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

The next most appropriate step in management is to proceed with a biopsy of the most accessible site. This can be done
by the surgeon or by an interventional radiologist trained in core biopsy techniques. It is imperative to make a pathologic diagnosis prior to proceeding with any further medical, surgical, or radiation treatments. A histologic diagnosis at this point is the only way a medical oncologist can have a meaningful discussion with the patient about their disease, its natural history, and ultimately discuss treatment options and prognosis. Further imaging at this point only delays the time to histologic evaluation. Consideration of surgical stabilization can be delayed until a diagnosis is established and a multidisciplinary approach is initiated. This fracture can be treated at least temporarily with nonsurgical protected weight bearing with a walker or crutches.
Hospice may soon serve a useful role but a diagnosis must first be rendered and a limited life expectancy anticipated. Pre Res # 100 is 2
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Chronic opioid consumption prior to total joint arthroplasty has been associated with increased pain after surgery, increased opioid requirements, a slower recovery and longer hospital stay, and higher 90-day postoperative complications compared with patients not on chronic opioids preoperatively. Based on this information, Nguyen and associates performed a study in three patient groups that included 1) chronic opioid users who underwent no preoperative intervention, 2) chronic opioid users who were weaned down to 50% of their prior opioid regimen, and 3) patients who were not chronic opioid users. The authors found that the reduction of preoperative opioid use improved postoperative function, pain, and recovery and that the weaned group performed more like the opioid naive group than the chronic opioid user
group. Increasing opioid use prior to surgery in this patient would make it more difficult to control pain after surgery. Stopping all of his opioids just prior to surgery would place the patient at substantial risk for opioid withdrawal and is not recommended. Avoiding the use of all narcotics and using only acetaminophen postoperatively is very unlikely to provide appropriate pain relief in a chronic opioid user. The recommendation based on the provided literature is to decrease the patient's narcotic use prior to
surgery.

The radiographs show severe osteoarthritis of the shoulder. The best surgical option would be an arthroplasty. The major determining factor for which type of arthroplasty to choose is the integrity of the rotator cuff tendons.
Although the radiographs do not reveal any obvious signs of rotator cuff failure, the patient had had an open Bankart 20 years ago. The integrity of the subscapularis tendon following a previous open shoulder procedure is crucial in deciding which type of arthroplasty to consider. Range of motion and infraspinatus strength do not affect the decision-making process, assuming the rotator cuff is intact. Activity level can be important when deciding whether to proceed with an arthroplasty, but it is not as important as the rotator cuff integrity when choosing which
arthroplasty to use.

With soft-tissue loss, local or free flap coverage may be necessary to treat exposed tendon and bone. However, a vacuum-assisted closure device is a good temporizing dressing. It prevents external contamination, reduces edema around the wound, increases oxygen tension in the wound, and promotes the formation of granulation tissue. The use of this negative pressure device has been described in both acute traumatic and in chronic wound scenarios. If sufficient granulation tissue forms, closure may be by split graft, avoiding a more complex coverage procedure. Immediate skin grafting over the exposed anterior tibial tendon and tibia would have a low likelihood of success. Dressing changes with sulfasalazine may be beneficial in a burn wound to assist with removal of skin slough; however, in a granulating wound, the material may be toxic to early epithelialization. Xenograft is a foreign body and should not be applied to an acute contaminated open wound. Historically, a cross-leg flap was a treatment alternative for lower extremity soft-tissue loss; however, its current applications are extremely limited.
REFERENCES: Webb LX: New techniques in wound management: Vacuum assisted wound closure. J Am Acad Orthop Surg 2002;10:303-311.
Clare MP, Fitzgibbons TC, McMullen ST, et al: Experience with the vacuum assisted closure negative pressure technique in the treatment of non-healing diabetic and dysvascular wounds. Foot Ankle Int 2002;23:896-901.

The anteroposterior and lateral radiographs show thinned cortices and a gentle S-shaped curve of the tibia. The overall alignment of the tibia, as well as the physes, is normal. These are the radiographiCfeatures of osteogenesis imperfecta.
In osteogenesis imperfecta, the genetiCdefect involves type I collagen. Type I collagen is made up of two alpha-1 chains and one alpha-2 chain in a triple helix. Glycine is the smallest amino acid and is crucial for coiling of the triple helix. Mutations in the
glycine chain lead to severe forms of osteogenesis imperfecta. One should also remember the Silence classification:
Type Inheritance Sclera Severity
I AD Blue Mild form, normal teeth
II AR Blue Lethal form, die early
III AR Normal Severe, progressively deforming
IV AD Normal Moderately severe
Biphosphonate therapy can be used to slow bone remodeling and increase bone mass. With regard to the incorrect choices:
FGF receptor 3 is associated with achondroplasia. Fibrillin is associated with Marfan's syndrome.
Type II collagen is associated with spondyloepiphyseal dsyplasia.
Cartilage oligomeriCmatrix protein is associated with pseudoachondroplasia. Correct Answer: Type I collagen

■
The patient has degenerative disk disease with diskogenic back pain. Several studies in both humans and animals have implicated TNF-α, IL-1, and MMP in extracellular matrix degeneration and disk degradation. TGF-β, BMP-2, latent membrane protein 1, and growth and development factor-5 are all postulated to play anabolic roles in the intervertebral disk. Biglycan is a small leucine-rich proteoglycan that regulates extracellular matrix assembly within the disk. Noggin and gremlin are biochemical factors not involved in disk degradation.

The next best course of action is total hip arthroplasty. The patient is an otherwise healthy woman requesting pain relief and expresses a desire to be dancing in 4 months. She has had more than 6 months of symptoms that are classic hip osteoarthritis symptoms, with pain in the groin and thigh. Severe osteoarthritis is seen in the radiograph as well. NSAIDs are no longer working. Given the objective findings, the subjective reports, and the duration of symptoms, this patient merits surgery. Consideration for steroid injection is reasonable, but given her desire to be dancing in 4 months, an injection would increase her risk of infection if total hip arthroplasty were to be performed within 3 months of the
injection.

- Nonsteroidal anti-inflammatory drugs and physical therapy_

The radiographs show a lytic, destructive, poorly marginated femur lesion. MR imaging confirms the infiltrative nature of the lesion, a communication with the joint, and a substantial nonenhancing joint effusion. Biopsy confirms numerous polymorphonuclear neutrophils consistent with osteomyelitis with septic arthritis. The treatment of femur osteomyelitis with a septic knee includes aggressive debridement of all nonviable tissue, placement of antibiotic beads, and IV antibiotics. Surgical wide resection and endoprosthetic reconstruction would be considered only if the lesion were a low-grade malignancy. Aggressive curettage with allograft placement would be considered for benign tumors. Allograft placement is not appropriate in the setting of an infection. Chemotherapy followed by wide surgical resection and reconstruction is only appropriate for a high-grade malignancy.
RECOMMENDED READINGS
82. [Lew DP, Waldvogel FA. Osteomyelitis. Lancet. 2004 Jul 24-30;364(9431):369-79. Review. PubMed PMID: 15276398.](http://www.ncbi.nlm.nih.gov/pubmed/15276398)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/15276398)
83. [Tetsworth K, Cierny G 3rd. Osteomyelitis debridement techniques. Clin Orthop Relat Res. 1999 Mar;(360):87-96. Review. PubMed PMID: 10101313.](http://www.ncbi.nlm.nih.gov/pubmed/10101313)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/10101313)
84. [Karchevsky M, Schweitzer ME, Morrison WB, Parellada JA. MRI findings of septic arthritis and associated osteomyelitis in adults. AJR Am J Roentgenol. 2004 Jan;182(1):119-22. PubMed PMID: 14684523.](http://www.ncbi.nlm.nih.gov/pubmed/14684523)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/14684523)
CLINICAL SITUATION FOR QUESTIONS 90 AND 91
Figures 90a and 90b are the axial MR image and histology of a 27-year-old woman who has a firm lesion in the popliteal fossa. Figure 90c is the gross specimen after resection.

A number of factors affect nerve conduction velocity; for example, increased body temperature increases nerve conduction velocity. Nerve conduction velocity is slowed by advancing age, compression, decreased blood flow, and fibrosis (from large imprecise sutures used for nerve repair). There is no _association between hand dominance and nerve conduction velocity._

C omplications of macrodactyly surgery include poor healing of flaps secondary to devascularization or undue tension, nerve injury or decreased sensation, infection, stiffness, bony nonunion or malunion, and failure of the epiphysiodesis.

A volar lunate fragment of a distal radial fracture is considered a critical component to overall joint stability and function. Obtaining a reduction is difficult through a standard volar approach to the radius between the flexor carpi radialis and radial artery. Visualization and reduction of the ulnar volar facet is not possible from this approach. An extended carpal tunnel incision provides access to the entire articular surface, except for the distal radial styloid component.
REFERENCES: Hanel DP, Jones MD, Trumble TE: Wrist fractures. Orthop Clin North Am 2002;33:35-57.
Trumble TE, Culp RW, Hanel DP, et al: Intra-articular fractures of the distal aspect of the radius. Instr Course Lect 1999;48:465-480.

Based on these findings, the most likely diagnosis is a rotator cuff injury and probable tear; therefore, MRI is the study of choice. CT is preferred for articular fractures. A bone scan is nonspecific and can identify inflammation or occult fracture. Joint aspiration is not likely to identify an effusion. Physical therapy and a functional capacity examination are used to identify weakness during recovery prior to a return to work or sports.
REFERENCES: Hawkins RJ, Bell RH, Hawkins RH, Koppert GJ: Anterior dislocation of the shoulder in the older patient. Clin Orthop 1986;206:192-195.
Matsen FA III, Thomas SC, Rockwood CA: Anterior glenohumeral instability, in Rockwood CA, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 526-622.

- weakness with finger abduction.

- chemotherapy and wide surgical resection._

Although amputation may be necessary in some patients with macrodactyly, it is too early in the course of this case to begin entertaining such a drastic measure. A debulking procedure is not recommended for a 2-year-old child. Radiation therapy is not an option in uncomplicated cases of macrodactyly. The surgeon must educate the parents about the disease process and order additional testing.

- Cam-type femoroacetabular impingement with an acetabular labral tear

Isolated palsy of the infraspinatus portion of the suprascapular nerve is common in volleyball players and is seen frequently in the throwing arm of baseball players. The exact cause is not known, but it may be the result of either tethering or traction on the nerve at the spinoglenoid notch. Synovial cysts in the spinoglenoid notch also can be a cause, but the patient’s negative MRI findings rule out that entity. Because many isolated nerve palsies of the infraspinatus branch are asymptomatic, initial management should always be nonsurgical. Surprisingly, many athletes with this injury can participate fully in sports. Surgical treatment with decompression at the notch is unpredictable and generally is indicated only if nonsurgical management fails.
REFERENCES: Ferretti A, Cerullo G, Russo G: Suprascapular neuropathy in volleyball players. J Bone Joint Surg Am 1987;69:260-263.
Martin SD, Warren RF, Martin TL, Kennedy K, O’Brien SJ, Wickiewicz TL: Suprascapular neuropathy: Results of non-operative treatment. J Bone Joint Surg Am 1997;79:1159-1165.

Polyethylene wear is evident due to the superiorly eccentric position of the femoral head within the acetabulum. Despite proximal femoral osteolysis, the component appears well fixed, as does the acetabulum. The acetabular component appears to be well positioned. Therefore, an isolated synovectomy and polyethylene liner exchange is indicated. If the hip is stable, there is no need for more extensive revision work.
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 521-528.

DISCUSSION: Tuberculosis of the spine typically has an indolent presentation. Unlike pyogenic infections of the spine, the disk space is usually preserved. Most commonly, the thoracic and lumbar spine are affected. Laboratory studies may be nonspecific. Delayed presentation usually results in neurologic compromise and a kyphotic deformity. Treatment includes a multidrug regimen. Surgery is indicated for deformity correction or failure of medical treatment.
REFERENCES: Rajasekaran S: Buckling collapse of the spine in childhood spinal tuberculosis. Clin Orthop Relat Res 2007;460:86-92.
_TAL-MaeKXCpy I_ Hu SS: Spinal infections. J Am Acad Orthop Surg 2002; 10:188-197fcUa-MJ ^

Figure 71a Figure 71b Figure 71c Figure 71 d Question 71
A 10-year-old child was referred for spinal curvature and a 2-year history of back pain. She has pain
during the day and pain at night that wakes her from sleep and is temporarily relieved with nonsteroidal anti-inflammatory drugs. Examination shows very tight hamstrings and an irritative spinal curvature. Figures 71a through 71 d show radiographs, a bone scan, and a CT scan. What is the most appropriate treatment?

1. ##### Bracing with a thoracolumbosacral orthosis (TLSO)
2. ##### Observation with repeat radiographs of the scoliosis in 3 months and nonsteroidal antiinflammatory drugs for the pain
3. ##### MRI of the neuro-axis
4. ##### Surgical removal
5. ##### Radiofrequency ablation
PREFERRED RESPONSE: 4
DISCUSSION: The history, examination findings, and studies are consistent with an osteoid osteoma. The CT scan shows a classic “target” lesion, and the bone scan has intense uptake at the site of the osteoid osteoma. The child has had a 2-year history of pain that even wakes her from sleep, so
obs _A_ e _L_ rv _-M_ at _a_ io _de_ n _na_ a _C_ n _o_ d _py_ anti-inflammatory drugs is not a preferred treatment. Bracing will not help with the

58 • American Academy of Orthopaedic Surgeons

discomfort because the pain is not mechanical in nature. MRI would not be needed in addition to the studies already completed. The osteoid osteoma is close to the spinal cord so radiofrequency ablation is not preferred. Surgical removal and biopsy is the treatment of choice.

REFERENCES: Frassica FJ, Waltrip RL, Sponseller PD, et al: Clinicopathologic features and treatment of osteoid osteoma and osteoblastoma in children and adolescents. Orthop Clin North Am 1996;27:559-
574/. Cantwell CP, Obyme J, Eustace S: Current trends in treatment of osteoid osteoma with an emphasis on radiofirequency ablation. Eur Radiol 2004;14:607-617.

Figure 72

The video shows the lack of tenodesis caused by the incompetence of the FDP tendon to the ring finger, which can be attributable to a laceration, tendon rupture, or avulsion. Note how the ring finger stays extended (compared to the other digits) when the extensor tendons are tightened during wrist extension. The other fingers are pulled into flexion by the FDP tendons when the extensor tendons are relaxed during wrist extension. With the wrist flexed, the extensor mechanism to all fingers appears to be functioning normally. Findings indicating a trigger finger would be locking in flexion of the proximal interphalangeal joint. FDS incompetence can only be detected by blocking FDP function of the other fingers and actively flexing the examined finger.

This patient has cervical myelopathy caused by both congenital stenosis and an ossified posterior longitudinal ligament (OPLL). OPLL typically is seen in populations of Asian people and appears more frequently in males. The pathogenesis is unclear, but the posterior longitudinal ligament that connects the posterior vertebral body becomes ossified, making it visible on CT scan.
A herniated disk may be difficult to see on a CT scan and is not typically calcified This patient has degenerative spondylosis and likely some ligamentum hypertrophy, but the OPLL is fairly prominent and thick in the upper cervical spine. The ligamentum flavum is located dorsal to the dural sac, and the ossification is ventral to the dural sac.
RECOMMENDED READINGS
22. [An HS, Al-Shihabi L, Kurd M. Surgical treatment for ossification of the posterior longitudinal ligament in the cervical spine. J Am Acad Orthop Surg. 2014 Jul;22(7):420-9. doi: 10.5435/JAAOS-22-07-420. Review. PubMed PMID: 24966248.](http://www.ncbi.nlm.nih.gov/pubmed/24966248)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24966248)
23. [Mizuno J, Nakagawa H. Ossified posterior longitudinal ligament: management strategies and outcomes. Spine J. 2006 Nov-Dec;6(6 Suppl):282S-288S. Review. PubMed PMID: 17097548. ](http://www.ncbi.nlm.nih.gov/pubmed/17097548)[View](http://www.ncbi.nlm.nih.gov/pubmed/17097548)[ ](http://www.ncbi.nlm.nih.gov/pubmed/17097548)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/17097548)

The anatomic structure labeled is the biceps tendon, which has subluxated medially from the intertubercular groove as a result of disruption of the biceps pulley that occurs with subscapularis tears. The anterior labrum is adjacent to the glenoid and is not normally torn with subscapularis pathology. The middle glenohumeral ligament may appear cord-like, but is shown more medial to the subluxated biceps tendon. The rotator interval tissue, or "comma" tissue, is generally along the upper border of the subscapularis and is pulled toward the coracoid base in subscapularis tears.

Various options exist to treat thumb CMC arthritis: trapezial resection alone, trapezial resection with ligament suspensionplasty or tendon interposition, trapezial resection with both ligament suspensionplasty and tendon interposition, CMC fusion, and CMC replacement. MCP hyperextension can develop in long-standing CMC arthritis, contributing to CMC instability as well as thumb pain and weakness. In patients with concomitant MCP hyperextension that exceeds 30°,
correction of the deformity of the MCP joint must also be addressed and can be done with MCP capsulodesis, extensor pollicis brevis tendon transfer, or MCP fusion. Fusion of both the thumb CMC and MP joints is not recommended as this would result in marked stiffness and dysfunction.

In adults, 70% to 85% will experience an episode of low back pain at some period during their life. Most recover quickly and without residual functional deficits. Of those patients with symptoms severe enough to require absence from work, 60% to 70% return within 6 weeks and 80% to 90% return within 12 weeks. After 12 weeks of symptoms, return to work is much slower.

Metal-on-metal THA was initially introduced in the 1990s, with the proposed advantages of decreased wear and improved stability. However, catastrophic adverse local tissue reactions associated with their use has raised numerous concerns. The work-up of a patient with a prior metal-on-metal total hip arthroplasty involves a thorough history and physical examination; blood analysis, including the erythrocyte sedimentation rate, C-reactive protein, and metal ion levels; and secondary imaging, including ultrasonography, CT, and MRI. In a patient with clinical symptoms, elevated metal ion levels, and a large fluid collection seen on MRI, the most appropriate treatment would be removal of the metal-on-metal bearing. Given the presence of an adverse reaction involving cobalt and chromium, a revision ceramic head may be most appropriate to avoid the potential of trunnion-associated corrosion.

2010 Pediatric Orthopaedic Examination
ook • 69

3. ##### Immediate exploration of the radial nerve with open reduction and plate fixation
4. ##### Monitoring of radial nerve function and application of a sling and swathe
5. ##### Monitoring of radial nerve function and external fixation PREFERRED RESPONSE: 4
DISCUSSION: Humeral shaft fractures in children rarely require open reduction. Shoulder and elbow function does not appear to be affected by up to 40 degrees of angulation in this patient population. Because of the high rate of remodeling in pediatric patients, the standard treatment is immobilization in a sling and swathe, a hanging arm cast, or a compressive dressing. Surgical fixation of humeral shaft fractures is usually only necessary in open injuries, multitrauma, or severely displaced fractures. Most radial nerve injuries associated with humerus fractures are secondary to contusion. Almost all associated radial nerve injuries in pediatric patients can be treated with observation.
REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 304.
Shrader MW: Proximal humerus and humeral shaft fractures in children. Hand Clin 2007;23:431-435. Caviglia H, Garrido CP, Palazzi FF, et al: Pediatric fractures of the humerus. Clin Orthop Relat Res 2005;432:49-56.

Minimally displaced fractures of the proximal humerus have a good outcome if physical therapy is initiated within 2 weeks of the injury. Results are not affected by age, open reduction and internal fixation, or involvement of the greater tuberosity. Immobilization for longer than 3 weeks will often result in stiffness.
REFERENCES: Koval KJ, Gallagher MA, Marsicano JG, et al: Functional outcome after minimally displaced fractures of the proximal part of the humerus. J Bone Joint Surg Am 1997;79:203-207.
Hodgson SA, Mawson SJ, Stanley D: Rehabilitation after two-part fractures of the neck of the humerus. J Bone Joint Surg Br 2003;85:419-422.

In the intertrochanteric hip fracture displayed, a sliding hip screw (SHS) or cephalomedullary nail (CMN) would be indicated; the SHS is the cheaper implant.
In a standard obliquity intertrochanteric fracture without lateral wall comminution, an SHS is a cost-effective option. In reverse obliquity fractures or those with lateral wall comminution (unstable), there is an increased failure rate with this implant and an CMN should be considered. There is some controversy in terms of short and intermediate nail indications, which are attractive because they do not require reaming. SHS implants are contraindicated in subtrochanteric fractures. Although some hospitals receive discounts on implants, in general, intramedullary nail options are more expensive than SHS.
Swart et al. examined the cost-effectiveness of different fixation options for intertrochanteric hip fractures. They compared SHS and CMN implants using an expected-value decision-analysis model, taking into account fracture patterns, failure rates, and revision costs. In their study, the average cost of a SHS was
$2,000 compared to $3,200 for a standard CMN. They concluded that the SHS was likely more cost-effective for stable and questionably stable fractures compared to CMN fixation; CMN was more cost-effective for reverse obliquity patterns.
Kaplan et al. provided a review article on the surgical management of intertrochanteric fractures. Factors to determine treatment should include the patient's medical co-morbidities, pre-existing arthritis, bone quality, and fracture morphology. Their study did not find an appreciable difference in patient outcomes using either CMN or SHS for stable intertrochanteric fractures; surgeon experience and implant costs should, therefore, drive the decision making process for implant selection.
Figures A and B are AP and lateral right hip radiographs, respectively, demonstrating a standard obliquity intertrochanteric hip fracture. Illustration A is an AP post-operative radiograph showing a hip fracture treated with a SHS.
Incorrect Answers:
Answers 1 and 2: Both of these options are appropriate for this fracture but more costly than a SHS.
Answer 4: Arthroplasty is not indicated for this patient with an intertrochanteric fracture and preserved joint space.
Answer 5: Cannulated screws are not indicated for an intertrochanteric fracture.

- Common peroneal nerve

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The images reveal a displaced tibial eminence fracture in a skeletally immature patient. These represent anterior cruciate ligament (ACL)-equivalent injuries in children. Though the ACL elongates as part of the injury process, when the bony fragment is replaced and heals, the knee is usually functionally stable, and patients return to preinjury levels of activity without difficulty.
No long-term injury is expected, so there is no reason to expect inability to return to sports or strenuous activity. This injury heals with normal bone and does not predispose to reinjury. There is no evidence that a stable knee, which is expected after this injury, will lead to premature osteoarthritis.

DISCUSSION: This question centers on the prophylactic treatment to reduce the risk of heterotopic bone formation. Prophylaxis is indicated because he has already demonstrated bone formation with his prior hip arthroplasty, which places him at increased risk for developing heterotopic bone on the contralateral side. He is on warfarin and has renal insufficiency, which makes the use of NSAIDs contraindicated. The recommended dose is 600 to 800 centigrey of radiation given within 24 hours of surgery preoperatively or 72 hours postoperatively.

REFERENCES: Kolbl O, Knelles D, Barthel T, et al: Preoperative irradiation versus the use of nonsteroidal anti-inflammatory drugs for prevention of heterotopic ossification following total hip replacement: The results of a randomized trial. Int J Radiat Oncol Biol Phys 1998;42:397-401.
Pakos EE, Ioannidis JP: Radiotherapy vs nonsteroidal anti-inflammatory drugs for the prevention of heterotopic ossification after major hip surgery: A meta-analysis of randomized trials. Int J Radiat Oncol Biol Phys 2004;60:888-895.
Seegenschmiedt MH, Makoski HB, Micke O, et al: Radiation prophylaxis for heterotopic ossification about the hip joint: A multicenter study. Int J Radiat Oncol Biol Phys 2001 ;51:756-765.

Figure 23 a Figure 23b

With a full-thickness articular cartilage injury, a healing response is initiated with hematoma, stem cell migration, and vascular ingrowth. This response produces type I collagen and resultant fibrous cartilage rather than desired hyaline cartilage as produced by chondrocytes. This repair cartilage has diminished resiliency, stiffness, poor wear characteristics, and the predilection for arthritis. Type I collagen is also found in the annulus of intervertebral disks, tendon, bone, meniscus, and skin. Type II is found in articular cartilage and nucleus pulposus of intervertebral disks. Type III is found in skin and blood vessels, type IV is found in basement membranes, and type X is found in the calcified layer of cartilage.
REFERENCES: Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 19-28.
Brinker M: Basic Science in Review of Orthopaedics, ed 3. Philadelphia, PA,
WB Saunders, 2000.

- Cortisone injection therapy with continued physical therapy (PT)

- decompress the ulnar nerve.

The primary action of the posterior tibialis tendon is inversion of the foot; secondarily, it plantar flexes the ankle. The anterior tibialis tendon also inverts the foot and only partially antagonizes the posterior tibialis tendon. The primary action of the peroneus longus is plantar flexion of the first ray. It secondarily everts the posterior tibialis tendon. The action of the flexor digitorum longus tendon is synergistic with the posterior tibialis tendon. The primary action of the peroneus brevis tendon is eversion; therefore, it is the primary antagonist of the posterior tibialis tendon.
REFERENCES: Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993, pp 550-551.
Mann RA: Biomechanics of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 2-36.

The peroneus brevis is usually the first muscle to atrophy. Varying patterns of loss of the other muscles of the lower extremity include the anterior tibial and, in particular, the intrinsic foot muscles. Weakness in these muscles accounts for the cavus and the claw foot deformities noted in patients with hereditary sensory motor neuropathy.

Excessive resection of the common extensor origin posterior to the equator of the radiocapitellar joint may lead to iatrogenic lateral collateral ligament (LCL) injury, causing posterior lateral rotatory instability (PLRI). Patients may present with lateral elbow pain, a positive lateral pivot shift test, or mechanical symptoms/subjective instability when pushing up from a chair (positive chair rise test). PLRI is often provoked with combined elbow extension and forearm supination, as the posterior support for the radiocapitellar joint has been lost. Therefore, placing the forearm in pronation during elbow extension places the radiocapitellar joint in a more stable position and is less likely to induce pain or mechanical symptoms. Valgus instability and MCL tenderness would be associated with an MCL injury.

The clinical photograph shows a hallux valgus and a crossover toe deformity. The plantar plate must be damaged for a crossover toe deformity to develop. A moderately severe hallux valgus deformity without arthritic change is best treated with a bunionectomy with a proximal metatarsal osteotomy. The surgeon must assume that the open joint is at least colonized and at significant risk for postsurgical infection; consequently, it is best to cancel elective surgery, and surgical debridement of soft tissue and bone with deep cultures is recommended.
RECOMMENDED READINGS
[Kaz AJ, Coughlin MJ. Crossover second toe: demographics, etiology, and radiographic assessment. Foot Ankle Int. 2007 Dec;28(12):1223-37. doi: 10.3113/FAI.2007.1223. PubMed PMID: 18173985. ](http://www.ncbi.nlm.nih.gov/pubmed/18173985)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18173985)
[Chalayon O, Chertman C, Guss AD, Saltzman CL, Nickisch F, Bachus KN. Role of plantar plate and surgical reconstruction techniques on static stability of lesser metatarsophalangeal joints: a biomechanical study. Foot Ankle Int. 2013 Oct;34(10):1436-42. doi: 10.1177/ 1071100713491728. Epub 2013 Jun 17. PubMed PMID: 23774466. ](http://www.ncbi.nlm.nih.gov/pubmed/23774466)[View ](http://www.ncbi.nlm.nih.gov/pubmed/23774466)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23774466)
[Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle. 1989 Dec;10(3):156-60. PubMed PMID: 2613128. ](http://www.ncbi.nlm.nih.gov/pubmed/2613128)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/2613128)

DISCUSSION
Glenoid exposure, while better than with surface replacements, is not improved over traditional stemmed replacements. Metaphyseal comminution would make it unlikely that a stemless implant could be used in most four-part fractures. Stemless replacement does have the unique advantage of allowing placement of a prosthesis with a malunion without an osteotomy, as the prosthesis is not constrained by the position of the stem. While early results are encouraging, there is no long-term data to suggest that survivorship is increased
with stemless arthroplasty.

This young child with total head involvement LCPD is at some risk of a poor outcome due to the extent of his disease. Most children of this age will recover well with a good outcome. He is more likely to end up with a spherical femoral head than an older child with the same extent of involvement.
_AL-Madena Copy_
REFERENCES: Schoenecker PL, Stone JW, Capelli AM: Legg-Perthes disease in children under 6 years old. Orthop Rev 1993;22:201-208.
Rosenfeld SB, Herring JA, Chao JC: Legg-Calve-Perthes disease: A review of cases with onset before six years of age. J Bone Joint Surg Am 2007;89:2712-2722.

Figure 78

- Charcot foot

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This is a 5-year-old girl with a new diagnosis of scoliosis, having an isolated right thoracic curve. This is considered juvenile onset idiopathic scoliosis, which presents between the ages of 3-9 years old. The initial radiographs show a curve measuring 41°. Any curve >20° in a patient with early onset scoliosis should undergo MRI of the entire spine to assess for intraspinal pathology, with an average of 20% of patients having underlying diagnoses, i.e. Arnold-Chiari, syringomyelia. Observation or TLSO bracing may be indicated; however, an MRI is still the first line of management in this patient. Physical therapy may be useful for adjunct treatment, but the MRI is still required at this stage of evaluation and diagnosis.

SCC in situ is a low-grade malignancy that typically presents as painless lesions on areas of high sun exposure such as the dorsum of the hand and fingers. The recommended treatment for lesions smaller than 100 mm is wide excision with 4 mm margins to a depth 1 layer below the tumor, along with any adjacent area of induration. Sentinel lymph node biopsy is typically not indicated in the setting of a low-grade tumor such as this one and in the absence of axillary lymphadenopathy.

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CT of the cervical spine is fast and readily available in most centers. The reported sensitivity of CT is greater than 95%, whereas specificity is almost 100%. In contrast, plain radiographs have a sensitivity of 70% and a missed injury rate of 15% to 30%. CT also has been found to be as cost effective or more cost effective compared with plain radiographs in diagnosing cervical injuries. MRI is expensive, not always readily available, and inferior to CT in diagnosing bony injuries. In this patient, dynamic imaging in the form of flexion-extension views is contraindicated as a first line radiographic test. The patient may have an unstable cervical injury which could be exacerbated with motion. The patient's mental status also does not allow voluntary motion. The maneuver would have to be done by the physician or radiology technician.

The radiograph reveals a rotator cuff dysfunction secondary to malpositioning of the humeral stem and a nonanatomic humeral head. Glenohumeral kinematics have been altered, resulting in damage to the rotator cuff, which in turn has led to impingement with the coracoacromial arch. This single radiograph reveals excessive humeral head height, “overstuffing” of the joint, and severe narrowing of the acromiohumeral interval. Osteolysis and implant loosening are not radiographically apparent. An orthogonal view (axillary lateral) would be necessary to evaluate for shoulder instability. A CT arthrogram is the most appropriate advanced imaging test in the setting of a retained shoulder arthroplasty to evaluate the integrity of the rotator cuff. An MRI evaluation would be obfuscated by artifact. Three-phase and indium-tagged white blood cell scans may be appropriate in the setting of an occult infection evaluation, but not as a test to evaluate rotator cuff injury.
In the absence of infection with rotator cuff compromise, the most appropriate procedure(s) during revision would involve humeral component explantation and conversion to rTSA Revision anatomic hemiarthroplasty may provide pain relief, but function may not appreciably change because of the unbalanced forced couples of the rotator cuff complex. Placement of a glenoid component in the setting of an irreparable rotator cuff tear is contraindicated because rapid glenoid loosening will occur due to eccentric loading during active shoulder motion. Resection arthroplasty should be reserved for recalcitrant cases of infection because this procedure does not provide functional improvement.
In the event that frozen section analysis and positive gram stain results indicate an infection, the treating surgeon should remove all components, perform a thorough debridement and irrigation of suspect tissue, implant an antibiotic spacer, and perform a second-stage reconstruction when deemed appropriate (in light of laboratory studies, repeat shoulder aspiration, frozen section analysis, and arthroscopic soft-tissue biopsy findings). Irrigation and debridement with primary exchange/conversion of components remains inferior to 2-stage reconstruction for infection eradication. Resection arthroplasty remains a salvage procedure for resistant cases that preclude reimplantation and generally is performed for symptom control and sepsis prevention.
RECOMMENDED READINGS
1. [Bohsali KI, Wirth MA, Rockwood CA Jr. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006 Oct;88(10):2279-92. Review. PubMed PMID: 17015609. ](http://www.ncbi.nlm.nih.gov/pubmed/17015609)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/17015609)
2. [Florschütz AV, Lane PD, Crosby LA. Infection after primary anatomic versus primary reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2015 Aug;24(8):1296-301. doi: 10.1016/j.jse.2014.12.036. Epub 2015 Feb 19. PubMed PMID: 25704211. ](http://www.ncbi.nlm.nih.gov/pubmed/25704211)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/25704211)
3. [Padegimas EM, Maltenfort M, Ramsey ML, Williams GR, Parvizi J, Namdari S. Periprosthetic shoulder infection in the United States: incidence and economic burden. J Shoulder Elbow Surg. 2015 May;24(5):741-6. doi: 10.1016/j.jse.2014.11.044. Epub 2015 Jan 13. ](http://www.ncbi.nlm.nih.gov/pubmed/25595360)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/25595360)
4. [Leung B, Horodyski M, Struk AM, Wright TW. Functional outcome of hemiarthroplasty compared with reverse total shoulder arthroplasty in the treatment of rotator cuff tear arthropathy. J Shoulder Elbow Surg. 2012 Mar;21(3):319-23. doi: 10.1016/j.jse.2011.05.023. Epub 2011 Aug 26. PubMed PMID: 21872496. ](http://www.ncbi.nlm.nih.gov/pubmed/21872496)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21872496)
5. [Iannotti JP, Spencer EE, Winter U, Deffenbaugh D, Williams G. Prosthetic positioning in total shoulder arthroplasty. J Shoulder Elbow Surg. 2005 Jan-Feb;14(1 Suppl S):111S-121S. PubMed PMID: 15726070. ](http://www.ncbi.nlm.nih.gov/pubmed/15726070)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/15726070)
6. [Iannotti JP, Gabriel JP, Schneck SL, Evans BG, Misra S. The normal glenohumeral relationships. An anatomical study of one hundred and forty shoulders. J Bone Joint Surg Am. 1992 Apr;74(4):491-500. PubMed PMID: 1583043.](http://www.ncbi.nlm.nih.gov/pubmed/1583043)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/1583043)
7. [Grosso MJ, Frangiamore SJ, Ricchetti ET, Bauer TW, Iannotti JP. Sensitivity of frozen section histology for identifying Propionibacterium acnes infections in revision shoulder arthroplasty. J Bone Joint Surg Am. 2014 Mar 19;96(6):442-7. doi: 10.2106/JBJS.M.00258. ](http://www.ncbi.nlm.nih.gov/pubmed/24647499)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24647499)

Anterior elbow release consists of lengthening of the lacertus fibrosus and the brachialis fascia. It may or may not include lengthening of the biceps tendon itself. Anterior elbow release effectively decreases the excessive flexion posture of the elbow during use, which one author has termed the âflexion posture angle.â It does not result in decreased (or increased) strength of elbow flexion if the biceps tendon is preserved. Unfortunately, increased use during bimanual activity and increased grip strength are usually not observed.

Lateral scapular winging is characteristic of trapezius palsy, whereas medial scapular winging is characteristic of long thoracic nerve palsy. During sports activity, injury to the spinal accessory nerve is rare but may occur with blunt or stretching trauma. Patients often report an asymmetric neckline, drooping shoulder, winging of the scapula, and weakness of forward elevation. Evaluation should include a complete electrodiagnostic examination.
REFERENCES: Wiater JM, Bigliani LU: Spinal accessory nerve injury. Clin Orthop 1999;368:5-16.
Wiater JM, Flatow EL: Long thoracic nerve injury. Clin Orthop 1999;368:17-27.
Mariani PP, Santoriello P, Maresca G: Spontaneous accessory nerve palsy. J Shoulder Elbow Surg 1998;7:545-546.
Porter P, Fernandez GN: Stretch-induced spinal accessory nerve palsy: A case report. J Shoulder Elbow Surg 2001;10:92-94.
Cohn BT, Brahms MA, Cohn M: Injury to the eleventh cranial nerve in a high school wrestler. Orthop Rev 1986;15:59-64.

The patient has a volar displaced two-part intra-articular distal radial fracture-dislocation of the wrist. Although a closed reduction is usually easily obtained, it is very difficult to maintain the reduction without internal fixation. The approach is determined by the direction of the dislocation, in this case volar. Stabilization with a buttress plate neutralizes the axial loading forces on the fractured fragment. A dorsal placed angular stable plate will not provide this buttress effect and will make the reduction difficult.
REFERENCE: Cohen M, McMurtry RY, Jupiter JB: Fractures and dislocations of the carpus, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1328-1335.