eminences of the tibia)

Two bundles

anteromedial bundle

posterolateral bundle

x ACL PCL Tight in flexion AM AL Tight in extension PL PM Blood supply middle geniculate artery Innervation posterior articular nerve (branch of tibial nerve) Composition 90% Type I collagen 10% Type III collagen Strength: 2200 N (anterior)

Presentation

Presentation felt a "pop" pain deep in knee immediate swelling (70%) / hemarthrosis

Physical exam large effusion quadricep avoidence gait (does not actively extend knee) Lachman's (most sensitive) Note: PCL tear may give "false" Lachman due to posterior subluxation Lachman Grading System 1A, B < 5mm translation 2A, B 5-10mm 3A, B > 10mm A = firm endpoint, B = no endpoint Pivot shift extension to flexion: reduces at 20-30° of flexion patient must be completely relaxed (easier to elicit under anesthesia) mimics the actual giving way event KT-1000 useful to quantify anterior laxity measured with knee in slight flexion and externally rotated 10-30°

Imaging

Radiographs usually normal Segond fracture (avulsion fracture of the proximal lateral tibia) is pathognomocic for an ACL tear

MRI ACL tear best seen on sagital view bone bruising occurs in more than half of acute ACL tears middle 1/3 of LFC (sulcus terminalis) posterior 1/3 of lateral tibial plateau subchondral changes on MRI can persist years after injury

Treatment

Surgical Videos (NOT testable material) Video: Double Bundle ACL Reconstruction (VuMedi.com)

Nonoperative

low demand patients with decreased laxity

increased meniscal/cartilage damage linked to

loss of meniscal integrity frequency of buckling episodes level I and II activity (e.g. jumping, cutting, side-to-side sports, heavy manual labor)

Operative
ACL reconstruction
  • indications

in younger, more active patients (reduces incidence of mensical or chondral injury)

older active patients (Age >40 is not contraindication if high demand athlete)

ACL reconstuction failure

  • attempted ligament "repair" has high failure rate
Treatment of associated injuries

MCL injury

nonoperative allow MCL to heal (varus/valgus stablity) and then perfom ACL reconstruction varus/valgus instability can jepardize graf

Meniscal tear

operative perform meniscal repair at same time as ACL reconstuction increased healing rate when repaired at the same time as ACL

Posterolateral corner injury

operative

reconstruct at the same time as ACL or as first-stage of two stage reconstruction

Treatment in Children (< 14 yrs with open physis)
strongly consider operative
  • activity limitation impractical
  • transphyseal soft tissue grafts rarely lead to growth disturbances
  • avoid transphyseal metallic fixation

Graft Selection

Autograft
using patient's own tissue
most common source of graft
faster incorporation
less immune reaction
no chance of acquiring someone else's infection
Bone patellar bone graft
  • pros and cons
    - longest history of use,
    - considered the "gold standard"
    - bone to bone healing
    - ability to rigidly fix at the joint line (screws)
    - highest incidence of anterior knee pain (up to 10-30%)
    - maximum load to failure is 2600 Newtons (intact ACL is 1725 Newtons)

complications
- rare: patella fracture (usually postop during rehab), patellar tendon rupture

Quadruple hamsting autograft

pros and cons

smaller incision,

less periop pain, less anterior knee pain fixation strength may be less than Bone-PT-Bone maximum load to failure is 4500 Newtons decreased peak flexion strength at 3 years compared to Bone-PT-Bone concern about hamstring weakness in female athletes leading to increased risk of re-rupture

complications

 "windshield wiper" effect (suspensory fixation away from joint line causes tunnel abrasion and expansion with flexion/extension of knee) residual hamstring weakness

Other Graft Options
  • Much less common
  • Quadriceps tendon (taken with patella bone plug)
  • Contralateral patellar tendon or hamstring
    - may be useful in revision situation when allograft is not desirable or available
Allograft
pros & cons
  • useful in revisions
  • longer incorporation time
  • risk of disease transmission (HIV is < 1:1 million, hepatitis is even greater)
  • possible increased risk of re-rupture in athletes
graft processing
  • radiation: > 3 Mrads is required to kill HIV (this however decreases the structural and mechanical properties of the graft)
  • freezing: destroys cells but does not affect strength of graft

Surgical Techniques

Femoral tunnel placement

proper placement 1-2 mm rim of bone between tunnel and posterior cortex of femur

anterior misplacement leads to a knee that is tight in flexion and loose in extension occurs from failure to clear "residents ridge" posterior misplacement (over-the-top) leads to a knee that is lax in flexion and tight in extension

Tibial tunnel placement
proper placement
  • center of tunnel entrance into joint should be 10-11mm in front of anterior border of PCL insertion
  • tunnel trajectory of < 75° from horizontal
    - obtain by moving tibial starting point halfway between tibial tubercle and posterior medial edge of tibia.
anterior misplacement
  • leads to knee that is tight in flexion with impingement in extension (motion of 10° to 120°)
posterior misplacement
  • leads to knee that is loose in flexion and extension
Graft preconditioning
can reduce stress relaxation up to 50%
High tibial osteotomy
limb malalignment in both the coronal and sagital plane must be addressed before or at the same time as ligament reconstuction

Rehabilitation

Early postoperative
aggressive cryotherapy (ice)
immediate weight bearing (shown to reduce patellofemoral pain)
emphasize early full passive extension (especicially if associated with MCL injury or patella dislocation)
emphasize closed chain (foot planted) exercises
avoid
  • isokinetic quadricep strengthening (15-30°) during early rehab
  • open chain quadriceps strengthening
Injury prevention
female athlete
  • neuromuscular training / plyometrics (jump training)
  • land from jumping in less valgus and more knee flexion
  • increasing hamstring strength to decrease quadriceps dominance ratio
skier training
  • teach skiers how to fall
ACL bracing
  • no proven efficacy except for ACL-deficient skiers

Complications

Failures
causes
  • surgical technical error is the most common cause of ACL failure
  • improper tunnel placement causes failure in 60% (leads to impingement and graft failure)
  • inadequate fixation
  • overaggressive rehab
evaluation
  • obtain X-ray, CT, and MRI to help with surgical planning
treatment : revision ACL Surgery  and surgical techniques
  • use high strength grafts (quad tendon, hamstring, allograft)
  • use dual fixation (suspension + interference screws)
  • bone grafting (tunnel dilatation, decreased bone stock, staged prn)
  • reharvesting BTB contraindicated
  • conservative rehab
Missed combined injury
in combined ACL and PLC injuries, failure to treat the PLC will lead to failure of ACL reconstruction
Cyclops lesion
fibroproliferative tissue blocks extension
"click" heard at terminal extension
Septic Arthritis
Staph aureus most common
presentation
  • pain, swelling, erythema, and increased WBC at 2-14 days postop
  • perform immediate joint aspiration with gram stain and cultures
treatment
  • immediate arthrocopic I&D
  • often can retain graft with multiple I&Ds and abx (6 weeks minimum)
Loss of motion

preop tabanon3wwwworthopedè_

be sure patient has regained full ROM before you operate ("pre-hab")

wait until swelling (inflammatory phase) has gone down to reduce incidence of arthrofibrosis

operative proper tunnel placement is critical to have full range of motion postop prevention aggressive cryotherapy (ice) treatment < 12 weeks than treat with aggressive PT and serial splinting > 12 weeks than treat with LOA / MUA

Patella Tendon Rupture
will see patella alta on lateral radiograph
RSD (complex regional pain syndrome)
Patella fracture (most fx occur 8-12 weeks postop)
Hardware failure Tunnel osteolysis (treat with observation)
Late arthritis (related to meniscal integrity)
Local nerve irritation (infra-patellar branch saphenous)

RATE CONTENT AVERAGE 0.0 of 0 RATINGS

QBank

(OBQ09-26) A 31-year-old male is 1 year status post primary anterior cruciate ligament reconstruction.
  • Despite adequate physical therapy, he has been
  • unable to return to sport due to recurrent instability and
  • elects to proceed with revision surgery.
What is the most common reason for failure of his primary ACL reconstruction? REVIEW TOPIC
  1. unrecognized varus malalignment preop
  2. improper bone tunnel placement
  3. reconstruction with a single bundle
  4. improper graft selection
  5. meniscal injury
PREFERRED RESPONSE ▼ 2

DISCUSSION:

Battaglia et al report that "More than 75% of all cases of failed ACL reconstruction are the result of technical error and, of these, more than 70% are attributed specifically to malpositioned tunnels." Varus malalignment (answer 1) can lead to ACLR failure if not also addressed at the time of surgery, but is a less common cause of failure. Anatomic double bundle ACLR (answer #3) has been shown to be better biomechanically, but not clinically. Graft selection (answer #4) among autograft BTB, autograft hamstring, and allograft have not been shown consistently to affect revision rate. Meniscal (answer #5) and articular cartilage injury may affect the long-term satisfaction following ACLR, but are not a common cause of need for revision surgery. The study by Grossman et al reviewed 29 ACL's that underwent revision surgery with good results. All had a positive pivot shift preoperatively.. REFERENCES: 1. OITE09 #26 2. Battaglia TC, Miller MD. Management of bony deficiency in revision anterior cruciate ligament reconstruction using allograft bone dowels: surgical technique. Arthroscopy. 2005 Jun;21(6):767. PMID:15944645 (Link to Abstract) 3. Grossman MG, ElAttrache NS, Shields CL, Glousman RE. Revision anterior cruciate ligament reconstruction: three- to nine-year follow-up. Arthroscopy. 2005 Apr;21(4):418-23. PMID:15800521 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ09-147) Tunnel malposition is thought to be a primary etiology for ACL graft failure. All of the following are true of tunnel position EXCEPT: REVIEW TOPIC 1. Vertical placement of the femoral tunnel can result in impingement against the PCL 2. Anterior placement of the femoral tunnel can result in elongation of the graft 3. Tibial tunnel placement in the posterior half of the tibia can result in loss of flexion and graft rupture 4. Transtibial drilling through a tibia tunnel that is too far anterior can result in a vertical (12:00) graft 5. Transtibial drilling through a tibia tunnel that is too far anterior can result in an oblique ( 10:30 or 1:30 position ) graft PREFERRED RESPONSE ▼ 5 DISCUSSION: Tunnel placement is the most critical aspect of ACL reconstruction. The most common error in an ACL reconstruction is to place either the tibial or femoral tunnel too anteriorly, leading to graft impingement and failure. If one decides to drill the femoral tunnel by way of the tibia tunnel (transtibial drilling), it is important to understand that the direction of the tibial tunnel influences femoral tunnel placement and a tibia tunnel placed too far anteriorly can lead to a vertical (12:00) graft orientation relative to the intercondylar notch. This problem can also be avoided by drilling the femoral tunnel through a medial portal. Illustration A is a summary of the results described by Pinczewski et al as they reviewed radiographs of 200 ACL reconstructed patients over 7 years. There was an 11% rate of graft failure and they found if the tibial tunnel was placed >50% posteriorly along the length of the anterior tibial plateau, the incidence of rupture was 17% (11 of 66) vs 7% (8 of 115) if the graft was placed <50% posteriorly. Illustrations: A REFERENCES: 1. OITE09 #147 2. Pinczewski LA, Salmon LJ, Jackson WF, von Bormann RB, Haslam PG, Tashiro S. Radiological landmarks for placement of the tunnels in single-bundle reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br. 2008 Feb;90(2):172-9. PMID:18256083 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS Comment Thread TAG (OBQ09-157) A 27-year-old male suffers a twisting injury to his knee with immediate swelling and pain. A radiograph is shown in figure A. Which of the following structures has most likely been injured? REVIEW TOPIC FIGURES: A 1. Posterior cruciate ligament 2. Anterior cruciate ligament 3. Medial collateral ligament 4. Ligament of Wrisberg 5. Biceps femoris PREFERRED RESPONSE ▼ 2 DISCUSSION: Figure A demonstrates a Segond fracture which is an avulsion fracture of the lateral tibia plateau which is pathognomonic for an ACL injury. Sometimes these injuries are difficult to detect on radiographs and MRI would demonstrate lateral tibial bruising and also confirm an ACL injury. This is a commonly tested question and recognition of a Segond fracture should immediately raise suspicion for an ACL injury. REFERENCES: 1. OITE09 #157 2. Bathala EA, Bancroft LW, Ortiguera CJ, Peterson JJ. Radiologic case study. Segond fracture. Orthopedics. 2007 Sep;30(9):689, 797-8. PMID:17899907 (Link to Abstract) 3. DeLee JC, Drez D Jr, Miller MD (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, WB Saunders, 2002, p 1643 : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS CAUTION ERROR ALERT Comment Thread TAG (OBQ08-120) A 25-year-old male undergoes an ACL reconstruction with an ipsilateral bone-patella tendon-bone autograft. At his two week followup he is noted to have complete loss of his extensor mechanism on exam, stable lachman and posterior drawer tests, and patella alta radiographically. Management should consist of? REVIEW TOPIC 1. Continued standard ACL rehab protocol 2. Quadraceps tendon repair 3. WBAT in a cylinder cast 4. Patellar tendon reconstruction 5. Revision ACL reconstruction with hamstring autograft PREFERRED RESPONSE ▼ 4 DISCUSSION: Patellar tendon rupture is a rarely reported complication of using a bone-patella tendon-bone (BPTB)autograft in ACL reconstruction. Most cases have been reported in the early post-operative period and should be treated with patellar tendon reconstruction to restore the extensor mechanism. The reference from Cain et. al details management options for intraoperative complications of patella tendon grafts. The reference from Lee et.al demonstrated a 0.2% complication rate from BPTB harvest including 2 patella fractures and 1 patellar tendon rupture treated with reconstruction. REFERENCES: 1. OITE08 #120 2. Cain EL Jr, Gillogly SD, Andrews JR. Management of intraoperative complications associated with autogenous patellar tendon graft anterior cruciate ligament reconstruction. Instr Course Lect. 2003;52:359-67. PMID:12690863 (Link to Abstract) 3. Lee GH, McCulloch P, Cole BJ, Bush-Joseph CA, Bach BR Jr. The incidence of acute patellar tendon harvest complications for anterior cruciate ligament reconstruction. Arthroscopy. 2008 Feb;24(2):162-6. PMID:18237699 (Link to Abstract) 4. Garrick, JG (ED): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 169-181 : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ08-186) Patients may complain of numbness over the antero-lateral aspect of the knee following ACL reconstruction. This is most commonly due to injury of which of the following? REVIEW TOPIC 1. Suprapatellar branch of the saphenous nerve 2. Infrapatellar branch of the saphenous nerve 3. The common peroneal nerve 4. The superficial femoral nerve 5. The lateral femoral cutaneous nerve PREFERRED RESPONSE ▼ 2 DISCUSSION: From Portland et al: “Damage to the infrapatellar branch of the saphenous nerve (IPBSN) has been described for knee arthrotomy and arthroscopy. The true incidence of damage to this structure during anterior cruciate ligament (ACL) reconstruction has not been reported. The traditional vertical incision for central patellar tendon harvesting runs perpendicular to the course of this nerve. Therefore, a horizontal incision to avoid this potential complication was developed.” The authors comment that a horizontal incision may lead to a more technically challenging procedure in terms of tunnel placement, but they believe lower incidence of IPBSN damage and greater cosmetic satisfaction makes the horizontal incision preferred. REFERENCES: 1. OITE08 #186 2. Portland GH, Martin D, Keene G, Menz T. Injury to the infrapatellar branch of the saphenous nerve in anterior cruciate ligament reconstruction: comparison of horizontal versus vertical harvest site incisions. Arthroscopy. 2005 Mar;21(3):281-5 PMID:15756180 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ08-193) Strategies which focus on increasing patient neuromuscular control are most effective at preventing which of the following female sporting injuries? REVIEW TOPIC 1. Shoulder dislocations 2. Concussion 3. Anterior cruciate ligament ruptures 4. Frieberg's infarction 5. Patellofemoral instability PREFERRED RESPONSE ▼ 3 DISCUSSION: Anterior cruciate ligament (ACL) prevention strategies currently focus on increasing patient neuromuscular control and has been shown to decrease ACL tear rates in certain populations. Women have different muscle fiber distribution, increased ratio of quadriceps to hamstring strength, electromechanical firing delay, and different knee kinematics. As described in the reference by Griffin et al., neuromuscular training reduces these factors and has been shown to decrease rates of ACL tears in women. REFERENCES: 1. OITE08 #193 2. Garrick JG (ED). Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 403-410 3. Griffin LY, Agel J, Albohm MJ, Arendt EA, Dick RW, Garrett WE, Garrick JG, Hewett TE, Huston L, Ireland ML, Johnson RJ, Kibler WB, Lephart S, Lewis JL, Lindenfeld TN, Mandelbaum BR, Marchak P, Teitz CC, Wojtys EM. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg. 2000 May-Jun;8(3):141-50. Review. PMID:10874221 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ08-213) When comparing autologous graft options for ACL reconstruction, a hamstring graft is associated with which of the following findings when compared to a patellar tendon graft? REVIEW TOPIC 1. Decreased tunnel widening 2. Decreased pivot shift 3. Decreased incidence of anterior knee pain 4. Increased knee flexion strength on Cybex testing 5. Increased stability on KT-1000 PREFERRED RESPONSE ▼ 3 DISCUSSION: Beynnon's randomized JBJS study compared bone-patellar tendon-bone autograft with two strand hamstring autograft for ACL reconstructions. They followed 22 subjects in each group for an average of 3 years and evaluated them in terms of clinical test findings, patient satisfaction, activity level, functional status, and isokinetic muscle strength. The patients in whom a hamstring graft had been used had significantly lower peak knee-flexion strength than those who had a bone-patellar tendon-bone graft (p = 0.039). In contrast, the two treatments produced similar outcomes in terms of patient satisfaction, activity level, and knee function (ability to perform a one-legged hop, bear weight, squat, climb stairs, run in place, and duckwalk). BTB autograft patients tend to have a higher incidence of knee pain and knee stiffness not affecting function. Hamstring autograft does not generate less tunnel widening or a smaller pivot-shift test or KT-1000 reading than patellar autograft. REFERENCES: 1. OITE08 #213 2. Rodeo SA, Arnoczky SP, Torzilli PA et al. Tendon-healing in a bone tunnel. A biomechanical and histological study in the dog. J Bone Joint Surg Am. 1993 Dec;75(12):1795-803. PMID:8258550 (Link to Abstract) 3. Beynnon BD, Johnson RJ, Fleming BC et al.Tendon-Bone Grafts with Two-Strand Hamstring Grafts : A Prospective Randomized Study. J Bone Joint Surg Am. 2002;84:1503-1513. PMID:12208905 (Link to Abstract) 4. Pinczewski LA, Lyman J, Salmon LJ, et al. A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: a controlled, prospective trial. Am J Sports Med. 2007 Apr;35(4):564-74. Epub 2007 Jan 29. PMID:17261567 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ07-14) When performing an ACL reconstruction using a bone-patellar tendon-bone graft, what is the maximum allowable diverge between an interference screw and the femoral tunnel before fixation strength is compromised? REVIEW TOPIC 1. 5 degrees 2. 10 degrees 3. 15 degrees 4. 30 degrees 5. 45 degrees PREFERRED RESPONSE ▼ 3 DISCUSSION: With single-incision arthroscopic ACL reconstruction, if the femoral tunnel is drilled trans-tibially and the interference screw is placed through the medial portal, there exists the possibility of screw divergence. Pull-out strength is significantly less with divergence of 30 degress compared to only 15 degrees. Drilling the femoral tunnel through the medial portal makes this less of an issue. REFERENCES: 1. SASPT07 #14 2. Lemos MJ, Jackson DW, Lee TO, et al: Assessment of initial fixation of endoscopic interference femoral screws with divergent and parallel placement. Arthroscopy 1995;11:37-41. 3. Dworsky BD, Jewell BF, Bach BR Jr. Interference screw divergence in endoscopic anterior cruciate ligament reconstruction. Arthroscopy. 1996 Feb;12(1):45-9. : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS CAUTION ERROR ALERT Comment Thread TAG (OBQ07-66) A 16 year old high school basketball player sustains a non-contact knee injury when she lands from a rebound. She develops immediate swelling and is noted to have a hemarthrosis. What is the most likely diagnosis? REVIEW TOPIC 1. MCL tear 2. PCL tear 3. ACL tear 4. Patellar dislocation 5. Contusion PREFERRED RESPONSE ▼ 3 DISCUSSION: This is the classic history for an ACL tear. Women's basketball has one of the highest rates of ACL tears. While all of the answers are possible, the incidence of ACL tears in adolescents with an acute knee injury with hemarthrosis is the highest. Stanitski et al reported that 65% of adolescents with an acute knee hemarthrosis had and ACL tear compared to 45% having a meniscal tear. Likewise, Bomberg et al reported that 71% of patients with an acute hemarthrosis had sustained an ACL injury. REFERENCES: 1. OITE07 #66 2. Stanitski CL, Harvell JC, Fu F: Observations on acute knee hemarthrosis in children and adolescents. JPO 1993;13:506-510 PMID:8370785 (Link to Abstract) 3. Bomberg BC, McGinty JB: Acute hemarthrosis of the knee: Indications for diagnostic arthroscopy. Arthroscopy 1990;6:221-225 PMID:2206185 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS Comment Thread TAG (OBQ07-87) A patient sustains a knee injury. The MRI image shown in Figure A is indicative of which of the following injuries? REVIEW TOPIC FIGURES: A 1. ACL tear 2. PCL tear 3. Medial meniscus tear 4. Lateral meniscus tear 5. Patellar tendon tear PREFERRED RESPONSE ▼ 1 DISCUSSION: This image shows a bone bruise pattern consistent with an ACL tear. The pattern of bone bruise on the middle 1/3 of the lateral femoral condyle and posterior 1/3 of the lateral tibial plateau is indicative of ACL tear. It makes sense because the tibia is allowed to subluxate anterior more than usual and make abnormal contact and experiences forces inappropriately. Viskontas et al. correlated the mechanism of ACL tear with the degree of bone bruising and found that a noncontact mechanism caused more severe bone bruising in both the medial and lateral compartments. In another MRI review study, Collins et al. found that the presence of bone contusions in the lateral compartment increased the specificity and positive predictive value in determining ACL injury. REFERENCES: 1. OITE07 #87 2. Viskontas DG, Giuffre BM, Duggal N, Graham D, Parker D, Coolican M. Bone bruises associated with ACL rupture: correlation with injury mechanism. Am J Sports Med. 2008 May;36(5):927-33. PMID:18354139 (Link to Abstract) 3. Collins MS, Unruh KP, Bond JR, Mandrekar JN. Magnetic resonance imaging of surgically confirmed anterior cruciate ligament graft disruption. Skeletal Radiol. 2008 Mar;37(3):233-43. PMID:18092160 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ07-155) Increased ACL injury rates in women athletes compared to male athletes may be due to muscular imbalance and relative weakness in which of the following muscle groups? REVIEW TOPIC 1. Quadriceps 2. Hamstrings 3. Gluteus muscles 4. Adductors 5. Abdominals PREFERRED RESPONSE ▼ 2 DISCUSSION: Imbalanced or excessive knee extensor power causes abnormal tension on the ACL. Strengthening and proprioreceptive control of the knee flexors/hamstrings protects against excessive or unopposed knee extensors which protect the ACL from excessive tensioning. The Ahmad reference states that "female athletes after menarche increase their quadriceps strength greater than their hamstring strength, putting them at risk for anterior cruciate ligament injury. Anterior cruciate ligament-prevention programs based on improving dynamic control of the knee by emphasizing hamstring strengthening should be instituted for girls after menarche." The Vescovi paper examines the effects of such a program on athletic performance. The Baratta paper looked at EMG results of quad and hamstrings and suggested exercise of the antagonist muscle to add to dynamic stability. REFERENCES: 1. OITE07 #155 2. Ahmad CS, Clark AM, Heilmann N, Schoeb JS, Gardner TR, Levine WN. Effect of gender and maturity on quadriceps-to-hamstring strength ratio and anterior cruciate ligament laxity.Am J Sports Med. 2006 Mar;34(3):370-4. Epub 2005 Oct 6. PMID:16210574 (Link to Abstract) 3. Baratta R, Solomonow M, Zhou BH, Letson D, Chuinard R, D'Ambrosia R. Muscular coactivation. The role of the antagonist musculature in maintaining knee stability. Am J Sports Med. 1988 Mar-Apr;16(2):113-22. PMID:3377094 (Link to Abstract) 4. Vescovi JD, Vanheest JL. Effects of an anterior cruciate ligament injury prevention program on performance in adolescent female soccer players. Scand J Med Sci Sports. 2010 Jun;20(3):394-402. PMID:19558381 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ07-274) Which of the following risk factors is felt to contribute greatest to the higher rate of ACL rupture in female compared to male athletes? REVIEW TOPIC 1. Body mass index 2. Femoral notch width 3. Generalized ligamentous laxity 4. Neuromuscular factors 5. Limb alignment PREFERRED RESPONSE ▼ 4 DISCUSSION: Hewett showed that increased valgus moments when jumping and landing and a relative weakness of hamstrings compared to quadriceps are present in female athetes and may contribute to higher ACL tear rates. It has subsequently been shown that neuromuscular training to address these issues can result in a reduction of ACL injuries in select groups of female athletes. Uhorchak conducted a 4 year study on 895 US Military cadets, there were 24 noncontact ACL tears. Significant risk factors for noncontact ACL tears included small femoral notch width, generalized joint laxity, and in women, higher than normal BMI and KT-2000 arthrometer values (indicating laxity). In the second study 205 females in high-risk sports were prospectively measured for neuromuscular control during a jump-landing task. It appears that increased valgus motion and valgus moments at the knee joint during the impact phase of jump-landing tasks are key predictors of an increased potential for ACL injury in females. The Alentorn-Geli paper reviews these risk factor in the soccer population. REFERENCES: 1. OITE07 #274 2. Alentorn-Geli E, Myer GD, Silvers HJ, Samitier G, Romero D, Lázaro-Haro C, Cugat R. Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: Mechanisms of injury and underlying risk factors. Knee Surg Sports Traumatol Arthrosc. 2009 Jul;17(7):705-29. Epub 2009 May 19. PMID:19452139 (Link to Abstract) 3. Uhorchak JM, Scoville CR, Williams GN, Arciero RA, St Pierre P, Taylor DC. Risk factors associated with noncontact injury of the anterior cruciate ligament: a prospective four-year evaluation of 859 West Point cadets. Am J Sports Med. 2003;31(6):831-42. PMID:14623646 (Link to Abstract) 4. Hewett TE, Myer GD, Ford KR, Heidt RS Jr, Colosimo AJ, McLean SG, van den Bogert AJ, Paterno MV, Succop P. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33(4):492-501. PMID:15722287 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ06-112) A 25-year-old male soccer player twisted his left knee 4 dyas ago and developed immediate swelling and pain. On exam, he has a 3+ effusion and decreased motion with active range from 15 to 60 degrees of flexion. MRI scan is shown in Figure A. What is the most appropriate initial management for his injury? REVIEW TOPIC FIGURES: A 1. Knee immobilizer to improve extension 2. Physical therapy for range of motion and strength 3. Acute reconstruction followed by mobilization 4. Arthrocentesis 5. Rest and nonsteroidal anti-inflammatories PREFERRED RESPONSE ▼ 2 DISCUSSION: The clinical presentation, physical exam, and imaging are consistent with an acute anterior cruciate ligament (ACL) tear. If the patient wants to return to sports requiring twisting/pivoting, an ACL reconstruction is recommended. He currently has an acute effusion (hemarthrosis) with decreased motion. Acute ACL reconstructions in patients with limited range of motion and weakness have been shown to lead to postoperative arthrofibrosis and weakness. Shelbourne and Patel noted several factors that go into optimizing ACL reconstruction results: Mental preparation of the patient; school, work, family, and social schedules; preoperative condition of the knee [i.e., minimal or no swelling, good strength, good leg control, and full range of motion including full hyperextension] and lack of associated ligamentous and/or meniscal injuries. Eitzen et al. recommended waiting until the affected quadriceps was within 20% of the strength of the contralateral unaffected one in order to mitigate postoperative strength deficits. Sterett et al found that acute reconstruction (within 3 weeks) yielded good range of motion and strength results but in patients in whom the parameters were excellent preoperatively. The other answers would not optimize postoperative results. Immobilization would promote arthrofibrosis, as would an acute reconstruction in this stiff, weak knee. Arthrocentesis is a reasonable diagnostic/therapeutic option acutely. However, it does expose the patient to a risk of infection. Furthermore, in this patient with a 4 day old injury, the hemarthrosis is likely mostly coagulated and would frustrate attempts at aspiration. Rest and NSAIDs would not help to promote range of motion and strength. REFERENCES: 1. OITE06 #112 2. Shelbourne KD, Patel DV: Timing of surgery in anterior cruciate ligament-injured knees. Knee Surg Sports Traumatol Arthosc 1995;3:148-156. PMID:8821270 (Link to Abstract) 3. Sterett WI, Hutton KS, Briggs KK, Steadman JR. Decreased range of motion following acute versus chronic anterior cruciate ligament reconstruction. Orthopedics 2003;26:151-154. PMID:12597218 (Link to Abstract) 4. Eitzen I, holm I, Risberg MA: Preoperative strength is a significant predictor of knee function two years after ACL reconstruction. Br J Sports Med. 2009 May;43(5):371-6. PMID:19224907 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ06-138) Following ACL reconstruction, which of the following tests most closely correlates with patient satisfaction with their reconstructed knee? REVIEW TOPIC 1. KT-1000 manual maximum value 2. Lachman's test 3. Anterior drawer test 4. Pivot shift test 5. Cybex testing PREFERRED RESPONSE ▼ 4 DISCUSSION: Kocher et al in a study looking at 202 post ACL-reconstruction patients found that the pivot shift test was the only test significantly associated with patient satisfaction, knee giving away, difficulty cutting and twisting, activity limitation, sports participation, Lysholm score, and overall knee function. KT-1000 is an instrument to measure the anterior translation of the tibia. REFERENCES: 1. OITE06 #138 2. Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ. Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med. 2004 Apr-May;32(3):629-34. PMID:15090377 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS Comment Thread TAG (OBQ06-177) A patient develops parasthesias on the antero-medial knee and proximal leg after autologous hamstring tendon harvest for an ACL reconstruction. Which of the following nerves is likely to be involved if the injury is related to the tendon harvest? REVIEW TOPIC 1. Medial retinacular 2. Inferior genicular 3. Saphenous 4. Superficial peroneal 5. Tibial PREFERRED RESPONSE ▼ 3 DISCUSSION: The infra-patellar brach of the saphenous nerve is at risk as it emerges between the sartorius and gracilis tendons and can be injured during autologous hamstring tendon harvest. Figueroa et al cites injury rates to infrapatellar branch of saphenous nerve durring autologous hamstring harvesting for ACL reconstruction to be between higher than previously reported. They found hypoesthesia of the IBSN territory was found in 17 knees (77%) with an average area of 36 cm(2) (1-120 cm(2)). Injury to the IBSN was electrophysiologically detected in 15 knees (68%). Two patients also had an injury to the saphenous nerve (9%). The Hoppenfeld and Medvecky references review the surgical approaches and relevant anatomy. REFERENCES: 1. OITE06 #177 2. Hoppenfeld S, deBoer PL The Knee, in Hoppenfeld and deBoer: Surgical Exposures in Orthopaedics, the Anatomic Approach. 3. Medvecky MJ, Noyes FR: Surgical approaches to the posteromedial and posterolateral aspects of the knee. JAAOS 2005;13:121-128. PMID:15850369 (Link to Abstract) 4. Figueroa D, Calvo R, Vaisman A, Campero M, Moraga C. Injury to the infrapatellar branch of the saphenous nerve in ACL reconstruction with the hamstrings technique: clinical and electrophysiological study.Knee. 2008 Oct;15(5):360-3. PMID:18583136 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS Comment Thread TAG (OBQ05-28) At what range of motion do seated leg extension exercises place the greatest amount of stress on the anterior cruciate ligament? REVIEW TOPIC 1. 0 to 30 degrees 2. 30 to 60 degrees 3. 60 to 90 degrees 4. 90 to 120 degrees 5. flexion greater than 120 degrees PREFERRED RESPONSE ▼ 1 DISCUSSION: Open chain leg extension exercises cause the most anterior shear stress that would affect the ACL. The Wilk article summarizes that isotonic closed kinetic chain exercises produced significantly greater compressive forces compared to the open kinetic chain knee extension. In addition, during closed kinetic chain exercises, a posterior shear force (PCL stress) was generated throughout the entire range with maximal shear occurring from 85° to 105° of flexion. During knee extension, there is an anterior shear force (ACL stress) from 38° to 0° and a posterior shear force from 40° to 101°. According to Beynnon, a closed chain program results in anteroposterior knee laxity values that are closer to normal, and earlier return to normal daily activities, compared with rehabilitation with an open chain program. REFERENCES: 1. OITE05 #28 2. Beynnon BD, Johnson RJ, Fleming BC. The science of anterior cruciate ligament rehabilitation. Clin Orthop Relat Res. 2002 Sep;(402):9-20. PMID:12218469 (Link to Abstract) 3. Wilk KE, Escamilla RF, Fleisig GS, Barrentine SW, Andrews JR, Boyd ML. A comparison of tibiofemoral joint forces and electromyographic activity during open and closed kinetic chain exercises. Am J Sports Med. 1996 Jul-Aug;24(4):518-27. PMID:8827313 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 3 RATINGS Comment Thread TAG (OBQ05-40) During anterior cruciate ligament reconstruction, a graft that is tight in flexion but lax in extension may be due to which technical error? REVIEW TOPIC 1. Femoral tunnel is too posterior 2. Femoral tunnel is too anterior 3. Femoral tunnel placed at 12:00 position 4. Tibial tunnel is too anterior 5. Tibial tunnel is too medial PREFERRED RESPONSE ▼ 2 DISCUSSION: The majority of early ACL reconstruction failures are felt to be due to errors in surgical technique. The most common error in ACL reconstruction is aberrant tunnel placement. The femoral tunnel can be placed too anteriorly, thereby causing increased strain on the graft in flexion because of the cam effect of the femoral condyle which can result in graft stretching, laxity in extension, and subsequent failure. Chhabra et al. performed a cadaveric study to demonstrate the anatomic footprints of the anteromedial and posterolateral bundles of the ACL. Markhof et al. performed a cadaveric study analyzing the effects of aberrant placement of the femoral tunnel. Illustration A demonstrates a well positioned femoral tunnel. Illustration B demonstrates a femoral tunnel that is too anterior. Illustration C is a table summarizing the effects of femoral and tibial tunnel malposition in ACL reconstruction. Illustrations: A B C REFERENCES: 1. OITE05 #40 2. Chhabra A, Starman JS, Ferretti M, Vidal AF, Zantop T, Fu FH. Anatomic, radiographic, biomechanical, and kinematic evaluation of the anterior cruciate ligament and its two functional bundles. J Bone Joint Surg Am. 2006 Dec;88 Suppl 4:2-10. PMID:17142430 (Link to Abstract) 3. Markolf KL, Hame S, Hunter DM, Oakes DA, Zoric B, Gause P, Finerman GA. Effects of femoral tunnel placement on knee laxity and forces in an anterior cruciate ligament graft. J Orthop Res. 2002 Sep;20(5):1016-24. PMID:12382968 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 3 RATINGS Comment Thread TAG (OBQ05-96) Which of the following exercises should be used with caution in the intial post-operative rehab following ACL reconstruction? REVIEW TOPIC 1. Quad sets 2. Seated leg extensions 3. Straight leg raises 4. Active range of motion 5. Closed chain exercises PREFERRED RESPONSE ▼ 2 DISCUSSION: Seated leg extensions are open chain exercises that are generally avoided early after ACL surgery. Closed chain exercises are emphasized because it allows physiologic contraction around the muscles of the knee. Closed chain exercises load an extremity with the most distal segment stabilized, preventing joint shear forces. This is ideal for post op rehab for an ACL. For open chain exercises, the foot is unsupported. Quad sets and straight leg raises are generally allowed to help regain quadriceps function. They produce less graft strain because they are isometric about the knee, compared to a seated leg extension in which the quad force is pulling the tibia anteriorly and potentially stressing the graft. REFERENCES: 1. OITE05 #96 2. Ross MD, Denegar CR, Winzenried JA. Implementation of open and closed kinetic chain quadriceps strengthening exercises after anterior cruciate ligament reconstruction. J Strength Cond Res 2001;15:466-473. PMID:11726258 (Link to Abstract) 3. Beutler AI, Cooper LW, Kirkendall DT. Electromyographic analysis of single-leg, closed chain exercises: Implications for rehabilitation after anterior cruciate ligament reconstruction. J Athl Train 2002;37:13-18. PMID:12937438 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ05-174) A high school girls basketball player sustains a non-contact knee injury and develops an acute hemarthrosis. What is the likelihood that she has an ACL tear? REVIEW TOPIC 1. 0-15% 2. 15-30% 3. 30-45% 4. 45-60% 5. >60% PREFERRED RESPONSE ▼ 5 DISCUSSION: The classic scenario is a non-contact deceleration, jumping or cutting action. The patient might hear or feel a "pop". The acute hemarthrosis is caused by bleeding from branches of the middle geniculate artery. Women's basketball has one of the highest rates of ACL injury. With the above history, the literature states that the likelihood of ACL injury is greater than 70%. The reference by Maffulli et al. prospectively evaluated 106 acute hemarthroses in athletes and found 71 had an injury to the ACL. REFERENCES: 1. OITE05 #174 2. Maffulli N, Binfield PM, King JB, Good CJ. Acute haemarthrosis of the knee in athletes. A prospective study of 106 cases. J Bone Joint Surg Br. 1993 Nov;75(6):945-9. PMID:8245089 (Link to Abstract) 3. Miller RH: Knee Injuries, In Canale ST (Ed): Campbell's Operative Orthopaedics, ED 10. ST. LOUIS, MO, MOSBY, 2003, p. 2254. : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ05-190) The primary blood supply for the anterior cruciate ligament comes from what artery? REVIEW TOPIC 1. inferior medial genicular 2. inferior lateral genicular 3. middle genicular 4. superior medial genicular 5. superior lateral genicular PREFERRED RESPONSE ▼ 3 DISCUSSION: The reference states “contrary to popular belief the major blood supply to the ACL does not originate from its bony attachments. The ACL is supplied mainly by the vessels that originate from the middle genicular artery which leave the popliteal artery and directly pierces the posterior capsule. Branches enter the synovial membrane at the junction of the joint capsule distal to the infrapatellar fat pad. The ligament is ensheathed by the synovial plexus along its entire length. Smaller connecting branches penetrate the ligament and anastomose with a network of endoligamentous vessels that are oriented in a longitudinal direction and lie parallel to the collagen bundles within the ligament. REFERENCES: 1. OITE05 #190 : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ05-214) All of the following are true regarding excessively anterior femoral tunnel placement during ACL reconstruction EXCEPT? REVIEW TOPIC 1. It may cause loss of knee flexion 2. It may cause graft over-stretching and failure 3. It is the most common technical error 4. It may cause interference screw divergence 5. It is often due to poor visualization PREFERRED RESPONSE ▼ 4 DISCUSSION: Anterior placement of the femoral tunnel is the most common surgical error during arthroscopic ACL reconstruction. Errors in surgical technique are the most common cause of graft failure in patients who present with recurrent instability after ACL reconstruction. Technical shortcomings that result in graft failure after primary reconstruction include nonanatomic tunnel placement, graft impingement, improper tensioning of the graft, inadequate fixation of the graft in bony tunnels, graft material problems, and the failure to address insufficiency of the secondary stabilizers of the knee during ACL reconstruction. It is estimated that 70% to 80% of graft failures are caused by malpositioned tunnels. The consequences of nonanatomic tunnel placement are well described in the literature. Inappropriate positioning of either the tibial or femoral tunnels results in excessive changes in graft length as the knee moves through its functional range of motion. Because biologic ACL grafts can only accommodate small changes in length before undergoing plastic deformation, a mal-positioned graft may result in either capturing of the knee or lengthening of the graft over time; this results in either a loss of motion or recurrent instability, respectively. To restore stability and retain a full range of motion, near-anatomic placement of the femoral and tibial tunnels is important during ACL reconstruction. Anterior placement of the femoral tunnel is the most common surgical error using arthroscopic ACL reconstruction. Improper femoral tunnel placement is most often caused by the failure to adequately visualize the most posterior aspect of the notch (the “over-the-top” position). Because the femoral attachment of the ACL is closer to the center of rotation of the knee, small errors in femoral tunnel placement may have deleterious effects on knee kinematics. Ideal femoral tunnel placement should be as posterior in the notch as possible without violating the posterior cortical wall. An ACL graft that is placed too anteriorly on the femoral side and tensioned in extension will be excessively strained during flexion; this results in either loss of flexion or graft lengthening. If the graft is tensioned in flexion, there may be unacceptable laxity in extension. REFERENCES: 1. OITE05 #214 2. Allen CR Giffin JR, Harner CD: Revision anterior cruciate ligament reconstruction. Orthop Clin North Am 2003:34:79-98. PMID:12735203 (Link to Abstract) 3. Sommer C, Friederich NF, Muller W; Improperly placed anterior cruciate ligament grafts: Correlation between radiological parameters and clinical results. Knee Surg Sports Traumatol Anthrosc 2000:8:207-213 PMID:10975260 (Link to Abstract) 4. Harner CD, Giffin JR Dunteman RC, et al: Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. Instr Course Lect 2001;50:463-474. PMID:11372347 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ04-9) When evaluating patients that needed revision surgery, what is the most common cause of a failed primary ACL reconstruction? REVIEW TOPIC 1. Tunnel malposition 2. Obesity 3. Smoking 4. Returning to sport too early 5. Inadequate physical therapy PREFERRED RESPONSE ▼ 1 DISCUSSION: Many factors may be involved in the failure of ACL reconstructions, including the surgical technique, the selection of graft material, the integrity of the secondary restraints, the condition of the articular and meniscal cartilage, postoperative rehabilitation, and the motivation and expectations of the patients. Early failure, usually within the first 6 months, most often is the result of technical errors, incorrect or overly aggressive rehabilitation, premature return to sports, or failure of graft incorporation. Later failure, usually after one year, is more typically the result of recurrent injury. The most avoidable and most common cause of failure is surgical technique. These errors include improper tunnel placement (most common), and errors in graft selection, size, physiognomy or tensioning. Anterior tunnels (most common) results in a graft tight in flexion and loose in extension. The Azar paper is an instructional course of revision ACL surgery. The Wolf paper and the Allen paper review both the causes for ACL graft failure and the planning steps needed to address them during revision reconstruction. REFERENCES: 1. OITE04 #9 2. Allen CR, Giffin JR, Harner CD. Revision anterior cruciate ligament reconstruction. Orthop Clin North Am. 2003 Jan;34(1):79-98. PMID:12735203 (Link to Abstract) 3. Azar FM. Revision anterior cruciate ligament reconstruction. Instr Course Lect. 2002;51:335-42. PMID:12064122 (Link to Abstract) 4. Wolf RS and Lemak LJ. Revision anterior cructiate ligament reconstruction surgery. J South Orthop Assoc. 2002 Spring;11(1):25-32. PMID:12741583 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ04-16) Women athletes have a higher rate of ACL tears than male athletes in the same sport. While the cause is likely multi-factorial, which of the following factors has been shown to contribute most significantly to this observation? REVIEW TOPIC 1. ACL size 2. Estrogen levels 3. Neuromuscular coordination and training 4. Intra-articular notch size 5. Valgus leg alignment PREFERRED RESPONSE ▼ 3 DISCUSSION: There are many theories to account for the increased incidence of ACL tears in women athletes. While each of the answers may contribute, recent studies have shown that differences in the level of neuromuscular training and coordination play the most significant role. This is a potentially modifiable factor and jump training and plyometric conditioning programs have been shown to decrease the rates of ACL injury in women. The Griffin and the Harmon papers are reviews by experts in ACL injury which list all of the answers as contributing factors to increased ACL injury rates seen in women athletes. Of these, neuromuscular imbalances were felt to be both the most significant and of particular interest because they are potentially modifiable. The Zebis reference states that neuromuscular training increased EMG activity for the medial hamstring muscles, thereby decreasing the risk of dynamic valgus. This observed neuromuscular adaptation during sidecutting could potentially reduce the risk for non-contact ACL injury. REFERENCES: 1. SASPT04 #16 2. Griffin LY, Albohm MJ, Arendt EA, Bahr R, Beynnon BD, Demaio M, Dick RW, Engebretsen L, Garrett WE Jr, Hannafin JA, Hewett TE, Huston LJ, Ireland ML, Johnson RJ, Lephart S, Mandelbaum BR, Mann BJ, Marks PH, Marshall SW, Myklebust G, Noyes FR, Powers C, Shields C Jr, Shultz SJ, Silvers H, Slauterbeck J, Taylor DC, Teitz CC, Wojtys EM, Yu B. Understanding and preventing noncontact anterior cruciate ligament injuries: A review of the Hunt Valley II Meeting. Am J Sports Med. 2006;34:1512-32. PMID:16905673 (Link to Abstract) 3. Harmon KJ, Ireland ML. Gender differences in noncontact anterior cruciate ligament injuries. Clin Sports Med 2000;19:287-302. PMID:10740760 (Link to Abstract) 4. Zebis MK, Bencke J, Andersen LL, Døssing S, Alkjaer T, Magnusson SP, Kjaer M, Aagaard P. The effects of neuromuscular training on knee joint motor control during sidecutting in female elite soccer and handball players. Clin J Sport Med. 2008;18(4):329-37. PMID:18614884 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ04-19) You are called by a 35-year-old male patient who had ACL reconstruction with hamstring autograft 5 days ago. He reports his knee pain and swelling have significantly increased in the last day, and now it is difficult for him to raise his leg off the bed. Upon questioning he denies fever, chills, or any new trauma to the knee. He has been wearing his brace and doing gentle CPM for a few hours per day as instructed. What is the next step in management? REVIEW TOPIC 1. Ice, NSAIDS, elevation, compression wrap and restart therapy once symptoms improve 2. Go to the ER immediately for knee aspiration with gram stain and cultures 3. Increase CPM use to 10 hours a day 4. Call the office staff in the morning to schedule an appointment 5. Start physical therapy visits once daily PREFERRED RESPONSE ▼ 2 DISCUSSION: Any patient who presents with a sudden increase in knee effusion in a delayed manner after ACL surgery should raise suspicion for infection, whether or not a fever is present. If suspected, an aspiration should be performed immediately and fluid sent for gram stain and cultures. If positive, immediate arthroscopy is indicated. Mangine et al recommend aspiration of all post-operative knees if there is any suspicion of infection. Shelbourne and Gray discuss their excellent results after ACL reconstruction with autologous bone-patellar tendon-bone graft followed by an accelerated rehab protocol. They did not discuss post-operative infections. REFERENCES: 1. OITE04 #19 2. Mangine RE, Noyes FR, DeMaio M. Minimal protection program: advanced weight bearing and range of motion after ACL reconstruction--weeks 1 to 5. Orthopedics. 1992 Apr;15(4):504-15. PMID:1565587 (Link to Abstract) 3. Shelbourne KD, Gray T. Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. A two- to nine-year followup. Am J Sports Med. 1997 Nov-Dec;25(6):786-95. PMID:9397266 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ04-32) In biomechanical testing, the highest maximum load to failure is one measure of strength. In such testing, which graft has the highest strength? REVIEW TOPIC 1. Quadruple semitendinosus and gracilis tendons 2. Bone-patellar tendon-bone with a width of 10 mm 3. Bone-quadriceps tendon with a width on 10mm 4. Tibialis tendon allograft 5. Native anterior cruciate ligament (ACL) PREFERRED RESPONSE ▼ 1 DISCUSSION: All of the potential ACL grafts mentioned are stronger than native ACL. Biomechanical studies show that the quadruple semitendinosus and gracilis tendons are the strongest of the tissues on maximal load to failure testing. However, other structural properties such as stiffness, creep, and strength of fixation are also important consideration. REFERENCES: 1. SASPT04 #32 2. Woo SL, Hollis JM, Adams DJ, et al: Tensile properties of the human femur-anterior cruciate ligament-tibia complex: The effects of specimen age and orientation. Am J Sports Med 1991;19:217-225. 3. Staubli HU, Schatzmann L, Brunner P, et al: Quadriceps tendon and patellar ligament cryosectional anatomy and structural properties in young adults. Knee Surg Sports Traumatol Arthrosc 1996;4:100-110. 4. Wilson TW, Zafuta MP, Zobitz M: A biomechanical analysis of matched bone-patellar tendon-bone and doubled looped semitendinosus and gracilis tendon grafts. Am J Sports Med 1999;27:202-207. : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS Comment Thread TAG (OBQ04-54) Both quadrupled hamstring tendon and 10-mm bone-patellar tendon-bone autografts are used for ACL recconstruction. Which of the following statements is true of the failure load of the hamstring graft relative to the patellar tendon graft on biomechanical testing? REVIEW TOPIC 1. Equal load to failure. 2. One half the failure load. 3. One quarter the failure load. 4. Roughly two times the failure load. 5. Roughly four times the failure load. PREFERRED RESPONSE ▼ 4 DISCUSSION: While the failure load for the native ACL is approximately 1700 Newtons, the grafts used for recontstruction are significantly stronger. The failure load for an evenly tensioned quadrupled hamstring tendon autograft has been reported to be 4,500 Newtons compared to. 2,600 N for a 10-mm patellar tendon autograft. REFERENCES: 1. SASPT04 #54 2. Corry IS, Webb JM, Clingeleffer AJ, Pinczewski LA: Arthroscopic reconstruction of the anterior cruciate ligament: A comparison of patellar tendon autograft and four-strand hamstring tendon autograft. Am J Sports Med 1999;27:448-454. 3. Hamner DL, Brown CH Jr, Steiner ME, et al: Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: Biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am 1999;81:549-557. 4. Noyes FR, Butler DL, Grood ES, et al: Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. J Bone Joint Surg Am 1984;66:344-352 : PENDING FINAL APPROVAL RATE CONTENT 2 RATINGS Comment Thread TAG (OBQ04-56) An 18-year-old athlete is now 3 months out from anterior cruciate ligament reconstruction. He has been unable to obtain full extension or full flexion and his range of motion is from 10° to 115° compared to 0° to 140° on the contralateral knee. He has no effusion, no pain, good patellar mobility and a stable Lachman’s test. What is the most common technical error which can account for these findings? REVIEW TOPIC 1. Femoral tunnel drilled too anteriorly 2. Femoral tunnel drilled too posteriorly 3. Femoral tunnel drilled too vertically 4. Tibial tunnel drilled too vertically 5. Tibial tunnel drilled too anteriorly PREFERRED RESPONSE ▼ 5 DISCUSSION: The majority of early ACL reconstruction failures are felt to be due to errors in surgical technique. The most common error in ACL reconstruction is aberrant tunnel placement. Here is a table of abberant tunnel placement and the clinical consequence. FEMORAL TUNNEL PLACEMENT 1. anterior > tight in flexion / laxity in extension 2. posterior > tight in extension / laxity in flexion 3. cental/vertical > rotational instability TIBIAL TUNNEL PLACEMENT 1.anterior > tight in flexion / roof impingement in extension 2. posterior > tight in extension 3. medial > impinges on medial femoral condyle 4. lateral > impinges on lateral femoral condyle REFERENCES: 1. OITE04 #56 2. Chhabra A, Starman JS, Ferretti M, et al. Anatomic, radiographic, biomechanical, and kinematic evaluation of the anterior cruciate ligament and its two functional bundles. J Bone Joint Surg. 2006;88:2-10. 3. Markolf KL, Hame S, Hunter DM, et al. Effects of femoral tunnel placement on knee laxity and forces in an anterior cruciate ligament graft. J Orthop Res. 2002;20(5):1016-24. 4. Zantop T, Petersen W, Sekiya JK, et al. Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006;14(10):982-92 : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ04-64) Historically, ACL reconstructions were performed using an "over-the-top" position where the graft was placed around the posterior aspect of the lateral femoral condyle rather than drilling a femoral tunnel. What effect might such graft positioning have on the tension observed in the graft? REVIEW TOPIC 1. Tight in flexion and tight in extension 2. Tight in flexion and lax in extension 3. The graft will remain isometric 4. Lax in flexion and lax in extension 5. Lax in flexion and tight in extension PREFERRED RESPONSE ▼ 5 DISCUSSION: While the over-the-top position is largely historical, it has has been advocated for use in pediatric ACL reconstructions to avoid drilling a femoral tunnel which could injure the physis. This excessively posterior position on the femur (relative to normal anatomy) may result in the graft becoming lax in flexion and more taut in extension. The question is used to illustrate the importance of proper ACL graft positioning. REFERENCES: 1. SASPT04 #64 2. Azar FM: Revision anterior cruciate ligament reconstruction. Instr Course Lect 2002;51:335-342. 3. Markolf KL, Hame S, Hunter DM, et al. Effects of femoral tunnel placement on knee laxity and forces in an anterior cruciate ligament graft. J Orthop Res. 2002;20(5):1016-24. 4. Zantop T, Petersen W, Sekiya JK, et al. Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006;14(10):982-92. : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ04-85) Which rehabilitation exercises places the greatest strain on a reconstructed ACL graft? REVIEW TOPIC 1. Active knee extension from 90 to 45 degrees 2. Active knee flexion from 45 to 90 degrees 3. Isometric quadriceps contraction with the knee at 0 degrees. 4. Isometric quadriceps contraction with a knee flexion angle between 15 and 30 degrees 5. Isometric quadriceps contraction with a knee flexion angle between 45 and 90 degrees PREFERRED RESPONSE ▼ 4 DISCUSSION: On strain-guage testing, the highest strain in the ACL graft was reported during isometric quadriceps contraction between 15 and 30 degrees of flexion. At this degree of flexion, the quadriceps is pulling the tibia anteriorly and may damage the graft. The other exercises demonstrated significantly less strain on a well-positioned ACL reconstruction graft. REFERENCES: 1. SASPT04 #85 2. Beynnon BD, Gleming BC, Johnson RL, Nichols CE, Renstrom PA, Pope MH: Anterior cruciate ligament strain behavior during rehabilitation exercises in vivo. Am J Sports Med 1995;23:24-34. 3. Beynnon BD, Johnson RJ, Fleming BC, Stankewaich CJ, Renstrom PA, Nichols CE: The strain behavior of the anterior cruciate ligament during squatting and active flexion-extension: A comparison of an open and a closed kinetic chain exercise. Am J Sports Med 1997;25:823-829. : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS Comment Thread TAG (OBQ04-91) Which of the following factors regarding a ACL-deficient knee correlates most closely with the develeopment of arthritis in the future? REVIEW TOPIC 1. Patient gender 2. Patient age 3. Leg dominance 4. Location of ACL tear 5. Integrity of the menisci PREFERRED RESPONSE ▼ 5 DISCUSSION: Factors that have been implicated in the progression of OA in the ACL deficient knee include meniscal lesions, osteochondral lesions, malalignment, and comcomitant ligamentous pathology. In the ACL deficient knee the posterior horn medial meniscus is the primary stabilizer to anterior translation of the tibia – therefore placing it under high loads with translation and leading to a high incidence of secondary meniscal tears in chronic ACL insufficiency. Rupture of the posterior horn leads to even greater anterior translation, increased instability, and ensuing arthritis. Studies have shown ACL combined with PCL rupture to increase the incidence of OA significantly however several studies have shown no arthritic progression with associated collateral ligament injury. Louboutin et al reported that the risk of developing osteoarthritis is lower after ACL reconstruction (14%-26% with a normal medial meniscus, 37% with meniscectomy) to untreated ruptures (60%-100%) at 20 year follow-up. The Gillquist paper noted that meniscus tears and subsequent repair, or ACL tears without major concomitant injuries, seem to increase the risk 10-fold (15 to 20% incidence of gonarthrosis) compared with an age-matched, uninjured population (1 to 2%). REFERENCES: 1. OITE04 #91 2. Louboutin H, Debarge R, Richou J, Selmi TA, Donell ST, Neyret P, Dubrana F. Osteoarthritis in patients with anterior cruciate ligament rupture: a review of risk factors. Knee. 2009 Aug;16(4):239-44. Epub 2008 Dec 20. PMID:19097796 (Link to Abstract) 3. Gillquist J, Messner K. Anterior cruciate ligament reconstruction and the long-term incidence of gonarthrosis. Sports Med. 1999 Mar;27(3):143-56. PMID:10222538 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ04-94) During ACL reconstruction, the center of the graft at the tibial tunnel should be located in what position relative to other anatomic landmarks for the most accurate and reporducible graft placement? REVIEW TOPIC 1. At the anterior border of the PCL 2. 5mm anterior to the anterior border of the PCL 3. 10mm anterior to the anterior border of the PCL 4. 5 mm posterior to the posterior border of the anterior horn of the lateral meniscus 5. 10mm posterior to the posterior border of the anterior horn of the lateral meniscus PREFERRED RESPONSE ▼ 3 DISCUSSION: The central insertion point of the ACL is consistently 10 to 11 mm anterior to the anterior border of the PCL ligament on sagital sections. The anterior border of the PCL is the most accurate and reproducible landmark for appropriate placement of the tibial tunnel for an ACL reconstruction. This corresponds roughly to the posterior border of the anterior horn of the lateral meniscus, which was not listed as an answer. Furthermore, referenceing off the lateral meniscus showed 2x the variability compared to the PCL reference point. REFERENCES: 1. SASPT04 #94 2. Hutchinson MR, Bae TS: Reproducibility of anatomic tibial landmarks for anterior cruciate ligament reconstructions. Am J Sports Med 2001;29:777-780. 3. McGuire DA, Hendricks SD, Sanders HM: The relationship between anterior cruciate ligament reconstruction tibial tunnel location and the anterior aspect of the posterior cruciate ligament insertion. Arthroscopy 1997;13:465-473. : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ03-166) A patient undegoes an uncomplicated anterior cruciate ligament reconstruction. Which of the following activites are generally not recommended during the first 6 weeks of physical therapy? REVIEW TOPIC 1. Patellar mobilizations 2. Passive extension 3. Heel slides to improve flexion 4. Isometric quadriceps strengthening 5. Isokinetic quadriceps strengthening PREFERRED RESPONSE ▼ 5 DISCUSSION: The initial goals of rehabilitation focus on achieving full extension, activation of the quadriceps muscles, progressive flexion, and restoring normal gait. Closed chain rehabilitation has been emphasized because it allows physiologic contraction of the musculature around the knee. Isometric exercises such as quad sets and straight leg raises are encouraged. Isokinetic exercises are generally reserved until after the graft attachment sites have healed. The reference is a systematic review of topics related to ACL rehabilitation. REFERENCES: 1. OITE03 #166 2. Wright RW, Preston E, Fleming BC, Amendola A, Andrish JT, Bergfeld JA, DunnWR, Kaeding C, Kuhn JE, Marx RG, McCarty EC, Parker RC, Spindler KP, Wolcott M,Wolf BR, Williams GN. A systematic review of anterior cruciate ligamentreconstruction rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics. J Knee Surg. 2008 Jul;21(3):225-34. PMID:18686485 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 5 RATINGS Comment Thread TAG References Show References Level of Evidence 2 (Prospective Cohort Study) Wright RW, Preston E, Fleming BC, Amendola A, Andrish JT, Bergfeld JA, DunnWR, Kaeding C, Kuhn JE, Marx RG, McCarty EC, Parker RC, Spindler KP, Wolcott M,Wolf BR, Williams GN. A systematic review of anterior cruciate ligamentreconstruction rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics. J Knee Surg. 2008 Jul;21(3):225-34. PMID:18686485 (Link to Abstract) Level of Evidence 4 (Case Series) Pinczewski LA, Salmon LJ, Jackson WF, von Bormann RB, Haslam PG, Tashiro S. Radiological landmarks for placement of the tunnels in single-bundle reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br. 2008 Feb;90(2):172-9. PMID:18256083 (Link to Abstract) Textbooks Review of Orthopaedics, 5th Edition, Mark D. Miller (editor), Saunders, an imprint of Elsevier, Philadelphia, Copyright 2008 First Aid for the Orthopaedic Boards, Robert Laminzak, Mark Albritton, Trevor Pickering (Editors), McGraw Hill Medical, Copyright 2009 Orthopaedic Knowledge Update 9, Jeffrey S Fischgrund (Editor). Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2008 Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009 OITE Questions, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2010 Frank H. Netter, John A. Craig. Netter's Concise Atlas of Orthopaedic Anatomy, Icon Learning Systems, Teterboro, NJ, Copyright 2002 Garrick, JG (ED): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 169-181 Miller RH: Knee Injuries, In Canale ST (Ed): Campbell's Operative Orthopaedics, ED 10. ST. LOUIS, MO, MOSBY, 2003, p. 2254. Undefined Battaglia TC, Miller MD. Management of bony deficiency in revision anterior cruciate ligament reconstruction using allograft bone dowels: surgical technique. Arthroscopy. 2005 Jun;21(6):767. PMID:15944645 (Link to Abstract) Grossman MG, ElAttrache NS, Shields CL, Glousman RE. Revision anterior cruciate ligament reconstruction: three- to nine-year follow-up. Arthroscopy. 2005 Apr;21(4):418-23. PMID:15800521 (Link to Abstract) Bathala EA, Bancroft LW, Ortiguera CJ, Peterson JJ. Radiologic case study. Segond fracture. Orthopedics. 2007 Sep;30(9):689, 797-8. PMID:17899907 (Link to Abstract) DeLee JC, Drez D Jr, Miller MD (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, WB Saunders, 2002, p 1643 Cain EL Jr, Gillogly SD, Andrews JR. Management of intraoperative complications associated with autogenous patellar tendon graft anterior cruciate ligament reconstruction. Instr Course Lect. 2003;52:359-67. PMID:12690863 (Link to Abstract) Lee GH, McCulloch P, Cole BJ, Bush-Joseph CA, Bach BR Jr. The incidence of acute patellar tendon harvest complications for anterior cruciate ligament reconstruction. Arthroscopy. 2008 Feb;24(2):162-6. PMID:18237699 (Link to Abstract) Portland GH, Martin D, Keene G, Menz T. Injury to the infrapatellar branch of the saphenous nerve in anterior cruciate ligament reconstruction: comparison of horizontal versus vertical harvest site incisions. Arthroscopy. 2005 Mar;21(3):281-5 PMID:15756180 (Link to Abstract) Garrick JG (ED). Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 403-410 Griffin LY, Agel J, Albohm MJ, Arendt EA, Dick RW, Garrett WE, Garrick JG, Hewett TE, Huston L, Ireland ML, Johnson RJ, Kibler WB, Lephart S, Lewis JL, Lindenfeld TN, Mandelbaum BR, Marchak P, Teitz CC, Wojtys EM. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg. 2000 May-Jun;8(3):141-50. Review. PMID:10874221 (Link to Abstract) Rodeo SA, Arnoczky SP, Torzilli PA et al. Tendon-healing in a bone tunnel. A biomechanical and histological study in the dog. J Bone Joint Surg Am. 1993 Dec;75(12):1795-803. PMID:8258550 (Link to Abstract) Beynnon BD, Johnson RJ, Fleming BC et al.Tendon-Bone Grafts with Two-Strand Hamstring Grafts : A Prospective Randomized Study. J Bone Joint Surg Am. 2002;84:1503-1513. PMID:12208905 (Link to Abstract) Pinczewski LA, Lyman J, Salmon LJ, et al. A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: a controlled, prospective trial. Am J Sports Med. 2007 Apr;35(4):564-74. Epub 2007 Jan 29. PMID:17261567 (Link to Abstract) Lemos MJ, Jackson DW, Lee TO, et al: Assessment of initial fixation of endoscopic interference femoral screws with divergent and parallel placement. Arthroscopy 1995;11:37-41. Dworsky BD, Jewell BF, Bach BR Jr. Interference screw divergence in endoscopic anterior cruciate ligament reconstruction. Arthroscopy. 1996 Feb;12(1):45-9. Stanitski CL, Harvell JC, Fu F: Observations on acute knee hemarthrosis in children and adolescents. JPO 1993;13:506-510 PMID:8370785 (Link to Abstract) Bomberg BC, McGinty JB: Acute hemarthrosis of the knee: Indications for diagnostic arthroscopy. Arthroscopy 1990;6:221-225 PMID:2206185 (Link to Abstract) Viskontas DG, Giuffre BM, Duggal N, Graham D, Parker D, Coolican M. Bone bruises associated with ACL rupture: correlation with injury mechanism. Am J Sports Med. 2008 May;36(5):927-33. PMID:18354139 (Link to Abstract) Collins MS, Unruh KP, Bond JR, Mandrekar JN. Magnetic resonance imaging of surgically confirmed anterior cruciate ligament graft disruption. Skeletal Radiol. 2008 Mar;37(3):233-43. PMID:18092160 (Link to Abstract) Ahmad CS, Clark AM, Heilmann N, Schoeb JS, Gardner TR, Levine WN. Effect of gender and maturity on quadriceps-to-hamstring strength ratio and anterior cruciate ligament laxity.Am J Sports Med. 2006 Mar;34(3):370-4. Epub 2005 Oct 6. PMID:16210574 (Link to Abstract) Baratta R, Solomonow M, Zhou BH, Letson D, Chuinard R, D'Ambrosia R. Muscular coactivation. The role of the antagonist musculature in maintaining knee stability. Am J Sports Med. 1988 Mar-Apr;16(2):113-22. PMID:3377094 (Link to Abstract) Vescovi JD, Vanheest JL. Effects of an anterior cruciate ligament injury prevention program on performance in adolescent female soccer players. Scand J Med Sci Sports. 2010 Jun;20(3):394-402. PMID:19558381 (Link to Abstract) Alentorn-Geli E, Myer GD, Silvers HJ, Samitier G, Romero D, Lázaro-Haro C, Cugat R. Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: Mechanisms of injury and underlying risk factors. Knee Surg Sports Traumatol Arthrosc. 2009 Jul;17(7):705-29. Epub 2009 May 19. PMID:19452139 (Link to Abstract) Uhorchak JM, Scoville CR, Williams GN, Arciero RA, St Pierre P, Taylor DC. Risk factors associated with noncontact injury of the anterior cruciate ligament: a prospective four-year evaluation of 859 West Point cadets. Am J Sports Med. 2003;31(6):831-42. PMID:14623646 (Link to Abstract) Hewett TE, Myer GD, Ford KR, Heidt RS Jr, Colosimo AJ, McLean SG, van den Bogert AJ, Paterno MV, Succop P. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33(4):492-501. PMID:15722287 (Link to Abstract) Shelbourne KD, Patel DV: Timing of surgery in anterior cruciate ligament-injured knees. Knee Surg Sports Traumatol Arthosc 1995;3:148-156. PMID:8821270 (Link to Abstract) Sterett WI, Hutton KS, Briggs KK, Steadman JR. Decreased range of motion following acute versus chronic anterior cruciate ligament reconstruction. Orthopedics 2003;26:151-154. PMID:12597218 (Link to Abstract) Eitzen I, holm I, Risberg MA: Preoperative strength is a significant predictor of knee function two years after ACL reconstruction. Br J Sports Med. 2009 May;43(5):371-6. PMID:19224907 (Link to Abstract) Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ. Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med. 2004 Apr-May;32(3):629-34. PMID:15090377 (Link to Abstract) Hoppenfeld S, deBoer PL The Knee, in Hoppenfeld and deBoer: Surgical Exposures in Orthopaedics, the Anatomic Approach. Medvecky MJ, Noyes FR: Surgical approaches to the posteromedial and posterolateral aspects of the knee. JAAOS 2005;13:121-128. PMID:15850369 (Link to Abstract) Figueroa D, Calvo R, Vaisman A, Campero M, Moraga C. Injury to the infrapatellar branch of the saphenous nerve in ACL reconstruction with the hamstrings technique: clinical and electrophysiological study.Knee. 2008 Oct;15(5):360-3. PMID:18583136 (Link to Abstract) Beynnon BD, Johnson RJ, Fleming BC. The science of anterior cruciate ligament rehabilitation. Clin Orthop Relat Res. 2002 Sep;(402):9-20. PMID:12218469 (Link to Abstract) Wilk KE, Escamilla RF, Fleisig GS, Barrentine SW, Andrews JR, Boyd ML. A comparison of tibiofemoral joint forces and electromyographic activity during open and closed kinetic chain exercises. Am J Sports Med. 1996 Jul-Aug;24(4):518-27. PMID:8827313 (Link to Abstract) Chhabra A, Starman JS, Ferretti M, Vidal AF, Zantop T, Fu FH. Anatomic, radiographic, biomechanical, and kinematic evaluation of the anterior cruciate ligament and its two functional bundles. J Bone Joint Surg Am. 2006 Dec;88 Suppl 4:2-10. PMID:17142430 (Link to Abstract) Markolf KL, Hame S, Hunter DM, Oakes DA, Zoric B, Gause P, Finerman GA. Effects of femoral tunnel placement on knee laxity and forces in an anterior cruciate ligament graft. J Orthop Res. 2002 Sep;20(5):1016-24. PMID:12382968 (Link to Abstract) Ross MD, Denegar CR, Winzenried JA. Implementation of open and closed kinetic chain quadriceps strengthening exercises after anterior cruciate ligament reconstruction. J Strength Cond Res 2001;15:466-473. PMID:11726258 (Link to Abstract) Beutler AI, Cooper LW, Kirkendall DT. Electromyographic analysis of single-leg, closed chain exercises: Implications for rehabilitation after anterior cruciate ligament reconstruction. J Athl Train 2002;37:13-18. PMID:12937438 (Link to Abstract) Maffulli N, Binfield PM, King JB, Good CJ. Acute haemarthrosis of the knee in athletes. A prospective study of 106 cases. J Bone Joint Surg Br. 1993 Nov;75(6):945-9. PMID:8245089 (Link to Abstract) Allen CR Giffin JR, Harner CD: Revision anterior cruciate ligament reconstruction. Orthop Clin North Am 2003:34:79-98. PMID:12735203 (Link to Abstract) Sommer C, Friederich NF, Muller W; Improperly placed anterior cruciate ligament grafts: Correlation between radiological parameters and clinical results. Knee Surg Sports Traumatol Anthrosc 2000:8:207-213 PMID:10975260 (Link to Abstract) Harner CD, Giffin JR Dunteman RC, et al: Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. Instr Course Lect 2001;50:463-474. PMID:11372347 (Link to Abstract) Allen CR, Giffin JR, Harner CD. Revision anterior cruciate ligament reconstruction. Orthop Clin North Am. 2003 Jan;34(1):79-98. PMID:12735203 (Link to Abstract) Azar FM. Revision anterior cruciate ligament reconstruction. Instr Course Lect. 2002;51:335-42. PMID:12064122 (Link to Abstract) Wolf RS and Lemak LJ. Revision anterior cructiate ligament reconstruction surgery. J South Orthop Assoc. 2002 Spring;11(1):25-32. PMID:12741583 (Link to Abstract) Griffin LY, Albohm MJ, Arendt EA, Bahr R, Beynnon BD, Demaio M, Dick RW, Engebretsen L, Garrett WE Jr, Hannafin JA, Hewett TE, Huston LJ, Ireland ML, Johnson RJ, Lephart S, Mandelbaum BR, Mann BJ, Marks PH, Marshall SW, Myklebust G, Noyes FR, Powers C, Shields C Jr, Shultz SJ, Silvers H, Slauterbeck J, Taylor DC, Teitz CC, Wojtys EM, Yu B. Understanding and preventing noncontact anterior cruciate ligament injuries: A review of the Hunt Valley II Meeting. Am J Sports Med. 2006;34:1512-32. PMID:16905673 (Link to Abstract) Harmon KJ, Ireland ML. Gender differences in noncontact anterior cruciate ligament injuries. Clin Sports Med 2000;19:287-302. PMID:10740760 (Link to Abstract) Zebis MK, Bencke J, Andersen LL, Døssing S, Alkjaer T, Magnusson SP, Kjaer M, Aagaard P. The effects of neuromuscular training on knee joint motor control during sidecutting in female elite soccer and handball players. Clin J Sport Med. 2008;18(4):329-37. PMID:18614884 (Link to Abstract) Mangine RE, Noyes FR, DeMaio M. Minimal protection program: advanced weight bearing and range of motion after ACL reconstruction--weeks 1 to 5. Orthopedics. 1992 Apr;15(4):504-15. PMID:1565587 (Link to Abstract) Shelbourne KD, Gray T. Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. A two- to nine-year followup. Am J Sports Med. 1997 Nov-Dec;25(6):786-95. PMID:9397266 (Link to Abstract) Woo SL, Hollis JM, Adams DJ, et al: Tensile properties of the human femur-anterior cruciate ligament-tibia complex: The effects of specimen age and orientation. Am J Sports Med 1991;19:217-225. Staubli HU, Schatzmann L, Brunner P, et al: Quadriceps tendon and patellar ligament cryosectional anatomy and structural properties in young adults. Knee Surg Sports Traumatol Arthrosc 1996;4:100-110. Wilson TW, Zafuta MP, Zobitz M: A biomechanical analysis of matched bone-patellar tendon-bone and doubled looped semitendinosus and gracilis tendon grafts. Am J Sports Med 1999;27:202-207. Corry IS, Webb JM, Clingeleffer AJ, Pinczewski LA: Arthroscopic reconstruction of the anterior cruciate ligament: A comparison of patellar tendon autograft and four-strand hamstring tendon autograft. Am J Sports Med 1999;27:448-454. Hamner DL, Brown CH Jr, Steiner ME, et al: Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: Biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am 1999;81:549-557. Noyes FR, Butler DL, Grood ES, et al: Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. J Bone Joint Surg Am 1984;66:344-352 Chhabra A, Starman JS, Ferretti M, et al. Anatomic, radiographic, biomechanical, and kinematic evaluation of the anterior cruciate ligament and its two functional bundles. J Bone Joint Surg. 2006;88:2-10. Markolf KL, Hame S, Hunter DM, et al. Effects of femoral tunnel placement on knee laxity and forces in an anterior cruciate ligament graft. J Orthop Res. 2002;20(5):1016-24. Zantop T, Petersen W, Sekiya JK, et al. Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006;14(10):982-92 Azar FM: Revision anterior cruciate ligament reconstruction. Instr Course Lect 2002;51:335-342. Markolf KL, Hame S, Hunter DM, et al. Effects of femoral tunnel placement on knee laxity and forces in an anterior cruciate ligament graft. J Orthop Res. 2002;20(5):1016-24. Zantop T, Petersen W, Sekiya JK, et al. Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006;14(10):982-92. Beynnon BD, Gleming BC, Johnson RL, Nichols CE, Renstrom PA, Pope MH: Anterior cruciate ligament strain behavior during rehabilitation exercises in vivo. Am J Sports Med 1995;23:24-34. Beynnon BD, Johnson RJ, Fleming BC, Stankewaich CJ, Renstrom PA, Nichols CE: The strain behavior of the anterior cruciate ligament during squatting and active flexion-extension: A comparison of an open and a closed kinetic chain exercise. Am J Sports Med 1997;25:823-829. Louboutin H, Debarge R, Richou J, Selmi TA, Donell ST, Neyret P, Dubrana F. Osteoarthritis in patients with anterior cruciate ligament rupture: a review of risk factors. Knee. 2009 Aug;16(4):239-44. Epub 2008 Dec 20. PMID:19097796 (Link to Abstract) Gillquist J, Messner K. Anterior cruciate ligament reconstruction and the long-term incidence of gonarthrosis. Sports Med. 1999 Mar;27(3):143-56. PMID:10222538 (Link to Abstract) Hutchinson MR, Bae TS: Reproducibility of anatomic tibial landmarks for anterior cruciate ligament reconstructions. Am J Sports Med 2001;29:777-780. McGuire DA, Hendricks SD, Sanders HM: The relationship between anterior cruciate ligament reconstruction tibial tunnel location and the anterior aspect of the posterior cruciate ligament insertion. Arthroscopy 1997;13:465-473. Visitor Comments for ACL Tear Please login to post comments Derek Moore commented at 9:41AM on 11/26/10 "Mehdi, Thanks for your feedback. Comments and star ratings are very helpful to us in improving the site." Anonymous commented at 9:12PM on 11/25/10 "Thank You! Very well organized! Great Value!" Derek Moore commented at 6:12PM on 11/06/10 "Spelling of Segond corrected. Thanks for bringing this to our attention!" Anonymous commented at 12:17PM on 11/06/10 "segund fracture....or segond fracture!!"

The AC joint is a diarthrodial joint

AC joint motion

clavicle rotates 40-50 degrees 8 degrees of rotation through AC joint remainder from scapular rotation

AC joint stability

acromioclavicular ligament provides horizontal stability has superior, inferior, anterior, and posterior components Superior ligament is strongest, followed by posterior coracoclavicular ligaments(trapezoid and conoid) provides vertical stability trapezoid inserts 3 cm from end of clavicle corocoid inserts 4.5 cm from end of clavicle in the posterior border capsule, deltoid and trapezius act as additional stabilizers

QBank

(OBQ04-221) When performing an arthroscopic distal clavicle excision for acromioclavicular joint arthrosis, which of the following structures must be preserved to prevent post-operative anteroposterior instability? REVIEW TOPIC

1. Trapezoid ligament 2. Anterior and inferior acromioclavicular joint capsule 3. Superior and posterior acromioclavicular joint capsule 4. Coracohumeral ligament 5. Conoid ligament PREFERRED RESPONSE ▼ 3

DISCUSSION

Numerous biomechanical studies have shown that the primary restraint to anteroposterior translation of the clavicle is the ligamentous thickenings of the acromioclavicular joint capsule.

Debski et al showed in one such study that the strongest of these ligaments is the superior one, verifying the findings of several other authors. They reported that the superior ligament supplies around 50% of the strength against anteroposterior translation, and it is thickest in its posterior aspect. Additionally, the posterior AC ligament adds an additional 25% of the overall strength. For this reason, these ligaments should be preserved when performing a distal clavicle resection. The length of distal clavicle that can be taken and still preserve stability of the joint is highly debated in the literature. The conoid and trapezoid ligaments are the primary restraints to vertical translation at the AC joint. Renfree and Wright review the published anatomic findings around the AC and SC joints, and come to similar conclusions as above.

REFERENCES: 1. OITE04 #221 2. Renfree KJ, Wright TW. Anatomy and biomechanics of the acromioclavicular and sternoclavicular joints. Clin Sports Med. 2003 Apr;22(2):219-37. PMID:12825527 (Link to Abstract) 3. Debski RE, Parsons IM 4th, Woo SL, Fu FH. Effect of capsular injury on acromioclavicular joint mechanics. J Bone Joint Surg Am. 2001 Sep;83-A(9):1344-51. PMID:11568197 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments. References Show References Textbooks Review of Orthopaedics, 5th Edition, Mark D. Miller (editor), Saunders, an imprint of Elsevier, Philadelphia, Copyright 2008 First Aid for the Orthopaedic Boards, Robert Laminzak, Mark Albritton, Trevor Pickering (Editors), McGraw Hill Medical, Copyright 2009 Orthopaedic Knowledge Update 9, Jeffrey S Fischgrund (Editor). Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2008 Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009 OITE Questions, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2010 Frank H. Netter, John A. Craig. Netter's Concise Atlas of Orthopaedic Anatomy, Icon Learning Systems, Teterboro, NJ, Copyright 2002

Acromioclavicular Joint References 
  1. Renfree KJ, Wright TW. Anatomy and biomechanics of the acromioclavicular and sternoclavicular joints. Clin Sports Med. 2003 Apr;22(2):219-37. PMID:12825527 (Link to Abstract)
  2. Debski RE, Parsons IM 4th, Woo SL, Fu FH. Effect of capsular injury on acromioclavicular joint mechanics. J Bone Joint Surg Am. 2001 Sep;83-A(9):1344-51. PMID:11568197 (Link to Abstract) Visitor Comments for Acromioclavicular Joint

Introduction Idiopathic scoliosis in children > 10 yrs

Incidence

3% for curves between 10 to 20 degrees

0.3% for curves > 30 degrees

10:1 female to male ratio for curves > 30 degrees

Right thoracic curve most common

 left thoracic curves are rare and indicate an MRI to rule out cyst or syrinx

curves > 90° are associated with cardiopulmonary dysfunction, early death, pain, and decreased self image

Most have family history

Increased incidence of acute and chronic pain in adults if left untreated

Potential causes multifactorial hormonal (melatonin) brain stem propioception disorder platelet calmodulin

Physical Exam

School screening patients often referred from school screening where a 7 degree curve on scoliometer is considered abnormal

Special tests Adams forward bending test axial plane deformity indicates structural curve forward bending sitting test can eliminate leg length inequality as cause of scoliosis Other important findings on physical exam leg length inequality midline skin defects shoulder height differences rib rotational deformity (rib hump) waist asymmetry and pelvic tilt cafe-au-lait spots in cases of neurofibromatosis foot deformities (cavovarus indicates neural axis abnormalities) asymmetric abdominal reflexes if present consider MRI to rule out syringomyelia

Imaging

Radiographs (standing AP and lateral required) Cobb angle > 10 degrees defined as scoliosis intra-interobserver error of 3-5° spinal balance determined by alignment of C7 plumb line to central sacral line stable zone between lines drawn vertically from lumbosacral facet joints stable vertebrae most proximal vertebrae that is most closely bisected by central sacral line neutral vertebrae rotationally neutral (spinous process equal distance to pedicles on AP xray) clavicle angle best predictor of postoperative shoulder balance

MRI (posterior fossa to conus) indicated when

atypical curve pattern (left thoracic curve) excessive kyphosis structural abnormalities neurologic symptoms or pain foot deformities asymmetric abdominal reflexes

Classification

King Classification

five part classification to describe thoracic curve patterns and help guide surgeons implanting Harrington instrumentation link to King classification (not testable)

Lenke Classification

more comprehensive classification based on AP, lateral, and supine bending films

link to Lenke classification (not testable)

Risks of Progression

Risk factors for progression

rapid growth peak height velocity in females occurs before menarche and before Risser-1 (girls usually reach skeletal maturity 1.5 yrs after menarche) curve magnitude before skeletal maturity > 20 degrees before skeletal maturity will continue to progress after skeletal maturity > 45 deg. thoracic curve will progress 1-2 deg. / year > 30 deg. lumbar curve will progress 1-2 deg. / year curve type lumbar curves progress more rapidly than thoracic curves double curves progress more rapidly than single curves

Treatment

Based on skeletal maturity of patient, magnitude of deformity, and curve progression

< 20 degrees observation

20-40 degrees

bracing only effective in flexible deformity in skeletally immature patient can prevent curve progression but cannot correct brace types curves with apex above T7 Milwaukee brace (extends to neck) for apex above T7 apex at T8 or below TLSO Boston-style brace (under arm) Charleston Bending brace is a curved night brace

> 50 degrees surgery

Surgical Techniques

Fusion level selection

Harrington recommends one level above and two levels below the end vertebrae if these levels fall wilthin the stable zone

Moe recommends fusion to the neutral vertebrae

Cochran found increase incidence of low back pain with fusion to L5, and to a lesser extent L4. Therefore, whenever possible avoid fusion to L4 and L5

it is almost never required to fuse to the pelvis in idiopathic scoliosis

ASF with instrumentation best for thoracolumbar and lumbar cases advantage is better correction while saving lumbar fusion levels

PSF with instrumentation remains gold standard for thoracic and double major curves (most cases) ASF/PSF with instrumentation indicated if curve > 75 degrees young age (Risser grade 0, girls <10 yrs, boys < 13 yrs) in order to prevent crankshaft phenomenon (if you perform PSF alone the anterior column with continue to grow and create a rotational or crankshaft deformity)

Neurologic monitoring monitoring with somatosensory-evoked potentials and/or motor-evoked potential is now the standard of care

Complications

Neurologic injury

paraplegia is 1:1000 increased risk with kyphosis, excessive correction, and sublaminar wires

Pseudoarthrosis (1-2%)

presents as late pain, deformity progression, and hardware failure

Infection (1-2%) presents as late pain incision often looks clean P. Acnes most common organism for delayed infection (requires 2 weeks for culture incubation)

Flat back syndrome described as early fatigability and back pain rare now that segmental instrumentation addresses sagital plane deformities treat with revision surgery with posterior closing wedge osteotomies

Crankshaft phenomenon

SMA syndrome (superior mesenteric artery syndrome)

presents with symptoms of bowel obstruction

treat with NG tube and IV fluids

Hardware failure CAUTION ERROR ALERT RATE CONTENT AVERAGE 0.0 of 0 RATINGS

QBank

(OBQ07-79) A 12-year-old female presents with a left thoracic rib prominence. Physical exam shows absent abdominal reflexes in the upper and lower quadrants on the left side. Radiographs show a 24 degree left thoracic curve. What is the next step in management? REVIEW TOPIC FIGURES: A 1. observation with repeat radiographs in 6 months 2. bracing with a thoraco-lumbar-sacral orthosis 3. magnetic resonance imaging (MRI) 4. posterior spinal fusion with instrumentation 5. anterior and posterior spinal fusion with instrumentation PREFERRED RESPONSE ▼ 3 DISCUSSION: This question tests whether one knows that left thoracic curves were found to be associated with Chiari and syringomyelia. One should recognize that right thoracic curves are more commonly seen in idiopathic scoliosis. The cited study concludes that: "Although the decision to obtain magnetic resonance imaging in a patient with scoliosis should be based on both clinical and radiographic criteria, we suggest that a heightened index of suspicion is warranted with certain curve patterns (left thoracic, double thoracic, triple, and a long right thoracic curve with end vertebra caudal to T12), and with a high or low apex and/or end vertebra, especially in males and patients with a normal to hyperkyphotic thoracic spine." The illustration below shows the MRI of the patient presented in this question. It shows a large syringomyelia with dilatation in the lower cervical and upper thoracic area. Also noted was an Arnold-Chiari malformation. This patient was referred to a neurosurgeon and treated with a posterior fossa decompression. Illustrations: A REFERENCES: 1. OITE07 #79 2. Spiegel DA, Flynn JM, Stasikelis PJ, Dormans JP, Drummond DS, Gabriel KR, Loder RT. Scoliotic curve patterns in patients with Chiari I malformation and/or syringomyelia. Spine (Phila Pa 1976). 2003 Sep 15;28(18):2139-46. PMID:14501926 (Link to Abstract) 3. Yngve D. Abdominal reflexes. J Pediatr Orthop. 1997 Jan-Feb;17(1):105-8. PubMed PMID:8989711 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS CAUTION ERROR ALERT Comment Thread TAG (OBQ06-17) A 16-year-old girl undergoes anterior lumbar surgery via the thoracoabdominal approach with multilevel diskectomy and cage insertion and screw-rod construct for thoracolumbar idiopathic scoliosis. This technique has NOT been associated with REVIEW TOPIC 1. less frequent reoperation 2. less correction of scoliosis 3. less hardware breakage 4. more sagittal imbalance 5. less nonunion PREFERRED RESPONSE ▼ 4 DISCUSSION: Sweet, Lenke et al. from the spine group at Washington University in St. Louis looked to prospectively investigate the clinical issue of maintaining instrumented segmental lumbar lordosis after anterior fusion and instrumentation for primary thoracolumbar or lumbar idiopathic adolescent scoliosis in 20 consecutive patients who were 18 years of age and younger. The authors performed an anterior approach to the spine, performing discectomies and anulectomies of all the convex discs, structural titanium mesh cages, morselized rib autograft and an anterior single solid rod convex compression spinal instrumentation with the appropriate lordotic rod contour and rotation as necessary. The anterior rod was placed just posterior to the cages. No postoperative bracing was performed. The authors concluded that they were able to correct and maintain coronal and sagittal plane correction at 2 years follow-up (making answer 1 incorrect). In addition, there were no instrumentation failures, pseudoarthroses, or reoperations. REFERENCES: 1. OITE06 #17 2. Sweet FA, Lenke LG, Bridwell KH, Blanke KM, Whorton J. Prospective radiographic and clinical outcomes and complications of single solid rod instrumented anterior spinal fusion in adolescent idiopathic scoliosis.Spine (Phila Pa 1976). 2001 Sep 15;26(18):1956-65. PMID:11547193 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 4 RATINGS CAUTION ERROR ALERT Comment Thread TAG (OBQ06-35) A 14-year-old girl has adolescent idiopathic scoliosis. Her parents would like to know what kind of problems she will have compared to her peers who do not have scoliosis. You should inform them that she will have: REVIEW TOPIC 1. difficulty with pregnancy in the future. 2. decreased pulmonary function regardless of the severity of scoliosis. 3. limitations in athletic participation. 4. more acute or chronic back pain. 5. increased risk of developing cancer. PREFERRED RESPONSE ▼ 4 DISCUSSION: Weinstein reported on a 50-year natural history of idiopathic scoliosis and found that scoliotic patients had more shortness of breath that was directly related to Cobb angle measurement. Also, they tended to have more either acute or chronic back pain and had cosmetic concerns. However, scoliosis itself did not cause any serious physical impairment. REFERENCES: 1. OITE06 #35 2. 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. PMID:12578488 (Link to Abstract) 3. Weinstein SL, Zavala DC, Ponseti IV. Idiopathic scoliosis: long-term follow up and prognosis in untreated patients. JBJS 1981; 63: 702-712. PMID:6453874 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS Comment Thread TAG (OBQ04-144) When compared to normal controls, adults with untreated idiopathic scoliosis have a higher rate of? REVIEW TOPIC 1. acute and chronic back pain 2. premature death 3. disability 4. clinical depression 5. limitation in activities of daily living PREFERRED RESPONSE ▼ 1 DISCUSSION: The best data regarding untreated adults with idiopathic scoliosis comes from Ponseti’s data from Iowa. In 2003 they published the 50 year follow up data of 117 untreated patients seen at University of Iowa between 1932 and 1948 compared to 62 age and sex matched volunteers. This is a follow up study to the presentation of their data in 1950 and then at 30 and 40 year follow up. The measured outcomes were mortality, back pain, pulmonary symptoms, general function, depression and body images. Acute and chronic back pain were more prevalent in patients relative to controls (Acute 77% vs 35%; Chronic 61% vs 35%). There was no statisical significant difference in disability, depression, age at death of patients, and capacity to perform activities of daily living. The scoliosis group was found to have a lower body satisfaction score compared to the control group. REFERENCES: 1. OITE04 #144 2. 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 Feb 5;289(5):559-67. PMID:12578488 (Link to Abstract) 3. Weinstein SL, Zavala DC, Ponseti IV. Idiopathic scoliosis: long-term follow-up and prognosis in untreated patients. J Bone Joint Surg Am. 1981 Jun;63(5):702-12. PMID:6453874 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS CAUTION ERROR ALERT Comment Thread TAG (OBQ04-193) A 14 year-old girl presents with thoracolumbar major idiopathic scoliosis that measures 55 degrees and corrects to 25 degrees on a side bending film. She also has a flexible proximal thoracic curve of 30 degrees that corrects to 10 degrees on a side bending film. Her mother says she had her first period 8 months ago. What would be the most appropriate management? REVIEW TOPIC 1. Do nothing and have her return to the office when she has pain 2. Repeat the x-rays in 6 months 3. Perform anterior instrumented fusion of the thoracolumbar curve only 4. Perform anterior instrumented fusion of both curves 5. Perform posterior instrumented fusion of both curves PREFERRED RESPONSE ▼ 3 DISCUSSION: This question highlights the indications for selective anterior fusion of a thoracolumbar or lumbar curve while leaving the associated thoracic curve uncorrected. This patient needs a spine fusion because her major curve measures greater than 40 degrees (<20 observe, 20-40 brace) and it will progress without fusion. Selective anterior fusion of a major curve has the advantage over posterior fusion of sparing motion segments. However, anterior fusion can be associated with kyphosis over the instrumented levels and higher pseudarthrosis rates when compared to PSF. This patient has a 55 degree thoracolumbar curve. The question tells you the there is a compensatory thoracic curve of 30 deg that corrects to 10 degrees. She is 8 mo postmenarchal and therefore past her major growth spurt, though she does have some growth remaining. The two citations are from Lenke and collaborators. The 2003 paper identified the best predictors of success in patients who underwent selective anterior fusion of thoracolumbar (TL) or lumbar (L) curves while leaving the associated thoracic curve uncorrected. These useful predictors included TL/L:T Cobb ratio was 1.25 or greater (42 out of 44 pts) and if the triradiate cartilage was closed (42 of 43 pts). The 2001 paper is a prospective outcome study in which 90 pts underwent anterior fusion for thoracic or thoracolumbar/lumbar scoliosis using intradiscal structural (Harms) cages placed below T12 with a single solid anterior rod. The rate of pseudarthrosis was 5.5%. The reoperation rate was 3.3% with posterior fusion required in 3 of 5 pseudos. Pseudarthrosis was associated with smoking, weight >70 kg, and hyperkyposis >40 deg at T5-T12. Given this data, we would predict that the patient would do well with an anterior fusion of the thoracolumbar curve only (answer 3)—provided that she doesn’t smoke or weighs more than 70 kg. REFERENCES: 1. OITE04 #193 2. Sweet FA, Lenke LG, Bridwell KH, Blanke KM, Whorton J. Prospectiveradiographic and clinical outcomes and complications of single solid rod instrumented anterior spinal fusion in adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2001 Sep 15;26(18):1956-65. PMID:11547193 (Link to Abstract) 3. Sanders AE, Baumann R, Brown H, Johnston CE 2nd, Lenke LG, Sink E. Selectiveanterior fusion of thoracolumbar/lumbar curves in adolescents: when can theassociated thoracic curve be left unfused? Spine (Phila Pa 1976). 2003 Apr 1;28(7):706-13; discussion 714. PMID:12671359 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS CAUTION ERROR ALERT Comment Thread TAG References Show References Level of Evidence 2 (Prospective Cohort Study) Sanders AE, Baumann R, Brown H, Johnston CE 2nd, Lenke LG, Sink E. Selectiveanterior fusion of thoracolumbar/lumbar curves in adolescents: when can theassociated thoracic curve be left unfused? Spine (Phila Pa 1976). 2003 Apr 1;28(7):706-13; discussion 714. PMID:12671359 (Link to Abstract) Level of Evidence 4 (Case Series) Sweet FA, Lenke LG, Bridwell KH, Blanke KM, Whorton J. Prospectiveradiographic and clinical outcomes and complications of single solid rod instrumented anterior spinal fusion in adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2001 Sep 15;26(18):1956-65. PMID:11547193 (Link to Abstract) Textbooks Review of Orthopaedics, 5th Edition, Mark D. Miller (editor), Saunders, an imprint of Elsevier, Philadelphia, Copyright 2008 First Aid for the Orthopaedic Boards, Robert Laminzak, Mark Albritton, Trevor Pickering (Editors), McGraw Hill Medical, Copyright 2009 Orthopaedic Knowledge Update 9, Jeffrey S Fischgrund (Editor). Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2008 Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009 OITE Questions, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2010 Frank H. Netter, John A. Craig. Netter's Concise Atlas of Orthopaedic Anatomy, Icon Learning Systems, Teterboro, NJ, Copyright 2002 Undefined Spiegel DA, Flynn JM, Stasikelis PJ, Dormans JP, Drummond DS, Gabriel KR, Loder RT. Scoliotic curve patterns in patients with Chiari I malformation and/or syringomyelia. Spine (Phila Pa 1976). 2003 Sep 15;28(18):2139-46. PMID:14501926 (Link to Abstract) Yngve D. Abdominal reflexes. J Pediatr Orthop. 1997 Jan-Feb;17(1):105-8. PubMed PMID:8989711 (Link to Abstract) Sweet FA, Lenke LG, Bridwell KH, Blanke KM, Whorton J. Prospective radiographic and clinical outcomes and complications of single solid rod instrumented anterior spinal fusion in adolescent idiopathic scoliosis.Spine (Phila Pa 1976). 2001 Sep 15;26(18):1956-65. PMID:11547193 (Link to Abstract) 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. PMID:12578488 (Link to Abstract) Weinstein SL, Zavala DC, Ponseti IV. Idiopathic scoliosis: long-term follow up and prognosis in untreated patients. JBJS 1981; 63: 702-712. PMID:6453874 (Link to Abstract) 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 Feb 5;289(5):559-67. PMID:12578488 (Link to Abstract) Weinstein SL, Zavala DC, Ponseti IV. Idiopathic scoliosis: long-term follow-up and prognosis in untreated patients. J Bone Joint Surg Am. 1981 Jun;63(5):702-12. PMID:6453874 (Link to Abstract) Visitor Comments for Adolescent Idiopathic Scoliosis Please login to post comments Anonymous commented at 6:43AM on 06/01/11 ""¦lumbar curves progress more rapidly than thoracic curves"?? On Campbell 11 edition is written that thoracic curves progress more rapidly than lombar curves. (box 38.2) "Factors Related to Progression of Adolescent Idiopathic Scoliosis Girls > boys Premenarchal Risser sign of 0 Double curves > single curves Thoracic curves > lumbar curves More severe curves" " Derek Moore commented at 3:45PM on 05/29/11 "We added "pain". Thanks Baher! We really appreciate your feedback!" Anonymous commented at 1:29PM on 05/29/11 "In line 11 from above increase incidence of acute and chronic (pain)if left untreated . pain is missing please add it , thanks ." Derek Moore commented at 1:24PM on 05/08/11 "Michael, thanks again for helping us improve this site. We really appreciate it! Spelling of based corrected." Michael Zlowodzki commented at 12:48PM on 05/08/11 "change "Bases on skeletal..." to "Based on skeletal..." "

Introduction

Acute respiratory failure secondary to pulmonary edema
caused by decreased lung compliance with poor gas exchange
50% mortality rate
Causes include
  • trauma
  • shock
  • infection
  • fat emboli
  • thromboembolism
  • multi-system organ failure
Presentation
  • tachypnea, dyspnea, hypoxemia
  • decreased lung compliance
Labs
  • diagnosis after long bone fracture made with ABGs
Imaging

diffuse infiltrative changes on CXR

Treatment
  • nonoperative
  • PEEP ventilation and steroids

operative

early stabilization of long bone fractures (femur)

QBank

References

Textbooks Review of Orthopaedics, 5th Edition, Mark D. Miller (editor), Saunders, an imprint of Elsevier, Philadelphia, Copyright 2008 First Aid for the Orthopaedic Boards, Robert Laminzak, Mark Albritton, Trevor Pickering (Editors), McGraw Hill Medical, Copyright 2009 Orthopaedic Knowledge Update 9, Jeffrey S Fischgrund (Editor). Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2008 Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009 OITE Questions, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2010 Frank H. Netter, John A. Craig. Netter's Concise Atlas of Orthopaedic Anatomy, Icon Learning Systems, Teterboro, NJ, Copyright 2002 Visitor Comments for Adult Respiratory Distress Syndrome

Cervical Trauma

C-spine clearence Occipital condyle fx Occipitocervical disloc. Atlas fxs (C1) Odontoid fxs (C2) Hangman's fxs (C2) Facet Dislocation & FX Cervical vertebral body fx Halo Immobilization

General

Level of amputation and prognosis

the general trend is increasing energy requirement for more proximal amputations amputation should be performed at the lowest possible level in order to preserve the most function. the only exception is the Syme amputation which is more energy efficient than the midfoot amputation even though it is more proximal

Amputation vs. reconstuction

LEAP study found that SIP (Sickness Impact Profile) score and return to work were not statistically signficantly different between amputation and reconstruction groups at 2 years in limb-threatening lower extremity injuries.

Wound Healing

Improved with

albumin > 3.0 g/dL transcutaneous osygen tension > 30 mm Hg (ideally . 45 mm Hg) toe pressure > 40 mm Hg (will not heal if < 20 mm Hg) Ankle-brachial index (ABI) > 0.45 Total lymphocyte count (TLC) > 1500/mm3

Hyperbaric oxygen therapy

contraindications include chemo- or radiation therapy pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) undrained pneumothorax

Upper Extremity Amputation

Wrist disarticulation has the following advantages over transradial amputation

better suspension with distal radial flare preserved forearm rotation

Transfemoral

Amputation Need 5-10 degrees of adduction of femur for improved function of prosthesis. perform adductor myodesis

Below-Knee-Amputation (BKA)

Perform transtibial amputation 12-15 cm below knee joint to ensure adequate lever arm

Need approximately 8-12 cm from ground to fit most modern high-impact prostheses

Osteomyoplastic transtibial amputation (Ertl) technique involves creating a strut from the tibia to fibula from a piece of fibula or osteoperiosteal flap

Ankle/Foot Amputation

Ankle disarticulation

be sure to bevel malleoli Syme amputation patent tibialis posterior artery is required more energy efficient than midfoot even though it is more proximal stable heel pad is most important factor Chopart amputation a partial foot amputation through the talonavicular and calcaneocuboid joints combine with lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck

LisFranc amputation equinovarus deformity is a concern caused by loss of peroneal brevis, peroneal longus, EDL, EHL and peroneus resulting in unopposed action of gastroc-soleus, posterior tibialis, and anterior tibialis.

Transmetatarsal amputation

spares length and less resulting deformity than Chopart and LisFranc amputations

Great toe amputations

attempt to perform distal to FHB insertion

RATE CONTENT AVERAGE 0.0 of 0 RATINGS

QBank

(OBQ10-2) A 34-year-old male sustains a traumatic injury to his foot following a motorcycle accident.
The patient's neurovascular status necessitates the amputation demonstrated in figures A through C.
One year following the amputation, the patient complains of difficulty with gait and deformity of the ankle.
Which of the following statements best describes the forces resulting in this deformity?
REVIEW TOPIC
Amputations
 
 
 
 
 
 
 
FIGURES: A B C
  1. Tight posterior capsule tissues of the ankle
  2. Neuropraxia of the deep peroneal nerve
  3. Unopposed pull of gastrocnemius-soleus only
  4. Unopposed pull of gastrocnemius-soleus, posterior tibialis, and peroneus brevis
  5. Unopposed pull of gastrocnemius-soleus and posterior tibialis
PREFERRED RESPONSE ▼ 5
DISCUSSION

The clinical photograph and radiograph demonstrate a Lisfranc amputation. The loss of the peroneus longus, EHL, EDL, and peroneus tertius insertions result in an equinovarus deformity due to the pull of the gastrosoleus complex, posterior tibialis, and anterior tibialis. The referenced article by Early reviews the indications and complications involved with Lisfranc and Chopart amputations of the midfoot.

REFERENCES

1. OITE10 #2 2. Early JS. Transmetatarsal and midfoot amputations. Clin Orthop Relat Res. 1999 Apr;(361):85-90. PMID:10212600 (Link to Abstract) 3. Sarrafian SK. Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, 2nd ed. Philadelphia, PA: JB Lippincott; 1983:218-247. : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments.

(OBQ09-13) All of the following represent absolute contraindications to hyberbaric oxygen (HBO) therapy EXCEPT: REVIEW TOPIC

1. pacemaker 2. concurrent radiation therapy 3. undrained pneumothorax 4. bleomycin exposure 5. crush injuries

PREFERRED RESPONSE ▼ 5

DISCUSSION: The idea behind HBO is to provide enhanced oxygen delivery to peripheral tissues affected by vascular disruption, cytogenic and vasogenic edema, and cellular hypoxia caused by extremity trauma. Indications include: air or gas embolism, carbon monoxide poisoning, clostridial myositis and myonecrosis (gas gangrene), crush injury, compartment syndrome, acute traumatic peripheral ischemia, decompression sickness, enhancement of healing in select problem wounds, exceptional blood loss anemia, intracranial abscess, necrotizing soft-tissue infections, osteomyelitis (refractory), delayed radiation injury (soft-tissue and bony necrosis), skin flaps and grafts (compromised), and thermal burns. Absolute contraindications to HBO include: concurrent chemo- or radiation therapy, pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump), undrained pneumothorax, and bleomycin exposure (pulmonary fibrosis). REFERENCES: 1. OITE09 #13 2. Greensmith JE: Hyperbaric oxygen therapy in extremity trauma. J Am Acad Orthop Surg 2004;12:376-384 PMID:15615503 (Link to Abstract) 3. Kindwall EP: Contraindications and side effects to hyperbaric oxygen treatment, in Kindwall EP, Whelan HT (eds): Hyperbaric medicine practice, ed 2. Flagstaff, AZ, Best Publishing Company, 1999, pp 83-98 4. Buettner MF, Wolkenhauer D: Hyperbaric oxygen therapy in the treatment of open fractures and crush injuries. Emerg Med Clin North Am 2007;25:177-188 PMID:17400080 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 3 RATINGS CAUTION ERROR ALERT TAG Please login to view and post comments. (OBQ09-201) A 33-year-old man requires a transfemoral amputation because of a mangling injury to his leg. Six months after the amputation he has persistent difficulty with ambulation because his femur bone moves into a subcutaneous position in his lateral thigh. It persists despite a well-fitted prosthesis. What technical error is the most likely cause of his disfunction? REVIEW TOPIC 1. inadequate posterior skin flap 2. inadequate anterior skin flap 3. failure to bevel the distal femur 4. lack of abductor myodesis to femur 5. lack of adductor myodesis to femur PREFERRED RESPONSE ▼ 5 DISCUSSION: Pinzur et al highlight the fact that amputations are reconstructive procedures and should leave the patient with a functional residual limb. Adductor myodesis is a critical part of a transfemoral amputation. If it is not performed, then the abductors and hip flexors can cause the femur to abduct, leading to severe problems with gait. The gait disturbance persists despite proper prosthetic fitting. A transfemoral amputation is usually performed with equal anterior and posterior flaps. REFERENCES: 1. OITE09 #201 2. Pinzur MS, Gottschalk F, Pinto MA, et al: Controversies in lower extremity amputation. Instr Course Lect 2008;57:663-672 PMID:18399614 (Link to Abstract) 3. Pinzur MS, Bowker JH, Smith DG, et al: Amputation surgery in peripheral vascular disease. Instr Course Lect 1999;48:687-691 PMID:10098097 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments. (OBQ08-235) Myodesis of which muscle group is most important for optimal outcome after transfemoral amputation? REVIEW TOPIC 1. Abductors 2. Adductors 3. Hip flexors 4. Hip extensors 5. Hip external rotators PREFERRED RESPONSE ▼ 2 DISCUSSION: Adductor myodesis is critical for optimal outcome after transfemoral amputation. Pinzur et al. emphasize that when the adductors are not anchored to bone, the hip abductors are able to act unopposed, producing a dynamic flexion-abduction deformity. This deformity prepositions the femur in an orientation that is not conducive to efficient walking. The retracted adductor muscles lead to a poorly cushioning soft-tissue envelope, further complicating prosthetic fitting. Preservation of a functional adductor magnus helps to maintain the muscle balance between the adductors and abductors by allowing the adductor magnus to maintain its power and retain the mechanical advantage for positioning the femur. Preservation is best accomplished with a myodesis. REFERENCES: 1. OITE08 #235 2. Pinzur MS: Amputations in trauma, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma: Basic Science, Management, and Reconstruction, ed 2. Philadelphia, PA, Saunders, 2003, pp 2613-2626 3. Pinzur MS, Gottschalk FA, Pinto MA, et al: Controversies in lower-extremity amputation. J Bone Joint Surg Am 2007;89:1118-1127 PMID:18399614 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 2 RATINGS TAG Please login to view and post comments. (OBQ08-246) In addition to lengthening the achilles, transfer of which tendon is important for functional ambulation after performing a Chopart amputation of the foot? REVIEW TOPIC 1. peroneus brevis 2. peroneus longus 3. tibialis anterior 4. tibialis posterior 5. flexor hallucis longus PREFERRED RESPONSE ▼ 3 DISCUSSION: The partial foot amputation through the talonavicular and calcaneocuboid joints is also known as the Chopart amputation. The Chopart amputation may result in significant equinovarus deformity with anterior weight bearing through the scar line, predisposing to skin breakdown over time. Therefore, lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck should also be performed in conjunction with this disarticulation. The tib ant transfer results in dorsiflexion and distributes the weight-bearing portion more centrally and the lengthening of the Achilles tendon is necessary to accommodate this posteriorly. Transfer of the tibialis anterior or posterior tibialis to the calcaneous would exacerbate the equinovarus deformity. Shortening of the Achilles tendon would also exacerbate the anterior loading of the scar. REFERENCES: 1. OITE08 #246 2. Brodsky JW: Amputations and prostheses of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St. Louis, MO, Mosby, 1999, pp 970-1006 3. Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL American Academy of Orthopaedic Surgeons, 2005, pp 645-654 : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments. (OBQ06-53) Which of the following is most important to acheive a good outcome following a Syme amputation? REVIEW TOPIC 1. trimming any dog ears 2. a viable and stable heel pad 3. achilles tendon lengthening 4. preserving the malleoli 5. tenodesing the extensor digitorum longus to the tibial shaft PREFERRED RESPONSE ▼ 2 DISCUSSION: A Syme amputation is effectively a tibiotalar disarticulation, which provides an end-bearing stump that could potentially allow ambulation without a prosthesis over short distances. It works better for tumor and trauma, but the heel pad must be viable. The two most common problems are 1) skin sloughing from compromised vascular supply and 2) migration of the heel pad due to instability. A hypermobile heel pad can cause difficulty with prosthesis wear and damage to the soft tissues which can eventually lead to failure. Both malleoli are usually removed in the procedure, except in children or during the first stage procedure of a diabetic or infection case. The tibialis anterior is usually tenodesed to the anterior heel pad along with the EDL tendon to avoid posterior migration of the heel pad. REFERENCES: 1. OITE06 #53 2. Brodsky JW: Amputations and prostheses of the foot and ankle, in Coughlin MJ, Mann RA (eds): surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 970-1006. 3. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 305-314. : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments. (OBQ06-145) Which of the following patients does NOT have a condition precluding a Syme's amputation as a treatment option? REVIEW TOPIC 1. A 70-year-old woman with diabetes and lesser toe gangrene due to emboli 2. A 25-year-old man with a healed open crush injury of the calcaneus and chronic osteomyelitis of the calcaneus 3. A 60-year-old man with diabetes and an ankle-brachial index <0.5 4. An 80-year-old woman with failed partial calcanectomy for a chronic non-healing ulcer 5. A 40-year-old man with severe penetrating trauma to the forefoot but intact plantar skin PREFERRED RESPONSE ▼ 5 DISCUSSION: A Syme’s amputation includes ankle disarticulation, removal of malleoli, and anchoring the heel pad to the weight bearing surface. It allows excellent gait and good cosmesis. It is vitally important that the heel pad (specialized elastic adipose tissue) is not damaged. This is ensured by dissecting the calcaneus out subperiosteally. Historically, there has been a high rate of wound healing complications in ischemic limbs and in general, if there is not a palpable PT pulse, a Syme's will not heal and a different amputation should be chosen. Therefore, the patients with emboli and abnormal ABIs would also be at significant risk for poor wound healing. Syme’s amputations are ideal for high energy forefoot or midfoot trauma, with a spared heelpad, such as the patient in answer 5. REFERENCES: 1. OITE06 #145 2. Brodsky JW. Amputations and prostheses of the foot and ankle. Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, 7th ed. St. Louis, MO: Mosby, 1999: 970-1006. 3. Mizel MS, Miller RA, Scioli MW, (eds). Orthopaedic Knowledge Update: Foot and Ankle 2. American Academy of Orthopaedic Surgeons, Rosemont, IL: 1998 4. Chapman’s Orthopaedic Surgery, Ch. 120: Amputations of the Lower Extremity. : PENDING FINAL APPROVAL RATE CONTENT 2 RATINGS CAUTION ERROR ALERT TAG Please login to view and post comments. (OBQ06-218) Which of the following amputations will lead to the greatest oxygen requirement per meter walked following prosthesis fitting? REVIEW TOPIC 1. Above-knee-amputation (transfemoral) 2. Below-knee-amputation (transtibial) 3. Through Knee 4. Syme 5. Midfoot PREFERRED RESPONSE ▼ 1 DISCUSSION: The general trend is increasing energy requirement for more proximal amputations. Amputation should be performed at the lowest possible level in order to preserve the most function. Pinzur compared 5 patients with amputations at midfoot, Syme’s, BKA, through knee, and AKA with five controls. Walking speed and cadence decreased while oxygen consumption per meter walked increased with each more proximal amputation. The only exception is the Syme which was the most energy efficient even though it is more proximal to the midfoot amputation. REFERENCES: 1. OITE06 #218 2. Pinzur MS, Gold J, Schwartz D, Gross N. Energy demands for walking in dysvascular amputees as related to the level of amputation. Orthopedics. 1992Sep;15(9):1033-6; discussion 1036-7. PMID:1437862 (Link to Abstract) 3. Rheinstein J, Yanke J, Marzano R: Developing an effective prescription for a lower-extremity prosthesis. Foot Ankle Clin 1999;4:113-138 : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments. (OBQ06-230) After a Lisfranc (tarsometatarsal) amputation of the foot, which of the following is crucial to prevent the patient from having a supinated foot during gait. REVIEW TOPIC 1. myodesis of the anterior tibialis to the medial and middle cuneiforms 2. preservation of the peroneus brevis 3. lengthening of the gastrocsoleus (achilles tendon) 4. releasing the posterior tibialis tendon 5. osteotomy through 1st metatarsal PREFERRED RESPONSE ▼ 2 DISCUSSION: A Lisfranc amputation is through the tarsometatarsal joints, except the 2nd metatarsal, which is osteotomized to preserve the stability of the medial cuneiform. To prevent the patient from inverting/supinating the foot requires maintaining plantarflexion and eversion of the foot, which is done by preserving the peroneus brevis. A lengthened Achilles would lead to dorsiflexion. Osteotomy of 2nd MT is crucial to preserve the medial cuneiform and midfoot stable. The anterior tibialis dorsiflexes and inverts the foot, but transferring it to the medial and middle cuneiforms would mimick its native function to dorsiflex and invert the foot. The posterior tibialis is the principal invertor of foot and also plantar flexes ankle. Therefore, releasing it would worsen the deformity. REFERENCES: 1. OITE06 #230 2. Early JS. Transmetatarsal and midfoot amputations. Clin Orthop Relat Res. 1999 Apr;(361):85-90. PMID:10212600 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS CAUTION ERROR ALERT TAG Please login to view and post comments. (OBQ05-271) A through-knee disarticulation has been shown to have what advantage over a traditional above-knee (transfemoral) amputation? REVIEW TOPIC 1. Decreased rate of prosthesis adjustment 2. Less postoperative time to final prosthesis fitting 3. Decreased neuroma formation 4. Decreased rate of revision 5. Less energy expenditure with ambulation PREFERRED RESPONSE ▼ 5 DISCUSSION: A through-knee disarticulation has been shown to have decreased energy expenditure with ambulation, improved limb proprioception, improved sitting capabilities, decreased hip joint flexion contracture incidence, and improved lever arm for mobilization. Knee disarticulation is also recommended in children to prevent overgrowth of the distal femur which may be seen in transfemoral amputations (if the physis remains open). No difference in prosthesis fitting has been shown between transfemoral amputation and through-knee disarticulation. The referenced paper by Pinzur et al is a excellent review of knee disarticulation, from technique to outcomes. REFERENCES: 1. OITE05 #271 2. Pinzur MS, Bowker JH. Knee disarticulation. Clin Orthop Relat Res. 1999 Apr;(361):23-8. PMID:10212592 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments. (OBQ04-11) A 40-year-old male who sustained an open pilon fracture 2 weeks ago is scheduled for a below-the-knee amputation (BKA). What laboratory value is the best predictor for wound healing? REVIEW TOPIC 1. serum albumin level 2. total protein level 3. calcium levels 4. C-reactive protein 5. ESR PREFERRED RESPONSE ▼ 1 DISCUSSION: Albumin is the best measure of nutrition that is vital for wound healing. Total protein is a valuable measure as well, however it is not as sensitive as albumin levels. Calcium levels and ESR/C-reactive protein levels play no role. REFERENCES: 1. OITE04 #11 2. Kay SP, Moreland JR, Schmitter E. Nutritional status and wound healing in lower extremity amputations. Clin Orthop Relat Res. 1987 Apr;(217):253-6. PMID:3829507 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments. (OBQ04-235) A 25-year-old male presents to the emergency department with a mangled lower extremity that is not salvageable. He undergoes transfemoral amputation. Three months later the patient presents to the office in valgus stance. What important step was forgotten during the amputation? REVIEW TOPIC 1. Beveling the distal femur 2. Saving the patella 3. Allowing the sciatic nerve to retract deep into the soft tissue 4. Myodesis of the adductors 5. Timely fitting of orthosis PREFERRED RESPONSE ▼ 4 DISCUSSION: Prior to the late 80’s, techniques for transfemoral amputation sacrificed the hip adductor muscles resulting in unopposed abductor forces. Amputation with an abducted femur leads to an increase in side lurch and higher energy consumption. Gottschalk in ’99 showed that myodesis of the adductor magnus through drill holes in the lateral femur preserved maximum muscle force and provided a mechanical advantage for the adductors of the thigh. This resulted in maintenance of the normal anatomic alignment of the femur and a balance between the abductor and adductor mechanisms of the hip, thus providing patients with improved control and easier prosthesis fit. REFERENCES: 1. OITE04 #235 2. Gottschalk F. Transfemoral amputation. Biomechanics and surgery. Clin Orthop Relat Res. 1999 Apr;(361):15-22. PMID:10212591 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments. References Show References Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies) Early JS. Transmetatarsal and midfoot amputations. Clin Orthop Relat Res. 1999 Apr;(361):85-90. PMID:10212600 (Link to Abstract) Textbooks Review of Orthopaedics, 5th Edition, Mark D. Miller (editor), Saunders, an imprint of Elsevier, Philadelphia, Copyright 2008 First Aid for the Orthopaedic Boards, Robert Laminzak, Mark Albritton, Trevor Pickering (Editors), McGraw Hill Medical, Copyright 2009 Orthopaedic Knowledge Update 9, Jeffrey S Fischgrund (Editor). Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2008 Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009 OITE Questions, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2010 Frank H. Netter, John A. Craig. Netter's Concise Atlas of Orthopaedic Anatomy, Icon Learning Systems, Teterboro, NJ, Copyright 2002 Undefined Sarrafian SK. Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, 2nd ed. Philadelphia, PA: JB Lippincott; 1983:218-247. Greensmith JE: Hyperbaric oxygen therapy in extremity trauma. J Am Acad Orthop Surg 2004;12:376-384 PMID:15615503 (Link to Abstract) Kindwall EP: Contraindications and side effects to hyperbaric oxygen treatment, in Kindwall EP, Whelan HT (eds): Hyperbaric medicine practice, ed 2. Flagstaff, AZ, Best Publishing Company, 1999, pp 83-98 Buettner MF, Wolkenhauer D: Hyperbaric oxygen therapy in the treatment of open fractures and crush injuries. Emerg Med Clin North Am 2007;25:177-188 PMID:17400080 (Link to Abstract) Pinzur MS, Gottschalk F, Pinto MA, et al: Controversies in lower extremity amputation. Instr Course Lect 2008;57:663-672 PMID:18399614 (Link to Abstract) Pinzur MS, Bowker JH, Smith DG, et al: Amputation surgery in peripheral vascular disease. Instr Course Lect 1999;48:687-691 PMID:10098097 (Link to Abstract) Pinzur MS: Amputations in trauma, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma: Basic Science, Management, and Reconstruction, ed 2. Philadelphia, PA, Saunders, 2003, pp 2613-2626 Pinzur MS, Gottschalk FA, Pinto MA, et al: Controversies in lower-extremity amputation. J Bone Joint Surg Am 2007;89:1118-1127 PMID:18399614 (Link to Abstract) Brodsky JW: Amputations and prostheses of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St. Louis, MO, Mosby, 1999, pp 970-1006 Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL American Academy of Orthopaedic Surgeons, 2005, pp 645-654 Brodsky JW: Amputations and prostheses of the foot and ankle, in Coughlin MJ, Mann RA (eds): surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 970-1006. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 305-314. Brodsky JW. Amputations and prostheses of the foot and ankle. Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, 7th ed. St. Louis, MO: Mosby, 1999: 970-1006. Mizel MS, Miller RA, Scioli MW, (eds). Orthopaedic Knowledge Update: Foot and Ankle 2. American Academy of Orthopaedic Surgeons, Rosemont, IL: 1998 Chapman’s Orthopaedic Surgery, Ch. 120: Amputations of the Lower Extremity. Pinzur MS, Gold J, Schwartz D, Gross N. Energy demands for walking in dysvascular amputees as related to the level of amputation. Orthopedics. 1992Sep;15(9):1033-6; discussion 1036-7. PMID:1437862 (Link to Abstract) Rheinstein J, Yanke J, Marzano R: Developing an effective prescription for a lower-extremity prosthesis. Foot Ankle Clin 1999;4:113-138 Early JS. Transmetatarsal and midfoot amputations. Clin Orthop Relat Res. 1999 Apr;(361):85-90. PMID:10212600 (Link to Abstract) Pinzur MS, Bowker JH. Knee disarticulation. Clin Orthop Relat Res. 1999 Apr;(361):23-8. PMID:10212592 (Link to Abstract) Kay SP, Moreland JR, Schmitter E. Nutritional status and wound healing in lower extremity amputations. Clin Orthop Relat Res. 1987 Apr;(217):253-6. PMID:3829507 (Link to Abstract) Gottschalk F. Transfemoral amputation. Biomechanics and surgery. Clin Orthop Relat Res. 1999 Apr;(361):15-22. PMID:10212591 (Link to Abstract) Visitor Comments for Amputations

Spine Upper Extremity Exam Lower Extremity Exam Spinal cord Anatomy Cervical spine Anatomy Thoracic spine Anatomy Lumbar spine Anatomy Biomechanics of Spine Neurophysiology & SCM

Introduction

A benign and non-neoplastic reactive condition
  • can be locally destructive to normal bone and may extend to soft tissue
  • may arise primarily or be associated with other tumors (giant cell tumor, chondroblastoma, fibrous dysplasia)
  • may be found in similar location as telangiectatic osteosarcomas
Age and location
  • 75% of patients are < 20 yrs.
  • 25% in spine
  • 20% in long bones usually in metaphysis

Presentation

Symptoms

pain and swelling

Imaging

Radiographs expansive, eccentric and lytic lesion with bony septae ("bubbly appearance") classic cases have thin rim of periosteal new bone surrounding lesion usually a metaphyseal lesion MRI or CT scan will show multiple fluid lines Bone scan is warm to hot

Histology

Characteristic findings cavernous space blood-filled spaces without endothelial lining cavity lining numerous benign giant cells spindle cells thin strands of bone present in fibrous tissue of septae

Treatment

ABC without fracture

operative aggressive curettage and bone grafting indicated if symptomatic some use adjuvant treatment (phenol) local recurrence in up to 25% and more common in children with open physis radiation for inaccessible lesions

ABC with fracture

nonoperative nonoperative fracture management indicated until fracture has healed. Once healed, treat as an ABC without fracture unless the fracture has led to spontaneous healing of the ABC.

Differential & Groups

"Bubbly" lytic lesion on xray "Lakes of Blood" on histology Treatment is curretage and bone grafting (1) Aneurysmal Bone cyst • • • UBC • NOF • Giant Cell Tumor • Chondroblastoma • Chondromyoid fibroma • Osteoblastoma • Telangiectatic osteosarcoma • ASSUMPTIONS: (1) assuming no impending fracture

IBank

Location Xray Xray CT B. Scan MRI MRI Histo(1) Case A tibia Case B calcaneus Case C pelvis Case D femur Case E femur (1) - histology does not always correspond to clinical case

RATE CONTENT AVERAGE 0.0 of 0 RATINGS

QBank

(OBQ10-124) a 40-year-old male has 6 months of increasing knee pain and has recently noticed a mass at his knee.
  • Radiographs are shown in Figures A and B.
  • A biopsy specimen of the proximal tibia mass is shown in Figure C.
  • What is the most appropriate next step in management?
REVIEW TOPIC
FIGURES: A B C
  1. Neoadjuvant chemotherapy
  2. Wide surgical excision
  3. Intralesional curettage and bone grafting
  4. Radiation therapy
  5. Hip disarticulation

PREFERRED RESPONSE ▼ 1

DISCUSSION

This patient's presentation, radiographs, and biopsy are consistent with telangiectatic osteosarcoma. Treatment is similar to classic osteosarcoma and initially includes multi-agent neoadjuvant chemotherapy (ex. adriamycin, cis-platinum, methotrexate, and ifosfamide) for 8-12 weeks followed by surgical resection (limb-salvage or amputation), followed by additional adjuvant chemotherapy for 6-12 months. The article by Capanna et al emphasizes that aneurysmal bone cyst's (ABC) occur in the same locations as telangiectatic osteosarcomas, and their radiographic appearances can be confused with each other. The treatment of ABC's are much different and includes intralesional curettage and bone grafting. A representative histology slide of an ABC is shown in Illustration A as a comparison to telangiectatic osteosarcoma. Illustrations: A

REFERENCES

OITE10 #124 2. Gitelis S, McDonald D. Common benign bone tumors and usual treatment. In: Simon M, Springfield D, eds. Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA: Lippincott-Raven; 1998:181-205. 3. Capanna R, Campanacci DA, Manfrini M. Unicameral and aneurysmal bone cysts.Orthop Clin North Am. 1996 Jul;27(3):605-14. Review PMID:8649741 (Link to Abstract)

PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments.

(OBQ09-236) You are seeing a 16-year-old female with shoulder pain.
She is otherwise healthy and denies trauma. Based on the radiograph, MRI, and histology shown in Figures A-C, what is your diagnosis?
REVIEW TOPIC
FIGURES: A B C
  1. Ewings sarcoma
  2. Osteosarcoma
  3. Simple bone cyst
  4. Aneurysmal bone cyst
  5. Unicameral bone cyst

PREFERRED RESPONSE ▼ 4

DISCUSSION

The radiographs, MRI, and histology are consistent with an aneurysmal bone cyst. While the radiographs could be interpreted in many ways, the "fluid-fluid" levels seen on the axial MRI are semi-diagnostic. The histology slide shows the "lakes of blood" within a fibrous stroma and adjacent normal appearing bone consistent with an aneurysmal bone cyst. Kaila et al. evaluated pediatric shoulder girdle aneurysmal bone cyst management and outcomes with a review of the literature and evaluation of their own patient cohort from 1998 to 2004. They found the proximal humerus and clavicle to be the most frequently affected areas about the shoulder. The authors found a high percentage of local recurrence from tumors of the proximal humerus lesions.

REFERENCES

OITE09 #236 2. Kaila R, Ropars M, Briggs TW, Cannon SR. Aneurysmal bone cyst of the paediatric shoulder girdle: a case series and literature review. J Pediatr Orthop B. 2007 Nov;16(6):429-36. PMID:17909342 (Link to Abstract) 3. Schwartz HS (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors 2. American Academy of Orthopaedic Surgeons. Rosemont, IL. 2007, pp 87-102 : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments.

(OBQ09-250) A 10-year-old male presents with knee pain after a collision with another soccer player

Knee radiographs are taken and show a cystic-appearing lesion in the metaphyseal region of the proximal tibia without evidence of fracture.

An MRI is performed and is shown in Figure A. If a biopsy is performed, the histology would most likely resemble which Figure (B-F).

REVIEW TOPIC

FIGURES: A B C D E F

  1. Image B
  2. Image C
  3. Image D 
  4. Image E 
  5. Image F

PREFERRED RESPONSE ▼ 1

DISCUSSION

The clinical presentation, described radiographs, and MRI in Figure A is consistent with an aneurysmal bone cyst.

On MRI, an ABC has characteristic multi-loculated cysts with fluid-fluid levels visible best on T1 weighted images. The pathology slide shown in Figure B shows the characteristic findings for an aneurysmal bone cyst, with a cystic space filled with red blood cells (“lake of blood”). ABCs are benign but locally aggressive lesions that occur in the younger population. Gibbs et al performed a retrospective review of their patients with an ABC who had undergone curettage with or without bone grafting. The recurrence rate was 12%, and recurrence was not correlated with marginal or intralesional excision, but rather young age and open growth plates. Basarir et al also found higher recurrence rates in younger patients, but this was not found to be related to contact between the lesion and the growth plate. The histology in Figure C is characteristic of an osteoid osteoma. The histology in Figure D is characteristic of an osteoblastoma. The histology in Figure E is characteristic of a chondroblastoma. The histology in Figure F is characteristic of multiple myeloma.

REFERENCES:

OITE09 #250 2. Basarir K, Piskin A, Güçlü B, Yildiz Y, Saglik Y. Aneurysmal bone cyst recurrence in children: a review of 56 patients. J Pediatr Orthop. 2007 Dec;27(8):938-43. PMID:18209619 (Link to Abstract) 3. Gibbs CP Jr, Hefele MC, Peabody TD, Montag AG, Aithal V, Simon MA. Aneurysmal bone cyst of the extremities. Factors related to local recurrence after curettage with a high-speed burr. J Bone Joint Surg Am. 1999 Dec;81(12):1671-8. PMID:10608377 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments.

(OBQ07-7) An 12-year-old female is involved in a low speed motor vehicle accident and presents with a pathologic fracture in the ulna.

Radiographs are shown in Figure A.

A needle biopsy is performed and histology is shown in Figure B. What is the best next step in treatment? REVIEW TOPIC FIGURES: A B

Open biopsy for adequate diagnostic tissue 2. Open reduction internal fixation of the distal ulna 3. Immediate curettage and adjuvant chemo/radiotherapy 4. Nonoperative fracture management 5. Preoperative chemotherapy and resection of tumor.

PREFERRED RESPONSE ▼ 4

DISCUSSION

This patient presents with a small nondisplaced fracture through an aneurysmal bone cyst. While the plain radiograph is not diagnostic, it does not suggest an aggressive lesion. The "lakes of blood" seen on the histology confirm the diagnosis. Given the alignment of the fracture, nonoperative management is preferred. Once the fracture has healed, if the ABC continues to grow treatment is curretage and grafting. If the fracture stimulates the bone cyst to resolve then no further treatment is required.

The reference by Cottalorda analyzes different treatment options used on 1256 cases of ABC in the literature
- They emphasize the importance of a needle biopsy in diagnosis and treatment.

REFERENCES

  1. OITE07 #7 2. Cottalorda J, Bourelle S. Current treatments of primary aneurysmal bone cysts.J Pediatr Orthop B. 2006 May;15(3):155-67. PMID:16601582 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments.
(OBQ06-79) Intralesional curettage and bone grafting is an accepted treatment option for all of the following conditions EXCEPT?

REVIEW TOPIC 1. Giant cell tumor 2. Aneurysmal bone cyst 3. Chondroblastoma 4. Chondromyxoid fibroma 5. Osteofibrous dysplasia PREFERRED RESPONSE ▼ 5 DISCUSSION: Benign tumors that are USUALLY treated with curettage and bone grafting include giant cell tumor, chondroblastoma, chondromyxoid fibroma, and osteoblastoma. Benign conditions that are OCCASIONALLY treated with curettage and bone grafting include unicameral bone cyst (UBC), enchondroma, and nonossifying fibroma (NOF). There is no role for curettage and bone grafting in patients with osteofibrous dysplasia. Nonoperative treatment is preferred for osteofibrous dysplasia until a child reaches maturity. These lesions usually regress and do not cause problems in adults unless the skeletal deformity requires surgical correction. The article by Athanasian reviews the presentation and treatment of giant cell tumors and aneurysmal bone cysts found in the hand and wrist. They emphasize that these lesions can be locally aggressive with high recurrence rates. They argue that while wide excision can be chosen, joint preservation is paramount.

REFERENCES

OITE06 #79 2. Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 305-312. 3. Athanasian EA. Aneurysmal bone cyst and giant cell tumor of bone of the hand and distal radius. Hand Clin. 2004 Aug;20(3):269-81, vi. Review PMID:15275686 (Link to Abstract)

References 

Level of Evidence 4 (Case Series)

Kaila R, Ropars M, Briggs TW, Cannon SR. Aneurysmal bone cyst of the paediatric shoulder girdle: a case series and literature review. J Pediatr Orthop B. 2007 Nov;16(6):429-36. PMID:17909342 (Link to Abstract) Athanasian EA. Aneurysmal bone cyst and giant cell tumor of bone of the hand and distal radius. Hand Clin. 2004 Aug;20(3):269-81, vi. Review PMID:15275686 (Link to Abstract) Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies) Gitelis S, McDonald D. Common benign bone tumors and usual treatment. In: Simon M, Springfield D, eds. Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA: Lippincott-Raven; 1998:181-205. Capanna R, Campanacci DA, Manfrini M. Unicameral and aneurysmal bone cysts.Orthop Clin North Am. 1996 Jul;27(3):605-14. Review PMID:8649741 (Link to Abstract)

Textbooks
  1. Schwartz HS (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors 2. American Academy of Orthopaedic Surgeons. Rosemont, IL. 2007, pp 87-102
  2. Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 305-312.
Aneurysmal Bone Cyst References
  1. Basarir K, Piskin A, Güçlü B, Yildiz Y, Saglik Y. Aneurysmal bone cyst recurrence in children: a review of 56 patients. J Pediatr Orthop. 2007 Dec;27(8):938-43. PMID:18209619 (Link to Abstract)
  2. Gibbs CP Jr, Hefele MC, Peabody TD, Montag AG, Aithal V, Simon MA. Aneurysmal bone cyst of the extremities. Factors related to local recurrence after curettage with a high-speed burr. J Bone Joint Surg Am. 1999 Dec;81(12):1671-8. PMID:10608377 (Link to Abstract)
  3. Cottalorda J, Bourelle S. Current treatments of primary aneurysmal bone cysts.J Pediatr Orthop B. 2006 May;15(3):155-67. PMID:16601582 (Link to Abstract)

Visitor Comments for Aneurysmal Bone Cyst Please login to view and post comments.

Indications

Exposes anterior vertebral bodies from C3 to T1
Indications
excision of herniated discs
interbody fusion
removal of osteophytes from uncinate processes
excise tumors
debride osteomyelitis and drain abscesses

Applied surgical anatomy

It is important to understand the three fascial layers of the neck
superficial fascia

formed by the investng layer of deep cervical fascia

platysma and external jugular vein are only structures superficial to it

surround neck like a collar, but splits around the SCM and trapezius

pretracheal fascia continous with carotid sheath at sheaths lateral margin superior and inferior thyroid vessels run from the carotid sheath through the pretracheal fascia to the midline prevertebral fascia thich and tough fascia that lines in front of the prevertebral muscles the cervical sympathetic trunk (runs over transverse processes) runs on its surface

Landmarks
carotid tubercle is the anterior tubercle of the transverse process of C6

Planes

Superificial divide platysma which is innervated high up in the neck by the facial (seventh) cranial nerve Deep plane between sternocleidomastoid (spinal accessory nerve) strap muscles (segmental innervation from C1, C2, C3) Deepest plane between left longus colli muscles (segmental branches of cervical nerves) right longus colli muscles

Approach

Incision

make transverse skin crease incision at appropriate level

extend obliquely from the midline to the posterior border of the SCN

Superficial Dissection incise fascia over platysma spit platysma with finger identify anterior border of SCM incise fascia and retract SCN lateral identify and retract strap muscles medially (sternohyoid and sternothyroid) identify the carotid pulse and retract carotid sheath lateral cut through pretrachial fascia localize superior and inferior thyroid arteries and tie off if necessary

Deep dissection

split longus colli muscles and anterior longitudinal ligament be aware of sympathetic chain that lies on longus colli lateral to vertebral body

subperiostally disect to expose anterior surface of vertebral body retract longus colli muscles and ALL laterally

identify level with needle in disc space and lateral xray

Dangers

Recurrent laryngeal nerve

left recurrent laryngeal nerve

ascends in neck between trachea and esophagus after branching off from parent nerve the vagus at the level of the arch of the aorta

right recurrent laryngeal nerve

runs alongside the trachea in the neck after hooking around the right subclavian artery

crosses from lateral to medial to reach midline

more vulnerable than left during exposure

protect by placing retractors under medial edge of longus colli muscle

Sympathetic nerves and stellate ganglion

damage or irritation causes Horner's syndrome protect by subperiosteal dissection of longus colli muscles from midline

Carotid sheath and contents

protected by the anterior border of SCM

be careful with lateral retractor placement

Postoperative respiratory difficulties

tense hematomas should be emergently decompressed if causing respiratory compromise

physical exam will show a tense mass under the incision

most common cause is postsurgical edema

QBank

(OBQ06-221) A myelopathic patient undergoes anterior cervical diskectomy and fusion through a left sided approach.
Facial asymmetry is noticed postoperatively in the recovery room.
A clinical photo is shown in Figure A.
What additional finding would likely be found on opthamlologic exam?
REVIEW TOPIC

Anterior Approach to Cervical Spine

 
 
 
 
 
 
 
 
 
FIGURES: A
  1. pupillary dilation and hyperhidrosis on the patient's right side
  2. pupillary dilation and hyperhidrosis on the patient's left side
  3. pupillary constriction and hyperhidrosis on the patient's right side
  4. pupillary constriction and anhidrosis on the patient's left side
  5. pupillary constriction and anhidrosis on the patient's right side
PREFERRED RESPONSE ▼ 4
DISCUSSION:

The patient has Horner's syndrome which is a rare but known complication of anterior approaches to the cervical spine.

In a retrospective study by Fountas et al, the incidence of Horner's syndrome was 0.1% (1 of 1140) in patients undergoing first-time ACDF for cervical radiculopathy and/or myelopathy.

Bertalanffy and Eggert reported an incidence of 1.1% in their series.

Horner's Syndrome is caused by an injury to the cervical sympathetic ganglia/trunk, which are located anterolaterally to the longus colli and longus capitis muscles.

  • These muscles lie anterolaterally to the cervical vertebral bodies.
  • Injury to the nerves can occur either during dissection or with aggressive (injudicious) retraction during an anterior approach to either side of the cervical spine.
  • It has been postulated that this complication can be avoided if subperiosteal dissection of the longest coli muscles is performed.

Horner’s Syndrome classically presents with

  1. ipsilateral ptosis (drooping eyelid caused by injury to nerve to Muller’s muscle)
  2. ipsilateral miosis (papillary constriction caused by injury to long ciliary nerve to pupil dilator) and 
  3. usually (but not always) ipsilateral anhidrosis.

The illustration below helps understand the location of the sympathetic chain in relation to the vertebral bodies.

  • Illustrations: A
REFERENCES:
  1. OITE06 #221
  2. Bertalanffy H, Eggert HR. Complications of anterior cervical discectomy without fusion in 450 consecutive patients. Acta Neurochir (Wien).1989;99(1-2):41-50. PMID:2667284 (Link to Abstract)
  3. Fountas KN, Kapsalaki EZ, Nikolakakos LG, Smisson HF, Johnston KW, Grigorian AA, Lee GP, Robinson JS Jr. Anterior cervical discectomy and fusion associated complications. Spine (Phila Pa 1976). 2007 Oct 1;32(21):2310-7. Review. PMID:17906571 (Link to Abstract)

(OBQ05-53) A 53-year-old female is 8 hours status post the procedure seen in Figure A.

You are called to the room by the nurse who reports the patient is having difficulty breathing. On arrival, you note that the patient has stridor on inspiration and a firm mass under the incision. What is the most likely cause of her respiratory compromise? REVIEW TOPIC FIGURES: A 1. Postoperative edema 2. Hematoma 3. Vocal cord paralysis 4. Allergic reaction 5. Laryngospasm PREFERRED RESPONSE ▼ 2 DISCUSSION: This patient is presenting with respiratory obstruction following a cervical corpectomy. Physical exam is consistent with a retropharyngeal hematoma as the cause of obstruction. The differential diagnosis of acute postoperative obstruction of the upper airway includes laryngospasm, hematoma, paralysis of the vocal cords, allergic reaction and edema. According to the first referenced article by Emery et al, edema is believed to be the most common cause of postoperative respiratory difficulties. In this clinical case, the patient has a tense mass under the incision which would not be found with obstruction caused by edema. Risk factors for respiratory failure as a cause of death were severe myelopathy and multilevel corpectomy. The referenced article by Roy discussed the importance of surgical decompression of patients presenting postoperatively with a tense neck mass (hematoma) and respiratory difficulties. REFERENCES: 1. OITE05 #53 2. Emery SE, Smith MD, Bohlman HH. Upper-airway obstruction after multilevel cervical corpectomy for myelopathy. J Bone Joint Surg Am. 1991 Apr;73(4):544-51. PMID:2013593 (Link to Abstract) 3. Roy SP. Acute postoperative neck hematoma. Am J Emerg Med. 1999 May;17(3):308-9. PMID:10337897 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 2 RATINGS Comment Thread TAG References Show References Textbooks Review of Orthopaedics, 5th Edition, Mark D. Miller (editor), Saunders, an imprint of Elsevier, Philadelphia, Copyright 2008 First Aid for the Orthopaedic Boards, Robert Laminzak, Mark Albritton, Trevor Pickering (Editors), McGraw Hill Medical, Copyright 2009 Orthopaedic Knowledge Update 9, Jeffrey S Fischgrund (Editor). Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2008 Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009 OITE Questions, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2010 Frank H. Netter, John A. Craig. Netter's Concise Atlas of Orthopaedic Anatomy, Icon Learning Systems, Teterboro, NJ, Copyright 2002 Undefined Bertalanffy H, Eggert HR. Complications of anterior cervical discectomy without fusion in 450 consecutive patients. Acta Neurochir (Wien).1989;99(1-2):41-50. PMID:2667284 (Link to Abstract) Fountas KN, Kapsalaki EZ, Nikolakakos LG, Smisson HF, Johnston KW, Grigorian AA, Lee GP, Robinson JS Jr. Anterior cervical discectomy and fusion associated complications. Spine (Phila Pa 1976). 2007 Oct 1;32(21):2310-7. Review. PMID:17906571 (Link to Abstract) Emery SE, Smith MD, Bohlman HH. Upper-airway obstruction after multilevel cervical corpectomy for myelopathy. J Bone Joint Surg Am. 1991 Apr;73(4):544-51. PMID:2013593 (Link to Abstract) Roy SP. Acute postoperative neck hematoma. Am J Emerg Med. 1999 May;17(3):308-9. PMID:10337897 (Link to Abstract) Visitor Comments for Anterior Approach to Cervical Spine Please login to view and post comments.

Open Fracture Antibiotics

Gustillo Grade I and II
  • 1st generation cephalosporin

Gustillo Grade III 1st generation cephalsporin amingoglycoside With farm injury / bowel contamination add PCN for clostridia Duration initiate as soon as possible studies show increased infection rate when antibiotics are delayed for more than 3 hours from time of injury continue for initial 72 hours after I&D 48 hours after each procedure

Gun Shot Wound Antibiotics

Low Velocity with no bone involvement or non-operative fractures
can be treated with local wound care and oral antibiotics

Prophylaxis

Preoperative
  • indications and evidence based medicine supporting
Postoperative
  • evidence based medicine supporting

Dental work in Joint Replacement patients indications recommended that all patients take prophylactic antibiotic coverage following a total joint replacement. patients who are immunocompromised or have immune altering comorbidities should receive lifetime prophylactic antibiotic therapy. This includes RA SLE medication induced immunosuppresion previous total joint infection diabetes HIV malignancy antibiotics is given 1 hour before procedure patients NOT allergic to penicillin amoxicillin or cephalexin 2 grams orally if unable to take oral medications than 1 gram cefazolin or 2 gram ampicillin IV or IM if allergic to penicillin clindamycin 600 mg orally if unable to take oral medications than clindamycin 600 mg IV

Splenectomy patients
Basic recommendations for splenectomized patients
  1. All splenectomized patients and those with functional hyposplenism should receive pneumococcal immunization.
  2. Patients not previously immunised should receive haemophilus influenza type B vaccine.
  3. Patients not previously immunised should receive meningococcal group C conjugate vaccine.
  4. Influenza immunisation should be given.
  5. Lifelong prophylactic antibiotics are still recommended (oral phenoxymethylpenicillin or erythromycin).

Penicillins

Mechanism

interfer with bacterial cell wall synthesis

Subclassification and tested examples natural penicillin G penicillinase-resistant methicillin (Staphcillin) aminopenicillins ampicillin (Omnipen, Polycillin)

Cephalosporins

Mechanism Inhibits cell wall synthesis Subclassification and tested examples first generation cefazolin (Ancef, Kefzol) second generation cefaclor (Ceclor) third generation cefriazone (Rocephin) fourth generation cefepime (Maxipime)

Fluoroquinolones

Mechanism Blocks DNA replication via inhibition of DNA gyrase Side effects inhibit early fracture healing through toxic effects on chondrocytes increased rates of tendinitis, with special predilection for the Achilles tendon. tenocytes in the Achilles tendon have exhibited degenerative changes when viewed microscopically after fluoroquinolone administration. recent clinical studies have shown an increased relative risk of Achilles tendon rupture of 3.7. Subclassification and tested examples ciprofloxacin (Cipro) levofloxacin (Levaquin)

Aminoglycosides

Mechanism

bacteicidal

Inhibition of bacterial protein synthesis

work by binding to the 30s ribosome subunit, leading to the misreading of mRNA. This misreading results in the synthesis of abnormal peptides that accumulate intracellularly and eventually lead to cell death. These antibiotics are bactericidal.

Subclassification and tested examples

gentamicin (Garamycin)

Other Class Antibiotics

Vancomycin
  • Vancomycin is an inhibitor of cell wall synthesis and is
  • bactericidal for gram positive organisms
Rifampin
  • Most effective against intracellular phagocytized Staphylococcus aureus in macrophages
Linezolid

Classification Overview

Classification Overview

PENICILLINS
CEPHALOSPORINS
FLUOROQUINOLONES
AMINOGLYCOSIDES
MONOBACTAMS
CARBAPENEMS
 MACROLIDES
OTHER
Natural
First generation
  • Ciprofloxacin (Cipro)
  • Levofloxacin (Levaguin)
  • Moxifloxacin (Avelox)
  • Norfloxacin
  • Amikacin
  • Gentamicin
  • Kanamycin
  • Neomycin
  • Tobramycin
Aztreonam Ertapenem Imienem Meropenem Azithromycin Clarithromycin Dirithromycin Erythromycin Clindamycin  Vancomycin Rifampin Doxycycline Linezolid Tetracycline Trimethoprim/ sulfamethoxacole
Penicillin G Penicillin-VK Cephalothin Cefazolin (Ancef, Kefzol) Cephapririn Cephalexin (Keflex) other
Penicillinase Resistant  
Second Generation
Methicillin Nafcillin Oxacillin other Cefacor Cefotetan (Cefotan) other
Aminopenicillins
Third Generation 
Ampicillin Ceftriaxone (Rocephin) other
Fourth Generation
Cefpirome Cefepime
Grouping By Mechanism
Interfer with cell wall synthesis
  • Cephalosporins
  • Penicillins
  • Vancomycin
  • Imipenim
Inhibit ribosomes and protein synthesis
  • Aminoglycosides (gentamycin - bind 30s subunit)
  • Macrolides (erythromycins)
  • Linezolid (bind 70s subunit)
  • Tetracyclines (70s and 80s)
Interfere with RNA synthesis
  • Rifampin
Interfere with DNA transcription
  • Quinolones (ciprofloxacin, levofloxacin)

Interfere with folic acid synthesis 

  • Sulfonamides

  RATE CONTENT

QBank

(OBQ08-275) What is the mechanism of action of vancomycin? REVIEW TOPIC 1. inhibition of cell wall synthesis 2. increase cell wall permeability 3. ribosomal inhibition 4. interference with DNA metabolism 5. antimetabolite action PREFERRED RESPONSE ▼ 1 DISCUSSION: Vancomycin is an inhibitor of cell wall synthesis and is bactericidal for gram positive organisms. Antibiotics exert their effects via five basic mechanisms: (1) inhibition of cell wall synthesis, (2) increasing cell membrane permeability, (3) ribosomal inhibition, (4) interference with DNA metabolism, and (5) antimetabolite action. REFERENCES: 1. OITE08 #275 2. Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007, pp 315-330 : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments.

(OBQ06-87) Which class of antibiotics inhibit early fracture healing through toxic effects on chondrocytes? REVIEW TOPIC 1. cephalosporins 2. quinolones 3. penicillins 4. macrolides 5. sulfonamides PREFERRED RESPONSE ▼ 2 DISCUSSION: These studies exposed rats with experimental fractures to quinolones. The cited study by Perry et al demonstrated that fracture calluses in the animals treated with quinolones showed a lower histologic grade as compared with control animals representing a less mature callus with the presence of more cartilage and less woven bone. The cited study by Huddleston et al demonstrated fracture calluses in the animals treated with ciprofloxacin showed abnormalities in cartilage morphology and endochondral bone formation and a significant decrease in the number of chondrocytes compared with the controls. None of the other antibiotics listed are known to have toxic effects on chondrocytes.

REFERENCES: 1. OITE06 #87 2. Perry AC, Prpa B, Rouse MS, et al: Levofloxacin and trovafloxacin inhibition of experimental fracture healing. Clin Orthop 2003; 414: 95-100. PMID:12966282 (Link to Abstract) 3. Huddleston PM, Steckelberg JM, Hanssen AD, et al: Ciprofloxacin inhibition of experimental fracture healing. JBJS Am 2000; 82: 161-173. PMID:10682725 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments.

(OBQ06-134) Rifampin is highly effective against phagocytized intracellular Staphylococcus aureus especially in combination with other antibiotics because of its: REVIEW TOPIC 1. hydrophilic activity 2. high cell penetration 3. structural similarity to penicillin 4. structural similarity to vancomycin 5. beta-lactamase activity PREFERRED RESPONSE ▼ 2 DISCUSSION: Darouiche et al examined antibiotic penetration and bactericidal properties of antibioics and discovered that rifampin had the best cell penetration and concentration among the drugs studied (nafcillin, cefazolin, cefuroxime, vancomycin, minocycline, and ciprofloxacin). In general the lipophilic drugs (minocycline, ciprofloxacin, rifampin) were better able to penetrate the cells than the hydrophilic drugs (nafcillin, cefazolin, cefuroxime, vancomycin). Rifampin by itself exhibited poor killing activity despite high concentration; it did however, potentiate the effects of other antibiotics such as nafcillin, vancomycin, and minocyclin.

REFERENCES: 1. OITE06 #134 2. Darouiche RO, Hamill RJ. Antibiotic penetration of and bactericidal activity within endothelial cells. Antimicrob Agents Chemother. 1994 May;38(5):1059-64. PMID:8067738 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments.

(OBQ05-99) A 62-year-old man undergoes an uncomplicated total shoulder replacement 9 months ago. What is an appropriate choice of prophylactic antibiotics to be taken prior to dental work if he has no allergies? REVIEW TOPIC 1. daptomycin 600 milligrams intravenous 2 hours prior to procedure 2. amoxicillin 4 grams oral 1 week prior to procedure 3. levaquin 500 milligrams oral 1 hour prior to procedure 4. trimethoprim-sulfamethoxazole 2 tablets double-strength oral 1 hour prior to procedure 5. cephalexin 2 grams oral 1 hour prior to procedure PREFERRED RESPONSE ▼ 5 DISCUSSION: Patients not allergic to penicillin should take 2 grams of Amoxicillin, Cephalexin, or cephradine, by mouth one hour prior to the dental procedure. IV antibiotics are very rarely used in dental offices. If allergic to penicillin, clindamycin would be the next best alternative. REFERENCES: 1. OITE05 #99 2. Buckwalter JA, Einhorn TA, Simon SR (ed): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 239-259. 3. American Academy of Orthopaedic Surgeons Website. Advisory Statement: Antibiotic Prophylaxis for Dental Patients with Total Joint Replacement. Available at http://www.aaos.org/news/aaosnow/may09/cover2.asp : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments.

(OBQ05-171) A 36-year-old male is brought to the trauma center following a motor vehicle accident. Physical exam shows a deformed left lower extremity with a 1-cm open wound over the anterolateral aspect of his leg. What is the recommended antibiotic prophylaxis for this injury? REVIEW TOPIC FIGURES: A B 1. Gentamicin and penicillin 2. Cephalosporin 3. Cephalosporin and penicillin 4. Cephalosporin and gentamicin 5. Cephalosporin, gentamicin, and penicillin PREFERRED RESPONSE ▼ 4 DISCUSSION: The patient has a Gustillo Grade IIIA open tibia fracture. We know it is a Grade III because there is a segmental fracture which is associated with significant periosteal stripping and comminution. Grade III fractures are treated with immediate antibiotics including a cephalosporin (gram positive coverage) and gentamicin (gram negative coverage). The first reference by Patzakis et al is a prospective study of 1104 patients with open fractures that found the following variables were associated with an increased rate of infection: 1) failure to give antibiotics, 2) resistance of wound contaminate organisms to antibiotics, 3) increased time from injury to initiation of antibiotic treatment, 4) extent of soft tissue injury, 5) open tibia fractures, 6) positive post debridement-irrigation culture, 7) wound closure in the presence of C. perfringens contamination in the absence of antibiotic treatment. They also found the lowest infection rate when a combination of antibiotics were used that offered both gram positive and gram negative coverage. Gustilo in 1976 published a study with prospective and retrospective arms including 1052 open fracture patients. Some conclusions that are still standard of care today include: 1. "adequate debridement and copious irrigation", 2. "Primary closure is indicated for Type I and II open fractures, but delayed closure....for Type III open fractures", 3. "Antibiotics should be administered before and during surgery, the antibiotics of choice currently being the cephalosporins in therapeutic doses."

REFERENCES: 1. OITE05 #171 2. Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracturewounds. Clin Orthop Relat Res. 1989 Jun;(243):36-40. PMID:2721073 (Link to Abstract) 3. Zalavras CG, Patzakis MJ. Open fractures: evaluation and management. J Am Acad Orthop Surg. 2003 May-Jun;11(3):212-9. PMID:12828451 (Link to Abstract) 4. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective andprospective analyses. J Bone Joint Surg Am. 1976 Jun;58(4):453-8. PMID:773941 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS CAUTION ERROR ALERT TAG Please login to view and post comments.

(OBQ04-42) A splenectomy is performed in a 7-year-old boy following a motor vehicle accident. All of the following are recommended for long-term management EXCEPT: REVIEW TOPIC 1. pneumococcal vaccination 2. haemophilus influenza type B vaccination 3. meningococcal group C vaccination 4. lifelong prophylactic antibiotics 5. hepatitis A vaccination PREFERRED RESPONSE ▼ 5 DISCUSSION: Basic recommendations for splenectomized patients 1. All splenectomized patients and those with functional hyposplenism should receive pneumococcal immunization. 2. Patients not previously immunised should receive haemophilus influenza type B vaccine. 3. Patients not previously immunised should receive meningococcal group C conjugate vaccine. 4. Influenza immunisation should be given. 5. Lifelong prophylactic antibiotics are still recommended (oral phenoxymethylpenicillin or erythromycin). This is seemingly despite lack of good data demonstrating a role for lifelong chemoprophylaxis and the acknowledgement that long-term compliance may be problematic. REFERENCES: 1. OITE04 #42 2. Davies JM. Update of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. Clin Med 2002; 2: 440-443. PMID:12448592 (Link to Abstract) 3. Gandhi RR. Pediatric splenic injury: Pathway to play? J Pediatr Surg 1999; 34: 55-58 PMID:10022143 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS CAUTION ERROR ALERT TAG Please login to view and post comments.

(OBQ04-58) All of the following antibiotics function by interfering with protein synthesis by inhibiting ribosomes EXCEPT

REVIEW TOPIC

  1. gentamycin
  2. tobramycin
  3. vancomycin
  4. erythromycin
  5. linezolid
PREFERRED RESPONSE ▼ 3
DISCUSSION
  • Gentamycin and tobramycin are aminoglycosides that function by inhibition of bacterial protein synthesis via irreversible binding to ribosomal subunits.
  • Erythromycin functions by binding to the 50s subunit of the bacterial 70s rRNA complex and thereby inhibits protein synthesis.
  • Linezolid binds to the 23S portion of the ribosomal subunit and inhibits protein synthesis.
In contrast, Vancomycin acts by inhibiting proper cell wall synthesis and does not inhibit the ribosome.

REFERENCES: 1. OITE04 #58 2. Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and biomechanics of the musculoskeletal system, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 239-259 : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments.

(OBQ04-190) All of the following antibiotics function by interfering with cell wall synthesis EXCEPT REVIEW TOPIC 1. cephazolin 2. penicillin G 3. vancomycin 4. imipenem 5. gentamicin PREFERRED RESPONSE ▼ 5 DISCUSSION: Cephalosporins (cephazolin), penicillins, vancomycin, and imipenim function by interfering with cell wall synthesis. Gentamicin, an aminoglycoside, functions by inhibiting ribosomes and protein synthesis and does not affect cell wall synthesis. The reference by Mader et al. is an instructional course lecture that reviews the different mechanisms of antibiotics and their indications in musculoskeletal infections. REFERENCES: 1. OITE04 #190 2. Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemount, IL, American Academy of Orthopaedic Surgeons, 3. Mader JT, Wang J, Calhoun JH: Antibiotic therapy for musculoskeletal infections. Instr Course Lect 2002;51:539-551 PMID:12064145 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 2 RATINGS TAG Please login to view and post comments. References Show References Textbooks Review of Orthopaedics, 5th Edition, Mark D. Miller (editor), Saunders, an imprint of Elsevier, Philadelphia, Copyright 2008 First Aid for the Orthopaedic Boards, Robert Laminzak, Mark Albritton, Trevor Pickering (Editors), McGraw Hill Medical, Copyright 2009 Orthopaedic Knowledge Update 9, Jeffrey S Fischgrund (Editor). Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2008 Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009 OITE Questions, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2010 Frank H. Netter, John A. Craig. Netter's Concise Atlas of Orthopaedic Anatomy, Icon Learning Systems, Teterboro, NJ, Copyright 2002 Undefined Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007, pp 315-330 Perry AC, Prpa B, Rouse MS, et al: Levofloxacin and trovafloxacin inhibition of experimental fracture healing. Clin Orthop 2003; 414: 95-100. PMID:12966282 (Link to Abstract) Huddleston PM, Steckelberg JM, Hanssen AD, et al: Ciprofloxacin inhibition of experimental fracture healing. JBJS Am 2000; 82: 161-173. PMID:10682725 (Link to Abstract) Darouiche RO, Hamill RJ. Antibiotic penetration of and bactericidal activity within endothelial cells. Antimicrob Agents Chemother. 1994 May;38(5):1059-64. PMID:8067738 (Link to Abstract) Buckwalter JA, Einhorn TA, Simon SR (ed): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 239-259. American Academy of Orthopaedic Surgeons Website. Advisory Statement: Antibiotic Prophylaxis for Dental Patients with Total Joint Replacement. Available at http://www.aaos.org/news/aaosnow/may09/cover2.asp Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracturewounds. Clin Orthop Relat Res. 1989 Jun;(243):36-40. PMID:2721073 (Link to Abstract) Zalavras CG, Patzakis MJ. Open fractures: evaluation and management. J Am Acad Orthop Surg. 2003 May-Jun;11(3):212-9. PMID:12828451 (Link to Abstract) Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective andprospective analyses. J Bone Joint Surg Am. 1976 Jun;58(4):453-8. PMID:773941 (Link to Abstract) Davies JM. Update of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. Clin Med 2002; 2: 440-443. PMID:12448592 (Link to Abstract) Gandhi RR. Pediatric splenic injury: Pathway to play? J Pediatr Surg 1999; 34: 55-58 PMID:10022143 (Link to Abstract) Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and biomechanics of the musculoskeletal system, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 239-259 Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemount, IL, American Academy of Orthopaedic Surgeons, Mader JT, Wang J, Calhoun JH: Antibiotic therapy for musculoskeletal infections. Instr Course Lect 2002;51:539-551 PMID:12064145 (Link to Abstract) Visitor Comments for Antibiotics

Coagulation Cascade

 Anticoagulation

 

 

 

 

 

 

 

 

 

Overview of Anticoagulants

Overview of Anticoagulants

Method Mechanism Advantage Disadvantage References
Lovenox (enoxaparin)  Enhancing ability of ATIII to inhibit factors IIa (thrombin) and Xa Fixed (?) dose  bleeding
IV heparin Enhances ability of Antithrombin III to inhibit factors IIa, IXa, Xa Reversible IV administration Subcutaneous heparin Enhances ability of Antithrombin III to inhibit factors IIa, IXa, Xa Reversible Not effective in extremities
ASA Platelet inhibition via thromboxane Dextran Dilutional Efficac fluid overload Convenience  limited efficacy
Compression stocking Mechanical Cost  inconvenient
Coumadin Affects Vit K metabolism in the liver, limiting production of clotting factors Most effective Difficult to reverse

 Warfarin

Mechanism of anticoagulation effect via inhibition of hepatic enzymes vitamin K epoxide and reductase leads to decreased carboxylation of vitamin K dependent proteins (via posttranslational inhibition - not direct competitive inhibition) factor II (prothrombin) VII (first affected) IX X protein C protein S Reversal anticoagulation effect can be reversed with vitamin K fresh frozen plasma Pharmacologic interference rifampin adn phenbarbital are antagonists to warfarin

ASA

Mechanism of anticoagulation platelet inhibition via thromboxane

Low Molecular Weight Heparin

Mechanism LMWH acts in several sites of the coagulation cascade, with its principal action being inhibition of factor 10a. reversed by protamine Risk bleeding

Herbal Supplements

Gingko, ginsing and garlic have been found to increase the rate of bleeding related to effect on platelets proper history taking can avoid complications CAUTION ERROR ALERT RATE CONTENT AVERAGE 0.0 of 0 RATINGS

QBank (OBQ10-11) Which of the following supplments effects blood clotting through its effect on platelets? REVIEW TOPIC 1. Ginkgo 2. Vitamin D 3. Ephedra 4. St. John's Wart 5. Selenium PREFERRED RESPONSE ▼ 1 DISCUSSION: Ginkgo and ginseng are two common supplements used in the general population that have inhibitory effects of platelet function. Adverse peri-operative complications consisting of increased bleeding and hematoma formation have been reported with the use of these two herbal supplements. The most commonly used supplements that could have an effect in the peri-operative period include echinacea, ephedra, garlic, ginkgo, ginseng, kava, St John's wort, and valerian. Bleeding has been shown to be effected by garlic, ginkgo, and ginseng; cardiovascular instability from ephedra; and hypoglycemia from ginseng. Kava and valerian have pharmacodynamic herb-drug interactions that can increase the sedative effect of anesthetics. St John's wort has been shown to alter the metabolism of certain drugs used in the perioperative period. Ang-Lee et al review common supplements used today and their potential anesthesia/operative effects. The article places emphasis on proper history taking of not only medications but also supplements which is often times left out of documentation. REFERENCES: 1. OITE10 #11 2. Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA. 2001 Jul 11;286(2):208-16. PMID:11448284 (Link to Abstract) 3. Moore TJ. Perioperative medical management. In: Fischgrund JS, ed. Orthopaedic Knowledge Update 9. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:105-113. : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments. (OBQ09-116) Low-molecular-weight heparin has been shown to have an increased rate of which of the following when compared to aspirin, clopidogrel, and compression devices? REVIEW TOPIC 1. Pneumonia 2. Fatal pulmonary embolism 3. Inferior vena cava filter placement 4. Renal failure 5. Postoperative hematoma PREFERRED RESPONSE ▼ 5 DISCUSSION: Usage of low-molecular-weight heparins (LMWH) have been shown to have an increased rate of postoperative hematomas and wound complications in several large studies. The referenced study by Dorr et al noted that wound complications and hematomas only existed in warfarin or low-molecular weight heparin patients, and not in patients treated with ASA, clopidogrel, or compression devices. The referenced study by Lee et al reviews the complication of retroperitoneal hematoma during LWWH usage. REFERENCES: 1. OITE09 #116 2. Dorr LD, Gendelman V, Maheshwari AV, et al: Multimodal thromboprophylaxis for total hip and knee arthroplasty based on risk assessment. J Bone Joint Surg Am 2007;89:2648- 2657 PMID:18056497 (Link to Abstract) 3. Lee MC, Nickisch F, Limbird RS: Massive retroperitoneal hematoma during enoxaperan treatment of pulmonary embolism after primary total hip arthroplasty: Case-reports and review of the literature. J Arthoroplasty 2006;21:1209-1214 PMID:17162185 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments. (OBQ08-262) What is the mechanism of action of coumadin? REVIEW TOPIC 1. binds to platelets 2. inhibits vitamin K-dependent clotting factors 3. COX-2 inhibition 4. unselective COX inhibition 5. binds to anti-thrombin III PREFERRED RESPONSE ▼ 2 DISCUSSION: Heparin is a heterogeneous mixture of branched glycosaminoglycans with anticoagulant properties. Heparin binds with a co-factor AT (anti-thrombin III) and decreases thrombin and Factor Xa. The main action of heparin is through thrombin inhibition whereas LMWH acts more on Factor Xa. Heparin has a short half-life and is difficult to dose compared to LMWH which has better bioavailability, 2-4 times longer half-life, and a more predictable dose-response relationship. Anticoagulants which work via direct platelet binding include aspirin and Plavix, not heparin (answer 1). Coumadin works by inhibiting vitamin K dependant clotting factors II, VII, IX, X, and protein C and S (answer 2). Thromboxane A2 inhibition is the mechanism of aspirin. Aspirin irreversibly inhibitis platelet Cox-1 preventing formation of prostaglanding H2 and therefore thromboxane A2(answers 3 and 5). REFERENCES: 1. OITE08 #262 2. Miller MD, Review of Orthopaedics, 4th Edition, W B Saunders Co, March 2004 : PENDING FINAL APPROVAL RATE CONTENT 1 RATINGS TAG Please login to view and post comments. (OBQ07-212) Protamine functions to reverse the pharmacologic effects of which of the following anti-coagulants? REVIEW TOPIC 1. Aspirin 2. Clopidogrel (e.g. plavix) 3. Low molecular weight heparin 4. Warfarin 5. Hirudin PREFERRED RESPONSE ▼ 3 DISCUSSION: Protamine functions to partially reverse the pharmacologic effects of low molecular weight heparin (LMWH). Protamine may help to stop bleeding related to LWMH, although anti-factor Xa activity is not fully normalized by protamine. Vitamin K reverses the pharmacologic effect of warfarin. As aspirin and clopidogrel function directly at the level of the platelet, there is no medical method to "reverse" these effects. Hirudin is a naturally occuring enzyme with anti-coagulant property in the salivary glands of leeches. REFERENCES: 1. OITE07 #212 2. Buckwalter J, OKeefe R, Einhorn T (EDS). Orthopaedic Basic Science, 3rd ed. American Academy of Orthopaedic Surgeons. Rosemont, IL. 2007 : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments. (OBQ04-218) Which of the following medications exerts its influence on the clotting cascade by replacing normal clotting factors with decarboxylated factors? REVIEW TOPIC 1. Warfarin 2. Enoxaparin 3. Dalteparin 4. Heparin 5. Hirudin PREFERRED RESPONSE ▼ 1 DISCUSSION: The answer is 1. Warfarin (Coumadin) exerts its anticoagulation effect through replacement of normal clotting factors with decarboxylated factors. Warfarin is a vitamin K antagonist that prevents the reductive metabolism of vitamin K epoxide back to its active form, hydroquinone, by inhibiting the enzymes responsible for the reaction. The vitamin K-dependent factors are II, VII, IX, X, proteins C, and S. The reference by Hyers is a review article discussing the antithrombotic agents that have been used in the last 50 years and also discusses some of the newer ones that have since been developed. Berry in his review discusses the risk factors, efficacy, and safety of agents used in 2003 after total hip arthroplasty. REFERENCES: 1. OITE04 #218 2. Buckwalter, Einhorn, Simon (ed): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2, AAOS 2000, pp 217-237 3. Hyers TM: Management of venous thromboembolism: Past, present, and future. Arch Intern Med 2003;163:759-768. PMID:12695266 (Link to Abstract) 4. Berry DJ: Venous thromboembolism after a total hip arthroplasty: Prevention and treatment. Instr Course Lect 2003;52:275-280. PMID:12690855 (Link to Abstract) : PENDING FINAL APPROVAL RATE CONTENT 0 RATINGS TAG Please login to view and post comments. References Show References Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies) Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA. 2001 Jul 11;286(2):208-16. PMID:11448284 (Link to Abstract) Textbooks Review of Orthopaedics, 5th Edition, Mark D. Miller (editor), Saunders, an imprint of Elsevier, Philadelphia, Copyright 2008 First Aid for the Orthopaedic Boards, Robert Laminzak, Mark Albritton, Trevor Pickering (Editors), McGraw Hill Medical, Copyright 2009 Orthopaedic Knowledge Update 9, Jeffrey S Fischgrund (Editor). Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2008 Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009 OITE Questions, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2010 Frank H. Netter, John A. Craig. Netter's Concise Atlas of Orthopaedic Anatomy, Icon Learning Systems, Teterboro, NJ, Copyright 2002 Buckwalter J, OKeefe R, Einhorn T (EDS). Orthopaedic Basic Science, 3rd ed. American Academy of Orthopaedic Surgeons. Rosemont, IL. 2007 Undefined Moore TJ. Perioperative medical management. In: Fischgrund JS, ed. Orthopaedic Knowledge Update 9. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:105-113. Dorr LD, Gendelman V, Maheshwari AV, et al: Multimodal thromboprophylaxis for total hip and knee arthroplasty based on risk assessment. J Bone Joint Surg Am 2007;89:2648- 2657 PMID:18056497 (Link to Abstract) Lee MC, Nickisch F, Limbird RS: Massive retroperitoneal hematoma during enoxaperan treatment of pulmonary embolism after primary total hip arthroplasty: Case-reports and review of the literature. J Arthoroplasty 2006;21:1209-1214 PMID:17162185 (Link to Abstract) Miller MD, Review of Orthopaedics, 4th Edition, W B Saunders Co, March 2004 Buckwalter, Einhorn, Simon (ed): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2, AAOS 2000, pp 217-237 Hyers TM: Management of venous thromboembolism: Past, present, and future. Arch Intern Med 2003;163:759-768. PMID:12695266 (Link to Abstract) Berry DJ: Venous thromboembolism after a total hip arthroplasty: Prevention and treatment. Instr Course Lect 2003;52:275-280. PMID:12690855 (Link to Abstract) Visitor Comments for Anticoagulation Please login to view and post comments.

Basic Principles

What is Spinal Deformity?
Definitions
  • Scoliosis,
  • Kyphosis,
  • Lordosis,
  • Spondylolisthesis
Comprehensive History
Symptoms, deformity onset, constitutional symptoms, treatment history, bowel/bladder issues, overall function
Medical History
Family History: spinal deformity, syndromes, familial disorders
Physical Examination
Inspection: Gait, skin, spinal movement, shoulder asymmetry, pelvic obliquity
  • Heel/Toe Walking, Static and Dynamic Romberg
Motor
Sensory
Reflexes: DTR’s, Babinski, Clonus, Abdominal
Special Tests: Adam’s Forward bend, Angle of Trunk Rotation, C7 plumb line
Imaging Studies
X-rays
  1. Full-length standing radiographs (C/T/L/S Spines + Pelvis/Hips)
    - Knees straight: assess sagittal balance
    - Coned-down views of selected regions
  2. Cobb Angle calculation
    - Main Thoracic, Proximal Thoracic, Thoracolumbar/Lumbar
    - Thoracic Kyphosis, Lumbar Lordosis
  3. Supine Left and Right Bending radiographs
  4. Push-Prone radiograph, Supine AP radiograph, Traction radiograph
  5. Fulcrum Bending
CT: risk of radiation exposure
  1. Congenital bony anomalies
  2. Pedicle Assessment: ??? Value
  3. Myelography: may be more helpful than MRI with severe deformity
MRI
  1. Assessment of patients with radiculopathy, myelopathy, claudication
  2. High grade spondy, spondy with radiculopathy
  3. Early onset, juvenile, selected AIS
Nuclear

Pediatrics

History: Symptoms/pain, onset of menses, family history of deformity, activity restrictions, development milestones, intrauterine course, ? rapid progression
Age Determination: Chronologic vs. Metabolic
  1. Tanner Stages: ? physician comfort (young girls): ask about early breast development and rapid foot growth
  2. Risser: convenient, but approach with skepticism
    - Often appears after peak height velocity
  3. Tri-radiate cartilage: closure signals end of peak growth spurt
Growth History
  1. Peak Height Velocity: occurs 6-12 months prior to onset of menses (F) or appearance of axillary/facial hair (M)
    - Normal Girls: 10 – 14 years; Normal Boys: 12 – 16 years 2.
  2. Onset of menses: after PHV and does not correlate w/ Risser sign
Physical Examination
Inspection: Scapulae, rib/paraspinal prominence, shoulder, pelvis/waistline
  1. Anterior: Breast asymmetry may be first sign of deformity
  2. Posterior Skin Changes: Café au lait spots, sinuses, hairy patches, palpable defects, step-off, dimpling
  3. Spondylolisthesis: hyperlordosis, step-off, heart- shaped buttocks
Forward Bend Test: Scoliometer: 70 better than 50. More sensitive and specific: If > 70, need x-rays and/or referral to spine specialist
Leg length discrepancy, hip pathology, ligamentous laxity
  • Hamstring tightness in setting of spondy
Neurologic Exam
  1. Complete neurologic assessment
  2. Assess for radiculopathy in spondy
    - High-grade spondy: rectal exam
Imaging Studies
MRI:
  1. Any neurologic abnormality on history or physical exam (NF)
  2. All congenital and Infantile/Juvenile Scoliosis > 200: (Occiput – Sacrum)
    - Controversial
    - Relationship to physical exam and progression
  3. Boys, left thoracic curves ????
Special Considerations in Congenital Scoliosis
Cardiac Abnormalities (10 – 37%): Echo
Urologic Abnormalities (21 – 34%): Renal Ultrasound
Neural Axis Abnormalities: (20 – 40%): Syrinx, Tethered Cord, Chiari
Thoracic Insufficiency: ??? Pulmonary Function Tests
Syndromes (38 – 55%): VATER, VACTERL, Goldenhar’s
Associated Orthopaedic conditions: DDH, C1-C2 instability, Klippel Feil

Adults

History: Axial pain, radicular pain, claudication
Assess for cancer, infection, trauma as cause of deformity
More likely to present with pain and/or progressive trunk imbalance
  1. Change in height or posture, waistline, fit of clothing: ? progression
  2. Most adults with spondylolisthesis are asymptomatic, but may present with back or leg pain or both
Prior surgical history: pseudoarthrosis, flatback, adjacent segment, post-laminectomy syndrome
Previous treatments
Quality of life assessment/ Cosmesis
Comprehensive medical history
  1. Shortness of breath/respiratory issues
  2. Cardiac history b
Physical Examination:
Don’t forget the Hips !
  • Asssessment of hip/knee contractures and leg length discrepancy
Thorough neurologic assessment for radiculopathy/ myelopathy
  • Patients usually have normal neurologic exams
Rib-Ilium contact: pain, GI issues
Imaging Studies
MRI: Assess for stenosis &/or disc degeneration
Spondylolisthesis: Must visualize the pelvis on x-rays: Pelvic Incidence, Pelvic Tilt, Sacral Slope
  1. Upright AP/ Lateral x-rays
  2. Flexion/Extension Views
Special Considerations
Cardiac Evaluation
Nutritional Assessment
Bone Density: osteopenia, osteoporosis

REFERENCES:

  1. Akbarnia BA. Management themes in early onset scoliosis. J Bone Joint Surg Am. 2007 Feb;89 Suppl 1:42-54.
  2. Ferguson RL. Medical and congenital comorbidities associated with spinal deformities in the immature spine. J Bone Joint Surg Am. 2007 Feb;89 Suppl 1:34-41.
  3. Hu SS, Tribus CB, Diab M, Ghanayem AJ. Spondylolisthesis and spondylolysis. J Bone Joint Surg Am. 2008 Mar;90(3):656-71
  4. Lenke LG, Dobbs MB. Management of juvenile idiopathic scoliosis. J Bone Joint Surg Am. 2007 Feb;89 Suppl 1:55-63
  5. Lonner, BS. Spinal Deformity in the Clinical Setting. In T.J. Errico, B.S. Lonner, A. Moulton, Surgical Management of Spinal Deformities, pp. 61-70, Saunders, 2008.
  6. O’Brien, MF and Shufflebarger, H. Evaluation of the Patient with Scoliosis. In P.O. Newton, Adolescent Idiopathic Scoliosis, pp. 11-21, AAOS, 2004.
  7. O’Brien, MF, Kuklo, TR, et al, editors. Spine Deformity Study Group Radiographic Measurement Manual. Medtronic Sofamor Danek USA, Inc. 2005.
  8. Sanders JO. Maturity indicators in spinal deformity. J Bone Joint Surg Am. 2007 Feb;89 Suppl 1:14-20.


Site Map  | Images  | TOP 100  | Index