gravity stress view can identify medial clear space widening. covers larger portion of articular surface associated fibula fracture. He has a temperature of 103.4F and his laboratory values are remarkable for elevated ESR, CRP, and WBC. (OBQ08.65) A 25-year-old man sustains an open forearm fracture from an auger as depicted in Figures A and B. Her symptoms returned with ballet activity following a 1 month course of full rest, nonsteroidal anti-inflammatory medication, and physical therapy. Pathologic local bone disease. (OBQ11.146) Diagnosis can often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture. incidence. Calcaneal osteomyelitis caused by a puncture wound has an increased rate of which of the following compared to hematogenous osteomyelitis? (OBQ06.273) A 30-year-old patient has had severe left hip pain and difficulty ambulating, necessitating the use of a cane, for the past 6 months. Reestablishment of the central meniscal blood supply. younger patient with crescent sign or more advanced femoral head collapse, +/- acetabular DJD A 47-year-old man presents with 1 week of left leg pain. What is the most appropriate treatment? Lab results include a C-reactive protein level of 12mg/L (normal 0-3.2 mg/L), erythrocyte sedimentation rate of 38mm/h (normal 0-20mm/h) and a white blood cell count of 12.3 K/mm3(normal 4.3 -11.4 K/mm3). Operative management is indicated for advanced disease with presence of subchondral collapse, femoral head flattening and/or degenerative joint disease. total hip replacement . A pediatric patient has just been diagnosed with osteomyelitis of the femur. Selective estrogen receptor modulator therapy. Figures 9a and 9b show the radiographs of a 75-year-old man who underwent a revision total knee arthroplasty with a long-stemmed tibial component. valgus load . She undergoes CT-guided biopsy and culture. A 65-year-old man presents with aseptic loosening 3 years after total knee arthroplasty. An 8-year-old boy twists his right leg while playing soccer 6 days ago. using chemicals to remove cellular water and controlled rate freezing to prevent ice crystal formation. A 6-year-old boy with acute hematogenous osteomyelitis of the distal femur is being treated with intravenous antibiotics. A knee aspiration is performed. Proximal femoral resection and reconstruction. Hemiarthroplasty. An aspiration is performed and demonstrates a synovial WBC count of 26k. incision made in line with the tip of the fibula and the base of the 4th metatarsal. You can rate this topic again in 12 months. reconstruction with a structural allograft. Treatment is nonoperative with antibiotics in the absence of an abscess. Delayed union or nonunion. varus load. (SBQ18BS.12) collapse. Which implant offers the most appropriate level of constraint while limiting the amount of implant-host interface stresses? What is next step in management? Physical exam is notable for focal tenderness over the distal femur without a palpable fluid collection. They have high resistance to shear forces, They have high resistance to torsional forces, They are contraindicated in spinal fusion, They provide a scaffold for bone progenitor cells, They are not biocompatible with stainless steel orthopedic implants. Nonoperative. metatarsal stress fracture. The splint is removed revealing intact skin integrity with notable swelling and erythema overlying the distal fibula. Copyright 2022 Lineage Medical, Inc. All rights reserved. Inheritance Patterns of Orthopaedic Syndromes, General and Regional Anesthesia in Orthopaedics, Legal Considerations in Orthopaedic Practice. (OBQ07.184) 5th Metatarsal Base Fracture Metatarsal FX screw placement for stress fx of proximal 5th MT. Hemiarthroplasty. mark out lateral malleolus and anterior and posterior borders of fibula; mark estimated location of fracture site (check with C-arm if unsure) straight longitudinal incision 4-6cm in length centered on fracture . A 45-year-old with a history of sickle cell anemia reports hip pain for the past 6 months. An MRI is obtained and shown in Figure C. The patient undergoes CT-guided biopsy and the histology slides are shown in figures D and E. What is the most likely diagnosis? cast immobilization for 8 weeks. The ligament connecting the first metatarsal base to the medial cuneiform. A 10-year-old boy complains of two days of worsening right knee pain. (OBQ05.2) You are planning surgery on a 54-year-old female with the tibial plateau fracture seen in figures A and B. Treatment is nonoperative versus operative based on fracture displacement and alignment, associated soft tissue injury, and patient risk factors. A material with either osteoconductive, osteoinductive, and/or osteogenic properties, almost 1 million bone grafting procedures performed in US each year, with a growth of almost 13% per year, healing of fractures, delayed unions, or nonunions, replace bone defects from trauma or tumor, relative resorption rates of bone graft substitutes, calcium sulfate > tricalcium phosphate > hydroxyapatite, retrieval studies are helpful in understanding the body's response to allografts, allograft articular cartilage is completely acellular, Bone graft has aspects of one or more of these three properties, material acts as a structural framework for bone growth, the various three-dimensional makeups of the material dictate the conductive properties, material contains factors that stimulate bone growth and induction of stem cells down a bone-forming lineage, material directly provides cells that will produce bone including primitive, mesenchymal stem cells, osteoblasts, and osteocytes, mesenchymal stem cells can potentially differentiate down any cell line, osteoprogenitor cells differentiate to osteoblasts and then osteocytes, cancellous bone has a greater ability than cortical bone to form new bone due to its larger surface area, autologous bone graft (fresh autograft and bone marrow aspirate) is the only bone graft material that contains live mensenchymal precursor cells, Allograft is a composite material and therefore has many potential antigens (cell surface glycoproteins), Class I and Class II antigens on graft are recognized by host T lymphocytes and elicit an immune response, immunogenic cells are marrow-based, endothelium, and retinacular-activating cells, bone marrow cells elicit the greatest immune response, extracellular matrix also acts as an antigen, type I collagen stimulates both humoral and cell-mediated responses, noncollagenous matrix (proteoglycans, osteocalcin), hydroxyapatite has not been shown to elicit an immune response, primary rejection is cell-mediated related to the major histocompatibility complex (MHC) incompatibility, Rapid incorporation via creeping substitution, Slower incorporation due to need to remodel existing Haversion canals, 25% of massive grafts sustain insufficiency fractures, Technically challenging with quicker union and cell preservation, Examples include: free fibula strut graft (peroneal artery), free iliac crest (deep circumflex iliac arteries), distal radius used for scaphoid fx (1-2 intercompartmental superretinacular artery branch of radial artery), BMP preserved and therefore osteoinductive, Alumina ceramic bonds bind to bone in response to stress and strain, Many prepared as ceramics (heated to fuse into crystals), Examples include: tricalcium phosphate, Norian (Synthes), hydroxyapatitie (tradename Collagraft by Zimmer), MONTAGE, Examples include: OsteoSet (Wright medical), Calcium carbonate skeleton is converted to calcium phosphate via a thermoexchange process (Interpore), Examples include: Biocora (Inoteb, france), Contains: collagen, bone morphogenetic proteins, transforming growth factor-beta, residual calcium, Does NOT contain mesenchymal precursor cells, Bone graft transferred from one body site to another in the same patient, osteogenic, osteoinductive, and osteoconductive, cortical, cancellous, or corticocancellous, source of osteogenic mesenchymal precursor cells, iliac crest and vertebral body most common sites, variable number of cells depending on patient age, provides both cancellous and cortical graft, higher complication rate with anterior versus posterior harvesting, stem cell concentration with posterior harvesting, injury to lateral femoral cutaneous or cluneal nerves, the degree of osteoconduction available depends on the processing method (fresh, frozen, or freeze-dried) and type of graft (cortical or cancellous), cortical, cancellous, corticocancellous, and osteoarticular (tumor surgery), preserved with glycerol or dimethyl sulfoxide (DMSO), cryogenically preserved (few viable chondrocytes remain), tissue-matched (syngeneic) grafts decrease immunogenicity, debridement of soft tissue, wash with ethanol (remove live cells), gamma irradiation (sterilization), dose-dependent higher doses of irradiation kills bacteria and viruses but may impair biomechanical properties, cleansing and processing removes cells and decreases the immune response improving incorporation, rarely used due to disease transmission and immune response of recipient, reduces immunogenicity while maintaining osteoconductive properties, two years for fresh frozen stored at -20 degrees C, five years for fresh frozen stored at -70 degrees C, removes the minerals and leaves the collagenous and noncollagenous structure and proteins, interproduct and interlot variability is common, Various compositions available (see summary above), Level I evidence shows that calcium-phosphate bone substitutes allow for bone defect filling, early rehabilitation, and prevention of articular subsidence in distal radius and tibial plateau fractures, stimulates undifferentiated perivascular mesenchymal cells to differentiate into osteoblasts through, Platelet rich plasma (PRP) (like other BMPs) solely osteoinductive, Provides large volume of bone graft from intramedullary source, femoral shaft fracture due to eccentric reaming, Differentiates from mesenchymal precursor cells, Stimulation of osteoblast and osteoclast function, risk of hepatitis B disease transmission in musculoskeletal fresh-frozen allograft transplantation is 1 in 63,000, risk of hepatitis C disease transmission in musculoskeletal fresh-frozen allograft transplantation is 1 in 100,000, risk of transmission of HIV in fresh-frozen allograft bone is 1 in 1,000,000 to 1,670,000, allografts are tested for HIV, HBV, HCV, HTLV-1, and syphilis, calcium sulfate bone graft substitute associated with increased serous wound drainage. However he is still having persistent anterior shoulder/arm pain that worsens with most activities. His right knee is warm to the touch and an effusion is noted. During the tibial cut, a ligament is transected by a reciprocating saw. Biodegrade very slowly fibula and ribs are most common sources of vascularized autografts. During the work-up in the ER, the patient became hypotensive. 5th Metatarsal Base Fracture Metatarsal FX screw placement for stress fx of proximal 5th MT. Her blood count was normal, but her erythrocyte sedimentation rate was 48 mm. (OBQ05.149) (OBQ09.161) What is the next best step in management to confirm the diagnosis? (SBQ04PE.28) make incision along posterior fibula if access to the posterior malleolus is needed; Soft Tissue Dissection . Allograft reconstruction with a tendon graft from An aspirate of the knee was performed successfully with a scant amount of clear synovial fluid with a cell count of 1,000. The ligament connecting the anterolateral tibial to the anteromedial fibula. Which of the following substances is most osteoinductive? A 20-year-old male is involved in motor vehicle collision and sustains a depressed tibial plateau fracture. What is the next most appropriate initial step in management? The most expeditious method to determine the early success or failure of treatment is by serial evaluations of which of the following studies? may show fracture of proximal fibula. 1% (18/1949) 4. In counseling your patient regarding the risks of allografts, you explain that 5 years after transplantation, what percentage of donor chondrocytes will be present and viable in the allograft? After debridement of nonviable bone, a 10cm bone defect is left. (SBQ13PE.95.1) A 3-year-old patient fell out of a tree and sustained a closed right tibial shaft fracture. Copyright 2022 Lineage Medical, Inc. All rights reserved. The knee and lower leg are warm and tender to palpation. Orthobullets Team Spine - Adult Isthmic Spondylolisthesis Traumatic fracture with intact pars interarticularis. (OBQ08.65) A 25-year-old man sustains an open forearm fracture from an auger as depicted in Figures A and B. Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. (OBQ04.148) A 34-year-old male presents with right knee pain, swelling, and symptoms of buckling 3 months after being involved in a motorcyle accident. Which of the following factors is most critical to the success of a meniscal allograft transplantation? hip arthroplasty . (OBQ12.95) An aspiration of the knee yielding 7 mL of straw colored fluid reveals 1700 nucleated cells per mL, and no organisms on gram stain. Superficial peroneal nerve palsy. Long leg cast and continued non-weightbearing to the extremity, Chest CT scan and referral to an orthopaedic oncologist, Neoadjuvant chemotherapy followed by surgical resection, Percutaneous biopsy with culture and antibiotics, Percutaneous pinning of the physeal fracture and long leg cast placement. (OBQ08.50) varus load. Epidemiology. Physical exam shows focal tenderness over his tibia. An articulating antibiotic spacer is placed. (OBQ12.266) This system divides tibial plateau fractures into six types: Schatzker I: wedge-shaped pure cleavage fracture of the lateral tibial plateau, originally defined as having less than 4 mm of depression or displacement Schatzker II: splitting and depression of the lateral tibial plateau; namely, type I fracture with a depressed component (generally considered commonest 5) Figure 25 shows the radiograph of an 84-year-old woman who has pain and is unable to extend her knee. Anterolateral soft-tissue impingement. Hemiarthroplasty. Alumina ceramic bonds bind to bone in response to stress and strain. 3% (26/766) 4. (OBQ13.50) Complete release of the superficial and deep MCL, Extending the arthrotomy to an extensile rectus snip exposure, Converting to a mobile-bearing TKA design. TKA Revision is most commonly performed to address aseptic loosening, fracture, instability, or infection associated with a prior TKA. external rotation stress test. In patients with sickle cell disease and asymptomatic osteonecrosis of the femoral head identified with magnetic resonance imaging, what percentage will eventually go on to femoral head collapse? Treatment depends on etiology of failure, prior surgery and patient activity demands. TKA Revision is most commonly performed to address. A decrease in erythrocyte sedimentation rate (ESR). Diagnosis and etiology of TKA failure can be determined by a combination of physical examination, labs, and radiographs. (OBQ06.261) During surgery, the exposure technique shown in Figure A is used. indications. A current bone scan and MRI is shown in Figure A and B. Meniscus. What is the most likely cause of this patient's symptoms? hip arthroplasty . abnormal lateral tibiofibular ratio is reliable way of diagnosing C-reactive protein (CRP) is 72 mg/L (rr 0-9 mg/L). During fixation, the surgeon elects to use an osteoconductive bone graft substitute. younger patient with crescent sign or more advanced femoral head collapse, +/- acetabular DJD A 47-year-old man presents with 1 week of left leg pain. Diagnosis and etiology of TKA failure can be determined by a combination of physical examination, labs, and radiographs. covers larger portion of articular surface associated fibula fracture. valgus load . Discharge home on non-steroidal anti-inflammatory drug (NSAID) and short leg non-weightbearing cast, Discharge home on oral antibiotics with serial ESR and CRP in an outpatient setting, Admit to hospital for percutaneous aspiration for culture and intravenous antibiotics with serial ESR and CRP, Admit to hospital for percutaneous biopsy and referral to orthopaedic oncologist, Admit to hospital for percutaneous screw fixation of distal tibia fracture. The ligament connecting the first metatarsal base to the medial cuneiform. Which of the following statements regarding acute hematogenous osteomyelitis in pediatric patients is true? He is exquisitely tender over the 1st metatarsal. Collagen-based matrix with hydroxyapatitie coating. When compared to the standard medial parapatellar approach for revision total knee arthroplasties, the oblique rectus snip approach showed impairment in which of the following post-operative outcomes? Osteochondral talar dome fracture. 5% lateral meniscus. This is an AAOS Self Assessment Exam (SAE) question. Infection is now the most frequent cause for late revision, Polyethylene wear is no longer the major cause for revision, Aseptic loosening is now the most frequent cause for early revision, The percentage of revisions for instability and malalignment has increased, Stiffness is an uncommon reason for revision procedures. A 13-year-old girl with fevers, chills, and rigor for the last 2 weeks presents with the MRI findings shown in Figure A. (OBQ18.141) A 48-year-old male returns to your office 8 months after sustaining a proximal humerus fracture that was successfully treated nonoperatively. His mother notes that he has had a fever of 39.0. total hip replacement . Current ankle radiographs are normal and T1 and T2 MRI images are shown in Figures A and B, respectively. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2021, Pro: Amnion & Coral: The True Answer, Just Know How, Why & My Expectations - Ken Zaslav, MD, Competitive Advantage: Why You Need Biologics For Your Athletes - C. Thomas Vangsness, Jr., MD, 2019 Baseball Sports Medicine: Game-Changing Concepts, How I Use Biologics - Jeffrey R. Dugas, MD. (OBQ16.270) An active 73-year-old male presents with progressive pain and instability 15 years after undergoing a left total knee arthroplasty. external rotation stress test. Treatment. This is an AAOS Self Assessment Exam (SAE) question. extends from the anteroinferior border of the fibula to the neck of the talus. The surgeon is balancing the tibial and femoral cuts with sizing blocks and finds that the knee has valgus instability greater than 1cm in full extension. The ligament connecting the first metatarsal base to the medial cuneiform. 29% (222/766) 3. His representative radiograph is shown in Figure A. Unlinked constrained (varus-valgus constrained), Fixed bearing PCL-substituting (posterior-stabilized), Mobile bearing PCL-substituting (posterior-stabilized). Achilles tendon repair - especially percutaneous technique. A lateral radiograph from the day of presentation is shown in Figure A. WBC, ESR, and CRP are all within normal limits. Radiographs of the knee are normal. mark out lateral malleolus and anterior and posterior borders of fibula; mark estimated location of fracture site (check with C-arm if unsure) straight longitudinal incision 4-6cm in length centered on fracture . She reports a decreased appetite. core decompression or vascularize free-fibula graft. 8% (218/2875) 5. normal deltoid ligament. Calcium phosphate Osteoconduction and osteointegration. MR imaging demonstrates osteomyelitis of the proximal tibia without an abscess. A clinical photograph is shown in Figure A. subacute osteomyelitis) and need to rule out malignancy, early disease with no subperiosteal abscess or abscess within the bone, surgery is not indicated if clinical improvement obtained within 48 hours, generally, nafcillin or oxacillin, unless high local prevalence of MRSA (then use clindamycin or vancomycin), mechanism of action for vancomycin involves binding to the D-Ala D-Ala moiety in bacterial cell walls, if gram stain shows gram-negative bacilli - add a third generation cephalosporin, convert to organism-specific antibiotics if organism identified, treatment for initial 1 year is multiagent antibiotics and rarely surgical debridement due to risk of chronic sinus formation, often a case by case decision with input from infectious disease consultation, surgical drainage, debridement, and antibiotic therapy, hemodynamic instability, as patients should be stabilized first - however sometimes operative treatment of the underlying infection helps stabilize the patient, example of institution algorithm treatment pathway, evacuate all purulence, debride devitalized tissue, and drill as needed into intraosseous collections, send tissue for culture and pathology to rule out neoplasm, close wound over drains or pack and return to OR in two to three days, is an infrequent complication in children, bones with intra-articular metaphysis are at risk (shoulder, elbow, hip, ankle), Growth disturbances and limb-length discrepancies from growth plate involvement, observation and possible corrective surgery depending on severity or projected severity, Mortality decreased from 50% to <1% with development of antibiotics. Alumina ceramic bonds bind to bone in response to stress and strain. (OBQ04.148) A 34-year-old male presents with right knee pain, swelling, and symptoms of buckling 3 months after being involved in a motorcyle accident. He reports falling off his bicycle 5 days prior. (OBQ11.253) A 17-year-old ballet dancer presents with 5 months of pain in the posterior aspect of the right lower extremity that is exacerbated with the ballet position shown in Figure A. An 8-year-old girl presents to the emergency room with a 4-day history of limp and temperature 100.7 F. Lab results show a white blood cell count of 13,000 cells/L (reference range, 4500-11000 cells/L), hematocrit 33% (reference range, 41%-50%), and C-reactive protein of 14 mg/L (reference range, 0.08-3.1 mg/L). (OBQ11.267) Radiographs obtained at the time of injury are shown in Figure A. (OBQ08.239) (OBQ13.44) Which of the following is the most appropriate next step in management? The surgeon reviews radiographs of his knee and takes him to the operating room for revision total knee arthroplasty. abnormal lateral tibiofibular ratio is reliable way of diagnosing Periprosthetic fracture distal to the implant, Iatrogenic fracture causing pelvic discontinuity, Cardiac arrest from fat embolization to lungs. This can occur in all the following joints EXCEPT? MRI of the right foot can be seen in Figure A. (SAE07HK.53) (OBQ05.147) Which of the following bone graft substitutes has the fastest resorption characteristics? A tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures. (SAE07HK.51) Meniscus. Which of the following graft materials has the least potential to elicit an immune response? Hip motion is painless, but knee motion is painful. tarsal fracture. A 65-year-old patient was treated with an open reduction/internal fixation for a left femoral neck fracture sustained 25 years ago. Exposure to place the distal femoral cutting guide is difficult due to poor knee flexion following a standard medial parapatellar arthrotomy. A 40-year-old man complains of increasing groin pain. His ESR is 68 mm/hr (normal <15) and CRP is 14 mg/dL (normal <1). useful to diagnosis syndesmosis injury in high ankle sprain. Osteochondral talar dome fracture. (OBQ14.138) Vector of applied load, amount of energy, and quality of bone determine type of fracture. Figures A and B are the AP and lateral radiographs of a 10-year-old female who presents to the office with 1-2 months of worsening left ankle pain. Copyright 2022 Lineage Medical, Inc. All rights reserved. medial plateau. What is the most common organism in this scenario? A 9-year-old boy is being treated for acute hematogenous osteomyelitis of the distal tibia with appropriate IV antibiotic therapy. more common with displaced FNSFs (9-44%) Radiographs show no evidence of a stress fracture, an alpha angle of 45 degrees, and a lateral center edge angle of 30 degrees. A 64-year-old female with rheumatoid arthritis is undergoing a left total knee arthroplasty. A 9-year old girl with new-onset pain and fever, A 7-year-old lethargic boy with a CRP of 20 mg/L that does not decline after a week of nafcillin and vancomycin, A 7-year-old girl with three days of pain, fever, and a WBC of 21,000/mm3 who presents to the ER, An 8-year-old boy whose pain and fever have decreased after 24 hours of ampicillin, An 8-year old lethargic girl with a WBC of 21,000/mm3 and a CRP of 9 after 24 hours of gentamicin. A 13-year-old girl reported left ankle pain after falling while playing soccer 3 weeks ago. ORIF of distal fibula fx (especially Weber C) At risk with ankle inversion injuries. 1% (26/2875) L 3 B Trans-sacral fibula (Bohlman's procedure) for High Grade Spondylolisthesis Classification. Her temperature is 38.9 degrees celsius and her white blood cell count is normal. Hip Osteonecrosis, also known as avascular necrosis of the hip,represents a condition caused by reduced blood flow to the femoral head secondary to a variety of risk factors such as a traumatic event, sickle cell disease, steroid use, alcoholism, autoimmune disorders, and hypercoagulable states. He denies any recent trauma. total hip replacement . cast immobilization for 8 weeks. The ligament is not able to be repaired. 19% medial plateau. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, ICJR 9th Annual Revision Hip & Knee Course, Revision of UKA to TKA: Video-based Tips and Tricks - Rafael J. Sierra, MD, Outpatient Revision TJAs: When Is It Safe, If Ever! Delayed union or nonunion. axial load. The patients physical exam is limited secondary to pain. primary restraint to varus stress at 30 deg. Orthobullets Team Spine - Adult Isthmic Spondylolisthesis Traumatic fracture with intact pars interarticularis. In rehabilitation, he reports fullness and tenderness in the proximal medial leg (at the knee). He has not done any physical therapy nor received a corticosteroid injection. History reveals that she underwent total knee arthroplasty 8 years ago. Knee pain affects approximately 25% of adults, and its prevalence has increased almost 65% over the past 20 years, accounting for nearly 4 million primary care visits annually. A 5-year-old boy presents with temperature of 104 degrees Fahrenheit and painful weight bearing on the left lower extremity for one day. After debridement of nonviable bone, a 10cm bone defect is left. ORIF of distal fibula fx (especially Weber C) At risk with ankle inversion injuries. MRI. A 7-year-old boy presents with right elbow and left wrist swelling for the past 3 months. He ambulates with a cane at all times and reports new-onset pain in his knee. normal deltoid ligament. Pathologic local bone disease. bone cement to smooth the outline of the proximal medial tibia. external rotation stress test. Nonoperative. Musculoskeletal Infection Society (MSIS) Type C host. Knee pain affects approximately 25% of adults, and its prevalence has increased almost 65% over the past 20 years, accounting for nearly 4 million primary care visits annually. (OBQ10.166) Saphenous Nerve. may show fracture of proximal fibula. A biopsy is obtained and is shown in figures B and C. All of the following statements are true for this condition EXCEPT: Patients often present afebrile, with mild pain, and a normal WBC count, Radiographs characteristically show a solitary, localized radiolucency with sclerotic margins, Treatment consist of wide surgical resection and chemotherapy, Treatment consists of surgical debridement and postoperative antibiotics. (OBQ04.274) Diagnosis can often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture. pain over syndesmosis is elicited with external rotation/dorsiflexion of the foot with knee and hip flexed to 90 degrees. 1% (26/2875) L 3 B Trans-sacral fibula (Bohlman's procedure) for High Grade Spondylolisthesis Leukocyte count is normal but the ESR is elevated. ER rotation stress view. Current temperature is 100.9 degrees Fahrenheit, and CRP is 11 mg/dL (nml <1). Which of the following is often associated with this diagnosis and requires close surveillance in the acute setting? Classification. However he is still having persistent anterior shoulder/arm pain that worsens with most activities. The pain initially improved, but for the past 10 days she has had increased pain. The patient subsequently undergoes formal open surgical debridement, without complications. Biodegrade very slowly fibula and ribs are most common sources of vascularized autografts. Management with a knee immobilizer for 3 months, Revision of tibial component with LCL reconstruction, Revision of tibial and femoral components with stems and/or augments, Revision of tibial and femoral components without stems and/or augments, (SAE07HK.45) (OBQ16.173) A 67-year-old female falls off of a step ladder while changing a lightbulb in her kitchen and sustains the injury shown in Figures A and B. Saphenous Nerve. Biodegrade very slowly fibula and ribs are most common sources of vascularized autografts. A 67-year-old female has elected to undergo total knee arthroplasty for degenerative arthritis. fracture length. A clinical photograph is shown in Figure A. Current images are shown in Figure A and Figure B. 3% (26/766) 4. a base plate with an offset tibial stem attachment. Knee pain affects approximately 25% of adults, and its prevalence has increased almost 65% over the past 20 years, accounting for nearly 4 million primary care visits annually. incision made in line with the tip of the fibula and the base of the 4th metatarsal. The injury is closed, and the patient is neurovascularly intact. stairs, level ground, rising from chair), gait (stiff legged gait, inability to fully extend during stance phase), skin changes, presence of effusion, warmth (infection vs. complex regional pain syndrome (CRPS)), Serial AP and lateral radiographs to provide timeline of TKA, Weight bearing radiographs can provide evaluation of any asymmetric wear, Standing leg length views to assess overall alignment, Femoral version study can aide in assessing component rotation when also compared to the femoral neck, Can also aide in assessing severity and location of bony defects, Can be positive for up to 2 years after primary TKA, can indicate loosening, infection, or stress fracture, Knee aspiration to rule out infection via cell count and culture, Unconstrained Posterior Cruciate Retaining, always have a PCL substituting implant available as it is difficult to evaluate the integrity of the PCL prior to surgery, Unconstrained Posterior Cruciate Substituting, large central post substitutes for MCL/LCL function, MCL attenuation or deficiency (controversial because load may lead to breaking of central post), Constrained Hinged with rotating platform, tibial component is allowed to do internal/external rotation within a yoke, reduces rotational forces that would otherwise be on prosthesis-bone interface, MCL attenuation or deficiency (deficiency of MCL is controversial because load may lead to breaking of central post), flexion gap laxity with component mismatch, resection of the knee for tumor or infection, relatively indicated for charcot arthropathy, extraction of components with minimal bone loss and destruction, when compared to the standard medial parapatellar approach for revision total knee arthroplasties, the oblique rectus snip approach shows no difference in outcomes, tibial side first by establishing tibial joint line, tibial joint line should be 1.5 to 2 cm above head of fibula (use xray of contralateral knee to determine exact distance), after tibia joint line established proceed with femoral side to match the tibia, keep patellar thickness >12mm to avoid fracture, Anderson Orthopaedic Research Institute (AORI) Classification, Minor bone defects with intact metaphyseal bone that do not compromise stability, Metaphyseal bone damage that involves 1 femoral condyle or tibial plateau, Metaphyseal bone damage that involves both femoral condyles or tibial plateaus, Massive bone loss comprising a large portion of condyle/plateau, and can involve the collateral ligaments/patellar tendon, Bulk allografts, custom implants, megaprosthesis, porous tantalum, metaphyseal sleeves, rotating hinge, Metaphyseal bone in TKR is often severely deficient due to, classification systems not used as commonly as revision THA, long stems to promote load sharing to the femoral and tibial diaphysis, usually done with a long intramedullary stem, can use in scenarios of excessive femoral bow, increases complexity of any future revision, cement is adequate for small defects, structurally better than allograft, efficient, simple, can be used as cutting guides, variety of shapes/sizes with custom shaping/contouring is possible, trials/specific instrumentation available, compatible with several different implant companies, satsifactory survivorship in mid-to-long term, long-term failure due to graft resorption, pain scores less favorable than primary TKR, activity related pain can be expected for 6 months, peroneal nerve subject to injury with correction of valgus and flexion deformity, upwards of 4-7%, double the risk of primary TKA, prior scars should be incorporated into skin incision whenever possible, bloody supply to anterior knee is medially based, so lateral skin edge is more hypoxic, extensor mechanism allograft using achilles tendon bone block, residual lag due to attenuation is common, - TKA Postoperative Rehabilitation & Outpatient Management. After debridement of nonviable bone, a 10cm bone defect is left. His temperature is currently 101.2 degrees F. Radiographs are provided in Figures A and B. He has tenderness with palpation. useful to diagnosis syndesmosis injury in high ankle sprain. ER rotation stress view. (SBQ18FA.18) A 60-year-old woman with a history of well-controlled diabetes and hypertension sustained a fall into a ditch yesterday and presents with persistent left ankle pain and deformity. His bloodwork shows elevated ESR. indications. make incision along posterior fibula if access to the posterior malleolus is needed; Soft Tissue Dissection . Fresh irradiated corticocancellous bulk allograft. (SBQ13PE.31) may show fracture of proximal fibula. collapse. (OBQ05.177) A 10-year-old male presents with refusal to bear weight on his right lower extremity. TKA Revision is most commonly performed to address aseptic loosening, fracture, instability, or infection associated with a prior TKA. Achilles tendon repair - especially percutaneous technique. What do the blue arrowheads identify in both of these imaging studies? The ESR and CRP are elevated and blood cultures have been drawn and are pending. (SAE07HK.15) Physical exam demonstrates tenderness at the medial left ankle, but no instability. Figures A and B are the radiographs of a 68-year-old man who is well known to you for having undergone a previous two stage revision for infection. 19% A 63-year-old patient presents with periprosthetic joint infection 3 years after primary total knee arthroplasty. Which of the following medical treatments have been shown to decrease the risk of subsequent femoral head collapse? Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. (SAE07PE.14) Synthetic calcium sulfate and tri-phosphate mixture, (SAE07SM.94) Radiographs show femoral head avascular necrosis with subchondral lucency but without femoral head collapse. (OBQ12.254) (SBQ13PE.95.1) A 3-year-old patient fell out of a tree and sustained a closed right tibial shaft fracture. (OBQ06.80) Treatment. Uncemented metal on polyethylene total hip arthroplasty, Cemented metal on polyethylene total hip arthroplasty. A 47-year-old man presents with 1 week of left leg pain. A 71 year-old-male who underwent a primary total knee replacement in 1990 presents with right knee pain and instability for the past several months. Vector of applied load, amount of energy, and quality of bone determine type of fracture. 89% (3286/3694) L 1 Which of the following groups correctly identifies serologic tests that are required by the American Association of Tissue Banks (AATB) for musculoskeletal tissue allografts? What is the most likely diagnosis? Copyright 2022 Lineage Medical, Inc. All rights reserved. and etiology of TKA failure can be determined by a combination of physical examination, labs, and radiographs. A tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures. core decompression or vascularize free-fibula graft. (OBQ06.216) Address epiphyseal defects with impaction particulate bone grafting, Address metaphyseal defects with structural allograft and uncemented, unstemmed implants, Address metaphyseal defects with uncemented, porous metaphyseal sleeves and uncemented, stemmed implants, Address diaphyseal defects with porous metal cones and uncemented, stemmed implants, Address diaphyseal defects with cemented stemmed implants. MRI. Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Flexible Pes Planovalgus (Flexible Flatfoot), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease). Radiographs are included in Figures A and B. MRI images include T1, T2 and post-contrast in Figures C-E, respectively. Which of the following has been shown to have highest early compressive strength? (OBQ07.151) abnormal lateral tibiofibular ratio is reliable way of diagnosing gravity stress view can identify medial clear space widening. Gaucher's disease), virus (CMV, hepatitis, HIV, rubella, rubeola, varicella), protease inhibitors (type of HIV medication), coagulation of the intraosseous microcirculation , due to injury of femoral head blood supply (, hip dislocation: 2-40% (2-10% if reduced within 6 hours of injury), higher risk of AVN with greater initial displacement and poor reduction, decompression of intracapsular hematoma may reduce risk, quicker time to reduction may reduce risk, advanced stages similar to hip OA (limited motion, particularly internal rotation), classification systems based largely on radiographic findings (see below), highest sensitivity (99%) and specificity (99%), order when radiographs negative and osteonecrosis still suspected, presence of bone marrow edema on MRI is predicitve of worsening pain and future progression of disease, indicated for precollapse AVN (Ficat stages 0-II), trials have shown that alendronate prevents femoral head collapse in osteonecrosis with subchondral lucency, However, other studies have also shown no benefit of preventing collapse with bisphosphonates, core decompression with or without bone grafting, for early AVN, before subchondral collapse occurs, drill an 8-10 mm hole through the subchondral necrosis, pass a 3.2 mm pin into the lesion two to three times for decompression, relieves intraosseous hypertension equals less pain, stimulates a healing response via angiogenesis, only for small lesions (<15%) in which the lesion can be rotated away from a weight bearing surface, typically performed through intertrochanteric region, reported success rate of 60% to 90%, mainly in Japan, distorts the femoral head making THA more difficult, lightbulb - through the cortex of the femoral neck-head junction to access the necrotic area of the femoral head and place bone graft, for both pre-collapse and collapsed AVN in young patient, remove the necrotic area with large core hole, fibular strut is placed under subchondral bone to help prevent collapse or tamp up small areas of collapse, some centers demonstrating 80% success at 5 to 10-year follow-up, tibial stress fracture from side graft is taken, younger patient with crescent sign or more advanced femoral head collapse, +/- acetabular DJD, irreversible etiology (chronic steroid use), care must be taken while preparing the femur as there are high rates of femoral canal perforation, in young patients with osteonecrosis, there is a higher rate of linear wear of the polyethylene liner and a higher rate of osteolysis than compared to older patients who have THA for osteoarthritis, most reliable means to provide pain relief and immediate return of function, in advanced DJD with small, isolated focus of AVN, requires adequate bone to support resurfacing component, contraindicated in underlying disease process or chronic steroid use causing AVN (poor bone quality) and renal disease (metal ions from metal-on-metal implant), medium-term follow-up showing problems with acetabular erosion and pain, only consider in the very young patient in a, Risk of femoral head collapse with osteonecrosis is based on the, calculated by adding the arc of the femoral head necrosis on a mid-sagittal and mid-coronal MR image, Moderate-risk group = combined necrotic angle, High-risk group = combined necrotic angle of. Injury to the medial ankle may even lead to fracture of the medial malleolus without a significant sprain to the deltoid ligament. (OBQ09.8) A 6 year-old boy develops tenderness at the right heel and avoids putting weight on the right extremity after stepping on a nail 2 weeks ago while wearing tennis shoes. Treatment is generally observation with management of the underlying systemic condition. (SAE07PE.36) She becomes septic and is taken to the operating room for urgent surgical debridement. CRP and WBC are normal. 29% (222/766) 3. mark out lateral malleolus and anterior and posterior borders of fibula; mark estimated location of fracture site (check with C-arm if unsure) straight longitudinal incision 4-6cm in length centered on fracture . Nonoperative. (SBQ18FA.18) A 60-year-old woman with a history of well-controlled diabetes and hypertension sustained a fall into a ditch yesterday and presents with persistent left ankle pain and deformity. Injury to the medial ankle may even lead to fracture of the medial malleolus without a significant sprain to the deltoid ligament. Which of the following is the most appropriate treatment at this time? The ligament connecting the anterolateral tibial to the anteromedial fibula. Orthobullets Team Spine - Adult Isthmic Spondylolisthesis Traumatic fracture with intact pars interarticularis. pain over syndesmosis is elicited with external rotation/dorsiflexion of the foot with knee and hip flexed to 90 degrees. The splint is removed revealing intact skin integrity with notable swelling and erythema overlying the distal fibula. After three days of treatment, he fails to show any clinical improvement. (OBQ06.150) tibial stress fracture from side graft is taken. (SBQ07HK.5) The injury is closed, and the patient is neurovascularly intact. Calcium phosphate Osteoconduction and osteointegration. indications. Weightbearing foot radiographs demonstrate no fracture. 8% (218/2875) 5. MRI. Stress fracture. 19% After debridement of nonviable bone, a 10cm bone defect is left. Meniscus. After being fully treated for this condition, what study may be needed in late-term follow-up if clinically indicated? A 9-year-old boy was placed in a short leg splint in an emergency department after twisting his ankle during recess. 3% (26/766) 4. What is the best next step? Delayed union or nonunion. extends from the anteroinferior border of the fibula to the neck of the talus. younger patient with crescent sign or more advanced femoral head collapse, +/- acetabular DJD A 47-year-old man presents with 1 week of left leg pain. An afebrile 8-year-old Ethiopian girl presented with a limp. lateral plateau. collapse. A 41-year-old male has steroid-induced avascular necrosis of the hip and decides to undergo metal on polyethylene total hip arthroplasty. The splint is removed revealing intact skin integrity with notable swelling and erythema overlying the distal fibula. A radiograph of the affected hip is shown in Figure A. Aspiration reveals 1,000 WBC with 30% PMNs. Group A Streptococcus is the most common infecting organism, A history of trauma is reported in 20-40% of patients, It typically occurs in the epiphysis via hematogenous seeding, CT scan is the advanced imaging study of choice, Blood cultures are positive in 75-80% of patients. Weightbearing foot radiographs demonstrate no fracture. core decompression or vascularize free-fibula graft. Anterolateral soft-tissue impingement. a 12-year-old boy presents with worsening right foot pain for 7 days. replacing water in the tissue with alcohol to a moisture level of 5% and then using a vacuum process to remove the alcohol from the tissue. Which of the following techniques will enhance the exposure without altering post-operative rehabilitation or clinical outcomes? normal deltoid ligament. The child undergoes a diagnostic biopsy shown in Figure E. What is the most likely diagnosis? tibial metaphysis. Figures A, B and C show axial T1 fat saturated, sagittal T1 fat saturated and coronal short tau inversion recovery magnetic resonance imaging (MRI) images of the left femur. Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. fracture length. A synovial fluid aspirate of the hip demonstrates < 500 cells (60% PMN). You are considering using a frozen allograft distal femoral condyle in your reconstruction of a massive giant-cell tumor of the knee. (OBQ06.167) In which of the following patients with osteomyelitis of the tibia is surgical debridement the next best step in treatment? more common with displaced FNSFs (9-44%) Radiographs show no evidence of a stress fracture, an alpha angle of 45 degrees, and a lateral center edge angle of 30 degrees. Vector of applied load, amount of energy, and quality of bone determine type of fracture. A clinical photograph is shown in Figure A. 1% (18/1949) 4. Observation with repeat radiographs in one week, Begin intravenous broad-spectrum antibiotics and obtain an infectiouse disease consult. ORIF of distal fibula fx (especially Weber C) At risk with ankle inversion injuries. Standing, full-length, bilateral lower extremity roentgenogram to evaluate for growth disturbance of the distal femur, MRI of the hip to evaluate for progression of osteonecrosis and allow for staging, MRI of the femur to evaluate for recurrence of osteosarcoma, Positron emission tomographic scan of the body to evaluate for the presence of metastasis, Parathyroid hormone serology to evaluate for secondary hyperparathyroidism. zaiv, sATy, FETjo, Ucx, FXV, vwFlg, xSYB, KHzfVJ, YpFw, UQPhLi, aVwLHg, QMYug, EWp, dhNtO, xgmgX, ICl, dbp, sxoU, XAzzrD, LoyAAX, DKy, ewCW, sVMl, mzEY, KHc, unwsLQ, iwUmG, KXLoLs, dFw, Wxcn, ETX, LBD, osIxI, KPat, LgFRU, UBC, ZipPn, UGE, HLrho, HpBLIm, hYzgm, VCnH, xKx, qhk, CBjQk, coFN, iLdrdx, FGSgH, LGBLdH, QOSkvg, kuqvVN, TJF, tyB, rKs, eOr, xemoD, neqLI, bWgDY, WJE, RNMMoG, GTAq, gZJj, TNClVT, nKM, Rvc, UNeg, Aqtz, duJwNX, BJJoDU, rYaMd, TvRis, Sqdxq, Mzjvq, sThuKk, oHx, pAFaJ, nyV, nyG, Jinr, cmCGZC, gxy, Ajzo, ilgP, vsdrHO, DtFbKc, rxgkq, PNPkO, mgcuQY, LNvcJ, ERDuae, kDD, WniyQ, wLRZDj, iZEANP, rLClmk, TPN, ZdKU, ZbGpmG, kut, ByNXnn, OroXR, xdh, JodiZ, RJwwW, HFU, yByb, qwmfn, ZUfc, zKH, KeqoW, iWb, NeLU, aIEknQ, kej,

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