Free Orthopedics Review | Dr Hutaif General Orthopedics -...

The dorsal approach has not shown evidence of avascular necrosis, whereas the posteromedial approach has shown such changes at follow-up in as many as 40% of cases.
The dorsal approach requires a less extensive dissection than the posteromedial approach.
The dorsal approach does not require or permit plication of the talonavicular capsule, whereas the posteromedial approach does.
The dorsal approach does not appear to have a higher rate of redislocation of the talonavicular joint than the posteromedial approach.
The dorsal approach requires a shorter tourniquet time than the posteromedial approach.

Patients with cerebral palsy do not have an increased risk of congenital vertical talus, but they may develop an acquired neuromuscular vertical talus.
Patients with myelomeningocele have approximately a 5% to 10% risk of vertical talus, far above that of the general population.
Arthrogryposis is associated with an increased risk of vertical talus.
Nail patella syndrome is associated with an increased risk of vertical talus. Sacral agenesis is associated with an increased risk of vertical talus.

Scoliosis curves are much more likely to begin in the juvenile period than idiopathic scoliosis.
There is no significant difference in the likelihood of left thoracic curves in Marfan syndrome. Brace treatment is less likely to be successful in Marfan syndrome than in idiopathic scoliosis. Marfan patients with scoliosis are more likely to have back pain.
Marfan curves are more likely to progress in adulthood.

Demineralized bone matrix is weakly osteoinductive.
The term osteogenic refers to direct transmittal of cells capable of making bone. Demineralized bone matrix is not osteogenic.
Demineralized bone matrix varies in efficacy between different forms and different methods of sterilization. The term osteoconduction refers to provision of a favorable scaffold and environment for bone formation. Demineralized bone matrix is osteoconductive.

Posterior fusion and instrumentation is the best-documented treatment. Although this form of treatment is followed by an increased incidence of wound healing problems, the problems can be treated.
Observation is not recommended because the curve is highly likely to increase and cause a decrease in pulmonary function.
Bracing has no role in large curves, and it is not known if bracing is successful at all in Ehlers-Danlos syndrome.
Anterior fusion with instrumentation would be difficult with a double curve. Anterior fusion carries an increased risk due to vascular fragility. It is not necessary because there is no increased risk of crankshaft or pseudarthrosis.
There is no particular reason for adding an anterior procedure in this situation in view of the vascular risk.

Scoliosis in osteogenesis imperfecta (OI) is due primarily to ligamentous laxity.
Scoliosis in OI is due primarily to ligamentous laxity, not bony fractures. There is no association between brainstem impression and scoliosis. Scoliosis in OI rarely responds to brace treatment.
Scoliosis, when present in OI, is a major impairment of quality of life.

Vertebral rotation is not a specific characteristic of dystrophic curves. Rotation is more pronounced in dystrophic curves than in nondystrophic curves, but it is commonly present in both types of curves.
Penciling of the ribs is one of the features specific for dystrophic curves in neurofibromatosis 1.
Scalloping of the vertebrae anteriorly and posteriorly is characteristic of dystrophic curves in neurofibromatosis 1. Widening of the neural foramen is specific for dystrophic curves in neurofibromatosis 1. Widening of the neural foramen is due to tumorous masses passing through the foramen.
Thinning of the transverse process is a characteristic of dystrophic curves in neurofibromatosis 1.

There is an increased risk of loss of fixation in familial dysautonomia curves due to decreased bone density and curve rigidity.
Scoliosis is common in patients with familial dysautonomia and affects up to one-half of patients with the disorder. The curves in familial dysautonomia are rigid, leading to limited correction.
The bone density in familial dysautonomia is decreased.
Spinal stenosis is not reported in patients with familial dysautonomia.

Symptomatic stenosis of the thoracic and lumbar spine is seen in almost half of all achondroplastic patients, although not all patients require surgery.
Atlantoaxial instability is rare in achondroplasia, although it is not uncommon in other dysplasias. Basilar invagination is not present in achondroplasia.
Kyphosis is often transient in achondroplasia and rarely persists beyond the second year. Kyphosis is rarely symptomatic. Spondylolisthesis is rare in achondroplasia.

Many of these kyphoses will correct spontaneously if the curve does not exceed 50°. In this patient, the inability to walk is most likely due to other skeletal factors.
There is no evidence that orthosis will change the natural history of the disorder.
There is no need for traction given the high chance of spontaneous resolution and the dangers of traction.
Posterior fusion is only indicated if the kyphosis is continually progressive, or if neurologic signs or symptoms develop. Anterior and posterior surgery is only indicated in cases with severe pre-existing neurologic deficit.

Patients with diastrophic dysplasia rarely have instability of the upper cervical spine.
Babies with diastrophic dysplasia often have rigid equinovarus feet that require surgery to become plantigrade and wear normal shoes.
A number of patients with diastrophic dysplasia develop progressive scoliosis that requires surgical treatment. Degenerative disease of the hips is common and often requires arthroplasty in early adulthood.
Degenerative disease of the knees is common and often requires arthroplasty in early adulthood.

Atlantoaxial instability, sometimes combined with stenosis of the atlas, is a frequent cause of myelopathy in spondyloepiphyseal dysplasia congenita.
Scoliosis does not account for developmental delay or myelopathy.
Foramen magnum stenosis is rare in spondyloepiphyseal dysplasia congenita.
Lumbar stenosis is rare with spondyloepiphyseal dysplasia congenita and would not account for myelopathy. Thoracolumbar kyphosis severe enough to cause myelopathy is rare in spondyloepiphyseal dysplasia congenita condition.

Scoliosis with cleidocranial dysplasia (C C D) is frequently associated with syringomyelia.
C ervical instability is rare in C C D. Spondylolisthesis is rare in C C D. Spinal stenosis is rare in C C D.
Spinal decompensation is rare in C C D.

Posterior cervical fusion has been proven effective in curves of 60°or less, in preventing progression, and allowing correction with anterior growth.
This curve is much more likely to worsen than to spontaneously improve, so preventive surgery is indicated. There is no role for halo traction in this situation.
Bracing has not been proven effective in helping patients with Larsen syndrome.
Addition of anterior fusion is not needed for this degree of curve in a neurologically normal child.

Anterior and posterior fusion will correct the translation, instability, and ensure a solid fusion.
Exercises will not correct the subluxation, which is the cause of the pain. A thoracolumbar orthosis is not corrective or well tolerated.
There is no need for halo traction.
Posterior fusion alone is not enough to control this focal instability if the patient is well enough to tolerate a more involved procedure.

Aneurysmal bone cyst of the spine is most common in the lumbar spine, followed by the cervical spine. Aneurysmal bone cyst of the spine is treated with embolization and/or surgical resection and reconstruction.

The most common age is the second decade; the mean age is 13 years old.

This patient has an aneurysmal bone cyst of the vertebra. Selective arterial embolization is a minimally invasive treatment that often succeeds in arresting the lesions. Many times it is the only treatment needed. Selective arterial embolization can also be used as part of a strategy to be followed by curettage and reconstruction to decrease operative bleeding.
This lesion will continue to expand and might cause neurologic compromise or mechanical instability. Radiation therapy poses risks of later malignant degeneration. There are other ways of treating this lesion. Radical en bloc resection may unnecessarily injure neurologic structures.
While curettage is often necessary, there is no reason to introduce the risk of radiation therapy.

Low back pain, followed closely by ipsilateral knee pain, is the most common late effect of hip arthrodesis in young patients. The tolerable pain usually occurs much later but may be treated by conversion to arthroplasty, if needed.
Ipsilateral hip pain should be minimal or absent if the fusion is successful.
Activity following arthrodesis is not significantly limited. Sports and heavy physical activities are feasible. The limp is usually minimal because the loss of hip motion is masked by lumbar motion.
Pain in the contralateral hip is rare and is often minimal after hip arthrodesis.

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

In situ fixation provides the best results no matter what the grade of slip.

Bilateral proximal femoral resection is the recommended treatment.
Femoral head dislocations may become painful in cerebral palsy at a much earlier age than in nonspastic individuals. Botulinum toxin or adductor tenotomy will not solve the problem.
Replacing the deformed femoral heads into the acetabulum will not achieve the long-term goal of good hip range of motion.

The translation and shortening are not problems and the amount of angulation will easily remodel with this fracture. There is nothing to be gained from operative reduction.

This patient should be treated like an adult. Eight inch-pounds is the currently recommended torque to provide optimal biomechanical fixation while minimizing pin penetration.

Spinal cord injury occurs in approximately 1% of patients operated upon for idiopathic scoliosis. In some cases, sensory spinal cord monitoring may be unchanged, especially if the injury preserves the dorsal columns. The instrumentation should be removed as soon as possible in case spinal traction or derotation or implant protrusion is producing effects on the cord or its blood supply.
C orticosteroids should be administered at spinal cord injury doses, but this should not be the only measure. Obtaining a myelogram may delay the removal of instrumentation and should not be the first step. Heparinization has no proven effect.

Extensive posterior decompression poses a high risk of postoperative increase in kyphosis because of both the patientâs age and pre-existing kyphosis.
Observation would not be a good idea because the risk is already known to be high.
Neither a brace nor an uninstrumented fusion would prevent the deformity from developing. C orpectomy is not indicated because the kyphosis is not focal.
Posterior instrumented fusion at the time of decompression is indicated.

Brace treatment is effective for Scheuermann kyphosis. Unlike idiopathic scoliosis, permanent improvement of the deformity is the goal.
The Milwaukee brace is often indicated.
Brace treatment is ineffective for curves over 74°. The brace should be worn until skeletal maturity.

Bone marrow transplantation is effective in minimizing the deposition of mucopolysaccharides in solid organs. Transplantation should be done early to prevent organ damage. Because the lysosomal enzyme does not cross the cell membrane of osteocartilaginous cells, it does not affect the orthopedic aspects. The risk of graft-versus-host disease is high but may be treated in most cases. Survival rate is 61% at 2 years for Hurler disease, which is otherwise fatal before maturity.

Eosinophilic granuloma often produces complete flattening of a single vertebral body in the absence of trauma or neurologic deficit.
Osteogenesis imperfecta produces a more uniform flattening of the vertebrae but not by this degree.
Tuberculosis rarely produces this much flattening of a single vertebra. The erythrocyte sedimentation rate is elevated in this condition.
Bacterial infection rarely produces this much flattening of a single vertebral body without associated disk changes. The lab studies should suggest an inflammatory process.
C ompression fracture produces less complete flattening of the vertebral bodies.

Radiation therapy combined with steroids should be tried first to try to halt progression of the tumor. Unfortunately, the prognosis for this child is extremely poor.
Increasing the dose of chemotherapy is not likely to work because the metastasis has already progressed despite initial treatment.
Surgical resection must be tried if radiation does not produce improvement. Steroids are an adjunct to treatment but not sufficient alone.
The patient is likely to have progressive paraparesis and loss of bowel function. In order to improve the quality of life remaining, surgical resection should be offered to the patient.

The primary purpose of osteotomy is to improve the chance of a successful urologic reconstruction. This is achieved by decreasing the tension on the closure of the abdominal wall and bladder.
The strain on the sacroiliac joints has not been measured with or without closure; this is not a primary purpose of the osteotomy.
There is no conclusive evidence that the hips are at increased risk of degenerative disease in patients with exstrophy, or that osteotomy will alter the condition.
In patients with exstrophy, the gait progressively normalizes over time. It is not possible to reconstruct a normal symphysis pubis in exstrophy.

Hydrocephalus is rare because most patients have lipomeningocele, not myelomeningocele.
Omphalocele is common in cloacal exstrophy.
Most patients with cloacal exstrophy have a lipomeningocele that is a form of spinal dysrhaphism. Many patients have malformations of the sacroiliac joints.
Approximately 25% of patients have dislocations of at least one hip.

It is recommended that the intramedullary nail be 40% of the diameter of the femoral isthmus.

The cost of prosthetics is greater in the disarticulation group.
Pain is greater in the lengthened group.
Function is equal to or better in the group who had disarticulation. Psychological acceptance is greater in the disarticulation group.
The lengthened group requires more than twice the number of procedures.

Nonaccidental injury was a factor in 29% of patients who were unable to walk vs 3% for patients who were able to walk.
The fracture pattern and level of fracture do not help determine nonaccidental injury.
Socioeconomic class is not the best discriminator and, generally, should not be factored into the decision process. C oexisting disability is not a significant discriminator.

A pseudotumor is a hemophilic subperiosteal hematoma. The pseudotumor expands by repeated bleeds and increasing osmotic pressure.
There was no periosteal reaction or intralesional calcification.
The bone wall itself is not expanded as in aneurysmal bone cyst.
There is nothing in the physical examination or patient history to point to infection.

A surprisingly small amount of circulating factor-VIII (approximately 5%) is necessary to protect a patient from severe bleeding complications.

Fracture is common in this condition because of osteopenia and the stress concentration due to joint stiffness.
Osteomyelitis is uncommon in the diaphysis and much less common in this scenario than fracture. Septic arthritis of the hip is uncommon in this disease.
Dislocation of the hip would not cause pain and swelling in this setting. Deep vein thrombosis is uncommon at this age.

The beginning and end of the range may change, but the total amount of motion remains about the same.
The amount of the range cannot be significantly increased. The endpoint can change, but not the amount of the range. The joint does not usually become stiffer.
There may be an indication for surgery to put the joints in a functional position.

C urves greater than 50° usually progress.
Scoliosis is most common in totally involved C P patients. Scoliosis is rare in patients with hemiplegia. Braces rarely halt curves in C P.
Surgery has no proven effect on prolonging life expectancy. The complication rate is higher in C P.

Home exercises and re-examination in follow-up is the most appropriate treatment in view of lack of any worrisome features. If this child had severe pain or significant night pain, then further imaging studies would be warranted.
The magnetic resonance imaging is not indicated in this situation. The bone scan has a low likelihood of being positive.
Bracing is not indicated for the curve or the pain.
C omputer tomography is unlikely to demonstrate any pathology.

The removal of posterior restraints in the young and growing flexible spine usually leads to cervicothoracic kyphosis.

He has a kyphosis of 35°.
This degree of kyphosis increases the risk of pseudarthrosis with posterior fusion alone. The laminectomy increases the risk of pseudarthrosis.
Anterior fusion should be added when there is a history of pseudarthrosis.
A 9-year-old boy has a high risk of crankshift phenomenon with posterior fusion alone.

All children should be screened at age 11.
The AAOS still recommends school screening for scoliosis.
The AAOS recognizes that yearly screening is counterproductive. Screening at age 9 is too early..
Screening at age 16 is too late.

Open reduction of the vertical talus will most likely prevent problems.
With observation only, the patient is likely to stand or walk and develop pressure problems. Talectomy will not produce the most usable foot.
Achilles tenotomy will not produce significant correction by itself. Triple arthrodesis will concentrate stress and lead to ulcers.