Knee, Shoulder, Arthroplasty MCQs - Part 212

About This Board Review Set

This is Part 212 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

This set has been strictly audited and contains 100 100% verified, high-yield multiple-choice questions (MCQs) modelled on the exact format of the Orthopaedic In-Training Examination (OITE) and the American Academy of Orthopaedic Surgeons (AAOS) board examinations.

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Topics Covered in Part 212

This module focuses heavily on: Arthroplasty, Knee, Ligament, Shoulder.

Sample Questions from This Set

Sample Question 1: Figure 74 shows the radiograph of an 84-year-old woman who reports severe right knee pain. At the time of total knee arthroplasty, she is found to have gross insufficiency and attenuation of the medial collateral ligament (MCL) complex. Opt...

Sample Question 2: A 22-year-old man reports that he initially dislocated his shoulder while playing basketball 2 years ago and was subsequently treated with an arthroscopic Bankart repair. Despite appropriate rehabilitation, the patient continues to report r...

Sample Question 3: The posterior horn of the medial meniscus receives its primary blood supply from what artery? Review Topic...

Sample Question 4: Lipohemarthrosis of the knee is most likely secondary to which of the following?...

Sample Question 5: The artery located within the substance of the coracoacromial ligament is a branch of what artery?...

Why Active MCQ Practice Works

Evidence consistently demonstrates that active recall through spaced MCQ practice yields substantially greater long-term retention than passive reading alone (Roediger & Karpicke, 2006). All questions in this specific module have been algorithmically verified for clinical integrity and complete explanations.

Comprehensive 100-Question Exam

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Question 1

Figure 74 shows the radiograph of an 84-year-old woman who reports severe right knee pain. At the time of total knee arthroplasty, she is found to have gross insufficiency and attenuation of the medial collateral ligament (MCL) complex. Optimal management should consist of

Explanation

DISCUSSION: Patients with severe valgus deformity may have near complete attenuation of the MCL. Attempts at ligament repair or reconstruction at the time of TKA can have unpredictable outcomes, leading to an unstable TKA. Although there may be a role for trying to reconstruct the ligament in conjunction with a nonconstrained implant in young patients with long life expectancies, in elderly patients a constrained prosthesis can provide varus-valgus stability with a predictable outcome. In younger patients, there is concern that the extra prosthetic constraint may shorten the longevity of the prosthetic fixation. In older patients, the constrained implant is likely to last a lifetime, with several studies documenting excellent survivorship (96%) at 10 years. Complete release of the LCL will leave the knee grossly unstable medially and laterally, and could necessitate a hinged prosthesis.
REFERENCES: Lachiewicz PF, Soileau ES: Ten-year survival and clinical results of constrained components in primary total knee arthroplasty. J Arthroplasty 2006;21:803-808.
Anderson JA, Baldini A, MacDonald JH, et al: Primary constrained condylar knee arthroplasty without stem extensions for the valgus knee. Clin Orthop Relat Res 2006;442:199-203.

Question 2

A 22-year-old man reports that he initially dislocated his shoulder while playing basketball 2 years ago and was subsequently treated with an arthroscopic Bankart repair. Despite appropriate rehabilitation, the patient continues to report recurrent instability. An axillary view radiograph and CT scan are shown in Figures 57a and 57b. What is the most appropriate management at this time? Review Topic

Explanation

Although the changes are subtle on the radiograph, an anterior inferior glenoid bone defect is clearly evident on the CT scan. With loss of greater than 20% to 25% of the glenoid width, patients may experience persistent instability despite appropriate labral repair and capsulorrhaphy. Therefore, nonsurgical management with supervised therapy or surgical treatments that do not address the bony defect, such as arthroscopic or open labral repair and capsulorrhaphy, are not likely to stabilize the joint. An open shoulder stabilization procedure with a bone block should address the defect and stabilize the joint. Shoulder arthrodesis is not warranted in this patient at this time because the shoulder is likely salvageable.

Question 3

The posterior horn of the medial meniscus receives its primary blood supply from what artery? Review Topic

Explanation

The middle genicular artery supplies the posterior capsule and intracapsular structures (anterior cruciate ligament, posterior cruciate ligament, posterior horns of the meniscus). The medial and lateral inferior geniculates anastomose anteriorly to form a capillary network to supply the fat pad, synovial cavity, and patellar tendon. The lateral superior and inferior genicular arteries supply the lateral retinaculum.

Question 4

Lipohemarthrosis of the knee is most likely secondary to which of the following?

Explanation

DISCUSSION: Lipohemarthrosis is formed when an intraarticular fracture occurs and can be detected with arthrocentesis or imaging such as xray, MRI, ultrasound, or CT. It is most commonly seen with occult tibial plateau fractures but can be associated with any intra-articular fractures. Up to three layers are visible on an MRI (fat/serum/cellular parts of blood), and this separation may take up to 3 hours to appear after injury. An example of hemarthrosis as seen on CT is shown in Illustration A. The referenced article by Ahn et al is a review of MRI findings in intraarticular knee injuries. They note that detection of lipohemarthrosis on an MRI is very sensitive and specific for intraarticular fracture. The referenced article by Schick et al reports that MRI can be as sensitive as arthrocentesis in detecting lipohemarthrosis (occult fracture).

Question 5

The artery located within the substance of the coracoacromial ligament is a branch of what artery?

Explanation

DISCUSSION: The acromial branch of the thoracoacromial artery courses along the medial aspect of the coracoacromial ligament and may be encountered when performing an open or arthroscopic subacromial decompression. Bleeding can be controlled by ligation of its branch from the thoracoacromial artery. The other arteries may be injured in other surgical exposures of the shoulder.
REFERENCES: Esch JC, Baker CL: The shoulder and elbow, in Whipple TL (ed): Arthroscopic Surgery. Philadelphia, PA, JB Lippincott, 1993, pp 65-66.
Woodburne RT (ed): Essentials of Human Anatomy, ed 2. New York, NY, Oxford University Press, 1983, pp 75-76.

Question 6

-The patient experienced little improvement with activity modification and physical therapy. An intraarticular corticosteroid injection provides excellent but short-lived pain control. She requests surgical treatment for her hip and she is counseled regarding arthroscopy and consent is obtained. Intraoperatively,a capsulolabral separation is observed with an underlying pincer lesion. No articular cartilage injury is seen. What treatment is most appropriate considering these findings?

Explanation

DISCUSSION FOR QUESTIONS 26 THROUGH 29
The clinical scenario, examination, and MRI scans are consistent with a pincer-type FAI. The decreased range of motion is secondary to the pain produced by the continued abutment of the femoral head against the anterosuperior acetabulum. Flexing the hip while internally rotating and adducting the leg recreates this contact and is typically painful. No clinical signs suggest sacroiliac joint arthritis, an intra-articular loose body, or trochanteric bursitis, although these are all diagnoses that should be considered in a patient with a painful hip. The most sensitive and specific study to detect an acetabular labral tear is an MRI arthrogram of the hip. This study should be obtained in this patient to evaluate the labrum as well as the status of the articular cartilage. An MRI scan without intra-articular contrast is not as sensitive as an arthrogram. An ultrasound can provide a dynamic assessment of the hip and help in the setting of a snapping hip; however, this study is not reliable to determine the presence of a labral tear. In the setting of pincer FAI, the forced leverage of the anterosuperior femoral head upon the anterior acetabulum results in abnormal forces against the posteroinferior acetabulum. This continued force can lead to a chondral lesion in this location know as a “counter-coup” injury. Chondral lesions of the femoral head are rare in the setting of pincer FAI. The posterosuperior quadrant does not experience increased force and rarely sustains chondral injuries. The patient is a young, active individual with no pre-existing degenerative changes, so repair of the tear with bony resection of the pincer lesion is the most appropriate treatment.A capsulolabral detachment should be repaired because these tears can heal and the labrum functions as a seal, preventing egress of synovial fluid from the joint space. If the pincer lesion is not resected, the patient will continue to experience abnormal contact and the repair will likely fail. There is no evidence that the patient has a cam impingement, and recontouring of the femoral head/neck junction is not appropriate. Simple debridement should be reserved for intrasubstance tears of the labrum, which would not be expected to heal with repair.
CLINICAL SITUATION FOR QUESTIONS 30 THROUGH 32
Figures 30a and 30b are the radiographs of a 20-year-old college multisport athlete who has had longstanding pain in his left hip. He denies any specific event that initiated his pain, but he notes that he had hip problems when he was an infant. He denies pain with activities of daily living, but he
believes his pain is increasingly limiting his ability to exercise. He localizes the pain to his groin. He denies low-back or buttock pain or pain that radiates down his leg.

Question 7

What is a risk factor for interdigital neuroma?

Explanation

DISCUSSION
The only proven risk factor for development of an interdigital neuroma is female gender, which likely is related to the use of fashionable shoes that force plantar flexion of the metatarsal heads and secondary hyperdorsiflexion of the metatarsophalangeal joints. The other factors listed have not been proven to cause interdigital neuroma, as well as mediolateral compression of the forefoot.
RECOMMENDED READINGS
Hill KJ. Peripheral nerve disorder. In: Pinzur MS, ed. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:307-327.
Schon LC, Mann RA. Diseases of the nerves. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed. Philadelphia, PA: Mosby-Elsevier; 2007:613-686.

Question 8

A high school athlete reports the sudden onset of low back pain while performing a dead lift. Examination reveals lumbar paraspinal spasm and a positive straight leg raising test. Deep tendon reflexes, motor strength, and sensation in the lower extremities are normal. Radiographic findings are normal. If symptoms persist for longer than a few weeks, what is the best course of action?

Explanation

DISCUSSION: In the adolescent population, a lumbar herniated disk is characterized by a paucity of clinical findings, with a positive straight leg raising test the only consistently positive finding. This may result in a prolonged period of nonsurgical management that fails to provide relief. Activities that place a significant shear load on the lumbar spine, such as the dead lift, are associated with an increased risk of central disk herniation. An adolescent who lifts weights and has a history of back pain that fails to respond to a short period of active rest should undergo MRI evaluation for the diagnosis of a lumber herniated disk.
REFERENCES: Epstein JA, Epstein NE, Marc J, et al: Lumbar intervertebral disk herniation in teenage children: Recognition and management of associated anomalies. Spine 1984;9:427-432.
Hashimoto K, Fujita K, et al: Lumbar disc herniation in children. J Pediatr Orthop

1990;10:394-396.

Question 9

A 55-year-old woman with a long history of low back and left lower extremity pain has failed to respond to exhaustive nonsurgical management. MRI scans show bulging and degeneration at L3-4 and L4-5 as well as a normal disk at L2-3 and L5-S1. She undergoes provocative lumbar diskography at L3-4, L4-5, and L5-S1. Post-diskography axial CT images of L3-4 and L4-5 are shown in Figures 6a and 6b, respectively. The injections at L3-4 and L4-5 produce no pain. The injection at L5-S1 produces 10/10 concordant back pain with radiation to the lower extremity. What is the most appropriate recommendation at this time? Review Topic

Explanation

The results of this patient’s lumbar diskography are equivocal at best. The two disks most likely to be her pain generators, based on their MRI appearance, produced 10/10 pain, however it was nonconcordant and did not reproduce any of her typical left-
sided radicular symptoms. The only disk that produced concordant back pain was the normal disk at the L5-S1 level and it reproduced radicular symptoms on the side opposite of her typical pain. Based on these findings, it would be difficult to select a level or levels to include in a lumbar fusion. As such, continued nonsurgical management is the safest treatment option at the current time. Brox and associates reported on a randomized clinical trial comparing lumbar fusion to cognitive intervention and exercise and found similar results in both groups, with significantly less risk in the latter.

Question 10

Rupture of the distal biceps tendon is predictably identified by the hook test, which is performed by bringing a finger from lateral to medial across the antecubital fossa of a flexed elbow, feeling for a cord-like structure on which the examiner can "hook" a finger. Bringing the finger from medial to lateral can cause a false-negative result, hooking the lacertus fibrosus, which can remain intact even with a ruptured distal biceps tendon. The Yergason test (option 3) and the Speed test (option 4) are used to assist in diagnosing proximal, not distal, biceps and labral pathology. Even if the distal biceps tendon is ruptured, the supinator remains intact. Although supination weakness may be present, an inability to supinate should not be observed. When treating a closed long finger central slip tendon rupture conservatively, what is the most appropriate plan of care?

Explanation

EXPLANATION:
Closed central slip injuries treated nonsurgically require extension splinting of the PIP joint. DIP joint active range of motion is allowed during this time period. This allows the connections between the lateral bands and the central slip to pull the central slip distally with DIP joint active motion, minimizing the gap
across the central tendon injury and keeping the DIP joint from getting stiff as well.

Question 11

A year-old woman has severe anterior knee pain. Her radiographs indicate end-stage patellofemoral compartment osteoarthritis. The tibiofemoral compartments are preserved. Extensive nonsurgical treatment has failed to provide relief, and she is offered patellofemoral arthroplasty (PFA). What is the most common long-term mode of failure for PFA using an implant with an onlay prosthesis design?

Explanation

DISCUSSION:
Contemporary onlay-design trochlear prostheses in PFA replace the entire anterior trochlear surface. Previous inlay designs were inset within the native trochlea and carried a higher risk of catching and patellar instability, particularly in patients with trochlear dysplasia; they also generally have higher failure rates. The current most common mode of failure is progression of arthritis throughout the knee, in some series as high as 25% at 15 years. Aseptic loosening, particularly of cemented implants, is less common. Infection is an uncommon long-term complication. Patients considering PFA should be advised of the risk of arthritis progression. Many authors routinely obtain a preoperative MRI to assess the status of the tibiofemoral compartments.

Question 12

A year-old man reports symptomatic medial knee pain that has become progressively worse during the past year. MRI reveals a complex, posterior horn medial meniscus tear with associated medial lateral and patellofemoral cartilage defects. Radiographs reveal medial joint space narrowing and osteophytes in the other compartments. What treatment is most likely to provide long-term, durable relief of symptoms?

Explanation

DISCUSSION:
Total knee replacement is a well-established surgery for diffuse, symptomatic osteoarthritis of the knee joint, and its efficacy has been shown in many studies. According to the 2008 AAOS Clinical Practice Guideline, Treatment of Osteoarthritis of the Knee, arthroscopy in the setting of existing osteoarthritis is efficacious for relieving the signs and symptoms of a torn meniscus but not for osteoarthritis. Likewise, in young and active patients, clinical outcomes show improvement after realignment osteotomy for single- compartment osteoarthritis. Unicondylar knee replacement is not indicated for tricompartmental disease
of the knee.

Question 13

below depict the AP and lateral radiographs obtained from a year-old man with long-standing right knee osteoarthritis and pain that is unresponsive to nonsurgical treatment. The patient undergoes navigated cruciate-retaining right total knee arthroplasty. After surgery, this patient continues to experience pain and swelling of the knee with recurrent effusions. He returns to the office reporting continued pain 2 years after surgery. He describes instability, particularly when descending stairs. On examination, range of motion of 0° to 120° is observed, with no extensor lag. Slope of the tibial component is 7°. The knee is stable to varus and valgus stress in extension, but flexion instability is present in both the anterior-posterior direction and the varus-valgus direction. Bracing leads to a slight decrease in symptoms but is not well tolerated. Isokinetic testing demonstrates decreased knee extension velocity at mid push. Radiographs demonstrate well-aligned and fixed knee implants. An infection work-up is negative. What is the most appropriate surgical intervention at this time?

Explanation

DISCUSSION:
The patient’s symptoms at follow-up—pain, swelling, and difficulty descending stairs—suggest knee flexion instability. Considering his history, an incompetent PCL must be considered. Revision of the knee to a posterior stabilized or nonlinked constrained condylar implant (depending on the condition of the ligaments) likely is needed to address his symptoms. The difference in extension stability and flexion stability makes polyethylene exchange a poor option. A constrained rotating hinge design is not necessary. Repeat use of a PCL-retaining insert is not recommended. Tibial and femoral revision both are required. Correction of excessive slope will be attained with tibial revision, femoral component revision is required to convert to a PCL-substituting design. There is also an opportunity to increase posterior condylar offset if needed.

Question 14

A 40-year-old man who is a manual laborer has had 3 years of worsening medial-sided left knee pain that has inhibited his ability to work. He reports undergoing a left subtotal medial meniscectomy 10 years ago. He has been treated with nonsteroidal anti-inflammatory drugs and two different corticosteroids, with the most recent injection given 1 month ago. Each injection provided him with a few weeks of pain control. His medical history is unremarkable, and he has smoked 20 cigarettes per day for the last 15 years. His BMI is 22. On examination, he has varus alignment of the involved leg and medial joint line tenderness and no lateral or patellofemoral pain. His knee range of motion is 3° shy of full extension to 130° of flexion. He has negative Lachman and posterior drawer test results. He demonstrates no lateral thrust with ambulation. What is the most appropriate next step in treatment?

Explanation

This patient has a classic presentation of postmeniscectomy medial compartment arthritis. The appropriate diagnostic study is weight-bearing radiographs to confirm the diagnosis. An MRI scan will reveal medial compartment arthritis but will not provide information about alignment. A CT scan would be appropriate to detect an occult fracture; however, this condition is not suspected in this clinical scenario. Ultrasonography can provide information about fluid collection around the knee or a deep vein thrombosis; however, these conditions also are not suspected in this clinical scenario. Because the patient has a correctable deformity (gaps 3 mm with valgus stress), and his symptoms are localized to the involved compartment, a trial of a medial unloader brace is appropriate both diagnostically and therapeutically. If unloading the medial compartment resolves the patient’s symptoms, he would be an excellent candidate for an osteotomy. An MRI scan may be obtained to evaluate ligamentous integrity or to evaluate degenerative involvement of the lateral and patellofemoral compartment for presurgical planning of an osteotomy; however, the integrity of the medial meniscus has no clinical importance in a patient with severe medial compartment arthritis. A repeat corticosteroid injection is not indicated within 1 month of his last injection, and referral to pain management is not appropriate with other options available to help this patient. A VPHTO is the appropriate intervention considering the patient’s young age, high-functional occupation, examination, radiographic findings, and response to medial unloader bracing. A revision knee arthroscopy would be appropriate for a recurrent medial meniscus tear, but not appropriate in a patient with severe medial compartment arthritis. The patient’s young age and high functional requirements are contraindications to TKA. The presence of severe arthritis is a contraindication to medial meniscus transplant. The patient is a candidate for a VPHTO. The technical options include a medial opening-wedge or a lateral closing-wedge osteotomy. Both techniques have advantages and disadvantages; however, a medial opening-wedge osteotomy is contraindicated in a smoker because of concern for nonunion. As a result, current smoking history is the only factor listed that would influence the technique used. The history of prior arthroscopy has no relevance in the decision about which type of osteotomy is appropriate. Normal BMI is between 18.5 and 24.9, so this patient’s BMI is considered normal and would not affect the surgical technique (if this patient were obese, a lateral closing-wedge osteotomy would be considered, but this is controversial). His age of 40 years is an indication for HTO but does not influence technique.

Question 15

A 40-year-old patient who has a type II odontoid fracture is placed in a halo vest for 12 weeks; however, current radiographs show no evidence of healing. The next most appropriate step in management should consist of

Explanation

DISCUSSION: Because nonsurgical managment has failed and a significant number of type II odontoid fractures will go on to a nonunion, the salvage treatment of choice is posterior fusion at C1-2. Odontoid screws are contraindicated in patients with a chronic nonunion, which this patient has at the end of 3 months.
REFERENCES: Montesano PX: Anterior and posterior screw and plate techniques used in the cervical spine, in Bridwell KH, DeWald RL (eds): The Textbook of Spinal Surgery, ed 2. Philadelphia, PA, Lippincott-Raven, 1996, vol 2, pp 1743-1761.
Bohler J: Anterior stabilization for acute fractures and non-unions of the dens. J Bone Joint Surg Am 1982;64:18-27.
Anderson PA, Steinmann JC: Internal fixation of the cervical spine, in Frymoyer JW (ed): The Adult Spine, Principles and Practice, ed 2. Philadelphia, PA, Lippincott Raven, 1997, pp 1119-1147.

Question 16

In patients who have undergone nonsurgical management for idiopathic adhesive capsulitis, long-term follow-up studies have shown which of the following results?

Explanation

DISCUSSION: Results have been satisfactory in many patients; however, at long-term follow-up, examination of the affected shoulder often shows some decrease in range of motion compared with the contralateral side. Although range of motion often improves over time, it does not return to normal in 60% of patients. Pain improves but is often increased compared with the contralateral side.
REFERENCES: Griggs SM, Ahn A, Green A: Idiopathic adhesive capsulitis: A prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am 2000;82:1398-1407.
Shaffer B, Tibone JE, Kerlan RK: Frozen shoulder: A long-term follow-up. J Bone Joint Surg Am 1992;74:738-746.

Question 17

Figure 10 is the radiograph of a 44-year-old man with a long-standing history of severe hip pain and a limp. Which clinical scenario most likely could occur when performing total hip arthroplasty on this patient?

Explanation

CLINICAL SITUATION FOR QUESTIONS 11 THROUGH 13
Figures 11a and 11b are the radiographs of a 35-year-old woman with end-stage debilitating osteoarthritis of the right hip. She is contemplating total hip arthroplasty (THA). She has a history of right hip dysplasia and underwent hip osteotomy as an adolescent. Over the years, she has failed nonsurgical treatment including weight loss, activity modifications, and intra-articular injections. Her infection workup reveals laboratory findings within defined limits.

Question 18

A 72-year-old woman underwent a primary total hip arthroplasty 14 months ago. She states that the hip has now dislocated four times when rising from a low chair, requiring closed reduction. A radiograph is shown in Figure 3a and a CT scan of her pelvis is shown in Figure 3b. What is the most reliable method for rectifying her instability?

Explanation

DISCUSSION: The radiograph shows well-fixed components without evidence of loosening. The CT scan shows severe retroversion of the acetabular component. Revision of the component into the correct amount of anteversion
will most reliably rectify the instability in the face of severe component malposition.
REFERENCES: Parvizi J, Picinic E, Sharkey PF: Revision total hip arthroplasty for instability: Surgical techniques and principles. J Bone Joint Surg Am 2008;90:1134-1142.
DeWal H, Su E, DiCesare PE: Instability following total hip arthroplasty. Am J Orthop 2003;32:377-382. 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 475-503.

Question 19

A 76-year-old woman has longstanding right shoulder pain affecting overhead function. Figures A and B are her original radiographs. She undergoes reverse total shoulder arthroplasty (rTSA) with iliac crest bone grafting behind the baseplate and is discharged from the hospital the following day. She returns for follow-up at 2 weeks. The incisions have healed and she has minimal pain, which is improving. What is the most accurate description for the cause of failure? Review Topic

Explanation

The metaglen (glenoid baseplate) failed because the central peg of the baseplate was not implanted in the glenoid, and the metaglen did not have a long enough central peg. This was the technical error during baseplate implantation.
Glenoid complications are the primary concern of rTSA. Historically, rTSA fail at the glenoid interface because of inadequate fixation. The Grammont-style prosthesis has a medialized center of rotation to circumvent this, but this lead to inferior scapular notching. Newer prosthesis include locking peripheral screws and 15° inferior tilt of the base plate. Further, changing the neck-shaft angle from 155 deg to 143 deg or 135 deg has reduced notching and instability, and reduced the need to for subscapularis repair.
Boileau et al. examined revision surgery for rTSA. They found that the most common cause for revision was prosthetic instability (48%). Humeral complications (loosening/derotation/fracture) were 2nd most common and infection was 3rd most common. Underestimation of humeral shortening and excessive medialization were common causes of recurrent prosthetic instability. Proximal humeral bone loss was found to be a cause for humeral loosening or derotation.
Holcomb et al. reviewed failure of the rTSA glenoid baseplate in 14 patients, which was defined as shift of the baseplate with or without screw breakage. Strategies for success include: (1) Incorporating increased inferior baseplate tilt in post-revision prosthesis-scapular neck angle (PSNA) compared to pre-failure PSNA because inferior tilt maximizes compressive force across the baseplate-glenoid interface. (2) Locking peripheral 5.0mm screws (rather than non-locking 3.5mm screws). (3) Using larger glenospheres to tighten the patulous soft tissue envelope and secure the glenoid allograft. Four patients required structural allograft (2 iliac crest, 2 femoral head).
Figures A shows Hamada 4A cuff tear arthropathy. Figure B shows severe static posterior instability of the humeral head and posterior Walch B2 erosion of the glenoid. Figure C shows the same patient treated with rTSA and iliac crest bone graft. Because of technical error, the central peg was not implanted in the native glenoid. Illustration A shows catastrophic failure of the glenoid baseplate. Illustration B shows the PSNA, with increase in the PSNA from initial rTSA to revision rTSA. Illustration C shows baseplate-glenosphere dissociation. Illustration D shows correction of technical error/too short peg with exchange to a baseplate with a longer peg. Illustration E shows and algorithm for treating unstable rTSA.
Incorrect Answers:

Question 20

A 42-year-old woman reports neck stiffness, upper extremity pain, clumsiness, weakness, and instability of gait. Examination reveals 4+ of 5 strength in the upper extremities and 3+ biceps, brachioradialis, and patellar reflexes with a positive Hoffman sign bilaterally. MRI and CT scans are shown in Figures 10a and 10b. Based on the history and imaging findings, what is the most likely diagnosis? Review Topic

Explanation

The sagittal T2-weighted MRI scan shows moderate-severe multilevel cervical stenosis. The cord compression is noted to be not only at the disk levels but also at the midvertebral body levels, and the posterior longitudinal ligament appears to be thickened. The CT scan confirms that the posterior longitudinal ligament is indeed thickened and ossified, compatible with a diagnosis of ossification of the posterior longitudinal ligament. This diagnosis is most common in individuals of Japanese descent and has a genetic linkage. The anterior osteophytes are smaller than those seen in diffuse idiopathic skeletal hyperostosis and are not syndesmotic. Patients with ankylosing spondylitis typically have non-marginal syndesmophytes. Patients with rheumatoid arthritis may have evidence of instability at C1-C2 on flexion-extension radiographs and subaxial subluxations.

Question 21

A 59-year-old man underwent interposition arthroplasty for osteoarthritis of the elbow 9 years ago. Over the past year the patient has had increasing pain and elbow instability. There is no clinical evidence of infection, and radiographs show no new bony process. What is the best option for this patient?

Explanation

DISCUSSION: In a series reported by Blaine and associates, 12 patients were converted from interposition to total elbow arthroplasty. This procedure was successful in 10 out of 12 patients.
REFERENCES: Blaine TA, Adams R, Morrey BF: Total elbow arthroplasty after interposition arthroplasty for elbow arthritis. J Bone Joint Surg Am 2005;87;286-292.
Cheng SL, Morrey FB: Treatment of the mobile, painful arthritic elbow by distraction interposition arthroplasty. J Bone Joint Surg Br 2000;82:233-238.

Question 22

An axial T 1 -weighted MRI scan of the pelvis is shown in Figure 13. The arrow is pointing to what muscle?

Explanation

DISCUSSION: The obturator internus muscle originates from the internal pelvic wall and passes laterally through the lesser sciatic foramen, banking around the ischium below the sacrospinous ligament before inserting on the medial aspect of the greater trochanter.
REFERENCES: Higuchi T: Normal anatomy and magnetic resonance appearance of the pelvis, in Takahashi HE, Morita T, Hotta T, Ogose A (eds): Operative Treatment of Pelvic Tumors. Tokyo, Japan, Springer-Verlag, 2003, pp 4-21.
Berquist TH: Pelvis, hips and thigh, in Berquist TH (ed): MRI of the Musculoskeletal System,

ed 4. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 210-238.

Question 23

A healthy, active year-old man trips and falls, landing on his left hip 10 weeks after an uncomplicated left primary uncemented total hip replacement. A radiograph taken 6 weeks after surgery and before the fall is shown in A radiograph taken after the fall is shown in He is unable to bear weight and is brought to the emergency department. Examination reveals a slightly shortened left lower extremity and some mild ecchymosis just distal to the left greater trochanteric region, but his skin is intact, without abrasions or lacerations. What is the most appropriate treatment?

Explanation

DISCUSSION:
This patient has a periprosthetic femoral fracture with a loose femoral stem and normal femoral bone stock, representing a Vancouver type B2 fracture. The most appropriate treatment is fixation of the fracture, along with revision of the stem. Considering his age, bone quality, and activity level, a longer uncemented stem is most predictable. Although a cylindrical stem may also be used, the fluted stem option is the only uncemented choice listed and is the most appropriate option. A cemented stem is a poorer choice because it is difficult to keep the cement out of the fracture site, which would pose a risk for nonunion at the fracture. Also, overall poorer results have been associated with long cemented stems in healthy, active people. Surgery does not need to be delayed to allow the ecchymosis to resolve, and simple open reduction and fixation does not address the loose stem.

Question 24

Which of the following is associated with increased fetal morbidity and mortality in acetabular fractures during pregnancy?

Explanation

Fixation of pelvic and acetabular fractures in pregnancy is not contraindicated. However, both maternal and fetal morbidity and mortality is increased in this patient subset. Factors shown to be associated with increased fetal mortality include: injury severity, mechanism of injury, and maternal hemorrhage. Surgical approach, fracture classification, fetal position, and the trimester of pregnancy have not been shown to affect fetal morbidity or mortality.

Question 25

A 12-year-old female is referred to the office by a community orthopaedic surgeon concerned that her shoulders appear to be at different heights. With Adam's forward bending, she is noted to have a significant right thoracic rib prominence. She denies pain. A detailed neurological examination reveals no abnormalities. Radiographs of her spine show an apex left lumbar curve measuring 32 degrees and an apex right thoracic curve measuring 28 degrees. She had her first menses last month and her Tanner-Whitehouse staging is consistent with an adolescent steady state. The most appropriate treatment would be? Review Topic

Explanation

A growing child presenting with a curve of 25°–40° or a curve 20- 25° with documented progression should be treated first with a thoracolumbosacral orthosis.
Assessing a child's skeletal maturity has important clinical implications when treating patients with idiopathic scoliosis. The Tanner-Whitehouse III method specifically
uses the distal radial and ulnar epiphyses, as well as the metacarpal and phalangeal epiphyses of the first, third, and fifth digits for determination of skeletal age. A Tanner-Whitehouse Stage in 'adolescent steady-state' means she is past peak height velocity. However, as she is before skeletal maturity, and her lumbar and thoracic curvatures are > 25 deg., these curvatures may continue to progress. Therefore, bracing would be the best treatment option at this time.
Hasler et al. randomized twenty post-pubertal young women (20°–40° idiopathic scoliosis to an observation or complementary and alternative osteopathic treatment in a prospective study. Pre- and post- intervention trunk morphology and spine flexibility were assessed at 3 month intervals. A regression analysis of repeat measurements revealed no therapeutic effect on rib hump, lumbar prominence, plumb line, sagittal profile or global spinal flexibility with either treatment.
Sponsellar et al. examined the literature form the past 25 years to summarize the current practice of bracing in the treatment of adolescent idiopathic scoliosis. They found the highest level of existing evidence from a prospective center-randomized study, which showed that thoracolumbosacral bracing was most effective for single curves of 25 to 35 degrees in female patients with a starting Risser score of 0 to 2.
Illustration A shows the bones of interest in the hand and wrist for the the Tanner-Whitehouse III skeletal maturity assessment. Each are divided into epiphysis, metaphysis and diaphysis to help identify these different ossification centers in the phalanx proximity as seen in Illustration B. The development of each region is divided into discrete stages and given a letter (A,B,C,D, . . ., I). These correlate with a score that are added together to give an overall maturity score on the graph.
Incorrect Answers:

Question 26

A 72-year-old woman who is right hand-dominant has severe pain in the right shoulder that has failed to respond to nonsurgical management. She reports night pain and significant disability. Examination reveals 30 degrees of active forward elevation. An AP radiograph is shown in Figure 27. Which of the following treatment options will provide the best functional improvement?

Explanation

DISCUSSION: The patient has end-stage rotator cuff tear arthropathy. The radiograph shows complete proximal humeral migration (acromiohumeral interval of 0 mm), severe glenohumeral arthritis, and acetabularization of the acromion. In addition, she has "pseudoparalysis" with active elevation of only 30 degrees. Reverse shoulder arthroplasty affords her the best opportunity for pain relief and functional improvement. The other procedures have mixed results but typically are better for pain relief than they are for functional gains.
REFERENCES: Frankle M, Siegal S, Pupello D, et al: The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: A minimum two-year follow-up study of sixty patients. J Bone Joint Surg Am 2005;87:1697-1705.
Werner CM, Steinmann PA, Gilbart M, et al: Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am 2005;87:1476-1486.

Question 27

Management of a grade IV osteochondritis dissecans lesion of the capitellum should consist of

Explanation

DISCUSSION: Osteochondritis dissecans of the capitellum is seen most commonly in adolescent athletes. It should be distinguished from osteochondrosis of the capitellum (Panner’s disease), a self-limiting condition seen in younger patients.
Lesions are graded I through V based on radiographic and arthroscopic appearance. Grade I lesions show intact but soft cartilage. Grade II lesions show fissuring of the overlying cartilage. Grade III lesions show exposed bone or an attached osteoarticular flap that is not loose. Grade IV lesions show a loose but nondisplaced osteoarticular flap. Grade V lesions show a displaced fragment.
Simple excision of the loose osteoarticular flap is the treatment of choice for grade IV and V lesions. More complex procedures such as drilling of the in situ lesion, bone grafting, or internal fixation are associated with significantly worse results. While some authors advocate abrasion chondroplasty, the long-term benefits of the procedure are yet to be proven.
REFERENCES: Baumgarten TE: Osteochondritis dissecans of the capitellum. Sports Med Arthroscopy Rev 1995;3:219-223.
Shaughnessy WJ, Bianco AJ: Osteochondritis dissecans, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, pp 282-287.

Question 28

A 69-year-old man reports pain over his bunion while wearing shoes and pain in the joint with push-off when barefoot. Nonsurgical management has failed to provide relief. Radiographs are shown in Figures 8a and 8b. What is the surgical procedure of choice?

Explanation

DISCUSSION: Arthrodesis is indicated for severe bunion and hallux valgus deformities, but particularly with extensive degenerative disease of the first metatarsophalangeal joint. The other bunionectomy procedures have different indications, none of which include symptomatic first metatarsophalangeal degenerative disease.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 3-15.
Tourne Y, Saragaglia D, Zattara A, et al: Hallux valgus in the elderly: Metatarsophalangeal arthrodesis of the first ray. Foot Ankle Int 1997;18:195-198.

Question 29

What is the prognosis for ambulation, from best to worst, for patients with an incomplete spinal cord injury?

Explanation

DISCUSSION: Of the incomplete spinal cord injuries, Brown-Sequard syndrome has the best prognosis for ambulation. Central cord syndrome has a variable recovery. Anterior cord syndrome has the worst prognosis, with motor recovery rare below the level of the injury.
REFERENCES: Apple DF: Spinal cord injury rehabilitation, in Herkowitz HN, Garfin SR, Balderston RA, Eismont FJ, Bell GR, Wiesel SW (eds): Rothman-Simeone The Spine, ed 4. Philadelphia, PA, WB Saunders, 1999, pp 1130-1131.
Northrup BE: Evaluation and early treatment of acute injuries to the spine and spinal cord, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 544-545.

Question 30

A 65-year-old woman presents with neck pain for 18 months. She has taken NSAIDs and undergone physical therapy without improvement. Over the past 6 months, she has also noticed progressive hand clumsiness and difficulty with gait. Sagittal and axial MRI images are shown in figures A and B, respectively. What is the most appropriate next step in management? Review Topic

Explanation

This patient presents with clinical and radiographic evidence of cervical myelopathy with progression of gait imbalance and hand clumsiness. The most appropriate management is anterior cervical discectomy and fusion (ACDF).
Cervical myelopathy is typically caused compression on the spinal cord and classically present with neck pain, parasthesias, clumsiness, gait imbalance, and/or urinary retention. Nonoperative management is reserved for patients without functional impairment. ACDF is the treatment of choice for focal compression from anterior disc-ostephyte changes. Posterior decompression is indicated in patients with multi-level disease. It is important to note in patients with significant kyphosis, the kyphosis must be reversed in order for decompression alone to be effective.
Hsu reviewed posterior decompression techniques in the cervical spine. They state that the choice of anterior versus posterior approach is determined based on sagittal spine alignment, extent and location of pathological involvement, and patient preference. They recommend laminectomy and fusion for cervical stenosis and kyphosis <10 degrees. The use of BMP-2 as an adjunct in the cervical spine is not recommended by the author.
Emery reviewed cervical spondylotic myelopathy and recommend nonoperative treatment in patients with minimal symptoms without pathologic reflexes or gait imbalances. They suggest that the preferred posterior techniques are now laminectomy and fusion or laminoplasty.
Figure A and B are sagittal and axial T2 MRI sequences showing a degenerative disc osteophyte complex at C5-C6 with resultant canal stenosis and cord compression. Illustration A is a lateral C spine radiograph in a patient who is status post ACDF at C5-C6.
Incorrect Answers:

Question 31

A 26-year-old weightlifter has increasing pain in his left shoulder for 4 months. Nonsurgical treatment consisting of anti-inflammatory medication, corticosteroid injections, and rest fails to alleviate his symptoms. He undergoes an arthroscopic distal clavicle resection with excision of the distal 8 mm of clavicle (Mumford procedure). Three months after surgery, he reports mild pain and popping by his clavicle. His clavicle demonstrates mild posterior instability on examination without any obvious deformity on his radiographs. What structures were compromised during his excision?

Explanation

The posterior and superior acromioclavicular ligaments provide the most restraint to posterior translation of the acromioclavicular joint and must be preserved during a Mumford procedure. Anterior and superior acromioclavicular joint ligaments are the opposite of the preferred response and prevent anterior translation of the clavicle. Injuries to the conoid and trapezoid ligaments are more pronounced with grade III or higher acromioclavicular separations, with superior migration of the clavicle relative to the acromion.

Question 32

A 23-year-old professional baseball pitcher reports shoulder pain and decreased velocity while pitching. Physical examination reveals a side-to-side internal rotation deficit of 25 degrees. The O’Brien sign is negative; Neer and Hawkins signs are negative. Rotator cuff strength is full. Radiographs are unremarkable. What is the next step in management?

Explanation

DISCUSSION: Throwing athletes with symptomatic internal rotation deficits often benefit from an intensive posterior capsular stretching program. Patients that fail to respond to nonsurgical management may benefit from an arthroscopic posterior capsular release.
REFERENCES: Wilk KE, Meister K, Andrews JR: Current concepts in rehabilitation of the overhead throwing athlete. Am J Sports Med 2002;30:136-151.
Myers JB, Laudner KG, Pasquale MR, et al: Glenohumeral range of motion deficits and posterior shoulder tightness in throwers with pathologic internal impingement. Am J Sports Med 2006;34:385-391.

Question 33

What structure is considered the single most important soft-tissue restraint to anterior-posterior stability of the sternoclavicular joint?

Explanation

DISCUSSION: In a cadaver ligament sectioning study, the posterior capsular ligament was considered the most important structure for anterior-posterior stability of the sternoclavicular joint. The anterior capsular ligament also helps prevent anterior displacement but not to the same degree as the posterior ligament. The interclavicular ligament provides little support for anteroposterior translation.
REFERENCES: Spencer EE, Kuhn JE, Huston LJ, et al: Ligamentous restraints to anterior and posterior translation of the sternoclavicular joint. J Shoulder Elbow Surg 2002;11:43-47.
Rockwood CA Jr, Matsen FA III, Jobe CM: Gross Anatomy of the Shoulder. Philadelphia, PA, WB Saunders, 1998.

Question 34

A healthy 72-year-old woman is seen 14 days after cemented total knee arthroplasty. She reports increasing pain and swelling for the last 4 days accompanied by 4 days of wound drainage. Examination reveals that she is afebrile, and has erythema and moderate serosanguinous drainage from the wound. The knee is moderately swollen. Aspiration of the knee reveals no organisms on Gram stain. Culture results are expected back in 48 hours. Optimal management should consist of

Explanation

AL-Madena Copy
8 • American Academy of Orthopaedic Surgeons
DISCUSSION: Increased pain, swelling, erythema, and drainage 2 weeks removed from the primary arthroplasty are all signs of a probable infection. Erythrocyte sedimentation rate and C-reactive protein may not be helpful as they are elevated postoperatively even in the absence of infection. Even in the absence of infection, persistent wound drainage is an indication for surgical debridement to prevent subsequent infection. When a postoperative infection is easily recognized by clinical examination, there is no need to wait for a positive culture before proceeding with debridement.
REFERENCES: Weiss AP, Krackow KA: Persistent wound drainage after primary total knee arthroplasty. J Arthroplasty 1993;8:285-289.
Jaberi FM, Parvizi J, Haytmanek CT, et al: Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty. Clin Orthop Relat Res 2008;466:1368-1371.
Insall JN, Windsor RE, Scott, WN: Surgery of the Knee, ed 2. New York, NY, Churchill Livingstone, 1993, pp 959-964.

Figure 3a Figure 3b

Question 35

In a pilon fracture, the Chaput fragment typically maintains soft tissue attachment via which of the following structures?

Explanation

DISCUSSION: The Chaput fragment, highlighted by the arrow in Illustration A, is the anterolateral fragment of the distal tibia. This section of bone attaches to the anterior inferior tibiofibular ligament and is often hinged off this structure due to the fracture. A pilon fracture is often split into three main fragments at the joint level (Illustration B): Chaput fragment (anterolateral), Volkmann fragment (posterolateral), and a medial fragment. The Volkmann fragment is the attachment site of the posterior inferior tibiofibular ligament. The Wagstaff fragment is the fibular corollary to the Chaput fragment, and serves as the other attachment of the anterior inferior tibiofibular ligament

Question 36

A 47-year-old obese man with a body mass index of 42 comes into the office with left knee pain 1 year after undergoing an uncomplicated left medial unicompartmental knee arthroplasty (UKA). Radiographs show a loose tibial component in varus. What is the most appropriate next step to treat this failed construct?

Explanation

DISCUSSION:
This patient likely is experiencing failure of the UKA secondary to poor patient selection. In this young, heavy man, the component likely loosened due to the ongoing varus alignment of the knee and his elevated
weight. Despite this likely scenario, the next step is determining whether an infection is the cause of his pain. Prior to obtaining an aspiration, the surgeon can order ESR and CRP studies to determine whether aspiration is warranted. If the laboratory studies are unremarkable, the surgeon likely can forgo the aspiration and proceed to a revision TKA with possible augments on standby.

Question 37

What is the theoretical advantage of an open subpectoral technique of tenodesis of the long head of the biceps tendon compared to arthroscopic soft-tissue tenodesis techniques? Review Topic

Explanation

A subpectoral biceps tenodesis requires an additional incision at the insertion of the pectoralis major tendon on the humerus. This can be difficult to do in the lateral decubitus position and certainly this technique does not decrease surgical time when compared to arthroscopic soft-tissue techniques. There have been no level I studies comparing the two techniques; however, the theoretical advantage of the open biceps subpectoral tenodesis is that the biceps tendon is removed from the bicipital groove, which may eliminate a source of pain in the biceps tendon.

Question 38

Genetic analysis has revealed a strong linkage between osteoarthritis in women with which of the following molecules?

Explanation

It is believed that both genetic and environmental factors play a role in the development of osteoarthritis (OA). Recent studies revealed that several genetic predispositions may be contributing to the disease process. A recent genetic analysis
of over 400 families showed that type IX collagen is linked to development of OA in women. Mice with a type IX collagen gene deletion are also susceptible to early arthritis. Other genes, such as cartilage enzyme aggrecanase ADAMTS-5, have also been associated with OA.

Question 39

Figure 10 shows the MRI scan of a 56-year-old woman with metastatic breast cancer who now reports progressive paraparesis. Her general health remains good. Treatment should consist of

Explanation

DISCUSSION: If the patient’s medical condition and prognosis remain good in the presence of significant and progressive neurologic deficit from cord compression, then the most reliable means of restoring function is via surgical decompression and fusion. Decompression should be directed toward the compressing structure (eg, anteriorly if the compression is from the anterior side). This procedure can be done via a posterolateral technique, such as costotransversectomy in some cases.
REFERENCE: Fardin DF, Garfin SR, Abitbol J, et al (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 123-133.

Question 40

Figure 50 shows the AP radiograph of an asymptomatic 82-year-old woman who underwent total hip arthroplasty 16 years ago. What is the most likely diagnosis?

Explanation

DISCUSSION: Pelvic osteolysis in the presence of a well-fixed porous-coated socket is a recognized complication in total hip arthroplasty. The radiograph shows large lytic lesions superiorly adjacent to an acetabular screw and inferiorly extending into the ischium. It also reveals eccentricity of the femoral head with respect to the acetabular component, consistent

with polyethylene wear.
REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 440.
Dowd JE, Sychterz CJ, Young AM, et al: Characterization of long-term femoral-head-penetration rates: Association with and prediction of osteolysis. J Bone Joint Surg Am 2000;82:1102-1107.

Question 41

When comparing the failure load of an evenly tensioned four-stranded hamstring tendon anterior cruciate ligament autograft to a 10-mm bone-patellar tendon-bone autograft, the hamstring graft will fail at a tension

Explanation

DISCUSSION: The failure load of an evenly tensioned four-stranded hamstring tendon autograft has been reported to be 4,500 Newtons. The failure load of a 10-mm patellar tendon autograft has been estimated at 2,600 Newtons. The intact anterior cruciate ligament failure load has been calculated at 1,725 Newtons.
REFERENCES: Corry IS, Webb JM, Clingeleffer AJ, Pinczewski LA: Arthroscopic reconstruction of the anterior cruciate ligament: A comparison of patellar tendon autograft and four-strand hamstring tendon autograft. Am J Sports Med 1999;27:448-454.
Hamner DL, Brown CH Jr, Steiner ME, et al: Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: Biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am 1999;81:549-557.
Noyes FR, Butler DL, Grood ES, et al: Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. J Bone Joint Surg Am 1984;66:344-352.

Question 42

A 10-year-old boy has a painful, swollen knee after falling off his bicycle. Examination reveals that the knee is held in 45 degrees of flexion, and any attempt to actively or passively extend the knee produces pain and muscle spasms. A lateral radiograph is shown in Figure 4. What is the most likely diagnosis?

Explanation

DISCUSSION: This is a typical patellar sleeve fracture. The patellar tendon avulses a portion of the distal bony patella, along with the retinaculum and articular cartilage from the inferior pole of the patella. It is common in children between ages 8 and 10 years. Anatomic reduction and repair of the extensor mechanism are mandatory to reestablish full knee extension.
REFERENCES: Houghton GR, Ackroyd CE: Sleeve fractures of the patella in children: A report of three cases. J Bone Joint Surg Br 1979;61:165-168.
Wu CD, Huang SC, Liu TK: Sleeve fracture of the patella in children: A report of five cases. Am J Sports Med 1991;19:525-528.

Question 43

A 10-year-old boy tripped as he was running down a hill, felt a painful pop in his right knee, and was unable to bear weight on the involved lower extremity. Examination reveals a tense effusion and an extensor lag of the right knee. Figures 36a and 36b show AP and lateral radiographs. Management should consist of

Explanation

DISCUSSION: The examination and radiographs are consistent with a sleeve fracture of the patella, which is an avulsion fracture of the distal pole of the patella with a disruption of the extensor mechanism. Treatment is open reduction and internal fixation of the patella, and repair of the extensor mechanism.
The distal fragment can be much larger than it appears on the radiographs because it consists largely of cartilage.
REFERENCES: Wu CD, Huang SC, Liu TK: Sleeve fracture of the patella in children: A report of five cases. Am J Sports Med 1991;19:525-528.
Grogan DP, Carey TP, Leffers D, et al: Avulsion fractures of the patella. J Pediatr Orthop 1990; 10:721 - 730. Question 37
When addressing a proximal intertrochanteric or subtrochanteric fracture in a juvenile with open growth plates, the arterial supply from what artery at the neck must be preserved?
Lateral femoral circumflex
Medial femoral circumflex
Superior gluteal
Inferior gluteal
Obturator
DISCUSSION: The medial femoral circumflex artery supplies blood to the femoral head. Its position along the posterior-superior femoral neck places this structure at risk with intramedullary nailing of the femur. Therefore, lateral entry through the greater trochanter is preferred when intramedullary fixation is performed.
REFERENCES: Gordon JE, Swenning TA, Burd TA, et al: Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children. J Bone Joint Surg Am 2003;85:1295- 1301.
Green NE, Swiontkowski MF: Skeletal Trauma in Children, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 419-424.

Question 44

A 32-year-old motorcycle rider is involved in a motor vehicle accident and radiographs show a burst fracture at L2 with 20 degrees of kyphosis. The neurologic examination is consistent with unilateral motor and sensory involvement of the L5, S1, S2, S3, and S4 nerve roots. He has no other injuries. CT demonstrates 20% anterior canal compromise with displaced laminar fractures at the level of injury. What is the best option for management of this patient?

Explanation

DISCUSSION: The patient has a burst fracture with probable unilateral entrapment of the cauda equina within the elements of the fractured lamina. A dural tear is likely in this scenario as well. It is recommended that this type of burst fracture be treated surgically with laminectomy, freeing of the entrapped nerve roots, and dural repair followed by stabilization of the fracture by either a posterior or combined approach. The degree of kyphosis and the extent of anterior canal compromise does not warrant corpectomy in this patient. Therefore, after completing the laminectomy and dural repair, posterior fusion and instrumentation should be sufficient to stabilize the fracture.
REFERENCES: Cammisa FP Jr, Eismont FJ, Green BA: Dural laceration occurring with burst fractures and associated laminar fractures. J Bone Joint Surg Am 1989;71:1044-1052.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.

Question 45

The rate of complications after in situ pinning of a chronic slipped capital femoral epiphysis is highest with placement of the screw in what quadrant of the femoral head?

Explanation

DISCUSSION: The rate of complications increases as the pin moves farther from the ideal position, which is the center of the head. This is the strongest argument for the use of a single pin. The highest rate of complications, primarily osteonecrosis and pin penetration, is associated with pin placement in the anterior superior quadrant.
REFERENCES: Raney EM, Ogden JA: Slipped capital femoral epiphysis. Current Ortho 1995;9:111-116.
Stambough JL, Davidson RS, Ellis RD, et al: Slipped capital femoral epiphysis: An analysis of 80 patients as to pin placement and number. J Pediatr Orthop 1986;6:265-273

Question 46

A newborn with myelomeningocele has no movement below the waist and has bilateral hips that dislocate with provocative flexion and adduction. What is the best treatment option for the hip instability?

Explanation

DISCUSSION: The status of the hips (located or dislocated) in children with thoracic-level myelomeningocele has no effect on the functional outcome of these patients. Management of unstable hips in this population should be limited to treatment of the contractures that may lead to poor limb positioning in either braces or a wheelchair. The use of the Pavlik harness and/or spica cast is contraindicated because they would promote flexion and abduction contractures. In the past, open reduction either through an anterior or medial approach had been performed with a high incidence of redislocation and other complications, with little functional gain for the child.
REFERENCES: Gabriel KG: Natural history of hip deformity in spina bifida, in Sarwark JR, Lubicky JP (eds): Caring for the Child With Spina Bifida. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2001, pp 89-103.
Schoenecker PL: Surgical management of hip problems in children with myelomeningocele, in Sarwark KR, Lubicky JP (eds): Caring for the Child With Spina Bifida. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2001, pp 117-131.

Question 47

A 46-year-old male sustains a patella fracture and is treated with cannulated screws and a tension band construct. Which of the following is correct regarding this treatment?

Explanation

Fixation of patella fractures with tension band constructs leads to a need to remove implants in over 50% of cases in multiple studies.
Tension band constructs result in absolute stability when performed correctly. This technique works by converting tension from muscle pull into compressive force on the articular side of the fracture. Tension band constructs require a fracture pattern or bone that is able to withstand compression, an intact cortical buttress opposite to the tension band, and fixation that withstands tensile forces.
LeBrun et al. and associates evaluated functional outcomes of surgically isolated patella fractures. They reported that 52% of patients underwent surgery for hardware removal, and 38% of patients who retained their hardware reported pain at some time. They also found that nearly 20% had extensor lag, and almost 38% had restricted flexion. Extension power on testing showed significant mean deficits when compared to the contralateral side.
Bayar et al. evaluated 20 patients with patella fractures and found that articular incongruity of >1mm was the largest risk factor for quadriceps weakness at a mean of 30 months postoperatively. No significant differences were seen with sex, fracture pattern, or time from injury to surgery.
Illustration A shows patella fixation with plate/screw construct. Incorrect Answers:

OrthoCash 2020

Question 48

What is the most common physical examination finding in a patient with chronic painful spondylolysis? Review Topic

Explanation

Patients with spondylolysis typically demonstrate increased pain with lumbar extension, not with forward flexion. In the absence of a disk herniation, a straight leg raise test result should be negative. Pain with forward flexion is not common in spondylolysis, and without nerve root impingement there should be no loss of the tendo-Achilles reflex.

Question 49

Figure 20 shows the radiograph of a 21-year-old college basketball player who jammed his left index finger on the rim. He reports pain and tenderness over the dorsum of the distal interphalangeal (DIP) joint. Examination reveals that he is unable to actively extend the DIP joint; however, the skin is intact. Management should consist of

Explanation

DISCUSSION: Mallet fingers without DIP joint subluxation can be treated with extension splinting. Surgical fixation may be necessary in bony mallet injuries when the joint is subluxated. Size of the bony fragment, while often correlating with stability, is not always an indication for fixation. Buddy taping allows motion; therefore, the fragment will not heal in the appropriate position. Intermittent splinting with range-of-motion exercises also will not allow the fragment to heal in the appropriate position.
REFERENCES: Crawford GP: The molded polyethylene splint for mallet finger deformities.

J Hand Surg Am 1984;9:231-237.
Wehbe MA, Schneider LH: Mallet fractures. J Bone Joint Surg Am 1984;66:658-669.

Question 50

A 14-year-old boy reports a 4-month history of increasing backache with difficulty walking long distances. His parents state that he walks with his knees slightly flexed and is unable to bend forward and get his hands to his knees. He denies numbness, tingling, and weakness in his legs and denies loss of bladder and bowel control. A lateral radiograph of the lumbosacral spine is shown in Figure 18. What is the best surgical management for this condition?

Explanation

DISCUSSION: The patient has a grade 4 spondylolisthesis. Optimal surgical management is posterior spinal fusion from L4 to the sacrum. The use of instrumentation is controversial. Vertebrectomy is typically reserved for spondylo-optosis (grade 5) cases. Spinal fusion from

L5 to S1 usually is not successful for a slip that is greater than 50%. Isolated anterior spinal fusion has not been successful, and direct repair of the pars defect is only useful for spondylolysis without spondylolisthesis.
REFERENCES: Lenke LG, Bridwell KH: Evaluation and surgical treatment of high-grade isthmic dysplastic spondylolisthesis. Instr Course Lect 2003;52:525-532.
Ginsburg GM, Bassett GS: Back pain in children and adolescents: Evaluation and differential diagnosis. J Am Acad Orthop Surg 1997:5:67-78.

Question 51

Which of the following processes does not account for decreased hematopoiesis in patients with metastatic disease?

Explanation

DISCUSSION: Paucytopenia is a common problem in patients with metastatic disease. Causes include chemotherapy, external beam radiation, marrow replacement by tumor, and anemia of chronic disease. There is no correlation with decreased calcium and a decrease in hematopoiesis. Supportive care with granulocyte-colony stimulating factor (G-CSF) and neupogen can stimulate hematopoiesis.
REFERENCE: Frassica FJ, Gitelis S, Sim FH: Metastic bone disease: General principles, pathophysiology, evaluation, and biopsy. Instr Course Lect 1992;41:293-300.

Question 52

A 20-year-old soccer player who collapsed after a goal kick reports weakness and nausea. He appears slightly confused. Examination reveals that he is not sweating. His skin is warm and dry. The outdoor temperature is 80 degrees F (26.6 degrees C) with a relative humidity of 80%. Management should consist of

Explanation

DISCUSSION: There is a spectrum of heat-related conditions. Heat cramps are the mildest form of heat illness. In heat exhaustion, cramps are associated with headache and weakness, and the skin is pale and moist. Treatment of heat cramps or heat exhaustion consists of removing and loosening excess clothing, applying ice to the axilla and groin, ingestion of cool water, and cool water sprays. This patient demonstrates symptoms of heat stroke which is a medical emergency. The core body temperature may be as high as 106 to 110 degrees F (41.1 to 43.3 degrees C). In heat stroke, the patient may no longer be sweating, and the skin may be hot and red. The athlete is usually confused, weak, nauseated, and may have seizure activity. Central nervous system depression has been called the most important marker of heat stroke, and progresses from confusion and bizarre behavior to collapse, delirium, and coma. Bizarre behavior is often the first sign of heat stroke. The patient needs to be treated and moved to a medical facility rapidly. During transfer, IV fluids and cooling of the athlete should be initiated. The best treatment of heat-related illness appears to be prevention with adequate hydration and monitoring of conditions (temperature and humidity), with cancellation of competition when conditions do not comply with guidelines.
REFERENCES: Griffin LY: Emergency preparedness: Things to consider before the game starts. J Bone Joint Surg Am 2005;87:894-902.
Barker TA, Motz HA, Gersoff WK: Environmental factors in athletic performance, in Fu FH, Stone DA (eds): Sports Injuries, ed 2. Philadelphia, PA, Lippincott, 2001, pp 67-68.
Roberts WO: Environmental concerns, in Kibler WB (ed): ACSM’s Handbook for the Team Physician. Baltimore, MD, Williams & Wilkins, 1996, p 172.

Question 53

Figure 23 shows the postoperative radiograph of a patient who underwent an anterior cruciate ligament (ACL) reconstruction (with bone-patella tendon-bone autograft) that failed. He initially had loss of flexion postoperatively. What is the most likely cause of this failure? Review Topic

Explanation

The key to this question is the fact that the patient initially lost flexion postoperatively and this relates to anterior placement of the femoral tunnel, thus capturing the knee. The bone plug seen on the radiograph is actually from the tibial tunnel, but this occurred as the patient forced flexion until failure of the ACL graft and pullout of the plug from the tunnel. Although it could be argued that better tibial fixation would have prevented this failure, poor placement of the femoral tunnel led to the failure of this ACL reconstruction.

Question 54

A collegiate division I football player ruptures his anterior cruciate ligament (ACL). After counseling him, you agree to perform a double-bundle ACL reconstruction. Which of the following is a correct statement for this technique? Review Topic

Explanation

The ACL is composed of two anatomic bundles: the anteromedial (AM) and the posterolateral (PL). They are both considered important to the stability of the knee. Although they work in concert, the AM bundle controls translation, especially in flexion, whereas the PL bundle prevents rotation.

Question 55

When performing elbow arthroscopy, it is often necessary to evaluate the posterior compartment. When entering the posterior compartment of the elbow, what are the two safest and most commonly used portals?

Explanation

DISCUSSION: The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps are the “workhorse” portals of the posterior compartment and although relatively safe, risks exist. The radial nerve proximity averages 4.8 mm (3 to 8 mm) from the posterolateral portal. The central posterior portal close to 20 mm from the ulnar nerve.
REFERENCES: Steinmann SP: Elbow arthroscopy. J Am Society of the Hand 2003 ;3:199-207.
Dodson CC, Nho SJ, Williams RJ III, et al: Elbow Arthroscopy. J Am Acad Orthop Surg 2008:16:574- 585.

Question 56

Deep anterior compartment

Explanation

How many compartments exist in the foot:

Question 57

-A collegiate offensive football lineman has decreased bench-press strength and shoulder pain as off-season workouts begin. Examination revealed no atrophy, and deltoid and rotator cuff strength testing findings were normal. Translational testing was difficult to achieve because of his large size.Apprehension and relocation test findings were negative. An O’Brien’s active compression test result was negative. Jerk testing was positive on the affected side. Which diagnosis is most likely revealed on an MRI arthrogram?

Explanation

Question 58

Hip pain of 1-month duration has developed in a 72-year-old man with a previous total hip arthroplasty. He underwent dental work 6 weeks ago. Aspiration shows a white blood cell count of more than 6,000 cells/μL (reference range 4,500 to 11,000 cells/μL) and the presence of gram-positive cocci in clusters on Gram stain. The orthopaedic surgeon recommends urgent debridement and irrigation. Fixation of the components is judged to be stable, and the surgeon elects to retain the implants. What is this patient's prognosis for infection resolution?

Explanation

DISCUSSION:
The patient has a late infection of at least 4 weeks symptomatic duration that most likely is hematogenous in etiology. This infection is not an acute hematogenous infection that can successfully be treated with irrigation and debridement. Retention of the implants with debridement and irrigation alone has been associated with a poor prognosis. In a recent study, the success rate was only 44% in a series of 104 patients at a mean 5.7-year follow-up. In one study of 50 infections attributable to MRSA or methicillin- resistant Staphylococcus epidermidis organisms treated with a two-stage protocol, the failure rate was
21%. Patients who experienced successful infection treatment had lower functional outcome measures using the Western Ontario and McMaster Universities Osteoarthritis Index, the University of California Los Angeles Activity Score, and the 12-item Oxford Knee Score, however.

Question 59

To preserve blood supply to the fractured bone seen in Figures 12a and 12b, care should be taken when exposing which of the following areas?

Explanation

DISCUSSION: The blood supply to the adult capitellum and lateral trochlea comes from posterior vessels arising from the radial recurrent, radial collateral, and interosseous recurrent arteries. These arteries penetrate the distal humerus posterior and superior to the capitellum.
REFERENCE: Yamaguchi K, Sweet FA, Bindra R, et al: The extraosseous and intraosseous arterial anatomy of the adult elbow. J Bone Joint Surg Am 1997;79:1653-1662.

Question 60

A 73-year-old woman reports a 4-month history of severe left-sided posterior buttock pain and left leg pain. The leg pain radiates into the left lateral thigh and posterior calf with cramping. Examination reveals mild difficulty with a single-leg toe raise on the left side and a diminished ankle reflex. There is also a significant straight leg raise test at 45 degrees which exacerbates symptoms. An MRI scan is shown in Figure 4. What is the most appropriate treatment at this time?

Explanation

DISCUSSION: Lumbar spinal stenosis with lumbar radiculopathy can be commonly caused by a synovial cyst arising from the facet joints. Lyons and associates reported on the surgical treatment of synovial cysts in 194 patients. Of the 147 with follow-up data, 91% reported good pain relief and 82% had improvement of their motor deficits. Epstein reported a 58% to 63% incidence of good/excellent results and a 38 to 42 point improvement on the SF-36 Physical Function Scale. It was also suggested that since the presence of a synovial cyst indicates facet pathology, possible fusion should be considered in these patients, especially those with underlying spondylolisthesis.
REFERENCES: Lyons MK, Atkinson JL, Wharen RE, et al: Surgical evaluation and management of lumbar synovial cysts: The Mayo Clinic Experience. J Neurosurg

2000;93:53-57.
Khan AM, Synnot K, Cammisa FP, et al: Lumbar synovial cysts of the spine: An evaluation of surgical outcome. J Spinal Disord Tech 2005;18:127-131.
Epstein NE: Lumbar laminectomy for the resection of synovial cysts and coexisting lumbar spinal stenosis or degenerative spondylolisthesis: An outcome study. Spine 2004;29:1049-1055.

Question 61

What is the minimum hours per day of wear that has been correlated with the effectiveness of bracing on curve progression in idiopathic scoliosis? Review Topic

Explanation

The efficacy of brace treatment for patients with adolescent idiopathic scoliosis is controversial because its effectiveness remains unproven. One of the challenges is patient noncompliance with prescribed bracing regimens. A recent study investigated curve progression based on actual brace wear using a temperature sensor to accurately assess brace wear. The total hours of brace wear correlated with lack of curve progression with a dose-response effect noted. Curves did not progress in 82% of patients who actually wore the brace more than 12 hours per day. For those who wore the brace for fewer than 7 hours per day, curves progressed in 69%. Prescribed bracing regimens (eg, 16 hours/day or 23 hours/day) had no effect on actual brace wear or curve progression.

Question 62

A 59-year-old active woman undergoes elective total hip replacement in which a posterior approach is used. She has minimal pain and is discharged to home 2 days after surgery. Four weeks later, she dislocates her hip while shaving her legs. She undergoes a closed reduction in the emergency department. Postreduction radiographs show a reduced hip with well-fixed components in satisfactory alignment. What is the most appropriate management of this condition from this point forward?

Explanation

DISCUSSION:
First-time early dislocations are often treated successfully without revision surgery, especially when no component malalignment is present. In this clinical scenario, it appears the patient would benefit from better education about dislocation precautions. Hip orthoses are of questionable benefit unless the patient is cognitively impaired. Revision surgery can be successful but is usually reserved for patients with recurrent dislocations.

Question 63

Figure 30 shows the current radiograph of a 32-year-old woman who had a giant cell tumor of the distal radius that was treated with curettage/burring and packed with polymethylmethacrylate 2 years ago. What is the most likely diagnosis?

Explanation

Number four is the correct answer because recurrence is the most likely cause of the lytic zone. Since cement resists invasion by the tumor, lysis of the surrounding bone is inevitably produced in a recurrence. A 1-2 mm lytic zone can be found normally, greater than 5 mm lytic zone is positive for recurrence and the 3 – 5 mm lytic zone is very suspicious and should be followed by MRI and image guided needle biopsy. No other sign of osteomyelitis or stress fractures are noted.

Question 64

Which of the following clinical scenarios represents an appropriate indication for convex hemiepiphysiodesis/hemiarthrodesis in the treatment of a child with a congenital spinal deformity?

Explanation

DISCUSSION: Convex hemiarthrodesis and hemiepiphysiodesis are procedures designed to gradually reduce curve magnitude in congenital scoliosis because of hemivertebrae. They are used to surgically create an anterior and posterior bar to arrest growth on the convexity of the existing deformity. Success of the technique is predicated on continued growth on the concave side of the deformity. Prerequisites for this procedure include curves of limited length (less than or equal to five vertebrae), curves of reasonable magnitude (less than 70°), absence of kyphosis, concave growth potential, and appropriate age (younger than age 5 years).
REFERENCE: Winter RB, Lonstein JE, Denis F, Sta-Ana de la Rosa H: Convex growth arrest for progressive congenital scoliosis due to hemivertebrae. J Pediatr Orthop 1988;8:633-638.

Question 65

A 78-year-old woman undergoes an uneventful semiconstrained total elbow arthroplasty through a Bryan-Morrey approach. Her immediate postoperative management should include which of the following? Review Topic

Explanation

Postoperative management of total elbow arthroplasty patients is directed to avoidance of complications commonly associated with this procedure. Following total elbow arthroplasty, 24 hours of perioperative antibiotics should be given, consistent with other arthroplasty procedures. Because of the relatively thin soft-tissue envelope surrounding the elbow, particularly in patients with rheumatoid arthritis, consideration must be given to the surrounding soft tissues postoperatively. The surgical wound should be given several days of quiescence prior to initiation of motion to minimize wound healing complications. Splinting at 60 to 90 degrees allows tension to be removed from the soft tissues. Immediate motion places these tissues under immediate stress; immobilization of the elbow for 6 to 8 weeks until the triceps has healed would result in significant stiffness. Splinting should not be used more than 10 days to avoid stiffness of the elbow.

Question 66

A 12-year-old girl has scoliosis at T5-T10 that measures 62°. A clinical photograph of the axilla is shown in Figure 56. Management should consist of

Explanation

DISCUSSION: Neurofibromatosis type 1 (NF-1) is an autosomal-dominant disorder affecting about 1 in 4,000 people. NF-1 causes tumors to grow along various types of nerves and affects the development of non-nervous tissues, such as bone and skin. The gene for NF-1 is located on the long arm of chromosome 17 and codes the protein neurofibromin. Research indicates that NF-1 acts as a tumor-suppressor gene and, as such, plays an important role in the control of cell growth and differentiation. Axillary and inguinal freckling is considered a good diagnostic marker for NF-1. The hyperpigmented spots that measure from 2 mm to 4 mm may be congenital, but these typically appear and increase later in life. Scoliosis is the most common musculoskeletal disorder of NF-1. The curves are frequently dystrophic, kyphotic, and have a high risk of pseudarthrosis following spinal fusion. Anterior and posterior spinal fusion with rigid posterior segmental instrumentation is the treatment of choice.
REFERENCES: Goldberg Y, Dibbern K, Klein J, Riccardi VM, Graham JM Jr: Neurofibromatosis type 1: An update and review for the primary pediatrician. Clin Pediatr 1996;35:545-561.
Kim HW, Weinstein SL: Spine update: The management of scoliosis in neurofibromatosis. Spine 1997;22:2770-2776.

Question 67

Which of the following methods is effective in correcting recurrent dislocation following total hip arthroplasty?

Explanation

DISCUSSION: Recurrent dislocation following total hip arthroplasty is a difficult problem to correct. Studies conducted by the Mayo Clinic show a failure rate of close to 40% with surgical treatment. A variety of methods have been successful, but no specific approach has been reported to be the most predictably successful. To select and institute the proper treatment option, the cause of the dislocation must be identified. Surgical options fall into several broad categories that include increasing soft-tissue tension (trochanteric advancement or longer neck lengths) or more stable articulation (larger diameter head component, bipolar prosthesis, or a constrained component). In a series of total hip arthroplasties done with a constrained cup, the loosening rates of the cup and the stem were reported to be 6% each, comparable to a reported series of complex revision total hip arthroplasties at a similar follow-up interval.
REFERENCES: Woo RY, Morrey BF: Dislocations after total hip arthroplasty. J Bone Joint Surg Am 1982;64:1295-1306.
Goetz DD, Capello WN, Callaghan JJ, Brown TD, Johnston RC: Salvage of a recurrently dislocating total hip prosthesis with use of a constrained acetabular component: A retrospective analysis of fifty-six cases. J Bone Joint Surg Am 1998;80:502-509.

Question 68

Which of the following types of ultra-high molecular weight polyethylene has been associated with the poorest clinical performance?

Explanation

DISCUSSION: Numerous studies have documented the poor performance of heat-pressed ultra-high molecular weight polyethylene used in the porous-coated anatomic tibial inserts of both total knee and unicompartmental arthroplasty. The other processing and sterilization methods have not been associated with significantly high failure rates.
REFERENCES: Wright TM, Rimnac CM, Stulberg SD, et al: Wear of polyethylene in total joint replacements: Observations from retrieved PCA knee implants. Clin Orthop 1992;276:126-134.
Landy MM, Walker PS: Wear of ultra-high molecular-weight polyethylene components of 90 retrieved knee prostheses. J Arthroplasty 1988;3:S73-S85.
Skyrme AD, Mencia MM, Skinner PW: Early failure of the porous-coated anatomic cemented unicompartmental knee arthroplasty: . A 5- to 9-year follow-up study. J Arthroplasty 2002;17:201-205.

Question 69

A 37-year-old laborer sustained a fracture of the posterior acetabular wall. Two years following operative management, the patient reports severely limited hip motion and back pain. Radiographs reveal extensive mature heterotopic ossification with preservation of the hip joint space. Management should now consist of

Explanation

Heterotopic ossification is very common after acetabular fracture surgery. It is most common with the extensive exposures, rates up to 45-100%. The HO is most extensive when these approaches are utilized and no prophylaxis is provided. The ilio-inguinal approach has the least common incidence of HO. Routine prophylaxis consists of either 1) Indomethacin 25 mg tid for 4-6 weeks, beginning POD #1 or 2) Low dose irradiation 1000 rads in divided doses or 700 rads single dose, begun before POD #4. Surgical excision is only considered when the HO severely reduces hip mobility. It is recommended to have a preop CT scan for your surgical plan, utilize the initial incision and to use great caution around the (unreadable).

Question 70

An obese 56-year-old woman with hypertension has had posterior heel pain for the past 6 months. She also notes some enlargement over the posterior aspect of the heel. Examination reproduces pain with palpation at the insertion of the Achilles tendon. A lateral radiograph is shown in Figure 45. What is the most likely diagnosis?

Explanation

DISCUSSION: The lateral radiograph shows a traction spur consistent with tendinopathy of the Achilles tendon. There is no displacement of the spur to suggest a rupture of the Achilles tendon, and os trigonum is not seen on the radiograph. The examination findings are not consistent with nerve entrapment.
REFERENCES: Schepsis AA, Wagner C, Leach RE: Surgical management of Achilles tendon overuse injuries: A long-term follow-up study. Am J Sports Med 1994;22:611-619.
Saltzman CL, Tearse DS: Achilles tendon injuries. J Am Acad Orthop Surg 1998;6:316-325.

Question 71

A 14-year-old girl reports a 3-week history of anterior thigh pain and a palpable mass after sustaining a soccer-related injury. Examination reveals a tender, firm mass in the midportion of the rectus femoris. MRI scans are shown in Figures 39a through 39c. What is the most appropriate management?

Explanation

DISCUSSION: The history, examination, and MRI scan findings are consistent with a midsubstance partial rupture of the rectus femoris muscle. This is an injury masquerading as a “pseudo tumor.” The lack of an appreciable mass effect on the T₁-weighted MRI scan, the defined fluid signal on the T₂-weighted scans, and the lack of significant contrast enhancement after gadolinium are all most consistent with injury rather than a neoplasm. Most of these injuries respond to nonsurgical management; a few will benefit from late debridement and repair if symptoms fail to resolve in 3 to 6 months. The treatment of choice is nonsurgical management with a follow-up MRI scan to verify that the findings are resolving.
REFERENCES: Hughes C IV, Hasselman CT, Best TM, et al: Incomplete, intrasubstance strain injuries of the rectus femoris muscle. Am J Sports Med 1995;23:500-506.
Temple HT, Kuklo TR, Sweet DE, et al: Rectus femoris muscle tear appearing as a pseudotumor. Am J Sports Med 1998;26:544-548.

Question 72

A 59-year-old woman who underwent a total hip arthroplasty 5 years ago now has recurrent dislocation following bariatric surgery and a weight loss of 200 lb. An attempt at converting to a larger head size and trochanteric advancement has failed. Her components are well aligned. What is the best course of action?

Explanation

DISCUSSION: When a patient has well-aligned components and soft-tissue tensioning with a larger femoral head and trochanteric advancement has failed, options are limited. The use of a constrained acetabular liner is the best option in this situation. Goetz and associates and Shrader and associates have demonstrated good results with these implants. Shrader used this device on 109 patients with recurrent instability with a successful outcome in all but 2 patients. Resection arthroplasty is a salvage situation and is not the best option at the present time. A hip abduction brace does not address the soft-tissue laxity. Conversion to a bipolar arthroplasty, although possibly minimizing the incidence of dislocation, will lead to groin pain and migration of the component with diminished functional results.
REFERENCES: Goetz DD, Capello WN, Callaghan JJ, et al: Salvage of recurrently

dislocating hip prosthesis with use of a constrained acetabular component: A retrospective analysis of fifty-six cases. J Bone Joint Surg Am 1998;80:502-509.
Shrader MW, Parvizi J, Lewallen DG: The use of constrained acetabular component to treat instability after total hip arthroplasty. J Bone Joint Surg Am 2003;85:2179-2183.
Hamilton WG, McAuley JP: Evaluation of the unstable total hip arthroplasty. Inst Course Lect 2004;53:87-92.

Question 73

Figures 27a through 27c show the AP radiograph, MRI scan, and biopsy specimen of an otherwise healthy man who has a painful wrist. Serum chemistry studies are normal. What is the most likely diagnosis?

Explanation

DISCUSSION: The osseous sites most frequently involved by giant cell tumor of bone are the distal femur, proximal tibia, and distal radius with approximately 10% of giant cell tumors involving the distal radius. The goals of treatment are to remove the tumor completely and to preserve maximum function of the extremity.
REFERENCE: Vander Griend RA, Funderburk CH: The treatment of giant-cell tumors of the distal part of the radius. J Bone Joint Surg Am 1993;75:899-908.

Question 74

What is the most common MRI appearance of a malignant soft-tissue sarcoma?

Explanation

DISCUSSION: The classic MRI appearance of a soft-tissue sarcoma is a well-defined heterogeneous mass deep to the fascia. MRI has greatly enhanced our ability to identify and characterize soft-tissue masses. In many patients, MRI is diagnostic and may obviate the need for biopsy. In other patients, it may indicate with high probability that the mass is malignant and consideration for referral can be made. A common misconception is that sarcomas are infiltrative; therefore, physicians mistakenly exclude the diagnosis of a sarcoma based on a well-defined mass seen on MRI. However, sarcomas grow centrifugally with balloon-like expansion compressing surrounding normal tissue; as such, they appear well defined. Many benign soft-tissue masses such as lipomas are similarly well defined. However, MRI is especially useful in identifying fat. Lipomas appear to be homogeneous masses with fat signal characteristics on all sequences. Ill-defined soft-tissue masses include infection, trauma, and desmoid tumors. Heterogeneity is not unique to malignant tumors but is a characteristic of soft-tissue sarcomas.
REFERENCES: Bancroft LW, Peterson JJ, Kransdorf MJ, Nomikos GC, Murphey MD: Soft tissue tumors of the lower extremities. Radiol Clin North Am 2002;40:991-1011.
Berquist TH, Ehman RL, King BF, et al: Value of MR imaging in differentiating benign from malignant soft-tissue masses: Study of 95 lesions. Am J Roentgenol 1990;155:1251-1255.
Crim JR, Seegar LL, Yao L, et al: Diagnosis of soft tissue masses with MR imaging: Can benign masses be differentiated from malignant ones? Radiology 1992;185:581-586.

Question 75

A 12-year-old boy with an ankle fracture undergoes closed reduction under sedation in the emergency department. Figure 27 shows a lateral radiograph of the ankle after two attempts at closed reduction. Based on these findings, treatment should now consist of Review Topic

Explanation

The widening of the physis associated with incomplete reduction of this fracture suggests that periosteum is interposed at the fracture site. Clinical and animal study findings suggest that the interposed periosteum may lead to premature physeal closure. Repeated forceful attempts at reduction may subject the physis to further injury and should be avoided. Growth problems are common in children with Salter-Harris type I fractures of the lower extremities. Nonunions are rare in children with Salter-Harris type I fractures.

Question 76

A 24-year-old female soccer player has had lateral joint line pain and a recurrent effusion in the left knee after sustaining a twisting injury 6 weeks ago. She reports that symptoms worsen with athletic activities. MRI scans are shown in Figures 2a through 2c. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scans show the typical findings of a torn discoid lateral meniscus. The average transverse diameter of the lateral meniscus is 11 or 12 mm. A discoid lateral meniscus is suggested when three or more contiguous 5-mm sagittal sections on the MRI scan show continuity of the menicus between the anterior and posterior horns, or when two adjacent peripheral sagittal 5-mm sections show equal meniscal height. Normally the black “bow tie” would be seen on two contiguous sagittal sections. The presence of a discoid meniscus can be further confirmed if coronal views reveal increased width.
REFERENCES: Jordan MR: Lateral meniscal variants: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:191-200.
Resnick D, Kang HS: Internal Derangement of Joints: Emphasis on MRI Imaging. Philadelphia, PA, WB Saunders, 1997, pp 625-630.

Question 77

A 6-year-old boy has had increasing pain and a mass in the suprapatellar region of the right femur for the past week. Examination of the mass reveals it may be firm, immobile, and tender to palpitation. The patient has no systemic symptoms. Laboratory studies show a WBC of 7000 per cubic millimeter, a hematocrit of 40%, and an erythrocyte sedimentation rate of 10 mm/hr. radiographs are normal. Figures 64a and 64b show saggital and axial T1-weighted MRI scans. Figure 64c shows frozen section pathology of the biopsy specimen. What is the most likely diagnosis?

Explanation

Multiple hints in this history, MRI and pathology section leads to the diagnosis of soft tissue abscess. The sarcomas are slow growing and mostly are asymptomatic. The mass is tender and enlarging over the past week. PVNS would give the patient a painful boggy joint and this mass is supracondyler. Esinophilic granuloma would give a punched-out lesion in the long bones on the plain radiographs. The best clue is the slide given which shows inflammatory cells. PVNS would show hemosiderin stained giant cells, synovial sarcoma would reveal a biphasic pattern of spindle cells, E.G. would show eosinophils and histiocytes, and rhabdomyosarcoma would have cross striation within the tumor cells.

Question 78

A 15-year-old male jumps off a 6 foot ramp and lands awkwardly. His knee swells up immediately and he is taken to the emergency room. Figures A is a sagittal CT scan image. In the next 3 hours, he complains of increasing leg pain. This is likely because of injury to which of the following structures? Review Topic

Explanation

This child has a tibial tuberosity avulsion fracture with intraarticular extension. There is a risk for anterior compartment syndrome of the leg because of rupture of the anterior tibial recurrent artery located around the lateral border of the tibial tubercle. The vessels retract under the fascia, leading to bleeding into the anterior compartment.
Tibial tubercle fractures usually occur during aggressive quadriceps contraction during sports. The Ogden classification classifies this by site of fracture (Type I, through the tubercle; Type II, at the level of the tibial physis; Type III, extending through the anterior tibial epiphysis). Other complications include extensive soft tissue damage, periosteal stripping, vascular compromise and intra-articular damage.
Pandya et al. reviewed 41 tibial tubercle fractures. They found compartment syndrome or vascular compromise in nearly 10%. They found that the degree of injury was underestimated 50% of the time when classified using lateral radiographs alone. They recommend CT scan or MRI as an adjunct. If intra-articular involvement is seen, arthroscopy or open arthrotomy should be performed.
Pape et al. describe 2 case reports of anterior compartment syndrome after tibial tubercle fracture. The compartment syndrome occurs as a result of proximity of the tibial tubercle physis to the anterior tibial recurrent artery.
Figure A shows the sagittal reconstruction CT image showing intraarticular involvement. Illustrations A and B are axial and coronal CT images in the subchondral region showing the fracture line traversing the zone between fused and unfused physis (see Illustration C for physeal closure pattern). Illustration C shows the direction of closure of the proximal tibial physis. In the sagittal plane, the proximal tibial physis closes from posterior to anterior, then to the tubercle apophysis which closes from proximal to distal also. In the coronal plane, the physis closes from medial to lateral. In the axial plane, the physis closes from posteromedial to anterolateral. Illustration D shows the anterior tibial recurrent artery.
Incorrect Answers:

Question 79

Figure 1 is the ultrasound of a 23-year-old patient who has had a volar radial 1.5-cm tender and painful wrist mass for 6 months. The additional workup prior to surgery should consist of

Explanation

EXPLANATION:
The ultrasound shows a homogeneous anechoic mass consistent with a ganglion cyst. As a benign lesion, no further workup or biopsy is required prior to a marginal surgical excision other than age-appropriate laboratory studies. An MRI study with contrast would provide no diagnostic benefit.

Question 80

A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. What is the most common sentinel event related to spine surgery?

Explanation

DISCUSSION: Patient safety and prevention of medical errors is a major focus of recent national advocacy groups. Analysis has shown that the most common sentinel event in spine surgery is surgery on the wrong level. Therefore, it is recommended that every patient have the surgical site signed, the level of surgery marked intraoperatively, and a radiograph taken. Surgery on the wrong level is most likely to occur in single-level decompressive procedures.
REFERENCES: Wong DA, Watters WC III: To err is human: Quality and safety issues in spine care. Spine 2007;32:S2-S8.
Wong DA: Spinal surgery and patient safety: A systems approach. J Am Acad Orthop Surg 2006;14:226-232.

Question 81

An 18-year-old rugby player has had pain in his ring finger after missing a tackle 1 week ago. Examination reveals tenderness in the distal palm, and he is unable to actively flex the distal interphalangeal (DIP) joint. Radiographs are normal. What is the most appropriate management?

Explanation

DISCUSSION: Flexor digitorum profundus rupture or “rugger jersey finger” often occurs in the ring finger after the player misses a tackle and catches the digit on the shirt of the opposing player. Surgical repair is required for zone I-type injuries.
REFERENCES: Moiemen NS, Elliot D: Primary flexor tendon repair in zone I. J Hand Surg Br 2000;25:78-84.
Strickland JW: Flexor tendon injuries: I. Foundations of treatment. J Am Acad Orthop Surg 1995;3:44-54.

Question 82

A 72-year-old man injured his right shoulder after tripping over a chair leg. Radiographs obtained in the emergency department reveal an isolated anterior dislocation. After successful closed reduction, the patient has recurrent anterior instability and is unable to elevate the arm. What is the most likely cause of the recurrent instability?

Explanation

DISCUSSION: A rotator cuff tear is the most common cause of recurrent instability following a first-time dislocation in patients older than age 40 years. Dislocations occur through a posterior mechanism rather than by an isolated labral avulsion or a Bankart lesion as seen in younger patients.
REFERENCES: Nevaiser RJ, Nevaiser TJ: Recurrent instability of the shoulder after age 40.

J Shoulder Elbow Surg 1995;4:416-418.
Pevny T, Hunter RE, Freeman JR: Primary traumatic anterior shoulder dislocation in patients 40 years of age and older. Arthroscopy 1998;14:289-294.

Question 83

A 79-year-old woman reports a history of left leg pain with walking. Her pain is exacerbated with walking and stair climbing, and her symptoms are improved by standing after she stops walking. Lumbar flexion does not provide any significant improvement of the symptoms and sitting does not significantly change symptoms. Her leg pain is worse at night and she obtains relief by hanging her leg over the side of the bed. The neurologic examination is essentially normal. Examination of the lower extremities demonstrates mild early trophic changes, and her pulses distally are palpable but are diminished bilaterally. Radiographs are shown in Figures 15a and 15b. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient has symptoms that are more consistent with vascular claudication than with the pseudoclaudication anticipated from lumbar spinal stenosis. Therefore, the patient is a candidate for further vascular work-up. The radiographs reveal early spinal stenosis and spondylolisthesis at L4-5 but also show significant calcification of the iliac arteries, suggestive of peripheral vascular disease. Vascular claudication is a manifestation of peripheral vascular disease and presents with crampy leg pain that is exacerbated by physical exertion. The pain is easily relieved by standing still or sitting. Unlike pseudoclaudication, a forward-flexed posture and/or sitting does not improve the symptoms. Night pain is common in vascular claudication due to the elevation of the extremities and patients often report pain improvement by hanging their extremities in a dependent position. In evaluation of a patient with suspected vascular claudication, the five “P’s” of vascular insufficiency should be monitored, including pulselessness, paralysis, paresthesia, pallor, and pain. While pain and paresthesias can be common in both vascular claudication and pseudoclaudication, the presence of any of the remaining symptoms is suggestive of vascular disease.
REFERENCES: Aufderheide TP: Peripheral arteriovascular disease, in Rosen P, Barkin R (eds): Emergency Medicine: Concepts and Clinical Practice, ed 4. St Louis, MO, Mosby, 1998,

pp 1826-1844.
Mirkovic S, Garfin SR: Spinal stenosis: History and physical examination. Instr Course Lect 1994;43:435-440.

Question 84

The photomicrograph seen in Figure 41 shows which of the following conditions?

Explanation

DISCUSSION: The photomicrograph shows a synovial cell sarcoma with a characteristic histology of a biphasic pattern of pleomorphic spindle cells and well-differentiated cuboidal to columnar cells forming gland-like spaces. The glandular zones contain mucous-like material that stains positively with periodic acid Schiff. Microscopic calcifications are usually found. Synovial cell sarcoma has a high rate of local recurrence as well as metastases. It is the most common malignancy found in the foot.
REFERENCES: Krall RA, Kostianovsky M, Patchefsky AS: Synovial sarcoma: A clinical, pathological and ultrastructural study of 26 cases supporting the recognition of a monophasic variant. Am J Surg Pathol 1981;5:137-151.
Wright PH, Sim FH, Soule EH, Taylor WF: Synovial sarcoma. J Bone Joint Surg Am 1982;64:112-122.

Question 85

Which of the following complications is more likely with an inside-out repair technique compared to an all-inside techniques for a medial meniscus tear?

Explanation

DISCUSSION: All of the answers are possible complications of meniscal repair. There are large volumes of literature evaluating the results of meniscal repair, both for the all-inside technique, as well as the inside-out technique. Failure rates are similar. Intra-articular synovitis occurs with absorbable sutures and absorbable implants. Peroneal nerve injuries are more common with the lateral-sided repairs. Saphenous nerve injuries are more common with medial-sided tears. Because of the incision required and the technique of tying over soft tissue, the risk of a saphenous nerve injury is greater with an inside-out technique than with an all-inside technique.
REFERENCES: Farng E, Sherman O: Meniscal repair devices: A clinical and biomechanical literature review. Arthroscopy 2004;20:273-286.
Jones HP, Lemos MJ, Wilk RM, et al: Two-year follow-up of meniscal repair using a bioabsorbable arrow. Arthroscopy 2002;18:64-69.

Question 86

Which of the following articulation couplings shows the lowest coefficient of friction as tested in the laboratory?

Explanation

DISCUSSION: Alumina ceramic is highly biocompatible when used as a biomaterial for joint arthroplasty implants. It has been shown to have good hardness, low roughness, and excellent wettability, therefore resulting in very low friction. However, it is expensive and limited reports have shown the problem of fracture on impact. The exact role for ceramic articulations is unknown at present.
REFERENCES: Cuckler JM, Bearcroft J, Asgian CM: Femoral head technologies to reduce polyethylene wear in total hip arthroplasty. Clin Orthop 1995;317:57-63.
Sharkey PF, Hozack WJ, Dorr LD, Maloney WJ, Berry D: The bearing surface in total hip arthroplasty: Evolution or revolution, in Price CT (ed): Instructional Course Lectures 49. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 41-56.

Question 87

A 60-year-old man reports that he has had shoe pressure pain over his right great toe for several years but has minimal discomfort when barefoot or in sandals. A clinical photograph and radiographs are shown in Figures 1a through 1c. Management should consist of

Explanation

DISCUSSION: Some patients have minimal symptoms associated with hallux rigidus despite significant radiographic evidence of osteoarthritis. This patient’s symptoms are primarily related to shoe pressure from the exostosis and can be managed with extra-depth shoe wear.
REFERENCES: Smith RW, Katchis SD, Ayson LC: Outcomes in hallux rigidus patients treated nonoperatively: A long-term follow-up study. Foot Ankle Int 2000;21:906-913.
Shereff MJ, Baumhauer JF: Hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint. J Bone Joint Surg Am 1998;80:898-908.

Question 88

-Figures a and b are the plain radiographs of a 26-year-old man with an elbow contracture. He denies any specific elbow trauma but reports a history of a closed-head injury sustained in a motor vehicle collision. Examination reveals the elbow lacked 55 degrees of extension and has flexion of 85 degrees.Supination and pronation are well preserved. Release of which structure is essential to restore elbow flexion?

Explanation

Question 89

The need for postoperative allogeneic blood transfusions after total hip arthroplasty has been shown to be reduced when using

Explanation

DISCUSSION: In a prospective study, 216 patients were randomized into three groups consisting of low-dose preoperative erythropoietin, high-dose preoperative erythropoietin, and placebo control. All patients were treated for 4 weeks prior to total hip arthroplasty. Both the low- and high-dose erythropoietin groups had a significantly lower rate of blood transfusions

(p < 0.001) after surgery.
REFERENCES: Waddell JP: Evidence-based orthopedics. J Bone Joint Surg Am 2001;83:788.
Feagan BG, Wang CJ, Kirkley A, et al: Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty: A randomized, controlled, trial. Ann Intern Med 2000;133:845-854.

Question 90

A healthy 27 year-old-male is brought into the emergency department after a fall from height. He has a suspected left C8-T1 nerve injury. Which of the following findings would most suggest a root avulsion injury rather than a brachial plexus injury at this level?

Explanation

Drooping of the left eyelid is a presenting feature of Horner's syndrome. Horner's syndrome represents a disruption of the sympathetic chain via C8 and/or T1 root avulsion after trauma.
Brachial plexus injuries are often classified as preganglionic vs. postganglionic injuries. Preganglionic injuries are typically avulsion injuries proximal to the dorsal root ganglion. Clinical features suggestive of lower root avulsion injury include a person falling from height clutching on object to save himself, Horner’s syndrome (drooping of the eyelid (ptosis), pupillary constriction (miosis) and anhidrosis), absence of a Tinel sign or tenderness to percussion in the neck, and a normal histamine test (C8-T1 sympathetic ganglion - intact triple response (redness, wheal, flare)).
Caporrino et al. reviewed 102 patients to assess the best modality (e.g. physical examination, MRI and nerve conduction studies [NCSs]) for diagnosing and localizing brachial plexus injuries. They found the best diagnostic performance with physical examination (sensitivity = 97.8%; specificity = 30.8%) and NCSs (sensitivity
= 98.9%; specificity = 23.1%). MRI had inferior performance for all measurements. They conclude that NCSs exhibited superior performance to MRI, and should be considered a more reliable supporting tool after detailed physical examination.
Incorrect Answers:

Question 91

A 12-year-old girl has had lower back pain for the past 6 months that interferes with her ability to participate in sports. She denies any history of radicular symptoms, sensory changes, or bowel or bladder dysfunction. Examination reveals a shuffling gait, restriction of forward bending, and tight hamstrings. Radiographs show a grade III spondylolisthesis of L5 on S1, with a slip angle of 20°. Management should consist of

Explanation

DISCUSSION: Indications for surgical treatment of spondylolisthesis include pain and/or progression of deformity. Specifically, surgery is necessary when there is persistent pain or a neurologic deficit that fails to respond to nonsurgical therapy, there is significant slip progression, or the slip is greater than 50%. For patients with mild spondylolisthesis, in situ posterolateral L5-S1 fusion is adequate. In patients with more severe slips (greater than 50%), extension of the fusion to L4 offers better mechanical advantage. Postoperative immobilization may be achieved with instrumentation, casting, or both. In patients with a slip angle of greater than 45°, reduction of the lumbosacral kyphosis with instrumentation or casting is desirable to prevent slip progression. Laminectomy alone is contraindicated in a child. Nerve root decompression is indicated if radiculopathy is present clinically.
REFERENCES: Seitsalo S, Osterman K, Hyvarinen H, Tallroth K, Schlenzka D, Poussa M: Progression of spondylolisthesis in children and adolescents: A long-term follow-up of 272 patients. Spine 1991;16:417-421.
Newton PO, Johnston CE II: Analysis and treatment of poor outcomes following in situ arthrodesis in adolescent spondylolisthesis. J Pediatr Orthop 1997;17:754-761.

Question 92

At the time of arthroscopy, a 9-year-old boy was found to have a Watanabe type II discoid lateral meniscus. What is the most appropriate treatment? Review Topic

Explanation

The Watanabe type II meniscus should only require saucerization for treatment because it is not unstable. The Watanabe classification defines 3 types of discoid mensici. In type I (stable, complete), the block-shaped lateral meniscus covers the entire lateral tibial plateau, whereas in type II (stable, partial), the lateral meniscus covers less than or equal to 80% of the tibial plateau. Type III discoid menisci (unstable, ligament of Wrisberg) appear to be normal except for a thickened posterior horn, but they lack posterior meniscal attachments, including the meniscotibial (ie, coronary) ligament. The type III discoid meniscus is stabilized only by the meniscofemoral ligament of Wrisberg. This results in hypermobility of the lateral meniscus at the posterior horn, which pulls into the intercondylar notch with knee extension, resulting in snapping knee syndrome. Complete menisectomy should be avoided if possible.

Question 93

Compared with surgically treated patients, patients with extra-articular distal third humeral shaft fractures that are treated nonsurgically with functional bracing can be expected to show which of the following findings?

Explanation

In a retrospective review of patients with extra-articular distal humeral shaft fractures treated surgically versus nonsurgically, the authors found that the amount of motion loss was not different between the treatment groups. Of 21 patients in the nonsurgical group, one lost 20 degrees of extension, one lost 30 degrees of extension, and one patient lost 15 degrees of flexion. Of the 19 patients in the surgical group, two patients lost 5 degrees of extension, and one each lost 10, 15, and 20 degrees of extension, respectively. One patient lost 5 degrees of flexion and one lost 15 degrees of flexion. The average loss of motion in the surgical group was 3 degrees, compared with 6 degrees in the nonsurgical group, but this difference was not significant. One hundred percent of the nonsurgically treated fractures healed. Both groups of patients regained shoulder motion within 10 degrees of normal. In the nonsurgically treated group, 10 healed with less than 10 degrees of malalignment, 6 healed with 11 to 20 degrees of malalignment, and three healed with greater than 30 degrees of malalignment, but the authors did not report any functional problems due to these deformities.

Question 94

Which of the following statements best describes results that have been reported with roentgen stereophotogrammetric analysis (RSA)?

Explanation

DISCUSSION: Migration of total hip femoral components has been measured by RSA, a technique that affords accuracy of 2 degrees and 0.5 mm. Several published studies on total hip arthroplasty femoral components have established the importance of this technique. Both cemented and cementless components migrate, with the rate of migration suggesting the adequacy of fixation of a component. Migration of 1 mm to 2 mm (occurring in either the

varus-coronal plane and retroversion-transverse plane, or both) has been associated with a higher risk of loosening of the component.
REFERENCE: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, p 100.

Question 95

A 16-year-old football player sustains a direct blow to the anterior aspect of his flexed right knee. Examination reveals a contusion over the anterior tibial tubercle and a small effusion. MRI scans are shown in Figures 33a through 33c. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scans show disruption of the fibers of the PCL. Patients sustaining an isolated acute PCL injury can present with only minimal discomfort and have full range of motion. When examination reveals a contusion over the tibial tubercle and discomfort with the posterior drawer examination, with or without instability, a possible injury to the PCL should be considered. In acute injuries, the reported accuracy of MRI imaging for diagnosing PCL tears ranges from 96% to 100%.
REFERENCES: Resnick D, Kang HS: Internal Derangement of Joints: Emphasis on MRI Imaging. Philadelphia, PA, WB Saunders, 1997, pp 699-700.
Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482.
Fischer SP, Fox JM, Del Pizzo W, Friedman MJ, Snyder SJ, Ferkel RD: Accuracy of diagnoses from magnetic imaging of the knee: A multi-center analysis of one thousand and fourteen patients. J Bone Joint Surg Am 1991;73:2-10.

Question 96

A 17-year-old football player is tackled with an opposing player's helmet hitting him hard in the abdomen. He is knocked backwards and suffers a diaphyseal femur fracture. He denies any loss of consciousness. Vital signs reveal a heart rate of 118, mean arterial pressure (MAP) of 68, and a respiration rate of 32 per minute. A FAST ultrasound study shows trace free fluid in the perisplenic space. A CBC taken prior to bolus IV fluids reveals a hematocrit of 48%, and a blood gas shows a lactate level of 1.8 and a base excess of -2.0. Which of the follow statements regarding the patient's hemodynamic status is correct?

Explanation

Normal lactate levels or base excess indicate adequate tissue perfusion.
Hypovolemic shock leads to poor tissue perfusion due to inadequate flow or oxygenation. If a patient is in compensated shock (i.e. normal vital signs), there may be ongoing inadequate perfusion of some end-organs. Elevated lactate or a base deficit are markers of poor end-organ perfusion, thus when normalized indicate appropriate end-organ perfusion even if vital sign derangements persist.
Rossaint et al. wrote a comprehensive review article in 2006 in which they discuss principles of fluid management, coagulopathy, hypothermia and tissue oxygenation in hypovolemic shock. In addition to prolonged elevated lactate levels correlating to mortality, lactate levels (or base deficits) can be used to evaluate for compensated shock in the setting of normal hemodynamic status.
Illustration A shows the classification of hypovolemic shock. Note the percent of blood loss required for vital sign abnormalities.
Incorrect Answers:
setting of massive blood loss. The hematocrit only changes once the patient has physiologic or iatrogenic fluid shifts in response to the blood loss. Answer 3: Vital sign derangements indicate uncompensated shock, but do not directly measure tissue perfusion or end-organ damage Answer 5: Though uncommon, bleeding from isolated femur fractures can lead to Class II shock (blood loss 15-30%)

Question 97

The images reveal T2-weighted MRI sequences with edema isolated to the infraspinatus. In the absence of a tear in the infraspinatus tendon, the edema is most likely due to compression of the suprascapular nerve in the spinoglenoid notch. As this pathology persists, progressive muscle atrophy and fatty infiltration can result. Compression of the suprascapular nerve in the suprascapular notch would have resulted in edema and weakness in both the supra- and infraspinatus muscles. Compression is commonly caused by cysts from the joint secondary to labral tears. A rotator cuff tear of the infraspinatus is not identified on these images, and there is no history of trauma provided. There is no evidence of an anteroinferior labral tear, nor would this be expected to result in external rotation weakness or MRI abnormality of the infraspinatus. Quadrilateral space syndrome results in compression of the axillary nerve, which supplies the teres minor. Correcr answer : C 40- A 41-year-old right-hand-dominant man has been treated nonsurgically for right elbow arthritis. His radiographs reveal end-stage ulnohumeral arthritis with complete loss of the joint space. He reports pain during the mid-arc of elbow flexion and extension. During the last 8 years, he has attempted activity modification, medication, physical therapy, and multiple cortisone injections. His symptoms have progressed, resulting in constant pain, loss of a functional range of motion, and an inability to perform many activities of daily living. Secondary to his age and activity demands, he undergoes a soft-tissue interposition arthroplasty of his elbow with an Achilles allograft. Which presurgical finding correlates with elevated risk for postsurgical complications?

Explanation

Figure 1 is the radiograph of a 12-year-old baseball player who has posterolateral elbow pain with throwing. The area of interest is designated by the black arrow. His range of motion and strength are full. No previous treatment has been provided. What is the most appropriate initial treatment?
A. Elbow arthroscopy with debridement
B. Immobilization and rest for 6 weeks
C. Corticosteroid injection
D. Open osteochondral autograft transfer
Osteochondritis dissecans of the capitellum is a painful condition that affects immature athletes who undergo repetitive compression of the radiocapitellar joint. Management is based primarily on the integrity of the articular cartilage surface and the stability of the lesion. Nonsurgical treatment is typically selected for patients
with early-grade, stable lesions, and it involves activity modification with cessation of sports participation. The duration of activity modification is dictated by symptoms, with 3 to 6 weeks of rest followed by return to sport in 3 to 6 months commonly used as a guideline. Strengthening and stretching exercises are commonly incorporated after the pain has subsided. Surgical intervention or corticosteroid injection would not be first-line treatment.
42- Figures 1 and 2 are the radiographs of a 69-year-old man with a history of treated prostate cancer and hemodialysis-dependent end- stage renal disease who presents to the emergency department with progressively worsening right shoulder pain and stiffness. Laboratory tests reveal a white blood cell count of 17,000, erythrocyte sedimentation rate, 75, and CRP, 10.1. He has a draining sinus located along the anterior shoulder. What is the best next step?

Question 98

A 29-year-old recreational basketball player has developed pain to the distal aspect of her patella that occurs during warm-ups and returns toward the end of the game. She reports no history of trauma, effusions, instability, and no mechanical symptoms. On examination, she is point tender at the inferior pole of the patella, lacks patella apprehension, and has a Q-angle of 15°. She has no ligamentous laxity. Radiographs are unremarkable. What is the best next step?

Explanation

Patellar tendinopathy is a relatively common condition in athletes for which repetitive jumping is the norm, especially volleyball and basketball athletes. The prevalence has been reported to be up to 32% in professional basketball players. Initial management is nonoperative in nature with eccentric exercises providing the most reliable clinical results. The other selections have not demonstrated consistent longterm results.

Question 99

A 24-year-old man has had pain in the left knee for the past several months. He reports that initially the pain was associated with weight-bearing activities, but it has now become more constant. He denies any swelling but reports a lateral fullness at the tibial plateau. Figures 23a through 23e show radiographs, a bone scan, and T1- and T2-weighted MRI scans. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs reveal a lytic subchondral lesion that has a poorly defined margin and lacks mineralization. The bone scan confirms an active lesion that has central photopenia, producing the characteristic doughnut configuration. The MRI scans confirm the presence of a subchondral lesion that is modestly expansile at the lateral plateau and has low signal intensity on the T1-weighted image and a mixed high signal on the T2-weighted image. These features strongly suggest giant cell tumor of bone, more than 50% of which appear around the knee. Simple cyst is excluded by the MRI characteristics. Fibrous dysplasia is unlikely to be in a subchondral location and typically does not show this intensity of uptake on bone scan.
REFERENCES: Parsons TW: Benign bone tumors, in Fitzgerald RH, Kaufer H,

Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1027-1035.
Resnick D, Kyriakos M, Greenway GD: Tumors and tumor-like lesions of bone: Imaging and pathology of specific lesions, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, ed 4. Philadelphia, PA, WB Saunders, 2002, vol 4, pp 3939-3962.

Question 100

Explanation

Lumbar spinal stenosis with lumbar radiculopathy can be commonly caused by a synovial cyst arising from the facet joints. Lyons and associates reported on the surgical treatment of synovial cysts in 194 patients. Of the 147 with follow-up data, 91% reported good pain relief and 82% had improvement of their motor deficits. Epstein reported a 58% to 63% incidence of good/excellent results and a 38 to 42
point improvement on the SF-36 Physical Function Scale. It was also suggested that since the presence of a synovial cyst indicates facet pathology, possible fusion should be considered in these patients, especially those with underlying spondylolisthesis.
(SBQ12SP.20) Amphotericin B is most appropriate for the treatment of which type of spine infection? Review Topic
Fungal osteomyelitis
Bacterial osteomyelitis with a gram-positive organism
Bacterial osteomyelitis with a gram-negative organism
Tuberculous osteomyelitis
Viral meningomyelitis
Amphotericin B would be most appropriate for the treatment of fungal infections of the spine.
Amphotericin B is a broad-spectrum anti-fungal medication. It is commonly used as the first-line agent for treatment of fungal infections of the spine. The most common fungi involving the spine include cryptococcus, candida, and aspergillus. The indications for débridement and stabilization with spinal fusion, includes resistance to antibiotic therapy, spinal instability, and/or neurologic deficits.
Kim et al. reviewed fungal infections of the spine. They comment that fungus infections are most commonly spread by hematogenous or direct spread. Access to the vascular system may include intravenous lines, during implantation of prosthetic devices, or during surgery.
Frazier et al. retrospectively reviewed 11 patients with fungal osteomyelitis of the spine. Nine of the patients were immunocompromised secondary to diabetes mellitus, corticosteroid use, chemotherapy for a tumor, or malnutrition. All were treated with anti-fungal medication. 10 of 11 patients were also treated with surgical debridement. Paralysis secondary to the spine infection developed in eight patients. After an average of 6.3 years of follow-up, the infection had resolved in all nine surviving patients.
Illustration A shows the mechanism of action of Amphotericin. Illustration B shows T1- (Image A and B) and T2-weighted (Image C) images of the lower thoracic and lumbar spine. There are hypointense signals within the T12 and L1 vertebral bodies (Images A and B) indicative of fungal osteomyelitis.
IncorrectAnswers:

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

primary repair of the MCL and use of a posterior stabilized total knee arthroplasty (TKA) prosthesis.
augmentation of the MCL with a collagenous tissue scaffold and use of a posterior stabilized TKA
prosthesis.
complete release of the lateral collateral ligament (LCL) and use of a posterior stabilized TKA prosthesis.
lateral unicompartmental arthroplasty.
use of a varus-valgus constrained TKA prosthesis.

Correct Answer: lateral unicompartmental arthroplasty.

Explanation:

Question 2:

Options:

Supervised physical therapy
Arthroscopic capsulorrhaphy and labral repair
Open shoulder capsulorrhaphy and labral repair
Open shoulder capsulorrhaphy and bone block
Shoulder arthrodesis

Correct Answer: Open shoulder capsulorrhaphy and bone block

Explanation:

Question 3:

The posterior horn of the medial meniscus receives its primary blood supply from what artery? Review Topic

Options:

Middle genicular
Medial inferior genicular
Medial superior genicular
Lateral superior genicular
Inferior lateral genicular

Correct Answer: Middle genicular

Explanation:

Question 4:

Lipohemarthrosis of the knee is most likely secondary to which of the following?

Options:

Seronegative monoarticular arthritis
Patellar tendon rupture
Medial meniscus tear
Medial patellofemoral ligament rupture
Occult fracture

Correct Answer: Seronegative monoarticular arthritis

Explanation:

Question 5:

The artery located within the substance of the coracoacromial ligament is a branch of what artery?

Options:

Thoracoacromial
Anterior circumflex humeral
Posterior circumflex humeral
Subscapular
Thyrocervical

Correct Answer: Thoracoacromial

Explanation:

Question 6:

Options:

Suture anchor repair of the labral tear and no bony resection
Suture anchor repair of the labral tear and bony resection of the pincer lesion
Debridement of the labral tear and bony resection of the pincer lesion
Debridement of the labral tear with no bony resection of the pincer lesion

Correct Answer: Suture anchor repair of the labral tear and bony resection of the pincer lesion

Explanation:

DISCUSSION FOR QUESTIONS 26 THROUGH 29
The clinical scenario, examination, and MRI scans are consistent with a pincer-type FAI. The decreased range of motion is secondary to the pain produced by the continued abutment of the femoral head against the anterosuperior acetabulum. Flexing the hip while internally rotating and adducting the leg recreates this contact and is typically painful. No clinical signs suggest sacroiliac joint arthritis, an intra-articular loose body, or trochanteric bursitis, although these are all diagnoses that should be considered in a patient with a painful hip. The most sensitive and specific study to detect an acetabular labral tear is an MRI arthrogram of the hip. This study should be obtained in this patient to evaluate the labrum as well as the status of the articular cartilage. An MRI scan without intra-articular contrast is not as sensitive as an arthrogram. An ultrasound can provide a dynamic assessment of the hip and help in the setting of a snapping hip; however, this study is not reliable to determine the presence of a labral tear. In the setting of pincer FAI, the forced leverage of the anterosuperior femoral head upon the anterior acetabulum results in abnormal forces against the posteroinferior acetabulum. This continued force can lead to a chondral lesion in this location know as a “counter-coup” injury. Chondral lesions of the femoral head are rare in the setting of pincer FAI. The posterosuperior quadrant does not experience increased force and rarely sustains chondral injuries. The patient is a young, active individual with no pre-existing degenerative changes, so repair of the tear with bony resection of the pincer lesion is the most appropriate treatment.A capsulolabral detachment should be repaired because these tears can heal and the labrum functions as a seal, preventing egress of synovial fluid from the joint space. If the pincer lesion is not resected, the patient will continue to experience abnormal contact and the repair will likely fail. There is no evidence that the patient has a cam impingement, and recontouring of the femoral head/neck junction is not appropriate. Simple debridement should be reserved for intrasubstance tears of the labrum, which would not be expected to heal with repair.
CLINICAL SITUATION FOR QUESTIONS 30 THROUGH 32
Figures 30a and 30b are the radiographs of a 20-year-old college multisport athlete who has had longstanding pain in his left hip. He denies any specific event that initiated his pain, but he notes that he had hip problems when he was an infant. He denies pain with activities of daily living, but he
believes his pain is increasingly limiting his ability to exercise. He localizes the pain to his groin. He denies low-back or buttock pain or pain that radiates down his leg.

Question 7:

What is a risk factor for interdigital neuroma?

Options:

Female gender
Increased mobility between the third and fourth rays
Achilles tendon contracture
Prolonged standing at work

Correct Answer: Female gender

Explanation:

Question 8:

Options:

Electromyography and nerve conduction velocity studies
MRI
CT
Bone scan
Psychiatric evaluation

Correct Answer: MRI

Explanation:

Question 9:

Options:

Consider fusion surgery
Intradiskal ozone therapy
Lumbar laminectomy
Vertebral augmentation
Cognitive intervention and exercise

Correct Answer: Cognitive intervention and exercise

Explanation:

Question 10:

Options:

Splint the proximal interphalangeal (PIP) joint in flexion with early motion of the distal interphalangeal (DIP) joint
Allow early motion of the PIP joint with DIP extension joint splinting
Splint both the PIP and DIP joints in full extension
Splint the PIP joint in extension with early motion of the DIP joint

Correct Answer: Splint the PIP joint in extension with early motion of the DIP joint

Explanation:

Question 11:

Options:

Infection
Patellar instability
Aseptic loosening
Progression of tibiofemoral arthritis

Correct Answer: Progression of tibiofemoral arthritis

Explanation:

Question 12:

Options:

High tibial osteotomy
Total knee replacement
Unicondylar knee replacement
Arthroscopic partial meniscectomy

Correct Answer: Total knee replacement

Explanation:

Question 13:

Options:

Tibial polyethylene exchange
Revision of the femoral and tibial components and conversion to a posterior stabilized insert
Revision of the femoral and tibial components to a constrained rotating hinge prosthesis
Isolated femoral component revision and upsizing of the femoral implant with a new posterior cruciate ligament (PCL)-retaining polyethylene insert

Correct Answer: Revision of the femoral and tibial components and conversion to a posterior stabilized insert

Explanation:

Question 14:

Options:

Repeat corticosteroid injection
Trial of a medial unloader brace
MRI scan of the knee to evaluate for recurrent medial meniscus tear
Referral to pain management

Correct Answer: Trial of a medial unloader brace

Explanation:

Question 15:

Options:

removal of the halo vest, followed by observation if the patient remains asymptomatic.
use of the halo vest for an additional 4 weeks, followed by repeat radiographs.
placement of one odontoid screw and the addition of bone graft.
placement of two odontoid screws.
posterior fusion at C1-2.

Correct Answer: posterior fusion at C1-2.

Explanation:

Question 16:

In patients who have undergone nonsurgical management for idiopathic adhesive capsulitis, long-term follow-up studies have shown which of the following results?

Options:

Continued night pain
Continuous decrease in forward elevation over time
Resolution of most symptoms, with range of motion equal to the contralateral shoulder
Decreased range of motion compared with the contralateral shoulder
Decreased pain compared with the contralateral shoulder

Correct Answer: Decreased range of motion compared with the contralateral shoulder

Explanation:

Question 17:

Options:

Placing the hip center too inferior
Overmedializing the acetabular component
Overlengthening the extremity
Intrasurgical acetabular fracture

Correct Answer: Overlengthening the extremity

Explanation:

DISCUSSION
The radiograph reveals hip dysplasia. Patients with hip dysplasia and severe limb shortening are at high risk for sciatic nerve palsy from overlengthening. Overmedializing the acetabular component is not the preferred response because overlateralization is more of a concern if the cup is placed in the pseudoacetabulum instead of in the true acetabulum. Placing the hip center too inferior is not the preferred response because the concern in this scenario is placing the hip center too superior if the cup is placed in the pseudoacetabulum or if a large-diameter cup is used. Acetabular fractures are possible because of osteoporotic bone at the true hip center, but is less likely than overlengthening of the extremity.
CLINICAL SITUATION FOR QUESTIONS 11 THROUGH 13
Figures 11a and 11b are the radiographs of a 35-year-old woman with end-stage debilitating osteoarthritis of the right hip. She is contemplating total hip arthroplasty (THA). She has a history of right hip dysplasia and underwent hip osteotomy as an adolescent. Over the years, she has failed nonsurgical treatment including weight loss, activity modifications, and intra-articular injections. Her infection workup reveals laboratory findings within defined limits.

Question 18:

Options:

Use of an abduction orthosis for 6 weeks
Modular exchange of the femoral head to a 36-mm head and a longer neck
Modular exchange of the polyethylene liner to a constrained acetabular insert
Revision and repositioning of the acetabular component and use of a 36-mm femoral head
A physical therapy program stressing abductor strengthening

Correct Answer: Revision and repositioning of the acetabular component and use of a 36-mm femoral head

Explanation:

Question 19:

Options:

Central peg error
Insufficient inferior tilt
Excessive inferior tilt
Component dissociation
Glenosphere too small

Correct Answer: Central peg error

Explanation:

Question 20:

Options:

Diffuse idiopathic skeletal hyperostosis
Ankylosing spondylitis
Ossification of the posterior longitudinal ligament
Rheumatoid arthritis
Degenerative cervical stenosis

Correct Answer: Ossification of the posterior longitudinal ligament

Explanation:

Question 21:

Options:

Bracing
Physiotherapy
Cortisone injection
Conversion to total elbow arthroplasty
Revision interposition arthroplasty

Correct Answer: Conversion to total elbow arthroplasty

Explanation:

DISCUSSION: In a series reported by Blaine and associates, 12 patients were converted from interposition to total elbow arthroplasty. This procedure was successful in 10 out of 12 patients.
REFERENCES: Blaine TA, Adams R, Morrey BF: Total elbow arthroplasty after interposition arthroplasty for elbow arthritis. J Bone Joint Surg Am 2005;87;286-292.
Cheng SL, Morrey FB: Treatment of the mobile, painful arthritic elbow by distraction interposition arthroplasty. J Bone Joint Surg Br 2000;82:233-238.

Question 22:

An axial T 1 -weighted MRI scan of the pelvis is shown in Figure 13. The arrow is pointing to what muscle?

Options:

Adductor magnus
Pectineus
Obturator externus
Obturator internus
Levator ani

Correct Answer: Obturator internus

Explanation:

DISCUSSION: The obturator internus muscle originates from the internal pelvic wall and passes laterally through the lesser sciatic foramen, banking around the ischium below the sacrospinous ligament before inserting on the medial aspect of the greater trochanter.
REFERENCES: Higuchi T: Normal anatomy and magnetic resonance appearance of the pelvis, in Takahashi HE, Morita T, Hotta T, Ogose A (eds): Operative Treatment of Pelvic Tumors. Tokyo, Japan, Springer-Verlag, 2003, pp 4-21.
Berquist TH: Pelvis, hips and thigh, in Berquist TH (ed): MRI of the Musculoskeletal System,
ed 4. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 210-238.

Question 23:

Options:

Open reduction and cerclage fixation of the fracture
Open reduction and revision of the femoral implant to a long cemented stem
Open reduction and revision of the femoral implant to a long fluted and tapered uncemented stem
Application of balanced traction followed by surgery after the ecchymosis has resolved

Correct Answer: Application of balanced traction followed by surgery after the ecchymosis has resolved

Explanation:

Question 24:

Which of the following is associated with increased fetal morbidity and mortality in acetabular fractures during pregnancy?

Options:

Fetal position
Surgical approach
Mechanism of injury
Fracture classification
Trimester of pregnancy

Correct Answer: Mechanism of injury

Explanation:

Question 25:

Options:

Posterior spinal fusion
Spinal manipulations
Observation and referral to an endocrinologist
Thoracolumbosacral orthosis
Halo-gravity traction

Correct Answer: Posterior spinal fusion

Explanation:

Question 26:

Options:

Arthroscopic debridement
Arthroscopic rotator cuff repair
Hemiarthroplasty with rotator cuff repair
Total shoulder arthroplasty
Reverse shoulder arthroplasty

Correct Answer: Reverse shoulder arthroplasty

Explanation:

Question 27:

Management of a grade IV osteochondritis dissecans lesion of the capitellum should consist of

Options:

use of a sling for 3 weeks followed by a gradual return to activities.
physical therapy.
arthroscopy with removal of the loose fragment.
arthroscopy with in situ drilling of the fragment.
internal fixation of the fragment.

Correct Answer: arthroscopy with removal of the loose fragment.

Explanation:

Question 28:

Options:

First metatarsophalangeal arthrodesis
Distal chevron osteotomy and bunionectomy with closing wedge osteotomy and soft-tissue release
Bunionectomy with proximal metatarsal osteotomy
Bunionectomy with first metatarsal cuneiform fusion
Bunionectomy with proximal phalanx osteotomy and distal chevron osteotomy

Correct Answer: First metatarsophalangeal arthrodesis

Explanation:

DISCUSSION: Arthrodesis is indicated for severe bunion and hallux valgus deformities, but particularly with extensive degenerative disease of the first metatarsophalangeal joint. The other bunionectomy procedures have different indications, none of which include symptomatic first metatarsophalangeal degenerative disease.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 3-15.
Tourne Y, Saragaglia D, Zattara A, et al: Hallux valgus in the elderly: Metatarsophalangeal arthrodesis of the first ray. Foot Ankle Int 1997;18:195-198.

Question 29:

What is the prognosis for ambulation, from best to worst, for patients with an incomplete spinal cord injury?

Options:

Central cord syndrome, anterior cord syndrome, Brown-Sequard syndrome
Central cord syndrome, Brown-Sequard syndrome, anterior cord syndrome
Brown-Sequard syndrome, anterior cord syndrome, central cord syndrome
Brown-Sequard syndrome, central cord syndrome, anterior cord syndrome
Anterior cord syndrome, central cord syndrome, Brown-Sequard syndrome

Correct Answer: Brown-Sequard syndrome, central cord syndrome, anterior cord syndrome

Explanation:

Question 30:

Options:

Physical therapy with emphasis on neck muscle strengthening and posture improvement
Epidural steroid injection
Anterior cervical discectomy and fusion
Laminectomy alone
Multi-level laminectomy and fusion

Correct Answer: Physical therapy with emphasis on neck muscle strengthening and posture improvement

Explanation:

Question 31:

Options:

Anterior and superior acromioclavicular joint ligaments
Posterior and superior acromioclavicular joint ligaments
Conoid ligament
Trapezoid ligament

Correct Answer: Posterior and superior acromioclavicular joint ligaments

Explanation:

Question 32:

Options:

MRI-arthrogram to evaluate the rotator cuff
Rotator cuff strengthening program
Posterior capsular stretching program
Shoulder arthroscopy with SLAP repair
Shoulder arthroscopy with posterior capsular release

Correct Answer: Posterior capsular stretching program

Explanation:

DISCUSSION: Throwing athletes with symptomatic internal rotation deficits often benefit from an intensive posterior capsular stretching program. Patients that fail to respond to nonsurgical management may benefit from an arthroscopic posterior capsular release.
REFERENCES: Wilk KE, Meister K, Andrews JR: Current concepts in rehabilitation of the overhead throwing athlete. Am J Sports Med 2002;30:136-151.
Myers JB, Laudner KG, Pasquale MR, et al: Glenohumeral range of motion deficits and posterior shoulder tightness in throwers with pathologic internal impingement. Am J Sports Med 2006;34:385-391.

Question 33:

What structure is considered the single most important soft-tissue restraint to anterior-posterior stability of the sternoclavicular joint?

Options:

Posterior capsular ligament
Anterior capsular ligament
Interclavicular ligament
Intra-articular disk
Subclavius tendon

Correct Answer: Posterior capsular ligament

Explanation:

Question 34:

Options:

initiation of a first-generation cephalosporin while awaiting culture results.
initiation of broad-spectrum antibiotics while awaiting culture results.
ultrasound to evaluate for fluid collection around the knee.
surgical debridement of the knee before culture results are available.
inpatient observation and no antibiotics until culture results are available.

Correct Answer: surgical debridement of the knee before culture results are available.

Explanation:

AL-Madena Copy
8 • American Academy of Orthopaedic Surgeons
DISCUSSION: Increased pain, swelling, erythema, and drainage 2 weeks removed from the primary arthroplasty are all signs of a probable infection. Erythrocyte sedimentation rate and C-reactive protein may not be helpful as they are elevated postoperatively even in the absence of infection. Even in the absence of infection, persistent wound drainage is an indication for surgical debridement to prevent subsequent infection. When a postoperative infection is easily recognized by clinical examination, there is no need to wait for a positive culture before proceeding with debridement.
REFERENCES: Weiss AP, Krackow KA: Persistent wound drainage after primary total knee arthroplasty. J Arthroplasty 1993;8:285-289.
Jaberi FM, Parvizi J, Haytmanek CT, et al: Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty. Clin Orthop Relat Res 2008;466:1368-1371.
Insall JN, Windsor RE, Scott, WN: Surgery of the Knee, ed 2. New York, NY, Churchill Livingstone, 1993, pp 959-964.
Figure 3a Figure 3b

Question 35:

In a pilon fracture, the Chaput fragment typically maintains soft tissue attachment via which of the following structures?

Options:

Interosseous ligament
Anterior inferior tibiofibular ligament
Posterior inferior tibiofibular ligament
Deltoid ligament
Tibiotalar ligament

Correct Answer: Interosseous ligament

Explanation:

Question 36:

Options:

Aspiration of joint fluid to obtain a cell count
Revision of the UKA using primary total knee arthroplasty (TKA) components
Revision of the UKA using a revision TKA with augments
Procurement of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level

Correct Answer: Procurement of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level

Explanation:

Question 37:

What is the theoretical advantage of an open subpectoral technique of tenodesis of the long head of the biceps tendon compared to arthroscopic soft-tissue tenodesis techniques? Review Topic

Options:

Improved cosmesis
Simpler to perform in the lateral decubitus position
Shorter surgical time
Removal of the biceps tendon from the bicipital groove
Superior outcomes when compared to soft-tissue tenodesis in level I studies

Correct Answer: Removal of the biceps tendon from the bicipital groove

Explanation:

Question 38:

Genetic analysis has revealed a strong linkage between osteoarthritis in women with which of the following molecules?

Options:

TGF-beta
Collagen type IX
Bone sialoprotein
Hyaluronic acid
Basic fibroblast growth factor

Correct Answer: Collagen type IX

Explanation:

Question 39:

Figure 10 shows the MRI scan of a 56-year-old woman with metastatic breast cancer who now reports progressive paraparesis. Her general health remains good. Treatment should consist of

Options:

posterior spinal fusion for stabilization, followed by radiation therapy of the anterior tumor.
radiation therapy and a brace.
chemotherapy, then reevaluation.
anterior corpectomy and stabilization.
laminectomy.

Correct Answer: anterior corpectomy and stabilization.

Explanation:

Question 40:

Figure 50 shows the AP radiograph of an asymptomatic 82-year-old woman who underwent total hip arthroplasty 16 years ago. What is the most likely diagnosis?

Options:

Wear-induced osteolysis
Infection
Metastatic tumor
Loosening of the femoral component
Hip subluxation

Correct Answer: Wear-induced osteolysis

Explanation:

DISCUSSION: Pelvic osteolysis in the presence of a well-fixed porous-coated socket is a recognized complication in total hip arthroplasty. The radiograph shows large lytic lesions superiorly adjacent to an acetabular screw and inferiorly extending into the ischium. It also reveals eccentricity of the femoral head with respect to the acetabular component, consistent
with polyethylene wear.
REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 440.
Dowd JE, Sychterz CJ, Young AM, et al: Characterization of long-term femoral-head-penetration rates: Association with and prediction of osteolysis. J Bone Joint Surg Am 2000;82:1102-1107.

Question 41:

Options:

equal to the bone-patellar tendon-bone graft.
one half the failure load of the bone-patellar tendon-bone graft.
one quarter the failure load of the bone-patellar tendon-bone graft.
approximately two times the failure load of the bone-patellar tendon-bone graft.
four times the failure load of the bone-patellar tendon-bone graft.

Correct Answer: approximately two times the failure load of the bone-patellar tendon-bone graft.

Explanation:

Question 42:

Options:

Patellar sleeve fracture
Avulsion of the tibial tubercle
Avulsion of the anterior tibial spine
Osteochondral fracture of the femoral condyle
Osteochondral fracture of the patella

Correct Answer: Patellar sleeve fracture

Explanation:

Question 43:

Options:

long leg casting in 30 degrees of flexion for 6 weeks.
a long leg cast in full extension for 6 weeks.
knee arthroscopy to rule out internal derangement.
physical therapy for range of motion and quadriceps strengthening.
open reduction and internal fixation.

Correct Answer: a long leg cast in full extension for 6 weeks.

Explanation:

Question 44:

Options:

Bed rest for 6 weeks, followed by mobilization in a thoracolumbosacral orthosis until the fracture has healed
Anterior corpectomy with strut grafting and placement of an anterior plate spanning L1 to L3
Anterior corpectomy with strut grafting, followed by posterior spinal fusion and instrumentation
Posterior spinal fusion and instrumentation from T11 to L4
L2 laminectomy and posterior spinal fusion and instrumentation from T11 to L4

Correct Answer: L2 laminectomy and posterior spinal fusion and instrumentation from T11 to L4

Explanation:

DISCUSSION: The patient has a burst fracture with probable unilateral entrapment of the cauda equina within the elements of the fractured lamina. A dural tear is likely in this scenario as well. It is recommended that this type of burst fracture be treated surgically with laminectomy, freeing of the entrapped nerve roots, and dural repair followed by stabilization of the fracture by either a posterior or combined approach. The degree of kyphosis and the extent of anterior canal compromise does not warrant corpectomy in this patient. Therefore, after completing the laminectomy and dural repair, posterior fusion and instrumentation should be sufficient to stabilize the fracture.
REFERENCES: Cammisa FP Jr, Eismont FJ, Green BA: Dural laceration occurring with burst fractures and associated laminar fractures. J Bone Joint Surg Am 1989;71:1044-1052.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.

Question 45:

The rate of complications after in situ pinning of a chronic slipped capital femoral epiphysis is highest with placement of the screw in what quadrant of the femoral head?

Options:

Anterior superior
Anterior inferior
Central
Posterior superior
Posterior inferior

Correct Answer: Anterior superior

Explanation:

DISCUSSION: The rate of complications increases as the pin moves farther from the ideal position, which is the center of the head. This is the strongest argument for the use of a single pin. The highest rate of complications, primarily osteonecrosis and pin penetration, is associated with pin placement in the anterior superior quadrant.
REFERENCES: Raney EM, Ogden JA: Slipped capital femoral epiphysis. Current Ortho 1995;9:111-116.
Stambough JL, Davidson RS, Ellis RD, et al: Slipped capital femoral epiphysis: An analysis of 80 patients as to pin placement and number. J Pediatr Orthop 1986;6:265-273

Question 46:

Options:

A Pavlik harness with the hips in 90 degrees of flexion and 60 degrees of abduction
A spica cast with the hips in 100 degrees of flexion and 70 degrees of abduction
Observation with range-of-motion exercises to minimize contractures
Open reduction through an anterior hip approach
Open reduction through a medial hip approach

Correct Answer: Observation with range-of-motion exercises to minimize contractures

Explanation:

Question 47:

A 46-year-old male sustains a patella fracture and is treated with cannulated screws and a tension band construct. Which of the following is correct regarding this treatment?

Options:

Knee flexion arc is restored to the contralateral side
Extensor lag is recovered by 15 months postoperatively
Implant removal rate can be as high as 50% or more
Quadriceps strength is not limited at long-term follow-up
Patients with retained implants have pain scores equivalent to healthy norms

Correct Answer: Patients with retained implants have pain scores equivalent to healthy norms

Explanation:

Question 48:

What is the most common physical examination finding in a patient with chronic painful spondylolysis? Review Topic

Options:

Positive straight leg raise
Pain with forward flexion
Pain with lumbar extension
Absent tendo-Achilles reflex

Correct Answer: Pain with lumbar extension

Explanation:

Question 49:

Options:

buddy taping to the adjacent digit.
open reduction and surgical fixation of the bony fragment.
excision of the bony fragment and advancement of the terminal extensor mechanism.
splinting of the DIP joint with intermittent removal and range-of-motion exercises to prevent stiffness.
full-time splinting of the DIP joint in slight hyperextension for 6 weeks.

Correct Answer: full-time splinting of the DIP joint in slight hyperextension for 6 weeks.

Explanation:

DISCUSSION: Mallet fingers without DIP joint subluxation can be treated with extension splinting. Surgical fixation may be necessary in bony mallet injuries when the joint is subluxated. Size of the bony fragment, while often correlating with stability, is not always an indication for fixation. Buddy taping allows motion; therefore, the fragment will not heal in the appropriate position. Intermittent splinting with range-of-motion exercises also will not allow the fragment to heal in the appropriate position.
REFERENCES: Crawford GP: The molded polyethylene splint for mallet finger deformities.
J Hand Surg Am 1984;9:231-237.
Wehbe MA, Schneider LH: Mallet fractures. J Bone Joint Surg Am 1984;66:658-669.

Question 50:

Options:

Vertebrectomy of L5
Posterior spinal fusion with or without instrumentation from L4 to S1
Posterior spinal fusion without instrumentation from L5 to S1
Anterior spinal fusion from L4 to L5
Direct repair of the spondylolysis defect

Correct Answer: Posterior spinal fusion with or without instrumentation from L4 to S1

Explanation:

DISCUSSION: The patient has a grade 4 spondylolisthesis. Optimal surgical management is posterior spinal fusion from L4 to the sacrum. The use of instrumentation is controversial. Vertebrectomy is typically reserved for spondylo-optosis (grade 5) cases. Spinal fusion from
L5 to S1 usually is not successful for a slip that is greater than 50%. Isolated anterior spinal fusion has not been successful, and direct repair of the pars defect is only useful for spondylolysis without spondylolisthesis.
REFERENCES: Lenke LG, Bridwell KH: Evaluation and surgical treatment of high-grade isthmic dysplastic spondylolisthesis. Instr Course Lect 2003;52:525-532.
Ginsburg GM, Bassett GS: Back pain in children and adolescents: Evaluation and differential diagnosis. J Am Acad Orthop Surg 1997:5:67-78.

Question 51:

Which of the following processes does not account for decreased hematopoiesis in patients with metastatic disease?

Options:

External beam radiation
A decrease in cellular calcium
Cytotoxic systemic chemotherapy
Decreased iron use secondary to anemia of chronic disease
Marrow replacement by tumor cells

Correct Answer: A decrease in cellular calcium

Explanation:

Question 52:

Options:

a drink of water.
a sports drink with electrolytes.
placement in the reverse Trendelenburg position in a shaded area.
immersion in a warm water bath.
transportation to the emergency department.

Correct Answer: transportation to the emergency department.

Explanation:

Question 53:

Options:

Fixation in the tibial tunnel
Fixation in the femoral tunnel
Posterior placement of the tibial tunnel
Anterior placement of the femoral tunnel
Size of the patellar autograft

Correct Answer: Anterior placement of the femoral tunnel

Explanation:

Question 54:

Options:

The anteromedial (AM) bundle limits translation and the posterolateral (PL) bundle controls rotation.
The PL bundle limits translation and the AM bundle controls rotation.
The anterolateral (AL) bundle limits translation and the posteromedial (PM) bundle controls rotation.
Both the AL and the PM control rotation equally.
The AL bundle controls rotation and the PM bundle limits translation.

Correct Answer: The anteromedial (AM) bundle limits translation and the posterolateral (PL) bundle controls rotation.

Explanation:

Question 55:

Options:

The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior medial portal created 3 cm from the tip of the olecranon and medial to the triceps
The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps
The posterior medial portal created 3 cm from the tip of the olecranon and medial to the tri ceps and the posterior lateral portal created 3 cm from the tip of the olecranon and lateral to the triceps
The posterior medial portal created 3 cm from the tip of the olecranon and the lateral portal made through the anconeus
The posterior portal created at the tip of olecranon and the posterior medial portal just medial to the triceps

Correct Answer: The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps

Explanation:

Question 56:

Deep anterior compartment

Options:

Anterior compartment
Compartment syndrome is most commonly missed in the deep posterior compartment. Like the anterior compartment, the deep posterior compartment is enveloped in fascia and is immediately adjacent to the tibia; however, the deep posterior compartment is more difficult to clinically assess secondary to its deep location. Associated findings include pain with passive extension of the toes and plantar foot numbness.
Compartment syndrome involving the superficial posterior compartment, lateral compartment, and anterior compartment is easy to detect because it is readily palpable on examination.
There is no deep anterior compartment in the leg.

Correct Answer: Compartment syndrome is most commonly missed in the deep posterior compartment. Like the anterior compartment, the deep posterior compartment is enveloped in fascia and is immediately adjacent to the tibia; however, the deep posterior compartment is more difficult to clinically assess secondary to its deep location. Associated findings include pain with passive extension of the toes and plantar foot numbness.

Explanation:

How many compartments exist in the foot:

Question 57:

Options:

SLAP tear
Subscapularis tear
Supraspinatous tear
Anterior labral tear
Posterior labral tear

Correct Answer: Posterior labral tear

Question 58:

Options:

Good because it is a gram-positive organism
Good because it is an acute infection
Poor because it is a gram-positive organism
Poor because it is a late infection

Correct Answer: Poor because it is a late infection

Explanation:

Question 59:

To preserve blood supply to the fractured bone seen in Figures 12a and 12b, care should be taken when exposing which of the following areas?

Options:

Anterolateral aspect of the distal humerus
Posterolateral aspect of the distal humerus
Medial epicondyle
Lateral epicondyle
Radial neck

Correct Answer: Posterolateral aspect of the distal humerus

Explanation:

Question 60:

Options:

Lumbar laminectomy with synovial cyst excision
Repeat epidural steroid injection
Microdiskectomy at L4-5
Nonsteroidal medication and outpatient physical therapy
Left-sided facet blocks at L4-5 and L5-S1

Correct Answer: Lumbar laminectomy with synovial cyst excision

Explanation:

DISCUSSION: Lumbar spinal stenosis with lumbar radiculopathy can be commonly caused by a synovial cyst arising from the facet joints. Lyons and associates reported on the surgical treatment of synovial cysts in 194 patients. Of the 147 with follow-up data, 91% reported good pain relief and 82% had improvement of their motor deficits. Epstein reported a 58% to 63% incidence of good/excellent results and a 38 to 42 point improvement on the SF-36 Physical Function Scale. It was also suggested that since the presence of a synovial cyst indicates facet pathology, possible fusion should be considered in these patients, especially those with underlying spondylolisthesis.
REFERENCES: Lyons MK, Atkinson JL, Wharen RE, et al: Surgical evaluation and management of lumbar synovial cysts: The Mayo Clinic Experience. J Neurosurg
2000;93:53-57.
Khan AM, Synnot K, Cammisa FP, et al: Lumbar synovial cysts of the spine: An evaluation of surgical outcome. J Spinal Disord Tech 2005;18:127-131.
Epstein NE: Lumbar laminectomy for the resection of synovial cysts and coexisting lumbar spinal stenosis or degenerative spondylolisthesis: An outcome study. Spine 2004;29:1049-1055.

Question 61:

What is the minimum hours per day of wear that has been correlated with the effectiveness of bracing on curve progression in idiopathic scoliosis? Review Topic

Options:

Prescribed brace wear 23 hours/day
Prescribed brace wear 16 hours/day
Actual brace wear more than 12 hours/day
Actual brace wear 6 hours/day

Correct Answer: Actual brace wear more than 12 hours/day

Explanation:

Question 62:

Options:

Observation and patient education regarding hip dislocation precautions
Revision to a larger-diameter femoral head
Revision to a constrained acetabular component
Application of a hip orthosis for 3 months

Correct Answer: Observation and patient education regarding hip dislocation precautions

Explanation:

Question 63:

Options:

Osteomyelitis
Malignant degeneration
Stress fracture
Local recurrence of the giant cell tumor
Bone resorption due to methylmethacrylate

Correct Answer: Local recurrence of the giant cell tumor

Explanation:

Question 64:

Which of the following clinical scenarios represents an appropriate indication for convex hemiepiphysiodesis/hemiarthrodesis in the treatment of a child with a congenital spinal deformity?

Options:

A 3-year-old child with a hemivertebra opposite a contralateral bar and thoracic scoliosis that measures 53°
A 4-year-old child with a fully segmented L1 hemivertebra and scoliosis that measures 80°
A 4-year-old child with a fully segmented T10 hemivertebra and scoliosis that measures 50°
A 4-year-old child with a posterolateral hemivertebra at the thoracolumbar junction and a kyphoscoliotic deformity that measures 45°
A 10-year-old child with a hemivertebra and scoliosis that measures 50°

Correct Answer: A 4-year-old child with a fully segmented T10 hemivertebra and scoliosis that measures 50°

Explanation:

Question 65:

Options:

Five days of intravenous antibiotics for perioperative prophylaxis
Use of continuous passive motion beginning on postoperative day one
Immediate initiation of active flexion and gravity-assisted passive extension
Splinting at 60 to 90 degrees of flexion for 5 to 10 days, followed by initiation of active flexion and gravity-assisted passive extension
Splinting at 60 to 90 degrees of flexion until the triceps has healed, followed by initiation of active flexion and extension

Correct Answer: Splinting at 60 to 90 degrees of flexion for 5 to 10 days, followed by initiation of active flexion and gravity-assisted passive extension

Explanation:

Question 66:

A 12-year-old girl has scoliosis at T5-T10 that measures 62°. A clinical photograph of the axilla is shown in Figure 56. Management should consist of

Options:

a thoracolumbosacral orthosis.
in situ posterior spinal fusion.
posterior spinal fusion with segmental instrumentation.
anterior spinal fusion with instrumentation.
anterior and posterior spinal fusion with posterior segmental instrumentation.

Correct Answer: anterior and posterior spinal fusion with posterior segmental instrumentation.

Explanation:

Question 67:

Which of the following methods is effective in correcting recurrent dislocation following total hip arthroplasty?

Options:

Lateralization of the greater trochanter without advancement
Use of a shorter neck length
Use of a constrained acetabular component
Use of a small diameter head
High cup abduction angle

Correct Answer: Use of a constrained acetabular component

Explanation:

Question 68:

Which of the following types of ultra-high molecular weight polyethylene has been associated with the poorest clinical performance?

Options:

Compression molded
Heat pressed
Ram extruded
Gamma irradiated
Ethylene oxide sterilized

Correct Answer: Heat pressed

Explanation:

Question 69:

Options:

Resection arthroplasty and local radiation
In situ fusion of the hip
Excision of heterotopic bone, total hip arthroplasty, and oral indomethacin
Excision of heterotopic bone and local radiation
Excision of heterotopic bone, hemiarthroplasty, and oral indomethacin

Correct Answer: Excision of heterotopic bone and local radiation

Explanation:

Question 70:

Options:

Stress fracture of the calcaneus
Painful os trigonum
Insertional Achilles tendinopathy
Entrapment of the calcaneal branch of the posterior tibial nerve
Rupture of the Achilles tendon

Correct Answer: Insertional Achilles tendinopathy

Explanation:

Question 71:

Options:

Incision and drainage of the abscess
Nonsteroidal anti-inflammatory drugs, physical therapy, and a repeat MRI scan in 6 to 8 weeks
Open biopsy
Hematoma evacuation and musculotendinous repair
Primary wide resection followed by radiation therapy

Correct Answer: Nonsteroidal anti-inflammatory drugs, physical therapy, and a repeat MRI scan in 6 to 8 weeks

Explanation:

DISCUSSION: The history, examination, and MRI scan findings are consistent with a midsubstance partial rupture of the rectus femoris muscle. This is an injury masquerading as a “pseudo tumor.” The lack of an appreciable mass effect on the T
1
-weighted MRI scan, the defined fluid signal on the T
2
-weighted scans, and the lack of significant contrast enhancement after gadolinium are all most consistent with injury rather than a neoplasm. Most of these injuries respond to nonsurgical management; a few will benefit from late debridement and repair if symptoms fail to resolve in 3 to 6 months. The treatment of choice is nonsurgical management with a follow-up MRI scan to verify that the findings are resolving.
REFERENCES: Hughes C IV, Hasselman CT, Best TM, et al: Incomplete, intrasubstance strain injuries of the rectus femoris muscle. Am J Sports Med 1995;23:500-506.
Temple HT, Kuklo TR, Sweet DE, et al: Rectus femoris muscle tear appearing as a pseudotumor. Am J Sports Med 1998;26:544-548.

Question 72:

Options:

Resection arthroplasty
Hip abduction brace
Constrained acetabular liner
Thermal ablation of the posterior capsule
Conversion to a bipolar prosthesis

Correct Answer: Constrained acetabular liner

Explanation:

DISCUSSION: When a patient has well-aligned components and soft-tissue tensioning with a larger femoral head and trochanteric advancement has failed, options are limited. The use of a constrained acetabular liner is the best option in this situation. Goetz and associates and Shrader and associates have demonstrated good results with these implants. Shrader used this device on 109 patients with recurrent instability with a successful outcome in all but 2 patients. Resection arthroplasty is a salvage situation and is not the best option at the present time. A hip abduction brace does not address the soft-tissue laxity. Conversion to a bipolar arthroplasty, although possibly minimizing the incidence of dislocation, will lead to groin pain and migration of the component with diminished functional results.
REFERENCES: Goetz DD, Capello WN, Callaghan JJ, et al: Salvage of recurrently
dislocating hip prosthesis with use of a constrained acetabular component: A retrospective analysis of fifty-six cases. J Bone Joint Surg Am 1998;80:502-509.
Shrader MW, Parvizi J, Lewallen DG: The use of constrained acetabular component to treat instability after total hip arthroplasty. J Bone Joint Surg Am 2003;85:2179-2183.
Hamilton WG, McAuley JP: Evaluation of the unstable total hip arthroplasty. Inst Course Lect 2004;53:87-92.

Question 73:

Options:

Aneurysmal bone cyst
Giant cell tumor
Renal cell carcinoma
Osteomyelitis
Brown tumor

Correct Answer: Giant cell tumor

Explanation:

Question 74:

What is the most common MRI appearance of a malignant soft-tissue sarcoma?

Options:

Well defined, homogeneous, and deep to fascia
Well defined, heterogeneous, and deep to fascia
Ill defined, homogeneous, and deep to fascia
Ill defined, heterogeneous, and superficial to fascia
Ill defined, homogeneous, and superficial to fascia

Correct Answer: Well defined, heterogeneous, and deep to fascia

Explanation:

Question 75:

Options:

at least two more attempts at closed reduction in the emergency department before the patient’s sedation wears off.
at least two attempts at closed reduction in the operating room under general anesthesia with muscle relaxation.
acceptance of the reduction because the alignment is satisfactory and growth problems are rare with Salter-Harris type I fractures.
open reduction, extraction of any interposed periosteum, and smooth wire fixation to prevent nonunion.
open reduction, extraction of any interposed periosteum, and smooth wire fixation to decrease the chance of premature physeal closure.

Correct Answer: open reduction, extraction of any interposed periosteum, and smooth wire fixation to decrease the chance of premature physeal closure.

Explanation:

Question 76:

Options:

Osteochondral fracture of the lateral femoral condyle
Trabecular injury of the lateral tibial plateau
Lateral meniscal tear with a parameniscal cyst
Fibular collateral ligament tear
Discoid lateral meniscal tear

Correct Answer: Discoid lateral meniscal tear

Explanation:

Question 77:

Options:

Synovial sarcoma
Soft-tissue abcess
Rhabdomyosarcoma
Eosinophilic granuloma
Nodular pigmented villonodular synovitis

Correct Answer: Soft-tissue abcess

Explanation:

Question 78:

Options:

Lateral femoral cutaneous nerve
Medial inferior genicular artery
Infrapatellar branch of the saphenous nerve
Anterior tibial recurrent artery
Lateral inferior genicular artery

Correct Answer: Lateral femoral cutaneous nerve

Explanation:

Question 79:

Figure 1 is the ultrasound of a 23-year-old patient who has had a volar radial 1.5-cm tender and painful wrist mass for 6 months. The additional workup prior to surgery should consist of

Options:

serum and urine protein electrophoresis.
a chest CT scan.
MRI with intravenous contrast.
age-appropriate presurgical laboratory studies.

Correct Answer: age-appropriate presurgical laboratory studies.

Explanation:

Question 80:

Options:

Surgery on the wrong patient
Surgery on the wrong side
Incorrect procedure performed
Intraoperative death
Surgery on the wrong level

Correct Answer: Surgery on the wrong level

Explanation:

DISCUSSION: Patient safety and prevention of medical errors is a major focus of recent national advocacy groups. Analysis has shown that the most common sentinel event in spine surgery is surgery on the wrong level. Therefore, it is recommended that every patient have the surgical site signed, the level of surgery marked intraoperatively, and a radiograph taken. Surgery on the wrong level is most likely to occur in single-level decompressive procedures.
REFERENCES: Wong DA, Watters WC III: To err is human: Quality and safety issues in spine care. Spine 2007;32:S2-S8.
Wong DA: Spinal surgery and patient safety: A systems approach. J Am Acad Orthop Surg 2006;14:226-232.

Question 81:

Options:

Acute tendon repair
DIP joint extension splinting for 6 weeks
DIP and proximal interphalangeal joint extension splinting for 6 weeks
Buddy taping to the middle finger for 2 weeks
Early range-of-motion exercises and return to play as pain permits

Correct Answer: Acute tendon repair

Explanation:

Question 82:

Options:

Infection of the anterior glenoid labral detachment
Anterior glenoid fracture
Axilllary nerve palsy
Occult surgical neck fracture
Rotator cuff tear

Correct Answer: Rotator cuff tear

Explanation:

DISCUSSION: A rotator cuff tear is the most common cause of recurrent instability following a first-time dislocation in patients older than age 40 years. Dislocations occur through a posterior mechanism rather than by an isolated labral avulsion or a Bankart lesion as seen in younger patients.
REFERENCES: Nevaiser RJ, Nevaiser TJ: Recurrent instability of the shoulder after age 40.
J Shoulder Elbow Surg 1995;4:416-418.
Pevny T, Hunter RE, Freeman JR: Primary traumatic anterior shoulder dislocation in patients 40 years of age and older. Arthroscopy 1998;14:289-294.

Question 83:

Options:

Decompression and posterior fusion at L4-L5
Epidural steroid injection at L4-5
Nonsteroidal medications and physical therapy for 6 weeks
Measurement of the ankle-brachial index
CT myelogram

Correct Answer: Measurement of the ankle-brachial index

Explanation:

DISCUSSION: The patient has symptoms that are more consistent with vascular claudication than with the pseudoclaudication anticipated from lumbar spinal stenosis. Therefore, the patient is a candidate for further vascular work-up. The radiographs reveal early spinal stenosis and spondylolisthesis at L4-5 but also show significant calcification of the iliac arteries, suggestive of peripheral vascular disease. Vascular claudication is a manifestation of peripheral vascular disease and presents with crampy leg pain that is exacerbated by physical exertion. The pain is easily relieved by standing still or sitting. Unlike pseudoclaudication, a forward-flexed posture and/or sitting does not improve the symptoms. Night pain is common in vascular claudication due to the elevation of the extremities and patients often report pain improvement by hanging their extremities in a dependent position. In evaluation of a patient with suspected vascular claudication, the five “P’s” of vascular insufficiency should be monitored, including pulselessness, paralysis, paresthesia, pallor, and pain. While pain and paresthesias can be common in both vascular claudication and pseudoclaudication, the presence of any of the remaining symptoms is suggestive of vascular disease.
REFERENCES: Aufderheide TP: Peripheral arteriovascular disease, in Rosen P, Barkin R (eds): Emergency Medicine: Concepts and Clinical Practice, ed 4. St Louis, MO, Mosby, 1998,
pp 1826-1844.
Mirkovic S, Garfin SR: Spinal stenosis: History and physical examination. Instr Course Lect 1994;43:435-440.

Question 84:

The photomicrograph seen in Figure 41 shows which of the following conditions?

Options:

Synovial cell sarcoma
Giant cell tumor
Aneurysmal bone cyst
Osteosarcoma
Eosinophilic granuloma

Correct Answer: Synovial cell sarcoma

Explanation:

Question 85:

Which of the following complications is more likely with an inside-out repair technique compared to an all-inside techniques for a medial meniscus tear?

Options:

Failure
Intra-articular synovitis
Peroneal nerve injury
Saphenous nerve injury
Arthrofibrosis

Correct Answer: Saphenous nerve injury

Explanation:

Question 86:

Which of the following articulation couplings shows the lowest coefficient of friction as tested in the laboratory?

Options:

Cobalt-on-polyethylene
Cobalt-on-cobalt
Titanium-on-polyethylene
Stainless steel-on-polyethylene
Ceramic-on-ceramic

Correct Answer: Ceramic-on-ceramic

Explanation:

Question 87:

Options:

cheilectomy.
extra-depth shoes.
steroid injection.
arthrodesis.
joint replacement arthroplasty.

Correct Answer: extra-depth shoes.

Explanation:

Question 88:

Options:

Radial head
Anterior capsule
Olecranon fossa osteophytes
Lateral ulnar collateral ligament
Posterior oblique band of the medial collateral ligament

Correct Answer: Posterior oblique band of the medial collateral ligament

Question 89:

The need for postoperative allogeneic blood transfusions after total hip arthroplasty has been shown to be reduced when using

Options:

cementless fixation.
suction drains.
general anesthesia.
preoperative erythropoietin injections.
low-molecular-weight heparin.

Correct Answer: preoperative erythropoietin injections.

Explanation:

DISCUSSION: In a prospective study, 216 patients were randomized into three groups consisting of low-dose preoperative erythropoietin, high-dose preoperative erythropoietin, and placebo control. All patients were treated for 4 weeks prior to total hip arthroplasty. Both the low- and high-dose erythropoietin groups had a significantly lower rate of blood transfusions
(p < 0.001) after surgery.
REFERENCES: Waddell JP: Evidence-based orthopedics. J Bone Joint Surg Am 2001;83:788.
Feagan BG, Wang CJ, Kirkley A, et al: Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty: A randomized, controlled, trial. Ann Intern Med 2000;133:845-854.

Question 90:

Options:

Reduced radial artery pulse
Double break in the ipsilateral superior shoulder suspensory complex
Elevated hemidiaphragm
Musculocutaneous nerve deficit
Drooping of the left eyelid

Correct Answer: Reduced radial artery pulse

Explanation:

Question 91:

Options:

brace treatment.
laminectomy, nerve root decompression, and in situ fusion of L4 to the sacrum.
in situ fusion of L4 to the sacrum.
excision of the L5 lamina.
physical therapy.

Correct Answer: in situ fusion of L4 to the sacrum.

Explanation:

Question 92:

At the time of arthroscopy, a 9-year-old boy was found to have a Watanabe type II discoid lateral meniscus. What is the most appropriate treatment? Review Topic

Options:

Saucerization of the meniscus only
Saucerization and stabilization of the meniscus
Stabilization of the meniscus only
Complete menisectomy

Correct Answer: Saucerization of the meniscus only

Explanation:

Question 93:

Options:

Similar loss of elbow motion
Greater loss of elbow extension
Higher rate of varus malalignment
Higher rate of functionally limiting malalignment
Significantly better shoulder motion

Correct Answer: Similar loss of elbow motion

Explanation:

Question 94:

Which of the following statements best describes results that have been reported with roentgen stereophotogrammetric analysis (RSA)?

Options:

Cemented total hip stems do not migrate.
Well-fixed total hip stems (cemented or cementless) migrate approximately 3 degrees and 5 mm in the first year.
Any early migration (ie, greater than 0 mm less than 6 months after surgery) portends failure of the component.
Migration greater than 1 mm to 2 mm in the first year is associated with a higher risk of loosening.
The system has been proven to not be as accurate as claimed and has been abandoned.

Correct Answer: Migration greater than 1 mm to 2 mm in the first year is associated with a higher risk of loosening.

Explanation:

DISCUSSION: Migration of total hip femoral components has been measured by RSA, a technique that affords accuracy of 2 degrees and 0.5 mm. Several published studies on total hip arthroplasty femoral components have established the importance of this technique. Both cemented and cementless components migrate, with the rate of migration suggesting the adequacy of fixation of a component. Migration of 1 mm to 2 mm (occurring in either the
varus-coronal plane and retroversion-transverse plane, or both) has been associated with a higher risk of loosening of the component.
REFERENCE: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, p 100.

Question 95:

Options:

Partial tear of the patellar tendon
Osteochondral fracture of the femur
Anterior cruciate ligament (ACL) tear
Posterior cruciate ligament (PCL) tear
Patella fracture

Correct Answer: Posterior cruciate ligament (PCL) tear

Explanation:

Question 96:

Options:

A well-placed and well-calibrated arterial line would be the most helpful clinical tool for determining when this patient is out of shock
The hematocrit well within normal limits means the patient is not in hemodynamic shock
A combination of heart rate greater than 120 and MAP less than 65 equates to poor tissue perfusion levels
Normal lactate levels and base excess are markers of adequate tissue perfusion
His orthopaedic injury alone cannot explain his vital sign derangements and an exploratory laparotomy is indicated

Correct Answer: A well-placed and well-calibrated arterial line would be the most helpful clinical tool for determining when this patient is out of shock

Explanation:

Question 97:

Options:

Inflammatory elbow arthritis
A presurgical flexion-extension elbow arc of approximately 50°
Retained distal humerus hardware on presurgical radiographs
Evidence of presurgical elbow instability End-stage posttraumatic or inflammatory elbow arthritis in active, high-demand patients remains difficult to treat. Traditional total elbow arthroplasty is discouraged in this demographic secondary to concerns about implant longevity. Soft-tissue interposition arthroplasty does not necessitate the same activity and weight restrictions for patients after surgery and remains a reasonable salvage procedure. Larson and Morrey published their findings on 38 patients with a mean age of 39 years following soft-tissue interposition arthroplasty for posttraumatic and inflammatory end-stage elbow arthritis. These investigators reported a significant improvement in Mayo Elbow Performance Score in addition to improvement in the flexion-extension arc from 51° to 97° after surgery. They reported worse results and elevated incidence of complications for patients with presurgical elbow instability. Retained hardware from prior surgery was not deemed a contraindication.

Correct Answer: A presurgical flexion-extension elbow arc of approximately 50°

Explanation:

Question 98:

Options:

Therapy with an emphasis on eccentric exercises
Steroid injection
Platelet-rich plasma
Extracorporeal shock therapy

Correct Answer: Therapy with an emphasis on eccentric exercises

Explanation:

Question 99:

Options:

Stress fracture
Simple bone cyst
Fibrous dysplasia
Infection
Giant cell tumor

Correct Answer: Giant cell tumor

Explanation:

DISCUSSION: The radiographs reveal a lytic subchondral lesion that has a poorly defined margin and lacks mineralization. The bone scan confirms an active lesion that has central photopenia, producing the characteristic doughnut configuration. The MRI scans confirm the presence of a subchondral lesion that is modestly expansile at the lateral plateau and has low signal intensity on the T1-weighted image and a mixed high signal on the T2-weighted image. These features strongly suggest giant cell tumor of bone, more than 50% of which appear around the knee. Simple cyst is excluded by the MRI characteristics. Fibrous dysplasia is unlikely to be in a subchondral location and typically does not show this intensity of uptake on bone scan.
REFERENCES: Parsons TW: Benign bone tumors, in Fitzgerald RH, Kaufer H,
Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1027-1035.
Resnick D, Kyriakos M, Greenway GD: Tumors and tumor-like lesions of bone: Imaging and pathology of specific lesions, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, ed 4. Philadelphia, PA, WB Saunders, 2002, vol 4, pp 3939-3962.

Question 100:

Options:

Lumbar laminectomy with synovial cyst excision
Repeat epidural steroid injection
Microdiskectomy at L4-5
Nonsteroidal medication and outpatient physical therapy
Left-sided facet blocks at L4-5 and L5-S1

Correct Answer: Repeat epidural steroid injection

Explanation:

Lumbar spinal stenosis with lumbar radiculopathy can be commonly caused by a synovial cyst arising from the facet joints. Lyons and associates reported on the surgical treatment of synovial cysts in 194 patients. Of the 147 with follow-up data, 91% reported good pain relief and 82% had improvement of their motor deficits. Epstein reported a 58% to 63% incidence of good/excellent results and a 38 to 42
point improvement on the SF-36 Physical Function Scale. It was also suggested that since the presence of a synovial cyst indicates facet pathology, possible fusion should be considered in these patients, especially those with underlying spondylolisthesis.
(SBQ12SP.20) Amphotericin B is most appropriate for the treatment of which type of spine infection?
Review Topic
Fungal osteomyelitis
Bacterial osteomyelitis with a gram-positive organism
Bacterial osteomyelitis with a gram-negative organism
Tuberculous osteomyelitis
Viral meningomyelitis
Amphotericin B would be most appropriate for the treatment of fungal infections of the spine.
Amphotericin B is a broad-spectrum anti-fungal medication. It is commonly used as the first-line agent for treatment of fungal infections of the spine. The most common fungi involving the spine include cryptococcus, candida, and aspergillus. The indications for débridement and stabilization with spinal fusion, includes resistance to antibiotic therapy, spinal instability, and/or neurologic deficits.
Kim et al. reviewed fungal infections of the spine. They comment that fungus infections are most commonly spread by hematogenous or direct spread. Access to the vascular system may include intravenous lines, during implantation of prosthetic devices, or during surgery.
Frazier et al. retrospectively reviewed 11 patients with fungal osteomyelitis of the spine. Nine of the patients were immunocompromised secondary to diabetes mellitus, corticosteroid use, chemotherapy for a tumor, or malnutrition. All were treated with anti-fungal medication. 10 of 11 patients were also treated with surgical debridement. Paralysis secondary to the spine infection developed in eight patients. After an average of 6.3 years of follow-up, the infection had resolved in all nine surviving patients.
Illustration A shows the mechanism of action of Amphotericin. Illustration B shows T1- (Image A and B) and T2-weighted (Image C) images of the lower thoracic and lumbar spine. There are hypointense signals within the T12 and L1 vertebral bodies (Images A and B) indicative of fungal osteomyelitis.
IncorrectAnswers:

Orthopedic Surgery Board Review MCQs: Arthroplasty, Trauma & Spine Part 255

Orthopedic Board Review MCQs: Knee, Shoulder & Arthroplasty | Part 212

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 212

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index