Orthopedic Surgery Mock Exam - Set 01830B

The proper sequence when listing common orthopediCbiomaterials in order of increasing modulus is:
ElastiCModulus Cancellous bone Polyethylene Methylmethacrylate Cortical bone Titanium alloy Stainless steel Cobalt chrome

- Percutaneous lag screw fixation
This patient’s MR images are indicative of a nondisplaced navicular stress fracture, which is best treated with percutaneous lag screw fixation. She has persistent symptoms despite appropriate nonsurgical treatment. Although all of the above choices may allow successful healing of her navicular, surgery has been shown to result in a shorter recovery and a more predictable outcome, which is especially important to serious athletes. Use of bone morphogenic protein has not been established as a treatment for this injury.
RECOMMENDED READINGS
1. [Lee S, Anderson RB. Stress fractures of the tarsal navicular. Foot Ankle Clin. 2004 Mar;9(1):85-104. Review. PubMed PMID: 15062216. ](http://www.ncbi.nlm.nih.gov/pubmed/15062216)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/15062216)
2. Anderson RB, Cohen BE. Stress fractures of the foot and ankle. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Vol 2. 8th ed. Philadelphia, PA: Mosby; 2007:1590-1597.

Salvage of a total elbow arthroplasty is possible with early aggressive management of acute infection (symptoms for less than 30 days) with serial irrigation and debridement and antibiotic bead placement. This form of treatment is indicated when there are no radiographic or intraoperative signs of loosening. However, successful treatment is largely dependent on the organism. Staphylococcus epidermidis is associated with persistent infection because it is an encapsulating organism, and it is best treated with implant removal and
IV antibiotics.
REFERENCES: Yamaguchi K, Adams RA, Morrey BF: Infection after total elbow arthroplasty. J Bone Joint Surg Am 1998;80:481-491.
Schoifet SD, Morrey BF: Treatment of infection after total knee arthroplasty by debridement with retention of the components. J Bone Joint Surg Am 1990;72:1383-1390.

This patient has a ball and socket ankle, which results from limited motion of the hindfoot during early childhood, either from extensive tarsal coalition, premature hindfoot arthrodesis, or trauma. The condition most commonly associated with a ball and socket ankle is a form of hemimelia of the fibula with lateral ray deficiencies and associated tarsal coalition of which the latter is usually extensive.

The superficial zone has a number of important characteristics: Thinnest articular cartilage layer
Two layers:
Most superficial – fine collagen fibrils (lamina splendens)
Deep layer – flattened fibroblast-like chondrocytes (parallel to joint surface) Forms a cartilage skin
Important chemical properties:
High collagen and low proteoglycan concentration
Fibronectin and water concentrations are highest in this zone
Great tensile stiffness and strength
Seals off the cartilage from the immune system

K. kingae is variably invasive and is a facultative anaerobic gram-negative bacillus. K. kingae is a common bacteria that causes osteoarticular infections in young children. Presentation is often delayed because of the moderate course of the infection. Ten percent of young children are colonized with K. kingae. Colonization occurs in the oropharynx and is a prerequisite for invasive K. kingae septic arthritis. The PCR test screens for the RTX protein,
the factor responsible for the bacteria’s cytotoxicity. Among children in daycare centers, 28% are colonized. The sensitivity of the oropharyngeal swab PCR has been reported at 100%, and the specificity is 90.5%.
RESPONSES FOR QUESTIONS 70 THROUGH 74
1. Thrower's elbow/physeal irritation of the medial epicondylar physis
2. Osteochondritis dissecans (OCD)
3. Supracondylar humeral stress fracture
4. Patellar sleeve fracture
5. Distal femoral physeal fracture
6. Sinding-Larsen-Johansson syndrome/inferior pole patella apophysitis
7. Medial meniscal tear
8. Patellar tendon rupture
9. Patellofemoral pain syndrome
10. Popliteal cyst
11. Osteochondroma
12. Synovial sarcoma
Match the appropriate orthopaedic condition above with the clinical scenario below.

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1. Reference(s)
2. Patzakis MJ: Management of osteomyelitis, in Operative Orthopaedics. Philadelphia, PA, JB Lippincott, 1993, p 3335.
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Compression plating remains the treatment of choice for most established humeral nonunions. Autograft is felt to be superior to allograft. Electrical stimulation has not been found to improve healing rates in patients with nonunion after intramedullary nailing. Retrograde nailing with flexible nails gives inadequate rotational control to promote healing in this patient. Adding cancellous graft alone will not stabilize the nonunion site. Dynamic locking has been successful only in the lower extremity because the bone can be loaded axially.
REFERENCES: McKee MD, Miranda MA, Riemer BL, et al: Management of humeral nonunion after the failure of locking intramedullary nails. J Orthop Trauma 1996;10:492-499.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.

Opening or closing wedge osteotomies NOT at the level of the apex of the deformity will create secondary translation deformities.
The optimal level for an osteotomy is at the apex of an angular deformity. However, there may be circumstances in which osteotomies at the apex may not be possible, for example, if the deformity is at the level of the growth plate or joint, or there are soft-tissue coverage problems. When angular corrections are performed above or below the level of the apex of the deformity this will create secondary translational deformities in the bone. To avoid translational deformities, the osteotomy should be performed as close to the apex as possible or by using a translation hinge of bone at the osteotomy site.
Paley et al. outlines the pre-operative considerations when planning the level of an osteotomy. For correction of diaphyseal deformities, a line can be drawn down the concave or convex cortex of the proximal and distal segments. The intersection of these two cortical lines is considered the true apex of deformity.
Feldman et al. retrospectively reviewed a consecutive series of 18 patients that underwent corrective osteotomies. A Taylor Spatial Frame (TSF), with adjunctive bone graft as necessary, was used to achieve union and significant correction of their deformities in six axes (ie, coronal angulation and translation, sagittal angulation and translation, rotation, shortening) in 17/18 patients. They concluded that TSF's are effective in correct significant posttraumatic malunions in all axises.
Figure A shows a clinical picture of the patients left leg deformity. Figure B shows a zoomed in AP radiograph of the distal tibia showing a significant posttraumatic varus malunion deformity. Illustration A shows the correction of the distal tibia deformity after osteotomy and application of a TSF using the ilizarov technique. Illustration B shows a translational deformity in the proximal tibia.
Incorrect Answers:
Answer 2: Angular deformities occur during the osteotomy stage with incorrect wedge resection or incorrect use of adjunctive bone graft.
Answer 3: Shortening occurs with transverse or closing wedge osteotomies. Shortening is controlled with obliquely oriented osteotomies or adjunctive bone
graft.
Answer 4: Rotational deformities are more common with transverse osteotomies > closing/opening wedge osteotomy > oblique osteotomies. Answer 5: Excessive lengthening is not common at the site of the osteotomy.

Time to definitive fixation is not a modifiable risk factor concerning open fractures. The other factors are risk factors that have been studied in regards to infection, and all are more important than definitive fixation. Definitive fixation can wait until complete closure and/or coverage.
When concerning management of open fractures, the most important factor is a thorough debridement. However, the quality of debridement is often not able to be quantified and thus, often not mentioned in studies. While early clinical and animal studies have shown that initial debridement should occur within 6 hours of injury, more recent clinical trials have not found a significant correlation within that urgent time frame, but rather recommend initial debridement as soon as possible within 24 hours. Time to antibiotic administration has been found to have a significant impact in lowering infection risk. Immediate administration in the emergency room is recommended. The ability to cover and/or close an open wound also has a significant impact on infection. Recent studies have recommended placing hardware after fasciotomy closure and have also demonstrated lower infection rates when flaps are placed
within 72 hours of injury.
Pape and Webb concisely review the evolution of open fractures and wound management. The authors describe the early days where amputation was favored, to wet-to-dry dressings, to the advent of negative pressure wound therapy. Throughout, however, the authors emphasize the importance of soft tissue coverage. They also stress the importance of a technically thorough debridement, the most important factor of any wound management.
Scheneker et al. performed a systematic review and meta-analysis of 16 studies to determine if time to the operating room for debridement was an independent, modifiable risk factor in regards to subsequent infection following open tibia fracture. At the time of the study, the gold standard (based on a previous rat model), had recommended initial debridement within 6 hours of injury. The results of this meta-analysis, however, could not find conclusive evidence to suggest that late debridement alone placed the patient at a significantly higher risk for infection. The authors provided a moderate recommendation that initial debridement should occur as soon as possible within 24 hours, although more data is required in order to find a definitive time.
The SPRINT investigators report a landmark study that randomized over 1200 patients to either reamed or unreamed tibial IMN with the primary outcome analyzed as return to the operating room for either non-union treatment or deep infection. A notable difference between the two cohorts was a significantly higher primary event rate in the unreamed group.
Figure A exhibits a distal third open tibia fracture. Incorrect answers:
Answer 1: Antibiotic administration as soon as an open fracture has been
diagnosed is a significant risk factor in minimizing infection risk.
Answer 2: Although a non-quantifiable measure, a thorough debridement is the most important component of treating an open fracture.
Answer 3: Initial animal models cite a 6 hour window to initial debridement, however, clinical trials have not found a significant window that can affect increased or lowered infection risk.
Answer 4: Coverage and/or closure of any open wounds or soft tissue defects is a significant factor in lowering infection risk; when flap coverage is needed, coverage within 72 hours is optimal.

■
Achondroplasia is the most common form of rhizomelic dwarfism, characterized by a disproportionate shortening of the proximal limbs relative to the trunk. In achondroplasia, a quantitative decrease in the rate of enchondral bone formation is seen, but rates of membranous bone formation; calcification; and remodeling are normal. This results in a variety of skeletal manifestations that are recognizable at birth.
In the pediatric population, foramen magnum stenosis with cervicomedullary compression is the most notable spinal condition that deserves attention. In preadolescent children with achondroplasia, thoracolumbar gibbus formation and kyphotic deformity can also produce neurologic dysfunction secondary to the compression of conus medullaris or cauda equina. In older children and adults with achondroplasia, multisegment spinal stenosis involving the subaxial cervical or thoracolumbar spine may also be present. Premature fusion of the ossification centers of the vertebral bodies and posterior neural arches results in laminae and pedicles that are short and thick. In addition, the vertebral bodies have reduced height, the neural foramina are smaller, and the interpedicular distance is narrowed. Figure 4 shows the spine and pelvis radiographs of an individual with caudal regression and sacral agenesis, which occurs sporadically and multigenetic and environmental factors likely play a part in determining the risk of developing this condition. Caudal regression and sacral agenesis is not considered to be a part of common skeletal manifestations of achondroplasia.

For the patient with an anterior sternoclavicular dislocation, the most appropriate initial treatment should be symptomatic. Surgical options are usually contraindicated because the incidence of intraoperative and postoperative complications is high. A deformity from an anterior sternoclavicular dislocation is usually well tolerated. Return to play is allowed when symptoms resolve.
REFERENCES: Rockwood CA Jr: Disorders of the sternoclavicular joint, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, pp 477-525.
Rockwood CA Jr, Odor JM: Spontaneous atraumatic anterior subluxation of the sternoclavicular joint. J Bone Joint Surg Am 1989;71:1280-1288.

The radiograph shows an atrophic nonunion of the humeral shaft. The management of humeral nonunions has been studied with compression plates and bone graft, as well as intramedullary nailing and bone graft. Compression plating with bone graft results in the highest rate of union. Compression plating by itself is not adequate, given the bone loss and lack of callous in this nonunion. Pulsed electromagnetic fields is a viable option for hypertrophic nonunions where there is inherent stability. Intramedullary nailing does not provide as much compression and stability as that achieved with compression plating.
REFERENCES: Pugh DM, McKee MD: Advances in the management of humeral nonunion.
J Am Acad Orthop Surg 2003;11:48-59.
McKee MD, Miranda MA, Riemer BL, et al: Management of humeral nonunion after the failure of locking intramedullary nails. J Orthop Trauma 1996;10:492-499.

- Ankle-foot orthosis

Irradiation of polyethylene in air (i.e. oxygen present) has been shown to be a risk factor for catastrophic failure after total knee replacement.
Free radicals are generated when polyethylene is irradiated in the presence of air. Initially, these free radicals result in cross-linking. However, if the polyethylene is exposed to these free radicals for an extended period of time, delamination, cracking, and catastrophic failure may ensue. The industry has completely abandoned this method of sterilization as a result. Currently, the standard of care is irradiation of polyethylene in an inert gas (e.g. argon, nitrogen or vacuum packaging). The amount of oxidative products when polyethylene is sterilized in the absence of oxygen is much less and does not lead to catastrophic failure.
Sterilization without irradiation is another option (ethylene oxide). When this occurs, there is no cross-linking and thus the increased wear properties are lost. However, since there is no oxidization, you do not have the risk of catastrophic failure as seen in those liners irradiated in the presence of oxygen.
The cited reference by McNulty et al. from Orthopedics discusses the influence of sterilization methods on wear performance. They found that gamma irradiation and storage of the polyethylene components in an essentially oxygen-free environment imparted by gamma irradiation in a vacuum foil pouch (GVF) protects the components from oxidization.
Illustration A shows a polyethylene liner that has undergone catastrophic wear as a result of irradiation in the presence of oxygen.
Incorrect Answers:

: Sterilization in ethylelne oxide has not been shown to lead to
catastrophic wear, although wear properties are less than gamma irradiation in the absence of air.
Answer 3: Vacuum packaging minimizes oxidation while still allowing some cross-linking.
Answer 4: Unlike air, nitrogen is an inert element that minimizes formation of free radicals.
Answer 5: Unlike air, argon is an inert element that minimizes formation of free radicals.

Which of the following interventions reduces osteolysis around distal portion of the femoral stem when performing a total hip arthroplasty?

1) Use of an extended offset femoral neck component

2) Use of a proximal circumferentially coated ingrowth stem

3) Use of a collared stem

4) Use of a long femoral stem

5) Ensuring that the stem fills the diaphysis of the femur

Osteolysis of the femur is caused by activation of macrophages by microscopic polyethylene particles within the "effective joint space", defined as any area where joint fluid can come into contact with bone. This can occur above the acetabular cup, through screw holes, and down the femoral shaft around the prosthetic stem. Ideally, with a cementless stem, both the proximal and metaphyseal femur are well filled by the prosthesis. Collared stems are used to augment poor calcar bone quality or bone loss.
Sinha et al showed in a retrospective review of 101 hips with cementless circumferentially coated femoral stems no distal femur osteolysis occurred, but 82% showed “evidence of proximal femur stress shielding”, though only 38% showed proximal femoral osteolysis.

During a minimally invasive approach to total hip arthroplasty a femoral periprosthetic fracture occurs. Which of the following steps is crucial to properly treat this complication?

1) Transitioning to an extensile approach to adequately visualize and reduce the fracture

2) Limiting post-operative weight bearing

3) Switching to a cemented femoral stem to avoid the stresses created during press-fit fixation

4) Delaying the arthroplasty until the fracture has healed

5) Supplementing the fracture with autograft

Proper treatment of an intraoperative femoral fracture during total hip arthroplasty involves adequate exposure, anatomic reduction, and bypassing the fracture site by 2 cortical diameters of the femur with a long stem. This may involve repositioning the patient on the table if the arthroplasty is performed in the supine position. Minimally invasive surgical techniques have been developed to insert the components through smaller exposures and less soft tissue dissection. The purported advantages include faster rehabilitation, less blood loss, shorter hospital stays, and better cosmesis. However, complications an arise if the surgeon sacrifices surgical exposure and visualization.
Fehring et al review 3 cases of total hip arthroplasty performed through minimally invasive techniques with catastrophic outcomes. Intra-operative fracture, chronic instability, and death were all identified.

A 70-year-old man underwent total hip arthroplasty 4 months ago and has experienced 3 dislocations. Radiographs reveal no failure of the hardware and an acetabular component that has an abduction
angle of 40 degrees and a version of 10 degrees retroverted. What is the most appropriate treatment for the recurrent dislocations?

1) hip abduction brace

2) revision of the acetabular liner to a constrained type

3) revision of the entire acetabular component

4) revision of the femoral head to a larger size

5) revision to an extended offset prosthesis

Per Dorr et al: post-operative hip instability can be caused by several factors: soft tissue imbalance, component malposition, or position. Component malposition, as in this case, should be treated with revision of the offending component. In this case the acetabulum was placed in retroversion when it should have been 15-20 degrees anteverted. None of the other options addresses the cause of the instability. According to Morrey, the most signficant risk factors to instability are prior hip surgery, trochanteric nonunion, and posterior surgical approach. He wrote that the most reliable way to correct instability is to reorient a retroverted acetabular cup.

In patients with sickle cell disease and asymptomatic osteonecrosis of the femoral head identified with magnetic resonance imaging, what percentage will eventually go on to femoral head collapse?
1/.
1) 11% to 25%

2) 26 to 50%

3) 51 to 75%

4) > 75%

Untreated asymptomatic osteonecrosis of the femoral head in patients with sickle cell disease has a > 75% likelihood of progression to pain and collapse.
In contrast to asymptomatic osteonecrosis in patients without sickle cell disease, patients with sickle cell disease have a high incidence of progression to collapse and functional impairment secondary to pain (33% compared to 75%, respectively). In patients with sickle cell disease who present with a symptomatic hip, the contralateral (presumably asymptomatic) hip should be screened carefully and periodically for signs of disease. Given the high rate of
progression, some argue for operative treatment of the asymptomatic hip at the same time the symptomatic hip is being treated.
Hernigou et al. studied patients with sickle cell disease who had symptomatic avascular necrosis (AVN) in one hip and asymptomatic AVN in the contralateral hip. Their goal was to understand the natural history of the asymptomatic side. Ninety-one percent eventually developed pain and 77% developed collapse. Collapse was preceded by symptoms of pain in all patients.
Aguilar et al. report bone and joint disorders are the most common cause of chronic pain in patients who have sickle cell disease, and that the femoral head is the most common area of bone destruction in sickle cell patients.
Incorrect Answers:
Answers 1-4: Patients with sickle cell disease and osteonecrosis of the femoral head have a high rate of progression to painful collapse.

All of the following are contraindications to medial unicondylar knee arthroplasty EXCEPT:

1) Flexion contracture greater than 10 degrees

2) Varus deformity greater than 10 degrees not correctable with stress testing

3) Lateral knee joint line pain

4) Rheumatoid arthritis

5) Osteonecrosis of the medial femoral condyle

Contraindications to performing a unicompartmental/unicondylar knee arthroplasty include: inflammatory arthritis, fixed varus/valgus deformity more than 10 degrees, flexion contracture more than 10 degrees, less than 90 degrees of flexion pre-operatively, ACL insufficiency, significant arthritis in the other compartments, and joint subluxation of more than 5mm. Marmor et al reviewed 34 cases of UKA performed for osteonecrosis of the knee. At 5.5 year follow up they reported 90% good or excellent results. They did notice a trend to worse clinical results in cases of lateral compartment osteonecrosis. Parrate et al reviewed 31 cases of UKA's completed for osteonecrosis of the knee. At 12 year follow-up, they reported 96% good clinical outcomes and a 96% survivorship as well.

A 65-year-old male presents with a painful right total knee arthroplasty, which was performed ten years ago. CRP is 15 mg/L. Knee aspiration reveals a purulent fluid with 3,100 WBC's with 83% PMN's. Culture results are pending. Which of the following is the best management option?

1) Physical therapy, ice, and follow-up evaluation in 2 weeks

2) Repeat aspiration if cultures are positive

3) Oral antibiotics

4) Intravenous antibiotics

5) Surgical explant of components

This patient is infected and requires explantation to cure the infection.
Ghanem et al reviewed 161 infected TKA's vs 268 aseptic failures and discovered synovial fluid aspiration with WBC of >1100 cells/mm3 and PMN > 64% are suggestive of infection. When both tests yielded results below their cutoff values, the negative predictive value was 98.2% (95% confidence interval, 95.5% to 99.5%), whereas when both tests yielded results greater, infection was confirmed in 98.6% (95% confidence interval, 94.9% to 99.8%) of the cases. Thus, according to the most recent literature, WBC >1100 and PMN > 64% should be considered suggestive of infection in a TKA.
In an earlier, smaller study, Mason et al reported on 31 septic TKA failures and concluded that aspirates with a WBC count greater than 2,500 and 60% PMNs are highly suggestive of infection.
In another small study focused on THA, Schinsky et al reviewed 55 infected THA's and found that when combined with an elevated erythrocyte sedimentation rate and C-reactive protein level, the optimal cut-point for the synovial fluid cell count was >3000 white blood cells/mL, which yielded the highest combined sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the tests studied.

After insertion of the trial components in a total knee replacement, the surgeon finds that he is unable to fully extend the knee and that the tibial tray lifts-off when the knee is flexed past 90
degrees. What intervention should be taken to achieve a knee that is balanced in flexion and extension?

1) Augment the distal femur

2) Resect more distal femur

3) Resect more proximal tibia

4) Downsize the femoral component

5) Increase polyethylene liner thickness

In this situation, the knee is both tight in flexion (tibial tray lift-off) and extension (unable to fully extend). Of the options listed, only resection of the proximal tibia will provide more room in both flexion and extension.
Proper sagittal plane balancing in total knee arthroplasty can help prevent post-operative stiffness and/or instability through the flexion arc. In a
cruciate-retaining knee arthroplasty, balancing is potentially more complicated given the presence of the posterior cruciate ligament. If the knee is too tight in flexion, the trial tibial tray can be seen "lifting-off." If the knee is too loose in flexion, the tibial tray can be easily extracted from beneath the femur when the knee is flexed to 90 degrees. If the knee is both tight in flexion and extension, which is the case here, the correct treatment should be to resect more proximal or downsize the polyethylene.
Illustration A shows normal tibial tray seating at the time of total knee arthroplasty.
Illustration B shows tibial tray lift off with flexion. This is due to the femoral component impinging on the tibial tray posteriorly and causing lift off of the tray anteriorly.
Incorrect Answers:
Answer 1: Augmenting the distal femur will increase the amount of tightness in extension.
Answer 2: Resecting more distal femur will decrease tightness in extension, but will not change the tightness in flexion.
Answer 4: Downsizing the femoral component will only affect the flexion space, not the extension space.
Answer 5: Increasing the polyethylene thickness will increase tightness in both flexion and extension. In this case, we want to do the opposite.

A 61-year-old male had a minimally-invasive unicompartmental knee replacement 8 months ago. He did well until recently when he developed persistent right knee pain that is worse with weight bearing. He denies any fevers or recent trauma. He does report that he had been exercising more over the past few months in an attempt to lose weight. WBC, ESR and C-reactive protein levels are normal. An AP radiograph and bone scan are shown in Figure A and B. What is the most likely cause of his symptoms?
1) Component failure/ polyethylene failure

2) Infection

3) Pes anserine bursitis

4) Stress fracture

5) Complex regional pain syndrome

The patient has knee pain following a unicompartmental knee replacement with a normal radiograph and uptake under the prosthesis on bone scan. This is consistent with a stress fracture.
Brumby et al. reported on tibial plateau stress fractures after UKA due to the guide pin holes placed in the proximal tibia. All of their cases required a revision to a TKA. They recommend that if 3 or more pin holes are created that the surgeon be aware of this potential complication. Pandit et al. report similarly on tibial plateau fractures after medial Oxford UKA.
Hamilton et al. retrospectively reviewed minimally invasive versus open unicompartmental arthroplasty. They found the MIS group to have a higher incidence of aseptic loosening and re-operations when compared to the open group.
Incorrect Answers: The patient's presentation is not consistent with infection, pes bursitis, or complex regional pain syndrome. Radiographs do not show component or polyethylene failure.

An 80-year-old man has a Charnley all-polyethylene acetabular shell shown in Figure A. When defining failure as revision for any reason, what is the failure rate at 35 years for this type of prosthesis?
1) Less than 10%

2) 20% to 30%

3) 40% to 50%

4) 50% to 75%

5) Greater than 75%

The estimated failure rate at 35 years for all polyethylene acetabular shells is 20-30%.
Della Valle, et. al, reported a 77.3% survivorship for the component at a mean of 21 years, with revision or definite loosening as an endpoint.
Kavanaugh et. al, reported that the probability of surviving 20 years without revision of the components was 84%. They did note that there is a significantly increased probability of revision based on the age of the patient at the time of the index THA(27% for 70 y.o.)
Callaghan, et. al. has demonstrated the remarkable durability of cemented Charnley total hip replacements over a span of three decades, with 88% of the
original prostheses intact at 20 years, and 78% at 35 years. In conclusion, the rate of revision definitely varies, but should be somewhere between 20-30%.

Following a left total knee arthroplasty, all of the following can cause the condition seen in Figure A EXCEPT:
1) Internal rotation of the femoral prosthesis

2) Internal rotation of the tibial prosthesis

3) Lateralization of the femoral prosthesis

4) Medialization of the tibial prosthesis

5) Lateralization of the patellar prosthesis

Lateralization of the femoral prosthesis would not lead to lateral patellar subluxation. However, lateralization of the patella or medialization of the tibial tray could lead to lateral patellar subluxation by increasing the Q angle.
The Malo article reviewed the common issues regarding the patellofemoral compartment after TKA. Patellar instability & maltracking can result from malpositioning of the component, prosthetic design, improper patellar preparation, or soft-tissue imbalance. Patellar instability & maltracking most often occurs due to internal malrotation of the femoral or tibial components, lateralization of the patellar component, or medialization of the femoral or tibial components. Medialization, not lateralization of the femoral prosthesis will increase the Q angle and lead to lateral subluxation of the patella.

Polyethylene gamma irradiation in nitrogen gas results in which of the following?

1) Annealing

2) Gas plasma

3) Uncross-linking

4) Free radicals

5) Remelting

As described in the review by Gordan et al. sterilization of polyethylene with irradiation causes free radical production which leads to cross-linking and increased wear resistance. Irradiation in inert gas reduces excessive oxidation. Remelting and annealing are heat treatments that reduce the excess free radicals formed by irradiation.
McKellop et al. showed sterilizing an ultra-high molecular weight polyethylene acetabular cup without radiation (ethylene oxide or gas plasma) avoids immediate and long-term oxidative degradation of the implant but does not improve the inherent wear resistance of the polyethylene.
Incorrect Answers:

The patient has a posterolateral rotatory instability (PLRI) of the elbow that is most likely the result of iatrogenic injury to the lateral ulnar collateral ligament, the main ligament implicated in PLRI. The anterior band of the medial collateral ligament is implicated in valgus instability. Injury to the radial nerve is unlikely, and the lateral radial collateral ligament makes less of a contribution to elbow stability than does the ulnar component. While the origin of the extensor carpi radialis brevis may contribute to elbow stability, it is not as important a stabilizer as the lateral ulnohumeral ligament.
REFERENCES: O’Driscoll SW, Morrey BF: Surgical reconstruction of the lateral collateral ligament, in Morrey BF (ed): The Elbow. Philadelphia, PA, Lippincott, Williams and Wilkins, 1994, pp 169-182.
O’Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446.

The anterior oblique (volar) ligament was considered the primary stabilizing structure of the thumb CMC joint until alternative theories were offered in the mid 1970s. Multiple clinical and anatomic studies since that time have supported the theory that the primary stabilizing structure is the dorsoradial ligament.
Shah and Patel reported on 4 cases of thumb CMC dislocation in 1983 and demonstrated that in each case, the dorsal ligaments were ruptured while the anterior oblique ligament remained intact. Strauch and associates sectioned the supporting structures of 38 cadaveric specimens. Isolated sectioning of the dorsoradial ligament complex led to the maximum degree of subluxation. Preserving the dorsoradial complex alone maintained the highest degree of stability.
The radiovolar and dorsal capsular ligaments are thin and insert farther from the articular surface, allowing for increased mobility. The ulnovolar capsule and anterior oblique (volar) ligament attach close to the articular surface and are short and robust. Further stability comes from the infratendinous layer of the abductor pollicis longus tendon. The abductor pollicis brevis does not substantially contribute to stability of the CMC joint.
RECOMMENDED READINGS
41. [Eaton RG, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg Am. 1973 Dec;55(8):1655-66. PubMed PMID: 4804988. ](http://www.ncbi.nlm.nih.gov/pubmed/%204804988)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/%204804988)
42. [Shah J, Patel M. Dislocation of the carpometacarpal joint of the thumb. A report of four cases. Clin Orthop Relat Res. 1983 May;(175):166-9. PubMed PMID: 6839582. ](http://www.ncbi.nlm.nih.gov/pubmed/6839582)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/6839582)
43. Strauch RJ, Behrman MJ, Rosenwasser MP. Acute dislocation of the carpometacarpal joint of the thumb: an anatomic and cadaver study. J Hand Surg Am. 1994 Jan;19(1):93-8.
44. [Bosmans B, Verhofstad MH, Gosens T. Traumatic thumb carpometacarpal joint dislocations. J Hand Surg Am. 2008 Mar;33(3):438-41. doi: 10.1016/j.jhsa.2007.11.022. Review. PubMed PMID: 18343304. ](http://www.ncbi.nlm.nih.gov/pubmed/18343304)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18343304)

Nonsurgical management such as a functional brace, hanging arm cast, or sugar tong splint is the treatment of choice for a fracture of the humeral shaft that is the result of throwing. The fracture surface typically is wide and the degree of displacement is not large; therefore, surgery is not indicated in most patients.
REFERENCES: Ogawa K, Yoshida A: Throwing fracture of the humeral shaft: An analysis of 90 patients. Am J Sports Med 1998;26:242-246.
Kaplan H, Kiral A, Kuskucu M, et al: Report of eight cases of humeral fracture following the throwing of hand grenades. Arch Orthop Trauma Surg 1998;117:50-52.

A Charcot flare in adjacent joints is not uncommon in patients with neuropathy who undergo surgery or other trauma. Venous thrombosis would present with swelling of the entire leg, while infection would present earlier in the postoperative period. The radiographs are pathognomonic of Charcot arthropathy, not an unrecognized fracture or gout. A compartment syndrome this late after injury is extremely rare, and there would be no bony distraction associated with compartment syndrome.
REFERENCE: Connolly JF, Csencsitz TA: Limb threatening neuropathic complications from ankle fractures in patients with diabetes. Clin Orthop 1998;348:212-219.

This patient has a septic distal interphalangeal joint, which was treated with antibiotics alone. As a result, the patient developed osteomyelitis with bone destruction and abscess. The best way to treat this problem is to perform surgical débridement of bone and soft tissue, along with abscess drainage and an appropriate antibiotic regimen. Antibiotic treatment without surgery would not be successful in eliminating this particular infection. Bone scan with biopsy is not the correct option, because this problem is an infection _and not a tumor, and MRI already has provided enough diagnostic information._

Due to the patients age, autograft is the preferred option. Also, due to the patientâs age, his growth plates are open and the surgeon is prohibited from using a graft with a bone construct due to the possible damage to the growth plate.

The natural history of cervical myelopathy is one of slow deterioration over time, typically in a stepwise fashion with a variable period of stable neurologic function. More recent studies suggest that surgery should be performed as soon as possible when cervical spondylotic myelopathy has been diagnosed. Both anterior and posterior are effective and there is no statistical difference between their outcomes. Surgical outcome is related to the patient’s age, disease course, the presence of osseous spinal stenosis, preoperative comorbidities, the preoperative spinal cord functional score, and the presence of high-signal abnormalities on T2-weighted images. To improve the operative result, all the influencing factors should be considered. Patients with focal high-intensity intramedullary signal changes on T2-weighted images have better clinical outcomes following surgery than do patients with demonstrable multisegmental high-intensity intramedullary signal changes on T2-weighted sequences. The transverse area and shape of the spinal cord at the involved segment may also be predictive of surgical outcome.
With progressive compression, the cross section of the spinal cord changes from a boomerang shape to a teardrop shape to a triangular shape. In patients with a Nurick grade of I, there are signs of cord involvement, but gait remains normal. With a Nurick grade of II, there are mild gait abnormalities,not affecting the patient’s employment status. With a Nurick grade of III, gait abnormalities prevent employment, but the patient remains able to ambulate without assistance. In Nurick grade IV, the patient is only able to ambulate with assistance. In Nurick grade V, the patient is chair-bound or bedridden. Clearly, it is desirable to operate when the patient is functioning with a Nurick grade of I or II. Whereas many patients presenting with cervical spondylotic myelopathy also report axial neck pain and radicular symptoms in the upper extremities, this is not always the case. Surgical intervention will generally be effective in eliminating this pain; however, the pain is not the determining factor for performing surgery.Surgery is performed to preserve and restore function. Changes in bowel and bladder function can occur
in extremely severe cases of myelopathy, but this is quite rare.

The patient has a chronic unrecognized volar lunate dislocation. Median nerve compression is the result of the lunate displaced into the carpal tunnel. The diagnosis can be made by radiographs; MRI is not necessary. A volar approach allows median nerve decompression with excision of the lunate, whereas a dorsal approach facilitates excision of the scaphoid and triquetrum.
REFERENCES: Rettig ME, Raskin KB: Long-term assessment of proximal row carpectomy for chronic perilunate dislocations. J Hand Surg Am 1999;24:1231-1236.
Howard FM, Dell PC: The unreduced carpal dislocation: A method of treatment. Clin Orthop 1986;202:112-116.

Following a calcaneal fracture, the patient has severe subtalar arthritis with loss of talar declination and shortening of the heel; therefore, the treatment of choice is subtalar distraction arthrodesis. Orthotics will not provide significant relief as bracing has failed. Ankle arthrodesis will not be beneficial because the arthritis is in the subtalar joint. Subtalar arthroscopy would only be helpful for a small area of arthrosis, and calcaneal osteotomy would not be beneficial given the extent of the arthritis of the subtalar joint.
REFERENCE: Robinson TF, Murphy GA: Arthrodesis as salvage for calcaneal avulsions. Foot Ankle Clin 2002;7:107-120.

Internal rotation of the distal segment of the femur relative to the proximal segment of the femur during nailing can cause a malrotation deformity.
Postsurgical internal malrotation after treatment for a diaphyseal femur fracture typically occurs either via internal rotation of the distal segment relative to the proximal or external rotation of the proximal segment relative to the distal. These clinical findings are consistent with an iatrogenic increase in femoral anteversion.
Dimitriou et al. performed a study to quantify the side-to-side anatomic variation in the proximal femur and the implications for preoperative planning and leg length discrepancy following hip arthroplasty. CT-based 3D femoral models were reconstructed for 122 paired femurs in 61 young healthy subjects with no history of hip pathology. Significant side-to-side differences were found in femoral anteversion, horizontal offset, and femoral head center location.
They concluded that relying on the anatomic landmarks of the contralateral femur during hip arthroplasty may not necessarily result in restoration of native anatomy and leg-length.
Karaman et al. conducted a study which saught to clarify the influence of a femoral rotational malalignment of ≥10° after intramedullary nailing on daily activities. They evaluated twenty-four femoral shaft fracture patients treated with closed antegrade IMN, and determined the presence of malrotation with post-operative CT scans. Ten of the 24 patients had a CT-detected true rotational malalignment of ≥10° compared with the unaffected side, and were noted to have significantly worse functional outcome scores compared with normally rotated femoral shaft patients.
Espinoza et al. present a technique using intraoperative fluoroscopy and the anteversion inherent to the IM nail for obtaining appropriate femoral rotational alignment during surgery. The authors state that their technique reliably sets the femoral anteversion within a normal physiologic range with minimal additional intraoperative steps and without preoperative measurements.
Illustration A shows a CT evaluation of femoral malrotation. The angle on the uninjured side measures 30°, while the malrotated fractured side measures only 3°, indicating a 27° external rotation deformity.
Incorrect Answers:
Answer 1: This would result in external rotation of the femur. Answer 2: This would result in external rotation of the femur. Answer 3: This would result in external rotation of the femur. Answer 4: The contralateral femur would not be affected in this case.

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This patient has a transabdominal gunshot wound (GSW) to the right hip. Urgent irrigation and debridement of the hip joint is indicated. Antibiotic coverage should be for at least 24 hours and should cover gram-positive, gram-negative and enteric organisms.
Transabdominal GSW of the hip and pelvis are those that traverse the gastrointestinal system before entering the pelvis and hip and may be contaminated by bowel contents. Blood on rectal examination, and bullet paths crossing the midline at or below the pelvic brim raise concern for lower GI injuries and should be evaluated with sigmoidoscopy.
Miller et al. reviewed transabdominal GSW to the hip and pelvis. They state that hip injury is evidenced by retained bullets in the joint, intraarticular air on CT, or acetabular or femoral head fracture without retained missile components. If there is hip injury, debridement is necessary. If the hip joint is not involved, the patient should be assessed for other pelvic injuries. If there is no need for surgical stabilization, at least 24 hours of antibiotics alone will suffice.
Bartkiw et al. reviewed 2808 GSW and found 1235 associated fractures including 42 fractures of the hip and pelvis. They performed 10 orthopaedic procedures on 7 patients. All fractures healed with no pelvic ring instability or chronic osteomyelitis. They recommend orthopedic intervention for intraarticular projectiles or bone fragments, and reconstruction of the hip and acetabulum.
Incorrect Answers
Answer 1: As the hip joint is involved, surgical debridement is necessary. Antibiotic coverage should include gram-positive coverage as contaminants can be introduced by bullet passage through clothes and skin.
Answer 2: At least 24 hours of antibiotic coverage is indicated for prophylaxis against osteomyelitis and localized abscess formation. A longer period may be necessary depending on injury severity and overall patient condition.
Answers 3 and 4: Bullet removal is only indicated for intra-articular bullets to prevent late septic arthritis, lead toxicity, and articular damage with motion of the joint. Bullets retained in soft tissues can be observed or removed on an elective basis if they prove problematic.

Chronic opioid consumption prior to total joint arthroplasty has been associated with increased pain after surgery, increased opioid requirements, a slower recovery and longer hospital stay, and higher 90-day postoperative complications compared with patients not on chronic opioids preoperatively. Based on this information, Nguyen and associates performed a study in three patient groups that included 1) chronic opioid users who underwent no preoperative intervention, 2) chronic opioid users who were weaned down to 50% of their prior opioid regimen, and 3) patients who were not chronic opioid users. The authors found that the reduction of preoperative opioid use improved postoperative function, pain, and recovery and that the weaned group performed more like the opioid naive group than the chronic opioid user
group. Increasing opioid use prior to surgery in this patient would make it more difficult to control pain after surgery. Stopping all of his opioids just prior to surgery would place the patient at substantial risk for opioid withdrawal and is not recommended. Avoiding the use of all narcotics and using only acetaminophen postoperatively is very unlikely to provide appropriate pain relief in a chronic opioid user. The recommendation based on the provided literature is to decrease the patient's narcotic use prior to
surgery.

On a lateral view of the wrist, when the lunate slips into a statically dorsiflexed position greater than 10°, the condition is defined as dorsal intercalated segmental instability (DISI). DISI deformity is also present when the scapholunate angle is greater than 60 degrees (45+/- 15 degrees is normal). The VISI deformity is seen on the lateral radiograph is characteristic of lunotriquetral dissociation. The other signs are seen on the anteroposterior projection.

A Gibbs artifact is a linear focus in the cord on T2-weighted images that parallels the ventral aspect of the cord and mimics a syrinx. The Gibbs artifact is due to the linear interface between two tissues of differing signal intensity. It is not seen on axial images or T1-weighted images.
Motion artifact is a blurring of the image due to patient motion, respiration, or cerebral spinal fluid pulsation. Ependymoma and astrocytoma are seen on both the axial and the sagittal images.

DISCUSSION: The child has a type III tibial spine avulsion fracture. When the avulsed fragment is completely displaced, the preferred treatment is open or arthroscopic reduction of the fragment and internal fixation with sutures or screws. Type I fractures are nondisplaced and can be treated with a long leg cast; type II fractures are hinged and can be treated in a long leg cast if closed reduction is successful. Many patients have some objective anterior cruciate ligament laxity after a tibial spine avulsion fracture; however, with adequate treatment most patients do not have symptomatic laxity.
REFERENCES: Mah JY, Adili A, Otsuka NY, et al: Follow-up study of arthroscopic reduction and fixation of type III tibial-eminence fractures. J Pediatr Orthop 1998; 18:475-477.
McLennen JG: Lessons learned after second-look arthroscopy in type III fractures of the tibial spine. J Pediatr Orthop 1995;15:59-62.
Meyers MH, McKeever FM: Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-1684.

72 • American Academy of Orthopaedic Surgeons

Mathematical modeling of cement stress predicted that a stem with a circular cross-sectional geometry transmits stresses to the cement mantle up to three times greater than stems with a rectangular cross-section

Plantarflexion of the first ray, especially if the first ray is not colinear with the talus on the lateral radiograph, should serve as an indication for a plantar release.
Anterior extrusion of the talus is common because of the tightness of the Achilles tendon and the posterior capsule. Inferior subluxation of the calcaneocuboid joint is not a feature of clubfoot.
Medial subluxation of the calcaneocuboid joint, in combination with the clinical appearance of a curved lateral border of the foot, should serve as an indication for a lateral release, not a plantar release.
Inability to dorsiflex the ankle is an indication for a posterior release.

- Ligamentum teres_

The images show a bucket handle medial meniscus tear, which is likely responsible for the block to motion. Therefore, surgery should be recommended with a meniscus repair if possible. Physical therapy or knee aspiration/manipulation under anesthesia is not the best definitive treatment.

Patellar clunk syndrome is caused by the development of a fibrous nodule on the posterior aspect of the quadriceps tendon at its insertion into the patella. It causes a painful catching sensation when the extensor mechanism traverses over the trochlear notch as the knee extends from 45° of flexion to 30° from full extension. It characteristically occurs in posterior stabilized total knee arthroplasties and appears to be related to femoral component design. The syndrome can usually be prevented by excising the residual synovial fold just proximal to the patella. Flexion gap instability can also cause a painful total knee arthroplasty but is less common in posterior stabilized implants. Femoral component malrotation can cause pain attributable to a flexion gap imbalance or patellar tracking problems. Polyethylene wear would be unlikely after just 1 year. Patellar clunk syndrome can usually be addressed successfully with arthroscopic synovectomy. Recurrence is uncommon. Physical therapy may help to strengthen the quadriceps following synovectomy but would not resolve the clunk syndrome symptoms. Femoral or tibial insert revision is not indicated if patellar clunk syndrome is the only problem resulting in a painful
total knee arthroplasty.

Surgical indications for scapular fractures are debatable in the literature. Historical indications for extra-articular fractures of the glenoid neck have ranged from 10-25 mm of medial displacement, 25-40⁰ of angular deformity of the glenoid, and a glenopolar angle cut-off of 20-30⁰. While the Judet approach can offer access to the entire scapular body, a modified Judet approach is a more limited approach that allows access to the glenoid neck in the interval
7
between the infraspinatus and teres minor. The infraspinatus is innervated by the suprascapular nerve, whereas the teres minor is innervated by the axillary nerve. The long thoracic nerve innervates the serratus anterior muscle. The spinal accessory nerve innervates the sternocleidomastoid and trapezius muscles.

The tibial cut is perpendicular to the tibial axis, the femoral cut is made in 4° to 6° valgus, and the knee aligned in 4° to 6° of valgus provided the ligaments are balanced

Most clinical venous thromboembolism events occur between the second and sixth weeks after surgery. It is estimated that 10% of patients are readmitted to the hospital within the first 3 months after total hip or knee arthroplasties. Most pulmonary events on the day of surgery are related to fat embolism or cardiac events.

Patella infera is encountered 80% of the time after a high tibial osteotomy. Patella infera makes it difficult for a surgeon to visualize and dislocate the patella laterally, and it also makes for a difficult salvage for a total knee replacement

It is unusual for an adolescent to require surgical correction of a flatfoot deformity, however, when the deformity is markedly symptomatic, surgery is a reasonable treatment option. Arthrodesis should not be considered as treatment of the flexible flatfoot in the adolescent. There is no indication of an accessory navicular bone being present. Lateral column lengthening (Evans Procedure) is a reliable procedure in this age group. The most common correction in kids with severe flexible pes planus is a lateral column lengthening. This is because most children, such as in this case, have severe forefoot abduction with significant talo-navicular uncoverage. (The description stated that the patient had a callus under the talar head, which means the talus is
protruding beyond the navicular medially.) Medial slide calcaneal osteotomy would only correct the heel valgus, whereas a lateral column lengthening has the potential to correct both heel valgus and forefoot abduction.

The resting position of the hallux in normal patients is 20° of dorsiflexion relative to the first metatarsal shaft. In patients with hallux rigidus, the resting position is decreased to 10° of dorsiflexion relative to the metatarsal shaft. This relatively plantarflexed position was not improved to a more normal value following cheilectomy.

The PCL is the primary posterior stabilizer of the knee. It has 2 bundles, anterolateral and posteromedial, which are described by their origin on the medial side of the femoral notch. Each of these bundles inserts on the posterior tibia, distal to the articular surface and extending up to 1 cm below. The anterolateral bundle inserts anterior to the posteromedial bundle on the tibia.
RECOMMENDED READINGS
9. [Amis AA, Gupte CM, Bull AM, Edwards A. Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 2006 Mar;14(3):257-63. Epub 2005 Oct 14. Review. PubMed PMID: 16228178. ](http://www.ncbi.nlm.nih.gov/pubmed/16228178)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16228178)
10. [Moorman CT 3rd, Murphy Zane MS, Bansai S, Cina SJ, Wickiewicz TL, Warren RF, Kaseta MK. Tibial insertion of the posterior cruciate ligament: a sagittal plane analysis using gross, histologic, and radiographic methods. Arthroscopy. 2008 Mar;24(3):269-75. doi: 10.1016/j.arthro.2007.08.032. Epub 2007 Nov 5. PubMed PMID: 18308177. ](http://www.ncbi.nlm.nih.gov/pubmed/18308177)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18308177)

DISCUSSION: Patients with developmental dysplasia of the hip share a common pattern of anatomic abnormalities including an acetabulum that is shallow, lateralized, anteverted, and deficient anteriorly and superiorly. On the femoral side, the head is usually small, the neck is short and anteverted with a posteriorly placed trochanter, and the femoral canal is small. The neck-shaft angle is typically increased. The contact area of the femoral head and acetabulum is typically decreased.

REFERENCE: Sanchez-Sotelo J, Trousdale RT, Berry DJ, et al: Surgical treatment of developmental dysplasia of the hip in adults: I. Nonarthroplasty options. J Am Acad Orthop Surg 2002; 10;321-333.

Figure 42

The most appropriate management is a fracture boot with weight bearing as tolerated.The radiographs are normal, but the history strongly suggests a metatarsal stress fracture. The MRI scan clearly shows edema of the third metatarsal which is consistent with a stress fracture. Patients can be treated successfully with weight-bearing
immobilization and activity modification. Some physicians treat metatarsal base fractures with limited weight bearing. Limiting his miles and repeat radiograph in 2 weeks would be an acceptable option if the MRI scan showing the fracture had not been obtained. A bone density examination typically will be normal in a teenager, and it does not help in treatment. A bone scan is a good test to diagnose the fracture, but an MRI scan has already been obtained.

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

Stage II of osteonecrosis has good cartilage space without collapse, and a dense necrotiClesion with sclerotiCborder but does not have a crescent sign. Stage I is detected on magnetiCresonance imaging, and stages III and IV are advanced forms of osteonecrosis

Suprascapular nerve injuries are more commonly seen in athletes who participate in overhead activities. When a patient is evaluated for posterior shoulder pain and infraspinatus muscle weakness or atrophy, electrodiagnostic studies are an essential part of the evaluation. In addition, imaging studies are indicated to exclude other diagnoses that can mimic a suprascapular nerve injury. Initial management should consist of cessation of the aggravating activity along with an organized shoulder rehabilitation program. If nonsurgical management fails to provide relief within 6 months to 1 year, surgical exploration of the suprascapular nerve should be considered. Release of the spinoglenoid ligament with resultant suprascapular nerve decompression may result in pain relief and a return of normal shoulder function. In this patient, who has a chronic neuropathy and mild symptoms, surgery is indicated only if nonsurgical management fails to provide relief and he is unable to perform at his position.
REFERENCES: Cummins CA, Bowen M, Anderson K, et al: Suprascapular nerve entrapment at the spinoglenoid notch in a professional baseball pitcher. Am J Sports Med 1999;27:810-812.
Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment. J Bone Joint Surg Am 2000;82:415-424.
Ferretti A, De Carli A, Fontana M: Injury of the suprascapular nerve at the spinoglenoid notch: The natural history of infraspinatus atrophy in volleyball players. Am J Sports Med 1998;26:759-763.