Orthopedics Hyperguide Review | Dr Hutaif General Ortho -...

The patient had an open fracture that was initially treated with what appears to be appropriate irrigation and debridement and intramedullary nail placement. The post-operative infection and need for rotational flap is worrisome, but she has not had any issues since the flap. She has abundant callus formation but the fracture line is still visible and unchanged on 2 sets of radiographs. The patient has persistent pain. The best initial evaluation is to ensure that there is no underlying infection with laboratory studies, including a complete blood count (CBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Nuclear medicine studies have questionable utility, but may be helpful if the inflammatory markers from laboratory studies come back elevated. A CT scan is not warranted because the sequential radiographs show persistent fracture lines and no changes. The patient has a hypertrophic nonunion. Originally, she had appropriate treatment and has shown the ability to make callus, thus her biologic capacity appears to be intact and bone grafting is not needed. The hypertrophic nature of her fracture nonunion indicates that she needs more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing. Based on successive radiographs and the lack of healing, observation is probably just delaying the inevitable. Plating with retention of the nail can be useful in recalcitrant long bone nonunions, especially in the femur.

intravenous antibiotics
DISCUSSION:
This patient clearly has a chronically infected total hip arthroplasty, indicated by the open, draining sinus, as well as trochanteric bone resorption on radiographs, and two years of pain. Recently, specific guidelines have been published to better help the clinician define infection. Repeating the hip aspiration is unnecessary, because infection is already evident. Initiating a wound care consult would not address the underlying infection. The determination whether to retain the components or perform a two-stage exchange is based more on the acuity of infection. In this particular case, the patient is chronically infected. Irrigation and debridement with a liner exchange and retention of the components are reserved for the acute setting.

DISCUSSION: Oxidation of polyethylene has been associated with increased rates of polyethylene wear. Oxidation occurs after polyethylene has been irradiated in the presence of oxygen. Gamma irradiation has been commonly employed to sterilize the polyethylene prior to sterile packaging. Over the last decade, several methods of reducing oxidation of polyethylene have been used. These include irradiation in an inert gas (such as argon or nitrogen), irradiation in vacuum packaging, and avoiding irradiation altogether and sterilizing the polyethylene with ethylene oxide, gas plasma, or vaporized hydrogen peroxide. Crosslinking polyethylene has been done with gamma irradiation and electron beam irradiation. Heating/ melting the material after irradiation allows the free radical chains within the polyethylene to cross-link together rather than oxidize.
REFERENCE: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 333-344.

Although the angle of trunk rotation (ATR) does not convert directly to a C obb angle, there are population-based figures for mean curve at each ATR. The mean C obb angle for curves having a 7° ATR is 20°.

Patients younger than 40 years of age who have ankle arthritis pose an ongoing clinical challenge. Nonsurgical treatment should be maximized, although distraction arthroplasty can be used in an effort to delay the need for fusion.
One of the strongest indications for ankle arthroplasty is a preexisting hindfoot fusion with a goal to retain some ankle/hindfoot motion. Ankle fusion is perhaps the most predictable surgical treatment for a relatively young, active patient with ankle arthritis. Moreover, there are concerns regarding implant loosening when performing TAA in active patients.
Outcome after syndesmosis ORIF has been linked to the quality of the reduction at the index procedure. Syndesmotic malreduction that is severe necessitates osteotomy and revision ORIF.
RECOMMENDED READINGS
1. [Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma. 2012 Jul;26(7):439-43. doi: 10.1097/BOT.0b013e31822a526a. PubMed PMID: 22357084. ](http://www.ncbi.nlm.nih.gov/pubmed/22357084)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22357084)
2. [Smith NC, Beaman D, Rozbruch SR, Glazebrook MA. Evidence-based indications for distraction ankle arthroplasty. Foot Ankle Int. 2012 Aug;33(8):632-6. Review. ](http://www.ncbi.nlm.nih.gov/pubmed/22995229)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22995229)
3. [Kim BS, Knupp M, Zwicky L, Lee JW, Hintermann B. Total ankle replacement in association with hindfoot fusion: Outcome and complications. J Bone Joint Surg Br. 2010 Nov;92(11):1540-7. doi: 10.1302/0301-620X.92B11.24452. PubMed PMID: 21037349. ](http://www.ncbi.nlm.nih.gov/pubmed/21037349)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21037349)
4. [Daniels TR, Younger AS, Penner M, Wing K, Dryden PJ, Wong H, Glazebrook M. Intermediate-term results of total ankle replacement and ankle arthrodesis: a COFAS multicenter study. J Bone Joint Surg Am. 2014 Jan 15;96(2):135-42. doi: 10.2106/JBJS.L.01597. ](http://www.ncbi.nlm.nih.gov/pubmed/24430413)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24430413)

Repetitive overhead slams and serves may produce a traction injury to the distal branch of the suprascapular nerve. Bankart, biceps, and superior labrum anterior and posterior injuries can occur but usually do not produce visible atrophy. Muscle avulsion is uncommon.
REFERENCES: Ferretti A, Cerullo G, Russo G: Suprascapular neuropathy in volleyball players. J Bone Joint Surg Am 1987;69:260-263.
Bigliani LU, Dalsey RM, McCann PD, April EW: An anatomical study of the suprascapular nerve. Arthroscopy 1990;6:301-305.

MRI reveals an anterior labral tear, and the radiograph shows minimal arthritis with possible dysplasia. The most common location of pain in patients with a labral tear is the groin, and the most common physical finding is a positive impingement test result. Pain during sitting, clicking, and buttock pain are frequently described by patients with a labral tear, but these symptoms are less common than groin pain. A positive posterior impingement test finding is more common in patients with a posterior labral tear. Although age over 40 years and a body mass index higher than 30 can adversely affect clinical outcomes after joint preservation procedures such as PAO, hip arthroscopy, and femoral acetabular impingement surgery, the presence of hip arthritis on presurgical radiographs is the most commonly mentioned cause of failed hip joint preservation surgery. Tönnis grade is a radiographic measure of hip arthritis. A higher Outerbridge score is associated with more frequent poor outcomes after hip arthroscopy; however, the Outerbridge cartilage score is determined by direct visualization at the time of surgery. The Outerbridge score cannot be determined presurgically.

Ankylosing spinal disorders, including ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis, are conditions that make the spine rigid and at risk for 3-column unstable fractures. Spinal fractures in these patients pose high risk for complications and death and patients should be counseled and observed closely. Mortality strongly correlates with older age and increased number of comorbidities.
These spine fractures often are not seen at the time of initial evaluation, and a delay in diagnosis can occur in up to 19% of cases. This is particularly common in the setting of non- or minimally displaced fractures following minor injuries. A delayed diagnosis can lead to displacement of a previously nondisplaced fracture that can incur a high neurologic injury risk. Advanced imaging with a CT scan or MRI should be obtained for patients with ankylosing spinal disorders even when minor injuries occur. Although bracing and observation can be used, posterior multilevel spinal instrumentation is typically required to obtain adequate spinal stabilization.
The radiographs show an osteopenic ankylosed thoracic spine; the anteroposterior radiograph clearly shows fusion of the sacroiliac joints. Recognition of these radiographic findings is important when evaluating patients after an injury.
RECOMMENDED READINGS
[Caron T, Bransford R, Nguyen Q, Agel J, Chapman J, Bellabarba C. Spine fractures in patients with ankylosing spinal disorders. Spine (Phila Pa 1976). 2010 May 15;35(11):E458-64. doi: 10.1097/BRS.0b013e3181cc764f. PubMed PMID: 20421858. ](http://www.ncbi.nlm.nih.gov/pubmed/20421858)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/20421858)
[Hendrix RW, Melany M, Miller F, Rogers LF. Fracture of the spine in patients with ankylosis due to diffuse skeletal hyperostosis: clinical and imaging findings. AJR Am J Roentgenol. 1994 Apr;162(4):899-904. PubMed PMID: 8141015. ](http://www.ncbi.nlm.nih.gov/pubmed/8141015)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/8141015)

Spondylolisthesis can be classified into five types. Type I, dysplastic, occurs at the lumbosacral junction as a result of congenital abnormalities of the upper sacrum and/or the arch of L5.Type II, isthmic, refers to those involving a lesion in the pars interarticularis. Type IIA, lytic, represents fatigue fractures of the pars. Type IIB describes those with elongated, but intact pars. Type IIC describes those that are a result of an acute fracture of the pars. Type III, degenerative spondylolisthesis, results from longstanding intersegmental disease. Type IV, traumatic, refers to those resulting from fractures in regions other than the pars, such as the pedicles. Type V, pathologic, refers to spondylolisthesis resulting from generalized or local bone disease. The radiographs demonstrate type II, isthmic spondylolisthesis.

**
Whereas all of the factors will have an impact on frame rigidity and stability, the single biggest factor is the pin diameter because it has an exponential effect.

A radial club hand is the result of an insult during weeks 4 to 7 of gestation.

Two studies have shown that supplemental vitamin C reduces the risk of developing complex regional pain syndrome following a distal radius fracture. The recommended dose is 500 mg daily for 50 days. Supplemental vitamin C is a recommendation of the AAOS evidence-based Clinical Practice Guidelines
and has moderate evidence. The vitamin supplements listed as alternative options have not been shown to prevent disproportionate pain following a distal radius fracture.

DISCUSSION: Age at presentation and range of motion of the hip are the two most significant predictors of long- term outcome. Younger patients and patients who maintain range of motion of the hip are more likely to have a good outcome. In Herring’s study, children with a chronologic age of younger than 8 years or a bone age of less than 6 years had significantly more favorable outcomes compared with older children. Limited hip range of motion may be due to muscle spasm early on, or synovitis; but in late disease, it may reflect incongruity of the joint.
Classifications based on femoral head shape have also been correlated to prognosis. Significant shortening of the affected hip is not common.

REFERENCES: Herring JA, Kim HT, Browne R: Legg-Calve-Perthes disease. Part II: Prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am 2004;86:2121-2134. Herring JA, Kim HT, Browne R: Legg-Calve-Perthes disease. Part I: Classification of radiographs with use of the modified lateral pillar and Stulberg classifications. J Bone Joint Surg Am 2004;86:2103-2120. Skaggs DL, Tolo VT: Legg-Calve-Perthes disease. J Am Acad Orthop Surg 1996;4:9-16.

Although the fracture is aligned in anatomic position, prominence of a least one of the distal screws is evident on the lateral radiographic view. The prominent screw is the most likely cause of the EPL tendon rupture. If the patient chooses surgical treatment, the best option would be removal of the offending hardware combined with extensor indicis proprius to EPL tendon transfer. Intercalary grafting would also be an acceptable option. If the tendon transfer were to be performed alone, the prominent screw(s) could rupture the transferred tendon as well. Also, it is rarely possible to repair the EPL tendon primarily in such cases, because this rupture is an attrition type. Casting would obviously not provide any benefit in this situation, and IP arthrodesis would not be the first surgical treatment option. This problem can be avoided by using shorter screws or not placing screws in plate holes that direct screws into the third dorsal extensor compartment. Intraoperative fluoroscopy and special views, such as the carpal shoot-through _view, are useful for avoiding this complication._

A brachial plexus injury would involve all of the upper extremity muscles as well as most of the periscapular muscles. Complete plexus palsies are rare, and are often associated with scapulothoracic dissociation or other high-energy injuries.
Preganglionic injuries often involve the cervical paraspinal musculature as well as a complete plexus injury. EMG evidence of intact signals in the serratus anterior (long thoracic nerve) and rhomboids (dorsal scapular nerve) are suggestive of a postganglionic lesion/injury.
Tubbs et al. reported on the surgical anatomy of the dorsal scapular nerve in a cadaver study. They found that the nerve came off the C5 nerve root in 95%, ran 2.5cm medial to the spinal accessory nerve as it traveled on the anterior border of the trapezius muscle, and was intertwined with the dorsal scapular artery in all specimens.
Balakrishnan et al reported on the comparison of clinical exam and EMG in predicting site of lesions in brachial plexus injuries. The combination of EMG and exam localized the nerve injury in 80%, while the paraspinal EMG was the most sensitive solitary examination method (67%).
Illustration A shows a diagram of the brachial plexus. Incorrect Answers:
2-5: These muscles are all innervated by nerves that come from the brachial
plexus, and would be affected with a postganglionic injury.

The patient has osteochondritis dissecans. While location, size, and knee stability are all relevant to the overall prognosis, studies have shown that younger patients with open growth plates have a better prognosis of healing when compared with patients who have closed growth plates. The degree of pain is also relevant to treatment, but it is subjective rather than objective and is not as reliable of a prognostic indicator as age.
REFERENCES: Stanitski CL: Osteochondritis dissecans of the knee, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, vol 3, pp 387-405.
Cahill B: Treatment of juvenile osteochondritis dissecans and osteochondritis dissecans of the knee. Clin Sports Med 1985;4:367-384.
Linden B: Osteochondritis dissecans of the femoral condyles: A long-term follow-up study. J Bone Joint Surg Am 1977;59:769-776.

Tensile testing of the inferior glenohumeral ligament at near physiologic strain rates has shown that the anterior band of the IGHL has the greatest stiffness of the three ligament regions and the glenoid insertion site shows greater strain than the ligament midsubstance.
REFERENCES: Bigliani LU, Pollock RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC: Tensile properties of the inferior glenohumeral ligament. J Orthop Res 1992;10:187-197.
Ticker JB, Bigliani LU, Soslowsky LJ, Pawluk RJ, Flatow EL, Mow VC: Inferior glenohumeral ligament: Geometric and strain-rate dependent properties. J Shoulder Elbow Surg 1996;5:269-279.

One should remember the important mutations that occur in musculoskeletal conditions: A. FGFR3 mutation: Achondroplasia
B. Type IX collagen mutation: Multiple epiphyseal dysplasia (MED)
C . WISP3 mutation: Spondyloepiphyseal dysplasia with progressive osteoarthropathy
D. Type II collagen mutation: Stickler syndrome
E. Sulfate transporter gene mutation: Diastrophic dysplasia
F. Fibrillin gene mutation: Marfanâs syndrome
G. Type V collagen mutation: Ehlers-Danlos syndrome
H. Type I collagen mutation: Osteogenesis imperfecta
C orrect Answer: Mutation in fibroblast growth factor receptor 3 gene

The MRI scan shows a posterior horn medial meniscus root avulsion with bony edema at the tibial root insertion. The radiograph shows no significant degenerative changes. If left untreated, posterior meniscal
root tears lead to progressive degenerative changes as a result of the altered tibiofemoral contact pressures and areas. Nonsurgical treatment including injections, physical therapy, and unloader braces are more _appropriate in the older patient with pre-existing advanced degenerative changes._

47
The medial sural arteries vascularize the gastrocnemius, plantaris, and soleus muscles proximally. These arteries arise from the popliteal artery. If this artery is not adequately mobilized, a gastrocnemius soleus flap can be devascularized.

The pathology is that of posterior ankle impingement, which is secondary to a symptomatic os trigonum. Endoscopic excision necessitates posteromedial and posterolateral ankle portals. Although plantar numbness has been described as a relatively common postsurgical complication, the neurovascular structure most commonly injured is the sural nerve.

Studies of titanium elastic nailing for femur fractures demonstrated a higher rate of complications, including angular deformity and construct failure, among patients weighing more than 50 kg (100 pounds). Other methods of fixation are recommended for these patients. Flexible nails are not commonly needed, but they also are not associated with a higher complication rate in children younger than age 6.5. Titanium elastic nailing works well in closed or minimally open transverse midshaft fractures, even in the setting of early or immediate weight bearing.

Video 8a

Video 8b

Based on the choices above, the most important predictor of wound healing is the serum albumin level.
Wound healing is based on several factors, which include the vascular status, the immune status, and the nutritional status of the patient. Some important clinical findings include an ankle brachial index (ABI) > 0.45, a total lymphocyte count > 1500/mm3 and a serum albumin > 3.0 g/dL.
Kay et al. discuss the importance of the nutritional status in wound healing after lower extremity amputation procedures. They found eleven of 25 patients who were malnourished sustained either local or systemic complications postoperatively. They recommend that patients should undergo nutritional screening prior to elective lower extremity amputations, to help optimize their wound healing.
Incorrect Answers
Answer 2: While total protein is a marker of nutritional status, it is not as sensitive as the serum albumin for wound healing potential.
Answers 3, 4, 5: Calcium levels, C-reactive protein and ESR are not markers of wound healing

- Reverse total shoulder arthroplasty (rTSA)_

In an ipsilateral unstable pelvic ring and acetabular fractures, the pelvic ring injury must be initially stabilized in order to reduce the acetabular fracture to a stable base.
The referenced article by Matta reviewed 259 patients with acetabular fractures treated within 21 days of injury and found that the hip joint can be preserved and post-traumatic osteoarthrosis can be avoided if an anatomical reduction is achieved.

Figure 25

The initial radiographs show a comminuted displaced distal radius fracture, along with a displaced fracture of the base of the ulnar styloid. The displacement is best seen on the oblique view. After reduction and fixation of the radius, DRUJ stability should be assessed. The majority of scenarios that involve this injury pattern will not be unstable because of the oblique band of the interosseous ligament. When DRUJ instability is present after fixation of the radius, reduction and fixation of the ulnar styloid fracture is the best option to provide stability of the distal radioulnar joint (DRUJ) (Figure 25d). A study by Lawton and associates revealed that all distal radius fractures complicated by DRUJ instability were accompanied by an ulnar styloid fracture. A fracture at the ulnar styloid’s base and substantial displacement of an ulnar styloid fracture were found to increase risk for DRUJ instability. An ulnar styloid base fracture involves the insertion of the radioulnar ligaments and can cause DRUJ instability if displaced. If persistent instability is present after fixation of the ulnar styloid, DRUJ pinning is a reasonable option. Early ROM with splinting would not allow reduction or healing of the ulnar styloid and would result in persistent instability. Short-arm casting also would not allow stability of the DRUJ and would be a less reliable method with which to achieve healing of the ulnar styloid.
RECOMMENDED READINGS
33. May MM, Lawton JN, Blazar PE. Ulnar styloid fractures associated with distal radius fractures: incidence and implications for distal radioulnar joint instability. J Hand Surg Am. 2002 Nov;27(6):965-
[71/. PubMed PMID: 12457345.](http://www.ncbi.nlm.nih.gov/pubmed/12457345)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/12457345)
34. [Sammer DM, Shah HM, Shauver MJ, Chung KC. The effect of ulnar styloid fractures on patient-rated outcomes after volar locking plating of distal radius fractures. J Hand Surg Am. 2009 Nov;34(9):1595-602. doi: 10.1016/j.jhsa.2009.05.017. PubMed PMID: 19896004. ](http://www.ncbi.nlm.nih.gov/pubmed/19896004)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19896004)
35. [Wysocki RW, Ruch DS. Ulnar styloid fracture with distal radius fracture. J Hand Surg Am. 2012 Mar;37(3):568-9. doi: 10.1016/j.jhsa.2011.08.035. Epub 2011 Oct 22. Review. PubMed PMID: 22018474. ](http://www.ncbi.nlm.nih.gov/pubmed/22018474)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22018474)

The radiograph shows a subtalar (talocalcaneal) dislocation with a talonavicular dislocation as well. If subtalar dislocations also involve dislocation of the articulations at both the talonavicular and ankle (tibiotalar) joint, a talar extrusion is seen. Subtalar dislocations are associated with high energy, open (25%), and irreducible (33%) fractures. Medial dislocations account for 65%, and reduction is blocked by the extensor digitorum brevis (EDB). Lateral dislocations that are irreducible are blocked by the posterior tibialis, FHL, and FDL tendons. These dislocations often require emergent open reductions, tendon relocation, and stabilization.
Bibbo et al reported clinical and radiographic outcome on 25 patients and the majority of these patients had radiographic degenerative changes at 5 years follow up.
The review reference by Bohay and Manoli covers subtalar joint dislocations and notes the importance of anatomic reduction to achieve optimal outcomes.

- increased dural tear risk.

- Proximal junctional kyphosis (PJK)

C heilectomy is the ideal treatment for correction of mild hallux rigidus. Although elevation of the first metatarsal rarely occurs (metatarsus primus elevatus) as the cause for hallux rigidus, osteotomy of the metatarsal should not be used as the treatment for correction of hallux rigidus with normal alignment of the first metatarsal.

A lower chance of curve control with brace treatment has been shown with curves greater than 40°, correction of less than 50% in brace, brace worn fewer than 16 hours per day, or male gender. Positive family history has not been shown to be related to curve progression or chance of control.

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DISCUSSION:
The management of patients with proximal femoral deformity can be difficult. Appropriate implant selection and preoperative templating are critical. In this patient, it would be difficult to avoid increasing the combined offset by too much, which could contribute to the overtensioning of the soft tissues and trochanteric pain. By medializing the acetabular component (decreasing the combined offset), using a low offset femoral component or a cemented component placed more valgus (decreasing the combined offset), and making a longer neck cut (to avoid shortening of the lower extremity), restoration of the patient’s native offset and leg length can be achieved.

DISCUSSION: The only reported cases of HIV transmission with tissue transplantation occurred more than 20 years ago. The only reported cases of tuberculosis and hepatitis B occurred more than 50 years ago. The donor-associated clostridium infection occurred in 2001. The facility was not AATB-accredited (American Association of Tissue Banks) and the local A ATB facility refused the graft. It is necessary for the surgeon using the allograft tissue to be aware of the current status of tissue regulation, and procurement and processing procedures.
REFERENCES: McAllister DR, Joyce MJ, Mann BJ, et al: Allograft update: The current status of tissue regulation, procurement, processing, and sterilization. Am J Sports Med 2007;35:2148-2158.
Safety of tissue transplants. American Association of Tissue Banks, 2006. Question 74
Which of the following types of intra-articular pathology is associated with lateral meniscal cysts?
1. #### Discoid meniscus
2. #### Posterolateral comer injury
3. #### Vertical meniscal tears
4. #### Middle third lateral meniscal tears
5. #### Popliteus tendon tears

PREFERRED RESPONSE: 4
DISCUSSION: Lateral meniscal cysts often arise from myxoid degeneration that progresses from the meniscal center and then outside the meniscus. Horizontal cleavage tears are commonly associated with the condition.
Cysts of the lateral meniscus are most commonly the consequence of a tear located in the medial third. If the
tear communicates with the joint, arthroscopic partial meniscectomy and cyst decompression are indicated. If the tear does not open into the joint, arthroscopy should be followed by an open cystectomy.
REFERENCES: Hulet C, Souquet D, Alexandre P, et al: Arthroscopic treatment of 105 lateral meniscal cysts with 5-year average follow-up. Arthroscopy 2004;20:831-836.
Ferrer-Roca O, Vilalta C: Lesions of the meniscus: Part I. Macroscopic and histologic findings. Clin Orthop
Relat Res 1980;146:289-300.
Ferrer-Roca O, Vilalta C: Lesions of the meniscus: Part II. Horizontal cleavages and lateral cysts. Clin Orthop Relat Res 1980:146:301-307.

Figure 75

DISCUSSION: Most imaging studies in mild traumatic brain injury will be normal. Neuropsychologic testing is the most sensitive test in assessing mild deficits after traumatic brain injury. Sideline assessment is important but less sensitive in assessing deficits. The precise role of neuropsychologic testing in determining return to play has not been fully defined.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 37-38.

62 • American Academy of Orthopaedic Surgeons

Maroon JC, Lovell MR, Norwig J, et al: Cerebral concussion in athletics: Evaluation and neuropsychological testing. Neurosurgery 2000;47:659-672.

Figure 79

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The patient's history and examination findings are consistent with a lumbar disk herniation at the L5-S1 level. Weakness of the gastrocnemius and gluteus maximus are consistent with an S1 lumbar radiculopathy. Nerve root tension signs are also consistent with a disk herniation at L5-S1, which typically affects the traversing S1 nerve root.

Use of mechanical compressive devices and aspirin during the postoperative period is
recommended by the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines.
In 2011, the American Academy of Orthopaedic Surgeons published their Clinical Practice Guidelines for preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. A summary of those guidelines provide general recommendations for venous thromboembolic disease in patients with and without bleeding disorders. These recommendations range from strong (recommending against the use of routine post-operative duplex ultrasonography), to moderate (using mechanical compressive devices or a pharmacologic agent for prophylaxis in the post- operative period), to inconclusive (they are unable to recommend for or against specific pharmacologic prophylaxis agents). Additionally, there are recommendations based on consensus agreement of the authors (the recommendation of early mobilization in the post-operative period).
These guidelines are now much closer to in agreement with the American College of Chest Surgeons (ACCS) 2012 guidelines for VTE prophylaxis. One of the differences between the guidelines is that the AAOS guidelines do not state a specific amount of time that a pharmacologic agent should be given post- operatively while the ACCS recommends such agents for a minimum of 10-14 days.
Incorrect answers:

: The AAOS guidelines recommend stopping platelet-inhibiting medications such as aspirin and clopidogrel prior to the procedure.
Answer 2: The AAOS guidelines do not state that using elastic compressive stockings is sufficient for VTE prophylaxis, either pre- or post-operatively. Answer 3: The AAOS guidelines recommend against using routine post- operative duplex ultrasound.
Answer 4: The AAOS guidelines do not make specific recommendations for or against the use of a specific INR range.

The definition of effect size is best described as which of the following?

1) Likelihood that a statistically significant difference would be found between 2 groups given that a difference truly did exist

2) Estimated magnitude of the difference in the means between two groups

3) Average of the squares of each value's deviation from the mean

4) Range within which it is probable that the true value lies for the whole population of patients

5) Probability of obtaining a result equal to or more extreme than what was actually observed assuming the null hypothesis is true

The effect size is best defined as the magnitude of the difference in the means of the control and experimental groups in a study with respect to the pooled standard deviation. Effect sizes are normally used for continuous variables in contrast to relative risk reduction which is used for dichotomous variables. Power (1), variance (3), confidence interval (4), and P value (5) are the other options provided.

Which of the following patients are at greatest risk of having a future vertebral fragility fracture?

1) Elderly female with prior hip fragility fracture

2) Elderly female with prior distal radius fragility fracture

3) Elderly female with prior T6 compression fragility fracture

4) Elderly female with a T-score of -3.0

5) Elderly female currently on hormone replacement therapy

History of a prior vertebral fragility fracture is the strongest predictor of a future fragility fracture. A meta-analysis by Klotzbuecher et al examined risk factors for fragility fractures and found an association between prior and subsequent fragility fractures. The strongest associations were observed between prior and subsequent vertebral fractures. They found women with preexisting vertebral fractures had an approximately 4 times greater risk of subsequent vertebral fractures than those without prior fractures. They also found this risk increases with the number of prior vertebral fractures. Other combinations of prior and future fracture sites, such as the hip or wrist, were also strongly associated, but none so high as vertebral fractures.

A 79-year-old female falls onto her right hip at home and sustains the injury shown in Figure A. She undergoes an uncemented unipolar hemiarthroplasty. During insertion of the stem into the femoral canal, the patient becomes hypotensive and hypoxic. Which of the following has most likely occurred?
1) Femoral shaft fracture

2) Inadequate fluid resuscitation during surgery

3) Acute myocardial infarction

4) Pulmonary embolism caused by dislodging of deep venous thrombosis during hip exposure

5) Intramedullary fat and marrow embolization

During insertion of the femoral stem, the intramedullary pressures are increased. Fat and marrow elements can become embolized into the bloodstream at this point resulting in ventilation perfusion mismatch in the lungs.
Kim et al prospectively followed 156 total hip arthroplasties including bilateral and unilateral procedures as well as cemented and uncemented procedures. They found no difference in fat embolization amongst any of the groups. However, they did find that if patients had evidence of bone marrow cells in the right atrium on the first postoperative day, they developed diffuse encephalopathy with confusion and agitation that lasted for about twenty-four hours.

Which of the following investigative studies is most useful in the definitive diagnosis of Amyotrophic Lateral Sclerosis (ALS)?

1) Genetic testing

2) MRI brain and spinal cord

3) Muscle biopsy

4) Serum protein electrophoresis and immunoelectrophoresis

5) Electrodiagnostic studies

The diagnosis of ALS requires a period of clinical observation to document the progressive loss of upper and lower motor function. Electrodiagnositic studies are required to make a definitive diagnosis.
Amyotrophic lateral sclerosis (ALS) is the most common degenerative disease of the motor neuron system. Nerve conduction studies and needle electromyography (EMG) are useful for confirming the diagnosis of ALS and for excluding peripheral conditions that resemble ALS. Hallmark findings in the electrodiagnosis of ALS are abnormal motor nerve conduction studies, with normal sensory nerve conduction studies. UMN signs are mild weakness, spasticity, and abnormally brisk reflexes; LMN signs are progressive weakness, wasting, and loss of reflexes and muscle tone.
Brooks et al. developed a diagnostic algorithm for the diagnosis of ALS. The algorithm is based on the degree of certainty of diagnosis, which is increased by the number of body segments that demonstrate upper motor neuron (UMN) and lower motor neuron (LMN) abnormalities. Clinical and electrophysiologic findings in 3 or more body segments is definitive of the diagnosis.
Incorrect Answers:
Answer 1: Genetic testing may be performed to identify genetic defects in some familial types of ALS. However to date, there is no single test that is definitive for diagnosing ALS.
Answer 2: MRI brain and spinal card are used to rule out structural lesions and neurologic conditions that have a slimilar clinical presentation as ALS.
Answer 3: Muscle biopsy is not required in the diagnosis of ALS
Answer 4: Serum protein electrophoresis and immunoelectrophoresis will not provide a definitive diagnosis for ALS. They are used to rule out the differential diagnoses of ALS.

Radiographic changes suggestive of osteopetrosis in children are a known complication of which of the following types of medications?

1) TNF-alpha inhibitors

2) Bone morphogenic proteins

3) Bisphosphonates

4) Fluoroquinolones

5) RANKL antibiodies

Radiographic changes suggestive of osteopetrosis (marble bone disease) are a known complication of bisphosphonate usage. The common cellular pathway in this process is the osteoclast. Bisphosphonates target and inhibit the osteoclast, and these cells are not functioning in patients with osteopetrosis.
Whyte et al describe a case report of a 12-year-old child with idiopathic hyperphosphatasia treated with bisphosphonates who developed osteopetrosis.
Falk et al report on their small case series which showed the beneficial effects and known complications in the treatment of osteogenesis imperfecta with bisphosphonate therapy.
Marini presents a perspective article describing the off-label use of bisphosphonates in children.

What function does computerized physician order entry have on medication monitoring?

1) Reduces the rate of medication errors

2) Improves physician satisfaction

3) Decreases narcotic requirements by patients

4) Increases rates of allergy related medication errors

5) Improves physician knowledge about the drugs they are prescribing

Computerized physician order entry has greatest impact on reducing medication errors.
Bobb et al. studied medication errors averted by pharmacists at a 700-bed academic center and concluded that 65% of them would likely have been prevented with computerized physician order entry.
Upperman et al. reviewed medication errors at a pediatric hospital before and after implementation of a computerized physician order entry system. They found a significant decrease in adverse drug events following establishment of the computerized system.
Incorrect Answers:
2: Physician satisfaction has not been correlated with computer entry for medications.
3: Narcotic requirements are related to injury or patient characteristics, not computerized entry.
4: Allergy-related errors are decreased with use of computerized entry.
5: Physician knowledge is not necessarily increased with computerized entry.

What is the cellular mechanism of action for non-nitrogen containing bisphosphonates (such as clodronate and etidronate) to induce osteoclast apoptosis?

1) Inhibiting caspase

2) Inhibiting matrix metalloprotease

3) Inhibiting reverse transcriptase

4) Targeting of farnesyl diphosphate synthase

5) Creating toxic analog of adenosine triphosphate that targets mitochondria

Bisphosphonates work by one of two mechanisms. Non-nitrogren containing bisphosphonates (such as etidronate and clodronate) work by creating a toxic analog of ATP which inhibits ATP and leads to osteoclast apoptosis. Nitrogen containing bisphosphonates (such as alendronate, risedronate, and zoledronate) inhibit the enzyme farnesyl diphosphate synthase which prevents protein geranylgeranylation and prevents osteoclastic bone resorption.
Reska et. al. specifically discuss the difference between the two pathways. Non-nitrogen containing compounds inhibit ATP production and cause osteoclast apoptosis. Nitrogen containing bisphophonates inhibit protein synthesis by interrupting the cholesterol biosynthetic pathway, which prevents osteoclastic resorption.

Which class of antibiotics inhibit early fracture healing through toxic effects on chondrocytes?

1) cephalosporins

2) quinolones

3) penicillins

4) macrolides

5) sulfonamides

Animal models have shown that quinolones inhibit early fracture healing through a toxic effect on chondrocytes. The 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 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.

A mutation of the retinoblastoma gene RB-1 leads to the development of malignancies such as retinoblastoma and osteosarcoma. Which term best characterizes the RB-1 gene?

1) growth factor

2) retro-oncogene

3) proto-oncogene

4) oncogene

5) tumor suppressor

A tumor suppressor is a gene whose presence normally prevents neoplasia and whose absence leads to unregulated cell growth. Two well-studied tumor suppressor genes include p53 and RB-1. P53 normally suppresses cell division by blocking the cell cycle if genetic damage is present. If it is absent or mutated, the p53 suppressing effect no longer regulates cell growth and neoplasm results. In a similar fashion, a mutation in RB-1, or the retinoblastoma gene, may leads to retinoblastoma and osteosarcoma.

**You********are********counseling a********young********female********patient********about her********future******risk of osteoporosis. Which of the following regarding peak bone mass (PBM) is true?

1) PBM is consistently attained by the end of the second decade of life in both men and women.

2) PBM is independent from environmental factors.

3) PBM correlates strongly with post-menopausal bone mineral density

4) Timing of PBM varies based on anatomic site.

5) Women attain PBM prior to men, regardless of anatomic site.


The timing and magnitude of PBM varies based on anatomic site. PBM is often reached in the appendicular skeleton earlier than in the axial skeleton.
PBM is defined as the greatest amount of bone an individual will attain in his or her lifetime. Controversy has surrounded the timing of PBM due to significant anatomical variations as well as strong gender-based, genetic, geographic, environmental, and mechanical influences. While women may reach PBM
earlier than men in the hip, the converse has been found to be true of the spine. Furthermore, the age at which each is obtained varies widely. Though the PBM of the hip is most often achieved by the end of the second decade of life, PBM of the spine may not occur until the third or fourth decade of life. Interestingly, PBM has been found to correlate poorly with post-menopausal bone mineral density, likely a result of these strong confounding influences.
Bonjour et al. reviewed the controversy behind peak bone mass. The authors note that the gender-based difference in bone mass becomes expressed during puberty and that there is a large variability in normal values of bone mineral density between anatomic sites.
They conclude that bone mass accumulation can be completed by the end of the second decade at both the lumbar spine and femoral neck, but that this may be significantly influenced by a number of variables during growth such as genetics, diet, endocrine and mechanical factors.
Berger et al. more recently evaluated trends in peak bone mass from longitudinal data in the Canadian Multicentre Osteoporosis Study (CaMos). The authors found that peak bone mass was highly variable between the axial and appendicular skeleton. Specifically, lumbar spine PBM was reached in women
at 33-40 years, but much earlier in men at 19-33 years. Conversely, hip PBM was reached earlier in women at 16-19 years and later in men at 19-21 years. Furthermore, there was a lack of concordance between PBM and BMD over age
65/. The authors concluded that there was a high geographic variance and strong confounding environmental influences.
Incorrect answers:
Answer 1: While PMB may be attained by the second decade in life, this is highly variable based on anatomic location and strongly influenced by environmental and genetic factors. While PBM in the hip may frequently be attained by the end of the second decade, that of the lumbar spine is not typically reached until the end of the third decade of life in men and fourth in women.
Answer 2: Environmental factors such as diet, exposures to toxins, and mechanical influences have a strong influence on the age and magnitude of PBM.
Answer 3: There is a lack of correlation between PBM and both the age of onset and severity of osteoporosis, regardless of anatomic location. This is thought to be due to strong genetic and environment influences.
Answer 5: There is significant variability in the age and magnitude of PBM between the
axial and appendicular skeleton. PBM is often attained earlier in women in the appendicular skeleton (the hip for instance) but later in the axial skeleton (the vertebrae for instance).

SOX9 is a transcription factor that is a key regulator of which of the following tissues shown in Figures A-E?
1) Figure A

2) Figure B

3) Figure C

4) Figure D

5) Figure E

Figure E is a histologic slide of cartilage. Activation of SOX9 leads to increased cartilage matrix production.
Sox9 is a transcription factor which directly regulates the expression of the major proteoglycans and collagens comprising the cartilage extracellular matrix. It is a member of the high mobility group superfamily of nonhistone nuclear proteins. During embryogenesis, SOX9 determines chondrocyte cell fate. It regulates the transcription of type II collagen as it binds to the
promoter and enhancer sequences. SOX9 also enhances the transcription of type IX collagen, type XI collagen, aggrecan, and link protein. These products form the major structural components of the cartilage matrix.
Haudenschild et al. performed a study to determine the factor responsible for the activation of the SOX9 transcription factor. They report that Rho-kinase (ROCK) has profound effects on the actin cytoskeleton, which is instrumental in determining the phenotype and differentiation of chondrocytes. They conclude that SOX9 was found to contain a consensus phosphorylation site for ROCK. They conclude that the interaction between ROCK and SOX9 leads to increased cartilage matrix production.
Hoffman et al. performed a study examining the molecular mechanisms regulating chondroblast differentiation. They report that retinoic acid prevents cells from differentiating into chondroblasts. The inhibition of retinoic acid signaling induces the expression of SOX9, which is a major transcriptional regulator of chondrogenesis. They conclude that retinoid receptor-mediated repression is both necessary and sufficient for chondroblast differentiation.
Figure A is a histologic slide of trabecular bone. Figure B is a histologic slide of adipose tissue. Figure C is a histologic slide of skeletal muscle. Figure D is a histologic slide of a peripheral nerve bundle. Figure E is a histologic slide of articular cartilage.
Incorrect Answers:
Answer 1: Figure A demonstrates trabecular bone. Answer 2: Figure B demonstrates adipose tissue. Answer 3: Figure C demonstrates skeletal muscle. Answer 4: Figure D demonstrates a peripheral nerve.

Which of the following factors uses serine-threonine kinase receptors to induce metaplasia of pluripotent mesenchymal stem cells into bone-forming cells?

1) Bone morphogenetic protein (BMP)

2) Osteoprotegerin (OPG)

3) Insulin-like grownth factor 2 (IGF-2)

4) Platelet-derived growth factor (PDGF)

5) Rank ligand (RANKL)

Bone morphogenetic proteins (BMPs) use serine-threonine kinase receptors to stimulate proliferation and differentiation of pluripotent mesenchymal stem cells into bone-forming cells.
Bone morphogenetic proteins are a highly studied family of growth factors of bone. With over twenty varieties of BMP, specific actions vary widely with most effects revolving around the development and repair of the musculoskeletal system. In the inflammatory phase of healing BMPs target undifferentiated mesenchymal stem cells through extracellular serine-threonine receptors. Following this extracellular interaction, the signal is transmitted to intracellular molecules called SMADs leading to different cellular responses. BMPs are of great interest given their ability to induce robust bone formation.
Cited concerns regarding BMPs are uncontrolled heterotopic bone formation and cost.
Cheng et al. looked at the osteogenic activity of fourteen different BMPs on mesenchymal progenitor cells. They found BMP-2, 6, and 9 induced high levels of alkaline phosphatase activity in pluripotent stem cells. They conclude BMP-
2, 6, and 9 may play important roles in inducing osteoblast differentiation of mesenchymal stem cells.
Lin et al. reviewed the uses of platelet-derived growth factor, bone morphogenetic proteins, and platelet-rich plasma in foot and ankle surgery. They state that BMPs play a large role in the differentiation and proliferation of pluripotent mesenchymal stem cells to bone-forming cells and cartilage.
Illustration A shows a graphic representation of the role BMPs play in the differentiation of mesenchymal stem cells into bone-forming cells.
Incorrect Answers:
Answer 2: OPG inhibits both osteoclast activation and differentiation by acting as a decoy receptor for RANK-L.
Answer 3: IGF-2 stimulates bone and cartilage formation by acting on a variety of cells through tyrosine kinase receptors.
Answer 4: PDGF uses tyrosine kinase receptors to signal inflammatory cells to migrate to the fracture site.
Answer 5: RANKL stimulates bone resorption through the interaction of RANK receptors on osteoclasts.

Which of the following disease-modifying antirheumatic drugs**
**(DMARDs) acts on the cell membrane receptor illustrated in Figure A?
1) Anakinra

2) Infliximab

3) Rituximab

4) Sulfasalazine

5) Abatacept

Anakinra is a disease-modifying antirheumatic drug (DMARD) that acts uniquely as an interleukin IL-1 receptor antagonist that blocks the binding of IL-1 to its cell membrane receptor (Figure A). Its action prevents this pro- inflammatory cascade.
Corticosteroids, biologic agents, tumor necrosis factor (TNF) antagonists (infliximab, etanercept, adalimumab, golimumab and certolizumab), IL-1 antagonists (anakinra), and other DMARDs are all used in the pharmacologic
management of rheumatoid arthritis (RA). Anakinra is considered a 4th line agent in the treatment of RA. Pharmacologic agents are the mainstay of treatment in RA and a more aggressive approach with DMARDs is now favored over a pyramid approach, as this has significantly improved the prognosis of RA.
Pisetsky provided an early overview of the role of TNF blockers in RA, specifically citing infliximab and etanercept. He noted their potent binding to TNF, preventing inflammation by blocking the downstream cascade of this cytokine. He further comments that these agents may be effective in patients who have failed other DMARDs and that their effects may be extended to children.
Howe et al. provided an overview of pharmacologic agents used in RA and provided perioperative recommendations for their use. Perioperative continuation is based on half- life and surgical stress, but the authors recommend continuing methotrexate, sulfasalazine, and hydroxychloroquine in the perioperative period. They conclude that consultation with a
rheumatologist is recommended when feasible, and that the risks and benefits of surgical
complications and RA control must be carefully weighed.
Incorrect Answers:
Answer 2: Infliximab (3rd line) is a human mouse chimeric anti-TNF-alpha monoclonal antibody
Answer 3: Rituximab (other biologic agent) is a monoclonal antibody to CD20 antigen (inhibits B cells)
Answer 4: Sulfasalazine (2nd line) is an anti-inflammatory agent that reduces ESR and CRP, although the exact mechanism is unknown
Answer 5: Abatacept (other biologic agent) is a selective co-stimulation modulator that binds to CD80 and CD86 (inhibits T cells)

A pharmaceutical company is marketing a new intra-articular injectable therapy that they claim is superior to intra-articular steroid injection for the treatment of knee osteoarthritis. Patients undergoing this new therapy report a larger improvement in their Knee injury and Osteoarthritis Outcome Score (KOOS) when compared to patients undergoing intra-articular steroid injections. This difference is reported with a p-value of 0.04. Which of the following is true when considering whether or not to use this new therapy on your patients?

1) There is no significant difference between therapies, no conclusion can be drawn.

2) There is not enough data to determine if the difference in KOOS scores is statistically significantly.

3) The difference in KOOS scores between therapies is statistically significant, therefore the new therapy will yield improved clinical outcomes

4) A larger sample size is needed to determine if there is truly a difference between the two treatments.

5) The minimum clinically important difference must be identified in order to determine the clinical significance of these findings.

When evaluating the merits of a new intervention, it is critical to determine whether or not a statistically significant difference in outcome between two groups leads to a clinically important difference.
Observed differences between samples reflect either true differences in the populations being compared or are due to random chance (i.e. occasionally random sampling will result in the comparison of two samples that do not reflect true population differences). Statisticians make this determination using p-values. For example, if an observed difference has a reported p-value of
0.05, this means that one would expect to see the observed difference less than 5% of the time if there was no true difference between the data sets. Because this is highly unlikely, p
Osteoblasts directly regulate the hematopoietic stem cell population through the Jagged1-Notch pathway. Which of the following activates this pathway?

1) Interleukin-1 (IL-1)

2) IL-6

3) Tumor necrosis factor alpha (TNF-alpha)

4) Transforming growth factor beta (TGF-beta)

5) Parathyroid hormone (PTH)

The Jagged1-Notch pathway becomes activated by the action PTH.
Osteoblasts have been found to regulate hematopoietic stem cells and the immune response. They do this through the Jagged1-Notch pathway. PTH induces Jagged1, a membrane-bound protein, on osteoblasts. Jagged1 stimulates Notch receptors on the membrane of hematopoietic stem cells (HSC). This stimulation leads to cell proliferation of HSC.
Lorenzo et al. performed a review of interactions of bone and the immune system. Thy report that stimulation of the PTH receptor on bone cells
increased the number of HSC in bone marrow. This also increased the levels of Jagged1 on osteoblasts. This effect was blocked by using inhibitors of Notch signaling. They conclude that PTH directly stimulates the production of Jagged1 by osteoblasts.
Weber et al. performed a study which demonstrated that activation of the PTH receptor in osteoblasts activates the Jagged1-Notch pathway and expands HSC. They found that PTH treatment increases Jagged1 levels in osteoblastic
cells in vivo and in vitro. They conclude that since Jagged1-Notch signaling has been implicated in HSC interactions and osteoblastic differentiation, this pathway may play a critical role in mediating the PTH-dependent expansion of HSC, as well as the anabolic effect of PTH on bone.
Illustration A is demonstrating PTH's effects. PTH activates numerous cytokines and other mediators on osteoblasts (OBs), osteoclasts (OCs), bone marrow mesenchymal stem cells (MSCs), and hematopoietic stem cells (HSCs) located close to the endosteal niche.
Incorrect Answers:
Answers 1, 2, 3, & 4: The Jagged1-Notch pathway becomes activated by the action of PTH. None of the listed mediators have been implicated in this pathway.

A 60-year-old female presents to your office for evaluation of 6 months of back pain. She was referred to you by her primary care physician and presents with a consultation request in hand. You note she was last seen by your partner for hip pain 4 years ago but has not returned to the office since. You perform a detailed history (level 3), comprehensive examination (level 4), and low complexity medical decision making (level 3). You dictate an office note and mail a letter to the referring primary care physician regarding your findings. This encounter should be billed as which of the following?

1) Level 3 return

2) Level 3 new

3) Level 3 consultation

4) Level 4 new

5) Level 4 consultation

This encounter should be billed as a level 3 consultation based on the lowest level history, examination, and medical decision making. The patient presented with a referral and a consultation letter was sent to the referring physician.
Billing for office visits can be component based or time-based. Component based billing consists of varying levels of history, examination, and medical decision making. Billing for an encounter is limited by the lowest level of these components. Patients fall into three categories of new, consultation, and
return patients. New patients are those who have not been seen by the physician or someone in the same practice in over 3 years. Consult patients are those who have been referred to the office for advice and not transfer of care with a letter or communication sent to the referring physician at the conclusion of the encounter.
Return patients are those who have been seen within 3 years by the physician or a partner in the practice.
Gill et al. reviewed trends in practice management training in residency. They cite multiple papers demonstrating that residents are not confident in coding abilities (96%), miscode visits (62%), rarely have formal training (87%), and feel programs should implement practice management training (62%). The conclude that practice management should be a part of resident education.
Shalowitz et al. assessed the impact of eliminating consultation codes. They found coding error rates of 32.4% and that changing ambulatory consultation codes to those for new patient visits would save Medicare 534.5 million per year. They conclude that consultation codes are being billed higher than appropriate and, in an effort to reduce costs, these codes should be reevaluated.
Illustration A (Centers for Medicare and Medicaid Services) shows the various coding levels for a new patient (99201-99205 representing Levels 1-5 respectively) and how each level may be determined based on key components as well as time. Illustration B shows the corresponding level of care for new, established, and consultation encounters.
Incorrect Answers:
Answer 1, 2, 4, and 5: This patient falls into the consult category and should be billed as a level 3 based on the lowest level of history, examination, and medical decision making.

A 29-year-old female presents to your clinic for surgical evaluation, referred by her family practitioner. She states she has a history of left arm numbness that comes and goes, and was told she had radiculopathy in the past. She recently completed a steroid taper pack, which provided moderate relief. On physical exam, she has decreased sensation in a non-dermatomal distribution involving most of her left arm. Left deltoid strength is 4/5. Left biceps and triceps reflexes are 3+. She has a positive Hoffmann’s sign bilaterally. A radiograph and magnetic**
**resonance imaging of her cervical spine are shown in Figures A and B, respectively. What is the most appropriate next step in management?
1) Plasmapharesis and immunoglobulin administration

2) Laminoplasty

3) Lumbar magnetic resonance imaging

4) Neurology referral

5) B12 injections

In a young female presenting with transient upper extremity neurological symptoms, upper motor signs, and magnetic resonance imaging (MRI) with multiple focal T2- enhancing cord lesions, the most likely diagnosis is multiple sclerosis (MS).
Multiple sclerosis is an inflammatory disorder of the central nervous system causing demyelination and axonal injury. It is capable of producing both motor and sensory dysfunction. It mainly affects young females ages 20-40. Symptoms are most commonly described as remitting and relapsing and may include weakness, paresthesias, falls, incontinence, muscle spasms, fatigue, and optic neuritis. Physical exam may be significant for upper motor findings, muscle weakness, and gait abnormalities. Work-up includes labs, MRI of the brain and spinal cord, and cerebrospinal fluid analysis. Specific MRI findings include multiple sites of focal demyelination and asymmetric periventricular plaques. Corticosteroid are indicated for acute exacerbations.
Kim et al. performed a literature review of 35 studies focusing on the differential diagnosis of cervical spondylotic myelopathy. The most commonly reported differentials included amyotrophic lateral sclerosis (ALS), MS, syringomyelia, and spinal tumors.
They conclude that physical exam findings should be correlated with plain radiographs, MRI, and history to establish the correct diagnosis and that electrodiagnostic studies and cerebrospinal fluid exam should be considered when the diagnosis is equivocal.
Sahraian et al. provided a review article on the role of MRI in the diagnosis and treatment of MS. They comment on the role MRI has played in providing an earlier and more accurate diagnosis, as well as its role in prognostics and as a tool to evaluate the efficacy of experimental research trails. Specific MRI techniques for detecting MS include proton density, T1/T2-weighted images, and fluid-attenuated inversion recovery sequences.
Rovira et al. provided a review article looking at the diagnostic features of MS and the differential diagnosis utilizing spinal MRI. Multiple sclerosis lesions typically are hyper- intense on T2 imaging and are ring enhancing on contrast- enhanced T1 imaging. They state that MS lesions are more commonly found in the cervical spine, typically present in the dorsolateral aspect of the spinal
cord, are short-segment, comprise less than half of the cross-sectional cord area, and are often associated with brain lesions. Other short-segment spinal cord lesions that may mimic MS on MRI include autoimmune disorders, vascular disorders, bacterial and viral infections.
Figure A is a normal cervical spine lateral radiograph. Figure B is a mid-sagittal T2- weighted cervical MRI with multiple focal T2-enhancing lesions. Illustration A is a T2- weighted MRI of the cervical spine demonstrating characteristic lesions of MS. There is one lesion in the dorsal upper cervical spine and one in the upper thoracic spine that are T2-enhancing. These lesions are less than
two vertebral body segment lengths, characteristic of MS lesions.
Incorrect Answers:
Answer 1: This describes the treatment of Guillain-Barre syndrome (GBS). Answer 2: This patient has MS and is not indicated for surgery at this time. Answer 3: While lumbar imaging may also reveal MS lesions, these lesions more commonly present in the cervical spine and additional imaging will not change management at this time.
Answer 5: B12 injections are used in the treatment of subacute combined degeneration of the spinal cord.

A 10-year-old male presents to your office with a proximal phalanx fracture. You perform a digital block, closed reduction, and place the patient into a cast. You bill for fracture care and reduction. The patient returns for follow-up at 4- weeks for radiographs and cast removal. At this visit, you perform an extended problem-focused history (level 3), detailed physical exam (level 4), and low-level medical decision making (level 3). You spent 15 minutes of face-to- face time with the patient and his family, half of which was spent on counseling and coordination of care. How should this visit be billed?

1) Level 1 established

2) Level 2 established

3) Level 3 established based on time

4) Level 4 established

5) This visit should not be billed

All follow-up related fracture care within 90 days of a procedure is included in a global fee under the "restorative treatment" model for the closed management of fractures. This visit should not be billed separately.
The concept of global payment refers to a "single fee" that is paid for the index surgery/procedure that encompasses all post-operative care within a 90-day window. Code 99024 is used for a postoperative follow-up visit and is associated with a zero-dollar amount. The concept of "restorative treatment" indicates that the physician has performed a manual closed reduction with manipulation, the fracture is placed in acceptable alignment for healing, and that the patient will follow up with that physician for future care.
When a physician provides "restorative treatment", the global fracture care code should be utilized.
For billing and coding purposes, patients are placed in the following categories: new, established, and consultation. The level of evaluation and management services performed is component based (history, physical exam, medical decision making) or time based. Billing must be based on the lowest level of component-based care delivered.
Further information on this topic can be found on the following website provided by the Centers for Medicare and [Medicaid Services: _htt_ ps://www.cms.g _ov/Outreach-and-_](https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf)__[_Education/Medicare-_](https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf)_Learnin_ g _-Network-MLN/MLNProducts/Downloads/eval-m_ g _mt-serv-_ g _uide- ICN006764._ pdf
Illustration A is a table explaining the different billing levels associated with established patient care. Two of the three (history, physical exam, medical
decision making) must be documented. Alternatively, billing can be time based.
Incorrect Answers:
Answers 1, 2, 3, 4: These visit codes do not apply to post-procedural care within a 90-day global fee window.

Which of the following is the correct cell lineage and mediator of differentiation of the cell identified by the black arrow in Figure A?
1) Myeloid lineage/receptor activator of nuclear factor kappa-B ligand (RANKL)

2) Myeloid lineage/bone morphogenetic protein (BMP)

3) Lymphoid lineage/receptor activator of nuclear factor kappa-B ligand (RANKL)

4) Lymphoid lineage/bone morphogenetic protein (BMP)

5) Lymphoid lineage/osteoprotegerin (OPG)

The osteoclast is derived from a myeloid lineage and differentiation is mediated by receptor activator of nuclear factor kappa-B ligand (RANKL).
The osteoclast is derived from a myeloid hematopoietic precursor cell. This pathway is of the monocyte/macrophage lineage and includes fusion of mononuclear cells into multinucleated osteoclasts. Differentiation is mediated by a combination of macrophage colony-stimulating factor (M-CSF) and RANKL. Osteoclast progenitor cells express RANK receptor on their membrane which allows for differentiation signaling.
Zaidi et al. reviewed recent literature surrounding signaling of osteoclasts. They discuss the various transcription factors and molecular molecules involved in the pathway of osteoclastogenesis. They conclude if any of the
genes encoding critical molecules that regulate osteoclastogenesis are deleted, the phenotype of osteopetrosis is almost always present.
Goodman et al. reviewed the effects of various medications on bone. They state corticosteroids increase production of RANKL and decreases osteoprotegerin (OPG) resulting in increased osteoclastogenesis. They conclude that corticosteroids increase osteoclast formation as well as osteoclast longevity leading to overall increased osteoclastic bone resorption.
Figure A shows a histologic specimen of bone with a black arrow identifying an osteoclast. Illustration A shows a depiction of the osteoclast lineage and associated mediators.
Illustration B shows the myeloid lineage of the osteoclast and the relationship to other cell types.
Incorrect Answers:
Answer 2: Bone morphogenetic proteins (BMPs) stimulate proliferation and differentiation of pluripotent mesenchymal stem cells into bone-forming cells. Answer 3 & 4: Lymphoid lineage leads to precursors of adaptive immunity such as T cells, B cells, and natural killer cells.
Answer 5: Osteoprotegerin downregulates osteoclastogenesis by acting as a decoy for RANKL and inhibiting RANKL binding with RANK receptors on osteoclasts.

**What does a power analysis determine and when should it be performed?**

1) Sample size; prior to initiating the study

2) Effect size; after the study is completed

3) Type-I error; after the study is completed

4) Type-II error; after the study is completed

5) Number needed to treat; prior to initiating the study

A power analysis determines sample size and should be performed prior to initiating a study.
Power is the probability of finding a significant association if one truly exists. It is defined as 1 - the probability of a type 2 error (beta). Usually, power is set
at > 80%, which means that there is a
Which of the following is involved in the process of osteoinduction and osteogenesis?

1) Bone morphogenic protein-1 (BMP-1)

2) BMP-2

3) BMP-3

4) Peroxisome proliferator-activated receptor gamma (PPAR-Gamma)

5) Insulin-like growth factor 1 (IGF-1)

Bone morphogenic protein-2 is directly responsible for osteoinduction and osteogenesis.
Bone morphogenic proteins were discovered as the bone-forming factors in demineralized bone used in surgical procedures. BMPs have therefore found a role in bone regeneration strategies as they have been found to initiate the complete cascade of
bone formation. As members of the transforming growth factor-beta (TGF-beta) superfamily, BMPs play important roles in skeletal development and bone formation. BMPs initiate their signaling transduction by binding to a heterodimeric complex of two transmembrane serine-threonine kinase receptors, BMP receptor (BMPR) type I and BMPR type I. The activated receptor kinases, in turn, phosphorylate the transcription factors Smad 1, 5, and 8. The phosphorylated Smads then form a heterodimeric complex with Smad 4 in the nucleus and activate the expression of target genes in concert with other coactivators. BMP-2, specifically, exhibits potent osteogenic and osteoinductive activity.
Cheng et al. performed a study to determine the activity of the 14 known types of BMP in mesenchymal progenitor and osteoblastic cells. Osteogenic activity was determined by measuring the induction of alkaline phosphatase. They found that BMP-2, 6, and 9 significantly induced alkaline phosphatase activity in pluripotent cells while BMP-2, 4, 6, 7, and 9 significantly induced alkaline phosphatase activity in preosteoblastic cells. BMP-3 was found to have no activity. They conclude that BMP-2, 6, and 9 may play an important role in inducing osteoblast differentiation of mesenchymal stem cells.
Kempen et al. performed a study to determine if the sequential release of vascular endothelial growth factor (VEGF) and BMPs could enhance BMP-2- induced bone formation. A microsphere composite of BMP-2 embedded in a propylene scaffold surrounded by a hydrogel loaded with VEGF was implanted in rats. Empty microspheres or microspheres with either VEGF or BMP were used as controls. They found that in combination with local sustained BMP-2 release, VEGF significantly enhanced ectopic bone formation compared to BMP alone. They conclude that sequential angiogenic and osteogenic growth factor release may be beneficial in bone regeneration.
Illustration A (Cheng et al.) is a figure demonstrating the distinct osteogenic activity of human BMPs. BMP-2, 6, and 9 are the most potent agents to induce osteoblast lineage differentiation of mesenchymal progenitor cells while most
BMPs can promote the terminal differentiation of committed osteoblast precursors.
Incorrect Answers:
Answer 1: BMP-1 is a metalloprotease which is a protease for types I, II, and III collagen. It is unable to induce bone formation.
Answer 3: BMP-3 does not exhibit osteogenic or osteoinductive ability. Answer 4: PPAR-gamma is an adipogenic factor of mesenchymal stem cells. Answer 5: IGF-1 is the most abundant growth factor in bone. It induces proliferation without maturation of the growth plate and is necessary for skeletal growth.

What is the role of matrix metallopeptidase-13 (MMP-13) in the early callus phase of bone healing?

1) Expressed by terminally differentiated chondrocytes to degrade the cartilaginous extracellular matrix

2) Expressed by immature chondrocytes to degrade the calcified extracellular matrix

3) Expressed by terminally differentiated chondrocytes to degrade the calcified extracellular matrix

4) Expressed by terminally differentiated osteoclasts to degrade the calcified extracellular matrix

5) Expressed by terminally differentiated osteoclasts to degrade the cartilaginous extracellular matrix

During the early callus phase of bone healing, MMP-13 is expressed by terminally differentiated chondrocytes to degrade the cartilaginous extracellular matrix.
MMPs are a family of zinc-dependent proteolytic enzymes that can degrade many protein components of the extracellular matrix. Their activity is necessary for matrix turnover during embryogenesis, morphogenesis, normal tissue remodeling, and repair. MMP-13 belongs to the collagenase subgroup of the MMP family as it is able to cleave interstitial fibrillar collagens. It is constitutively produced by terminally differentiated chondrocytes and, in the normal state, it is rapidly endocytosed and degraded. In the presence of a fracture, MMP-13 degrades the collagenous extracellular matrix in the early callus phase and assists in converting the soft callus into woven bone. It's aberrant activity has been implicated in arthritis, cancer, atherosclerosis, and fibrosis.
Gerstenfeld et al. performed a study to develop three-dimensional reconstructions of fracture callus morphogenesis. They collected rat and mouse femur and tibia fracture calluses over various time points of healing. They found that endochondral bone formation occurs asymmetrically with cartilage tissues seen proximal or distal to the fractures in the callus. Remodeling of the calcified cartilage proceeded from the edges of the callus inwards producing a supported trabecular structure over which a thin outer cortex formed. They concluded that remodeling of calcified cartilage produces a trabecular bone structure which provides rapid increases in weight bearing capacity.
Gerstenfeld et al. performed a study to determine if the inhibitory effects of cyclooxygenase-2-(COX-2)-specific anti-inflammatory drugs and nonsteroidal anti- inflammatory drugs (NSAIDs) are reversible after short-term treatment. They administered the medications orally to rats for either 7 or 21 days and assessed fracture-healing with biomechanical, histological, and biochemical analyses. They found that COX-2-specific drugs inhibit fracture-healing more than NSAIDs, and the effect is related to the duration of treatment. They conclude that reduced prostaglandin levels in callus rebound with drug withdrawal, and impairment in the mechanical integrity of fractures is reversed after short- term treatment.
Illustration A demonstrates the stages of fracture healing.
Incorrect Answers:
Answer 2: MMP-13 is produced by terminally differentiated chondrocytes, not immature chondrocytes.
Answer 3: MMP-13 degrades cartilaginous extracellular matrix, not calcified extracellular matrix.
Answers 4 & 5: MMP-13 is produced by terminally differentiated chondrocytes, not osteoclasts.

A 68-year-old woman presents to review the results of a dual- energy x-ray absorptiometry scan. She was found to have a T-score of**
**-2.6. When discussing treatment options, the patient mentions that she saw a commercial advertising a medication that builds new bone. Which of the following is the correct description of this drug?

1) A protein that is produced by osteocytes and is encoded by the SOST gene.

2) A recombinant form of a hormone that is produced by chief cells

3) A competitive partial agonist of the estrogen receptor

4) A polypeptide hormone produced by parafollicular cells

5) A drug which contains a P-C-P backbone

Parathyroid hormone (PTH) is a hormone which is produced by chief cells in
the parathyroid gland. Teriparatide is a recombinant protein form of PTH and is the only available anabolic agent in the United States.
PTH stimulates bone formation and resorption and can increase or decrease bone mass, depending on the mode of administration. Teriparatide or PTH (1-
34), comprises the first 34 amino acids of the hormone and produces its chief biologic effects. Continuous infusions which will result in a persistent elevation of serum PTH concentration will lead to greater bone resorption and hypercalcemia compared to daily injections. Daily injections lead to only
transient increases of PTH which may stimulate bone formation. Intermittent administration increases the number of osteoblasts, activation of pre-existing osteoblasts, increased differentiation of lining cells to become osteoblasts, and reduced osteoblast apoptosis.
Neer et al. performed a study to determine the effect of PTH for the treatment of postmenopausal women with prior vertebral fractures. They randomly assigned 1637 postmenopausal women with prior vertebral fractures to
receive 20 or 40 µg of PTH (1-34) or placebo administered daily. They performed serial measurements of bone mass by dual-energy x-ray absorptiometry. They found new vertebral fractures in 14% of the placebo group compared to 5% in the treatment group. Compared with placebo, PTH increased bone mineral density by 9-13%. They conclude that treatment with PTH (1-34) decreases the risk of vertebral fractures and increases bone mineral density.
Deal wrote a review on the use of intermittent human PTH in the treatment of osteoporosis. He reports that biosynthetic human PTH (1-34) is also known as teriparatide. Its bioavailability is approximately 95% after subcutaneous administration and maximum serum levels are achieved after approximately
30 minutes. It is metabolized in the liver and kidney and no clinically important interactions with other drugs have been found. He reports that in a rat toxicology study in which PTH was administered in high doses of an extended period of time, osteosarcoma was seen. None of the patients in clinical trials have developed osteosarcoma, however.
Incorrect Answers:
Answer 1: A protein that is produced by osteocytes and is encoded by the SOST gene describes sclerostin. Sclerostin decreases bone mass by inhibiting the Wnt pathway. Answer 3: A competitive partial agonist of the estrogen receptor describes raloxifene. Raloxifene slows bone resorption and is not anabolic.
Answer 4: A polypeptide hormone produced by parafollicular cells describes calcitonin. Calcitonin is produced by the thyroid and binds membrane receptors on osteoclasts to inhibit resorption. It is not anabolic.
Answer 5: A drug which contains a P-C-P backbone describes a bisphosphonate. Bisphosphonates inhibit osteoclast resorption and are not anabolic.

A patient previously diagnosed with hypovitaminosis D follows up for repeat laboratory values following initiation of repletion therapy. In the pathway shown in Figure A, what letter corresponds to the serum marker commonly obtained in this scenario?
1) A

2) B

3) C

4) D

5) E

Letter B corresponds to 25-hydroxyvitamin D, the preferred laboratory assay for evaluating vitamin D deficiency.
Vitamin D has two bioequivalent forms; D2 (ergocalciferol) is from vegetables and oral supplements and D3 (cholecalciferol) is from UVB radiation/sunlight, oily fish, food (milk, juices, margarines, yogurts, cereals, and soy), and oral supplements. Both D2 and D3 are biologically inert and are metabolized in the liver to 25-hydroxyvitamin D (calcidiol, which includes 25-hydroxy D2 and 25- hydroxy D3). Calcidiol is converted to 1,25-hydroxy (calcitriol) in the kidney
by 1α-hydroxylase. For measuring serum levels, 25-hydroxy is the best indicator of vitamin D stores because it has half-life of 15 days; 1, 25- dihydroxy has a half-life of 15 hours, and only a fraction of 25-hydroxy is converted to 1,25 dihydroxy. The recommended daily allowance of Vitamin D3 for patients ages 1-70 years old is 600 International Units (IU) (both male and female, lactating/pregnant and non-lactating/pregnant), 400 IU for infants 70 years old.
Norman et al. provide an overview of the role and metabolic pathways involving vitamin D, and also include a historical perspective. They emphasize its importance in calcium and phosphorous regulation. They also note its role in rickets and the discovery of ultraviolet light in cholecalciferol's metabolic pathway.
Patton et al. provide a general review article commenting on the role of vitamin D in orthopaedics. They emphasize its role in bone healing, neuromuscular function, and musculoskeletal development. They conclude that many orthopaedic patients may be at risk for vitamin D deficiency, which may increase their risk of fracture and impair bone healing.
Figure A is a diagram of the metabolic pathway involving cholecalciferol, and Illustration A is the completed diagram shown in Figure A.
Incorrect Answers:
Answer 1: Letter A corresponds to vitamin D3 (cholecalciferol) Answer 3: Letter C corresponds to 1,25(OH)2D3 (calcitriol) Answer 4: Letter D corresponds to 24,25(OH)2D3
Answer 5: Letter E corresponds to 1,24,25(OH)3D3

The seventh character in the ICD-10 coding system describes which of the following?

1) Site of injury

2) Laterality of injury

3) Etiology of injury

4) Category of pathology

5) Phase of treatment

The seventh character in the ICD-10 coding system is used to relay information about the phase of treatment.
ICD-10-CM is a clinical modification of the World Health Organization’s ICD-10, which consists of a diagnostic system. ICD-10-CM includes the level of detail needed for morbidity classification and diagnostic specificity. It also provides
code titles and language that complement accepted clinical practice. As with ICD-9- CM, ICD-10-CM is maintained by the National Center for Health Statistics.
The system consists of more than 68,000 codes, compared to approximately
13,000 ICD-9-CM codes. ICD-10-CM codes have the potential to reveal more about quality of care so that data can be used in a more meaningful way to better understand complications, better design clinically robust algorithms, and better track the outcomes of care. ICD-10-CM incorporates greater specificity and clinical detail to provide information for clinical decision making and outcomes research.
The ICD-10 system consists of 3-7 characters: the first character is alpha, the second is numeric, and the third through seventh are alpha or numeric.
The seventh character can be listed as any of the following: A - Initial encounter for closed fracture
B - Initial encounter for open fracture type I or II
C - Initial encounter for open fracture type IIIA, IIIB, or IIIC D - Subsequent encounter for fracture with routine healing
E - Subsequent encounter for open fracture type I or II with routine healing
F - Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing G - Subsequent encounter for fracture with delayed healing
H - Subsequent encounter for open fracture type I or II with delayed healing J -
Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing K - Subsequent encounter for fracture with nonunion
M - Subsequent encounter for open fracture type I or II with nonunion
N - Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion P - Subsequent encounter for fracture with malunion
Q - Subsequent encounter for open fracture type I or II with malunion
R - Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion S - Sequela
Illustration A shows the overall ICD-10 coding system format.
The referenced instructional course lecture by Bert et al. notes that the ICD- 10-CM allows for more specific descriptors of a procedure and is broken down
by category, etiology, anatomic site, severity, and extension, and contains 4.9 times more codes than ICD-9.

A new patient presents to your office with a one-week history of lower back pain. English is her second language. She endorses radicular-type pain radiating down her left thigh without motor weakness and specifically denies saddle anesthesia or incontinence. Her physical exam is benign other than lumbar paraspinal tenderness and a positive straight leg raise test on the left. In this encounter, which of the following interventions may have the effect of increasing both patient satisfaction and the quality of care provided?

1) Prescribing hydrocodone to a patient at their request

2) Ordering an MRI

3) Providing an interpreter to a patient with limited English proficiency

4) Ensuring that the waiting room is supplied with adequate reading material and beverages

5) Referral to pain management for diagnostic and therapeutic lumbar injections

Providing an interpreter to a patient with limited English proficiency will likely improve both patient satisfaction and the quality of care delivered.
Several measures have been developed to assess patient-centered care and the patient experience. As hospitals are now being measured, ranked, and reimbursed based partially on patient satisfaction, increased resources have been allocated to
improve and study these metrics. One such patient satisfaction survey is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), designed to evaluate and compare the inpatient experience in U.S. hospitals. However, there is concern that these patient-reported measures do not accurately reflect the quality of care delivered and may have several adverse effects.
Shirley et al. describe the relationship between quality of care and patient satisfaction scores. They state that, although quality comprises such factors as safety, efficiency, outcomes, and patient experience, patient satisfaction surveys incorporate factors outside of these domains that may impede the quality of care delivered and increase costs in an effort to boost satisfaction metrics. They conclude that satisfaction surveys are not appropriate measures of overall healthcare quality.
Godil et al. performed a prospective cohort study including 58 patients undergoing transforaminal lumbar interbody fusions for degenerative lumbar spondylolisthesis in order to determine the most valid and responsive instruments to assess quality and effectiveness. Measures to assess pain, disability, general health, quality of life, and depression were utilized. They concluded that the Oswestry Disability Index was the most valid and
responsive measure for assessing pain and disability, whereas the EuroQol five dimensions was the most valid and responsive measure of improvement for health-related quality of life.
Manary et al. provide a perspective piece on the patient experience and health outcomes. They raise concerns that, although such measures are increasingly utilized in research and policy, their accuracy in quality assessment has not been proven. Despite this, the authors feel that available evidence supports that survey content, risk adjustment, and timing of survey administration utilized in surveys such as HCAHPS does correlate with healthcare quality.
Incorrect Answers:
Answer 1: Prescribing medications requested by patients will likely increase patient satisfaction scores but not improve the quality of care provided; narcotics are not indicated in the first-line treatment of acute low back pain. Answer 2: Obtaining imaging, especially when requested by the patient, may improve patient satisfaction but not necessarily the value or quality of care provided; MRI is not indicated initially in the scenario described.
Answer 4: While patient satisfaction ratings may include cleanliness and facility features, these have little to do with the value or quality of care delivered.
Answer 5: A referral to pain management for injections is not indicated acutely in the scenario described, but may be considered, along with advanced imaging, if the patient does not improve with therapy, activity modification,
and non-narcotic analgesics.

An orthopaedic surgeon published an article on double-bundle ACL reconstruction. He describes his current surgical technique developed over the course of 25 years of experience. Which of the following is**
**the most accurate representation of this study's level of evidence?

1) Therapeutic study, Level III

2) Prognostic study, Level III

3) Therapeutic study, Level IV

4) Prognostic study, Level IV

5) Level V

This study is based solely on one surgeon's expert opinion which indicates a Level V study.
Levels of evidence are assigned to determine the clinical value of a study. A Level V study is the lowest level of evidence assigned and is based on either a case report, a personal observation, or an expert opinion. Level I studies are randomized controlled trials or meta-analyses of randomized trials with homogeneous results. Level II studies are prospective cohort studies or meta- analyses of prospective cohort studies. Level III studies are retrospective cohort studies or case-control studies or meta-analyses of Level III studies. Level IV studies include case series.
Wright et al. performed a review of the grades of evidence assigned to studies. They report that levels of ratings for multiple studies addressing a clinical
grade recommendation are summarized with the use of a grade of recommendation. Grade A recommendations are based on consistent Level I studies. Grade B recommendations are based on consistent Level II or III evidence. Grade C recommendations represent either conflicting evidence or are based on Level IV or V evidence. A grade of I indicates that there is insufficient evidence to make a treatment recommendation.
Wright et al. published a table detailing levels of evidence for orthopaedic studies. They define a Level V study as an expert opinion.
Illustration A is a table detailing the levels of evidence for orthopaedic studies (Wright et al.). Illustration B is a table detailing the grades of evidence (Wright et al.).
Incorrect Answers:
Answer 1: A therapeutic study investigates the results of treatment. A Level III study is a case-control study, a retrospective cohort study, or a systematic review of Level III studies.
Answer 2: A prognostic study investigates the outcome of disease.
Answers 3 & 4: A Level IV study is a case series with no historical or control group.

A patient presents with the clinical images shown in Figures A-C. Which of the following is true?
1) Most patients with this skin condition develop arthritis

2) All patients that develop arthritis are positive for HLA-B27

3) The skin lesions respond well to systemic anti-fungal therapy

4) Rheumatoid factor and ANA are usually positive

5) DIP erosions are often centripetal

The clinical presentation is consistent with psoriatic arthritis. DIP joint involvement is characterized by centripetal erosions (pencil-in-cup deformity).
Psoriatic arthritis is one of the seronegative spondyloarthropathies. As such, it most commonly will have have a negative rheumatoid factor and a predilection for patients with the HLA-B27 gene. The majority of patients with psoriasis do not develop psoriatic arthritis. For those that do develop arthritis, the hands and feet are often involved with the DIP joints classically affected. The centripetal erosions and classic pencil-in-cup deformity help differentiate it
from osteoarthritis. These patients require referral to and management by a rheumatologist, as first-line therapies are medically based.
Choo et al. review inflammatory arthroses of the hand and wrist. They state that the management of these and several other conditions is typically medical in nature and continues to evolve with the development of biologically targeted medications. Surgical treatment is infrequently undertaken but can be efficacious for severe cases to alleviate symptoms and for deformity
correction.
Taylor et al. discuss the development of a new classification system for psoriatic arthritis. The CASPAR (ClASsification criteria for Psoriatic ARthritis) criteria is a scoring system based on some of the most common manifestations.
Figures A, B, and C are clinical pictures of a psoriatic plaque, nail pitting, and dactylitis, respectively. These are classic manifestations of psoriatic arthritis.
Illustration A shows the classic centripetal erosion in a left hand with psoriatic arthritis. Due to the erosions and osteolysis, the joint space often widens and deformity may develop. Illustration B is the CASPAR criteria for the diagnosis of psoriatic arthritis.
Incorrect Answers:
Answer 1: Only 5-20% of patients with psoriasis develop psoriatic arthritis. Answer 2: Approximately 50% of patients with psoriatic arthritis are HLA-B27 positive.
Answer 3: The skin lesions are not a result of a fungal infection and are therefore not treated with anti-fungal medications.
Answer 4: RF and ANA are usually negative in psoriatic arthritis.

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The knee ALL is a fibrous band at the anterolateral aspect of the knee. It first was reported by Segond and also is known as the lateral capsular ligament, mid-third lateral capsular ligament, and anterior band of the lateral collateral ligament. It is thought to be injured with varus and internal rotation. It is associated with a torn anterior cruciate ligament 75% of the time and it is located in the third layer on the anterolateral side of the knee. It is 90% collagen I, with some collagen III and VI. The ALL originates at the lateral epicondyle between the lateral collateral ligament and popliteal tendon. It runs obliquely down and forward, inserting in the lateral meniscus and lateral aspect of the proximal tibia. Its role in rotational stability is debated but certainly worthy of consideration, especially in revision knee surgery.
The iliotibial band inserts on Gerdy’s tubercle. A portion of the ALL may insert on the lateral meniscus; however, a lateral meniscus tear is not directly associated with avulsion fractures. The fibular collateral ligament inserts on the fibular head.
RECOMMENDED READINGS
14. Macchi V, Porzionato A, Morra A, Stecco C, Tortorella C, Menegolo M, Grignon B, De Caro R. The anterolateral ligament of the knee: a radiologic and histotopographic study. Surg Radiol Anat. 2015 Oct
[17/. [Epub ahead of print] PubMed PMID: 26476833.](http://www.ncbi.nlm.nih.gov/pubmed/26476833)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/26476833)
15. Kennedy MI, Claes S, Fuso FA, Williams BT, Goldsmith MT, Turnbull TL, Wijdicks CA, LaPrade RF. The Anterolateral Ligament: An Anatomic, Radiographic, and Biomechanical Analysis. Am J Sports Med. 2015 Jul;43(7):1606-15. doi: 10.1177/0363546515578253. Epub 2015 Apr 17. PubMed
[PMID: 25888590. ](http://www.ncbi.nlm.nih.gov/pubmed/25888590)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/25888590)
RESPONSES FOR QUESTIONS 51 THROUGH 57
Figure 51 a- h

a b c
h

d

e
f
g

If wound healing does not occur and deep soft tissues such as the patellar tendon are exposed following TKA, local rotational flap is the procedure of choice. The procedure should be performed relatively early after the recognition of a soft-tissue wound-healing problem. In the setting of TKA, the gastrocnemius muscle is an excellent source of flaps for wound coverage of the proximal tibia.

Proximal humeral fractures in children are classified as metaphyseal or Salter-Harris type I or II fractures, and most of these fractures are treated with closed methods. Eighty percent of the growth of the humerus comes from the proximal physis; therefore, tremendous remodeling potential is present. Indications for open reduction include open fractures or severely displaced fractures in adolescents with minimal growth remaining. Acceptable limits of reduction in adolescent proximal humeral fractures include bayonet apposition and angulation of less than 35°. Common blocks to reduction in adolescents include the biceps tendon and periosteum. For this fracture, use of a shoulder sling without reduction will lead to healing and an excellent result as the proximal humerus remodels.
REFERENCES: Kohler R, Trillaud JM: Fracture and fracture separation of the proximal humerus in children: Report of 136 cases. J Pediatr Orthop 1983;3:326-332.
Beaty JH: Fractures of the proximal humerus and shaft in children. Instr Course Lect 1992;41:369-372.
Dobbs MB, Luhmann SL, Gordon JE, et al: Severely displaced proximal humeral epiphyseal fractures. J Pediatr Orthop 2003;23:208-215.
Beringer DC, Weiner DS, Noble JS, et al: Severely displaced proximal humeral epiphyseal fractures: A follow-up study. J Pediatr Orthop 1998;18:31-37.
Wang P Jr, Koval KJ, Lehman W, et al: Salter-Harris type III fracture-dislocation of the proximal humerus. J Pediatr Orthop B 1997;6:219-222.

The patient has a fixed deformity of the hindfoot and an Achilles tendon contracture; therefore, the treatment of choice is triple arthrodesis with Achilles tendon lengthening. Further bracing will not be helpful. Amputation is not indicated, and ankle arthrodesis will not address the hindfoot deformity. Palliative management would be more appropriate if the knee was unstable or the quadriceps were weak, because the equinus balances the ground reaction force across the knee.
REFERENCES: Perry J, Fontaine JD, Mulroy S: Findings in post-poliomyelitis syndrome: Weakness of muscles of the calf as a source of late pain and fatigue of muscles of the thigh after poliomyelitis. J Bone Joint Surg Am 1995;77:1148-1153.
Dehne R: Congenital and acquired neurologic disorders, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 1, pp 552-553.

Type I mallet injuries are by far the most common mallet injuries. There is no such classification as a type V injury.C orrect
Answer: Type I

The radiograph shows a displaced type II distal clavicle fracture with nonunion. Because the patient’s symptoms are minimal, the injury can be treated like a grade III acromioclavicular separation. Present management should consist of ice, anti-inflammatory drugs, activity modification, and perhaps physical therapy. If nonsurgical management fails to provide relief, the surgical options are varied with no uniformity in the literature regarding surgical treatment of this injury.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.
Craig EV: Fractures of the clavicle, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, pp 428-482.

- First metatarsophalangeal (MTP) joint arthrodesis and lesser metatarsal head resection

This injury pattern is one of a direct trauma to the mid aspect of the foot. Without additional forces involved, capsular ligamentous injury is not anticipated; therefore, the injury should be a stable pattern. Treatment should consist of protected weight bearing as tolerated in a walking boot or walking cast. Surgical intervention with open reduction and internal fixation, percutaneous pinning, or open reduction and internal fixation with primary tarsometatarsal joint fusion is not indicated with this pattern of injury. The use of external bone stimulation in this acute fracture setting is not indicated. With injuries to the midfoot area where the exact mechanism of injury is uncertain, there should be a high index of suspicion for an associated injury to the tarsometatarsal joint, and standing radiographs or stress radiographs should be obtained.
REFERENCES: Myerson MS: Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1265-1296.
Early JS: Fractures and dislocations of the midfoot and forefoot, in Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001,
pp 2181-2245.

This patient presents with an acute neuroarthropathy. The acute painless swelling, associated with warmth and absence of radiographic findings, is typical of the acute phase of a C harcot process. A short leg cast or a boot to immobilize the foot is ideal, and no weight bearing should be permitted until the acute phase of this neuroarthropathy has subsided.

Over the past two decades, a continuous shift toward outcome assessment in medicine has occurred. Publications previously devoted to technical details and surgical technique have started analyzing and measuring the impact and longevity of medical procedures on patients' quality-of-life and have compared the cost-effectiveness of different procedures

Follow-up examination at 6 months revealed no statistically significant differences in quadricep or hamstring strength when comparing surgical versus nonsurgical extremities isokinetically. Therefore, the selection of autogenous hamstring or patellar tendon for ACL reconstruction should not be based solely on the assumption of the graft tissue source altering the recovery of quadricep and/or hamstring strength.
REFERENCES: Carter TR, Edinger S: Isokinetic evaluation of anterior cruciate ligament reconstruction: Hamstring versus patellar tendon. Arthroscopy 1999;15:169-172
Howell SM, Taylor MA: Brace-free rehabilitation, with early return to activity, for knees reconstructed with a double-looped semitendinosus and gracilis graft. J Bone Joint Surg Am 1996;78:814-825.
Shelbourne KD, Nitz P: Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med 1990;18:292-299.