2011 Annual Meeting San Diego, California

ORTHOPAEDIC REVIEW COURSE

David L. Skaggs, MD Course Chairman

Friday, February 18, 2011 Hilton Bay Front Sapphire Ballroom

DISCLAIMER The material presented at this course has been made available by the American Academy of Orthopaedic Surgeons for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed, but rather is intended to present an approach, view, statement or opinion of the faculty, which may be helpful to others who face similar situations. The AAOS disclaims any and all liability for injury or other damages resulting to any individual attending the course and for all claims, which may arise from the use of techniques, demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. No reproductions of any kind, including audiotapes and videotapes, may be made of the presentations at the Academys Annual Meeting. The Academy reserves all of its rights to such material, and commercial reproduction is specifically prohibited. FDA STATEMENT Some drugs or medical devices demonstrated at the Annual Meeting have not been cleared by the FDA or have been cleared by the FDA for specific purposes only. The FDA has stated that it is the responsibility of the physician to determine the FDA clearance status of each drug or medical device he or she wishes to use in clinical practice. Academy policy provides that off label uses of a device or pharmaceutical may be described in the Academys CME activities so long as the off-label status of the device or pharmaceutical is also specifically disclosed (i.e. that the FDA has not approved labeling the device for the described purpose). Any device or pharmaceutical is being used off label if the described use is not set forth on the products approved label. DISCLOSURE Each participant in the Annual Meeting is required to disclose if he or she has received something of value from a commercial company or institution, which relates directly or indirectly to the subject of their presentation: The Academy has identified the options to disclose as follows: The numbers after the name are identified as 3-royalties; 4-speakers bureau/paid presentations; 5a-paid consultant or employee; 5b-unpaid consultant; 7-research or institutional support has been received; 8-stock or stock options; 10-miscellaneous nonincome support (e.g. equipment or services); n-no conflicts to disclose. The Academy does not view the existence of these disclosed interests or commitments implying bias or decreasing the value of the authors participation in the meeting.

American Academy of Orthopaedic Surgeons ORTHOPAEDIC REVIEW COURSE Friday, February 18, 2011 San Diego Bayfront Hotel Sapphire Ballroom Course Chairman: David L. Skaggs, MD
8:00-10:00 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM Lower Extremity Hip and Knee Reconstruction Thomas S. Thornhill, MD Sports Knee James P. Bradley, MD Foot and Ankle Steven L. Haddad, MD Trauma Donald A. Wiss, MD STRETCH BREAK Upper Extremity Hand and Wrist Jeffrey A. Greenberg, MD Forearm and Elbow Rick F. Papandrea, MD Shoulder and Humerus Marc Safran, MD LUNCH (box lunch included) Pediatrics Moderator: Lori A. Karol, MD Moderator: Marc Safran, MD Moderator: Thomas S. Thornhill, MD

10:00-10:15 AM 10:15 AM-12:00 PM 10:15 AM 10:50 AM 11:25 AM

12:00-12:50 PM 12:50-2:50 PM 12:50 PM 1:20 PM 1:50 PM 2:20 PM 2:50-3:00 PM 3:00-4:30 PM 3:00 PM 3:30 PM 4:00 PM

Hip William C. Warner Jr., MD Infection, Congenital, Developmental Problems/Miscellaneous Jeffrey R. Sawyer, MD Fractures of the Upper and Lower Extremities John M. Flynn, MD Lower Extremity Lori A. Karol, MD STRETCH BREAK Spine Trauma Jens R. Chapman, MD Degenerative Todd J Albert, MD Pediatric David L Skaggs, MD STRETCH BREAK Tumors and Metabolic Bone Disease Tumors Albert J. Aboulafia, MD Metabolic Bone Disease Joseph M. Lane, MD Adjourn Moderator: Albert J. Aboulafia, MD Moderator: David L Skaggs, MD

4:30-4:40 PM 4:40-5:40 PM 4:40 PM 5:10 PM 5:45 PM

Session: 490A-E Session Title: Orthopaedic Review Course Location: Hilton Bayfront Date and Time: February 15, 8:00 AM

Orthopaedic Review Course - Lower Extremity NOTE: This output does not display responses to all questions (see footnote) and only looks at data after 3/5/2010 in the new disclosure program).

James P Bradley, MD: 1 ( Arthrex, Inc);5 (Arthrex, Inc); Submitted on: 05/27/2010 and last confirmed as accurate on 09/24/2010. * Steven L Haddad, MD: 2 (Stryker); 3B (Wright Medical Technology, Inc.); 3C (OrthoHelix Surgical Designs); 4 (OrthoHelix Surgical Designs); 5 (Biomimetic); Submitted on: 10/10/2010. * Thomas S Thornhill, MD: 1 (DePuy, A Johnson & Johnson Company);3B (DePuy, A Johnson & Johnson Company);3C (Scientific Advisory Board of Conformis);4 (Conformis);7 (Up to Date); Submitted on: 03/14/2010. * Donald A Wiss, MD: (n) Submitted on: 09/27/2010 and last confirmed as accurate on 11/29/2010. *

Orthopaedic Review Course - Upper Extremity

Jeffrey A Greenberg, MD: 3B (Stryker);5 (Acumed, LLC); Submitted on: 10/14/2010. * Rick F Papandrea, MD: 2 (Acumed, LLC; Exactech, Inc);3B (Acumed, LLC; Exactech, Inc); Submitted on: 05/26/2010 and last confirmed as accurate on 09/12/2010. * Marc Safran, MD: 1 (Stryker);3B (Cool Systems, Inc; Arthrocare);3C (Cool Systems, Inc Cradle Medical, Inc Ferring Pharmaceuticals Biomimedica);4 (Cool Systems, Inc Cradle Medical, Inc Biomimedica);5 (Ferring Pharmaceuticals);7 (Wolters Kluwer Health - Lippincott Williams & Wilkins; Saunders/Mosby-Elsevier); Submitted on: 10/13/2010 and last confirmed as accurate on 12/18/2010. *

Orthopaedic Review Course - Pediatrics

John M Flynn, MD: 1 (Biomet);7 (Wolters Kluwer Health - Lippincott Williams & Wilkins); Submitted on: 10/21/2010. *

Lori A Karol, MD: 7 (Journal of the American Academy of Orthopaedic Surgeons; Saunders/Mosby-Elsevier); Submitted on: 09/13/2010. * Jeffrey R Sawyer, MD: 3B (Synthes);3C (Medtronic); Submitted on: 09/13/2010. * William C Warner Jr, MD: 3C (Medtronic Sofamor Danek);7 (Saunders/Mosby-Elsevier); Submitted on: 06/21/2010 and last confirmed as accurate on 11/05/2010. *

Orthopaedic Review Course - Spine

Todd J Albert, MD: 1 (DePuy, A Johnson & Johnson Company); 3B (DePuy, A Johnson & Johnson Company); 4 (Bioassets; Biomerix; Breakaway Imaging; Crosstree; Gentis; International Orthopaedic Alliance; Invuity; Paradigm Spine; PIONEER; Reville Consortium; Vertech); 6 (United Healthcare); 7 (Saunders/Mosby-Elsevier; Thieme); Submitted on: 09/01/2010 and last confirmed as accurate on 09/09/2010. * Jens R Chapman, MD: 2 (Synthes);5 (Medtronic; Stryker); Submitted on: 09/23/2010. * David Lee Skaggs, MD: 2 (Medtronic; Stryker);3B (Medtronic; Stryker);7 (Wolters Kluwer Health - Lippincott Williams & Wilkins); Submitted on: 09/15/2010. *

Orthopaedic Review Course - Tumor/Metabolic Disease

Albert J Aboulafia, MD: 7 (AAOS); Submitted on: 05/27/2010 and last confirmed as accurate on 09/27/2010. * Joseph M Lane, MD: 2 ( Eli Lilly; Harvest Technologies, Inc. Novartis, Weber Chilcott );3B (Amgen Co; Biomimetic; Zimmer, DFine, Inc, Graftys SA, ; Eli Lilly, Bone Therapeutics, Inc. Innovative Clinical Solutions, Zelos, Inc., Kuros, Inc.); Submitted on: 09/28/2010. * NOTE: Disclosures do not display responses to questions 8 and 9 (i.e., one of those items may be 'yes,' but is not evaluated or listed).

* Disclosure Items Answered: (n) = Respondent answered 'No' to all items indicating no conflicts. 1= Royalties from a company or supplier; 2= Speakers bureau/paid presentations for a company or supplier; 3A= Paid employee for a company or supplier; 3B= Paid consultant for a company or supplier; 3C= Unpaid consultant for a company or supplier; 4= Stock or stock options in a company or supplier; 5= Research support from a company or supplier as a PI; 6= Other financial or material support from a company or supplier; 7= Royalties, financial or material support from publishers.

AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS ORTHOPAEDIC REVIEW COURSE FACULTY FRIDAY, FEBRUARY 18, 2010 SAN DIEGO HILTON BAYFRONT, SAPPHIRE BALLROOM Albert J. Aboulafia, MD Life Bridge Health Lapidus Cancer Institute Medical School: University of Michigan Medical School, Ann Arbor Residency: University of Southern California Medical Center LAC Fellowship: Washington Hospital Center
Todd J. Albert, MD Thomas Jefferson University and Hospital Dr. Todd Albert holds several positions at Jefferson Medical College at Thomas Jefferson University in Philadelphia, PA. He is the Richard H. Rothman Professor and Chairman of Orthopaedic Surgery, and Professor of Neurosurgery. Additionally, he is President of The Rothman Institute at Jefferson Hospital. The American Board of Orthopaedic Surgery certified Dr. Albert in 1995. Dr. Albert interned at Pennsylvania Hospital. During his residency at Thomas Jefferson University Hospital in Orthopaedic Surgery, Dr. Albert was recognized as the Outstanding Chief Resident. His fellowship was at Minnesota Spine Center in Spinal Surgery. He was awarded the John J. Fahey Orthopaedic Association Memorial North American Traveling Fellowship. Dr. Albert is a member of the American Academy of Orthopaedic Surgery, American Medical Association, Cervical Spine Research Society, Scoliosis Research Society, North American Spine Society, American Spinal Injury Association, and the International Society for Study of the Lumbar Spine. Dr. Albert has written four books, contributed more than 40 book chapters and published 200 peer-reviewed and non-peer-reviewed articles. He has received an outstanding paper award from the North American Spine Society and from the Cervical Spine Research Society. Dr. Albert is a guest editor for several academic journals. In addition, Dr. Albert frequently gives presentations at professional meetings. His commitment to education also extends to training residents; he has been recognized with the John J. Gartland Award for Resident Education. For six years running, Dr. Albert participated in the Marine Corps Marathon.

James P. Bradley, MD, MS Burke & Bradley Orthopedics UPMC Sports Medicine Specialty: Orthopaedic Surgery Sub Specialty: Sports Medicine Medical School: Georgetown University Academic Affairs, Washington, DC Florida Institute of Technology, Melbourne, FL Residency: University of Pittsburgh Medical School, Pittsburgh, PA Fellowship: Kerlan Jobe Orthopedic Clinic, Los Angeles, CA Jens R. Chapman, MD University of Washington Dr. Chapman is a professor of orthopaedics and sports medicine and director of the Spine Service at Harborview Medical Center. He is an expert in surgery for spinal disorders and in orthopaedic trauma surgery, and is also an adjunct professor in the Department of Neurological Surgery. He earned his medical degree at Munich Technical University, Germany, in 1983 and after an internship there came to the United States for an internship and residency in orthopaedic surgery

at the University of Texas Southwestern Medical Center at Dallas. He came to the UW for a fellowship in traumatology and spine surgery in 1990. His patient care philosophy is to provide the best possible state-of-the-art spine care. John M. Flynn, MD Attending Surgeon Associate Trauma Director, Orthopaedic Surgery Associate Professor of Orthopaedic Surgery University of Pennsylvania School of Medicine Medical School: University of Pittsburg School of Medicine Residency: Harvard Combined Orthopaedic Residency Program, Childrens Hospital of Boston Fellowship: Pediatric Orthopaedics, A.I. DuPont Hospital for Children, Wilmington, DE Board Certification: Orthopaedic Surgery Special Interests: Scoliosis and other disorders of the spine; Hip disorders; Fractures; Cerebral palsy; Pediatric sports medicine Research Interests: Optimal treatment of pediatric fractures; Evaluation and treatment of children with spinal deformities; Osteochondritis dissecans in athletes with open physes; Early diagnosis and treatment of pediatric bone and joint infections; Hip reconstruction for children with cerebral palsy Jeffrey A. Greenberg, MD The Indiana Hand Center
Jeffrey A. Greenberg, M.D., was raised in Brooklyn, NY. Dr. Greenberg received his training in orthopedic surgery at the Syracuse program, prior to being selected to receive his hand surgery training in Indianapolis. He is yet another passionate hand surgeon, bringing a high level of enthusiasm for clinical research and teaching to our practice. Dr. Greenberg is currently the director of our fellowship program and is instrumental in regularly organizing prospective studies and clinical research projects with our fellows.

Steve L. Haddad, MD Associate Professor of Clinical Orthopaedic Surgery Department of Orthopaedic Surgery University of Chicago Pritzker School of Medicine Section Head, Foot and Ankle Surgery Department of Orthopaedic Surgery Evanston Northwestern Healthcare Illinois Bone and Joint Institute B.S., University of Michigan, Ann Arbor, Michigan M.D., The Johns Hopkins University, Baltimore, Maryland Internship, General Surgery - Georgetown University, Washington, D.C. Residency, Orthopaedic Surgery - Georgetown University, Washington, D.C. Fellowship, Foot and Ankle Surgery - Union Memorial Hospital, Baltimore, Maryland Certification: Diplomate of the American Board of Orthopaedic Surgery Lori A. Karol, M.D. Texas Scottish Rite Hospital for Children Medical Director of Movement Science Laboratory and Medical Director of Performance Improvement Dr. Lori Karol is a staff orthopaedist and the medical director of performance improvement and the movement science lab at Texas Scottish Rite Hospital for Children. She earned her

undergraduate and medical degrees from the University of Michigan. Dr. Karol completed her general surgery internship and orthopaedic surgery residency at Wayne State University School of Medicine. She also completed the Harrington Fellowship of Pediatric Orthopaedics and Scoliosis at TSRHC. Dr. Karol is a professor in the department of orthopaedic surgery at The University of Texas Southwestern Medical Center at Dallas. She is a member of the American Academy for Cerebral Palsy and Developmental Medicine; the American Medical Association; a member and chairperson of the Communication Counsel of the Pediatric Orthopaedic Society of North America; a member of the American Academy of Orthopaedic Surgeons; the North American Society for Gait and Clinical Movement Analysis; the Scoliosis Research Society; and SICOT.

Joseph M. Lane, MD Hospital for Special Surgery Joseph M. Lane, MD, was born in New York City and raised in Great Neck, Long Island. He received his AB degree (Magna Cum Laude) from Columbia College (1961) and his medical degree from Harvard Medical School (1965). General surgical internship and residency were performed at the Hospital of the University of Pennsylvania (1965-67). Dr. Lane performed bone collagen research at the NIDR at NIH (USPHS) from 1967-69 in Bethesda, Maryland, under Karl Piez and Edward Miller. He had a collagen research fellowship under Darwin Prochop at the CCRC University of Pennsylvania (1969-70) and a three-year orthopaedic residency at the Hospital of the University of Pennsylvania during which time he was awarded the Kappa Delta Award (AAOS) for inhibiting scar formation. Dr. Lane was the Elsee Butz Assistant Professor (Orthopaedics) at the Hospital University of Pennsylvania and Childrens Hospital of Philadelphia (1973-75). He was appointed Assistant Professor and Chief of the Metabolic Bone Disease Service at Hospital for Special Surgery at Cornell Medical School in 1975, ultimately attaining full Professorship, Assistant Dean, Director of Clinical Research, and Medical Director of the Metabolic Bone Disease Service and Osteoporosis Prevention (1976-93, 96present). He was appointed Chief of the Bone Tumor Service (osteogenic sarcoma, Ewings sarcoma) at the Memorial Sloan-Kettering Cancer Center (1976-91) and Senior Attending (1991-93). From 1993-96 he was Professor and Chairman of the Department of Orthopaedic Surgery at UCLA. He is currently the Associate Director of the Orthopaedic Trauma Service at New York-Presbyterian Hospital. Dr. Lane has published extensively on bone biology, tissue injury and repair, trauma, bone and soft tissue sarcomas (including osteogenic sarcoma and Ewings sarcoma), limb preservation, functional amputations, limb regeneration, and metabolic bone diseases (osteoporosis, Pagets disease, rickets, osteomalacia, fibrous dysplasia). He has served on numerous committees for the AAOS, including the Board of Directors and Chairman of COMSS, the Chairman Oversight Panel on Womens Health Issues. He was President of the Orthopaedic Research Society, Musculoskeletal Tumor Society, Chairman of NIH Orthopaedic Study Section, OREF grants review board, ABOS Question Writing Task Force. He is a member of the AAOS, AOA, ABJS, ASBMR, ORS, MSTS, and OTA. He has earned NIH career and R01 grants, OREF grants, and foundation awards. He has been a visiting professor at educational institutes and is on the editorial board of several peer journals. Rick F. Papandrea, MD Vice Chairman, Department of Surgery, Waukesha Memorial Hospital

Assistant Clinical Professor of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee Orthopaedic Associates of Wisconsin Special Interests / Training: Elbow arthroscopy; joint replacement; total elbow; hemiarthroplasty; fracture/instability reconstruction; ligament reconstruction; contracture treatment; pediatric elbow surgery; Hand wrist arthroscopy; wrist reconstruction; arthritis reconstruction; post-traumatic reconstruction; fracture reconstruction; tendon/nerve/artery repair; Shoulder fracture reconstruction; joint replacement; arthroscopy Medical School: University of Wisconsin School of Medicine Residency: The Mount Sinai Medical Center Fellow: Adult Upper Extremity Reconstruction (Shoulder/Elbow) Mayo Clinic Certification: ABOS Board Certified in Orthopaedic Surgery; ABOS Certified in Hand Surgery; ABOS Board Certified in Sports Medicine Marc Safran, MD Stanford University Medical School: Duke University School of Medicine, NC Residency: UCLA Fellowship: University of Pittsburgh, PA Professor Med Center Line, Orthopaedic Surgery Clinical Focus: Hip Arthroscopy; Sports Medicine; Arthroscopy Research Interest: Arthroscopic Management of Hip problems; articular cartilage regeneration; shoulder surgery and athletic shoulder and elbow problems. Jeffrey R. Sawyer, MD Campbell Clinic Dr. Sawyer joined Campbell Clinic in July 2005. He received his college degree at Rochester Institute of Technology and went on to complete medical school at University of Rochester and completed his residency at the Hospital of the University of Pennsylvania with completion of his fellowship at UT Campbell Clinic. He was certified by the American Board of Orthopaedic Surgeons and has affiliations with the following professional societies - American Academy of Orthopaedic Surgeons; Pediatric Orthopaedic Society of North America; Scoliosis Research Society; American Academy for Cerebral Palsy and Developmental Medicine David L. Skaggs, MD Associate Professor Childrens Hospital Los Angeles Division of Orthopaedic Surgery Medical School: Columbia University College of Physician Residency: Columbia-Presbyterian Medical Center Fellowship: Childrens Hospital Los Angeles, University of Southern California - Pediatric Orthopaedics and Frank E. Stinchfield Orthopaedic Research Fellowship, Columbia University Board Certification: American Board of Orthopaedic Surgery Research Interests: Bone density in children; public policy affecting pediatric orthopaedic care; care of spinal deformities in children; treatment of thoracic insufficiency syndrome with thoracic expansion; pediatric orthopaedic trauma Professional Memberships: Pediatric Orthopaedic Society of North America; American Academy of Orthopaedic Surgeons; American Academy of Pediatrics; Scoliosis Research Society; Orthopaedic Research Society; American Medical Association; California Orthopaedic Association; Los Angeles County Medical Society

Thomas S. Thornhill, MD Brigham and Womens Hospital Chairman, Department of Orthopaedic Surgery John B and Buckminster Brown Professor of Orthopaedic Surgery Clinical Specialty: Orthopaedic Surgery Joint Replacement Medical School: Weill Medical College of Cornell University Residencies: Peter Brent Brigham Hospital Medicine Harvard Combined Orthopaedic Residency Program Orthopaedic Surgery Fellowship: Robert Breck Brigham Hospital - Total Joint Certifications in Internal Medicine and Orthopedic Surgery Clinical Interests in joint replacement (hip); joint replacement revision; knee; shoulder and elbow William C. Warner, Jr., MD Campbell Clinic Joined the Campbell Clinic staff in July, 1989 and graduated from Mississippi State University went on to graduate from Tulane University School of Medicine in New Orleans and completed his residency at UT-Campbell Clinic and completed his fellowship in Pediatric Orthopaedic Surgery at Scottish Rite Childrens Hospital in Atlanta. Dr. Warner received his board certification from the American Board of Orthopaedic Surgery and currently has his university appointment as Associate Professor, UT-Campbell Clinic, Department of Orthopaedic Surgery. He is a member of several professional societies including American Academy of Orthopaedic Surgeons; Scoliosis Research Society; Pediatric Ortho. Society of N. America; Chief of Orthopaedics, Mississippi Crippled Childrens Services, Memphis; Orthopaedic Consultant, Muscular Dystrophy Service; Orthopaedic Consultant, Scoliosis and Spina Bifida Clinics; Orthopaedic Consultant Spasticity Clinic; Orthopaedic Consultant St. Jude Hospital Donald A. Wiss, MD Cedars-Sinai Medical Center Director, Orthopaedic Trauma Dr. Donald A. Wiss is a board-certified orthopaedic surgeon. His clinical and research focus is on the diagnosis, treatment and rehabilitation of musculo-skeletal injuries and post-traumatic fracture reconstruction. Dr. Wiss has held academic appointments at the Boston University School of Medicine and the University of Southern California, where he was Clinical Professor of Orthopedic Surgery and Director of the Orthopaedic Trauma Service at Los Angeles County/USC Medical Center. For the past 17 years, Dr. Wiss was the Head of the Orthopaedic Trauma at the Southern California Orthopaedic Institute. Dr. Wiss earned his bachelor's degree from Michigan State University and his medical degree from Wayne State University School of Medicine. He completed his internship and one year of general surgery at Cedars-Sinai Medical Center followed by an orthopaedic surgical residency at the University of Pittsburgh. He was awarded the prestigious Girdlestone Scholarship in Orthopaedic Surgery at Oxford University's Nuffield Orthopaedic Center in England, and was a

trauma Fellow both at the AO Fracture Clinic in Tubingen, Germany and a senior trauma Fellow at Boston University, City Hospital.

Lower Extremity

LOWEREXTREMITY

Moderator:ThomasS.Thornhill,MD 8:00AMHipandKneeReconstruction ThomasS.Thornhill,MD 8:30AMSportsKnee JamesP.Bradley,MD 9:00AMFootandAnkle StevenL.Haddad,MD 9:30AMTrauma DonaldA.Wiss,MD

ADULT HIP AND KNEE RECONSTRUCTION AAOS REVIEW COURSE: SAN DIEGO 2011
Thomas S. Thornhill M.D. John B. and Buckminster Brown Professor of Orthopedic Surgery Harvard Medical School Chairman, Department of Orthopedics Brigham and Women's Hospital Boston Massachusetts

1 Introduction A. Presentation Format -core material in handout (pages 1-55) (presented material in bold) -selected annotated references from 2009-2010(pages 55-72) -what's in/what's out -author's preference

B. Adult Hip Reconstruction -Osteonecrosis -pathophysiology, treatment options, results -Arthritis (inflammatory, non-inflammatory) -pathophysiology -treatment options (osteotomy,arthrodesis, hemiarthroplasty, arthroplasty, revision) -results, complications, future directions C. Adult Knee Reconstruction -Surgical options in non-inflammatory arthritis -arthroscopy, debridement, cartilage regeneration, osteotomy, uni TKR, TKR -Surgical options in inflammatory arthritis -synovectomy(radiation, arthroscopic, open), TKR -Results of treatment -survivorship analysis,complications, future directions 2 Adult Hip Reconstruction/Osteonecrosis A) Etiology 1) compartment syndrome-ischemia occurs as the pressure in the confined femoral head exceeds filling pressure. 2) direct cellular injury-the initial event leading to osteonecrosis is direct injury to the osteoblast with apoptosis. B) Staging 1) FICAT I-nl x-ray

2)

II-sclerosis, cystic nl contour III-subchondral fracture /collapse, nl joint space IV-acetabular changes, joint space STEINBERG I-nl x-ray; nl scan II-nl x-ray; abn scan III-sclerosis and/or cyst formation, A,B,C IV-crescent sign; no flattening V-flattening; decreased joint space VI-advanced DJD ARCO (ASSOCIATION FOR RESEARCH ON OSSEOUS CIRCULATION) ARCO News 1992;4:41 0-Bone Biopsy: AVN. All Other Tests Normal I- Scintigraphic or MRI Positive Lesions Subdivided based on Location (medial, central and lateral) and percentage of head involvement Ia-<15% involvement Ib-15-30% involvement Ic->30% involvement II- Radiographs: Osteosclerosis, cystic, osteopenia or Mottled femoral head without collapse or acetabular involvement Scintigraphy or MRI: Positive Lesions subdivided based on location (medial, central, and lateral) and percentage of involvement of Femoral Head IIa-<15% involvement IIb-15-30% involvement IIc->30% involvement III- Radiographs: Crescent sign; lesions subdivided based on location (medial, central and lateral) and percentage involvement of Femoral Head IIIa-<15% involvement or <2mm depression of head IIIb-15-30% involvement or 2-4mm depression IIIc->30% involvement or>4mm depression IV- Radiographs: Flattened articular Surface, joint space narrowing, acetabular changes, osteophytosis

3)

3)

KEY FACTORS ARE 1. Sclerotic vs. cystic 2. Size and Location of Lesion 3. Crescent sign 4. Intact lateral column 5. Synovitis 6. MRI Pattern

C)

Diagnosis and surgical options 1) x-ray- plain x-rays are selective but not very sensitive in determining osteonecrosis. Computerized tomography is the best technique to determine the area of bone death. 2) scintigraphy-99Tc-MDP scans are sensitive but there are a surprising number of false positives. Sulfur colloid scans offer no apparent advantage to MRI. Scintigraphy is not very specific. 3) MRI- T1 and T2 weighted MRI is highly sensitive and specific but not good for estimating the extent of the lesion. Diffusion and persusion technical improvements may be beneficial 4)PET scans not clear to Date

Options For Treatment of Osteonecrosis

-Protective Weight Bearing -Provide Mechanical Support -Bonfiglio -Tantulum Rod -Stimulate Bone Formation -Core Decompression -Vascularized Fibular Graft -Trap Door Procedures Allograft Autograft BMP Mesenchymal Stem Cells (Bone Marrow Derived) -Inhibit Bone Resorption -Bisphosphonates

_Osteotomy -Hemiarthroplasty Bipolar Surface Hemiarthroplasty -High Failure Rate -Total Hip Arthroplasty Conventional Resurfacing Bearing Surface metal poly ceramic metal on metal

Treatment of Osteonecrosis of the femoral head : Everythings new. This review article from a strong proponent of non-arthroplasty options in osteonecrosis points out that improvements in hip arthroplasty have changed surgical indications in this disease. In the authors opinion core decompression is still indicated in the proper patient but that procedures such as femoral osteotomy and free vascular grafts can no longer be justified

Hungerford, D.S. John Hopkins Orthopedics at Good Samaritan Hospital, Baltimore, Maryland. J Arthroplasty. 2007 June;22(4Suppl 1):91-4.

D)

Surgical Options 1)Protective weight bearing a)Enneking and Steinberg -showed greater than 90% progression b)Morrey (AAOS 1989) - demonstrated progression in treated side of patients with bilateral disease c)Recent data with MRI has suggested the early stages of osteonecrosis may be reversible

E)

Core Decompression 1) Positive results -Ficat (I,II,III) -Hungerford (I,II,III)

2)

-Thornhill (I, IIa sclerotic) -Stulberg (I,II) Negative results -Colwell -Hopson

Bozic, Zurakowski and Thornhill, JBJS Am 1999 Feb;81(2):200-9 Core Decompression -54 hips in 34 patients ave follow/up 9.5 yrs. -Steroids 37 hips, ETOH 8 hips Idiopathic 7 hips, Misc 2 hips -34 (63%) radiographic failures at ave 25 months -28(52%) clinical failures at ave 40 months -combined failure by Ficat class Stage One 4/13(31%) Stage IIA Sclerotic 0/7 (0%) Stage IIA Sclerocystic 13/16(81%) Stage IIB 9/10(90%) Stage III 8/8 (100%) -predictors of failure by Cox proportional hazards regression model -advanced Ficat Stage -shorter duration of symptoms -steroid use F) Electrical Stimulation -Its role in pre collapse Osteonecrosis is Still Unclear

G)

Vascularized Fibular Graft -The principle is to provide mechanical support as suggested by Bonfiglio but, in addition, to graft the femoral head, remove necrotic bone and provide a vascularized fibula. -Urbanaik has reported good results with this technique in later stages unsuitable for core decompression .

Urbaniak et al JBJS-A. 77(5):681-94, May 1995- Vascularized Fibular Graft for AVN -103 hips/89 patients -ETOH 30%: Steroids 17%: Trauma 13%: Perthes 3%: Idiopathic 38% -minimum 5 year follow/up -31 hips converted to THR Marcus /Enneking classification stage 2- 11% conversion stage 3- 23% conversion stage 4- 29% conversion stage 5- 27% conversion -younger patients did better

-results independent of etiology of the osteonecrosis

Free vascularized fibular grafting for the treatment of postcollapse osteonecrosis of the femoral head. Surgical technique. -188 Patients(224 hips) underwent free vascularized fibular grafting between 1989 and 1999 for AVN with collapse but no arthrosis -Ave follow-up was 4.3 years (2-12 years) -Failure defined as Revision to THR -Survival of 67.5% at 2 years and 64.5% at 5 years -Worse results in ETOH, Idiopathic and Post-traumatic Aldridge JM 3rd, Berend KR, Gunneson EE, Urbaniak JR. J Bone Joint Surg Am. 2004 Mar;86-A Suppl 1:87-101.

Histopathologic retrieval analysis of clinically failed porous tantalum osteonecrosis implants. 113 porous tantalum osteonecrosis intervention implants were studied 17 implants(15%) were retrieved at the time of failure which averaged 13.4 months Subchondral fracture was present in all cases Bone growth was present in 13 cases with a mean extent of bone growth of 1.9% Tanzer M, Bobyn JD, Krygier JJ, Karabasz D. JBJS(A). 2008 Jun;90(6):1282-9

H)

Osteotomy a)Rotational, angular b)Principle is to deliver or contain the lesion b)Results of Rotational Osteotomy are Variable c)Angular Osteotomy works well if arc of necrotic area is <200 degrees

Femoral Osteotomy and Iliac Graft Vascularization for Femoral Head Osteonecrosis Between 1978-1986 41 Patients (52 hips) were Treated with Intertrochanteric Osteotomy and Pedicled Iliac Bone Block Transfer for Ficat Stage 2 and 3 Disease. 33 Patients (44 hips) available for follow-up at 13.5 years mean 15 (34%) were Converted to THR 6 Patients died. 2 lost At Latest follow-up 31% had Severe Arthritis, 59% Moderate Arthritis, 3 had mild Arthritis. Consider this Operation only in Young Symptomatic patients with Good Preoperative Function and Ficat Stage 2 Disease

Fuchs B, Knothe U, Hertel R and Ganz R. Clin Orthop. 2003 Jul; (412): 84-93.

I) Bipolar Hemiarthroplasty a)Positive -spares acetabulum -easier revision b)Negative -acetabulum may be involved -late protrusion -significant polyethylene debris

Hemi-Surface for AVN -33 hips/25patients -mean follow-up 10.5 year (4-14) -61% good/ excellent -Mean time to failure 60 mos. -successful total hip replacement post failure Hungerford MW, et al J Bone Joint Surg Am 1998 Nov;80(11):1656-64

Femoral head resurfacing for the treatment of osteonecrosis in the young patient. -29 consecutive femoral head resurfacing procedures for AVN -18 male10 female -average age 31.6 years -Harris Hip Score improved from 48.1 to 79.3 points -Overall Survivorship was 75.9% at 3 years -8 hips converted to THR at ave 18 mos. -only 62.5% with satisfaction and good pain relief Adili A, Trousdale RT. Clin Orthop. 2003 Dec;(417):93-101.

J)Total Hip Arthroplasty

Failure of Femoral Surface Replacement for Femoral Head Avascular Necrosis

37 surface hemiarthroplasties perform between 1997 and 2003 failure defined as revision surgery or Harris hip pain score of 20 or less overall failure rate was 64.8% revision rate was 40.5%

Squire, M., Fehring et al. J. Arthroplasty 2005 Oct;20: 108-114

Total Hip Arthroplasty in Osteonecrosis is Associated with a Greater Failure Rate due to: -High patient demand -Dislocation -Young Age -High Expectation -? higher response to particulate debris

Piston, Engh et al: JBJS, 1994- THR in Patients with AVN -30 patients (35 hips) with Ficat stage III/IV -7.5 years mean follow/up (range 5-10 yrs) -Average patient age (32 years) -Femoral stem osteointegration in 33 hips(94%) -3% femoral revision, 6% acetabular revision -Femoral remodeling (17%), osteolysis (17%) Stulberg et al: 1997 Uncemented THR in AVN -64 pts (98 hips) 87 available -Ave age 41 yrs (2169) -Ave f/up 7.3 yrs -Steroids 42, ETOH 27 -18 (21%) revised -4 with osteolysis

5) Author's preference Stage 1- establish diagnosis: if certain to be osteonecrosis then consider core decompression in younger patient and observe older patient. Stage 2- core decompression for IIa sclerotic disease in younger patient. Stage 3- core decompression only if on opposite side of patient undergoing surgical procedure on other hip. Osteotomy on younger

patient if mechanically correct. Consider vascularized fibula in selected patients. Resurfacing hemiarthroplasty or bipolar hemiarthroplasty if no significant synovitis or effusion. Otherwise THR. Stage 4- Arthrodesis only if absolutely certain that there is not bilateral involvement. Otherwise, THR.

Stage / X-ray

Intact Lateral Column 1,2,3 3 1,4 1,4 6 7

<200

>200

Synovitis

I II III IV V VI

Normal / +MRI Sclerosis Cystic/Sclerocystic Crescent w/o collapse Collapse/NL, Acet, Jt. Space Acet Changes / Jt space

3 4,5 5 6 7

3 4 6 6 7

1,2,3 3 4 7 7 7

arc in degrees of involved area as measured on AP and lat radiograph determined by MRI (T2 weighted)* OPT for more conservative option in elderly or minimally symptomatic patients

Treatment Options 1 Observation 2 Electrical stimulation 3 Core decompression 4 Vascularized Fibular Graft 5 Angular Osteotomy 6 Hemiarthroplasty 7 Total Hip Arthroplasty

WHAT'S IN/WHAT'S OUT - HIP OSTEONECROSIS*

10

WHAT'S IN -MRI for diagnosis -Intertrochanteric osteotomy -Acetabular resurfacing during arthroplasty -Vascularized fibular grafts in limited situations -core decompression only for I or IIa sclerotic disease -Hemi Resurfacing for Hemiarthroplasty -Move towards Arthroplasty WHAT'S OUT -Scintigraphy -Core decompression for beyond Ficat IIa sclerotic -Bipolar hemiarthroplasty -Rotational osteotomies *WHAT'S IN/WHAT'S OUT reflects trends within the past year and does not specifically indicate the author' preference or the standard of practice.

3. Adult Hip Reconstruction/Osteotomy/Debridement/Impingement 1) Goals a)Decrease unit load b)Decrease muscle forces c)Increase surface area d)Biological events e)Stabilize the unstable joint

2) Unit loading of hip a)contact area 26.7 cm@ b)unit load 23 kg/cm2 3) Types of osteotomy a)Femoral 1 angular 2 displacement b)Pelvic 1 Innominate -Salter-Steel-Sutherland 2 Wagner-Dial 3 Ganz-Periacetabular

11

4) Ideal Candidate for Osteotomy a)Less than 50 yrs b)No obesity c)Evidence of Mechanical overload -Decreased. jt. space by 1/2 -Increased subchondral density -No large cysts 5) Pelvic versus Femoral Osteotomy a) Femoral osteotomy should be used to correct femoral deformity -Osteonecrosis -Slipped capital femoral epiphysis -Legg-Calve-Perthe's disease -Proximal femoral deformities (growth arrests, congenital coxa vara) -Osteochondral defects b) Pelvic osteotomy should be used to correct acetabular deformity -primary hip dysplasia -secondary acetabular dysplasia (LCP) -neuromuscular disorders 6) Preoperative evaluation -Plain radiographs -AP(abd/add)-severe arthritis by 65 yrs if: -lat. center edge angle <16o -fem. head uncovered >1/3 -acetabular roof that does not turn down past horizontal -false profile (standing weight bearing view with patient turned 25o from true lateral. -CT imaging analysis and simulation 7) Pros and Cons of Osteotomy for Osteoarthritis -PROS -conservative -avoids arthroplasty -does not burn bridges -allows greater activity -improves acetabular stock -CONS -more difficult rehabilitation -less pain relief -temporary solution -difficult conversion to THR

12

Ganz et al. JBJS-B 79(2) Mar 97 THR After Femoral Osteotomy -74 THAs post osteotomy -74 THAs primary -No difference except -increased OR time -increased troch. osteotomy

Perlau, Wilson, Poss. JBJS-A 78(10) Oct 1996- Osteotomy for DDH/OA: 5-10 yr -17 hips DDH -8 satisfied -9 not satisfied -4 THRs -16 hips OA -6 satisfied -Best results in early OA or less dysplasia

Lessons learned from early clinical experience and results of 300 ASR Hip Resurfacing Implantations 300 ASR metal on metal resurfacing hip arthroplasty mean follow-up was 202 days Harris hip score improved from 44 to 89 eight revisions, five neck fractures and 3 cup provisions higher failure in patients with previous proximal femoral surgery distinct learning curve demonstrated Siebel et al Proc Inst Mech Eng 2006 Feb;220(2): 345-53

Intertrochanteric Osteotomies Do Not Impair Long-Term Outcome of Subsequent Cemented Total Hip Arthroplasties 121 total hip replacements after osteotomy compared to 290 total hip replacements with no prior osteotomy there was no difference in survival rate, radiographic findings or clinical findings higher incidence of intraoperative perforation of the femur in patients following osteotomy Haverkamp, D, Marti RK et al. CORR 2006 Mar; 444:154-160

8) Authors Preference

13

Femoral, pelvic or combined osteotomy is indicated for the young (biologically and emotionally not chronologically) individual with a mechanical problem that can be corrected. The patient must be educated to understand the rationale of osteotomy over THR. WHAT'S IN/WHAT'S OUT-HIP OSTEOTOMY WHAT'S IN -Preoperative Evaluation -Intertrochanteric osteotomies for femoral deformity -Periacetabular osteotomies for acetabular deformities WHAT'S OUT -Rotational osteotomies -Osteotomy for mod/severe osteoarthrosis

Femoral-Acetabular Impingement-Prof Reinhold Ganz -Anterior impingement as cause of hip pain and DJD -limited range of motion -limited internal rotation -anterior overcoverage secondary to (Pistol grip deformity): -acetabular retroversion -coxa profunda -nonspherical head -no anterior head-neck offset -retrotilt of femoral head -coxa vara -femoral neck retroversion

Developmental alterations of the Hip Femur - Cam lesion Acetabulum - Pincer lesion Malrotation of acetabulum and/or femur Secondary Arthritis Ganz, et al: FAI: a cause of aosteoarthritis of hip. CORR 2003

14

-Surgical Treatment to increase the impingement free hip joint clearance may include hip dislocation and -acetabular reorientation -trimming of the rim -femoral head shaping -increase head neck offset -change femoral anteversion -Arthroscopic Intervention with labral Debridement and Removal of Impingement

Treatment of Femoral Acetabular Impigement with Surgical Dislocation and Debridement in Young Adults. 30 hips in 29 patients underwent debridement with anterior dislocation of the femoral head Mean age 31 years with mean follow-up of 32 months Mean Harris hip score improved from 70 to 87 points no evidence of osteonecrosis unrecognized severe acetabular damage seen in 18 hips(poor prognostic indicator) Peters, C. L. and Erickson, JA. JBJS 2006:88(8) 1735-41

Arthroscopic Treatment Byrd, J.W., et al: Arthroscopic Femoroplasty for FAI. CORR 2008 Minimum one year f/u 200 pts - 83% improvement Philippon, et al: Outcome of FAI and Chondrolabral dysfunction. (B) JBJS 2009. Prospective study with 112 pts, minimum 2 year f/u < less than 2 mm joint space narrowing did well Labral repair did better than debridement Older patients more likely to undergo THR

4. Adult Hip Reconstruction/Arthrodesis 1) Indications -infection -high activity Contraindications -osteonecrosis

2)

15

-hip, knee, back problems 3) Technique -30 degrees flexion -0-5 degrees ext. rot. -0-10 degrees adduction 4) Author's preference -arthrodesis if performed more often in conference than in the operating room. It is indicated in the young active patient with limited motion who has oligoarticular disease and wants to return to an active life style.

WHAT'S IN/WHAT'S OUT - HIP ARTHRODESIS WHAT'S IN -Fusion to allow for later THR -Careful patient counselling WHAT' OUT -Cobra plate fixation if trochanter is destroyed -Arthrodesis in patients with good motion 5. Adult Hip Reconstruction/Hemiarthroplasty 1) Indications a)femoral neck fractures -bipolar vs. Moore b)avascular necrosis c)revision hip arthroplasty -acetabular reconstr. -joint stability 2) Long term concerns a)acetabular wear b)protrusion c) polyethylene wear debris Kim, Rubash J. Arth. 12(1) Jan 1997- Bipolar Hemiarthroplasty -Interface membranes 17 bipolars vs 17 THRs -Bipolars produced more PGE2 (p<.05) -Raised concern of poly wear with bipolars 3) Author's preference -Hemiarthroplasty is indicated in younger patients with osteonecrosis who are not candidates for core decompression or osteotomy and who have Stage III disease without significant synovitis or effusion. Moreover, it is indicated in

16

femoral neck fractures (? bipolar or unipolar) not amenable to internal fixation (except in the elderly who should be considered for THR).

6. Adult Hip Reconstruction/Total Hip Arthroplasty(Go to Page 20) I Results of Primary Cemented Total Arthroplasty A. Early Results-cemented -acetabular failure -30-50% at 10-14 years -femoral failure -20-30% at 5 years -30-40% at 10 years B. Improvements in cement technique -improved stem design for cemented application -improved femoral canal preparation -pulsatile lavage -distal plugging -porosity reduction

C. Current U.S. Long Term Results-Cemented Mancuso et al. J Arth 12(4) Jun 97-Patient Satisfaction: THR -180 pts 2 yrs post-op (HSS) -89% satisfied -Lower satisfaction if -less preoperative loss -nonessential demands -worse post-op function -50% referred by patient/friend -64% would refer others for surgery Maloney and Harris- 105 hips/93 pts. 10-12.7 yr f/up -femoral loosening- 3 loose/2.8% (24 possibly loose) -acetabular loosening-42% Eftekhar-1009 Charnley LFA THRS. 5-15 yr f/up -over all failure rate of 4.5% -higher incidence of late failure in the acetabulum -poor pressurization, elasticity of pelvis.

17

Bosco- High modulus design (HD2,CAD). 86 hips 6.7 yrs f/up -cement gun, 2nd gen. design, distal plug (1979-82) -19 excellent; 44 good; 15 fair; 11 poor -Survivorship 5 year 10 year Acetabulum Femur Combined 97% 93% 91% 58% 78% 50%

Mulroy, Harris: JBJS 77 (12) 1995-Cemented THR Results -Grit blasted stem HD2 -162 hips (149 pts) -51 patients died (60 hips) -102 hips (90 pts): min. 14 yr F/up -8 (10%) acetabular revision: 42% loose -2% femoral loosening Twenty-five Year Results after Charnley THR in Patients less than 50 Years old: A Concise Follow-up of a Previous Report.

93 Charnley cemented THRs in 69 patients less than 50 yo at Index Arthroplasty Minimum 25 years follow-up or until death Results on 42 of 43 living Patients (38% deceased) 29 Revised or Removed (31%) 13% Femoral Failure 34% Acetabular Failure 69% of Hips Functioning well at Latest Follow-up or Death 5% Required more than one Revision. Keener JD, Callaghan JJ, Johnston RC et al. JBJS 2003 Jun. 85-A(6):1066-72 Madey, Callaghan, Johnston et al. JBJS-A 79(1) Jan 1997-Long Term Charnley Results -357 Charnley LFA (320) pts -2nd generation cement technique -189 pts (214 hips) died/1 lost -130 pts (142 hips) available at 15 yrs -356 hips with follow-up -Acet loosening -12% in whole group(356 hips) -22% at 15 yrs(142 hips) -Femoral loosening -10(3%) in whole group -6 (5%) at 15 years

18

II Hybrid Hip Arthroplasty-Cemented Femur; Uncemented Acetabulum A. Rationale Difference in long term results with late socket loosening B. Early Results-Hybrid Wixson et al-131 pts 2-4 yr f/up uncemented femur in men <70 yrs, women <60 yrs and good bone quality. no clinical difference in cemented, uncemented and hybrid except; -2/65 loose uncemented femurs(one revised) -24% incidence of thigh pain at one yr in the uncemented group -higher incidence of migration and radiolucencies in the cemented sockets Maloney and Harris-25 hybrid /25 uncemented min. 2 yr HHS 96 for hybrid, 84 for cementless (p<0.02) uncemented group had 24% thigh pain, 5 migrated, 4 revised. Callaghan, Johnston: Clin Orthop 1997-THR in the Young Patient (<50 yo) -93 cemented hips (20 yr f/up) -5% femoral loosening -19% acetabular loosening -45 hybrid hips (510 yr f/up) -18% femoral loosening -0% acetabular loosening -Current technique is hybrid with uncemented acetabulum with Charnley type polished stem. -Early Cemented Stem Failure -Stem debonding -Surface finish -Stem geometry -Cement mantle

Verdonschot, Huiskes:J. Biomech 1997-Stem Debonding -Finite element analysis -Increases initial stresses -Fourfold increase in failure -Promotes pathway for debris -Surface Finish -Polished

19

-Matte finish -Bead blasted -Grit blasted -RA (avg roughness in) Stem Geometry -Influence of surface finish on subsidence -1st order effect -tapered stem -2nd order effect -Charnley stem

Cement Mantle -Increased failure with -Thin mantle -Mantle fracture -Weak perimantle bone Early Loosening with Precoat Stems -Callaghan -Rubash -Coutts, Santore Santore, Coutts: Intl Soc Tech Arth 1997-Early Loosening with Precoat Stems -110 THR (101 patients) -4 deaths, 8 lost -90 hips (89 patients) -10 failures (11.4%) at 32.8 mos ave f/up -Prosthesis cement Gruen 1 failure

Early Failure of Cemented Femoral Stems 84 Centralign femurs (76 patients) ave flu 35.8 mos, ave age 48.2 yrs 10 loose (12%) 9 revised (11%) failed by debonding Sylvain, Kassib, Coutts, Santore J Arthroplasty 16(2):141-8 Feb 2001

20

Early Loosening with Precoat Stems -Associated factors Inadequate cement mantle Increased surface finish Stem design Small flexible stems Precoat debonding

Grit Blast vs. Pre-coat In Cemented Total Hip Replacement -Iowa Hip -36 hips (25 pts) bead blasted (0.8um) -45 hips (37 pts) grit blasted pre coated (2.1um) -Average follow up 11.3 years beaded blasted, 8.2 years pre coated -Revised or radiographically loose 4/36 (11%) bead blasted 11/45 (24%) pre coat (p = .007) Sporer SM, Callaghan JJ., et al J Bone Joint Surg Am 1999 Apr;81(4):481-92

III Results of Uncemented THR Most investigators agree that uncemented femoral stems -have greatly improved -require immediate stability in host bone -transfer load by spot welding at endosteal cortex -have a higher incidence of thigh pain postoperatively.

Engh et al. JBJS-A 79(2) Feb 1997- Uncemented THR-AML Long Term - 223 hips (215 pts) - 55 yr ave age (16-87 yrs) - 21 lost, 27 died (174 hips left) - 11 yr ave f/u (10-13 yr) - 97% stem survival - 92% cup survival

Results of Porous Coated Anatomic THR without Cement at 15 Years; A Concise Follow-up of a Previous Report. 100 PCAs Implanted between 1983 and 1986.

21

55 Patients alive at 15 Years (ave 15.6 yrs) 17% of and 23% of the living Cohort had Undergone Acetabular Revision and 6% and 7% respectively had Undergone Femoral Revision. Femur was more Durable than the Acetabulum Bojecsul JA, Callaghan JJ et al. JBJS 2003 Jun; 85-A (6) : 1079-83.

Bugbee, Engh et al. JBJS-A 79(7) July 1997- Uncemented THR- AML - 48/207 hips (23%) showed stress shielding - 10 yr minimum f/up - No increase in loosening, pain, lysis in stress shielded stems

Capello et al. JBJS-A 79(7) Jul 1997-Uncemented THR-HA -133 pts (152 hips) -6.4 yr mean f/u (5-8.3 yr) -Harris Hip Score 47 93 -2 thigh pain -32% Gruen 1,7 lysis -One distal lysis -All stems osseointegrated

Dorr et al. CORR (336) March 1997-THR in patients 65 yrs & older - 89 hips (79 pts.) - 5-9 yr f/up - 22% died, 38% function limiting medical problems - 10% with hip limitation (all cementless implants)

IV Summary of Past 25 Years in Hip Arthroplasty(19) Cemented Hips -High Acetabular Failure Hybrid Hip Arthroplasty -Femoral Failure with Some Roughened Surfaces Predominant Use of Uncemented Implants Surgical Decision Points -When to Cement -Surgical Approach -Minimally Invasive Techniques

22

One incision Anterior Anterolateral Posterior Two incision -Modular or Not -Proximal and/or Distal Fixation - Resurfacing -Head Neck Ratio -Altered Anatomy -Women -? High Performance -Bearing Surface -Type of Polyethylene -Metal Poly -Ceramic on Ceramic -Metal on Metal -IDE Ceramic on Metal -Component Orientation Influences Edge Loading - Edge Loading leads Wear, Fracture, Squeaking, ALVAL -Head Size

V Author's preference -There is a role for both cemented and uncemented THR. In virtually every case the acetabular component should be uncemented. . A porous coated, under-reamed cup should be press fit with ancillary screws if necessary. In elderly,sedentary individuals with type C bone, the femoral component should be cemented. There is a trend towards Uncemented Designs in patients with Type C bone. A collared cobalt chrome implant is preferable for cemented situations. In young active people with good bone (Type A or B) the femoral component should be uncemented. A straight, collarless proximally porous titanium stem with proximal fit and distal fill is preferred for uncemented arthroplasty. V Mechanisms of Failure of THR and Possible Solutions/Questions A. Loosening -Poor patient selection. Current metallurgy, fixation, and the mechanical/biologic response of the host precludes THR in the young, active individual. As our technology improves will we be able to broaden the patient base for THR? -Generation of wear debris. Can we improve on existing materials or

23

develop new materials? -hydroxyapatite(HA) advantages -osteoconductive -avoids porous coating -potentially stronger bond disadvantages -inflammatory as a particulate -critical parameters for application -questionable bond to substrate -lower frictional resistance -cost issues

Comparison of Hydroxyapatite and Porous Coated Stems in THR No difference in S-ROM ZTT HA or Porous Component in Thigh pain, Bone Reaction or Hip Scores up to 4 years Park YS et al. Acta Orthop[ Scand. 2003 Jun; 74 (3):259-263.

-ceramic heads advantages -lower frictional resistance -scratch resistant -possible less polyethylene wear -potentially less Morse taper wear -newer ceramic materials are promising disadvantages -clip fracture -squeaking microseparation edge loading component specific -stripe wear -taper sizes -cost issues -revision limitations Ceramic Recall Demarquest- switch from batch to tunnel oven processing. Two Eighty-two fractured zirconia heads.

24

No known risk in the Ceramtec 80% aluminun and 20% zirconia heads or ceramic on ceramic bearings

Revision THR Performed after Fracture of a Ceramic Femoral Head. A Multicenter Study 105 Fractured Alumina Ceramic Heads Follow-up post Revision was 3.5 years Cup Loosening in 21%, Femoral Loosening in 21% One or more subsequent Revisions in 31% 5 year Survival rate was 63% Survival Worse if cup not Revised, new head was Stainless Steel, When a Total Synovectomy was not done and if Patient was less than 50 years old. Allain J, et al. JBJS 2003 May; 85-A: 825-30.

-improved polyethylene advantages -potential less polyethylene wear disadvantages -increased stiffness may increase wear -cost issues Methods of polyethylene sterilization -gamma in air -ethylene oxide -gas plasma -gamma in vacuum with hydrogen retention -gamma in inert gas with heating -highly cross linked ( gamma or electron beam). Variations in -dose and method of irradiation -method of free radical quenching -terminal sterilization -second/third generation highly cross linked polys(goal is to maintain both wear and mechanical characteristics) -antioxidants -sub melt annealed -melt annealed with better resin Are free radicals sbabilized or gone? Increased wear seen in Cross linked poly at 5 years-Malchau Ex Vivo Oxidation seen in retrieved highly cross linked Components. ? Squalines and/or loading-Murtaglou

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Besong et al. Bio-med Mater & Engr 7(1) 1997- Polyethylene Wear - Wear dramatically increased with shelf life of gamma irradiation polyethylene and femoral head roughness Collier et al. CORR 342 Sept 1997- Polyethylene Wear Gamma sterilized poly with less than one year shelf life had less oxidation and better in vivo performance

-Metal on Metal Articulations Promising clinical data but concerns remain: Shanbhag et al. CORR 342 Sept 1997- Wear Debris THR -In vitro monocyte challenge -Metal (Ti) particles more effective than poly particles in stimulating fibrogenesis Brodner et al. JBJS-B 79(2) March 1997- Metal-on-Metal Articulations -27 metal-on-metal CoCr (1yr) serum cobalt 1.1 g/l -28 ceramic on poly (1 yr) serum cobalt 0.3 g/l p < .001 -Raised concern of long term toxicity Levels of Metal Ions after Small and Large Diameter Metal on Metal Hip Arthroplasty.

22pts MOM Resurfacing vs. Matched Group With 28mm MOM THR Median Follow-up 16 mos (7-56) Measured serum Cobalt and Chromium (nl 5 nmol/l) levels Resurfacing MOM- 38 nmol/l cobalt and 53 nmol/l chromium compared to 22 and 19 for 28mm MOM. Both significantly higher than normal. Clarke MT et al. JBJS Br 2003 Aug;85(6): 913-17.

26

Four Year Study of Cobalt and Chromium Blood Levels in Patients Managed with Two Different Metal-on-Metal THRs 259 Patients with THR 131 with METASUL, 128 with SIKOMET-SM21 THRs Both Prostheses are cobalt-chromium metal-on metal Implants Blood Cobalt and Chromium Measured by Atomic Absorption Spectrophotometry 31 age and gender matched controls No Difference in levels between Implants Both showed Cobalt levels up to 50 times higher and Chromium levels up to 100 times Higher than Controls Lhotka C., Zweymuller et al J Orthop Res. 2003 Mar; 21 (2): 189-95 Metal on Metal Advantages -Lubricity -Good for large diameter heads -No Poly or Ceramic debris -Optimal Bearing for Resurfacing Arthroplasty -Metal ions likely Prosthesis Specific due to carbides and clearance -Larger heads appear to have lower metal ion risk Disadvantages -Patient Selection -Systemic Metal Ion Toxicity -Hard Bearing -Local Delayed Hypersensitivity -ALVAL/Pseudotumor -Recent Recalls/Withdrawels

Neo-capsule tissue reactions in metal-on-metal hip arthroplasty. Neo-capsule tissue samples from 46 hips with a modern second-generation metal on metal articulations were examined histopathologically and immunohistochemically A distinct lymphocytic infiltrate was found in all cases with in situ times of more than seven months This consisted of CD20 positive B Lymphocytes and CD3 positive T lymphocytes At times there were CD 138 positive plasma cells This pattern has not been seen in metal on polyethylene or ceramic on polyethylene replacements

Witzleb WC, et al. Acta Orthop. 2007 Apr;78(2):211-20.

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The blood flow to the femoral head/neck junction during resurfacing arthroplasty: a comparison of two approaches using Laser Doppler flowmetry Laser Doppler flowmetry was used to measure the effect on the blood flow to the femoral head during resurfacing arthroplasty 24 hips undergoing resurfacing arthroplasty were studied 12 had a posterior approach and 12 had a trans-trochanteric approach There was a greater reduction in blood flow with the posterior approach (40%) then with a trans-trochanteric approach (11%) Amarasekera HW, Griffin DR. et al. JBJS(B). 2008 Apr;90(4):442-5

Current Controversies In THR - Use of highly cross linked polyethylene - Which one to use? - How Thick Should Poly be? - Amount of gamma irradiation As dose increases wear decreases but so do mechanical properties. -Head size 22,26,28,32,36,38,42 Need 36 head to Increase Stability - Bearing Metal Ceramic Metal on Metal Technical/ Design ways to decrease wear. DESIGN -avoid titanium bearing -limit modularity -improve acetabular metal/poly couple -improve Morse taper tolerances TECHNIQUE -avoid vertical cup -avoid edge loading -clean Morse taper -clean acetabular surface

28

-avoid scratching of femoral head

B. Infection -A) The incidence of infection in THR varies from 0.4% to1.5% by use of prophylactic antibiotics and by additional use of laminar flow, UV lights, and exhaust systems. Treatment generally consists of delayed exchange with a treatment period where implant and cement are removed. Will antibiotic impregnated implants shorten the exchange period? What is the role for immediate exchange? -B) Surgical options -incision and debridement -immediate exchange -delayed exchange -C) Indications for incision and debridement -superficial infection - acute perioperative infection with susceptible organism and adequate host response -D) Indications for immediate exchange -established deep infection with susceptible organism (non glycocalyx former, adequate antibiotic susceptibility) -good host response -straight forward revision E) Indications for delayed exchange -majority of patients with established deep infection F) Results of treatment for infected THR -Immediate exchange- Bucholtz (ENDO Clinic) -77% success (583 patients) using gentamicin impregnated cement. Fifty55% recurrence if gram negative infection. Further follow-up by Rottger should 30% failure at 6 years and 50% failure at 11 years. Salvati reported 81% success with immediate exchange in adequate host if bactericidal antibiotic levels >1:8. -Delayed exchange-Fitzgerald reported 87% success in 83 THRs at 2-13 years. If a patient received 3 weeks of antibiotics, had all cement removed and waited 12 weeks before reimplantation, there was a 97% success rate. Patients with retained cement, less than 28 days of antibiotic treatment, reconstruction less than one year following (p<0.05) increased risk of recrudescent infection. -Delayed Exchange Protocol Options

29

-interval to reimplantation -beads or Prostalac system -length and type of antibiotic therapy -reported worse results in MRSA and MRSE -If exchange fails: Pagnano, Trousdale, Hanssen CORR 338 May 1997-Septic THR: Reinfection -34 hips reinfected -Avg 2.2 yrs following revision -Resection arthroplasty successful -Reimplantation: 8/11 failed -Consider delayed exchange if same organism

C. Dislocation -Incidence- 1-10% -Causes component malposition. The combination of acetabular forward flexion and femoral anteversion should be 45o. Intraoperatively, the construct should be tested in flexion and internal rotation, extension and external rotation, for any impingement and for abductor tension component impingement. Increased incidence of dislocation using 20o liners and plus 10mm head. You want Maximal Head Neck Ratio. surgical approach. There is an increased posterior dislocation rate using the posterior approach. surgeon experience sepsis. Late unexplained dislocation should raise the suspicion of indolent sepsis. patient issues. Senility, alcoholism, ataxia, basal ganglia disorders. revision surgery especially when only a single component is revised severe coxa vara. should consider trochanteric advancement in such cases. You must reproduce the proper offset.

Hedlundh et al. JBJS-B 78(2) Mar 1996-Hip Dislocation -4230 primary THRS -Posterior approach -3% dislocation -Correlated with surgeon experience

30

-with each 10 hips done(up to 30), rate by 50% Hedlundh et al. JBJS-B 79(3) May 1997-Hip Dislocation: Recurrent -121 primary THA -39 revision THA -All with primary dislocation -Only 35% with no further dislocation or revision -best result with revision if components were found to be malaligned

D. Heterotopic ossification(HO) Associated with; -revision surgery -previous HO -ankylosing spondylitis -DISH -neuropathic states -Pagets disease Treatment radiation (700 rads as single dose) preoperatively(4 hrs) or postoperatively (48 hrs) indomethicin 50mg BID x 7days diphosphonates do not work Knelles et al. JBJS-B 79(4) Jul 1997-Heterotopic Ossification -700 rads or 50 mg indocin BID x 7d -More effective than 500 RADS CRP for Determining Risk of HO - CRP in early post of period indicates increased risk of HO Sell S, Schleh T Arch Orthop Trauma Surg 1999;119(3-4):205-7

E. Fracture As a general rule unstable fractures around THR implants should undergo ORIF. If stability can't be achieved consider revision to a long stemmed implant. F. Component breakage

31

Not as large a problem as with earlier designs. Most likely occurs with a well fixed implant distally that is loose proximally. There has been a reported incidence of neck fracture with the large size chrome cobalt stem with a plus 10mm head.

G. Osteolysis -One must differentiate between stress shielding in components with distal fixation and osteolysis. Osteolysis is recognized by focal endosteal erosion and is predominantly due to wear debris (polyethylene, metal, and cement).

WHAT'S IN/WHAT'S OUT -HIP ARTHROPLASTY WHAT'S IN -Uncemented acetabular components with -minimal holes -good locking mechanisms -full back side contact -Use of screws if necessary -Cemented polyethylene cups for elderly -Cemented femoral components with limited surface roughness (depends on design) -Adequate cement mantle, careful cement technique -Increased use of uncemented femoral component (especially type A and B) -Use of Highly Cross Linked Polyethylene -Consider larger heads for better stability and improved head neck ratio

WHAT'S OUT -Gamma irradiated polyethylene in air -Cemented femurs in good bone -Use of cement in cardiac patient -Bipolar hemiarthroplasty -Routine acetabular screw fixation -Threaded acetabular cups -Titanium bearing surfaces -Highly modular systems -Custom components

Revision Total Hip Arthroplasty.

A) The first issue is to determine the mechanism of failure and to

32

establish what is missing. B) Classification of femoral deficiency 1 Segmental -level 1 (to lesser troch) -level 2 (to mid shaft) -level 3 (distal half) 2 Cavitary -with cortical shell expansion -ectasia 3 Combined 4 Malalignment AAOS HIP COMM., 1993 Proprosky Femoral Bone Loss Classification

Type 1 Metaphysis: Minimal bone loss Isthmus: Intact > 5cm Diaphyseal cortex: Supportive

Type 2 Metaphysis: Damaged, calcar, non-supportive Isthmus: Intact > 5cm Diaphyseal cortex: Supportive

Type IIIA

Metaphysis: Severely deficient, Non-supportive Isthmus: Intact 4-6cm Diaphyseal cortex: Supportive distally

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Type IIIB Metaphysis: Severely deficient, Non-Supportive Isthmus: Intact < 4cm Diaphyseal Cortex: Supportive distally

Type IV Metaphysis: Severely deficient, Non-supportive Isthmus: Deficient Diaphyseal cortex: Paper thin endosteal canal enlarged

C)Classification of Acetabular Deficiency 1 Segmental deficiencies -Peripheral Superior Anterior Posterior -Central (medial wall absent) 2 Cavitary deficiencies -Peripheral Superior Anterior Posterior Central (medial wall intact) 3 Combined deficiencies 4 Pelvic discontinuity 5 Arthrodesis AAOS HIP COMM,1989

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Acetabular Classification Proprosky

Kohlers line Integrity of medial wall and superior anterior column Ischial lysis Integrity of posterior wall and posterior column Tear drop Integrity of medial wall and inferior portion of anterior and posterior column Vertical migration Integrity of superior dome

Dependent upon four radiographic criteria Kohlers line Acetabular tear drop Ischial lysis Vertical migration

DEALING WITH OSTEOLYTIC LESIONS IN THE ACETABULUM

Characterize Extent of Lesion Eliminate the Debris Generator Estimate Extent of Viable Host Bone ? Graft the Lytic Lesions ? Choice of Graft Material ? Biological Solution

D) Bone loss in revision THR: Surgical Options

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1) Acetabular -large hemispherical cup -bone graft -autograft -allograft -morselllized -structural -high hip center -custom component -oblong cup -reinforcement ring -reconstruction ring -trabecular metal augments -cup and cage

2) Femoral -bone graft -autograft -allograft -morsalized -structural -whole bone - cortical struts E) Surgical options for Revision THR

-Cemented revision- the early results suggested that cemented revision THR had a higher failure rate and that uncemented revision was preferable. Recent data has supported the use of cemented revision, with impaction grafting when necessary, in some cases. -Cemented Options -routine cement with 4th generation technique -impaction grafting

Katz, Callaghan, Johnston JBJS-B 79(2) Mar 1997-Cemented Hip Revision -83 cemented revision THA -22% reoperation at 8-10 year -2 (2.5%) sepsis -3 (4%) dislocation

36

-13 (16%) loose -5.4% femoral -16.0% acetabular -Uncemented revision- many investigators feel that uncemented revision are preferable as they obviate the high failure rate reported for cemented revisions. -Uncemented Options -Acetabulum high hip center jumbo cup oblong cup (bilobed cup) allograft protrusio shell Reinforcement Reconstructive trabecular metal augments Augment, Cage, Cup

The Fate of Cementless Jumbo Cups in Revision THR 43 Porous Jumbo cups used in 42 Patients. Mean age 63 yrs. ( range 25-86) Morsallized allograft in 27 hips, Bulk Allograft in 8 5 Died; 2 Lost; 36 cases with minimum 10 year follow-up 2 cups Revised for loosening, 2 for Dislocation 92% Kaplan Meier Survival at 10 years. Patel JV, Masonis JL, Bourne RB and Rorabeck CH. J Arthroplasty. 2003 Feb; 18 (2): 129-33

-Femur Unitized proxmially porous coated Extensively porous coated Modular Allograft Prosthetic composite

FAILED FEMUR
Establish proximal hoop stresses and diaphyseal fit (struts, osteotomy, etc.)

37

Yes

No

Modular implant

Establish diaphyseal fit (4cm x < 16 mm)

yes

no

Extensively coated implant

Tapered stem Impaction graft Reduction osteotomy Allograft pros. Composite

FAILED ACETABULUM
Intact Ant. and Post Columns

Yes

No

Large Hemispherical Cup

Pelvic Discontinuity No Yes

Reconstruction or Reinforcement Ring Trabecular Metal Augments Cup and Cage

ORIF A PO

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F) Author's preference -In most revision situations, uncemented revision is preferable. In older patients cemented revision with 4th generation cementing is reasonable .In most revisions a modular implant is used. If proximally bone can not be made to carry hoop stresses, an extensively coated implant is used. Allografts are generally preferrable to custom components but the concerns about long term incorporation and disease transmission must be considered.

WHAT'S IN/WHAT'S OUT -REVISION HIP ARTHROPLASTY WHAT'S IN -Limited modularity -Extensively coated implants -Limited use of cancellous packing/Cemented revision (Impaction Grafting) -Higher hip centers/protrusio cages/jumbo cups/?trabecular metal -Mechanical cement removal with windows/extended osteotomies -Cortical struts -Implant cost concerns WHAT'S OUT -Unitized prox. coated implants -Massive allografts that bear load -Acetabular allografts -Bipolars for revision -Custom components

II

Adult Knee Reconstruction

-Surgical options in non-inflammatory arthritis -arthroscopy, debridement, osteotomy, uni TKR, TKR -Surgical options in inflammatory arthritis -synovectomy(radiation, arthroscopic, open), TKR -Results of treatment -survivorship analysis,complications, future directions Adult Knee Reconstruction/Surgical options in non-inflammatory arthritis

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A. Non Arthroplasty Options -arthroscopic debridement -abrasion arthroplasty -osteochondral allograft -autologous chondrocyte implantation/mosaic -osteotomy -arthrodesis B. Arthroplasty Options -Unispacer -Unicompartmental knee arthropolasty (UKA) Fixed Mobile Patient Specific -Duocondylar -Isolated Patellofemoral -Total Knee Arthroplasty (TKA) Adult Knee Reconstruction/arthroscopic debridement,abrasion arthroplasty, open debridement -Bert (Arthroscopy 1989)- 126 patients (follow-up 60 mos. mean) Debridement good to excellent 66% fair 13% poor 21% worsened 15% Abrasion arthroplasty plus debridement good to excellent 51% fair 16% poor 33% worsened 20% - Johnson, L. 1990- results of abrasion arthroplasty (423 knees) asymptomatic 12% painful 66% using pain meds 44% loss of motion 24% limp 36% subsequent surgery 14% - Rand 1991-compared abrasion with debridement Concluded that abrasion (50% of patients required TKR at 5 years) was no better than debridement (6 improvement) - Salisbury CORR 1985- results of abrasion arthroplasty 32% good or fair if in varus 94% goodor fair if in neutral

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-Magnuson 1941, Insall 1964-results of open debridement- 60 knees successful in 77% at 6.5 years -Janzen et al. A J Roent. 169(3) Sept 1997-AVN Following Laser Menisectomy -2 cases of arthroscopic menis. with neodymium: yttrium alum. garnet laser leading to osteonecrosis -MRI showed subchondral tibial & femoral AVN at 56 mos. -1 TKR, 1 HTO for continued symptoms

- Current indications for specific treatment in non-inflammatory osteoarthritis Arthroscopy- evidence of internal derangement, normal alignment, preservation of joint space. Arthroscopic debridement -impinging osteophytes (intercondylar, patellofemoral) -sealing techniques(not validated) Be Aware of the Prospective Studies of Arthroscopy in OA -Moseley/VA, Toronto, METEOR Open debridement-limited Marrow stimulation techniques -limited to focal (<1.5 cm.2) areas of eburnated bone in patient with reasonable alignment. abrasion chondroplasty microfracture drilling Autologous chondrocyte implantation-not for OA. changes in technique worse results following microfracture Osteochondral grafting-small lesions, suitable donor site OATS, mosaicplasty, COR, SDS

Adult Knee Reconstruction/Osteotomy/UKR Advantages of Osteotomy Compared with UKA/TKA -Biologic solution -Bone sparing -No concerns of wear debris -Less activity restriction Concerns With Osteotomy -Higher perioperative complication rate -Longer Rehabilitation -Less pain relief -Less functional return -Higher failure rates

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Factors Associated With Failure of Osteotomy -Obesity -High adduction moment -Subluxation -Greater than 50% loss of joint space -Laxity -Limited motion -Technical error -Undercorrection Results of Tibial Osteotomy Satisfactory pooled results of HTO from different centers85% at 2 years 75% at 5 years 40-60% at 10 years Pooled complications of HTO from different centers inadequate correction 20% recurrent varus 5-30% nonunion 1-3% infection 1-8% neurologic 1-10% vascular <1% Increased interest in Opening Wedge HTO and HTO in Combination with Cartilage Repair

SPECIFIC DATA Long term Results(Varus) Coventry, JBJS,1993 -87 valgus HTOs with 3-14 yr. (mean 10 year follow up) -90% survivorship at 5yrs and 65% at 10 years if valgus angulation was 8 degrees or more and patient's weight was 1.32 times ideal weight or less. Otherwise, the survivorship was 38% at 5 years ands 19% at 10 years. Lootvoet et al, 1993 -8 year f/up of 193 valgus osteotomies -71% good results with 7.2% reoperation -statistically better results (p=0.0004) if tibio-femoral space is 50% of normal Yasuda et al, CORR, 1992

42

-86 HTOs at 10-15 year follow up -88% 6yr. and 63% 10 year satisfactory results -best if tibiofemoral angle was 164-168 degrees. Odenbring et al, Acta Orthop Scand,1990 -314 HTOs 10-19 year follow up -32% revision in undercorrected knees -5% revision in normal or overcorrected knees -20% revised to TKR; 3% revised to HTO Long term Results (Valgus) Gross et al, JBJS,1988 -24 patients with varus femoral osteotomies for lat. OA -ave follow up of 4 years -22/24 with satisfactory results -best done medially with rigid fixation Edgerton, Mariani, and Morrey,CORR, 1993 -23 patients with varus femoral osteotomies for lat. OA -5-11 year f/up (ave. 8.3 years) -71% good/excellent results -high incidence of failure with staple fixation -13% conversion to TKR Finkelstein, Gross et al. JBJS-A 78(9): 1348-52, Sept 1996 -1 knees (20 patients) Ave follow/up(97-240) -13 still successful 7 failed 1 died(functional) -survival 64% at 10 years Medial OA and Anterior Instability Lattermann and Jakob. Arthroscopy 4(1):32-38 1996 -30 patients:medial OA and ACL def:3 groups -1, HTO: 2, HTO and ACL: 3, HTO with ACL 6-12 mos later -Post op pain 1, 1/11: 2, 3/8 : 3, 2/8 -Post op pivot shift 1, 2/11: 2, 4/8: 3, 3/8 -Post op complications 1, 4/11: 2, 5/8: 3, 3/8 -High rate of major complications in Group 2 -If over 40 do HTO alone -If less than 40 do HTO and wait

Results compared with UKA Weale and Newman, CORR, 1994 -12-17 yr. f/up of 21 HTOs vs. 15 UKAs

43

-42% good result, 12% revision with UKA -21% good result, 40% revision with HTO Broughton JBJS 1986 Results better with uni at 6 years UKR 76% good HTO 42% good Results of Failed HTO Converted to TKR Neyret et al, 1992 -TKR post HTO. -38 patients, mean 8.5 years post HTO -3 year mean follow up -as compared with primary TKR these patients decreased walking distance and less flexion (p< 0.001) - no difference in knee score Results of Unicompartmental Arthroplasty -Thornhill, Clark et al- UKR results 1991 AAOS 307 UKAs in 251 patients mean age 66.2 years;153 female/98 male mean f/up 4.2 years (range 2-9 years) 90% pain relief 13 knees revised (4.5%) wear- 5 knees progression of disease- 5 knees loosening - 2knees synovitis - 1 knee

-Advantages of UKR preservation of bone stock, ACL, PCL, PF joint easier rehabilation than HTO and TKR fewer perioperative complications less metabolic demand Potential as an outpatient arthroscopic procedure (Minimally invasive) Cost benefits -Disadvantages of UKR technically demanding difficulty in patient selection -Strict contraindications to UKR inflammatory arthritis

44

multicompartment disease severe deformity/subluxation non articular deformity ACL deficiency ? Patellofemoral Disease -Relative contraindications to UKR chondrocalcinosis ? osteonecrosis obesity

Results of Failed HTO Converted to TKR Neyret et al, 1992 -TKR post HTO. -38 patients, mean 8.5 years post HTO -3 year mean follow up -as compared with primary TKR these patients had decreased walking distance and less flexion (p< 0.001) - no difference in knee score Gill, Thornhill et al CORR 321: 10-18, Dec 1995 -Matched group of failed UKRs and HTOs UKRS had more revision problems with bone loss HTOs had more problem with exposure HTOs had better knee and function scores after revision

-Results of Failed UKR Converted to TKR Levine, Thornhill et al: J Arthroplasty 11(7):797-801, Oct 1996 29 Patients (31 knees) failed RBBH UKR ave age 72.3 yrs (range(49-88) ave weight 179 lbs (range 112 -242) interval to revision ave 62 months (7-106) ave follow up 45 months (24-104) PCL sparing knees 30: One PCL sub TKR grafted contained defects 7 4 tibial and 2 femoral wedges no structural grafts knee and functional results similar to primary TKR -Current indications for UKR ~8-10% of patients with OA undergoing TKR

45

transition patient between HTO and TKR elderly patient (especially with bilateral disease ?role of mobile bearing uni-TKR ?role of patient specific UKR

WHAT'S IN/WHAT'S OUT-ARTHROSCOPY/OSTEOTOMY/UNI KNEE WHAT'S IN -Unloader braces/Hyaluronic acid gels -Glucosamine/Chondroitin Sulfate -Debridement, lavage and partial menisectomy -HTO earlier in the disease process -Rigid fixation for HTO -Metaphyseal or dome osteotomy for large corrections -Staging of combined HTO and ACL reconstruction -Minimally invasive unicompartmental arthroplasty WHAT'S OUT -Arthroscopy with primary diagnosis of OA -Abrasion chondroplasty -Osteotomy without rigid fixation -Osteotomy for the elderly

Adult Knee Reconstruction/Total Knee Arthroplasty A Cruciate Sacrificing 1. Insall- Total Condylar (1974-1986) 7 yr survivorship (revision defines failure)-93% 10 yr survivorship-90% 2 Ranawat- Total Condylar 8-11 yr (112 TKRs) 11 yr survivorship-94% B Cruciate Substituting 1. Insall- Posterior Stabilized 7 yr survivorship- 97% 10 yr survivorship-97% C Cruciate Sparing

46

1 Wright et al- Kinematic (5-9yr) 98% survivorship 88.6% good/excellent 2 Martin, Scott and Thornhill PFC(5-9 yr) J Arth 12 (6): 603-14, 1997 Sept 378 TKRs (290 patients) KSS 28-pre 88-post no loosening failures predominately with metal backed patellae 3 Rotating bearing designs Jordan et al. CORR 338 May 1997- Meniscal Bearing TKR -473 LCS MB TKRS (375 pts) -Avg 5 yr f/up -17 bearing failures -12 fracture/dislocation -5 tibial subluxation 4 High Flex Designs High incidence of loosening of the femoral component in legacy posterior stabilized-flex total knee replacement 72 NexGen legacy posterior stabilized high flexed total knee replacements in 47 patients were studied Aseptic loosening was found in 27 (38%) and a mean follow-up of 32 months 15 knees (21%) required revision at a mean of 23 months Postoperatively, the mean maximum flexion was 136 in the loosened group and 125 in the well-fixed group Han HS, Kang SB, Yoon KS. JBJS(B). 2007 Nov;89(11):1457-61

5 Gender Specific/Patient Specific

D Gait Study Comparisons 1 Andriacchi-JBJS 1972- PCL sparing knees better on stairs. 2 Dorr-CORR 1988- PCL sacrificing TKR required more work from Quadriceps, B. Femoris, and Soleus 3 Kelman-CORR 1989- PCL Sparing knees performed like normal contralateral knee.

47

E. Prosthetic options Posterior cruciate 1. Cruciate sparing 2. Cruciate augmentation 3. Cruciate sacrifice 4. Cruciate substitution 5. Constrained Bearing configuration flat and fixed conforming and fixed meniscal bearing rotating platform F Fixation Options (Potential concerns) 1 Cemented (bone stock loss, fem. stress distribution) 2 Uncemented (tibial fixation, metal backed patellae) -press fit (fibrous ingrowth) -porous coated (cost, metal toxicity) -screw fixation (screw osteolysis) 3 Hybrid -cemented patellar button - cemented tibia -plateau only (requires uniform and strong proximal tibial bone) -plateau and keel - uncemented femur Minimally Invasive Techniques Quad Sparing Subvastus Midvastus No Patellar Eversion

Computer Assisted Techniques Advantages Limits Outliers in Alignment Marketing Suitable for Minimally Invasive Disadvantages Cost Surgical Time Not Ideal for Soft Tissue Balance Microarrays are Invasive and Cumbersome

48

Gender Specific Issues

Patient Specific Designs (Pre Operative Navigation) MR or CT based Patient Specific Components/Instruments -Uni, Duo, TKR Disposable Instruments

WHAT'S IN/WHAT'S OUT KNEE ARTHROPLASTY WHAT'S IN -Cemented arthroplasty -Patellar resurfacing -Improved contact areas/minimum of 8mm poly -Limited or controlled Modularity -Minimally Invasive Techniques -Computer Assisted Surgery -? Use of Moderately Cross linked Polyethylene WHAT'S OUT -Uncemented tibial fixation -Tibial screw fixation -flat inserts -gamma irradiated polyethylene in air -Metal backed patellas -Titanium bearing surfaces WHAT'S IN/WHAT'S OUT-REVISION KNEE ARTHROPLASTY WHAT'S IN -Press fit stems -Modular systems -Wedges for bony defects -Delayed exchange for infected TKR WHAT'S OUT -Fully uncemented revision -Cemented long stems -Custom implants -Hinge designs

Adult Knee Reconstruction/TKR Complications

49

Malalignment and loosening related to patient selection, design considerations and surgical technique Soft tissue imbalance related to surgical technique differences between PCL sparing, sacrificing and substitution

Patellofemoral problems fracture loosening wear metal backed concerns subluxation/dislocation avascular necrosis D Infection Incidence-single institution -TKR- Wilson, Kelley, Thornhill JBJS 1990 -1973-1987 -4171 TKRs -67 (1.6%) infections -predominantly late hematogenous infection Risk Factors -Wilson, Kelley, Thornhill JBJS 1990-TKR -significant factors (p< .05) -RA -RA male -Skin breakdown -Prior surgery in OA -associated factors (p> .05) -Obesity -UTI -Steroid use in RA -not associated -Age -Weight (RA) -Prior Surgery (RA) -Non RA medical conditions

Diagnosis -Exam -swelling, drainage, erythema, tenderness, warmth -Lab -acute phase reactants, leukocytosis, synovial analysis wound cultures, blood cultures

50

-Radiographic -plain films, scintigraphy, arthrograms

Prevention -Predominant organisms -Staph Aureus -Staph Epi. -Streptococci Emerging organisms -Meth. res. Staph aureus(MRSA) -Meth. res. Staph epi.(MRSE) -Enterococci -Strep faecium -VREF

-Preoperative Screening -Mupirocin Treatment of carriers -Antibiotics in Cement Revisions High Risk Patients ? All TJRs -Systemic antibiotics -Cefazolin 1 GM IV at surgery 1 GM IV q8 hr X 24 hrs. - Cefuroxime 1.5 GM IV at surgery 750 MG IV q8 hr X 24 hrs.

-? Vancomycin 1 GM IV (slowly) at surgery 0.5-1 GM IV q12 hr X 24 hrs. - if penicillin anaphylaxis or cephalosporin allergy, use vancomycin as above. -Late Antibiotic Prophylaxis (significant dental, GI, GU) -Amoxycillin 3 GR. PO 1 hr before

- Erythromycin 1 GM PO 1 hr before -Indications for late prophylaxis -all patients who tolerate treatment -all high risk patients

51

- OR Environment -Ultraviolet lights -2537 A -Vertical laminar flow -Horizontal laminar flow -Exhaust system -Greenhouse - J.P.Nelson Hip Society 1977 There is a significant decrease in infection with IV antibiotics. Addition of vertical laminar flow further reduces infection as does ultraviolet light (UV not significant secondary to low numbers) - Lidwell et al In a conventional OR, IV antibiotics reduces the infection rate from 3.4% to 0.8%. Addition of ultraclean air and exhaust systems further reduces the incidence of infection. - Salvati et al JBJS 64A 1982 horizontal laminar flow reduced the incidence of infection in THR but not TKR. -Planning of skin incision -dissect below deep investing fascia -avoid large skin flaps -honor previous incisions (especially lateral incisions) -Meticulous surgery -avoid dead space -handle tissues carefully -efficient operative time -close quadriceps tendon in two layers -Antibiotic Irrigation - if a tourniquet is used antibiotics are necessary to provide a local antibiotic environment. -Antibiotics in Cement -indications -immunosupressed patient -systemic illness -presence of risk factors -revision surgery -usual choices

52

-Gentamicin 0.5- 1.0 gm/40 gm -Cephamandole 1.0 gm/40 gm -Tobramycin 600 mg/ 40 gm - Treatment options (all include the use of intravenous antibiotics) -Prosthesis retention -aspiration alone -debridement -arthroscopic -open -Prosthesis exchange -immediate -intermediate - Delayed -CPM -spacers -prostalic -Salvage -arthrodesis -resection arthroplasty -amputation

Long Term Suppression Of Infection in Total Joint Arthroplasty All Patient underwent Debridement, 4-6 Weeks of IV Antibiotics with Prosthesis Retention. At 5 years overall success was 86.2% and 69% for Staph Aureus. This is a Viable Option in Patients not suitable for Prosthesis Removal. Rao N, Crossett LS et al. Clin Orthop. 2003 Sept; (414); 55-60.

- Factors affecting choice of treatment -host factors -delay in diagnosis -type of prosthesis -organism -radiographs

53

-skin and soft tissue -response to treatment - Indications/Results for Specific Treatment Option Indication for Aspiration -early detection (<48 hrs.) -penicillin sensitive streptococci -rapid clinical response -decreased effusion, lower synovial WBCs, negative cultures, no systemic toxicity. -no synovial reaction Results of Aspiration -Wilson, Kelley, Thornhill JBJS 1990 -5 of 12 TKRs free of infection off antibiotics. When above criteria are applied the results have been favorable in a small series. -Bengston et al Acta Orthop Scand. 1991- 357 infected TKRs. There was only a 15% success rate with aspiration and antibiotics alone. Indications for Open Debridement -not suitable for aspiration alone -early detection -no radiographic loosening, osteolysis, periosteal reaction -no malalignment -immunocompetent host -sensitive organism Results of Open Debridement -Borden et al J. Arthroplasty 1987.- 11 infected TKRs. (mean f/up 51 mos.) 6 failures (55%) -Wilson, Kelley, Thornhill JBJS 1990- 42 infected TKRs. (31 knees>2 yrs.) mean f/up 43 mos. 14 failures (45%). Staph aureus was a poor organism for consideration of prosthesis retention. -Schoifet, Morrey JBJS 79(2) 1990.-31 infected TKRS (27 patients) mean f/up 8.8 yrs. 77% recurrence Staph aureus was associated with a 58% failure. -Bengston et al Acta Orthop Scand. 1991- overall 24% success rate with soft tissue surgery Indication for Early Exchange The indications for early or immediate exchange are unclear as most series are small. Moreover, newer antibiotics and treatment regimens may increase these indications.

54

At present, immediate exchange is considered when there is a loose or malaligned TKR that otherwise fulfills all other criteria for aspiration alone. Results of Early/Immediate Exchange -Mayo Clinic 14 acute infected TKRs 6/7 low virulence and 2/7 high virulence were salvaged but overall there was only a 35% satisfactory functional result. -Bengston et al Acta Orthop Scand. 1991.- overall 75% success rate with revision surgery with no difference between one and two stage procedures -vonFoerster ENDO Clinic 1991-104 infected TKRs 5-15 yr, f/up 73% cure with single exchange and overall 84% cure with second exchange. Indication for Delayed Exchange This is the principle treatment option utilized in most cases. The protocol involves removal of all components and closure over large drains. Cement spacers or prostalac systems impregnated with antibiotics may be used. The interval to reimplantation is variable and determined in conjunction with an infectious disease consult. Reimplantation is by standard techniques using antibiotic impregnated cement. Results of Delayed Exchange -Windsor, Insall et al JBJS 1990.-38 infected TKRs (35 pts.) 4 yrs. ave. f/up (2.5-10 yrs) Overall 89.5% success rate. -Wilson, Kelley, Thornhill JBJS 1990- 24 infected TKRs. Mean f/up 34 mos. Overall 80% success rate. -Borden et al J. Arthroplasty 1987.- 11 infected TKRs. Mean f/up 2 yrs. Overall 91% success rate. -Teeny, Dorr et al J Arthroplasty 1990. 9 infected TKRs with 100% success rate with delayed exchange as compared to a 77% failure rate in 21 infected TKRs treated with prosthesis retention. Indication for Arthrodesis -resistant organisms -immunocompetent host -failure of delayed exchange -inadequate skin or soft tissues Results of Arthrodesis -Bengston et al Acta Orthop Scand. 1991.- overall 88% success rate in 135 infected TKRs Indications for Resection Arthroplasty

55

-failure of arthrodesis -non ambulatory patient Results of Resection Arthroplasty -Falahee, Matthews, Kaufer JBJS 69(A) 1013-1021, 1987- 28 infected TKRs (26 pts) Overall 89% success of controlling local and systemic infection. Six knees required 2o arthrodesis and 3 spontaneously fused. Indications for Amputation -failure of all other treatment options - life threatening situation

SELECTED ANNOTATED HIP AND KNEE REFERENCES 2010

The posterior approach reduces the risk of thin cement mantles with a straight femoral stem design. Macpherson GJ, Hank C, Schneider M, Trayner M, Elton R, Howie CR, Breusch SJ. Acta Orthop. 2010 Jun;81(3):292-5. Two hundred seventy patients underwent cemented Exeter total hip arthroplasty. 135 stems used the anterolateral approach and 135 stems the posterior approach. All radiographs were graded according to Gruen zones. With a straight femoral stem design, the posterior approach gave a lower risk of a thin cement mantle.

Validity of frozen sections for analysis of periprosthetic loosening membranes. Tohtz SW, Mller M, Morawietz L, Winkler T, Perka C. Clin Orthop Relat Res. 2010 Mar;468(3):762-8. Epub 2009 Sep 19. This study analyzes the benefit of frozen section in evaluating 64 patients who underwent exchange for failed total hip replacement. Eighty percent of the sample tested at frozen section correlated with the results found at permanent section. The authors recommend this technique for evaluating hip revision membranes.

56

Incidence of lateral femoral cutaneous nerve neuropraxia after anterior approach hip arthroplasty. Goulding K, Beaul PE, Kim PR, Fazekas A. Clin Orthop Relat Res. 2010 Sep;468(9):2397-404. This study examined the incidence of injury to the lateral femoral cutaneous nerve in 132 patients who underwent an anterior hip approach. Eighty one percent of the patients reported some evidence of neuropraxia. Most patients had a decrease in symptoms over time.

Hip resurfacing data from national joint registries: what do they tell us? What do they not tell us? Corten K, MacDonald SJ. Clin Orthop Relat Res. 2010 Feb;468(2):351-7. The authors reviewed the results of hip resurfacing from metal-on-metal hip resurfacing implants. Patients with a diagnosis other than primary osteoarthritis had a higher risk of early revision. Revision of surface replacement had a re-revision rate of 11% at 5 years.

The influence of head size and sex on the outcome of Birmingham hip resurfacing. McBryde CW, Theivendran K, Thomas AM, Treacy RB, Pynsent PB J Bone Joint Surg Am. 2010 Jan;92(1):105-12. This study looked at head size and gender on the outcome of hip resurfacing and found that female gender was not in itself a risk factor but that a smaller head size led to greater risk.

Histological features of pseudotumor-like tissues from metal-on-metal hips. Campbell P, Ebramzadeh E, Nelson S, Takamura K, De Smet K, Amstutz HC Clin Orthop Relat Res. 2010 Sep;468(9):2321-7. This article reviewed the histological features of pseudotumor and attempted to differentiate between excessive wear and metal hypersensitivity. They reviewed 32 revised hip replacements and found that those patients with suspected high wear had fewer lymphocytes but more macrophages and metal particles than those tissues revised for pain and suspected metal hypersensitivity.

Inferior outcome after hip resurfacing arthroplasty than after conventional arthroplasty. Evidence from the Nordic Arthroplasty Register Association (NARA) database, 1995 to 2007.

57

Johanson PE, Fenstad AM, Furnes O, Garellick G, Havelin LI, Overgaard S, Pedersen AB, Krrholm J. Acta Orthop. 2010 Oct;81(5):535-41. This is a review from the Nordic Arthroplasty Registry and compared hip resurfacing with conventional arthroplasty and found that resurfacing had an almost threefold increased revision rate compared to THA.

Femoral head size and wear of highly cross-linked polyethylene at 5 to 8 years. Lachiewicz PF, Heckman DS, Soileau ES, Mangla J, Martell JM. Clin Orthop Relat Res. 2009 Dec;467(12):3290-6. Epub 2009 Aug 19. The authors studied 146 hips implanted in 90 patients with a minimum follow up of 5 years. The mean linear wear rate was 0.028 mm per year and the median volumetric weight was 25.6 mm3 per year. There was no association between femoral head size and linear wear rate, but there was an association between a larger head size and volumetric wear. The authors urged caution in using large femoral heads in young and active patients.

Risk of complication and revision total hip arthroplasty among Medicare patients with different bearing surfaces. Bozic KJ, Ong K, Lau E, Kurtz SM, Vail TP, Rubash HE, Berry DJ. Clin Orthop Relat Res. 2010 Sep;468(9):2357-62. This study reviewed the Medicare database and found that in Medicare patients a hard on hard bearing had no benefit and, given the higher cost may not be indicated in the Medicare patient.

The risk of revision after primary total hip arthroplasty among statin users: a nationwide population-based nested case-control study. Thillemann TM, Pedersen AB, Mehnert F, Johnsen SP, Sballe K. J Bone Joint Surg Am. 2010 May;92(5):1063-72. The authors compared the revision rate in patients taking statin therapy versus those not taking the drug. This review was of 58,000 total hip arthroplasties with a cumulative revision rate of 8.9%. Statin use was associated with a reduced risk of revision due to deep infection, aseptic loosening, dislocation and periprosthetic fracture. No difference in the risk of revision due to pain or implant failure was found.

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Dislocation after total hip arthroplasty with 28 and 32-mm femoral head. Amlie E, Hvik , Reikers O. J Orthop Traumatol. 2010 Jun;11(2):111-5. Epub 2010 May 27. This retrospective study of 2572 primary total hip arthroplasties compared dislocation rate with 28mm or 32-mm diameter femoral heads. The authors found that a 32-mm head had a reduced incidence of dislocation, with dislocations occurring in 49 hips with a 28 femoral head and 4 hips with a 32 femoral head. The authors did not compare this with acetabular component size.

Delamination of a highly cross-linked polyethylene liner associated with titanium deposits on the cobalt-chromium modular femoral head following dislocation. Patten EW, Atwood SA, Van Citters DW, Jewett BA, Pruitt LA, Ries MD. J Bone Joint Surg Br. 2010 Sep;92(9):1306-11. This is a single case report of a revision of a total hip with highly cross-linked polyethylene that had undergone recurrent dislocation. At revision there were large areas of visible delamination, and the authors concluded that the cobalt chrome modular femoral head had scraped against the titanium shell and had transferred deposits of titanium which led to the delamination.

Reduced dislocation rate after hip arthroplasty for femoral neck fractures when changing from posterolateral to anterolateral approach. Skldenberg O, Ekman A, Salemyr M, Bodn H Acta Orthop. 2010 Oct;81(5):583-7. . This study reaffirms the reduced dislocation rate when total hip arthroplasty was performed for femoral neck fractures. There were 199 fractures in 2007 in which 77% were done through a posterolateral approach. In 2008, 78% were operated on with an anterolateral approach. Switching to the anterolateral approach reduced the dislocation from 8% to 2%.

Retrospective analysis of infection rate after early reoperation in total hip arthroplasty. Darwiche H, Barsoum WK, Klika A, Krebs VE, Molloy R. Clin Orthop Relat Res. 2010 Sep;468(9):2392-6. The authors performed a retrospective analysis of 60 patients undergoing revision total hip as an unplanned and unavoidable return to the operating room during the acute recovery phase. This was due to instability, periprosthetic fracture, retained hardware and nerve exploration. The minimum follow-up averaged 3.7 years and the goals were to study the infection rate and implant survivorship.

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The infection rate for the cohort was 33%. Six of these 20 infected hips retained their implants at 2 years. This study underscores the high incidence of complications following early return to the OR.

The impact of obesity on weight change and outcomes at 12 months in patients undergoing total hip arthroplasty. Dowsey MM, Liew D, Stoney JD, Choong PF Med J Aust. 2010 Jul 5;193(1):17-21. This study underscores the higher complication rate in obese patient. The authors studied 529 patients undergoing primary total knee arthroplasty using conventional body mass index rates with nonobese less than 30, obese 30-39 and morbidly obese greater than 40. Overall, 60% were obese or morbidly obese. At 12 months, a significant weight loss (5% or greater) had occurred in 21% of patients but a significant gain in 21%. Adverse events occurred in 14.2% of the nonobese patients, 22.6% in the obese group and 35% in the morbidly obese.

Perioperative outcomes after unilateral and bilateral total knee arthroplasty. Memtsoudis SG, Ma Y, Gonzlez Della Valle A, Mazumdar M, Gaber-Baylis LK, MacKenzie CR, Sculco TP Anesthesiology. 2009 Dec;111(6):1206-16. This study from Hospital for Special Surgery, the authors compared their experience with bilateral versus staged total knee arthroplasty. They concluded that staging bilateral knee replacement during the same hospitalization offered no mortality benefit and may even expose patients to increase morbidity. They also stated that bilateral knee replacement even in a selected group of patients had a higher complication rate than a unilateral procedure. They did not, however, add complication rate of a second total knee replacement from a separate hospitalization.

Risk of revision for infection in primary total hip and knee arthroplasty in patients with rheumatoid arthritis compared with osteoarthritis: a prospective, population-based study on 108,786 hip and knee joint arthroplasties from the Norwegian Arthroplasty Register. Schrama JC, Espehaug B, Hallan G, Engesaeter LB, Furnes O, Havelin LI, Fevang BT. Arthritis Care Res (Hoboken). 2010 Apr;62(4):473-9. This is a study from the Norwegian Arthroplasty Registry based on the population study of 108 thousand patients and concluded that rheumatoid patients had a 1.6 times higher rate a revision for infection than osteoarthritis patients in total knee, but there was no difference in total hip replacement. The risk of revision for infection as a late hematogenous event was higher in rheumatoid patients as well.

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Total knee replacement in patients with end-stage haemophilic arthropathy: 25-year results. Goddard NJ, Mann HA, Lee CA J Bone Joint Surg Br. 2010 Aug;92(8):1085-9. This is a British study reviewing 70 primary total knee replacements performed in 57 hemophiliac patients between 1983-2007. Six patient had died at, 60 knees were available at 9.2 years followup and 95% had good or excellent results. There was 1 deep infection. Using infection and aseptic loosening as an endpoint, the survival rate at 20 years was calculated to be 94%.

Two-stage exchange knee arthroplasty: does resistance of the infecting organism influence the outcome? Kurd MF, Ghanem E, Steinbrecher J, Parvizi J Clin Orthop Relat Res. 2010 Aug;468(8):2060-6. This study reviewed the reinfection rate after 2-stage exchange arthroplasty, calculated risk factors that would predict failure and the variables associated with acquiring a resistant organism. One hundred and two patients with infected total knee underwent a 2-stage procedure, 96 patients had a minimum follow-up of 2 years. Two-stage exchange arthroplasty was successful in 70 patients. Those who failed had a 3.4 times greater likelihood to have a methicillin-resistant organism. Older age, a high BMI and a history of thyroid disease were associated with a higher incidence of resistance organisms. These data suggest that the emergent resistant organisms may decrease the likelihood of a successful 2-stage exchange.

Cruciate-retaining TKA using a third-generation system with a four-pegged tibial component: a minimum 10-year followup note. Schwartz AJ, Della Valle CJ, Rosenberg AG, Jacobs JJ, Berger RA, Galante JO. Clin Orthop Relat Res. 2010 Aug;468(8):2160-7. Epub 2010 May 4. This is a follow-up of a third generation cruciate retaining total knee with a 4 peg tibial component. One hundred sixty-one patients underwent 179 total knee replacements. All components were cemented and the patella was resurfaced. Forty patients with 44 knees had died. For the remaining patients mean follow-up was 10 years. Survivorship with revision for any reason was 97.7%. Three knees were revised, 1 for infection, 1 for fracture and 1 for arthrofibrosis.

Comparison of a standard and a gender-specific posterior cruciate-substituting high-flexion knee prosthesis: a prospective, randomized, short-term outcome study. Kim YH, Choi Y, Kim JS. J Bone Joint Surg Am. 2010 Aug 18;92(10):1911-20. This is a review of the gender specific high flexion cruciate substituting total knee arthroplasty. Eighty-five patients (170 knees) received a cruciate substituting high flex knee on one

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side and a gender specific cruciate substituting high flex knee in the contralateral knee with a mean duration of follow-up of 2.13 years. All patients were female. Postoperative Knee Society Scores were 95.5 points in the standard group and 96.5 in the gender specific group. There was no difference in the range of motion, the patient's satisfaction or radiographic results. The femoral component in the standard group fit significantly better than in the gender specific group. These authors showed no clinical benefits of the gender specific knee.

Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA: a prospective trial. Burnett RS, Aggarwal A, Givens SA, McClure JT, Morgan PM, Barrack RL Clin Orthop Relat Res. 2010 Jan;468(1):127-34. Epub 2009 Aug 11. These authors question whether prophylactic antibiotics should be with held prior to cultures taken at revision total knee arthroplasty. Twenty-five patients with 26 infected total knees with a known preoperative infecting organism were studied. Antibiotic prophylaxis was then given prior to intraoperative cultures. The use of perioperative antibiotics prior to culture did not affect the interoperative culture results.

Isolated tibial polyethylene insert exchange outcomes after total knee arthroplasty. Willson SE, Munro ML, Sandwell JC, Ezzet KA, Colwell CW Jr. Clin Orthop Relat Res. 2010 Jan;468(1):96-101. Epub 2009 Aug 12. This study reviewed isolated tibial polyethylene insert exchange after total knee arthroplasty. Fortytwo patients were studied at a minimum follow-up of 2 years. The authors found that isolated tibial polyethylene exchange had only a 58% survivorship at 11 years. The group who underwent exchange less than 3 years from index arthroplasty had a higher failure rate.

A prospective randomized study of minimally invasive total knee arthroplasty compared with conventional surgery. Wlker N, Lambermont JP, Sacchetti L, Lazar JG, Nardi J. J Bone Joint Surg Am. 2010 Jul 7;92(7):1584-90. The authors prospectively randomized 134 patients to undergo total knee arthroplasty with either a minimally invasive or standard approach. They found no significant difference in terms of range of motion, Knee Society Scores, pain scores or activities of daily living. The patients with MIS surgery had a longer mean surgical time and less mean blood loss. The authors found no advantage to a minimally invasive approach.

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SELECTED TKR REFERENCES 2009

Range of motion of standard and high-flexion posterior cruciate-retaining total knee prostheses a prospective randomized study.
Kim YH, Choi Y, Kim JS J Bone Joint Surg Am. 2009 Aug;91(8):1874-81.

54 patients (mean age 69.7 years) received a standard posterior cruciate retaining total knee on one side and a high flexion posterior cruciate retaining total knee prosthesis on the contralateral side. At a mean three years postoperatively, there were no significant differences in WOMAC, Knee Society or HSS scores. Postoperatively, the mean ranges of motion weightbearing/non wgt bearing was 131 degrees and 115 degrees for the standard prosthesis, and 133 degrees and 118 degrees for the high flex design. There were no significant differences between the two groups.

The impact of obesity on the mid-term outcome of cementless total knee replacement.
Jackson MP, Sexton SA, Walter WL, Walter WK, Zicat BA. J Bone Joint Surg Br. 2009 Aug;91(8):1044-8.

535 consecutive primary cementless total knee replacements were performed with a mean follow-up of 9.2 years. 153 obese patients (BMI greater than 30) and 382 nonobese patients were studied. There was a significant lower mean improvement and lower postoperative total clinical score in the obese group. There was no difference in rate of radiographic osteolysis or lucent lines, and no difference in alignment. Ten year survivorship was 96.4% in the obese and 98% in the nonobese cohort. While mid term survival is similar in the two groups, obesity appears to have a negative impact on the clinical outcome.

The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty.
Marchant MH Jr, Viens NA, Cook C, Vail TP, Bolognesi MP. J Bone Joint Surg Am. 2009 Jul;91(7):1621-9.

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This study uses the Nationwide Inpatient sample which recorded over one million patients undergoing This total joint replacement. The present study compared 3973 patient with uncontrolled diabetes relative to 105,485 patients with controlled diabetes. Patients with uncontrolled diabetes had significant increased odds of stroke, urinary tract infection, ileus, postoperative hemorrhage, wound infection, hospital length of stay and death.

All-polyethylene compared with metal-backed tibial components in total knee arthroplasty at ten years. A prospective, randomized controlled trial.
Bettinson KA, Pinder IM, Moran CG, Weir DJ, Lingard EA. J Bone Joint Surg Am. 2009 Jul;91(7):1587-94 This study reviews 510 patients with 566 total knees with the mean patient age of 69.3 years. Ten year survivorship with revision as the end point for both metal back and all polyethylene tibial components was similar.

Fifteen-year survival and osteolysis associated with a modular posterior stabilized knee replacement. A concise follow-up of a previous report.
Lachiewicz PF, Soileau ES J Bone Joint Surg Am. 2009 Jun;91(6):1419-23. This is a followup report of a group of patients who underwent a modular posterior stabilized total knee replacement with mechanical failure as the endpoint. The 15 years survival was 96.8% with failure defined as reoperation. The 15 years survivorship with failure defined as reoperation was 90.6%.

Early recovery after total knee arthroplasty performed with and without patellar eversion and tibial translation. A prospective randomized study.
Dalury DF, Mulliken BD, Adams MJ, Lewis C, Sauder RR, Bushey JA J Bone Joint Surg Am. 2009 Jun;91(6):1339-43. This study considers the impact of patellar eversion and tibial translation on the outcome of total knee arthroplasty. Forty patients were prospectively randomized into one of two treatment groups. In group 1, the patellar was everted, and in the group 2 the patella was subluxed but not everted. At six weeks, there were no significant differences with regard to range of motion, quadriceps strength or knee society scores. At 12 weeks and 6 months, there were no differences seen and no difference in the patient preference.

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The effect of an intravenous bolus of tranexamic acid on blood loss in total hip replacement.
Rajesparan K, Biant LC, Ahmad M, Field RE. J Bone Joint Surg Br. 2009 Jun;91(6):776-83.

This study reviews the effect of tranexamic acid as a fibrinolytic agent to reduce blood loss in total joint surgery. A standard 1 gram intravenous bolus was given at the induction of anesthesia in patients undergoing total hip replacement. 36 patients receiving the drug were compared to 37 standard THRs. Tranexamic acid reduced the early postoperative blood loss and total blood loss, but not the intraoperative blood loss. The tranexamic acid group required fewer transfusions and had no increase in deep venous thrombosis.

How often do patients with high-flex total knee arthroplasty use high flexion?
Huddleston JI, Scarborough DM, Goldvasser D, Freiberg AA, Malchau H. Clin Orthop Relat Res. 2009 Jul;467(7):1898-906.

This study reviews 20 consecutive patients who have high flexion TKA reviewed at two years. The patient wore a validated smart activity monitor to document the prevalence of knee flexion greater than 90 degrees. Activities performed with flexion greater than 90 degrees were, on average, 70% in single leg stance, 12% moving from sitting to standing, 8% walking. 7% moving from standing to reclining, 2% stepping, 1% moving from lying to standing, and 0.1% running. The patients studied in this group rarely used deep flexion.

Periprosthetic infection due to resistant staphylococci: serious problems on the horizon.

Parvizi J, Azzam K, Ghanem E, Austin MS, Rothman RH. Clin Orthop Relat Res. 2009 Jul;467(7):1732-9. This study reviewed the results of treatment of periprosthetic infection caused by resistant Staphylococcus species. Debridement controlled the infection in only 30% of cases, whereas delayed exchange arthroplasty controlled the infection in 75% of hips and 60% of knees. These data are worse than previously reported indicating increased virulence for these organisms

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Functional outcome and range of motion of high-flexion posterior cruciate-retaining and high-flexion posterior cruciate-substituting total knee prostheses. A prospective, randomized study.
Kim YH, Choi Y, Kwon OR, Kim JS. J Bone Joint Surg Am. 2009 Apr;91(4):753-60.

This study is similar to the above reported study from the same institution comparing a standard versus high flex cruciate retaining in the present study. Similar observations were made in a standard and high flex cruciate substituting knee. There were no differences in WOMAC score, Knee Society score or HSS score. The mean nonweightbearing and weightbearing range of motion was 133 degrees and 118 degrees in the standard group, and 135 degrees and 122 degrees in high flex design. This study reported no significant differences between the groups.

The intra-operative joint gap in cruciate-retaining compared with posterior-stabilised total knee replacement.
Matsumoto T, Kuroda R, Kubo S, Muratsu H, Mizuno K, Kurosaka M. J Bone Joint Surg Br. 2009 Apr;91(4):475-80.

This paper reviews the use of a tensor for total knee replacement, which was designed to assist with soft tissue balancing throughout the range of motion. Measurement of the joint gap with a reduced patella in posterior stabilized knees increased from extension to flexion. For cruciate retaining TKRS the gap was similar throughout a full range of motion. The joint gaps at the knee flexion were significantly smaller for both types of prosthetic knee when the patellofemoral joint was reduced. This study underscores the importance of the quadriceps mechanism in determining flexion gap during knee replacement.

Analysis of the outcome in male and female patients using a unisex total knee replacement system.
Dalury DF, Mason JB, Murphy JA, Adams MJ. J Bone Joint Surg Br. 2009 Mar;91(3):357-60. This report reviews 1970 cruciate retaining knees implanted in 920 women and 592 men with a mean aged 69.7 years. At a mean followup of 7.3 years, there were minimal differences in the outcome between genders. Men had a higher overall Knee Society score and more osteolysis. There were no significant differences between men and women in terms of complications or improvement in

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function, pain score or range of motion. The 10-year survivorship was 97% in women and 98% in men. There were no gender differences seen.

Staged revision for knee arthroplasty infection: what is the role of serologic tests before reimplantation?
Ghanem E, Azzam K, Seeley M, Joshi A, Parvizi J. Clin Orthop Relat Res. 2009 Jul;467(7):1699-705. This reviewed the diagnostic value of sedimentation rate and C-reactive protein as an indicator to reimplanting an infected implant as a second stage procedure. The authors found that both of these acute phase reactants are poor predictors of reinfection and that other markers should be evaluated.

Outcome of a second two-stage reimplantation for periprosthetic knee infection.

Azzam K, McHale K, Austin M, Purtill JJ, Parvizi J. Clin Orthop Relat Res. 2009 Jul;467(7):1706-14.

This study reviewed 18 patients with failed two-stage total knee arthroplasties treated with a second two-stage reimplantation. Minimal followup was 24 months. Recurrent or persistent infection was diagnosed in 4 of 18 patients, two of whom were successfully treated with a third two-stage arthroplasty. The authors suggest that a repeat two-stage arthroplasty is a reasonable option for treating these patients.

Limitations of structural allograft in revision total knee arthroplasty.

Bauman RD, Lewallen DG, Hanssen AD. Clin Orthop Relat Res. 2009 Mar;467(3):818-24. This paper reviews the outcome of treatment of major bone defects treated with a structural allograft at the time of knee revision. 74 patients with 79 knees were evaluated at a minimum five years. 65 patients and 70 knees were available for review. 16 patients (22.8%) had failed reconstructions and underwent additional revision surger. 8 of the 16 were secondary to the allograft failure. An additional 3 were secondary to failure of a component not supported by an allograft and 5 became infected. The revision free survivorship in this study was 80.7% at 5 years and 75.9% at 10 years.

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Case reports: Tantalum debris dispersion during revision of a tibial component for TKA.
Sanchez Marquez JM, Del Sel N, Leali A, Gonzlez Della Valle A. Clin Orthop Relat Res. 2009 Apr;467(4):1107-10. This is a case report of tantalum debris seen during revision of a tibial component. The authors revised 3 well fixed tantalum tibial trays. The component was removed with osteotomes and oscillating saws. They state that the removal of the components was laborious and resulted in generation of abundant tantalum debris that seeded the periarticular soft tissues, despite meticulous protection with gauze. The retained debris was visible on postoperative radiographs.

SELECTED HIP REFERENCES 2009

Total hip arthroplasty with shortening subtrochanteric osteotomy in Crowe type-IV developmental dysplasia.
Krych AJ, Howard JL, Trousdale RT, Cabanela ME, Berry DJ. J Bone Joint Surg Am. 2009 Sep;91(9):2213-21.

Medium-term outcome of periacetabular osteotomy and predictors of conversion to total hip replacement.
Troelsen A, Elmengaard B, Sballe K. J Bone Joint Surg Am. 2009 Sep;91(9):2169-79.

Intermediate to long-term results following the Bernese periacetabular osteotomy and predictors of clinical outcome.
Matheney T, Kim YJ, Zurakowski D, Matero C, Millis M. J Bone Joint Surg Am. 2009 Sep;91(9):2113-23.

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Fulfillment of patients' expectations for total hip arthroplasty.

Mancuso CA, Jout J, Salvati EA, Sculco TP. J Bone Joint Surg Am. 2009 Sep;91(9):2073-8.

Acetabular revision with impacted morsellised cancellous bone grafting and a cemented acetabular component: a 20- to 25-year follow-up.
Schreurs BW, Keurentjes JC, Gardeniers JW, Verdonschot N, Slooff TJ, Veth RP. J Bone Joint Surg Br. 2009 Sep;91(9):1148-53

Early clinical failure of the Birmingham metal-on-metal hip resurfacing is associated with metallosis and soft-tissue necrosis.
Ollivere B, Darrah C, Barker T, Nolan J, Porteous MJ. J Bone Joint Surg Br. 2009 Aug;91(8):1025-30.

Hip resurfacings revised for inflammatory pseudotumour have a poor outcome.

Grammatopolous G, Pandit H, Kwon YM, Gundle R, McLardy-Smith P, J Bone Joint Surg Br. 2009 Aug;91(8):1019-24.

The epidemiology of bearing surface usage in total hip arthroplasty in the United States.
Bozic KJ, Kurtz S, Lau E, Ong K, Chiu V, Vail TP, Rubash HE, Berry DJ. J Bone Joint Surg Am. 2009 Jul;91(7):1614-20

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Acetabular revision using an anti-protrusion (ilio-ischial) cage and trabecular metal acetabular component for severe acetabular bone loss associated with pelvic discontinuity.
Kosashvili Y, Backstein D, Safir O, Lakstein D, Gross AE. J Bone Joint Surg Br. 2009 Jul;91(7):870-6.

The squeaking hip: a phenomenon of ceramic-on-ceramic total hip arthroplasty.

Jarrett CA, Ranawat AS, Bruzzone M, Blum YC, Rodriguez JA, Ranawat CS. J Bone Joint Surg Am. 2009 Jun;91(6):1344-9.

The painful metal-on-metal hip resurfacing.

Hart AJ, Sabah S, Henckel J, Lewis A, Cobb J, Sampson B, Mitchell A, Skinner JA. J Bone Joint Surg Br. 2009 Jun;91(6):738-44

Periacetabular osteotomy for acetabular dysplasia in patients older than 40 years: a preliminary study.
Millis MB, Kain M, Sierra R, Trousdale R, Taunton MJ, Kim YJ, Rosenfeld SB, Kamath G, Schoenecker P, Clohisy JC. Clin Orthop Relat Res. 2009 Sep;467(9):2228-34.

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Primary total hip arthroplasty with a porous-coated acetabular component. A concise follow-up, at a minimum of twenty years, of previous reports.
Della Valle CJ, Mesko NW, Quigley L, Rosenberg AG, Jacobs JJ, Galante JO. J Bone Joint Surg Am. 2009 May;91(5):1130-5.

Outcome after primary and secondary replacement for subcapital fracture of the hip in 10 264 patients.
Leonardsson O, Rogmark C, Krrholm J, Akesson K, Garellick G. J Bone Joint Surg Br. 2009 May;91(5):595-600.

Outcome of uncemented primary femoral stems for treatment of femoral head osteonecrosis.
Hungerford MW, Hungerford DS, Jones LC. Orthop Clin North Am. 2009 Apr;40(2):283-9.

Charnley low-frictional torque arthroplasty: follow-up for 30 to 40 years.

Wroblewski BM, Siney PD, Fleming PA. J Bone Joint Surg Br. 2009 Apr;91(4):447-50.

Clinical comparison of polyethylene wear with zirconia or cobalt-chromium femoral heads.

Stilling M, Nielsen KA, Sballe K, Rahbek O. Clin Orthop Relat Res. 2009 Oct;467(10):2644-50.

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Slower recovery after two-incision than mini-posterior-incision total hip arthroplasty. Surgical technique.
Pagnano MW, Trousdale RT, Meneghini RM, Hanssen AD. J Bone Joint Surg Am. 2009 Mar 1;91 Suppl 2 Pt 1:50-73.

The effect of a single infusion of zoledronic acid on early implant migration in total hip arthroplasty. A randomized, double-blind, controlled trial.
Friedl G, Radl R, Stihsen C, Rehak P, Aigner R, Windhager R. J Bone Joint Surg Am. 2009 Feb;91(2):274-81.

Femoroacetabular impingement treatment using arthroscopy and anterior approach.

Laude F, Sariali E, Nogier A. Clin Orthop Relat Res. 2009 Mar;467(3):747-52.

Relationship between perioperative urinary tract infection and deep infection after joint arthroplasty.
Koulouvaris P, Sculco P, Finerty E, Sculco T, Sharrock NE Clin Orthop Relat Res. 2009 Jul;467(7):1859-67.

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The use of alendronate in the treatment of avascular necrosis of the femoral head: follow-up to eight years.
Agarwala S, Shah S, Joshi VR. J Bone Joint Surg Br. 2009 Aug;91(8):1013-8

Pyrolytic carbon endoprosthetic replacement for osteonecrosis and femoral fracture of the hip: a pilot study.
Bernasek TL, Stahl JL, Pupello D. Clin Orthop Relat Res. 2009 Jul;467(7):1826-32

Athletic Injuries of the Knee: A Comprehensive Review

James P. Bradley, MD
Clinical Associate Professor University of Pittsburgh Medical Center Team Physician, Pittsburgh Steelers

Timothy L. Miller, MD
Sports Medicine Fellow University of Pittsburgh Medical Center

OVERVIEW
Biomechanics, Kinematics, and Anatomy History and Physical Exam Radiology Arthroscopy Menisci Articular Lesions Synovial Pathology Ligamentous Injuries Overuse Injuries Patellofemoral Joint Pediatric Injuries Questions

HANDOUT
This handout contains an outline, a copy of the slides used for the talk, and sample questions. Each section contains a detailed bibliography for reference. Anything in BOLD has been asked on a review test

BIOMECHANICS, KINEMATICS, & ANATOMY

KINEMATICS The motion of the knee joint and interplay between the ligamentous supports of the knee is described as the four bar cruciate linkage system. It consists of the ACL, PCL, femoral link, and tibial link. As the knee flexes, the center of joint rotation (intersection of the cruciate ligaments) moves posterior, causing rolling and gliding to occur. It is critical to attempt to achieve ligament "isometry" during reconstructions, meaning the ligaments should lie within the flexion axis in all positions of knee motion.

KNEE BIOMECHANICS Diarthrodial Joint, allows for simultaneous rotation and translation The role of the ligaments of the knee is to provide passive restraints to abnormal motion. The height of the lateral femoral condyle is greater than that of the medial condyle. The alignment of the condyles is also different; the lateral condyle is relatively straight, but the medial condyle is curved. This allows the medial tibial plateau to rotate externally in full extension termed the "screw home mechanism" 6 degrees of freedom KNEE ANATOMY AND BIOMECHANICS: ACL LFC => Tibia (The tibial insertion is a broad, irregular, oval-shaped area just anterior to and between the intercondylar eminences of the tibia. The femoral attachment is a semicircular area on the posteromedial aspect of the lateral femoral condyle.) Average length and width 33 mm x 11 mm 2 Bundles: anteromedial bundle that is tight in flexion posterolateral bundle that is tight in extension The intercondylar ridge and bifurcate ridge are bony landmarks on the medial aspect of the lateral femoral condyle that can be used to help identify the insertion sites of the bundles of the ACL. Middle Geniculate A. is the primary blood supply for both cruciates but the primary ACL blood supply is via epiligamentous tissue not the insertion sites 1% composed of nerve tissue The ACL is composed of 90% type I collagen and 10% type III collagen

KNEE ANATOMY AND BIOMECHANICS: PCL MFC => Tibia sulcus (The Posterior cruciate ligament (PCL) originates from a broad, crescent-shaped area anterolaterally on the medial femoral condyle and inserts on the tibia in a sulcus that is below the articular surface.) Average length and width 38 mm x 13 mm (compare this to ACL) 2 Bundles: anterolateral bundle that is tight in flexion posteromedial bundle that is tight in extension Variable meniscofemoral ligaments (Humphry'santerior; Wrisberg's posterior) originate from the posterior horn of the lateral meniscus and insert into the substance of the PCL. Middle Geniculate A. is the primary blood supply for both cruciates

KNEE ANATOMY AND BIOMECHANICS: MCL MFC => Tibia Superficial The superficial MCL is also known as the tibial collateral ligament and lies deep to the gracilis and semitendinosis tendons. It originates from the medial femoral epicondyle and inserts onto the periosteum of the proximal tibia, deep to the pes anserinus. The anterior fibers of the superficial MCL tighten during the first 90 of motion, while the posterior fibers tighten in extension. Deep The deep portion of the ligament is also referred to as the medial capsular ligament and is a capsular thickening that blends with the superficial fibers and is intimately associated with the medial meniscus by attachments to the coronary ligaments. KNEE ANATOMY AND BIOMECHANICS: LCL Also called the fibular collateral ligament Cord-Like when on stretch Since it is located behind the axis of knee rotation, the LCL is tight in extension and lax in flexion. Originates on the lateral femoral epicondyle posterior and superior to the insertion of the popliteus tendon and inserts on the lateral aspect of the fibular head. KNEE ANATOMY AND BIOMECHANICS: Tensile strength of Ligaments ACL: approximately 2200 N, and up to 2500 N in young individuals. The PCL is though to have a higher tensile strength than the ACL, but its value is disputed. The MCL has approximately twice the stiffness and tensile strength as the ACL. LCL is approximately 750 N. KNEE ANATOMY AND BIOMECHANICS: Posteromedial Corner Structures deep to the MCL Important for rotary stability. Layer 1: Sartorius Layer 2: Sup MCL, POL (originates on the adductor tubercle), SM Layer 3: Deep MCL, capsule

KNEE ANATOMY AND BIOMECHANICS: Posterolateral Corner The Posterolateral Corner is becoming increasingly more important in treating the multiple ligament-injured knees. It consists of superficial and deep layers. PLC: Superficial:

Biceps, ITT PLC: Deep: LCL capsule Popliteus (originates on the back of the tibia and inserts medial, anterior, and distal to the LCL) Arcuate ligament (contiguous with the oblique popliteal ligament medially) Popliteofibular ligament (from popliteus to fibular head) KNEE ANATOMY AND BIOMECHANICS: PF JOINT The patellofemoral joint is composed of the patella (with variably sized medial and lateral facets) and the femoral trochlea. 2 Facets: Medial (Proper & Odd) -- Lateral (Longer & Wider) Patella increases moment arm (Quads) Fully engaged @ 20-40o Cartilage 5 mm thick (thickest in the body and can withstand forces several times body weight (Forces normally = 3-5 x BW) The patella is restrained in the trochlea by the valgus axis of the quadriceps mechanism (Q angle), the oblique fibers of the vastus medialis and lateralis muscles (and their extensionsthe patella retinacula), and the patellofemoral ligaments. The medial patellofemoral ligament (MPFL), originates from the femur 1.9 mm anterior and 3.8 mm distal to the adductor tubercle. It inserts onto the proximal 1/3 of the medial border of the patella and is the key restraint in preventing lateral displacement of the patella. Biomechanically, it has been shown to account for 53-60% of the restraining force of the patella to lateral subluxation. When tensioning a MPFL reconstruction, the graft should be tensioned with 2N at 30 degrees of flexion KNEE ANATOMY AND BIOMECHANICS: Meniscus Crescent shaped fibrocartilaginous structures that are triangular in crosssection Medial = C-shaped Lateral = Semicircular The role of the menisci is to deepen the tibial surface, act as a secondary stabilizer (the posterior horn of medial meniscus [PHMM]), nutrition, and lubrication The menisci are connected anteriorly by the transverse (intermeniscal) ligament The menisci are attached peripherally via the coronary ligaments

MENISCUS: LOAD TRANSMISSION 50% joint load transmitted in full ext. 85% joint load transmitted in 90 flex. Total meniscectomy decreases contact area by 50% 15-34% partial meniscectomy increases contact pressure by 350% KNEE ANATOMY AND BIOMECHANICS: Meniscus Perimeniscal capillary plexus (med and lat genicular arteries) provides blood supply to the periphery of the menisci. The peripheral 2030% of the medial menisci and 10-25% of the lateral meniscus are vascularized. Blood supply regresses with age, which changes the demarcation of the red-red, red-white, and white-white zones. KNEE ANATOMY AND BIOMECHANICS: Meniscus The collagen fibers of the menisci are arranged radially and longitudinally The longitudinal fibers help dissipate hoop stresses Both fibers help the menisci expand under compressive force Type I collagen is the predominant collagen in the menisci Lateral meniscus has 2x the excursion of medial. The menisci increase the contact area of the joint significantly. ACL deficiency increases the load on the menisci, particularly the posterior horn of the medial menisci. Acute ACL tear > 50% have tears of menisci 83% are lateral, however in chronic ACL tears medial meniscal tears are more common Attachment @ horns is critical: Lateral: Near ACL Medial: Far separated from the ACL

KNEE ANATOMY AND BIOMECHANICS: Key Testable Items Four-bar linkage system Screw home mechanism When are the bundles of ACL/PCL tight/lax (Ant bundles are tight in flexion) Insertion of LCL in relation to popliteus Superficial and Deep Components of PLC Anatomy / Insertion of the menisci Contact pressure increases with menisectomy Hoop stresses of menisci and blood supply KNEE ANATOMY AND BIOMECHANICS: REFERENCES Arnoczky, S.P.: Anatomy of the anterior cruciate ligament. Clin. Orthop. 172:19 25, 1983.

Arnoczky, S.P., and Warren, R.F.: Microvasculature of the human meniscus. Am. J. Sports Med. 10:9095, 1982. Beck P, Brown NA, Greis PE, Burks RT. Patellofemoral contact pressures and lateral patellar translation after medial patellofemoral ligament reconstruction. Am J Sports Med. 35(9): 1557-63, 2007. Chhabra, A., Elliot, C., Miller, M.D.: Normal Anatomy and Biomechanics of the Knee. Sports Medicine and Arthroscopy Review. 9: 166-177, 2002. Cooper, D.E., Deng, X.H., Burnstein, A.L., et al.: The strength of the central third patellar tendon graft: A biomechanical study. Am. J. Sports Med. 21:818824, 1993. Daniel, D.M., Akeson, W.H., and O'Connor, J.J., eds.: Knee Ligaments: Structure, Function, Injury, and Repair. New York, Raven Press, 1990. Ferretti M, Ekdahl M, Shen W, Fu FH. Osseous Landmarks of the femoral attachment of the anterior cruciate ligament: an anatomic study. Arthroscopy. 23(11): 1218-25, 2007. Fu, F.H., Harner, C.D., Johnson, D.L., et al.: Biomechanics of knee ligaments: Basic concepts and clinical application. J. Bone Joint Surg. 75:17161725, 1993. Girgis, F.G., Marshall, J.L., and Al Monajem, A.R.S.: The cruciate ligaments of the knee joint: Anatomical, functional and experimental analysis. Clin. Orthop. 106:216231, 1975. LaPrade RF, Engebretsen AH, Ly TB, Johansen S, Wentorf FA, Engebretsen L. The anatomy of the medial part of the knee. J Bone Joint Surg [Am] 89(9): 20010. Noyes, F.R., Butler, D.L., Grood, E.S., et al.: Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. J. Bone Joint Surg. [Am.] 66:344352, 1984. Seebacher, J.R., Inglis, A.E., Marshall, J.L., et al.: The structure of the posterolateral aspect of the knee. J. Bone Joint Surg. [Am.] 64:536541, 1982. Thompson, W.O., Theate, F.L., Fu, F.H., et al.: Tibial meniscal dynamics using three-dimensional reconstruction of magnetic resonance images. Am. J. Sports Med. 19:210216, 1991. Warren, L.F., and Marshall, J.L.: The supporting structures and layers of the medial side of the knee. J. Bone Joint Surg. [Am.] 61:5662, 1979.

Warren, R., Arnoczky, S.P., and Wickiewicz, T.L.: Anatomy of the knee. In Nicholas, J.A., and Hershman, E.B., eds.: The Lower Extremity and Spine in Sports Medicine, St. Louis: CV Mosby, 1986, pp. 657694.

HISTORY & PHYSICAL EXAM

KNEE: HISTORY A complete history and clarification of mechanism is essential. The age of the patient is also critical (younger patients have meniscal or ligamentous injuries) (older patients usually have degenerative conditions) Pain with stair climbing = Patellofemoral etiology Mechanical symptoms, squatting pain = meniscal tear Noncontact with pop = ACL Ant blow with DF foot = patella Ant blow with PF foot = PCL

PHYSICAL EXAM Injury Exam ACL Lachman, Pivot Shift PCL Post Drawer Quad Active, sag MCL Valgus 30o LCL Varus 30o PLC ER Asymmetry Menisci JLT, McMurray Patellar Apprehension Instab Pat. Grind PF pathology KNEE: PHYSICAL EXAM Exam Injury PCL increased ER at 90 PLC increased ER at 30 PCL/PLC increased ER at 30 & 90 KNEE: LAXITY TESTING KT 1000 and 2000 is the accepted standardized laxity device ACL is measured with the knee slightly flexed and ER 20-30 degrees Side to side comparison (> 3 mm significant) PCL laxity measurement much less accurate HISTORY & PHYSICAL EXAM: Key Testable Items Non-contact injury, + pop, unable to RTP (ACL injury)

Most sensitive PE test for ACL (Lachman) Lachman AM bundle, pivot PL bundle Quad active test (they will describe the test) (for PCL injury) ER at 30 and 90 degrees to distinguish between PCL and PLC injuries Position of foot for PCL injuries vs patella fractures HISTORY & PHYSICAL EXAM: REFERENCES Fetto, J.F., and Marshall, J.L.: Injury to the anterior cruciate ligament producing the pivot shift sign. J. Bone Joint Surg. [Am.] 61:710714, 1979. Fulkerson, J.P., Kalenak, A., Rosenberg, T.D., et al.: Patellofemoral pain. Instr. Course Lect. 41:5771, 1992. Galway, R.D., Beaupre, A., and MacIntosh, D.L.: Pivot shift. J. Bone Joint Surg. [Br.] 54:763, 1972. Hosea, T.M., and Tria, A.J.: Physical examination of the knee: clinical. In Scott, W.N., ed.: Ligament and Extensor Mechanism Injuries of the Knee: Diagnosis and Treatment. St. Louis, CV Mosby, 1991. Ritchie, J.R., Miller, M.D., and Harner, C.D.: History and physical examination of the knee. In Fu, F.H., Harner, C.D., and Vince, K.G., eds.: Knee Surgery. Baltimore, Williams & Wilkins, 1994. Slocum, D.B., and Larson, R.L.: Rotatory instability of the knee. J. Bone Joint Surg. [Am.] 50:211, 1968.

IMAGING
KNEE IMAGING: STANDARD RADIOGRAPHS Standard Radiographs. Standard plain films include an AP view, 45 degree PA View, Lateral View and a Merchant (45 degrees) or Laurin View (20 degrees) of the patella. Additional views include long cassette lower extremity views, obliques, and stress radiographs. KNEE IMAGING: STRESS RADIOGRAPHS Varus/Valgus for collaterals and peds growth plate injuries: MCL/LCL Physeal Fractures Posterior: -PCL Measurement KNEE IMAGING: NUCLEAR IMAGING Stress fractures

Early DJD Reflex Sympathetic Dystrophy KNEE IMAGING: MRI Imaging modality of choice for ligamentous injuries, AVN, articular cartilage defects, and meniscal tears Bone Bruise in ACL teas Osteochondral injury LFC (Mid 1/3) & LTP (Post 1/3) with ACL tears OCD: Look for fluid interposition which determines stability, and thus operative vs. non-operative treatment Patellar dislocation bone edema LFC & medial patella Discoid meniscus Displaced lateral meniscal tear

KNEE IMAGING: CT SCANS Largely replaced by MRI Still useful for bony tumors or fractures IMAGING: Key Testable Items Fairbanks changes Segond lesion is an avulsion of what? What does it indicate? Bone bruise pattern for ACL / PCL injuries, MRI findings in discoid meniscus & patellar dislocations Stress radiographs for physeal injuries IMAGING: REFERENCES Blackburne, J.S., and Peel, T.E.: A new method of measuring patellar height. J. Bone Joint Surg. [Br.] 59:241242, 1977. Blumensaat, C.: Die lageabweichunger and verrenkungen der kniescheibe. Ergeb. Chir. Orthop. 31:149223, 1938. Insall, J., and Salvati, E.: Patella position in the normal knee joint. Radiology 101:101104, 1971. Jackson, D.W., Jennings, L.D., Maywood, R.M., et al.: Magnetic resonance imaging of the knee. Am. J. Sports Med. 16:2938, 1988. Jackson, R.W.: The painful knee: Arthroscopy or MR Imaging. J. Am. Acad. Orthop. Surg. 4:9399, 1996. Merchant, A.C., Mercer, R.L., Jacobsen, R.H., et al.: Roentgenographic analysis of patellofemoral congruence. J. Bone Joint Surg. [Am.] 56:13911396, 1974.

Newhouse, K.E., and Rosenberg, T.D.: Basic radiographic examination of the knee. In Fu, F.H., Harner, C.D., and Vince, K.G., eds.: Knee Surgery. Baltimore, Williams & Wilkins, 1994, pp. 313324. Rosenberg, T.D., Paulos, L.E., Parker, R.D., et al.: The forty-five degree posteroanterior flexion weight-bearing radiograph of the knee. J. Bone Joint Surg. [Am.] 70:14791483, 1988. Thaete, F.L., and Britton, C.A.: Magnetic resonance imaging. In Fu, F.H., Harner, C.D., and Vince, K.G., eds.: Knee Surgery. Baltimore, Williams & Wilkins, 1994.

KNEE ARTHROSCOPY
KNEE ARTHROSCOPY: GENERAL CONCEPTS The Gold Standard for diagnosis of knee pathology is arthroscopy. The benefits of arthroscopy include smaller incisions, improved visualization, and less recovery time KNEE ARTHROSCOPY: PORTALS Standard portals include superomedial or superolateral inflow portal (made with knee in extension), inferolateral (arthroscope) and inferomedial (instruments) portals Accessory portals, sometimes helpful for visualizing the posterior horns of the menisci and PCL, include the posteromedial portal (1 cm above the joint line behind the MCL [avoid saphenous nerve branches]) and the posterolateral portal (1 cm above the joint line between the LCL and biceps tendon [avoiding the common peroneal nerve]). Posterior Horn of Medial Menisci (PHMM): AL & PM = Best visualization Patellar tracking: Superior = Best visualization KNEE ARTHROSCOPY: COMPLICATIONS Complications - Iatrogenic articular cartilage damage (most common) - Hemarthrosis - Infection - Neurovascular injury - Blood clots KNEE ARTHROSCOPY: Key Testable Items Portals Most common complications Prophylaxis for those with prior DVT KNEE ARTHROSCOPY: REFERENCES

DeLee, J.C.: Complications of arthroscopy and arthroscopic surgery: Results of a national survey. Arthroscopy 4:214220, 1988. DiGiovine, N.M., and Bradley, J.P.: Arthroscopic equipment and set-up. In Fu, F.H., Harner, C.D., and Vince, K.G., eds.: Knee Surgery. Baltimore, Williams & Wilkins, 1994. Gillquist, J.: Arthroscopy of the posterior compartments of the knee. Contemp. Orthop. 10:3945, 1985. Johnson, L.L.: Arthroscopic Surgery: Principles and Practice, 3rd ed. St. Louis, CV Mosby, 1986. O'Connor, R.L.: Arthroscopy in the diagnosis and treatment of acute ligament injuries of the knee. J. Bone Joint Surg. [Am.] 56:333337, 1974. Rosenberg, T.D., Paulos, L.E., Parker, R.D., et al.: Arthroscopic surgery of the knee. In Chapman, M.W., ed.: Operative Orthopaedics. Philadelphia, JB Lippincott, 1988, pp. 15851604. Small, N.C.: Complications in arthroscopy: The knee and other joints. Arthroscopy 2:253258, 1986. Wantanabe, M., and Takeda, S.: The number 21 arthroscope. J. Jpn. Orthop. Assoc. 34:1041, 1960.

MENISCI
MENISCAL TEARS Most common injury to the knee that requires surgery Higher risk in ACL-deficient knee The medial meniscus is torn approximately three times more frequently than the lateral meniscus due to less excursion (Lat meniscus motion 2X medial) Acute ACL tear Posterior horn of lateral meniscus Chronic ACL deficiency Medial Meniscus tear Young: Traumatic injury, usually peripheral, 60% with ACL tears Older: Degenerative tears, usually posterior horn medial meniscus due to increase contact stresses, usually insidious onset Meniscal tears are classified based on their: Location in relation to the vascular supply (and healing potential) Position (anterior, middle, or posterior third) Appearance Orientation. Meniscal root tears are becoming more commonly diagnosed. They are especially problematic for patients because they represent complete disruption

of the longitudinal fibers and are difficult to repair. PARTIAL MENISECTOMY Is indicated if tear is irreparable Complex/ degenerative/ central/ and sometimes radial Motorized shaver is helpful in creating a smooth transition zone Lasers and Radiofrequency (RF) are not the answer because of iatrogenic chondral risk Minimal removal while giving smooth and stable rim DJD Risk proportional to amount removed MENISCAL REPAIR Indications Peripheral longitudinal tears Young patients With ACL Reconstruction Contraindication: ACL Deficiency Improved healing with combined ACL reconstruction (90%) 80-90% success rate with appropriate indications Healing by inflammatory cell infiltration Techniques: Open, Outside-in, All inside, Inside-out Augmentation techniques, including fibrin clot, trephinization, and rasping can extend the indications for repair The gold standard for meniscal repair is the inside-out technique with vertical mattress sutures. (If this is an option, it is the answer) Newer techniques for all-inside repairs (arrows, darts, staples, screws, etc.) are easy to use, but not proven to be superior to vertical mattress sutures. Risks of new all inside devices include Breakage, Migration, Synovitis, Chondral Injury, and Decreased strength MENISCAL REPAIR RISKS Medial: Saphenous N/V Popliteal vessels Lateral: Peroneal Nerve Popliteal vessels Common Peroneal Nerve can be found posterior and medial to biceps femoris long head tendon MENISCUS TRANSPLANTATION Indications are controversial Indicated in young active patients with pain who have had a near total menisectomy good axial alignment and only early chondrosis (up to Grade II Chondrosis)

Avoid in patients with Grade III or IV Chondrosis Need near normal mechanical alignment to have success Technically Difficult May require concomitant realignment procedure (HTO) ? Long-term Results Shrinkage/Degeneration Technique is evolving, but generally, is arthroscopic with the menisci introduced through the contralateral portal Medial: Usually use Bone Plugs Lateral: Usually use Bone Bridge Peripheral Sutures for both medial and lateral Proteoglycans decreased and Water content increased at 6 months Question is do they function MENISCAL CYSTS Most commonly associated with LM horizontal cleavage tears Cyst fluid is gel-like and similar in content to synovial fluid Partial meniscectomy and arthroscopic decompression (sometimes including needling the cyst) Popliteal cysts are also related to meniscal disorder and will usually resolve with treatment. Their classic location is between the semimembranosus and medial head of the gastrocnemius. They will ask the anatomic landmarks of this space DISCOID MENISCI Often called Popping knee syndrome Clinical findings include mechanical symptoms or popping as the knee reaches extension X-Ray findings joint space widening squaring of lateral tibial plateau hypoplastic lateral spine MRI can help in diagnosis and to find a tear (3 sequential cuts for diagnosis of meniscal tear) Classification Type I - Incomplete Type II - Complete Type III- Wrisberg (peripheral detachment) Treatment: Saucerization of tears Meniscal repair of posterior detachments (Wrisbergs variant) Observation if Asymptomatic MENISCI: Key Testable Items Medial > Lateral tears Most common location of degenerative tears Gold standard for menical repairs

Risks for medial and lateral meniscal repairs Meniscal cysts are associated with what type of meniscal tears? Location of Popliteal cysts Classification/MRI/Treatment of Discoid Menisci MENISCI: REFERENCES Arnoczky, S.P., Warren, R.F., and Spivak, J.M.: Meniscal repair using an exogenous fibrin clotAn experimental study in dogs. J. Bone Joint Surg. [Am.] 70:12091220, 1988. Baratz, M.E., Fu, F.H., and Mengato, R.: Meniscal tears: The effect of meniscectomy and of repair on intra-articular contact areas and stresses in the human knee. Am. J. Sports Med. 14:270275, 1986. Belzer J.P., and Cannon W.D. Meniscus tears: Treatment in the stable and unstable knee. J. Am. Acad. Orthop. Surg. 1:4147, 1993. Boenisch, U.W., Faber, K.J., et. al.: Pull out strength and stiffness of meniscal repair using absorbable arrows or Ti-cron vertical and horizontal loop sutures. Am J Sports Med, 27: 626-631, 1999. Carter, T.R.: Meniscal allograft transplantation. Sports Med Arthrosc Rev, 7: 5162, 1999. Cannon, W.D., and Vittori, J.M.: The incidence of healing in arthroscopic meniscal repairs in anterior cruciate ligament reconstructed knees versus stable knees. Am. J. Sports Med. 20:176181, 1992. DeHaven, K.E., Black, K.P., and Griffiths, H.J.: Open meniscus repair: Technique and two to nine year results. Am. J. Sports Med. 17:788795, 1989. DeHaven, K.E.: Meniscus Repair. Am. J. Sports Med, 27: 242-250, 1999. Dickhaut, S.C., and DeLee, J.C.: The discoid lateral meniscus syndrome. J. Bone Joint Surg. [Am.] 64:10681073, 1982. Fairbank, T.J.: Knee joint changes after meniscectomy. J. Bone Joint Surg. [Br.] 30:664670, 1948. Henning, C.E., Lynch, M.A., Yearout, K.M., et al.: Arthroscopic meniscal repair using an exogenous fibrin clot. Clin. Orthop. 252:64, 1990. Jordan M.R., Lateral meniscal variants: Evaluation and treatment. J. Am. Acad. Orthop. Surg. 4:191200, 1996. Miller, M.D., Ritchie, J.R., Royster, R.M., et al.: Meniscal repair: An experimental study in the goat. Am. J. Sports Med. 23(1):124128, 1995.

Miller, M.D., Warner, J.J.P., and Harner, C.D.: Mensical repair. In Fu, F.H., Harner, C.D., and Vince, K.G., eds.: Knee Surgery. Baltimore, Williams & Wilkins, 1994. Neuschwander, D.C., Drez, D., and Finney, T.P.: Lateral meniscal variant with absence of the posterior coronary ligament. J. Bone Joint Surg. [Am.] 74:1186 1190, 1992. Parisien, J.S.: Arthroscopic treatment of cysts of the menisci: A preliminary report. Clin. Orthop. 257:154158, 1990. Warren, R.F.: Meniscectomy and repair in the anterior cruciate ligamentdeficient patient. Clin. Orthop. 252:5563, 1990.

OSTEOCHONDRAL INJURIES
OSTEOCHONDRAL LESIONS: OCD Involves subchondral bone and overlying cartilage separation, most likely as a result of occult trauma. Most often involves the lateral aspect of the medial femoral condyle. Juvenile form open physes Majority heal spontaneously Less risk of DJD Good prognosis Adult Form MFC (85%); LFC (15%) usually symptomatic Posterolateral aspect of MFC (70%) Pathological changes begin in subchondral bone Worse prognosis because leads to DJD Operative treatment in most loose, symptomatic, and adult forms OSTEOCHONDRAL LESIONS: Treatment Initial treatment for stable fragment is 6 weeks of activity modification and restricted weightbearing. Cartilage soft but intact w/o separation Retrograde drilling Cartilage soft but intact w/ early separation Retrograde drilling + fixation Cartilage partially detached Debride base, reduce + fixation Loose body / Crater (NWB area) Debride and microfracture Loose body / Crater (WB area)

 Debride + microfracture (<2cm) OATS vs. Autologous Chondrocyte Implant (larger lesion) Best harvest location = medial femoral trochlea Osteotomy or arthroplasty (large)

Microfracture (Produces Type I Collagen fibrocartilage Not type II collagen) small (<2cm) focal lesions OSTEONECROSIS Atraumatic ON Same risks as hip ON Risk factors are the same as for hip AVN Common in elderly females Often is wedge shaped by MRI Core decompression is treatment if caught early enough. In later stages, arthroplasty is treatment of choice SONK (Spontaneous Osteonecrosis of the Knee) Subchondral Insufficiency Fracture May follow arthroscopy in older patients Diagnosis is by MRI Often is a self-limiting condition Intra-articular use of lidocaine Recent work has shown that lidocaine is cytotoxic to chondrocytes of articular cartilage in a dose- and time-dependent manner. Post-operative intra-articular lidocaine catheters are no longer recommended. OSTEOCHONDRAL LESIONS: Key Testable Items Most important prognostic factor for OCD lesions Most common locations of OCD When is operative treatment indicated in OCD lesions Basic science of microfracture technique Recognize SONK following scope, treat conservatively OSTEOCHONDRAL LESIONS: REFERENCES Bauer, M., and Jackson, R.W.: Chondral lesions of the femoral condyles: A system of arthroscopic classification. Arthroscopy 4:97102, 1988. Buckwalter, J.A., Restoration of injured or degenerated articular cartilage. J. Am. Acad. Orthop. Surg. 2:192201, 1994. Buckwalter, J.A., and Mankin, H.J., Articular cartilage (parts I&II). Instructional Course Lectures. J. Bone Joint Surg. 79A:600632, 1997.

Bugbee, W.D., Convery, F.R.: Osteochondral allograft transplantation. Clin Sports Med, 18: 67-75, 1999. Cahill, B.R.: Osteochondritis dissecans of the knee: Treatment of juvenile and adult forms. J. Am. Acad. Orthop. Surg. 3:237247, 1995. Ecker, M.L., and Lotke, P.A.: Spontaneous osteonecrosis of the knee. J. Am. Acad. Orthop. Surg. 2:173178, 1994. Guhl, J.: Arthroscopic treatment of osteochondritis dissecans. Clin. Orthop. 167:6574, 1982. Karpie JC, Chu CR. Lidocaine exhibis dose- and time-dependent cytotoxic effects on bovie articular chondrocytes in vitro. Am J Sports Med. 35(10): 16217, 2007. Mandelbaum, B.R., Browne, J.E., Fu, F.H., et al.: Articular cartilage lesions of the knee: Current concepts. Am. J. Sports Med. 26:853861, 1998. Menche, D.S., Vangsness, C.T., Pitman, M, et al.: The treatment of isolated articular cartilage lesions in the young individual. AAOS Instr. Course Lect. 47:505515, 1998. Murray, P.B., and Rand, J.A.: Symptomatic valgus knee: The surgical options. J. Am. Acad. Orthop. Surg. 1:19, 1993. Newman, A.P.: Articular cartilage repair: Current concepts. Am. J. Sports Med. 26:309324, 1998. O'Driscoll, S.W.: Current concepts review: The healing and regeneration of articular cartilage. J. Bone Joint Surg. 80A:17951812, 1998. Schenck, R.C., and Goodnight, J.M.: Current concepts review: Osteochondritis dissecans. J. Bone Joint Surg. 78A:439456, 1996.

SYNOVIAL PATHOLOGY
SYNOVIAL LESIONS Pigmented Villonodular Synovitis (PVNS) Patients present with pain and swelling and may have a palpable mass. Synovectomy is effective, but there is a high recurrence rate. Arthroscopic techniques are just as effective as traditional open procedures. They will give you a brownish synovium and a hemorrhagic aspirate in the question Recognize gross histological specimen Synovial Chondromatosis

This proliferative disease of the synovium is associated with cartilaginous metaplasia, resulting in multiple intra-articular loose bodies. Synovectomy is treatment of choice SYNOVIAL LESIONS: Treatment Synovectomy is effective treatment and treatment of choice for: Pauciarticular JRA Hemophilia Rheumatoid Arthritis (following failed medical management) Chondromatosis PVNS Additional arthroscopic portals are required for complete synovectomy Intra-articular instillation of radioactive isotopes and extermal beam radiotherapy have been used to augment synovectomy in cases of synovial lesions SYNOVIAL LESIONS: Plica Synovial folds that are embryologic remnants Plica Syndrome includes pathologic plica Medial Plicae most common Causes abrasion to the MFC There is often a history of blunt trauma Often presents with chronic anteromedial knee pain or subpatellar tightness with squatting Treatment arthroscopic resection Diagnosis is overused SYNOVIAL PATHOLOGY: Key Testable Items Recognize gross histology of PVNS and Synovial Chondromatosis Open synovectomy if multiple arthroscopic failures Plica is a diagnosis of exclusion, but is rarely the answer on boards SYNOVIAL PATHOLOGY: REFERENCES Curl, W.W.: Popliteal cysts: Historical background and current knowledge. J. Am. Acad. Orthop. Surg. 4:129133, 1996. Ewing, J.W.: Plica: Pathologic or not? J. Am. Acad. Orthop. Surg. 1:117121, 1993. Flandry, F., and Hughston, J.C.: Current concepts review: Pigmented villonodular synovitis. J. Bone Joint Surg. [Am.] 69:942, 1987. Mendenhall WM, Mendenhall CM, Reith JD, Scarborough MT, Gibbs CP, Mendenhall NP. Pigmented villonodular synovitis. Am J Clin Oncol. 29(6): 54850, 2006.

LIGAMENTOUS KNEE INJURIES

LIGAMENTOUS KNEE INJURIES: ACL Non-contact pivoting injury Hear or feel a Pop / with effusion (70%+ ACL rupture rate) Most are unable to Return to play Patients demonstrace a quadriceps avoidance gait The natural history of chronic ACL deficiency is a higher incidence of complex meniscal tears not amenable to repair and chondral injuries (usually posterior medial tibial plateau) over time Bone bruises (trabecular microfractures) occur in over half of acute ACL injuries and are typically located near the sulcus terminalis on the lateral femoral condyle and the posterolateral aspect of the tibia Treatment decisions should be individualized based on age, activity level, instability, associated injuries, and other factors The development of late arthritis in ACL-deficient versus reconstructed knees is controversial ACL injuries commonly associated with lateral meniscal tears Especially in skiers Med meniscal tears are more common in chronic ACL tears Female athlete 2-8X increased incidence of ACL tears when compared to males due to: Smaller notch width index to size of ACL ligament Increased valgus landing jumps (different landing biomechanics) Hormonal influences Training (quads > hamstrings) Neuromuscular Control Imbalances Increased joint laxity ACL: PHYSICAL EXAM Lachman test (30 degrees) is the most sensitive examination for acute ACL injuries Anterior Drawer (90 degrees) Pivot Shift or Jerk Test is often helpful during the exam under anaesthesia KT-1000 or 2000 is useful in quantifying laxity ACL TREATMENT Nonoperative treatment is recommended in: Low-demand patients with less laxity Operative treatment is recommended in: Higher demand, active patients Because it reduces the incidence of chondral and meniscal injury Intra-articular reconstruction is currently favored for patients who meet the criteria

 Primary repair of ACL tears is not currently recommended Over the top femoral tunnels are used primarily in revision situations and in

children Graft choices are dependent on patient factors and surgeon preference Bone Patellar Tendon Bone: gold standard Hamstrings grafts have been shown to be fixation dependent Highest Strength & Stiffness in biomechanical studies Quadriceps rarely used Allograft becoming more popular HIV Risk 1:1.7 Million Hepatitis Risk 1:700,000 DB ACL reconstruction is becoming more popular. It is thought to better reproduce normal knee kinematics when compared to single bundle ACL reconstruction. Long term clinical studies are required to show a significant benefit for patients. ACL GRAFTS Preconditioning of grafts can reduce stress relaxation up to 50% Graft Healing: inflammation and necrosis, revascularization (synovium important), repopulation (~4wks), gradual remodeling 6 months necessary before return to play for graft tunnel fixation ACL ALLOGRAFTS Radiation (dose controversial) required to kill HIV Affects structural and mechanical properties of the graft. Techniques are still being developed Risk of bacterial infection transmission Clostridium most common Freezing destroys cells Doesnt adversely affect grafts Delayed Incorporation in Animal Studies Loss of cellular DNA by 4 weeks Similar process as autograft, just delayed HIV transmission risk = 1: 1.5-1.7 million Hepatitis C Risk = 1: 600,000 ACL: POST-OP REHAB ROM (full extension) is goal in early rehab phase Beware with medial sided surgery (This will slow down rehab and require longer brace wear) Avoid isokinetic quad strengthening (15-30o) early because can cause increased graft laxity Closed chain exercises are emphasized because it encourages physiologic co-contraction of knee musculature Immediate weight-bearing has been shown to reduce patellofemoral pain ACL RECONSTRUCTION: COMPLICATIONS

Aberrant tunnel placement is most common cause of late (> 6 weeks) ACL failure If tunnels are too anterior, tight in flexion If tunnels are too posterior, tight in extension If femoral tunnel is vertical (12 oclock) lachman is stable, but positive pivot shift If tibial tunnel is too vertical, there is an increased loss of flexion and a late increased anterior translation as the graft stretches out Femoral Tunnel at 10:30-11 (right) or 1-1:30 (left) has been shown to increase rotational control Arthrofibrosis most common complication in ACL surgery Incidence increased with Patella Baja and Acute ACL Reconstruction if preop motion not returned Hardware / Fixation of Graft Most common cause of early failure (< 6 weeks) - Double the tendon in tunnels with soft tissue grafts results in >50% increases in strength at six weeks (Greis AJSM 2001) Fractures (usually occur 8-12 weeks post-op) Reduce incidence for Patella or Tibial Fractures by: Smaller Saw Blade Cutting Undersurface Drill holes at corners Less Rectangular graft Bone graft defects Cyclops Fibroproliferative tissue blocks extension Click at terminal extension Missed concurrent injuries (posterolateral corner injury), which may cause graft failure Bone Tunnel Widening (Osteolysis) More common with hamstring grafts Cause unknown Implications unknown ACL COMPLICATIONSLoss of Motion Can be due to Pre-op, Intra-op, or Post-op Causes Pre-op Causes Decreased ROM, Effusion, Decreased Quad tone, Abnormal Gait MCL/MPFL Injury Intra-op Tunnels & Tension inadequate Post-op Hemarthrosis (Treat with ice) RSD (Complex Regional Pain Syndrome [CRPS]) Early LOM (Extension is key)

Lysis of Adhesions (LOA) / Manipulation Under Anaesthesia (MUA) after 6-12 weeks if PT and serial extension splinting fails ACL SHRINKAGE Radiofrequency treatment of 18 Canine ACLs resulted in 100% ACL rupture @ 8 weeks post-tx! (Lopez and Markel AJSM 2003) Never the board answer! ACL INJURY PREVENTION Skier (Proprioceptive) Training in Vermont Beneficial for Elite Skiers, not novices Female Athlete Neuromuscular training / plyometrics are beneficial ACL Bracingonly beneficial in skiers Not effective in transition from NWB to WB LIGAMENTOUS INJURIES: PCL Mechanism of Injury Includes: Anterior blow to tibia (dashboard injury) Forceful landing on a hyperflexed knee & plantarflexed foot Hyperextension injuries can also result in PCL ruptures History: Acute Injuries: mechanism of injury and feeling of instability Chronic PCL deficient patients complain of pain with stairs and initiating sprint Chronic PCL deficiency can result in late chondrosis of the patellofemoral compartment and/or medial femoral condyle. PCL: Physical Exam Acute injuries may not have a significant effusion (distinguish this from an ACL injury) Quadriceps Active Test (Reduction of posterior subluxation with quad firing) they have described this test the last 2 years on the boards. Posterior Drawer is the key exam test with an absent or posteriorly directed tibial step off (Normal Step-off is 1 cm, i.e. the tibial plateau is 1 cm anterior to the condyles at 90 degrees of flexion) Reverse Pivot Shift / Dynamic posterior shift are valuable for high grade PCL injuries or chronic injuries Posterior Sag test is also known as Godfreys test Increased external rotation at 90 degrees only PCL: ASSOCIATED INJURIES Acute isolated PCL injuries are less common than acute isolated ACL injuries PLC (including LCL) and MCL are secondary restraints to posterior tibial translation

If PCL torn, there is an increased strain on the secondary restraints Also, if PLC injury, there is increased strain on PCL because the PCL is a secondary restraint to external tibial translation With PCL injuries, bone bruises and meniscal teas are less common than with ACL tears because of decreased loading on the posterior meniscal horns with posterior tibial translation PCL: TREATMENT Treatment is controversial, although reports suggest that nonoperative management may result in late patellar and medial femoral condyle chondrosis. Primary repair (as with ACLs), has not been successful, unless it is a bony avulsion. Bony Avulsion ORIF acutely with good results Isolated PCL injury: The answer is initial nonoperative treatment on the boards. Natural history = RTP at previous level despite increased posterior KT values Favored by some surgeons if Posterior Drawer improves with Internal Rotation (because this indicates that the PLC is intact) Quadriceps Rehab to prevent posterior subluxation is the treatment of choice Extension Brace for 2-4 wks for Grade III injuries Late Chondrosis (MFC and Patella) In the case of varus deformity and chronic PCL tear if a high tibial osteotomy is done. you must remember that you can also change the tibial slope which can address the PCL.. By increasing the slope the posterior aspect of the tibia is elevated & this will decrease posterior tibial translation Combined Injuries Reconstruction is recommended. Timing and technique are controversial, so will not be asked. PCL: RECONSTRUCTION Arthroscopic (Transtibial) reconstruction: Often technically difficult because of in passing the graft. (The killer turn around the tibia) Tibial Inlay: Uses a bone plug through a posterior approach. Puts posterior structures at risk for injury. Double-bundle PCL reconstructions are often used for chronic reconstructions

tensioned in 30o of flexion Single Bundle PCL reconstructions recreate the anterolateral bundle

Anterolateral graft is tensioned in 90o, while the posteromedial bundle is

PCL RECONSTRUCTION: OUTCOMES Single bundle PCL (arthroscopic) provides satisfactory return to function Two-bundle technique results in decreased posterior tibial translation in biomechanical studies. Tibial Inlay: Can be done as a single or double bundle Superiority not proven clinically or biomechanically yet PCL RECONSTRUCTION: REHAB Pre-op: Fixed (chronic PCL) posterior tibial translation must be corrected pre-op with posterior tibial support brace Post-op: Immobilize in extension (This question has been asked) protect against gravity (a posterior sag is present when recumbent) Quad rehabilitation Avoid open chain hamstrings (critical) Return to Play is typically 9-12 months PCL RECONSTRUCTION: COMPLICATIONS Most Common: Residual laxity over time Most Serious: Neurovascular injury: Popliteal Artery during tibial tunnel preparation (Possible with arthroscopic or tibial inlay) Other complications include: Loss of Motion Infection MFC osteonecrosis due to tunnel/tunnels in the MFC and single vessel blood supply Anterior Knee pain (due to muscle atrophy) KNEE LIGAMENTOUS INJURIES: PLC These injuries occur rarely as isolated injuries but more commonly are associated with other ligamentous injuries (especially the PCL > than the ACL). Because of poor results with chronic reconstructions, acute repair is advocated. Mechanism of Injury: Rotational injury If PLC injury missed, may be late cause of failure of ACL or PCL reconstruction

PE: ER Asymmetry (most sensitive and specific test) Increased at 30o only = Isolated PLC Increased at 30o & 90o = PCL/PLC Increased at 90o only = isolated PCL ER Recurvatum Test Posterolateral Drawer Reverse Pivot Shift (this has been asked on test) KNEE LIGAMENTOUS INJURIES: PLC Acute Treatment: Primary repair +/- augmentation vs reconstruction is often successful within 2-3 weeks For chronic treatment, the best technique is controversial, so will not be asked. Procedures recommended include posterolateral corner advancement, popliteus bypass, two and three tailed reconstruction, biceps tenodesis and, "split" grafts, which are used to reconstruct both the LCL and the popliteus/posterolateral corner,. More recently, there has been a focus to reconstruct the popliteofibular ligament. KNEE LIGAMENTOUS INJURIES: MCL Mechanism of Injury: Valgus contact stress to the knee Patients complain of pain and instability PE: Valgus opening at 30o is diagnostic for isolated MCL injuries. If there is increased opening at 0o, there is combined ligamentous injury (either ACL/MCL [more common] or PCL/MCL) Injuries most commonly occur at the femoral insertion of the ligament, and these heal more predictably than tibial sided injuries. Prophylactic bracing may be helpful for football players (interior linemen only). Delay ACL reconstruction in combined ACL-MCL Injuries until medial sided stability is improved Chronic injuries may have calcification at the medial femoral condyle insertion (Pellegrini-Stieda sign). Treatment Hinged knee brace for 6-8 weeks Initial Tx of grade II MCL - Wt. bearing as tolerated with crutches Sometimes, advancement and reinforcement of the ligament are necessary for chronic injuries that do not respond to conservative treatment. KNEE LIGAMENTOUS INJURIES: LCL Mechanism of Injury: Varus contact stress to knee PE: Varus opening at 30o is indicative of an isolated LCL injury. If there is varus opening at 0o, there is a combined ligamentous (either ACL or PCL).

Treatment Isolated (rare) Brace and Rehab Combined injuries Repair or Reconstruction. Techniques are varied and will not be asked. MULTIPLE LIGAMENT INJURIES: DISLOCATION Combined ligamentous injuries (especially ACL/PCL injuries) can be a result of a knee dislocation, and neurovascular injury must be suspected. The incidence of vascular injury following anterior knee dislocation is 30 to 50%. Peroneal Artery Vascular exam before and after reduction imperative If pulseless after reduction: Arteriogram in OR - repair / ex-fix Have a low threshold for fasciotomies Have a low threshold for primary collateral repairs If diminished after reduction: Stat angiography If normal after reduction: Serial ABIs vs. angiography ABI < 0.9 end systolic vascular injury Remember a normal pulse does not rule out an intimal tear. MULTIPLE LIGAMENT INJURIES: CLASSIFICATION Named by direction of tibial displacement Anterior Dislocation>Posterior Dislocation >Lateral Dislocation MULTIPLE LIGAMENT INJURIES: TREATMENT Reduction initially Reconstruction vs Repair of all torn structures Emergent surgical indications include popliteal artery injury, open dislocations, and irreducible dislocations. Timing of ligamentous repairs controversial most surgeons recommend delaying surgery 512 days to ensure that there is no vascular injury. High energy injuries with increased soft tissue damage, temporary spanning ex-fix, then MUA, then ligamentous reconstructions. Capsule must heal prior to arthroscopy, especially with a pump, to decrease risk of fluid extravasation and compartment syndrome. MULTIPLE LIGAMENT INJURIES: PROGNOSIS Improved prognosis Functional rehabilitation and early motion is critical to avoid a high incidence of a stiff knee after these combined procedures. Cruciate reconstruction / stable knee needed for rehab Worse prognosis Peroneal injury on initial assessment Delay in diagnosis of vascular injury

 Unstable knee
PROXIMAL TIB-FIB DISLOCATION Mechanism of Injury: Fall on flexed adducted knee (common in equestrians or sky divers) Anterolateral dislocation most common Closed reduction is performed with flexion and pressure onto the fibular head Post-operative, immobilize in extension For Chronic/Recurrent cases, Reconstruction ligaments or fibular head resection is treatment (controversial) LIGAMENTOUS KNEE INJURIES: Key Testable Items Mechanisms of injury of all ligaments Female vs male ACL injury rate Natural history of ACL deficient knee Gait pattern with ACL injury HIV /Hepatitis risk with allograft ACL Improper tunnel placement on xrays For ACL with loss of motion (LOM), no Manipulation under Anaesthesia (MUA) or Lysis of Adhesions (LOA) until 8 weeks LIGAMENTOUS KNEE INJURIES: Key Testable Items Recognize cyclops lesion arthroscopically (lose extension) Shrinkage is never the right answer Treat isolated PCLs non-operatively initially Risk during PCL reconstruction Diagnosis of vascular injuries after knee dislocations MOI and treatment of proximal tib-fib dislocations LIGAMENTOUS KNEE INJURIES: REFERENCES Almekinders, L.C., and Dedmond, B.T.: Outcomes of Operatively treated knee dislocations. Clin Sports Med, 19:503-518, 2000. Albright, J.P., and Brown, A.W.: Management of chronic posterolateral rotatory instability of the knee: Surgical technique for the posterolateral corner sling procedure. AAOS Instr. Course Lect. 47:369378, 1998. Carson, E.W., Simonian, P.T., Wickiewicz, T.L., et al: Revision anterior cruciate ligament reconstruction. AAOS Instr. Course Lect. 47:361368, 1998. Chen, F.S., Rokito, A.S., and Piutman, M.I.: Acute and Chronic posterolateral rotary instability of the knee. J Am Acad Orthop Surg 8: 97-110, 2000.

Clancy, W.G., Ray, J.M., and Zoltan, D.J.: Acute tears of the anterior cruciate ligament: Surgical versus conservative treatment. J. Bone Joint Surg. [Am.] 70:14831488, 1988. Cooper, D.E., Warren, R.F., and Warner, J.J.P.: The posterior cruciate ligament and posterolateral structures of the knee: Anatomy, function, and patterns of injury. Instr. Course Lect. 40:249270, 1991. Dye, S.F., Wojtys, E.M., Fu, F.H., et al.: Factors contributing to function of the knee joint after injury or reconstruction of the anterior cruciate ligament. J. Bone Joint Surg. 80A:13801393, 1998. Fowler, P.J., and Messieh, S.S.: Isolated posterior cruciate ligament injuries in athletes. Am. J. Sports Med. 15:553557, 1987. France, E.P., and Paulos, L.E.: Knee bracing. J. Am. Acad. Orthop. Surg. 2:281 287, 1994. Frank, C.B.: Ligament healing: Current knowledge and clinical applications. J. Am. Acad. Orthop. Surg. 4:7483, 1996. Frank, C.B., and Jackson, D.W.: Current concepts review: The science of reconstruction of the anterior cruciate ligament. J. Bone Joint Surg. 79A:1556 1576, 1997. Frassica, F.J., Sim, F.H., Staeheli, J.W., et al.: Dislocation of the knee. Clin. Orthop. 263:200205, 1991. Fu, F.H., Bennett, C.H., et. al.: Current trends in anterior cruciate ligament reconstruction, Part I. Am J Sports Med 27: 821-830, 1999. Fu, F.H., Bennett, C.H., et. al.: Current trends in anterior cruciate ligament reconstruction, Part II. Am J Sports Med 28: 124-130, 2000. Good, L., and Johnson, R.J.: The dislocated knee. J. Am. Acad. Orthop. Surg. 3:284292, 1995. Harner, C.D., and Hoher, J.: Evaluation and treatment of posterior cruciate ligament injuries: Current concepts. Am. J. Sports Med. 26:471482, 1998. Harner, C.D., Irrgang, J.J., Paul, J., et al.: Loss of motion following anterior cruciate ligament reconstruction. Am. J. Sports Med. 20:507515, 1992. Howell, S.M., and Taylor, M.A.: Failure of reconstruction of the anterior cruciate ligament due to impingement by the intercondylar roof. J. Bone Joint Surg. [Am.] 75:10441055, 1993.

Indelicato, P.A., Isolated medial collateral ligament injuries in the knee. J. Am. Acad. Orthop. Surg. 3:914, 1995. Indelicato, P.A., Hermansdorfer, J., and Huegel, M.: Nonoperative management of complete tears of the medial collateral ligament of the knee in intercollegiate football players. Clin. Orthop. 256:174177, 1990. Larson, R.L., and Taillon, M.: Anterior cruciate ligament insufficiency: Principles of treatment. J. Am. Acad. Orthop. Surg. 2:2635, 1994. Miller, M.D., Bergfeld, J.A., et al.: The posterior cruciate ligament injured knee: Principles of evaluation and treatment, AAOS Instr Course Lecture. 48: 199-207, 1999. Miller, M.D., Osbourne, J.R., et. al.: The natural histories of bone bruises. Am J Sports Med. 26: 15-19, 1998. Myers, M.H., and Harvey, J.P.: Traumatic dislocation of the knee joint: A study of eighteen cases. J. Bone Joint Surg. [Am.] 53:1629, 1971. Noyes, F.R., Barber-Westin, S.D., Butler, D.L., et al.: The role of allografts in repair and reconstruction of knee joint ligaments and menisci. AAOS Instr. Course Lect. 47:379396, 1998. O'Brien, S.J., Warren, R.F., Pavlov, H., et al.: Reconstruction of the chronically insufficient anterior cruciate ligament with the central third of the patellar ligament. J. Bone Joint Surg. [Am.] 73:278286, 1991. Paulos, L.E., Rosenberg, T.D., Drawbert, J., et al.: Infrapatellar contracture syndrome: An unrecognized cause of knee stiffness with patellar entrapment and patella infera. Am. J. Sports Med. 15:331341, 1987. Shelbourne, K.D., and Nitz, P.: Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am. J. Sports Med. 18:292299, 1990. Shelton, W.R., Treacy, S.H., Dukes, A.D., et al.: Use of allografts in knee reconstruction. J. Am. Acad. Orthop. Surg. 6:165175, 1998. Sisto, D.J., and Warren, R.F.: Complete knee dislocation: A follow-up study of operative treatment. Clin. Orthop. 198:94101, 1985. Sitler, M., Ryan, J., Hopkinson, W., et al.: The efficacy of a prophylactic knee brace to reduce knee injuries in football: A prospective, randomized study at West Point. Am. J. Sports Med. 18:310315, 1990. Veltri, D.M., and Warren, R.F.: Isolated and combined posterior cruciate ligament injuries. J. Am. Acad. Orthop. Surg. 1:6775, 1993.

OVERUSE INJURIES
KNEE OVERUSE INJURIES Patella tendinitis Also called Jumper's Knee Most common in basketball and volleyball Patients complain of pain and tenderness near the inferior border of the patella (worse in extension than flexion) Treatment includes nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy (strengthening and ultrasound), and orthotics Rarely surgery is indicated, but when done, excise necrotic tendon fibers significant partial tear excise and repair Quadriceps Tendonitis Less common tan patellar tendonitis but just as painful Patients may note painful clicking and localized pain superiorly Symptomatic treatment Operative treatment is occasionally necessary Prepatellar bursitis Also called Housemaid's Knee The most common form of bursitis of the knee (Extra-articular) Associated with a history of prolonged kneeling or direct blow Supportive treatment (knee pads, occasional steroid injections) are usually enough Rarely, bursal excision is recommended for refractory cases Aspirate in Wrestlers ITB SYNDROME History: runners (especially running hills) and cyclists The result of abrasion between the iliotibial band and the lateral femoral condyle Physical Exam: Localized tenderness, worse with the knee flexed 30 degrees and a positive Ober Test Patient on side with symptomatic leg up (ABD-Ext-ADD) Patient lies in a lateral decubitus position and abduction and hyperextension of the hip demonstrate tightness of the iliotibial band Treatment: Stretch / Strengthening Rarely Surgical Excision (remove an ellipse of the iliotibial band ) for refractory cases EXTENSOR MECHANISM INJURIES Quadriceps rupture More common than patellar tendon ruptures Most commonly in patients >40 years old with indirect trauma Diabetic history A palpable defect and inability to extend the knee are diagnostic

Delay in surgical repair of the extensor mechanism is the factor that most significantly diminishes results of surgical Tx Patella tendon rupture Usually in patients < 40 yo Mechanism with direct or indirect trauma A palpable defect and inability to extend the knee are diagnostic Patella fracture ORIF if displaced and loss of extensor mechanism OVERUSE INJURIES: Key Testable Items Treat conservatively initially PE findings for ITB Syndrome Dont forget about stress fractures in runners Ober test OVERUSE INJURIES: REFERENCES Buckwalter, J.A., Einhorn, T.A., and Simon, S.R. (eds).: Orthopaedic Basic Science, Biology and Biomechanics of the Musculoskeletal System, 2nd ed. American Academy of Orthopaedic, 2000. Garrick, J.G. (ed.) Orthopaedic Knowledge Update, Sports Medicine 3, American Academy of Orthopaedic Surgeons, 2004 Koval, K.J. (ed). Orthopaedic Knowledge Update 7. American Academy of Orthopaedic Surgeons, 2002.

PATELLOFEMORAL DISORDERS
PATELLOFEMORAL DISORDERS: PHYSICAL EXAM Standing: Alignment @ pelvis, knee and ankle / hindfoot Look for anteverted hip, valgus knee, externally rotated tibia, hindfoot valgus, or pronated foot Assess for tight hamstrings (Anterior popliteal angle) Quad tightness Seated/ knee flexed @ 90: Patella alta J sign (tracking of patella) Tubercle Sulcus Angle (Seated Q angle) Supine: Patellar translation / ? Apprehension Patellar tilt Q angle (<10 in men, <15 in women)

Femoral and tibial version/ torsion Quad tightness PATELLOFEMORAL DISORDERS: RADIOGRAPHIC ANALYSIS AP/ Lat Insall-Salvati Ratio (length of patella to length of patellar tendon) (normal range is 0.8 1.2) Blackburne-Peel Ratio (ratio of the articular length of the patella to the height of the lower pole of the articular cartilage above the tibial plateau (normal range is between .54 and 1.06; patella alta ratio is greater than 1.0) Trochlear depth on lateral film Merchant Trochlea hypoplasia Congruence angle (A line bisecting the lateral ridge of the femur, the deepest portion of the trochlear groove and the medial ridge of the femur is drawn. A second line from the deepest portion of the trochlear grove to the lowest point on the medial ridge of the patella is drawn. If this angle is to the right of the bisector, the value is negative (medial), if it is to the left, the value is positive (lateral). The normal range for the congruence angle is 8 + 6 degrees.) Measure patellar tilt OA CT scan with mid-patellar cuts at 0, 10, 20, and 30 degrees of flexion Tibial Tubercle/ Trochlear Groove Index Normal < 20mm on overlayed axial cut CT MRI Acute patellar dislocation to look for MPFL tear and medial facet chondral shear fracture with loose body PATELLOFEMORAL DISORDERS: GENERAL Pain / Normal alignment Risk Factors for PF pain Shortened quad muscle Abnormal vastus medius obliquus muscle reflex response time Decreased explosive strength Hypermobile patella Pain / abnormal alignment: Patellar tilt / lateral patellar compression (This problem is associated with a tight lateral retinaculum and excessive lateral tilt without excessive patellar mobility) McConnell taping initially Rehab - stretch lateral Retinaculum and strengthen quad / VMO Lateral Release only if lateral Retinaculum tight and no lat quad vector force (i.e. tilt only, not subluxation or just pain)

- The best candidates for lateral release have a neutral or negative tilt and medial patellar glide less than one quadrant with a lateral patellar glide less than three quadrants - For an adequate lateral release, patella should be able to be passively tilted 80 degrees Medial tibial tuberosity transfer If lateral Quad vector and no chondrosis Anteromed tibial tubercle transfer if arthrosis in lateral facet

PATELLOFEMORAL DISORDERS: SUBLUXATION Recurrent subluxation / dislocation of the patella can be characterized by lateral displacement of the patella, a shallow intercondylar sulcus, or patellar incongruence Risk Factors include: Lat. Tuberosity Increased Q angle Patella alta Increased valgus at knee (genu valgus) Trochlear dysplasia Pronated feet Decreased quad function Treatment: Rehab / bracing is often enough Anteromedialization of tibial tubercle MPFL repair / reefing PATELLOFEMORAL DISORDERS: ACUTE DISLOCATION Pathology MPF ligament tear (from femoral side) Also have medial retinaculum tear +/-VMO tear 40% Osteochondral defect not seen on x-ray MRI to evaluate location of MPFL tear and loose body Most common sites of osteochondral injury are medial inferior patellar facet and lateral femoral condyle. Rehabilitation 50% recurrence rate i Of those w/o recurrent dislocations, 58% limited sports performance at 6 months Surgical repair <10% recurrence PATELLOFEMORAL DISORDERS: RECURRENT DISLOCATION Exam:

Usually have mal-alignment of the extensor mechanism Apprehension test positive Radiographs Sulcus, Incongruence of patella Patella Alta Trochlear dysplasia Treatment Rehabilitation Proximal / Distal Realignment Most significant risk factors for recurrence is prior instability episode and early age at first dislocation. Superomedial arthrosis of the patella is a contraindication for a distal bony realignment procedure

PATELLAR CHONDROSIS Injury and malalignment can contribute to patellar degenerative joint disease Lateral release may be beneficial early; however, other procedures may be required for advanced patellar arthritis Exam: Compression and crepitation Radiographs Merchant view most helpful Treatment Rehabilitation Tubercle Elevation Contraindicated with superomedial patellar arthrosis Patellectomy for extreme cases (never the answer on the boards) Patellofemoral Disorders: Key Testable Items Patella Baja vs. Alta measurements Essential structure to repair with subluxing / dislocating patella Superomedial patellar arthrosis is contraindication for bony distal realignment PATELLOFEMORAL DISORDERS: REFERENCES Boden, B.P., Pearsall, A.W., Garrett, W.E., et al.: Patellofemoral instability: Evaluation and management. J. Am. Acad. Orthop. Surg. 5:4757, 1997. Cooper, D.E., and DeLee, J.C.: Reflex sympathetic dystrophy of the knee. J. Am. Acad. Orthop. Surg. 2:7986, 1994. Cramer, K.E., and Moed, B.R.: Patellar fractures: Contemporary approach to treatment. J. Am. Acad. Orthop. Surg. 5:323331, 1997.

Fulkerson, J.P.: Anteromedialization of the tibial tuberosity for patellofemoral malalignment. Clin. Orthop. 177:176181, 1983. Fulkerson, J.P.: Patellofemoral pain disorders: Evaluation and management. J. Am. Acad. Orthop. Surg. 2:124132, 1994. Fulkerson, J.P., and Shea, K.P.: Disorders of patellofemoral alignment: Current concepts review. J. Bone Joint Surg. [Am.] 72:14241429, 1990. Gambardella, R.A.: Technical pitfalls of patellofemoral surgery. Clin Sports Med. 18: 897-903, 1999. James, S.L.: Running injuries to the knee. J. Am. Acad. Orthop. Surg. 3:309 318, 1995. Kelly, M.A.: Algorithm for anterior knee pain. AAOS Instr. Course Lect. 47:339 343, 1998. Kilowich, P., Paulos, L., Rosenberg, T., et al.: Lateral release of the patella: Indications and contraindications. Am. J. Sports Med. 18:361, 1990. Larson, R.L., Cabaud, H.E., Slocum, D.B., et al.: The patellar compression syndrome: Surgical treatment by lateral retinacular release. Clin. Orthop. 134:158167, 1978. Matava, M.J.: Patellar tendon ruptures. J. Am. Acad. Orthop. Surg. 4:287296, 1996. Merchant, A.: Classification of patellofemoral disorders. Arthroscopy 4:235240, 1988. Merchant, A.C., Mercer, R.L., Jacobsen, R.J., et al.: Roentgenographic analysis of patellofemoral congruence. J. Bone Joint Surg. [Am.] 56:13911396, 1974. Post, W.R.: Clinical evaluation of patients with patellofemoral disorders. Arthroscopy, 15: 841-851, 1999.

PEDIATRIC KNEE DISORDERS

PEDIATRIC KNEE DISORDERS: TRACTION APOPHYSITIS Osgood-Schlatters Tibial Tubercle Sinding-Larsen-Johansson Inferior patella Treatment

Usually treated with Rest and activity modification, NSAIDs, and Quadriceps Stretch Occasionally, procedures such as ossicle excision are indicated for refractory cases

PEDIATRIC KNEE DISORDERS: PHYSEAL INJURIES Most commonly involve Salter-Harris II fractures of the distal femoral physis. Know the Salter Harris Classification (in peds and trauma section) PE: Pain, swelling, and inability to ambulate Stress radiographs are often necessary to make diagnosis ORIF for Salter-Harris III and IV fractures and Salter-Harris I and II fractures that cannot be adequately reduced Crosspin distal femoral fractures is the fixation of choice Late effects often carry a worse prognosis due to angular growth deformities PEDIATRIC KNEE DISORDERS: ACL Midsubstance ACL injuries in skeletally immature individuals remain a subject of debate. Patients who have ACL tears have a higher risk of meniscal and chondral damage if treated non-operatively. Most ligament injuries are treated like those in adults except use a physeal sparing technique (esp. the femur) an over the top femoral tunnel is used to not violate the undulating growth plate of the femur. Use a soft tissue graft for Tanner Stage 1 or 2 Displaced avulsion fractures Usually involve the Medial Tibial Eminence ORIF is the treatment of choice Lateral Meniscus/Inter-meniscal ligament may block reduction Dont forget to look for interstitial injury also PEDIATRIC KNEE DISORDERS: PATELLA SLEEVE FRACTURE High index of suspicion required May have no associated fracture Obtain MRI if patient is unable to perform a straight leg raise PEDIATRIC KNEE DISORDERS: OTHER PROBLEMS Popliteal cyst Usually spontaneously resolves Bipartite Patella Male >> Female Bilaterality uncommon (reported ranges between 0.2% to 9%) Observe Bone Scan if Acute Role for lateral release debated

PEDIATRIC KNEE DISORDERS: Key Testable Items Natural Course of Osgood-Schlatters Treatment of Pediatric ACL injuries (physeal growth disturbances with tunnels) Recognize patella sleeve fractures Recognize Bipartite patella PEDIATRIC KNEE DISORDERS: REFERENCES Andrish, J.T.: Meniscal injuries in children and adolescents: Diagnosis and management. J. Am. Acad. Orthop. Surg. 5:231237, 1996. Aronowitz, E.R., Ganley, T.J. et al.: Anterior cruciate ligament reconstruction in adolecscents with open physes. Am J Sports Med. 28: 168-175, 2000. Baxter, M.P., and Wiley, J.J.: Fractures of the tibial spine in children: An evaluation of knee stability. J. Bone Joint Surg. [Br.] 70:228230, 1988. Edwards, P.H., and Grana, W.A.: Physeal fractures about the knee. J. Am. Acad. Orthop. Surg. 3:6369, 1995. Lo, I.K.Y., Bell, D.M., and Fowler, P.J.: Anterior cruciate ligament injuries in the skeletally immature patient. AAOS Instr. Course Lect. 47:351359, 1998. McCarroll, J.R., Rettig, A.C., and Shelbourne, K.D.: Anterior cruciate ligament injuries in the young athlete with open physes. Am. J. Sports Med. 16:4447, 1988. Meyers, M.H., and McKeever, F.M.: Fractures of the intercondylar eminence of the tibia. J. Bone Joint Surg. [Am.] 41:209222, 1959. Micheli, L.J., and Foster, T.E.: Acute knee injuries in the immature athlete. Instr. Course Lect. 42:473481, 1993. Ogden, J.A., Tross, R.B., and Murphy, M.J.: Fractures of the tibial tuberosity in adolescents. J. Bone Joint Surg. [Am.] 62:205215, 1980. Parker, A.W., Drez, D., and Cooper, J.L.: Anterior cruciate ligament injuries in patients with open physes. Am. J. Sports Med. 22:4447, 1994. Riseborough, E.J., Barrett, I.R., and Shapiro, F.: Growth disturbances following distal femoral physeal fracture-separations. J. Bone Joint Surg. [Am.] 65:885 893, 1983. Stanitski, C.L.: Anterior cruciate ligament injury in the skeletally immature patient: Diagnosis and treatment. J. Am. Acad. Orthop. Surg. 3:146158, 1995.

Stanitski, C.L.: Patellar instability in the school age athlete. AAOS Instr. Course Lect. 47:345350, 1998.

KNEE QUESTIONS

Wrong answers:
Indiscriminate ordering of MRIs Steroid injections Thermal Shrinkage Diagnostic arthroscopy ACL repair for Acute ACL reconstruction Initial operative treatment of PCL injuries Initial operative treatment of PF/overuse problems
QUESTION 1: Which of the following statements best describes the tension in the different components of the posterior cruciate ligament when the knee is taken from full extension to 90 degrees of flexion? 1- Both the AL and PM bands are isometric and do not change 2- AL band is lax and becomes tight; PM is tight and becomes lax 3- AL is tight and becomes lax; PM is lax and becomes tight 4- Both the AL and PM bands are lax and become tight 5- Both the AL and PM bands are tight and become lax QUESTION 2: Which of the following ligaments provides the major static restraint to lateral patellar displacement? 1- Medial patellotibial 2- Medial patellofemoral 3- Medial patellomeniscal 4- Lateral patellofemoral 5- Lateral patellotibial QUESTION 3: A college football player twists his knee when he attempts to tackle an oncoming player. Examination reveals no medial lateral laxity or jointline tenderness. The anterior and posterior drawer tests and pivot shift results are negative; however, the Lachman test result is positive. What is the most likely diagnosis? 1- Minor knee sprain

2- Medial collateral ligament injury 3- Lateral collateral ligament injury 4- Anterior cruciate ligament injury 5- Posterior cruciate ligament injury QUESTION 4: The lateral fragment of bone (Segond fracture) associated with an injury of the anterior cruciate ligament is the result of an avulsion of the 1- oblique popliteal ligament 2- lateral capsule 3- popliteal tendon 4- fibular collateral ligament 5- posterior oblique ligament QUESTION 5: A 13-year-old quarterback feels a pop in his knee while being tackled. Radiographs of the knee and results of a Lachmans test are normal. Examination reveals tenderness over the distal femoral physis. To help confirm the diagnosis, management should first include 1- an MRI scan 2- arthroscopic examination 3- AP and frog-leg radiographs of the pelvis and hips 4- varus and valgus stress radiographs of the knee 5- physical examination of the knee under anesthesia QUESTION 6: A patient sustains a tear of the ACL, and an MRI reveals a bone contusion. Signal changes as the result of this injury would most likely be located at the 1- posterior 1/3 of the LFC and middle 1/3 of the LTP 2- posterior 1/3 of the LFC and anterior 1/3 of the LTP 3- anterior 1/3 of the LFC and posterior 1/3 of the MTP 4- middle 1/3 of the MFC and posterior 1/3 of the MTP 5- middle 1/3 of the LFC and posterior 1/3 of the LTP QUESTION 7: What part of the meniscus has the highest incidence of degenerative tears? 1- Anterior horn of the medial meniscus 2- Anterior horn of the lateral meniscus 3- Posterior horn of the lateral meniscus 4- Posterior horn of the medial meniscus 5- Middle and posterior horns of the lateral meniscus

QUESTION 8: Successful healing of a meniscal repair is most likely associated with which of the following tear patterns? 1- Radial tear 2- Parrot-beak tear 3- Vertical tear in the red-red zone 4- Vertical tear in the red-white zone 5- Vertical tear in the white-white zone QUESTION 9: Palpable jointline cysts in the knee are most commonly associated with 1- Bakers cyst 2- medial meniscus tears 3- lateral meniscus tears 4- congenital discoid lateral meniscus 5- anterior cruciate ligament and meniscal tears QUESTION 10: Osteochondritis dissecans of the knee most commonly involves what structure? 1- Medial tibial plateau 2- Lateral tibial plateau 3- Patella 4- Medial femoral condyle 5- Lateral femoral condyle QUESTION 11: A 13-year-old boy complains of knee pain and swelling following training lessons for ski racing for the past six months. MRI demonstrates an OCD lesion with open physes. The only abnormal finding on physical examination is an effusion. Management should consist of 1- cast immobilization for 6 weeks 2- activity modification and re-evaluation in 2 months 3- internal fixation with or without bone grafting 4- retrograde drilling of the defect without articular cartilage penetration 5- drilling of the defect directly through the articular cartilage

QUESTION 12: A 20-year-old football player reports hearing a pop in his knee as a result of a noncontact deceleration injury. Examination 24 hours later reveals a large effusion. The incidence of a rupture of the anterior cruciate ligament in this situation is closest to 1-15% 2-30% 3-70% 4-90% 5-95% QUESTION 13: What type of gait pattern characterizes the patient with an anterior cruciate ligament-deficient knee? 1- Normal biphasic flexion-extension moment 2- Quadriceps avoidance gait 3- Hamstring avoidance gait 4- Prolonged stance phase on the involved leg 5- Prolonged swing phase on the involved leg QUESTION 14: An 18-year-old high school football player injures his knee while decelerating and pivoting to throw a ball. Hemarthrosis develops immediately after the injury. Examination shows a large effusion, a 15- to 90-degree range of motion, a 2+ Lachman test result, and no jointline tenderness. Treatment should consist of 1- acute ACL repair 2- acute ACL reconstruction using autogenous graft 3- acute ACL reconstruction using autogenous graft and a LAD 4- ACL repair when ROM has returned to normal 5- ACL reconstruction with autogenous graft when ROM has returned to normal QUESTION 15: Physical examination of a high school soccer player who sustains a knee ligament injury reveals grade III tears of the anterior cruciate and medial collateral ligaments. In addition, a MRI scan reveals a lateral meniscal injury. Delaying anterior cruciate ligament surgery until the patient has full, painfree range of motion will decrease the risk of: 1- patellar chondromalacia 2-failure of meniscus repair 3-arthrofibrosis 4-varus-valgus instability 5-anteroposterior instability

QUESTION 16: Which of the following mechanisms is most likely to result in graft failure 4 weeks after anterior cruciate ligament reconstruction with a patellar tendon graft? 1- Loss of fixation 2- Midsubstance graft rupture 3- Notch impingement 4- Stretching of the graft 5- Tear at the bone-tendon interface QUESTION 17: A 23-year-old football player sustains a hyperflexion injury to the knee, reports feeling a pop, and is then unable to bear weight. A trace hemarthrosis develops within 1 day. Which of the following ligaments has most likely been damaged? 1- Medial collateral 2- Posterolateral complex 3- Posterior cruciate 4- Anterior cruciate 5- Anterior and posterior cruciate QUESTION 18: Posterior cruciate insufficiency diagnosed using the quadriceps active test is confirmed with tibial translation 1- anteriorly at 20 to 30 degrees of flexion 2- anteriorly at 70 to 90 degrees of flexion 3- posteriorly at 20 to 30 degrees of flexion 4- posteriorly at 70 to 90 degrees of flexion 5- anteriorly with the knee in full extension QUESTION 19: Which of the following best describes the relationship of the tibia to the femur during a positive reverse pivot shift? 1- Tibia reduced with flexion and subluxates posteriorly in extension 2- Tibia reduced with flexion and subluxates anteriorly in extension 3- Tibia reduced with flexion and fibula subluxates posteriorly in knee extension 4- Tibia subluxated posteriorly with flexion and reduces in extension 5- Tibia subluxated anteriorly with flexion and reduces in extension QUESTION 20: Examination of a 25-year-old man who has knee pain after a motorcycle accident reveals an effusion, normal stability to varus/ valgus stress, a negative Lachman test, and a grade III posterior drawer. Radiographs demonstrate a bony piece off the posterior aspect of the tibia. Treatment should consist of

1- Repair of the injured structures 2- Posterior cruciate reconstruction with patellar tendon graft 3- Immobilization for 4 weeks 4- Physical therapy focused on quadriceps strengthening and ROM 5- Diagnostic arthroscopy followed by rehabilitation QUESTION 21: A 32-year-old man has swelling of the knee as a result of falling with the knee flexed and his foot in plantar flexion. A Lachmans test reveals an apparent increase in anterior translation. Passive external tibial rotation at 30 degrees and 90 degrees is equal to the contralateral side, and the quadriceps active test is positive on the affected side. The neurovascular exam is normal. Treatment should consist of 1- an anterior cruciate functional knee brace 2- a physical therapy program 3- reconstruction of the PCL and posterolateral corner 4- reconstruction of the PCL 5- reconstruction of the ACL QUESTION 22: Examination of a 27-year-old man who injured his knee playing soccer shows full range of motion, no jointline tenderness, negative Lachman and anterior drawer tests, but a positive grade I posterior drawer test result. Radiographs and signs of posterolateral instability are negative. Initial management should consist of 1- primary posterior cruciate ligament repair 2- rehabilitation, with emphasis on quadriceps strengthening 3- rehabilitation, with emphasis on hamstring strengthening 4- reconstruction of the PCL using an autogenous patellar tendon 5- reconstruction of the PCL using an autogenous hamstring tendon

QUESTION 23: Cadaver studies show that alteration in joint kinematics following posterior cruciate ligament sectioning leads to 1- increased contact pressures in all three compartments of the knee 2- increased contact pressures in the medial and patellofemoral compartments 3- increased contact pressures in the lateral and patellofemoral compartments 4- decreased contact pressure in the patellofemoral compartment, but increased contact pressures in the medial compartment 5- decreased contact pressure in the patellofemoral compartment, but increased contact pressure in the lateral compartment

QUESTION 24: Treatment to minimize posterior sag following posterior cruciate ligament reconstruction consists of immobilization at which of the following flexion angles? 1- 0 degrees 2- 30 degrees 3- 45 degrees 4- 70 degrees 5- 90 degrees QUESTION 25: Which of the following findings on physical examination best indicates isolated posterolateral instability of the knee? 1- Reverse pivot shift 2- Positive Lachman test result 3- Positive quadriceps active test result 4- Increased external rotation of the foot relative to the contralateral side at 30 degrees of knee flexion only 5- Increased external rotation of the foot relative to the contralateral side at both 30 and 90 degrees of knee flexion QUESTION 26: A 25-year-old woman who sustains a direct blow to the anteromedial aspect of her leg while playing basketball has immediate pain and cannot walk. Examination of the knee reveals an increase in posterior translation and external rotation at 90 degrees of flexion. At 30 degrees of flexion, posterior translation and external rotation are symmetrical to the unaffected side. Radiographs are normal. Which of the following structures are injured? 1- Posterolateral complex 2- Posterior cruciate ligament 3- Lateral collateral ligament 4- Posterior cruciate ligament and posterolateral complex 5- Posterior cruciate ligament and medial collateral ligament QUESTION 27: A 25-year-old man is struck by a motor vehicle and sustains an injury to the right lower extremity. Radiographs show a posterior dislocation of the knee; however, examination reveals that the limb is neurologically intact. Initial management of the limb should include 1- application of an above-knee splint 2- application of an external fixator 3- an arteriogram 4- closed reduction of the knee dislocation 5- open reduction of the knee dislocation

QUESTION 28: The incidence of vascular injury after an anterior knee dislocation is 1- less than 5% 2- 10 to 25% 3- 30 to 50% 4- 60 to 80% 5- greater than 95% QUESTION 29: A 26-year-old marathon runner reports lateral knee pain after hill training. Examination reveals no effusion; and results of Obers test are positive. What is the most likely diagnosis? 1- Lateral meniscal tear 2- Popliteus tenosynovitis 3- Iliotibial band friction syndrome 4- Peroneal nerve entrapment 5- Biceps tendinitis QUESTION 30: A middle-aged woman who runs about 30 miles weekly on hilly terrain is evaluated for a several months history of lateral knee pain that has progressively worsened. She has pain with weightbearing on her flexed knee and complains of deep lateral knee pain with tibial rotation. Exam confirms diffuse lateral pain and no ligamentous instability. Radiographs are normal. The physician should recommend 1- a lateral heel wedge 2- arthroscopy 3- neutral mold running orthotics 4- injection of steroid into the iliotibial band 5- a stretching and strengthening program

QUESTION 31: What is the most common clinical indicator of reflex sympathetic dystrophy of the knee? 1- Effusion 2- Muscle atrophy 3- Atrophic hair changes 4- Disproportionate pain 5- Decreased range of motion QUESTION 32: A 38-year-old woman was treated surgically for a transverse patellar fracture 4 months ago. The fracture is healed and the hardware is intact; however, she now reports severe diffuse pain. Although she has gained 60o of

flexion soon after surgery, and her pain was initially tolerable, she now has continuous and severe searing pain. Exam reveals that the knee is cool to touch with a small effusion. Radiographs show osteopenia. Management should consist of 1- arthroscopic lysis of adhesions 2- arthroscopic irrigation and debridement 3- ionophoresis 4- a sympathetic block 5- neuroma resection QUESTION 33: What is the most appropriate indication for lateral retinacular release in the knee? 1- Diffuse knee pain following arthroscopy 2- Anterior knee pain following physiotherapy 3- Acute patellar dislocation associated with an increased Q angle 4- Lateral patellar compression syndrome following physiotherapy and associated lateral patellar subluxation 5- Lateral patellar compression syndrome following physiotherapy and associated lateral patellar tilt QUESTION 34: A 21-year-old woman has had anterior knee pain for the past 4 weeks that worsens when she descends stairs and squats. Examination shows patellar apprehension and medial facet tenderness; however, there is minimal effusion, full range of motion, no jointline tenderness, and stable ligaments. Treatment should include 1- lateral retinacular release 2- patellar tendon realignment 3- arthroscopic debridement of chondromalacia 4- short arc open chain quadriceps exercises 5- short arc closed chain quadriceps exercises QUESTION 35: A 6-year-old girl has an area of painless swelling in the medial popliteal fossa that is 4 cm in diameter. Aspiration reveals the swelling to be consistent with a popliteal Bakers cyst, and the cyst disappears following aspiration. Three months later the cyst recurs but is still painless. What is the appropriate treatment at this time? 1- Excision 2- Observation 3- Repeat aspiration 4- Aspiration and steroid injection 5- Aspiration and phenol injection

Question 36: An 18-year-old collegiate football player sustains a varus contact injury to his right knee. His knee was dislocated and reduced on the field. His physical examination revealed a grossly unstable knee with loss of peroneal nerve function and a diminished pulse. What is the most appropriate next step in management of this patient? 1. 2. 3. 4. 5. Admission to the hospital with serial neurovascular checks Ice, elevation, brace and follow-up at the next available clinic Emergent vascular consultation and angiogram MRI to evaluate the injury Immediate surgical repair of torn ligaments

Question 37: A 32-year-old recreational tennis player complains of chronic anterior knee pain. Physical examination shows patellofemoral crepitence and a small effusion. Medial patellar glide is 1+ and there is a positive J sign during active knee extension. Imaging studies demonstrate lateral patellofemoral arthrosis. Which procedure is most appropriate for management of this patient? 1. Lateral release and distal tibial tubercle transfer 2. Lateral release and medial capsular shrinkage 3. Lateral release and anteromedial transfer of the tibial tubercle 4. Lateral release 5. Lateral release and medial patellofemoral ligament reconstruction

Question 38: A 22-year-old professional football player sustains a blow to his anterior tibia. Physical examination shows a negative Lachman, 2+ posterior drawer, and no instability to varus or valgus stress at 0 or 30 degrees. There is no increase in external rotation at 30 degrees. What is the most appropriate treatment? 1. Physical therapy and delayed PCL reconstruction 2. Physical therapy focusing on hamstring strengthening and non-operative treatment 3. Immediate PCL reconstruction 4. Physical therapy focusing on quadriceps strengthening and non-operative treatment

5. Arthroscopic debridement Question 39: a 17 year old high school football player sustained a contact injury and landed on a flexed knee. Examination revealed a negative Lachman test. He had increased external rotation, varus and posterior translation at 30 degrees that decreased at 90 degrees flexion. What is the structure most likely injured? 1. Posterior cruciate ligament 2. Anterior cruciate ligament and posterior cruciate ligament 3. Posterolateral ligament complex 4. Posterior cruciate ligament and posterolateral ligament complex 5. Anterior cruciate ligament Question 40: Which of the following is a contraindication to isolated meniscal repair? 1. Tear older than 6 weeks 2. Displaced bucket handle tear 3. Age greater than 30 4. Tear length greater than 20 mm 5. ACL deficiency Question 41: You are developing a program to potentially decrease risk of ACL injuries in your female e college soccer players. Identify a strategy to best achieve this goal. 1. Neuromuscular training program 2. Fit players with prophylactic knee braces 3. Obtain radiographic evaluation to assess cross-sectional area of the intercondylar notch 4. Limit play during luteal phase of menstrual cycle 5. Institute aggressive quadriceps strengthening program

Question 42: A 22-year-old wrestler sustains a first-time patellar dislocation. Examination reveals that she has a 40 cc traumatic hemarthrosis. What is the most common location for osteochondral injury due to an acute lateral patellar dislocation? 1. Lateral patellar facet 2. Medial trochlea 3. Lateral trochlea 4. Central patellar ridge 5. Medial patellar facet

Question 43: Historically, the Hauser procedure, a medial tibial tubercle transfer, was frequently used to surgically treat patellofemoral pain and instability. What risk has caused this procedure to be largely abandoned? 1. Wound healing problems 2. Popliteal artery laceration 3. Compartment syndrome 4. Reflex sympathetic dystrophy 5. Increased patellofemoral contact force Question 44: A 16-year-old high school soccer player injures his knee while playing. He states that he planted on his right knee and cut to his left, and felt a pop and developed medial knee pain. He states that he has never injured this knee before. Physical examination several hours later shows a moderate effusion and medial knee tenderness. The patient has full knee extension, but flexes only to 20. Further examination is compromised by pain, apprehension and guarding; Lachman test is equivocal. There is no varus or valgus laxity, but diffuse pain over the medial side of the knee. Aspiration is done and reveals 30 cc of bloody effusion without fat droplets, but further examination remains compromised by pain and guarding. X-rays are normal. What is the most likely diagnosis? 1. Osteochondral fracture 2. Rupture of the MPFL 3. ACL rupture 4. PCL rupture 5. MCL injury

Question 45: A 29 year old male sustains complete ACL tear playing recreational basketball. At the time of reconstructions using patellar tendon bone autograft, a lateral femoral condyle full thickness chondral lesion measuring 1.5 cm by 1.5 cm is identified. He has intact menisci and the cartilage lesion is not treated. You see the patient 8 years later. Compared to a similar ACL reconstructed patient without chondral injury, what would you expect for your patient. 1. Be able to perform the same activities with minimally more symptoms 2. Have a higher risk of recurrent knee instability

3. Be a candidate for realignment/reconstructive surgery (osteotomy or total knee replacement) 4. Remain the same with an increased risk of a subsequent meniscal tear 5. Be much more symptomatic with limitation in daily activities Question 46: You are performing a PCL reconstructive surgery on a high school football player using a single bundle technique. What is the best position to tension the PCL graft when reconstructing the anterolateral bundle? 1. 45 degrees of flexion 2. full flexion 3. full extension 4. 30 degrees of flexion 5. 90 degrees of flexion Question 47: A 30 year old teacher is seen for recurrent patellar instability. After careful history, you proceed to physical examination. What is the significance of the Tubercle Sulcus Angle (also known as Seated Q angle)? 1. It is a measure of lateral displacement of the tibial tubercle with reference to the femoral sulcus 2. It is a measure of the mechanical axis of the lower extremity 3. It is a measure of lateral patellar tilt 4. It is a measure of patellar height 5. It is a measure of femoral anteversion

Question 48: A high school for which you are the team physician is starting up an interscholastic football program. The head athletic trainer comes to you for your opinion on prophylactic knee brace use in the players. What advice would you give to the trainer. 1. Prophylactic knee braces may be helpful for interior lineman and linebackers, although significant controversy exists regarding its efficacy 2. Prophylactic knee braces are definitely not helpful in reducing the risk of knee injuries and may even be harmful to the players.

3. Prophylactic knee braces may be helpful for all of the players to decrease the risk of knee injury, particularly to the medial collateral ligament 4. Prophylactic knee braces are particularly useful for running backs and linebackers, whose knees are often targets for tackling and chop blocking 5. Prophylactic knee braces should be used for all interior lineman, as definitive evidence in well designed clinical studies recommends their use Question 49: A 16 year old cheerleader sustains a patellar dislocation. A discussion is carried out with the parents regarding the prognosis. What is the single most significant factor predicting risk of recurrent patellar instability after a traumatic patellar dislocation? 1. MRI evidence of MPFL injury 2. Age 3. Gender 4. Elevated Q angle 5. Previous patellofemoral instability episodes Question 50: A 22 year old female skier has severe anterior knee pain of one year duration which has failed non-operative treatment. What is the best indication for lateral retinacular release? 1. Patellar subluxation 2. Recurrent patellar dislocation 3. Medial patellar chondral lesion 4. Painful infrapatellar contracture 5. Painful patellar tilt Question 51: A 17 year old quarterback sustained a left knee injury after being tackled five days ago. You suspect a posterolateral corner injury. What is the most accurate physical examination test to confirm your diagnosis. 1. Increased posterior tibial translation at 90 degrees of knee flexion 2. Positive pivot shift test 3. Asymmetrical tibial external rotation at 30 degrees of knee flexion 4. Asymmetrical tibial internal rotation at 30 degrees of knee flexion 5. Excessive valgus laxity at 30 degrees of knee flexion Question 52: A 35 year old runner sustained a PCL injury 15 years ago which was treated non-operatively. The athlete now presents with knee pain. Where in the knee would you most likely find degenerative changes? 1. Patellofemoral and medial compartments 2. Medial compartment 3. Lateral compartment 4. Patellofemoral and lateral compartments

5. Medial and lateral compartments Question 53: Osteochondral autograft transplantation has become a treatment option for some symptomatic isolated chondral injuries in the knee. In an effort to diminish donor site morbidity, you would like to harvest cartilage from the area of lowest contact pressure. What is the area with the lowest contact pressure. 1. Inferolateral trochlea 2. Superior aspect of the intercondylar notch 3. Superior margin of the femoral trochlea 4. Medial femoral trochlea 5. Superolateral trochlea Question 54: You are performing a revision ACL reconstruction in a 17 year old female basketball player. What is the most common technical error associated with ACL graft failure? 1. Insufficient graft material 2. Inadequate graft fixation 3. Inadequate notchplasty 4. Nonanatomic tunnel placement 5. Improper graft tension Question 55: A skeletally immature 13 year old developed a hemarthrosis and new onset of knee pain one week ago from a football injury. Radiographs reveal a loose body and probable osteochondral lesion of the lateral femoral condyle. During arthroscopic evaluation a 1.5 x 2 cm osteochondral defect is identified at the lateral femoral condyle. The loose body contains articular cartilage and subchondral bone. What is the proper treatment? 1. Perform retrograde drilling at the base of the osteochondral lesion 2. Remove the loose body and harvest articular cartilage for later cartilage transplantation 3. Remove the loose body and debride the base of the lesion 4. Perform anatomic reduction and internal fixation of fragment in the defect 5. Perform anterograde drilling at the base of the lesion Question 56: Arthroscopic lateral release is often performed as treatment for the painful or unstable patellofemoral joint, either as an isolated procedure or as part of a larger operation. Cutting the retinaculum too superiorly may be associated with what condition? 1. Injury to the lateral superior geniculate artery 2. Recurrent lateral patellar subluxation 3. Patella baja 4. Loss of knee motion

5. Medial subluxation of the patella Question 57: A 29 year old motorcyclist sustains an isolated avulsion fracture of the PCL tibial insertion. You plan an open posteromedial approach. How does the surgeon protect the posterior neurovascular bundle? 1. Direct visualization and gentle retraction medially 2. Direct visualization and gentle retraction laterally 3. Retraction of the medial head of the gastrocnemius muscle medially 4. Retraction of the semimembranosus muscle medially 5. Retraction of the medial head of the gastrocnemius muscle laterally

Question 58: A 29 year old male presents to your office complaining of recurrent knee instability following hamstring ACL reconstruction done 2 years previously. He has not been able to return to sports, and notes instability even with walking. He notes no history of trauma since his initial reconstruction. Physical examination reveals a 3+ Lachman with a soft endpoint, a 2+ pivot shift with guarding, 3+ reverse pivot shift, and no instability with varus or valgus stress testing. Dial testing reveals 10 degrees of increased external rotation at 30 degrees that improves at 90 degrees. Gait reveals a varus thrust. Long leg alignment films reveals 4 degrees of varus mechanical alignment symmetrical to his contralateral, uninvolved limb. What is the most appropriate management for this patient. 1. Posterolateral corner reconstruction 2. High tibial osteotomy 3. Revision ACL reconstruction 4. Posterolateral corner repair 5. PCL reconstruction

Question 59: A 30 year old jockey failed microfracture technique for a 3x 4 cm bar bone articular cartilage lesion of the medial femoral condyle. Surgical treatment is planned. What would be the most appropriate treatment for this lesion? 1. Osteochondral allograft 2. Osteochondral autograft 3. Lavage and debridement 4. Abrasion chondroplasty 5. Repeat microfracture Question 60: A 32 year old beach volleyball player has an articular cartilage lesion of bare bone measuring 1cm2 at knee arthroscopy. The decision is made to perform a microfracture technique. What is the most important technical step in this technique? 1. The calcified cartilage layer must be removed 2. The appropriate hole depth is greater than 4 mm 3. The holes should be made less than 2 mm apart 4. Fat droplets should not be seen coming from the awl holes 5. The procedure must be done without a tourniquet Question 61: An 11 year old boy falls off his bike sustaining the injury depicted in the figures. Figure 1: Lateral Knee Xray: Physes open. Displaced anterior tibial spine fracture, angled 45 degrees upwards. Figure 2: AP Knee Xray: Tibial spine fracture, with elevation approximately 80% of height of tibial spine. 1. Arthroscopic ACL Reconstruction 2. Reduction and fixation of the fracture 3. Cast, non weight bearing for six weeks 4. Cylinder weight bearing cast for two weeks 5. Brace, weight bearing as tolerated for six weeks Question 62: A 39 year old female volleyball player complains of acute exacerbation of chronic anterior knee pain after a recent tournament. Figure 1: T2 MRI, fat sat, Sagittal cut of knee demonstrates edema within the inferior pole of the patella and proximal patellar tendon. Figure 2: T2 MRI, fat sat, Sagittal cut of knee demonstrates focal edema within the proximal, posterior 50% of the patellar tendon. Mild fat pad edema.

Figure 3: T2 MRI, fat sat, Axial cut of knee demonstrates focal signal change of the central 25% of the patellar tendon. With which pathophysiologic finding do the MRIs shown correlate best? 1. The injured tissue maintains its normal reflective appearance under polarized light. 2. The location of the process is typically in the anterior portion of the patellar tendon adjacent to insertion on the tibia. 3. The underlying pathologic process of this condition is primarily degenerative in nature. 4. Avascular hypocellularity is a consistent finding with this process. 5. The underlying pathologic process of this condition is primarily inflammatory in nature. Question 63: A 20 year old female cross country runner is seen in clinic for pain over the medial side of her right knee that increases with activity. This 55, 116 pound runner complains of pain in her right knee with walking. There is pain to palpation over the medial aspect of her knee. She has no knee effusion. Radiographs are shown. Figure 1: AP XR of the knee shows no evidence of fracture. Ostopenia can not be ruled out. Figure 2: Lateral XR of the knee shows no evidence of fracture. No patella alta or baja. What would you advise? 1. Injection of the pes anserine bursa. 2. MRI prior to resuming activity. 3. Sports cream applied to the area, stretches and plyometric exercises. 4. Double upright brace, orthotics, and anti-inflammatory. 5. Double contrast arthrogram. Question 64: After the posterior cruciate ligament is completely sectioned in the cadaveric knee, what abnormal motion has been described? 1. Posterior tibial translation is independent of other sectioned ligaments. 2. Posteriori tibial translation is independent of flexion angle. 3. Posterior tibial translation is greatest at high flexion angles. 4. Posterior tibial translation is greatest near full extension. 5. Total anterior and posterior tibial translation is increased near full extension.

Question 65: A 16 year old, 6 ft, 160 lb female basketball player scores a great shot and does a jumping belly bump with a fellow player to celebrate. When she lands awkwardly, she has pain in her right knee. When she returns to play a week later, she pivots off her injured foot, experiences sudden pain and has difficulty bearing weight. Examination reveals diffuse right knee pain with effusion and lack of full range of motion. X-Rays are normal. MRI is shown in the figures. Figure 1: T1 MRI, sagittal cut demonstrates displacement of the lateral meniscus, and femoro-tibial bone bruise pattern consistent with anterior translation of the tibia. Figure 2: T1 MRI, sagiital cut demonstrates large knee effusion Figure 3: T1 MRI, sagittal cut demontstrates intact PCL, displaced meniscus adjacent to the PCL. What would you advise? 1. A patella stabilizing brace with physical therapy 2. Further evaluation with a bone scan 3. Physical therapy to restore motion prior to surgery 4. Toe touch weight-bearing and surgery within several days 5. Genetic testing with appropriate counseling Question 66: A 19 year old football player has a valgus contact injury. Examination reveals an effusion, 5mm of opening to valgus stress at 30 degrees of knee flexion, a normal Lachman and normal posterior drawer. There is tenderness over the medial epicondyle and radiographs are normal. In addition to rehabilitation, what is the next appropriate step in management? 1. Aspiration and injection of corticosteroid. 2. Cast immobilization for 2 weeks 3. A functional knee brace, weight bearing as tolerated 4. Open surgical repair of medial structures 5. Arthroscopic evaluation and treatment Question 67: The quadriceps tendon has been used as autograft tissue for many different ligamentous reconstructive procedures about the knee. What characteristics of the quadriceps tendon make it a favorable choice as a graft? 1. It has a broad area of insertion on the patella and is juxtaposed to the articular cartilage. 2. It is 1.8 times as thick as the patellar tendon and is readily accessible. 3. It readily replaces itself and can be harvested, in part, arthroscopically. 4. It is symmetric and redundant throughout its length. 5. It is harvested with a full thickness bone plug, and an intact synovial sheath is recommended with the quadriceps tendon.

Question 68: A 56 year old golfer reports right knee swelling for five days without a history of injury. He leaves for a golf trip in Scotland in two days. Clinical examination shows an effusion and pain over the medial joint line of his right knee. Knee radiographs are in the figures. Figure 1: AP XRay of knee shows mild to moderate medial joint space narrowing, osteophyte formation, and preservation of joint space laterally. Figure 2: Lateral XRay of knee shows minimal patellar osteophyte formation, with preservation of patello-femoral joint space. What would you advise? 1. Immediate diagnostic arthroscopy 2. An oral anti-inflammatory, a knee compression sleeve and strengthening exercises 3. Meniscal allograft if Xrays of his other knee show similar findings 4. A bone scan prior to advising him regarding his trip 5. Consideration of joint replacement on his return from the trip Question 69: A 30 year old male presents with recurrent left knee instability. He underwent a hamstring ACL reconstruction 5 years ago. Examination after his index surgery showed a normal Lachman and no pivot shift. Now his examination reveals a positive Lachman test, positive pivot shift, normal varus and valgus stress and negative posterior drawer. He has increased external rotation at 30 degrees. Radiographs show excellent tunnel placement. What is the most likely cause of the ACL failure? 1. Lateral collateral ligament injury 2. Poor rehabilitation of the hamstrings 3. Inadequate soft tissue graft fixation 4. Untreated injury to posterior lateral corner 5. Untreated or unrecognized meniscus injury Question 70: A 15 year old cross country skier complains of anterior knee pain since beginning squats and lunges as part of her conditioning program. On examination, she has pain to palpation about the patella, a mild valgus angle to her knee and foot pronation. She has no medial or lateral joint line tenderness and no knee instability. MRI images are shown. Figure 1: T2 MRI, sagittal cuts demonstrate intact lateral meniscus with rectangular appearance on 3 consecutive images. Figure 2: T2 MRI, fat sat, sagittal cuts demonstrate intact lateral meniscus with rectangular appearance on 3 consecutive images. Figure 3: Intact ACL, PCL

What would you advise? 1. Avoidance of all physical activities for 3 months with repeat MRI at that time 2. Orthotics, knee brace and exercises to improve patella tracking 3. Arthroscopy to address abnormalities seen on MRI 4. A bone mineral density study and a complete metabolic work-up 5. Further evaluation with an MRI with contrast Question 71: An active 22 year old male presents with a significant pain and radiographic joint space narrowing five years after a subtotal medial meniscectomy. Which of the following factors are most consistent with a successful meniscal allograft? 1. Knee joint ligament instability 2. Advanced articular cartilage degeneration 3. Pain and swelling with mechanical symptoms 4. Axial malalignment 5. Flattening of the medial femoral condyle Question 72: You diagnose a partial ACL tear in a collegiate lacrosse player. A rehabilitation program is initiated. Alpha smooth muscle actin is active after ACL injury. Which statement below best describes its role in the healing of this ligament. 1. It produces cells that retract the torn ligmanet ends. 2. It produces a synovial cell layer that bridges the injury site. 3. It produces synovial fluid, inducing inflammation. 4. It produces epiligamentous tissue that induces healing. 5. It produces cytokines that cause inflammation, leading to proliferation, remodeling, and maturation. Question 73: The anterior cruciate ligament may be reconstructed with a double bundle technique such that the construct is placed in two tunnels through the femur and two tunnels through the tibia. Which of the following characteristics are shown in biomechanical studies comparing the single and double bundle techniques using human cadaveric knees? 1. The graft construct can better withstand internal rotation forces but not valgus tourque, compared to the single bundle technique. 2. The in situ loads for anterior translation for the single bundle and double bundle reconstructions were the same and similarly close to the intact ACL. 3. The in situ loads for anterior translation and rotation for the double bundle reconstruction were closer to the intact ACL.

4. The two graft limbs are close to the central axis of the tibia and femur, making them better able to resist rotational loads. 5. The graft limbs on the femoral side are best positioned at the posterolateral and the anteromedial site. Question 74: A 16 year old athlete has a meniscus tear and is undergoing arthroscopic treatment. What statement is most true regarding the vascular anatomy of the meniscus? 1. The peripheral 10% of the medial meniscus and the peripheral 10% of the lateral meniscus contains blood vessels. 2. The peripheral 10-20% of the medial meniscus and the peripheral 25-50% of the lateral meniscus contains blood vessels. 3. The peripheral 20-30% of the medial meniscus and the peripheral 10-25% of the lateral meniscus contains blood vessels. 4. The peripheral 30-60% of the medial meniscus and the peripheral 25-50% of the lateral meniscus contains blood vessels. 5. The peripheral 50% of the medial meniscus and the peripheral 50% of the lateral meniscus contains blood vessels. Question 75: A 10 year old is undergoing knee arthroscopy for removal of a foreign body. Prior to the foreign body he had no knee symptoms. In addition to the foreign body, an incomplete discoid lateral meniscus is found. What is the most appropriate treatment of the discoid lateral meniscus? 1. No treatment is required 2. Arthroscopic saucerization should be performed. 3. Meniscus allograft should be performed 4. Total mensicectomy should be performed 5. Suture repair should be performed Question 76: A 25 year old female runner trips on an uneven pavement while running. She hears a pop and has immediate knee pain, but is able to limp home. The following day in your office, her knee is diffusely tender and swollen. She is able to perform a straight leg raise. Pain limits further examination. X-rays are unremarkable. An MRI is ordered and the results are shown in the figures. Figure 1: T1 MRI, saggital cut throught the notch demonstrates an intact ACL Figure 2: T2 MRI, fat-sat, coronal cut demonstrates bone bruising of the trochlea and lateral femoral condyle. Figure 3: T2 MRI, fat-sat, axial cut demonstrates bone bruising of the medial patellar facet, and lateral femoral condyle. What would you advise?

1. A total body bone scan, CBC with diff, CRP, and sed rate. 2. Consideration of surgical correction of her injury within the next 5-7 days. 3. Slowly increase weight bearing as pain permits, a brace for protection and physical therapy. 4. Physical therapy to decrease swelling, improve range of motion and strength, followed by grafting to correct her pathology. 5. A CAT scan to better define pathology prior to advising specific treatment. Question 77: During ACL Reconstruction, the tension in the graft after femoral fixation needs to be determined using a tensiometer. The force trasducer in the tensiometer is calibrated by hanging various masses on the transducer and measuring the output voltage. A linear relationship was found between the independent variable (mass) and the dependent variable (voltage.) What statistical test was most likely used to determine this conclusion? 1. Analysis of covariance (ANCOVA) 2. Simple Regression 3. Poisson Regression 4. Analysis of variance (ANOVA) 5. Logistic regression Question 78: A 30 year old male presents to your office on post operative day 14 after an uncomplicated right anterior cruciate ligament reconstruction with an autologous quadrupled semitendinous and gracilis graft. He complains of increasing pain, persistent swelling, and unresolving redness at the incision sites. His oral temperature is 98.9 degrees F. He has pain with weight bearing. There is moderate effusion, erythema and warmth around the incisions, and no drainage. Active range of motion is 25 to 60 degrees and painful. The calf is non-tender. What is the most appropriate course of action? 1. Obtain a joint aspirate with Gram stain, fluid analysis, aerobic and anaerobic cultures 2. Obtain a repeat physical examination in 3 to 5 days as part of a serial knee evaluation 3. Obtain AP and lateral radiographs to evaluate tunnel and fixation placement 4. Obtain a physical therapy consultation for aggressive range of motion 5. Obtain a CBC with a differential, C reactive protein, and erythrocyte sedimentation rate Question 79: A 29 year old male is undergoing a marrow stimulation procedure for a grade IV cartilage defect on the MFC. What is the predominant type of collagen that results from this procedure? 1. Type X

2. Type II 3. Type V 4. Type I 5. Type VI Question 80: An 11 year-old soccer player complains of knee pain, which increased with activity and improves with rest. He localizes his pain to the front of his knee. The pain is severe and acute. A radiograph shows Osgood-Schlatter lesion at the tibial tubercle. What is the appropriate next step? 1. Apply a long leg cylinder cast for 4 weeks, then repeat radiographs. 2. Apply a brace and recommend non-weight bearing ambulation 3. Order an immediate bone scan 4. Cessation of activity until the pain resolves 5. Order a CT with thin sliced imaging Question 81: A 12 year-old boy has had a knee effusion and painful catching for 6 weeks. Radiographs reveal a well-circumscribed, crescent shaped bony fragment of subchondral bone. It is surrounded by a radiolucent rim. What is the most common location for this lesion in the knee? 1. Posterolateral aspect of medial femoral condyle 2. Anteromedial aspect of lateral femoral condyle 3. Superolateral patella 4. Inferomedial patella 5. Posteromedial aspect of lateral femoral condyle Question 82: A 22 year-old collegiate basketball player developed anterior knee pain 8 months ago. The pain has persisted despite rest and ibuprofen. An MRI shows an OCD lesion of the trochlea. What do you recommend in the next step in management? 1. Double upright brace with patellar stabilizing pad 2. Glucosamine and chondroitin sulfate 3. Arthroscopic evaluation and treatment 4. Positron emission tomography scan 5. Referral to an endocrinologist Question 83: A 33 year-old female semi-professional beach volleyball player presents complaining of a six month history of vague interior knee pain and occasional catching. She denies any instability or giving way, but has an effusion and is now unable to play for an extended period of time. MRI supports a diagnosis of localized pigmented villonodular synovitis. What is the most appropriate treatment? 1. Intra-articular chemotherapy 2. Radioactive synovectomy 3. Open debridement

4. Arthroscopic total synovectomy 5. Arthroscopic excision of the focal lesion Question 84: A 13 year-old female patient sustains a patella dislocation which is reduced by the patients uncle who is a physician. She obtains an MRI the next day and presents to the office within 24 hours after the injury. MRI shows a displaced osteochondral fragment from the lateral femoral condyle. What is the most appropriate treatment option for this patient? 1. ORIF lateral femoral condyle articular cartilage fragment 2. Tibial tubercle osteotomy 3. Lateral meniscal repair 4. Lateral retinacular release 5. Arthroscopic medial retinacular plication Question 85: The structure of cartilage proteoglycans can be described as: 1. Multiple hyaluronate molecules bound to a core protein, which is subsequently bound to glycosaminoglycan chain 2. Multiple glycosaminoglycan chains bound to hyaluronate, which is subsequently bound to core protein 3. Multiple glycosaminoglycans bound to core protein, which is subsequently bound to hyaluronate via a link protein 4. Multiple link proteins bound to a core protein, which is subsequently bound to glycosaminoglycan 5. Multiple hyaluronate chains bound to link protein, which is subsequently bound to glycosaminoglycan Question 86: Pressurization of interstitial fluid is one mechanism of load support in articular cartilage. Fluid within a cartilage layer is pressurized under dynamic joint motion because of what factor? 1. Low hydraulic permeability of the tissue 2. Nonporous structure of cartilage 3. High tensile strength of the collagen fibrils 4. Viscoelastic shear forces of the matrix 5. Low coefficient of friction at the cartilage Question 87: What factor has been associated with better outcome after cartilage repair after surgery? 1. Older age 2. Higher BMI 3. Longer duration of symptoms 4. Smaller lesion size 5. Higher patient activity Question 88: Which factor is not associated with the limited capacity of cartilage to heal following injury? 1. Lack of blood supply

2. Inhibition of cell migration 3. No initial response by chondrocytes to injury 4. Extracellular matrix 5. Limited inflammatory response Question 89: What is the relationship of the insertions of the LCL and the popliteus tendon on the femur? 1. The popliteus insertion is more distal, anterior and deep 2. The popliteus insertion is more proximal, anterior and deep 3. The popliteus insertion is more distal, inferior and deep 4. The popliteus insertion is more proximal, inferior and deep 5. The popliteus insertion is more distal, anterior and superficial Question 90: List the four knee ligaments in order of biomechanical strength (load to failure) from weakest to strongest: 1. ACL, PCL, LCL, MCL 2. LCL, MCL, ACL, PCL 3. LCL, ACL PCL, MCL 4. MCL, ACL, PCL, LCL 5. PCL, ACL, LCL, MCL Question 91: What is the most common reason for failure of anterior cruciate ligament reconstruction? 1- Malposition of the bone tunnels 2- Medial meniscus deficiency 3- Lateral meniscus deficiency 4- Improper graft selection 5- Articular surface damage Question 92: What is the central concept in rehabilitating an athlete during nonsurgical care of an isolated grade II posterior cruciate ligament tear? 1- The knee should be splinted in full extension for 6 weeks. 2- Early range of motion and quadriceps strengthening should start as soon as pain permits. 3- Open chain hamstring strengthening exercises should be initiated early. 4- Functional braces have a high rate of success in patients with persistent symptoms. 5- Patients should not return to sport until hamstring strength equals the contralateral side. Question 93: What anatomic structure inserts most anteriorly on the proximal fibula? 1- Sartorius 2- Iliotibial band 3- Biceps femoris 4- Popliteofibular ligament

5- Lateral collateral ligament Question 94: A 12-year-old boy has had pain in the right knee for the past 6 weeks. He has had two episodes of giving way but no locking. He denies any history of injury. Examination reveals no effusion, ligaments are stable, range of motion is full, and there is no localized tenderness. Plain radiographs and MRI scans show a non-displaced OCD lesion of the medial femoral condyle. What is the most appropriate management? 1- Excision of the lesion 2- Retrograde drilling of the lesion 3- Antegrade drilling of the lesion 4- Arthroscopic reduction and fixation 5- Observation and limitation of activities Question 95: Without a history of a significant reinjury, a 22-year-old student reports recurrent instability 1 year after undergoing autologous patellar tendon anterior cruciate ligament reconstruction. What is the most likely cause of the instability? 1- Varus alignment 2- Tunnel malposition 3- Failure of biological graft ingrowth 4- Failure of bone healing in the tunnels 5- Unrecognized posterolateral corner injury Question 96: Plain x-rays of 30-year-old individual who sustained a noncontact knee injury while playing soccer 2 days ago show a capsular avulsion fracture of the anterolateral tibial plateau. What physical examination test is most likely to be abnormal? 1- McMurray 2- Lachman 3- Posterior drawer 4- Varus laxity at 30 5- Patellar apprehension Question 97: A 25-year-old man injured his knee in a motor vehicle collision. Abnormal examination findings include 10 increased external tibial rotation at 30 and 90 knee flexion. What additional examination finding is expected? 1- Increased opening to valgus stress at 30 of knee flexion 2- Increased varus opening at 0 of knee flexion 3- Positive apprehension sign with lateral patellar translation 4- Positive pivot shift test 5- Medial tibial plateau rests 10 mm anterior to the medial femoral condyle Question 98: Current ACL injury prevention strategies for femal athletes have focused on which of the following strategies? 1 Weight loss

2 Avoidance of at-risk activities during certain phases of the menstrual cycle 3 Neuromuscular control 4 Year-round strength training 5 Intercondylar notch widening Question 99: When Performing a single-bundle posterior cruciate ligament reconstruction, the graft should be tensioned when the knee is in what position? 1- Full extension 2- Full Flexion 3- 30 of flexion 4- 45 of flexion 5- 90 of flexion Question 100: What area of articular cartilage is most likely injured with patellar dislocation? 1- Medial trochlea 2- Odd facet of the patella 3- Medial facet of the patella 4- Lateral facet of the patella 5- Keel of the patella

Knee-Answers 1) 2 2) 2 3) 4 4) 2 5) 4 6) 5 7) 4 8) 3 9) 3 10) 4 11) 2 12) 3 13) 2 14) 5 15) 3 16) 1 17) 3 18) 2 19) 4 20) 1 21) 2 22) 2 23) 2 24) 1 25) 4 26) 2 27) 4 28) 3 29) 3

30) 31) 32) 33) 34) 35) 36) 37) 38) 39) 40) 41) 42) 43) 44) 45) 46) 47) 48) 49) 50) 51) 52) 53) 54) 55) 56) 57) 58)

5 4 4 5 5 2 3 3 4 3 5 1 5 5 2 1 5 1 5 5 5 3 1 4 4 4 5 5 2

59) 1 60) 1 61) 2 62) 3 63) 2 64) 3 65) 4 66) 3 67) 2 68) 2 69) 4 70) 2 71) 3 72) 1 73) 3 74) 3 75) 1 76) 3 77) 2 78) 1 79) 4 80) 4 81) 1 82) 3 83) 5 84) 1 85) 3 86) 1 87) 4 88) 3 89) 1 90) 3 91) 1 92) 2 93) 5 94) 5 95) 2 96) 2 97) 2 98) 3 99) 5 100) 3

AAOS Orthopaedic Review Course

Foot and Ankle Disorders

Frequency of Questions
OITE
Bunions & HV (11%) Hallux rigidus (11%) Other forefoot arthritis (6%) Diabetic foot (5%) Tendon disorders (3%) Heel pain (3%) Lesser toe deformities (2%) Sesamoid disorders (2%) Bunionette (1%) Other - Mortons neuroma, anatomy & problems, lesser MP joint synovitis/instability, sprains, ankle osteochondral lesions, ankle

Steven L. Haddad, M.D.

Associate Professor of Clinical Orthopaedic Surgery University of Chicago Pritzker School of Medicine

Overview
Forefoot
Bunions Hallux Rigidus Hallux Varus Hammertoes Clawtoes Mallet toes MTP Instability Sesamoiditis Bunionette

Bunions
Diseases
Diabetes Rheumatoid Arthritis

Midfoot Hindfoot
Arthritis Painful Flatfoot Achilles tendonitis Plantar heel pain
Just plantar fasciitis

Ankle
Instability OCD Arthritis

Bunions
Treatment
Conservative management is the best option
Find a shoe that fits the foot: wider toe box shoes, extra-depth toe box shoes Shoe stretching Orthotics have value in those with pes planus and hypermobility

Bunions
Treatment
Conservative management is the best option
Find a shoe that fits the foot: wider toe box shoes, extra-depth toe box shoes Shoe stretching Orthotics have value in those with pes planus and hypermobility

Bunions
Surgery
Angles of Measurement
Intermetatarsal angle

Bunions
Surgery
Angles of Measurement
Hallux valgus angle

Normal<15 Normal<9

Bunions
Surgery
Angles of Measurement
Distal metatarsal articular angle

Bunions
Surgery
Angles of Measurement
Hallux interphalangeal angle

Normal<6 Normal<10

Bunions
Congruent Hallux Valgus Incongruent Degenerative Congruent

Bunions
Hallux Valgus Incongruent Degenerative Double Osteotomy

Biplanar Akin and Chevron Exostectomy

Bunion Deformities
Congruent Biplanar Chevron Osteotomy

Bunion Deformities
Congruent
Hallux valgus interphalangeus

Bunion Deformities
Congruent

Akin Osteotomy
3mm

Double Osteotomy
For those with larger intermetatarsal angles (>15):

Bunion Deformities Incongruent Joints

IM<15; HV< 30 *May add an Akin
(double osteotomy)

Bunion Deformities Incongruent Joints

IM>15; HV< 40 IM>20; HV>40 Prox. Osteotomy (Crescentic, Oblique, Scarf) and distal soft tissue release* Proximal Osteotomy and distal soft tissue release* or MTP arthrodesis

Distal Osteotomy (Chevron)*

*May add an Akin

(double osteotomy)

Bunion Deformities Incongruent Joints

TMT Hyper mobility *May add an Akin
(double osteotomy)

Bunion Deformities
Degenerative
Congruent Hallux Valgus Incongruent Degenerative Fusion
Note auto-correction Of IMA

TMT arthrodesis (Lapidus) and DSTR

Implant

Keller Resection Arthroplasty

Bunion Deformities
Degenerative
Congruent Hallux Valgus Incongruent Degenerative Fusion
Shortening isnt The only problem

Bunion Deformities
Degenerative
Congruent Hallux Valgus Incongruent Degenerative Fusion

Implant

Shortening isnt The only problem

Implant

Keller Resection Arthroplasty

Keller Resection Arthroplasty

Bunion Complications
Chevron Osteotomy
Avascular necrosis
Kenzora (1985): Suggested 20% in distal osteotomies
40% of this group had lateral release Very low N

Bunion Complications
First metatarsophalangeal joint arthrodesis
Malunion
Follow guidelines:
2.5cm

Resch (1992): Defined blood supply and determined not at risk with careful dissection Richardson (1994): 0% in 80 cases with lateral release

15 to 20 degrees of dorsiflexion with respect to 1st metatarsal Neutral rotation 10 to 15 degrees of valgus

Bunion Complications
Hallux varus
By definition: medial deviation of great toe Observed after:
Lateral collateral ligament disruption Overcorrection Extreme ligament laxity (ie Ehlers Danlos)

Bunion Complications
Hallux varus
Surgery
Passively correctible with no arthritis
EHB tendon transfer vs. split EHL tendon transfer

Conservative management
Tape

Bunion Complications
Hallux varus
Surgery
Rigid deformity, arthritis
1st MTP fusion

Hallux Rigidus

Hallux Rigidus
Second most common pathology affecting 1st metatarsophalangeal joint Variations of osteoarthritis
Grade 1: Mild periarticular osteophytes, no joint space collapse, stiff ROM

Hallux Rigidus
Second most common pathology affecting 1st metatarsophalangeal joint Variations of osteoarthritis
Grade 2: Significant osteophytes, joint space visible but narrowed

Hallux Rigidus
Second most common pathology affecting 1st metatarsophalangeal joint Variations of osteoarthritis
Grade 3: Severe osteophytes, joint space completely collapsed

Hallux Rigidus
Conservative management
Extra depth shoes to accommodate bump Steel shank placed in shoe sole v. carbon fiber footplate with Mortons extension to protect 1st MTP motion Rocker bottom sole to shoe

Hallux Rigidus
Conservative management
Rocker bottom sole to shoe

Hallux Rigidus
Surgery
Cheilectomy (Grade 1,2)
Allows shaving of up to 30% of metatarsal head Mann (1988)
90% with pain relief 38% with Grade 3 dissatisfied

Moberg osteotomy (1979)

Goal is to achieve 25 dorsiflexion Smith (1999)
96% satisfaction v. 76% with cheilectomy alone

Hallux Rigidus
Surgery
Type 3: first metatarsophalangeal joint arthrodesis
Must prepare surfaces carefully

Lesser Toes

Keller arthroplasty, Implant arthroplasty

Limited indications (elderly, low demand ONLY)

Lesser Toe Deformities

Conservative Care

Lesser Toe Deformities

Conservative Care

Hammertoe
Extension MTP Flexion IP Extension DIP

Silipos Sleeve Shoe Stretch Metatarsal pad Budin splint

Clawtoe
Extension MTP Flexion PIP Flexion DIP

Toe Crest Silipos Sleeve

Lesser Toe Deformities

Conservative Care

Lesser Toe Deformities

Fixed
Hammertoe Proximal interphalangeal joint
resection arthroplasty EDL lengthening MTP capsulotomy and collateral ligament release

Flexible
FDL to EDL transfer (Girdlestone-Taylor)

Mallet toe
Flexion DIP

Toe Tip Silipos

* Address EACH joint Deformity, think flexible or fixed

Lesser Toe Deformities

Fixed Flexible

Lesser Toe Deformities

Fixed Flexible

Clawtoe

PIP joint resection arthroplasty Distal interphalangeal joint resection arthroplasty FDL tenotomy

FDL tenotomy

Mallet toe

Distal interphalangeal joint resection arthroplasty

FDL tenotomy

* Address EACH joint Deformity, think flexible or fixed

* Address EACH joint Deformity, think flexible or fixed

Metatarsophalangeal Joint Instability

2nd metatarsophalangeal joint Stability of the joint compromised through
Laxity of volar plate (stretch or rupture) Subsequent rupture of lateral collateral ligament
Dorsal subluxation, dislocation of MTP joints

Weil Osteotomy
Distal metatarsal osteotomy
Useful for dislocated 2nd MTP joint Weil-Barouk (1994)
axial decompression resolving the hammer toe/MP subluxation that increases metatarsalgia

Weil Osteotomy
Distal metatarsal osteotomy
Vandeputte (FA Int, 2000)
Excellent or good in 86% 95% had reduction in callus

Sesamoid Disorders

Sesamoid Disorders
History
Pain under plantar 1st metatarsal (sesamoid) Acute dorsiflexion event
Heard pop

Sesamoid Disorders
MRI better than bone scan, more helpful in difficult cases
Avascular necrosis, non-union, acute fracture

Radiographs
Standing foot films
Medial bipartite 10% Lateral rarely bipartitie Bilateral bipartite 25%

Bone scan obtain when xrays normal & pain persists

Results may be obscured if there are degenerative changes in the MTPJ Collimation will help Increased activity reported in up to 30% of asymptomatic people especially elite athletes

Sesamoid view
Osteochondritis Degenerative between sesamoid at MT head

Sesamoid Disorders
Disorder Management Permanent Issues

Sesamoid Disorders
Treating altered biomechanics
Utilize off-loading orthotic
Carbon-fiber with sesamoid welled-out Utilize plastazote if patient cannot tolerate carbon-fiber

Acute Fracture

Cast 6 Alter biomechanics weeks NWB Alter training Orthotics

Bone graft Cast Partial or Total Sesamoidectomy

Non-union

Alter biomechanics

Sesamoid Problems
Synchondrosis Pain Arthritis AVN; Osteochondritis IPK
Risk of disruption FHB Bipartite Partial sesamoidectomy 80% tibial 25% bilateral Total Sesamoidectomy

Sesamoid Complications
Medial sesamoidectomy
Inadequate repair FHB: Hallux Valgus Medial plantar nerve at risk

Partial or Total Sesamoidectomy Plantar Shaving

Sesamoid Complications
Lateral sesamoidectomy
Inadequate repair FHB: Hallux Varus Lateral plantar nerve at risk

Sesamoid Complications
Both sesamoids removed
Cock-up toe

Bunionette

Bunionette
Davies: Initial Description (1949)
pressure over lateral condyle 5th metatarsal head
bursa irritation

Bunionette Classification
Type 1
Enlarged 5th metatarsal head
true hypertrophy exostosis

Bunionette Classification
Type 2
Bowing of the diaphysis laterally
congenital

Bunionette Classification
Type 3
Widened 4th5th intermetatarsal angle

Bunionette Surgical Management

Type 1
Isolated metatarsal head shaving
Fallen out of favor Kitaoka (1991)
Disruption lateral capsule creates increased valgus of 5th toe

Chevron osteotomy with lateral capsule release

1mm shift reduces 4th5th IM angle by 1 degree Usual displacement 3 to 4mm Limitation imposed by width of metatarsal neck

Bunionette Surgical Management

Type 2 and 3
Both treated similar due to wide IMA Oblique diaphyseal 5th metatarsal osteotomy described by Mann (1986) May be uniplanar or biplanar
Adds advantage of correcting plantar AND lateral keratoses Medial capsule release may be added to improve correction of 5th toe

Bunionette Correction
Proximal osteotomies
Avoided in the 5th metatarsal shaft due to potential violation of blood supply
High rate of nonunion

Midfoot Disorders

Midfoot Arthritis
Comprises tarsometatarsal and naviculocuneiform arthritic conditions

Anatomy
Bone
Three separate columns Based on Stability, Structural Rigidity, Movement
Medial: 1st MT + medial cuneiform
3.5mm dorsal/plantar movement

Midfoot Arthritis
Physical Exam
Painful, swollen midfoot
2nd TMT most common

Middle: 2nd/3rd MT + middle/lateral cuneiform

0.6mm dorsal/plantar movement

Piano Key test Flatfoot deformity

Standing Foot Films

Lateral: 4th/5th MT + cuboid

13mm dorsal/plantar movement pronation and supination

Midfoot Arthritis
Conservative care
Stiff sole shoe with Vibram sole Plastazote insert
Support, dont correct deformity Do not use rigid orthotics Surgery

Midfoot Arthritis
Hansen (1990)
Accuracy of reduction of deformity correlates directly with patient satisfaction Do not fuse in situ

Cortisone injections
May require fluoroscopy

Midfoot Arthritis
Surgery
Hansen (1990)
Accuracy of reduction of deformity correlates directly with patient satisfaction Do not fuse in situ

Midfoot Arthritis
Surgery
Mann (1996)
If joint has questionable arthritis, fuse it at index procedure

Do not fuse lateral column

Maintain mobility through joint arthroplasty

Hindfoot

Tarsal Coalition

Tarsal Coalition
Facts
Results from failure of differentiation lack of joint formation Incidence debated between <1% to 12% Bilateral in 20 60% Talocalcaneal & calcaneonavicular more common than talonavicular Presentation freq after trauma i.e. sprained ankle

Tarsal Coalition
Physical Examination
Flatfoot deformity of variable rigidity Talocalcaneal no calcaneal inversion w/ heel rise; medial pain over middle facet Calcaneonavicular fraction of inversion compared to contralateral side, TT motion limited Occasional bony prominence Stressing coalition may elicit pain

Tarsal Coalition
Imaging
Xray WB AP, lateral, oblique
Look for distortion of normal bone anatomy Lateral talar beaking

Tarsal Coalition
Imaging
Calcaneonavicular coalition: Internal oblique xray as union or extension of ant neck of calc to navicular

Tarsal Coalition
Imaging
Talocalcaneal Visualized as narrowing of post subtalar joint, loss of middle facet, flattening of talar neck

Tarsal Coalition
Imaging CT limited ability to assess fibrous coalition, MRI better

Tarsal Coalition
Treatment
Conservative NSAIDs Activity modification SLC immobilization Orthoses Operative
Symptomatic & <14 yrs resection +/- interposition grafting/bone wax Older, more severe involvement, degenerative changes fusion Also, if greater than 50% of the TOTAL talocalcaneal joint involved=fusion

Adult Acquired Flatfoot

Adult Acquired Flatfoot

Primary offender
Posterior tibial tendon insufficiency

Primary offender Anatomy

Adult Acquired Flatfoot

Posterior tibial tendon insufficiency 2 cm excursion Watershed zone of vascularity Between Medial Malleolus and Navicular

Anatomy
2 cm excursion Watershed zone of vascularity Between Medial Malleolus and Navicular

Ultimate failure: Spring Ligament Joins calcaneus to navicular

Acts as a sling supporting talonavicular joint

Ultimate failure: Spring Ligament Joins calcaneus to navicular

Acts as a sling supporting talonavicular joint

Function
Invert hindfoot, adduct forefoot Produced rigid lever for toe off

Function
Invert hindfoot, adduct forefoot Produced rigid lever for toe off

Adult Acquired Flatfoot

Primary offender
Posterior tibial tendon insufficiency

Adult Acquired Flatfoot

Thus, when it goes bad:

Anatomy
2 cm excursion Watershed zone of vascularity
Between Medial Malleolus and Navicular

Function
Invert hindfoot, adduct forefoot Produced rigid lever for toe off

Hindfoot valgus

Forefoot Abduction

Adult Acquired Flatfoot

Radiographs
Standing Foot series
Talonavicular incongruency Subluxation subtalar joint Arthritis

Adult Acquired Flatfoot

Radiographs
Standing Foot series
Talonavicular incongruency Subluxation subtalar joint Arthritis

Adult Acquired Flatfoot

Radiographs
Standing A/P ankle
Talar tilt Fibula fracture

Adult Acquired Flatfoot

Radiographs
+/- MRI

Adult Acquired Flatfoot

Non-operative treatment
Medial heel and sole wedge orthosis

Adult Acquired Flatfoot

Non-operative treatment
UCBL orthosis Custom molded lace up ankle brace AFO

Staging
Disease is on a continuum, but artificially staged
Stage 1: tenosynovitis

Staging
Disease is on a continuum, but artificially staged
Stage 2: rupture, passively correctable

Staging
Disease is on a continuum, but artificially staged
Stage 3: rupture, rigid deformity

As If We Didnt Have Enough Stages

Stage 4 (Myerson): ankle arthritis
valgus angulation of talus

Adult Acquired Flatfoot Stages

Stage 1 PTT Hindfoot Pain SLHR Too Path Peritendonitis Mobile, normal Medial/focal Negative Negative Synovial Prolif Stage 2 Elongation Mobile/valgus Medial Positive Positive Degeneration Stage 3 Absent Rigid Medial/Lateral Positive Positive Degeneration

Adult Acquired Flatfoot

Surgery
Stage I (after 3-6 months)
Tenosynovectomy Evaluate carefully for deformity

Stage II
Tendon and Bone work +/TAL/Strayer
FDL to PTT transfer AND (one or more) Medial displacement calcaneal osteotomy Lateral column lengthening (abduction) Spring ligament repair

Adult Acquired Flatfoot

Surgery
Stage I (after 3-6 months)
Tenosynovectomy Evaluate carefully for deformity

Adult Acquired Flatfoot

Surgery
Stage III
Triple arthrodesis with deformity correction TAL/Strayer

Stage II
Tendon and Bone work +/TAL/Strayer
FDL to PTT transfer AND (one or more) Medial displacement calcaneal osteotomy Lateral column lengthening (abduction) Spring ligament repair

Stage IV
Triple arthrodesis with deltoid reconstruction
Most longstanding hindfoot valgus patients have an isolated contracture of the gastrocnemius Test ankle flexibility with the knee in full extension and full flexion
Notice improved dorsiflexion with the need flexed (relaxing gastroc)

Requires Strayer procedure

Cavovarus Deformities

Cavus Foot
Abnormal elevation of the medial arch in weightbearing = cavus
Forefoot equinus relative to the hindfoot Forefoot pronation from plantarflexion of the first MT relative to the hindfoot Equinus and calcaneus describe position of the hindfoot

Cavus Foot
Wide spectrum of disease
Mild elevation of the longitudinal arch Rigid deformities
Secondary arthritis Stress fractures Profound weakness Ligamentous insufficiency

Etiology
Often underlying spinal cord or neuromuscular etiology
Common factor is a muscle imbalance that disturbs the synergy between intrinsic and extrinsic muscles

Etiology
Potential progressive neurological disorders
2/3 with high arch have underlying progressive neurological condition
Hereditary Sensory Motor Neuropathies

Etiology
Unilateral involvement: static condition
Poliomyelitis Spina Bifida
Lesions below 2nd sacral segment
Loss of intrinsic muscles to the foot

1/2 of these have CharcotMarie-Tooth

Inherited degenerative disorder of the central and peripheral nervous system
Muscle atrophy Loss of proprioception

Trauma
Deep posterior compartment syndrome Crush injuries to the foot with intrinsic muscle ischemia

Bilateral Condition

Pathophysiology
Progressive conditions
Caused by overpull of one muscle relative to weak antagonist
Initially flexible, becomes rigid deformity

Physical Examination
Posterior v. Anterior
Anterior Pes Cavus
Calcaneal shape and orientation normal
Gastrocnemius-soleus LAST muscle group affected

Progressive means NOT static: muscles will continue to weaken, creating further deformity
May affect an initially excellent surgical correction

Origin of cavus from MIDFOOT, with plantarflexion of metatarsals Radiographically:

arch high, plantar angulation originates at or between the transverse tarsal and tarsometatarsal joints calcaneal pitch angle less than 30 degrees

20

Physical Examination
Posterior v. Anterior Anterior Pes Cavus: HSMN Evaluate valgus of forefoot with patient prone

Physical Examination
Posterior v. Anterior Anterior Pes Cavus: HSMN Coleman lateral block test evaluates rigidity of the hindfoot in the deformity Block placed under heel and lateral forefoot Allows first ray to drop to floor If hindfoot corrects, this is a flexible hindfoot deformity

Physical Examination
Posterior v. Anterior
Anterior Pes Cavus: HSMN
Muscle weakness: Anterior Tibial Tendon: becomes weak early Peroneus Brevis: becomes weak early Peroneus Longus: remains strong, pulling the 1st ray into plantarflexion without opposition (ATT) Posterior Tibial Tendon: remains strong, aggravates hindfoot varus without opposition (PB) Intrinsics: becomes weak early Extensor Digitorum Longus: remains strong, creating clawtoe contractures without opposition (Intrinsics)

Treatment: Anterior Pes Cavus

Global Metatarsus Equinus
Conservative
Usually function well, no calcaneal varus Problems with metatarsalgia, clawtoes Orthosis made with thermal moldable cork transfers weight to metatarsal shafts
PPT to cushion the metatarsal heads

Deep toe box for clawtoes

Treatment: Anterior Pes Cavus

Global Metatarsus Equinus
Surgical
Multiple basal metatarsal dorsiflexion osteotomies
May result in bayonet shaped foot

Treatment: Anterior Pes Cavus

Plantar fascia release to allow closure of osteotomies

Treatment: Anterior Pes Cavus

Hindfoot
Lateral displacement calcaneal osteotomy Add closing wedge to eliminate deforming force

Treatment: Anterior Pes Cavus

Forefoot valgus
Surgical: Hindfoot varus rigid
Peroneus longus to peroneus brevis tendon transfer
Eliminated longus as deforming force plantarflexion 1st ray Assists weakened peroneus brevis in active eversion and ankle stability

Results
Combination of procedures required, thus results for any particular procedure absent in literature
Most studies agree that joint preserving operations leave higher patient satisfaction than triple arthrodesis
Wetmore and Drennan (1989): 24% good to excellent results with triple for cavus Mann and Hsu (1992): 42% with plantigrade foot following triple for cavus

Plantar Heel Pain

Plantar Heel Pain Differential Diagnosis

Proximal Plantar Fasciitis Tarsal Tunnel Syndrome Calcaneal Stress Fracture Heel Pad Atrophy

Localized pain Quality of pain Mechanical vs. neuritis pain Past history (cortisone ruptures PF) Systemic symptoms (spondyloarthropathies)

Plantar Heel Pain Evaluation

Plantar Heel Pain Proximal Plantar Fasciitis

Plantar medial heel pain
Worst in am with first few steps or after sitting (mechanical)

Plantar Heel Pain Proximal Plantar Fasciitis

Plantar medial heel pain
Heel spur (attachment of EHB) irrelevant
Only 50% have spurs

Plantar Heel Pain Proximal Plantar Fasciitis

Plantar medial heel pain
Non-op treatment 6-9 months
Stretching PF and Achilles NSAID Shock absorbing soles and orthoses Physical therapy Cortisone injection Night splints (50-80% successful)

Plantar Heel Pain Proximal Plantar Fasciitis

Plantar medial heel pain
Non-op treatment 6-9 months
Stretching PF and Achilles NSAID Shock absorbing soles and orthoses Physical therapy Cortisone injection Night splints (50-80% successful)

Plantar Heel Pain Proximal Plantar Fasciitis

Plantar medial heel pain
Non-op treatment 6-9 months
Stretching PF and Achilles NSAID Shock absorbing soles and orthoses Physical therapy Cortisone injection Night splints (50-80% successful)

Plantar Heel Pain Proximal PF

Operative treatment
LAST RESORT
6 months of failed conservative care Endoscopic vs open release
Partial release (medial and central slips) Release first branch to lateral plantar nerve (Baxters nerve) Complete release leads to dorso-lateral foot pain

Plantar Heel Pain Proximal PF

Operative treatment
LAST RESORT
Extracorporeal Shock Wave Rx
High Energy Single treatment of 1000impulse, anesthesia required Low Energy 20 minutes session, no anesthesia Literature suggests 80% success rate

Plantar Heel Pain Calcaneal Stress Fracture

History of increased activity Tenderness with medial and lateral compression heel Pain may be present with or without weightbearing Fracture line is perpendicular to trabecular bone Treatment
SLC NWB for 6-8 weeks Alter training or biomechanics

Achilles Tendinosis/Chronic Rupture

Posterior Heel Pain Achilles Tendon Disorders

Achilles Bursitis
Retrocalcaneal

Achilles Paratendonitis
Thickened paratenon, normal tendon

Achilles Tendinosis
Focal degeneration within tendon

Posterior Heel Pain Chronic Achilles Tendinosis

Mean Age 24-30 years; range 16-52 Etiology
Overuse Poor training conditions Foot architecture
Varus hindfoot

Posterior Heel Pain

Chronic Achilles Tendinosis
Radiographs
Standing ankle series
Calcifications in Achilles (intrasubstance or insertion) Soft tissue swelling Haglunds Deformity
Prominence of posterior calcaneus

Poor vascularity
Watershed area 4 to 6cm proximal to insertion

Systemic disease (Reiters Syndrome, HLA-B27) Tendon narrowest 4cm proximal to insertion

MRI
Preop for OR
Haglunds

Posterior Heel Pain Chronic Achilles Tendinosis

Surgery
Paratendonitis (after 6 months conservative)
Brisement (injections) Excision of paratenon

Posterior Heel Pain Chronic Achilles Tendinosis

Surgery Intrasubstance tendinosis VY advancement/ turndown to fill void

Intrasubstance tendinosis
Aggressive debridement Excision of entire diseased segment if full thickness

Posterior Heel Pain Chronic Achilles Tendinosis

Surgery
Flexor hallucis longus tendon transfer required if more than 50% of tendon removed
Pulvertaft tendon weave

Posterior Heel Pain Insertional Achilles Tendinosis

Surgery
Haglunds with insertional calcifications
Central splitting approach Remove entire exostosis
Debride Achilles insertion

Posterior Heel Pain Insertional Achilles Tendinosis

Surgery
Haglunds with insertional calcifications
Flexor hallucis longus tendon transfer to calcaneus through posterior incision

Posterior Heel Pain Insertional Achilles Tendinosis

Surgery
Haglunds with insertional calcifications
Repair limbs of Achilles to calcaneus

Ankle Instability

Ankle Instability
Instability = Pain
Osteochondritis dessicans talus Peroneal Tendonitis (Peroneus Brevis) Occult fracture (anterior process calcaneus, lateral process talus, posterolateral tubercle talus; 5th MT) Peroneal tendon subluxation/dislocation Ankle arthritis

Anatomy
ATFL 66% ATFL and CFL 25% PTFL rarely injured

Ankle Instability
Acute lateral ankle sprain
85-95% improved with Functional Rehab
RICE Ankle Brace Ankle ROM, Peroneal strengthening, proprioception 15-20% residual instability episodes NO ACUTE REPAIR

Ankle Instability
Ankle instability
Mechanical (demonstrate on stress x-rays) Functional (feelings of giving way)
BOTH treated the same way
Functional rehab initially 6-8 weeks If recurrent instability then Modified Brostrom lateral lig repair Tendon weave procedures reserved for Large Athletes and hypermobility syndromes (Chrisman-Snook)

Ankle Instability
Surgery is 90-95% successful Brostrom has lower complication rate
less nerve damage no loss of subtalar motion (inversion) modification

Surgery is 90-95% successful Brostrom has lower complication rate

less nerve damage no loss of subtalar motion (inversion) modification

Ankle Instability

Beware of Hindfoot Varus

inferior extensor retinaculum augmentation provides subtalar stability

inferior extensor retinaculum augmentation provides subtalar stability

May need calcaneal osteotomy

Beware of isolated subtalar instablity

difficult to diagnose treatment with standard ligament reconstruction

Osteochondritis Dissicans

Talus Osteochondritis Dissicans

Posteromedial
Avascular lesion Congenital

Anterolateral
Trauma induced

Talus OCD
Conservative
Non WB Cortisone injection

Systemic Conditions

Operative
Debridement, microfracture, drilling
70 to 90% good to excellent results

OATS, Mosaicplasty, Carticel

Salvage procedures (p 493, OKU8) 88 to 94% good to excellent results

Ankle ligament repair simultaneously

Rheumatoid Arthritis

Inflammatory Arthropathies Rheumatoid Arthritis

17% RA begins in feet
MTP< talonavicular<subtalar<calcaneal cuboid Ankle and Midfoot arthritis occur
commonly do not require treatment

89% RA patients have foot involvement HLA-DRW4

Inflammatory Arthropathies Rheumatoid Arthritis

Forefoot deformity
Hallux valgus with joint changes Dorsolateral MTP subluxation/dislocation
Synovitis of MTP joints Incompetency of plantar plate Distal migration of the plantar fat pad uncovering of MTH

Rheumatoid Arthritis
Forefoot
Conservative treatment
Total contact orthoses Extra depth shoe/shoe stretching Maximize medical management

Symptoms
Walking on marbles; occasional ulceration Difficulty fitting into shoes Joint pain

Operative
Synovectomy if early (after 3-6 months non-operative management) 1st MTP arthrodesis and metatarsal head resections 2nd through 5th (Hoffman)

Rheumatoid Arthritis
Forefoot
Conservative treatment
Total contact orthoses Extra depth shoe/shoe stretching Maximize medical management

Rheumatoid Arthritis Hindfoot

Treatment
Conservative
UCBL orthosis or custom lace up ankle brace Maximize medical management

Operative
Synovectomy if early (after 3-6 months non-operative management) 1st MTP arthrodesis and metatarsal head resections 2nd through 5th (Hoffman)

Operative
Tenosynovectomy (joint or posterior tibial tendon) Arthrodesis of affected joints

Rheumatoid Arthritis Hindfoot

Subtalar Arthrodesis
5 valgus hindfoot alignment

Rheumatoid Arthritis Ankle

Conservative
Solid ankle AFO Maximize medical management

Choparts joints (talonavicular/ calcaneocuboid)

Neutral abduction/adduction Neutral varus/valgus

Operative
ArthrodesisGOLD STANDARD 5-10 External rotation 0-5 Dorsiflexion 5-10 Valgus Distraction Arthroplasty Ankle Replacement

Rheumatoid Arthritis Ankle

Conservative
Solid ankle AFO Maximize medical management

Diabetes

Operative
ArthrodesisGOLD STANDARD
5-10 External rotation 0-5 Dorsiflexion 5-10 Valgus

Ankle Replacement

The Diabetic Foot

Neuropathy Autonomic neuropathy develops from injury to the nerves
Apocrine/endocrine source
due to poorly controlled glucose balance

Diabetic Foot
The Problems
Neuropathy
Sensory
Polyneuropathy

Pre-arteriole Vascular Control

due to decreased blood flow to the nerves less likely, as blood flow is initially increased

Semmes-Weinstein monofilament 5.07

Motor
Most commonly common peroneal Foot drop and intrinsic clawtoes Dry, scaly, fissuring skin leads to loss of skin integrity

Autonomic

Diabetic Foot
Peripheral vascular disease
Small and Large vessel disease Non-palpable pulses get non-invasive vascular studies ABI >0.45 for healing (diabetics) Absolute toe pressures >0.40 mm Hg Calcifications in vessels lead to falsely pressures Tc0 toe > 30-40 mmHg

Diabetic Foot
Immune system impairment
Altered chemotaxis Poor phagocytosis Poor cytotoxic environment ( sugars)

Metabolic deficiency
Albumin < 2.5 g/dL WBC < 1500 Total protein < 6.0

Hypomobility Syndrome
Glycosolated tissue leads to soft tissue contractures
Achilles tendon Clawtoes

Ulcers (Painless)

Diabetic Ulcers

Conservative Ulcer Management

Total Contact Cast
Brand developed in 1950 Cast must be changed weekly Contraindications
Active infection Vascular disease Noncompliant

Due to increased pressure (bone prominence) and neuropathy Classified by depth, location, infection
Wagner 1-5 (0 = at risk)

Heel is worst

1 2 3 4 5

Superficial ulcer Deep ulcer Abscess Forefoot gangrene Full foot gangrene

Diabetic Ulcers
May require supplementary procedures to lessen deforming forces
Hoke Strayer

Ulcers Treatment
Wagner 1,2

Diabetic Foot

TAL Wagner 3,4,5

Total contact cast or brace until healed Total contact insert, appropriate shoes and/or bracewear Surgery for ostectomy or osteotomy to improve alignment if reoccurrence

Surgical debridement or amputation +/- TAL Total contact cast until healed Appropriate inserts/shoes/brace

Diabetic Foot
Infection
Polymicrobial Culture of ulcer NOT helpful Probe to bone 67% sensitive for infection Intra-op cultures at time of surgery
Injectables Piperacillin/Tazobactam Ampicillin/Sulbactam Ticarcillin disodium/Clavulanate potassium Ciprofloxacin hydrochloride (good for staph, pseudomonas poor for anaerobes, strep Contraindicated in children, pregnancy

Diabetic Foot
Charcot Arthropathy
Neuropathic Osteoarthropathy
Destructive bone fractures and joint dislocations associated with peripheral neuropathy Erythema, Warmth Swelling (skin intact) Staged: Eichenholtz 1,2,3

IF acute fracture (Stage 1) and unstable

fix the fracture and cast 2-3 times longer than normal Ankle needs to be braced with AFO for 1 year

Isolated Tc scan not helpful (TC/IND)

+ with charcot arthropathy Add tagged WBC scan

MRI may be helpful

Diabetic Foot
Charcot Arthropathy
Stage 2 Fractures
Cast until swelling, erythema, warmth resolves (Stage 3) then OR if unbraceable

Charcot Arthropathy
Stage 1 Frag. Stage 2 Coales. Rads normal or fragmenting; demineralized Red hot and Rads show less warm but less acute Dont operate on WET WOOD so fragments and joint disruption Temp normal; Bone healing no swelling; may have deformity Red, hot and warm

Stage 3 Charcot
Brace if no complications OR for Plantigrade Foot

Stage 3 Consol.

35 yo woman underwent a distal chevron osteotomy for a hallux valgus deformity complicated by a post operative infection 2 years ago. The patient now has a painful limited hallux MTP motion without drainage. Surgical management should consist of a

Thank You
1. 2. 3. 4. 5. Silastic implant 1st MTP arthrodesis Resection arthroplasty (Keller) First Ray amputation Fascial arthroplasty

37 yo woman with seronegative RA underwent a bunionectomy without complications 1 year ago. Now has a recurrence of pain and difficulty with accommodative shoe wear. Examination demonstrates a recurrent bunion and pain at the MTP joint. Which is the best course of treatment?
1. 2. 3. 4. 5. Modified Lapidus procedure MTP arthrodesis Proximal first MT osteotomy and DSTR Akin Osteotomy Resection arthroplasty of the Hallux-MT joint

The figure below shows the radiograph of an 82 yo male with a hammertoe deformity of the 2nd toe and a bunion deformity associated with a painful callosity under the Hallux IP joint. The patient has type II DM which is well controlled with oral meds. Surgical treatment should consist of
1. 2. 3. 4. 5. A distal Chevron bunionectomy A proximal 1st MT osteotomy and DSTR Resection arthroplasty of the 1st MTP joint (Keller) Arthrodesis of the 1st MTP joint Silicone arthroplasty

57 yo woman with pain from shoe abutment on the hallux and difficulty fitting into shoes 4 years after a bunion procedure (radiograph below). Exam reveals a flexible 1st MTP and IP joints. Surgical treatment consists of
1. 2. 3. 4. 5. 1st MTP arthrodesis FHL transfer with IP arthrodesis and medial soft tissue reconstruction Reconstruction with the EHL or EHB tendon transfer Closing wedge osteotomy hallux proximal phalanx A Keller bunionectomy with medial soft tissue reconstruction

Which is the best orthotic prescription for treatment of the symptomatic condition shown below?

1. 2. 3. 4. 5.

Longitudinal metatarsal arch support Soft liner Full-length rigid orthosis UCBL orthosis Bunion splint

The clinical picture below is of a 26 yo patient 1 year after a crush injury to the foot. The patient has symptomatic lesser toe deformities with MTP ext, a stiff flexed toe at the PIP joint and a flexible DIP joint. Ankle DF does not affect toe motion. Surgical management includes
1. 2. 3. 4. 5. Intrinsic muscle stripping of the affected toes on the plantar foot. Excision of the contracted intrinsic muscles of the plantar foot. Lengthening of the EDL, resection of the DPPP and FDL tenotomy. PIP joint resection arthroplasty and a Flex to Ext transfer FDL and EDL tenotomies of the affected toes

A 56 yo woman has a discreet, painful hyperkeratotic lesion under the plantar medial aspect of the 1st MTH. Conservative management has failed, treatment should now consist of

1. 2. 3. 4. 5.

Shaving of the tibial sesamoid Shaving of the tibial and fibular sesamoids Excision of both the tibial and fibular sesamoids Dorsiflexion MT osteotomy 1st MTP arthrodesis

47 yo woman with a symptomatic bunion refractory to nonop methods and pain over a prominent 5th MTH. In addition to the bunion correction treatment should include
1. 2. 3. 4. 5. Pressure relief on the fifth MTH Proximal midshaft osteotomy of the 5th MT Resection of the lateral exostosis of the 5th MTH Resection of the 5th MTH Resection of both the 5th proximal phalanx and the lateral condyle of the 5th MTH

16 year old boy with an asymptomatic flatfoot

1. OBSERVATION 2. OBSERVATION 3. OBSERVATION 4. OBSERVATION 5. OBSERVATION

2. 16 year old boy with a symptomatic fixed flatfoot, non-op treatment failed Dx: Tarsal coalition; CT scan to evaluate for excision or Arthrodesis 3. 55 year old man with NIDDM and painless flatfoot Dx: Charcot arthropathy; Tx Bracewear and Custom orthoses

53 yo female with diffuse swelling and pain in the right ankle For 1 month. She is unable to perform a single limb heel rise due to pain but can initiate a double heel rise. No injury Was sustained and no prior treatment has been rendered. Examination reveals tenderness and fullness along the posterior Tibial tendon. Standing examination demonstrates a planovalgus Foot deformity. Treatment should consist of: 1. 2. 3. 4. 5. A short leg walking cast then bracewear A custom-molded shoe A corticosteroid injection into the posterior tibial tendon sheath Physical therapy for ROM and Strengthening Surgical reconstruction

The diagnosis and treatment of tarsal tunnel syndrome Should be primarily based on 1. 2. 3. 4. 5. Clinical symptoms and physical findings Radiographic studies MRI studies Electrodiagnostic studies Response to corticosteriod injection

30 yo male with posterior heel pain which began 9 months earlier after playing soccer. No history of trauma. MRI demonstrates a fusiform swelling of focal degeneration of the Achilles 3 cm proximal to insertion. Treatment to date has included heel lifts, NSAIDS, PT without success. the patient has been unable to play soccer due to this pain. Management should now include: 1. 2. 3. 4. 5. Surgical debridement of the paratenon Surgical debridement of the involved area of the Achilles Resection of the involved Achilles tendon with a flexor hallucis longus tendon transfer Injection of cortisone into the involved area of the Achilles Gastrocnemius recession with paratenolysis

A 53 yo male sustains a spontaneous non-traumatic rupture Of the Achilles tendon. This condition may be associated With the use of what class of antibiotics? 1. 2. 3. 4. 5. Penicillins Aminoglycosides Antifungals Fluoroquinolones Cephalosporins

34 yo man with no history of trauma has has bilateral posterior Heel pain for the past 15 months and a painful swollen fourth Toe for the past 6 weeks. Examination reveals retrocalcaneal Tenderness at the Achilles insertion and bursa, and a chronic Maculopapular rash over both tibial tubercles. ESR is 45 and HLA-B27 are positive. Plain radiographs show a large posterior And plantar calcaneal exostosis. The most likely diagnosis is: 1. 2. 3. 4. 5. Gout Lupus erythematosus Rheumatoid arthritis Lymes Disease Psoriatic arthritis

A 72 yo man who has type II DM for the past 20 years reports a painful ulcer on the tip of the great toe of the right foot for the past 3 weeks. Examination reveals multiple mild claw toe deformities with decreased sensitivity to light touch. Which of The following studies will best confirm the diagnosis? 1. 2. 3. 4. 5. Electromyography and nerve conduction velocity studies Trancutaneous oxygen pressure measurement Ankle-brachial index by arterial doppler Plain radiograph Indium-111 WBC scan

A 47 yo female with no history of trauma has a progressive deformity of the ankle managed with an AFO. Medical history is significant for type 1 DM and a contralateral BKA. examination reveals a rigid deformity of the ankle and hindfoot and diffuse loss of sensation. Pedal pulses are normal. radiographs demonstrate severe malalignment of ankle and Hindfoot into valgus with loss of joint space. Mild lateral skin breakdown from bracewear is occurring. The next step in management is: 1. 2. 3. 4. 5. Symes amputation Transtibial amputation Fibulectomy Brace modification to a PTB with a medial T-strap Realignment tibiocalcaneal arthrodesis

56 yo woman with type 1 DM for the past 10 years has multiple Clawtoes and a palpable dorsalis pedis pulse. She denies any History of foot problems other than callosities at the toe tips. Which of the following screening tools is most appropriate for This patient? 1. 2. 3. 4. 5. 5.07 (10 g) Semmes-Weinstein monofilament 125-MHz tuning fork Transcutaneous oxygen pressure measurement Doppler ultrasound Water displacement test

Hallux Valgus Questions

Which of the following is considered the primary indication for surgery for patients with hallux valgus? 1-Cosmetic appearance 2-Split-size shoe requirements 3-An intermetatarsal angle of greater than 15 between the first and second metatarsals 4-Symptoms that persist despite nonsurgical management 5-Arthritic changes in the first metatarsophalangeal joint
OITE 1999

Which of the following is considered the primary indication for surgery for patients with hallux valgus? 1-Cosmetic appearance 2-Split-size shoe requirements 3-An intermetatarsal angle of greater than 15 between the first and second metatarsals 4-Symptoms that persist despite nonsurgical management 5-Arthritic changes in the first metatarsophalangeal joint
OITE 1999

Hallux Rigidus Questions

A 42-year-old laborer has significant, limiting pain around the first metatarsophalangeal joint despite undergoing a dorsal cheilectomy 2 years ago. Radiographs show progression of arthritis in the joint. What is the next most appropriate step in treatment? 12345Resection of the first metatarsal head Resection of the proximal phalanx Proximal phalangeal closing wedge osteotomy Arthrodesis of the first metatarsophalangeal joint Silastic implant arthroplasty

OITE 2005

A 42-year-old laborer has significant, limiting pain around the first metatarsophalangeal joint despite undergoing a dorsal cheilectomy 2 years ago. Radiographs show progression of arthritis in the joint. What is the next most appropriate step in treatment? 12345Resection of the first metatarsal head Resection of the proximal phalanx Proximal phalangeal closing wedge osteotomy Arthrodesis of the first metatarsophalangeal joint Silastic implant arthroplasty

The radiographs shown are of a 44-year old woman who has had great toe pain for the past 5 years. What is the most likely diagnosis? 12345Lupus arthritis Rheumatoid arthritis Gouty arthritis Psoriatic arthritis Hallux rigidus

OITE 2005

OITE 2003

The radiographs shown are of a 44-year old woman who has had great toe pain for the past 5 years. What is the most likely diagnosis? 12345Lupus arthritis Rheumatoid arthritis Gouty arthritis Psoriatic arthritis Hallux rigidus

The figures below are radiographs of a 61-year-old man who has had chronic pain in the right great toe. Nonsteriodal anti-inflammatory drugs and shoe modifications have failed to provide relief. Treatment should now consist of 1- interphalangeal joint fusion. 2- cheilectomy. 3- implant arthroplasty of the metatarsophalangeal joint. 4- proximal phalangeal osteotomy. 5- metatarsophalangeal joint fusion

OITE 2003

OITE 2004

The figures below are radiographs of a 61-year-old man who has had chronic pain in the right great toe. Nonsteriodal anti-inflammatory drugs and shoe modifications have failed to provide relief. Treatment should now consist of 1- interphalangeal joint fusion. 2- cheilectomy. 3- implant arthroplasty of the metatarsophalangeal joint. 4- proximal phalangeal osteotomy. 5- metatarsophalangeal joint fusion

A 36-year-old runner presents with increasing pain in his great toe with running. A change of shoes and adding orthotics did not improve his discomfort nor did oral anti inflamatories. His toe does not swell, and he has had no known injury. On physical examination the foot and toe are not swollen. He is neurovascularly intact in the extremity. He has no calf tenderness. He does have pain and decreased range of motion of the MTP joint of the great toe. His radiographs follow. The next most appropriate treatment is: 1- injection of corticosteroids. 2- metatarsophalangeal fusion. 3- short-leg walking cast. 4- injection of hyaluronic acid and activity modification. 5- a SACH shoe and oral nonsteroidal anti inflammatory drugs.
AOSSM 2006

OITE 2004

A 36-year-old runner presents with increasing pain in his great toe with running. A change of shoes and adding orthotics did not improve his discomfort nor did oral anti inflamatories. His toe does not swell, and he has had no known injury. On physical examination the foot and toe are not swollen. He is neurovascularly intact in the extremity. He has no calf tenderness. He does have pain and decreased range of motion of the MTP joint of the great toe. His radiographs follow. The next most appropriate treatment is: 1- injection of corticosteroids. 2- metatarsophalangeal fusion. 3- short-leg walking cast. 4- injection of hyaluronic acid and activity modification. 5- a SACH shoe and oral nonsteroidal anti inflammatory drugs.
AOSSM 2006

When evaluating a patient with hallux rigidus, what is the most important clinical factor indicating the need for an arthrodesis as opposed to cheilectomy? 1- Dorsal foot pain with shoe wear 2- Pronounced limited motion in the first MTPJ 3- Pain at the midrange of motion in the first MTPJ 4- Large dorsal osteophytes clinically and radiographically 5- Flattened first metatarsal head with periarticular sclerosis

When evaluating a patient with hallux rigidus, what is the most important clinical factor indicating the need for an arthrodesis as opposed to cheilectomy? 1- Dorsal foot pain with shoe wear 2- Pronounced limited motion in the first MTPJ 3- Pain at the midrange of motion in the first MTPJ 4- Large dorsal osteophytes clinically and radiographically 5- Flattened first metatarsal head with periarticular sclerosis

F&A Self Assessment 2006

F&A Self Assessment 2006

Which of the following orthotic features best reduces pain in patients with hallux rigidus? 1- Plastazote layer to absorb shock 2- Medial posting to offload the medial forefoot 3- Rigid shank or forefoot rocker 4- Metatarsal bar to offload the first metatarsal head 5- Full length as opposed to three-quarter length
F&A Self Assessment 2006

Which of the following orthotic features best reduces pain in patients with hallux rigidus? 1- Plastazote layer to absorb shock 2- Medial posting to offload the medial forefoot 3- Rigid shank or forefoot rocker 4- Metatarsal bar to offload the first metatarsal head 5- Full length as opposed to three-quarter length
F&A Self Assessment 2006

A 40-year-old woman has had pain and swelling in the metatarsophalangeal (MTP) joint of the second toe for the past 5 months. Dorsal-plantar stress of the MTP joint reproduces the pain. The remainder of the foot examination and radiographs is normal. Shoe modification, steroid injections, and anti-inflammatory drugs have failed to provide relief. The next most appropriate step in management should consist of 1- arthrodesis of the second MTP joint. 2- MTP synovectomy and reconstruction of the MTP joint capsule. 3- dorsiflexion osteotomy of the second metatarsal. 4- resection of the second metatarsal head (resection arthroplasty). 5- resection of the base of the proximal phalanx.
OITE 2002

A 40-year-old woman has had pain and swelling in the metatarsophalangeal (MTP) joint of the second toe for the past 5 months. Dorsal-plantar stress of the MTP joint reproduces the pain. The remainder of the foot examination and radiographs is normal. Shoe modification, steroid injections, and anti-inflammatory drugs have failed to provide relief. The next most appropriate step in management should consist of 1- arthrodesis of the second MTP joint. 2- MTP synovectomy and reconstruction of the MTP joint capsule. 3- dorsiflexion osteotomy of the second metatarsal. 4- resection of the second metatarsal head (resection arthroplasty). 5- resection of the base of the proximal phalanx.
OITE 2002

A 36-year-old man has pain in the metatarsophalangeal (MTP) joint of the great toe with all weight-bearing activities, and management consisting of shoe modification and an insert has failed to provide relief. Examination reveals a painful 100 arc of motion. Radiographs show degenerative changes with dorsal and medial osteophytes and joint narrowing. Treatment should now consist of 1-excision of the osteophytes and the dorsal third of the metatarsal head. 2-a dorsiflexion osteotomy of the metatarsal head. 3-resection arthroplasty of the MTP joint. 4-a Silastic implant of the MTP joint. 5-arthrodesis of the MTP joint.
OITE 2001

A 36-year-old man has pain in the metatarsophalangeal (MTP) joint of the great toe with all weight-bearing activities, and management consisting of shoe modification and an insert has failed to provide relief. Examination reveals a painful 100 arc of motion. Radiographs show degenerative changes with dorsal and medial osteophytes and joint narrowing. Treatment should now consist of 1-excision of the osteophytes and the dorsal third of the metatarsal head. 2-a dorsiflexion osteotomy of the metatarsal head. 3-resection arthroplasty of the MTP joint. 4-a Silastic implant of the MTP joint. 5-arthrodesis of the MTP joint.
OITE 2001

A 40-year-old man has limited, painful motion in dorsiflexion at the metatarsophalangeal (MTP) joint of the right great toe, despite nonsurgical treatment. Radiographs show dorsal and medial osteophytes and minimal narrowing of the articular space. Treatment should consist of 1- arthrodesis of the MTP joint. 2- a Silastic implant of the MTP joint. 3- resection arthroplasty of the MTP joint. 4- cheilectomy of the MTP joint. 5- osteotomy of the base of the proximal phalanx.
OITE 1998

A 40-year-old man has limited, painful motion in dorsiflexion at the metatarsophalangeal (MTP) joint of the right great toe, despite nonsurgical treatment. Radiographs show dorsal and medial osteophytes and minimal narrowing of the articular space. Treatment should consist of 1- arthrodesis of the MTP joint. 2- a Silastic implant of the MTP joint. 3- resection arthroplasty of the MTP joint. 4- cheilectomy of the MTP joint. 5- osteotomy of the base of the proximal phalanx.
OITE 1998

TURF TOE & SESAMOID QUESTIONS

A professional football player sustains a hyperextension injury to his great toe during practice. He is diagnosed with a turf toe. You explain to him that turf toe is: 1- an interphalangeal joint contusion of the great toe. 2- a sprain of the first metatarsophalangeal joint. 3- flexor hallucis longus tenosynovitis. 4- sesamoid bursitis of the great toe. 5- plantar fasciitis.
AOSSM 2006

A professional football player sustains a hyperextension injury to his great toe during practice. He is diagnosed with a turf toe. You explain to him that turf toe is: 1- an interphalangeal joint contusion of the great toe. 2- a sprain of the first metatarsophalangeal joint. 3- flexor hallucis longus tenosynovitis. 4- sesamoid bursitis of the great toe. 5- plantar fasciitis.
AOSSM 2006

A 24-year-old professional lacrosse player has severe pain in his great toe at the first metatarsalphalangeal joint. The most likely reason for his symptoms would be: 12345bipartite sesamoid. first metatarsal stress fracture. forced hyperextension injury. bunion deformity. chronic sesamoiditis

AOSSM 2007

A 24-year-old professional lacrosse player has severe pain in his great toe at the first metatarsalphalangeal joint. The most likely reason for his symptoms would be: 12345bipartite sesamoid. first metatarsal stress fracture. forced hyperextension injury. bunion deformity. chronic sesamoiditis

A 21-year-old collegiate track athlete increased her training 4 months ago in anticipation of starting the season. Two months into her training program, she reported pain followed by a 1-month history of diffuse pain in the first MTPJ that was aggravated by weight bearing. A removable walker boot partially relieved the pain, and she was able to complete the season. Her pain has now returned; however, she denies any history of injury. Examination reveals tenderness over the medial sesamoid but no deformities. Images follow on next slide. What is the best treatment option at this time? 1- Cast immobilization and no weight bearing for 4 to 8 weeks 2- Immobilization in a walking cast for 4 to 8 weeks 3- Hard soled shoe for 4 to 8 weeks 4- Sesamoid bone grafting 5- Medial sesamoidectomy

F&A Self Assessment 2006

AOSSM 2007

A 21-year-old collegiate track athlete increased her training 4 months ago in anticipation of starting the season. Two months into her training program, she reported pain followed by a 1-month history of diffuse pain in the first MTPJ that was aggravated by weight bearing. A removable walker boot partially relieved the pain, and she was able to complete the season. Her pain has now returned; however, she denies any history of injury. Examination reveals tenderness over the medial sesamoid but no deformities. Images follow on next slide. What is the best treatment option at this time? 1- Cast immobilization and no weight bearing for 4 to 8 weeks 2- Immobilization in a walking cast for 4 to 8 weeks 3- Hard soled shoe for 4 to 8 weeks 4- Sesamoid bone grafting 5- Medial sesamoidectomy

F&A Self Assessment 2006

A hyperextension injury to the metatarsophalangeal joint of the great toe most commonly results in a tear of the 1- intersesamoid ligament. 2- insertion of the plantar plate on the proximal phalanx. 3- adductor hallucis tendon. 4- medial and accessory collateral ligaments. 5- flexor hallucis brevis insertion on the proximal phalanx.
OITE 1999

A hyperextension injury to the metatarsophalangeal joint of the great toe most commonly results in a tear of the 1- intersesamoid ligament. 2- insertion of the plantar plate on the proximal phalanx. 3- adductor hallucis tendon. 4- medial and accessory collateral ligaments. 5- flexor hallucis brevis insertion on the proximal phalanx.
OITE 1999

MORTONS NEUROMA QUESTIONS

A 50-year-old woman reports a burning sensation on the plantar aspect of her left forefoot, distal to the metatarsal heads between her third and fourth digits. Palpation of the third web space recreates her symptoms. Which of the following will most accurately aid in confirming a diagnosis? 12345History and physical examination Ultrasonography MRI Radiographs Nerve conduction velocity studies
F&A Self Assessment 2006

A 50-year-old woman reports a burning sensation on the plantar aspect of her left forefoot, distal to the metatarsal heads between her third and fourth digits. Palpation of the third web space recreates her symptoms. Which of the following will most accurately aid in confirming a diagnosis? 12345History and physical examination Ultrasonography MRI Radiographs Nerve conduction velocity studies
F&A Self Assessment 2006

BUNIONETTE QUESTIONS

The radiograph below is of a 38-year-old man who reports persistent pain laterally and plantarly about the fifth metatarsal head. Examination reveals calluses dorsolaterally and plantarly about the fifth metatarsal head. Nonsurgical management has failed to provide relief. Surgical treatment should include 1- simple lateral eminence resection. 2- distal chevron osteotomy of the fifth metatarsal. 3- oblique mid-diaphyseal osteotomy of the fifth metatarsal. 4- proximal diaphyseal osteotomy of the fifth metatarsal. 5- excision of the fifth metatarsal head.

The radiograph below is of a 38-year-old man who reports persistent pain laterally and plantarly about the fifth metatarsal head. Examination reveals calluses dorsolaterally and plantarly about the fifth metatarsal head. Nonsurgical management has failed to provide relief. Surgical treatment should include 1- simple lateral eminence resection. 2- distal chevron osteotomy of the fifth metatarsal. 3- oblique mid-diaphyseal osteotomy of the fifth metatarsal. 4- proximal diaphyseal osteotomy of the fifth metatarsal. 5- excision of the fifth metatarsal head.

F&A Self Assessment 2006

F&A Self Assessment 2006

In treatment of all magnitudes of bunionette deformities, what is the most common complication associated with lateral condylectomy of the fifth metatarsal head? 12345Metatarsophalangeal arthrosis Transfer metatarsalgia Recurrent deformity Overcorrection of the deformity Dislocation of the metatarsophalangeal joint

In treatment of all magnitudes of bunionette deformities, what is the most common complication associated with lateral condylectomy of the fifth metatarsal head? 12345Metatarsophalangeal arthrosis Transfer metatarsalgia Recurrent deformity Overcorrection of the deformity Dislocation of the metatarsophalangeal joint

LISFRANC QUESTIONS

A 16-year-old male athlete presents one week after an injury with a swollen right foot and an inability to bear weight. On AP standing radiographs, there is widening of the first and second metatarsal spaces, and the medial border of the second metatarsal is not aligned with the medial border of the middle cuneiform. What is the optimal management of this injury? 12345Closed reduction and non-weight-bearing cast Non-weight-bearing cast immobilization Primary tarsometatarsal fusion Rest, ice, compression, and elevation Reduction and internal fixation

AOSSM 2006

A 16-year-old male athlete presents one week after an injury with a swollen right foot and an inability to bear weight. On AP standing radiographs, there is widening of the first and second metatarsal spaces, and the medial border of the second metatarsal is not aligned with the medial border of the middle cuneiform. What is the optimal management of this injury? 12345Closed reduction and non-weight-bearing cast Non-weight-bearing cast immobilization Primary tarsometatarsal fusion Rest, ice, compression, and elevation Reduction and internal fixation

A 32-year-old man who sustained a tarsometatarsal (Lisfranc) injury 3 years ago now reports increasing pain in the left foot. Orthotics, nonsteroidal anti-inflammatory drugs, and injections have provided only temporary relief. Examination reveals swelling and tenderness over the tarsometatarsal joints. Radiographs show advanced arthrosis of the first and second tarsometatarsal joints. Management should now include 12345midfoot arthrodesis. a rocker sole show with orthotic inserts. shock wave or orthotripsy. an ankle-foot orthoses. triple arthrodesis
F&A Self Assessment 2006

AOSSM 2006

A 32-year-old man who sustained a tarsometatarsal (Lisfranc) injury 3 years ago now reports increasing pain in the left foot. Orthotics, nonsteroidal anti-inflammatory drugs, and injections have provided only temporary relief. Examination reveals swelling and tenderness over the tarsometatarsal joints. Radiographs show advanced arthrosis of the first and second tarsometatarsal joints. Management should now include 12345midfoot arthrodesis. a rocker sole show with orthotic inserts. shock wave or orthotripsy. an ankle-foot orthoses. triple arthrodesis
F&A Self Assessment 2006

The Lisfranc ligament connects the base of the 1- first metatarsal and the medial cuneiform. 2- first metatarsal and the base of the second metatarsal. 3- first metatarsal and the middle cuneiform. 4- second metatarsal and the medial cuneiform. 5- second metatarsal and the middle cuneiform.

F&A Self Assessment 2006

The Lisfranc ligament connects the base of the 1- first metatarsal and the medial cuneiform. 2- first metatarsal and the base of the second metatarsal. 3- first metatarsal and the middle cuneiform. 4- second metatarsal and the medial cuneiform. 5- second metatarsal and the middle cuneiform.

Figure 11 shows the radiograph of an otherwise healthy 22-year-old man who sustained a midfoot injury in a motor vehicle accident 9 days ago. Treatment should consist of 1- open reduction and internal fixation. 2- a short leg weight-bearing cast. 3- a short leg non-weight-bearing cast. 4- first tarsometatarsal fusion. 5- functional brace application and early range of motion.

F&A Self Assessment 2006 F&A Self Assessment 2006

Figure 11 shows the radiograph of an otherwise healthy 22-year-old man who sustained a midfoot injury in a motor vehicle accident 9 days ago. Treatment should consist of 1- open reduction and internal fixation. 2- a short leg weight-bearing cast. 3- a short leg non-weight-bearing cast. 4- first tarsometatarsal fusion. 5- functional brace application and early range of motion.

A 23-year-old football player was injured when another player fell on his flexed and planted foot. He reports severe pain in the midfoot with a feeling of numbness on the dorsum of the foot, and he is unable to bear weight on the limb. Examination reveals mild swelling. Xrays are shown on the next slide. Management should consist of 1- casting. 2- closed reduction, casting, and no weight bearing for 6 weeks. 3- open reduction and internal fixation. 4- closed reduction and percutaneous K-wire fixation. 5- closed reduction and percutaneous screw fixation.

F&A Self Assessment 2006 F&A Self Assessment 2006

A 23-year-old football player was injured when another player fell on his flexed and planted foot. He reports severe pain in the midfoot with a feeling of numbness on the dorsum of the foot, and he is unable to bear weight on the limb. Examination reveals mild swelling. Xrays are shown on the next slide. Management should consist of 1- casting. 2- closed reduction, casting, and no weight bearing for 6 weeks. 3- open reduction and internal fixation. 4- closed reduction and percutaneous K-wire fixation. 5- closed reduction and percutaneous screw fixation.

F&A Self Assessment 2006

Intramedullary screw fixation of a Jones fracture has a statistically higher failure rate in

JONES FRACTURE QUESTIONS

1- elite athletes. 2- female patients. 3- patients who did not undergo bone grafting. 4- patients younger than age 40 years. 5- fractures that have been fixed with screws larger than 4.5mm in diameter.

OITE 2003

Intramedullary screw fixation of a Jones fracture has a statistically higher failure rate in 1- elite athletes. 2- female patients. 3- patients who did not undergo bone grafting. 4- patients younger than age 40 years. 5- fractures that have been fixed with screws larger than 4.5mm in diameter.

A 21-year-old elite college football player has ecchymosis, swelling, and pain on the lateral side of his foot after a game. Radiographs are shown below. Management should consist of 12345open reduction and internal fixation with a plate and screws. open treatment with calcaneal bone graft. percutaneous screw fixation with a 4.5 mm screw. weight-bearing cast for 8 weeks. spanning external fixation.

OITE 2003

F&A Self Assessment 2006

A 21-year-old elite college football player has ecchymosis, swelling, and pain on the lateral side of his foot after a game. Radiographs are shown below. Management should consist of 12345open reduction and internal fixation with a plate and screws. open treatment with calcaneal bone graft. percutaneous screw fixation with a 4.5 mm screw. weight-bearing cast for 8 weeks. spanning external fixation.

An 18-year-old collegiate basketball player sees you for increasing pain on the lateral side of his left foot. The pain has increased over the last eight weeks to the point where now he is limping. On clinical examination, the foot is tender to palpation at the base of the fifth metatarsal. Peroneal tendons are intact and not swollen. Radiographs of his foot are shown. You would advise: 1- intramedullary screw fixation. 2- a walking boot for six weeks. 3- surgical repair using a tension band wire technique. 4- crutches and a cast with instructions to not bear weight upon the foot. 5- custom made orthoses followed by physical therapy for ROM and strengthening exercise.

F&A Self Assessment 2006

AOSSM 2007

An 18-year-old collegiate basketball player sees you for increasing pain on the lateral side of his left foot. The pain has increased over the last eight weeks to the point where now he is limping. On clinical examination, the foot is tender to palpation at the base of the fifth metatarsal. Peroneal tendons are intact and not swollen. Radiographs of his foot are shown. You would advise: 1- intramedullary screw fixation. 2- a walking boot for six weeks. 3- surgical repair using a tension band wire technique. 4- crutches and a cast with instructions to not bear weight upon the foot. 5- custom made orthoses followed by physical therapy for ROM and strengthening exercise.

A 20-year-old collegiate football player notes the sudden onset of lateral foot pain after a cutting maneuver. Based on the radiographic findings shown in the figures below, what is the best surgical option? 12345Single intramedullary screw Crossed Kirschner wires Crossed absorbable pins Crossed cannulated screws Compression plate

AOSSM 2007

OITE 2005

A 20-year-old collegiate football player notes the sudden onset of lateral foot pain after a cutting maneuver. Based on the radiographic findings shown in the figures below, what is the best surgical option? 12345Single intramedullary screw Crossed Kirschner wires Crossed absorbable pins Crossed cannulated screws Compression plate

Figure 19 shows the radiograph of an 18-year-old recreational soccer player who has had pain in the lateral foot for the past 4 weeks. He reports no specific injury and has not undergone any treatment. Initial management should consist of 1- an orthosis. 2- observation. 3- electrical stimulation. 4- open reduction and internal fixation. 5- application of a nonweightbearing short leg cast.

OITE 2005

OITE 1998

Figure 19 shows the radiograph of an 18-year-old recreational soccer player who has had pain in the lateral foot for the past 4 weeks. He reports no specific injury and has not undergone any treatment. Initial management should consist of 1- an orthosis. 2- observation. 3- electrical stimulation. 4- open reduction and internal fixation. 5- application of a nonweightbearing short leg cast.

ACCESSORY NAVICULAR QUESTIONS

OITE 1998

A 12-year-old boy has pain in the medial arch of his left foot with weight-bearing activities. Nonsurgical management has failed to provide relief. Radiographs show an Ogden type II accessory navicular (accessory ossicle joined to the prominence of the navicular by a synchondrosis). Treatment should consist of 1- arthodesis of the ossicle to the navicular. 2- excision of the ossicle and the navicular prominence. 3- talonavicular arthodesis, with elevation of the medial arch. 4- calcaneal neck lengthening by opening wedge osteotomy and bone graft. 5- subtalar joint arthrodesis.

A 12-year-old boy has pain in the medial arch of his left foot with weight-bearing activities. Nonsurgical management has failed to provide relief. Radiographs show an Ogden type II accessory navicular (accessory ossicle joined to the prominence of the navicular by a synchondrosis). Treatment should consist of 1- arthodesis of the ossicle to the navicular. 2- excision of the ossicle and the navicular prominence. 3- talonavicular arthodesis, with elevation of the medial arch. 4- calcaneal neck lengthening by opening wedge osteotomy and bone graft. 5- subtalar joint arthrodesis.

OITE 2003

OITE 2003

An 11-year-old girl has had pain in the medial arch of her foot for the past 3 months. She reports that pain is present even with daily activities such as walking to class at school, and ibuprofen provides some relief. She denies and history of trauma. Examination reveals a flexible pes planus with focal tenderness over a prominent tarsal navicular tuberosity. Radiographs show a prominent accessory navicular. Management should consist of 1- cast immobilization for 4 to 6 weeks. 2- posterior tibial tendon advancement and repair (Kidner procedure) 3- corticosteroid injection of the PTT insertion. 4- triple arthodesis. 5- needle biopsy of the trochar
F&A Self Assessment 2006

An 11-year-old girl has had pain in the medial arch of her foot for the past 3 months. She reports that pain is present even with daily activities such as walking to class at school, and ibuprofen provides some relief. She denies and history of trauma. Examination reveals a flexible pes planus with focal tenderness over a prominent tarsal navicular tuberosity. Radiographs show a prominent accessory navicular. Management should consist of 1- cast immobilization for 4 to 6 weeks. 2- posterior tibial tendon advancement and repair (Kidner procedure) 3- corticosteroid injection of the PTT insertion. 4- triple arthodesis. 5- needle biopsy of the trochar
F&A Self Assessment 2006

The figure below shows a radiograph of a 12-year-old boy who has medial midfoot pain with activity. The pain persists despite activity modifications and trials of orthotics and cast immobilization. Management should now consist of 1- an external bone growth stimulator 2- autogenous bone grafting to the nonunion 3- excision of the medial prominence of the navicular, including the synchondrosis 4- internal fixation with a compression screw 5- injection of bone morphogenetic protein into the synchondrosis

The figure below shows a radiograph of a 12-year-old boy who has medial midfoot pain with activity. The pain persists despite activity modifications and trials of orthotics and cast immobilization. Management should now consist of 1- an external bone growth stimulator 2- autogenous bone grafting to the nonunion 3- excision of the medial prominence of the navicular, including the synchondrosis 4- internal fixation with a compression screw 5- injection of bone morphogenetic protein into the synchondrosis

OITE 2005

OITE 2005

Where is the watershed zone for tarsal navicular vascularity?

NAVICULAR STRESS FRACTURE QUESTIONS

12345-

Medial one third Central one third Lateral one third Tuberosity Inferior pole

F&A Self Assessment 2006

Where is the watershed zone for tarsal navicular vascularity? 12345Medial one third Central one third Lateral one third Tuberosity Inferior pole

TARSAL TUNNEL QUESTIONS

F&A Self Assessment 2006

A 37-year-old female has had intermittent paresthesias and numbness in the plantar foot for the past 6 months. She reports that the symptoms are worse with activity, and the paresthesias are beginning to awaken her at night. MRI scans are shown in Figures 6a and 6b. What is the most likely diagnosis? 12345Lipoma Giant cell tumor of the tendon sheath Synovial sarcoma Metastatic adenocarcinoma Ganglion cyst

A 37-year-old female has had intermittent paresthesias and numbness in the plantar foot for the past 6 months. She reports that the symptoms are worse with activity, and the paresthesias are beginning to awaken her at night. MRI scans are shown in Figures 6a and 6b. What is the most likely diagnosis? 12345Lipoma Giant cell tumor of the tendon sheath Synovial sarcoma Metastatic adenocarcinoma Ganglion cyst

F&A Self Assessment 2006

F&A Self Assessment 2006

Patients with tarsal tunnel syndrome are most likely to obtain a favorable outcome from decompression of the posterior tibial nerve if which of the following conditions is present? 1- A space-occupying lesion is compressing the tarsal tunnel,. 2- Nerve conduction studies reveal slowing across the medial malleolus. 3- The posterior tibial tendon is ruptured. 4- The integrity of the posterior tibial tendon is compromised. 5- The spring ligament is ruptured, resulting in the development of a dynamic flatfoot.
F&A Self Assessment 2006

Patients with tarsal tunnel syndrome are most likely to obtain a favorable outcome from decompression of the posterior tibial nerve if which of the following conditions is present? 1- A space-occupying lesion is compressing the tarsal tunnel,. 2- Nerve conduction studies reveal slowing across the medial malleolus. 3- The posterior tibial tendon is ruptured. 4- The integrity of the posterior tibial tendon is compromised. 5- The spring ligament is ruptured, resulting in the development of a dynamic flatfoot.
F&A Self Assessment 2006

Adequate decompression of the medial and lateral plantar nerves during a tarsal tunnel release requires 1- release of the medial half of the plantar fascia. 2- release of the deep fascia of the abductor hallucis muscle. 3- release of the inferior extensor retinaculum. 4- release of the quadratus plantae fascia. 5- resection of a plantar exostosis of the calcaneus, when present.
OITE 1999

Adequate decompression of the medial and lateral plantar nerves during a tarsal tunnel release requires 1- release of the medial half of the plantar fascia. 2- release of the deep fascia of the abductor hallucis muscle. 3- release of the inferior extensor retinaculum. 4- release of the quadratus plantae fascia. 5- resection of a plantar exostosis of the calcaneus, when present.
OITE 1999

TARSAL COALITION QUESTIONS

A 15-year-old boy has had hindfoot pain and very limited subtalar motion. A CT scan reveals a talocalcaneal coalition involving 40% of the middle facet. He has no degeneration of the posterior subtalar facet. Following failure of nonsurgical management, treatment should consist of 1- resection of the coalition with fat graft interposition. 2- Grice extra-articular subtalar arthrodesis. 3- subtalar arthroresis. 4- intra-articular subtalar fusion. 5- medial sliding calcaneal osteotomy.
F&A Self Assessment 2006

A 15-year-old boy has had hindfoot pain and very limited subtalar motion. A CT scan reveals a talocalcaneal coalition involving 40% of the middle facet. He has no degeneration of the posterior subtalar facet. Following failure of nonsurgical management, treatment should consist of 1- resection of the coalition with fat graft interposition. 2- Grice extra-articular subtalar arthrodesis. 3- subtalar arthroresis. 4- intra-articular subtalar fusion. 5- medial sliding calcaneal osteotomy.
F&A Self Assessment 2006

A 14-year-old boy has midfoot pain with activity, and nonsurgical management has failed to provide relief. Radiographs and a CT scan are shown in the following figures. Estimated involvement of the subtalar joint includes the entire combined anterior and middle facets and at least 35% of the posterior facet. Treatment should now consist of 12345resection of the coalition and an interposition fat graft. Resection of the coalition and a modified Dwyer osteotomy Resection of the coalition and extensor brevis interposition Triple arthrodesis Calcaneocuboid arthrodesis

OITE 2005

A 14-year-old boy has midfoot pain with activity, and nonsurgical management has failed to provide relief. Radiographs and a CT scan are shown in the following figures. Estimated involvement of the subtalar joint includes the entire combined anterior and middle facets and at least 35% of the posterior facet. Treatment should now consist of 12345resection of the coalition and an interposition fat graft. Resection of the coalition and a modified Dwyer osteotomy Resection of the coalition and extensor brevis interposition Triple arthrodesis Calcaneocuboid arthrodesis

A 12-year-old boy has had foot pain for the past 6 months, and immobilization in a cast for 6 weeks has failed to provide relief. CT scans are shown. To optimize his foot biomechanics, the next step in management should consist of 12345triple arthrodesis resection of the subtalar coalition resection of the calcaneonavicular coalition repair of the anterior tibial tendon repair of the ruptured posterior tibial tendon

OITE 2005

OITE 2005

A 12-year-old boy has had foot pain for the past 6 months, and immobilization in a cast for 6 weeks has failed to provide relief. CT scans are shown. To optimize his foot biomechanics, the next step in management should consist of 12345triple arthrodesis resection of the subtalar coalition resection of the calcaneonavicular coalition repair of the anterior tibial tendon repair of the ruptured posterior tibial tendon

A 16-year-old boy has had pain in the lateral ankle and hindfoot after sustaining a minor ankle sprain 6 months ago. The pain is worse with any twisting activity of the foot. Examination reveals normal alignment of the foot and ankle. An AP radiograph of the ankle and foot is normal. A lateral radiograph is shown in Figure 61. What is the most likely cause of his persistent pain? 1-Fracture of the lateral process of the talus 2- Fracture of the anterior process of the calcaneus 3- Fracture of the tibial plafond 4- Talocalcaneal coalition 5- Stress fracture of the calcaneus

OITE 2005

OITE 2001

PLANTAR FASCIITIS QUESTIONS

A patient who underwent an endoscopic plantar fascia release 3 months ago now reports pain in the medial arch with weight bearing and notes progressive flattening of the foot. What is the most likely explanation for this problem? 12345Recurrence of the calcaneal heel spur Surgical injury to the medial plantar nerve Excessive release of the plantar fascia Injury to the posterior tibial tendon Injury to the spring (calcaneonavicular) ligament
OITE 2002

A patient who underwent an endoscopic plantar fascia release 3 months ago now reports pain in the medial arch with weight bearing and notes progressive flattening of the foot. What is the most likely explanation for this problem? 12345Recurrence of the calcaneal heel spur Surgical injury to the medial plantar nerve Excessive release of the plantar fascia Injury to the posterior tibial tendon Injury to the spring (calcaneonavicular) ligament
OITE 2002

A 46-year-old woman has had plantar heel. pain for the past 5 months. She reports that the pain is most severe when she arises out of bed in the morning and when she stands after being seated for a period of time. Initial management should consist of 1- surgical lengthening of the Achilles tendon. 2- surgical release of the plantar fascia. 3- a custom orthosis. 4- a stretching program and a cushioned heel insert. 5- a corticosteroid injection.
OITE 2001

A 46-year-old woman has had plantar heel. pain for the past 5 months. She reports that the pain is most severe when she arises out of bed in the morning and when she stands after being seated for a period of time. Initial management should consist of 1- surgical lengthening of the Achilles tendon. 2- surgical release of the plantar fascia. 3- a custom orthosis. 4- a stretching program and a cushioned heel insert. 5- a corticosteroid injection.
OITE 2001

A patient has proximal plantar fasciitis. To achieve the greatest amount of improvement, initial management should consist of stretching in combination with 12345a silicone insert. a felt insert. a custom insert. a steroid injection. strapping of the heel.

OITE 2000

A patient has proximal plantar fasciitis. To achieve the greatest amount of improvement, initial management should consist of stretching in combination with 12345a silicone insert. a felt insert. a custom insert. a steroid injection. strapping of the heel.

The development of plantar fasciitis is frequently associated with which of the following conditions? 12345Equinovarus deformity Contracture of the Achilles tendon Plantar spur on the calcaneus Previous fracture of the calcaneus Plantar fibromatosis

OITE 2000

OITE 1999

The development of plantar fasciitis is frequently associated with which of the following conditions? 12345Equinovarus deformity Contracture of the Achilles tendon Plantar spur on the calcaneus Previous fracture of the calcaneus Plantar fibromatosis

A 30-year-old patient who underwent an endoscopic plantar fascia release several months ago now reports pain in the medial arch of the foot with weightbearing and progressive flattening of the foot. What is the most likely diagnosis? 12345Surgical injury to the medial plantar nerve Excessive release of the plantar fascia Degeneration of the posterior tibial tendon Inadequate release of the abductor hallucis fascia Late rupture of the proximal quadratus plantae aponeurosis

OITE 1999

OITE 1999

A 30-year-old patient who underwent an endoscopic plantar fascia release several months ago now reports pain in the medial arch of the foot with weightbearing and progressive flattening of the foot. What is the most likely diagnosis? 12345Surgical injury to the medial plantar nerve Excessive release of the plantar fascia Degeneration of the posterior tibial tendon Inadequate release of the abductor hallucis fascia Late rupture of the proximal quadratus plantae aponeurosis

A 33-year-old woman reports a 3-month history of pain in both feet while running. Examination reveals bilateral point tenderness over the plantar fascia at its origin, and the pain is accentuated when the ankle is dorsiflexed. Management should consist of 1- steroid injections. 2- stretching of the heel cord. 3- surgical release of the plantar fascia. 4- application of short leg casts for 6 to 8 weeks. 5- wearing dorsiflexion night splints.
OITE 1998

OITE 1999

A 33-year-old woman reports a 3-month history of pain in both feet while running. Examination reveals bilateral point tenderness over the plantar fascia at its origin, and the pain is accentuated when the ankle is dorsiflexed. Management should consist of 1- steroid injections. 2- stretching of the heel cord. 3- surgical release of the plantar fascia. 4- application of short leg casts for 6 to 8 weeks. 5- wearing dorsiflexion night splints.
OITE 1998

CALCANEAL STRESS FRACTURE QUESTIONS

An 18-year-old female gymnast reports increasing heel pain for the past six weeks. The pain worsens with activity. She recalls no one particular episode of injury, but has been practicing a new dismount from the uneven bars. She has had no prior history of pain in her ankle or foot. She is healthy with no medical problems. On clinical evaluation, she has pain with palpation and compression of her heel. She has good flexibility of her Achilles tendon and plantar fascia. Her neurovascular exam is normal. Radiographs are shown in the images. The most likely diagnosis is: 12345calcaneal apophysitis. calcaneal stress fracture. plantar fasciitis. plantar osteitis. calcnaeal deficiency syndrome

An 18-year-old female gymnast reports increasing heel pain for the past six weeks. The pain worsens with activity. She recalls no one particular episode of injury, but has been practicing a new dismount from the uneven bars. She has had no prior history of pain in her ankle or foot. She is healthy with no medical problems. On clinical evaluation, she has pain with palpation and compression of her heel. She has good flexibility of her Achilles tendon and plantar fascia. Her neurovascular exam is normal. Radiographs are shown in the images. The most likely diagnosis is: 12345calcaneal apophysitis. calcaneal stress fracture. plantar fasciitis. plantar osteitis. calcnaeal deficiency syndrome

AOSSM 2006

AOSSM 2006

Donald A. Wiss, MD Orthopaedic Review Course #390 AAOS Annual Meeting February 18, 2011
Timing of Fracture Care Damage Control Surgery I. HISTORICAL PERSPECTIVE A. Evolution in Ortho Care Since Mid 1970s 1. Fixation within 2 weeks 2. Fixation within 48 hours 3. Fixation within 24 hours B. Concurrent Improvements in ICU Care 1. Pulmonary toilet 2. Skin care 3. Nutritional support 4. Sepsis surveillance II. EARLY FRACTURE STABILIZATION A. Inflammatory Mediators B. Facilitates Early Mobilization C. Permits Upright Chest D. More Rapidly Reduces Pain E. Need for Depressant Narcotics F. Return of Pulmonary & GI Function G. Sub-Group of MIP Managed by Immediate or Early Internal Fixation of Their Fractures That Are Associated with High Morbidity & Mortality 1. Chest injuries 2. Head injuries 3. Severe open fractures 4. Geriatric trauma 5. High AIS-ISS scores III. DAMAGE CONTROL ORTHOPEDICS DEFINITIONS A. Treatment Philosophy & Approach Which Emphasizes the Stabilization and Control of the Injury Rather Than Primary Repair IV. HISTORY A. Developed in General Surgery B. Control Hemorrhage & Contamination C. Pack Abdomen Open D. ICU Resuscitation, Monitoring, Warming E. Return to OR 24-72 Hours Later for Repair V. PATHOPHYSIOLOGY A. Inflammatory Response is a Normal Physiologic Reaction to Injury B. Amplitude of the Inflammatory Response is Related to the Severity of the Injury VI. PATHOPHYSIOLOGY A. Traumatic Event First Hit 1. Local tissue damage 2. Systemic inflammation a) Cytokines b) Complement c) Proteins d) Neuro-endocrine mediators B. Consequences of First Hit 1. Endogenous Second Hit: a) Hypoxia b) Hemorrhage c) Tissue necrosis d) Contamination 2. Exogenous Second Hit a) Massive transfusion b) Ill advised surgery C. First Hit (Injury) Primes Immune System D. Second Hit (Surgery) Activates Immune System E. Hyperstimulation of the Inflammatory System by Either Single or Multiple Hits is Considered by Many to be the Key Element in the Pathogenesis of ARDS and MODS F. Biologic Responses to the First and/or Second Hit Have Now Become the Basis for Our Treatment Algorithm VII. TIMING OF FRACTURE CARE ETC VS DCO A. Must Balance the Benefit of Early Fracture Stabilization Against the Potential Side Effects of an Excessive Surgical Burden VIII. STAGE 1 DAMAGE CONTROL SURGERY A. Timing of Fracture Care 1. Stable patient early fracture care 2. Borderline patient ????? 3. Unstable patient damage control 4. Extremis patient damage control B. Patient Selection 1. Persistent hypotension 2. Ongoing transfusion requirements 3. Hypothermia, coagulopathy, acidosis 4. ISS>35 points 5. Head injuries/mental status change 6. Severe chest injury 7. Abdominal/pelvic trauma with shock IX. STAGE 2 DAMAGE CONTROL SURGERY Abdomen Laporotomy A. 1. Control hemorrhage 2. Exploration 3. Control contamination

X.

XI.

XII.

XII.

4. Temporary packing 5. Delayed closure B. Pelvic Ring Injuries 1. Rapid reduction & stabilization 2. Anterior ring external fixation 3. Posterior ring C-clamp 4. North America angiography 5. Europe pelvic packing C. Extremity Fractures 1. Rapid I & D open fractures 2. Bridging external fixation 3. Fasciotomy when necessary 4. Amputation mangled extremity STAGE 3 DAMAGE CONTROL SURGERY A. ICU Resuscitation 1. Reversal of lethal triad a) Warming b) Coagulopathy correction c) Reversal acidosis 2. Control ICP, vital signs 3. Fluid & electrolyte replacement 4. Blood transfusion STAGE 4 DAMAGE CONTROL SURGERY A. 2nd Look Definitive Surgery 1. Return to OR based on: a) Injury pattern b) Planned operative procedure c) Response to ICU Rx d) Development of complications 2. Hemorrhage control 24 hrs 3. Sepsis control 48-72 hrs a) GI tract repair b) Colostomy 4. Pelvic & extremity fixation delayed 4-5 days (avoid 2nd hit) STAGE 5 DAMAGE CONTROL SURGERY o A. 2 Reconstructive Procedures 1. Complex joint reconstructions 2. Nerve reconstruction 3. Bone grafts 4. Joint replacement SUMMARY Morbidity & Mortality A. B. Selected Group of Multiply Injured Patients C. Planned Staged Surgery D. Early Reports Favorable E. Fix the Patient NOT Just the Bone

II.

III.

IV.

V.

VI.

Pelvic Fractures I. INTRODUCTION A. 15-30% of High Energy Pelvic Injuries are Hemodynamically Unstable B. Bleeding Remains the Leading Cause of Death in Patients With Pelvic Fxs C. Pelvic Anatomy 1. Posterior sacro-iliac ligaments

VII.

2. Sacro-spinous 3. Sacro-tuberous D. 60-80% of Patient With High Energy Pelvic Fractures Have Other Musculoskeletal Injuries 1. 10-15% urologic injuries 2. 8-10% lumbosacral plexus injuries E. Sustained Shock in Patients With Pelvic Fxs 1. Mortality 2. Respiratory distress 3. MODS 4 CATEGORIES A. Stable Pelvic Ring Injuries B. Unstable Fracture Hemodynamically Stable Patient C. Unstable Fracture Hemodynamically Unstable Patient D. Unstable Fracture Patient in Extremis STABLE INJURIES A. The Pelvis is Able to Withstand the Physiologic Forces Incurred for Bed to Chair Transfers and Protected Weight Bearing without Abnormal Deformation of the Pelvis Until Bony Union and Soft Tissue Healing Occurs CLINICAL SIGNS OF INSTABILITY A. Deformity B. Abnormal Motion C. Posterior Bruising D. Open Wounds E. Associated Injuries X-RAY SIGNS OF INSTABILITY A. Posterior Fracture Displacement>1 cm B. Avulsion Sacrospinous Ligament C. Avulsion Transverse Process L-5 UNSTABLE INJURIES A. Unstable Fracture Hemodynamically Stable Patient B. Definitive Internal Fixation When Conditions Permit C. MAS(T) Trousers D. Sheet or Pelvic Binder E. Anterior External Fixator F. Pelvic C-Clamp G. Angiographic Embolization H. Pelvic Packing I. Algorithm 1. Bluid & blood ressuscitation 2. Sheet or pelvic binder 3. CT or FAST scan 4. Exp. Laporotomy if indicated 5. Externation fixation or C-clamp 6. Pelvic packing ??? 7. Angiography if unstable ANGIOGRAPHY A. Indications for Angiography

Persistent hypotension after resuscitation & stabilization 2. CT or FAST negative 3. No evidence of coagulopathy B. Fracture Surfaces C. L-S Venous Plexus D. Pelvic Arterial Injury 1. Internal iliac 2. Superior & inferior gluteal 3. Obturator 4. Lateral sacral E. Disadvantages of Angiography 1. Time consuming a) Transport b) Procedure c) 90 minutes VIII. PATIENT IN EXTREMIS A. BP<60 mm Hg B. Continued Massive Bleeding C. Not Responding to Treatment D. Imminent Threat of Death E. Urgent Life Saving Surgery F. Angiography NOT Helpful G. Pelvic C-Clamp H. Thoracotomy I. Laparotomy J. Aortic Clamping K. Abdominal/Pelvic Packing IX. TAKE HOME MESSAGE A. Life Threatening Injury B. Unstable Injuries Should be Fixed! C. Refer to Specialist D. Percutaneous Fixation Techniques E. Computer Guided Imaging & Surgery HIP FRACTURES General I. BURDEN OF DISEASE A. 300,000 Hip Fxs/Year B. $15 Billion Dollars C. 25% Mortality at 1 Year D. Risk of Second Fracture 3-5% II. MANAGEMENT A. Not All Hip Fracture Patients 1. Are debilitated 2. Live in a nursing home 3. Have cognitive impairment 4. Are non-ambulatory III. OUTCOMES A. Patients Functional Expectations Are Changing B. Healing of the Fracture Alone Should No Longer Be Defined As Success C. Outcome Failure is the Inability to Restore Pre-Injury Levels of Activity Femoral Neck Fractures I. NON-DISPLACED GARDEN 1 & 2 A. Nonoperative Treatment B. Displacement 15-18%

1.

C. Recommend ORIF D. In Situ Fixation E. Cannulated Screws II. DISPLACED GARDEN III & IV A. Younger Patients With Good Bone B. Urgent ORIF 6-8 Hours C. Cannulated Screws D. Capsulotomy? E. Patients <65 Years 1. Good Bone High Function 2. Rapid Medical Evaluation 3. Hemi-Arthroplasty vs. THR 4. ORIF High Complications F. Patients 65-80 Years 1. Poor Bone Quality 2. Lower Functional Demands 3. Medical Co-Morbidities 4. Arthroplasty NOT ORIF G. Patients >80 Years 1. Poor Bone Quality 2. Low Demand 3. Chronic Illness 4. Uni-Polar Prosthesis III. COMPLICATIONS A. Avascular Necrosis B. Fixation Failure C. Nonunion D. Infection E. Heterotopic Bone F. DVT & PE IV. TAKE HOME MESSAGE A. Urgent Reduction & Fixation in Physiologically Young Patients B. High Complication Rates Following ORIF in Garden III & IV Fractures C. Elderly High Function Patient Treatment Controversial D. Renewed Interest in Total Hip Arthroplasty Intertrochanteric Hip Fractures I. CLASSIFICATION A. Evans B. Kyle-Gustilo C. AO-ASIF D. OTA E. Stable vs. Unstable Should The Treatment Be The Same? II. WHAT IS STABILITY? A. Ability of the Reduced Fracture to Support Physiologic Loads B. Contact Between the Fragments C. Implant Will Prevent Shortening, Varus, Medial Displacement III. COMPRESSION HIP SCREW A. Gold Standard??? B. Controlled Impaction C. Early Mobilization & WB D. Early Weight Bearing E. Complications 4%-12%

IV.

V.

VI.

VII.

F. Familiar to All Surgeons G. Easy Set-up H. Time Honored & Tested I. Ideal: Stable Fracture J. Concerns: Unstable Fractures COMPLICATIONS CHS A. Screw Cut-out B. Excessive Shortening C. Medialization of Shaft D. Implant Breakage INTRAMEDULLARY HIP SCREW A. Rationale 1. Minimally invasive technique 2. Decreased OR time/Decreased blood loss 3. Improved biomechanics 4. Greater stability of fixation 5. Earlier patient mobilization 6. Shorter length of stay ADVANTAGES OF IM FIXATION A. Less Bending Moment B. Less Stress on Implant C. Less Hardware Failure D. Better Sliding Mechanics WHAT DOES THE LITERATURE SAY? WHAT IS THE EVIDENCE? A. Parker MJ, Handall HH. Cochrane Database Syst Rev 2005;4:000093 1. 27 Prospective randomized studies 2. N=4588 3. Short nails vs. sliding compression hip screw 4. Conclusions a. Sliding compression hip screw resulted in fewer intraop & postop femoral fxs, fewer technical complications & fewer reoperations b. No difference between the two techniques in terms of cut-out, nonunion, infection, mortality c. Not enough information regarding OR time, blood loss, would complications, radiation, limb shortening, or functional outcomes B. Kregor et al. J Orthop Trauma 2005;19:229-233. 1. Meta-analysis 11 studies comparing CHS vs IM fixation (unstable fxs only) 2. Conclusion Failure rate associated with IM fixation was significantly lower than with CHS C. Jones et al. Int Orthop 2006;30:69-78 1. Scientific evidence does NOT support the superiority of IM nail fixation over SCHS for the

treatment of intertrochanteric hip fxs D. The Literature Suggests That IM Nail Fixation Is Associated With Higher Complication Rates & No Better Outcomes E. Anglen, Weinstein. JBJS 2008;90A:700707 1. 1999-2006 2. 18,720 intertrochanteric fxs 3. 3823 surgeons (6 month Board collection period) 4. IM fixation a. 1999 3% b. 2006 65% 5. Higher rates of fracture & procedure related complications 6. Equivalent pain & deformity scores 7. Conclusions a. Young surgeons at beginning of career b. IM nail 2-4 times the cost of SCHS c. Higher surgeon fees d. No improvement in patient outcomes e. Theoretical advantages of IM fixation not realized VIII. INDICATIONS FOR COMPRESSION HIP SCREW A. Stable Fracture Patterns B. Younger Patients (Spare Abductor Mechanism) C. Basi-Cervical Fractures D. Ipsilateral Femoral Implants IX. INDICATIONS FOR IM FIXATION A. Unstable Fractures B. IT-Subtroch C. Reverse Oblique Subtrochanteric Femur Fractures I. PROBLEMS IN TREATMENT A. Difficult To Reduce B. High Stress Concentration C. Prolonged Healing Times D. Fixation Failures E. Increased Complications II. RUSSELL-TAYLOR CLASSIFICATION A. 1A Lesser Trochanter Intact B. 1B Lesser Trochanter Fractured C. 2A Lesser Trochanter Intact; Piriformis Fossa Compromised D. 2B Lesser Trochanter Fractured; Piriformis Fossa Compromised III. TYPE 1A st A. 1 Gen Locked Nail B. Plate 1. Blade plate 2. DCS 3. Locked plate

TYPE 1B A. Intramedullary Nail 1. Reconstruction 2. IMHS or PFN B. Piriformis vs Trochanteric Entry C. Locking Plate V. TYPE 2A A. Intramedullary Nail 1. Reconstruction 2. IMHS or PFN B. Piriformis vs Trochanteric Entry C. Locking Plate VI. TYPE 2B A. Intramedullary Nail 1. Reconstruction 2. IMHS or PFN B. Piriformis vs Trochanteric Entry C. Locking Plate VII. TAKE HOME MESSAGE A. Nail When Possible B. Fracture Table C. Piriformis or Trochanteric Entry D. Outcomes & Implants Improving E. Proximal Femur Locked Plate? Femoral Shaft Fractures I. EVALUATION A. Trauma Work-Up B. Resuscitation C. ATLS D. Physical Exam E. High Quality Imaging II. ASSOCIATED INJURIES A. Femoral Neck Fxs 3-5% 1. 30% missed on plain films 2. CT of abdomen & pelvis should include the hip B. Patella Fxs Often Overlooked 1. Dashboard injuries 2. Impacts knee function III. TREATMENT A. Fracture Stabilization Critical B. ORIF Standard of Care st C. IM Nailing Treatment of 1 Choice D. The Question is Timing! IV. IMPLANT CHOICES A. External Fixation B. Plate C. Nail V. EXTERNAL FIXATION INDICATIONS A. Pediatric Femur Fxs B. Damage Control VI. PLATE FIXATION INDICATIONS A. Neck-Shaft B. Proximal Fxs C. Distal Fxs D. Peds E. Other VII. IM NAILING INDICATIONS A. Vast Majority Shaft Fractures

IV.

1. Gold Standard 2. Closed Nailing 3. Load sharing implant 4. Stable fixation 5. Mechanical sound VIII. WHAT TECHNIQUED IS APPROPRIATE? A. Early vs Delayed B. Antegrade vs. Retrograde C. Fracture Table vs. Jackson Table D. Pririformis Fossa vs Trochanteric Entry E. Reamed vs. Unreamed F. Static vs Dynamic Nailing IX. ANTEGRADE VS RETROGRADE A. Antegrade Nailing Remains the Most Commonly Used Technique B. Retrograde Nailing Useful in Selected Circumstances X. ANTEGRADE NAILING A. Fracture or Jackson Table B. Supine or Lateral Position C. Closed or Open Fxs D. Majority of Fractures XI. DISADVANTAGES OF ANTEGRADE NAILING A. Heterotopic Ossification B. Hip Pain & Dysfunction C. Limited in Neck-Shaft Fractures D. Fracture Table Problems E. Pudental Nerve Palsies F. More Difficult in Multiple Trauma XII. RETROGRADE NAILING A. Viable Alternative to Antegrade Nailing B. Better or Easier?? C. Specific Indications D. Concerns in Open Fractures E. Multiply Injured Patients F. Bilateral Femur Fractures G. Ipsilateral Hip Fracture H. Ipsilateral Pelvis, Acetabular Fracture I. Ipsilateral Tibia or Patella Fracture J. Ipsilateral Vascular Injury K. Morbidly Obese Patient L. Peri-Prosthetic Fracture XIII. CONTRAINDICATIONS RETROGRADE NAILING A. Subtrochanteric Fxs B. Contaminated Knee Wounds?? C. Grade IIIB Open Fxs ?? D. Open Distal Femoral Epiphysis XIV. ANTEGRADE VS. RETROGRADE A. No Difference in Outcome With Canal Fill Nails 1. Time to union 2. Rates of union 3. Alignment B. Hip Symptoms Antegrade C. Knee Symptoms Retrograde XV. ENTRY POINT A. Piriformis Fossa Pros

1. Long track record 2. In line with canal 3. Less hoop stresses 4. Less secondary deformity 5. Less injury to abductor mechanism B. Piriformis Fossa Cons 1. Difficult supine 2. Difficult in large patients 3. Damage to short ext rotations 4. risk of AVN in adolescence C. Trochanteric Entry Pros 1. Easier to find starting pt 2. Makes supine nailing easier 3. Less OR & fluoro time ??? 4. risk of AVN in adolescence D. Trochanteric Entry Cons 1. Secondary deformity with conventional nails (varus) 2. Damage to abductions 3. Fracture specific implants 4. Easier or better?? XVI. THE ROLE OF REAMING A. Reaming Pros 1. Larger implant 2. Fills canal 3. Less malalignment 4. Fewer mechanical failures 5. Reaming as bone graft B. Reaming Cons 1. Marrow & fat embolism 2. Pulmonary injury 3. IM pressure & temp 4. blood loss 5. Technical issues C. The Exact Relationship Between Reaming, Fat Embolism & ARDS is Not Fully Understood XVII. CURRENT CONCEPTS IN REAMING A. Sharp Reamers B. Deep Flutes C. Small Head Size D. Narrow Drive Shaft E. Careful Advancement F. Not Too Much XVIII. STABLE VS DYNAMIC A. All Nails Should Be Statically Locked B. 1 Locking Screw if >7.5 cm From Fx Site C. 2 Locking Screws if <7.5 cm From Fx Site XIX. CONCLUSIONS A. Antegrade Reamed Statically Locked IM Nailing for Both Closed & Open Femur Fxs is Safe & Effective B. Surgeons Choice 1. Supine or lateral position 2. Fx table or Jackson table 3. Piriformis or troch entry

Supracondylar Femur Fractures I. CLASSIFICATION A. Extraarticular B. Intraarticular C. Unicondylar Fractures II. GOALS OF SURGICAL TREATMENT A. Restore Joint Congruity B. Anatomic Alignment C. Stable Internal Fixation D. Early ROM Knee III. SURGICAL TREATMENT A. Plate Osteosynthesis B. IM Nailing 1. Antegrade 2. Retrograde C. External Fixation IV. INDICATIONS FOR SURGERY A. Comminuted Fxs B. Severe Soft Tissue Injury C. Multiple Injuries D. Compromised Host E. Prei-Prosthetic Fxs V. PERI-ARTICULAR LOCKED PLATES A. Minimally Invasive Surgery B. Sub-Muscular Placement C. Multiple Fixed Angle Screws D. Self-Drilling, Self-Tapping E. Unicortical Options VI. TAKE HOME MESSAGE A. Restore Articular Congruity B. Individualize Treatment C. Avoid Stiffness Early ROM D. Locking Plates LISS & Others Tibial Plateau Fractures I. SCHATZKER CLASSIFICATION A. I Split Lateral Condyle B. II Split Depressed Lateral Plateau C. III Pure Depression Lateral Plateau D. IV Medial Plateau Fracture E. V Bicondylar Plateau Fracture F. VI Bicondylar Plateau-Diaphyseal Ext. II. IMAGING STUDIES A. Axial B. Sagittal C. Coronal D. 3D CT Scans E. Preop Plan III. DECISION MAKING 3 KEY FACTORS A. Evaluation Soft Tissue B. Evaluation Fracture C. Patient Factors IV. EVALUATION OF SOFT TISSUE A. Low Energy B. Intermedial Energy C. High Energy V. EVALUATION OF FRACTURE A. Plain Films B. CT

C. MRI EVALUATION OF LATERAL PLATEAU A. Split B. Depressed C. Meta-Diaphyseal D. Combinations VII. TREATMENT OF LATERAL PLATEAU A. Screws Alone B. Conventional Plate C. Locking Plate D. Based On 1. Fracture pattern 2. Bone quality VIII. MEDIAL PLATEAU A. Two Distinct Fracture Patterns 1. Sagittal 2. Coronal B. Sagittal Fx Pattern 1. Medial buttress 2. Laterally based locked plate C. Coronal Fx Pattern 1. Requires a posteromedial plate! IX. PATIENT FACTORS A. Associated Injuries B. Co-Morbidities C. Functional Demands X. DECISION MAKING A. The Surgeon Must Have a Clear Understanding of the Soft Tissue Injury & the Fx Pattern in Order to Determine the Timing of Fixation, The correct Surgical Approach, As Well As the Location and Type of Implants XI. SURGICAL TECHNIQUES A. Traction B. Distractor C. Ex-Fix D. Tension Device E. Push-Pull F. Plate XII. INDICATIONS FOR SURGERY A. Displaced Fxs B. Articular Incongruity C. Knee Instability D. Axial Deformity E. Timing of Surgery XIII. IMMEDIATE SURGERY A. Open Fxs B. Compartment Syndrome C. Neuro-Vasc Compromise XIV. EARLY DEFINITIVE SURGERY A. Lower Energy Closed Fxs B. Schatzker I, II, III Patterns C. Classic Internal Fixation D. 24-72 Hours Post Injury XV. DELAYED SURGERY A. Higher Energy Fxs 1. Significant swelling 2. Fx blisters VI.

Degloving injuries Open Fxs Multiply injured patients Early internal fixation is contraindicated!! XVI. SURGICAL CONTROVERSIES A. Type of Bone Graft B. External Fixation vs ORIF C. Role of Arthroscopy D. Peds/Open Epiphysis E. Late Presentation XVII. CONCLUSIONS A. Understand Soft Tissues B. Recognize Fx Pattern C. Correct Surgical Approach D. Correct Choice of Fixation Tibial Shaft Fractures: Decision Making I. INTRODUCTION A. Huge Spectrum of Injury B. Isolated Low Energy C. Severe Open Fxs D. Multiply Injuried E. Limb Salvage Decisions II. DECISION MAKING IN CLOSED FRACTURES A. Isolated or Not B. Compartment & N-V Status C. Condition of Soft Tissues D. Fx Location and Geometry E. Timing of Surgery III. DECISION MAKING IN OPEN FRACTURES A. Magnitude of Soft Tissue Injury B. Degree of Contamination C. Timing & Type of Stabilization D. Soft Tissue & Bone Reconstruction IV. CAST TREATMENT A. Low energy injuries B. Closed fractures C. Stable fracture patterns D. Non-multiply injured patients V. PLATE FIXATION o A. 1 for metaphyseal-diaphyseal fractures B. Acceptable soft tissue envelope C. Indirect reduction D. Percutaneous techniques VI. REAMED NAILS A. Primarily unstable closed fractures B. Selected grade I & II open fractures C. Middle 3/5ths of tibia D. Fracture table or radiolucent table VII. UNREAMED NAILS A. Primarily open fracture management B. Selected closed fractures with severe soft tissue injury C. Static interlocking D. Aggressive treatment to achieve union VIII. EXTERNAL FIXATION A. Grade III open fracture management

3. 4. 5. 6.

IX.

B. Closed fractures bad soft tissues C. Spanning frames D. Sick patients rapid application TAKE HOME MESSAGE A. Most Common Long Bone Fracture B. Most Problems Infection, Nonunion, etc. C. Assessment, Resuscitation, N-V Status, R/O Compartment Syndrome, Stabilize D. Individualize Treatment E. Staged Reconstruction

Tibial Pilon Fractures I. INTRODUCTION A. Life Altering Event B. Impacts Work & Recreation C. Full Recovery Rare D. Functional Impairment E. Limb Threatening II. HISTORICAL PERSPECTIVE A. Poor Understanding of the Soft Tissue Envelope B. Large Bulky Implants C. High Complication Rates 1. Infection 2. Arthrodesis 3. Amputation III. CHALLENGES IN TREATMENT A. Soft Tissue Management B. Articular Reduction C. Fx Comminution D. Associated Injuries IV. FRACTURE PERSONALITY A. Low Energy B. High Energy V. GOALS IN TREATMENT A. First 1. Assess soft tissues 2. Restore length & alignment 3. Imaging studies B. Second 1. Articular reduction 2. Stable fixation 3. Early ROM VI. DECISION MAKING A. Open vs Closed B. Status of Soft Tissues C. Associated Injuries D. Fracture Personality E. Imaging Studies VII. TIMING OF SURGERY A. Immediate Surgery 1. Open Fxs 2. Compartment syndrome 3. N-V compromise 4. Soft tissue compromise B. Delayed Definitive Fixation 1. Limb swelling 2. Compromised skin

3. Associated injuries 4. Post-reduction CT scan 5. Special implants VIII. TREATMENT STRATEGIES A. Timing of Surgery B. Staging of Surgery C. Planning of Surgery D. Surgical Approaches IX. TIMING OF SURGERY A. Early Internal Fixation of High Energy Pilon Fxs Associated with Increased Incidence of 1. Wound infection 2. Additional surgeries 3. Poor outcomes 4. Amputations X. STAGING OF SURGERY A. Planned 2 (or More) Staged Procedure(s) B. Temporary Bridging External Fixation C. ORIF Fibula D. Delayed ORIF Tibia E. Most Open Fxs F. High Energy Closed Fxs G. Compromised Soft Tissues H. Associated Injuries I. Awkward Time (Night) J. Staged Reconstruction 1. Simple frames 2. Pins outside zone of injury 3. Foot in neutral with pin 4. Soft tissue reconstruction a. Wound VAC b. STSG c. Free flap K. Early ORIF of Fibula Helps Control Talus L. Bi-Columnar Posterior Distraction Centralizes the Talus Between the Tibia XI. TAKE HOME MESSAGE A. Soft Tissue Assessment Guides Rx B. Good Soft Tissues Internal Fixation C. Bad Soft Tissues External Fixation D. Planned Staged Reconstruction 1. Simple spanning external fixator 2. Delayed ORIF with locked plates Fractures of the Talus I. TALAR NECK FRACTURES A. High Energy Trauma B. Hyper-Dorsiflexion Injury C. Significant Morbidity D. Complications Frequent II. HAWKINS CLASSIFICATION 1. Type I non-displaced 2. Type II displaced with disruption of subtalar joints

III.

3. Type III displaced with disruption of subtalar & tibiotalar joints 4. Type IV displaced with disruption of subtalar, tibiotalar & talonavicular joints B. Treatment 1. Type I cast or cannulated screws 2. Type II, III, IV ORIF C. Complications 1. skin necrosis and infection 2. delayed union and nonunion 3. malunion 4. avascular necrosis Type I 10% Type II 40% Type III 75% Type IV 95% 5. post-traumatic arthritis TAKE HOME MESSAGE A. Injuries Easily Overlooked B. High Index of Suspicion C. Best Results with ORIF D. Complications Common

D. E.

Low Profile Peri-Articular Plates Fix Them or Refer Them

References 1. Adams CK, Robinson CM, Court-Brown CM, McQueen MM: Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. J Orthop Trauma 15:394400, 2001. 2. Afsari A, Liporace F, Lindvall E, et al.: Clampassisted reduction of high subtrochanteric fracture of the femur. J Bone Joint Surg Am 91:1913-8, 2009. 3. Ahrengart L, Tornkvist H, Fornander P, et al.: A randomized study of the compression hip screw and gamma nail in 426 fractures. Clin Orthop 401:209-222, 2002. 4. Ali AM, Burton M, Hashmi M, Saleh M: Treatment of displaced bicondylar tibial plateau fractures in patients older than 60 years of age. J Orthop Trauma 17:346-352, 2003. 5. Anglen JO, Weinstein JN: Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. J Bone Joint Surg 90A:700707, 2008. 6. Baker RP, Squires B, Gargan MF, Bannister GC: Total hip arthroplasty and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck. J Bone Joint Surg 88A:2583-2589, 2006. 7. Barei DV, Nork SE, Mills WJ, et al.: Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates. J Bone Joint Surg 88A:17131721, 2006. 8. Barei DV, Nork SE, Mills WJ, Henley MB, Senirschke SK: Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique. J Orthop Trauma 18:649-657, 2004. 9. Barei DP, OMara TJ, Taitsman LA, et al.: Frequency and fracture morphology of the posteromedial fragment in bicondylar tibial plateau fracture patterns. J Orthop Trauma 22:176-182, 2008. 10. Barton TM, Gleeson R, Topliss C et al.: A comparison of the long gamma nail with the sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur. J Bone Joint Surg Am 92:792-8, 2010. 11. Bhandari M, Matta J, Ferguson T, Matthys G: Predictors of clinical and radiological outcome in patients with fractures of the acetabulum and concomitant posterior dislocation of the hip. J Bone Joint Surg 88B:1618-1624, 2006.

Fractures of the Calcaneus I. CONSEQUENCES OF INJURY A. Shortening of heel B. Widening of heel C. Varus hindfoot D. Subtalar arthrosis E. Fibulo-calcaneal impingement F. Heel pain II. INDICATIONS FOR SURGERY A. Adequate Soft Tissues B. Fixable Fracture C. Low Profile Implants D. Disruption of the Posterior Facet E. Achilles Tendon Avulsion III. CONTRAINDICATIONS TO SURGERY A. Compromised Soft Tissues B. Geriatric Pts C. Neuropathic or Occlusive Disease D. Smokers E. Inexperience IV. TECHNICAL CONSIDERATIONS A. Lateral Decubitus Position B. Image Intensifier C. L-Shaped Incision D. Provisional K-wire Fixation E. Low Profile Implants F. Locked Plates ??? G. Splint to Avoid Equinus H. Early Range of Motion I. Delayed Weight Bearing V. TAKE HOME MESSAGE A. Fairly Common Injury B. Significant Morbidity/Disability C. Articular Injury to WB Joint

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Upper Extremity

 UPPEREXTREMITY

Moderator:MarcSafran,MD 10:10AMHandandWrist JeffreyGreenberg,MD 10:50AMForearmandElbow RickF.Papandrea,MD 11:25AMShoulderandHumerus Marc Safran, MD

Orthopedic Review Course Hand Surgery Update AAOS, San Diego, February 2011
Jeffrey A. Greenberg, MD, MS Indiana Hand to Shoulder Center Indianapolis, IN

Hand Flexor Tendon Surgery Rationale re: Treatment Decisions Repair Techniques Evidence Future Direction PIP Injuries Classification Mechanism/biomechanics Stability Treatment options Rehabilitation Small Joint Arthroplasty Surgical options Implants Approaches Evidence Wrist

Distal Radius Fractures Evolution in treatment decisions Rational Approach to Treatment Treatment Options Outcomes/Evidence Ulnar Styloid Acute Chronic Evidence Distal Radius Malunion Pathomechanical changes Rationale for Treatment Treatment Options Outcomes Scaphoid Fractures Factors affecting treatment decisions Treatment Options Outcomes Nonunion Carpal Instability Acute Subacute Chronic Salvage (SLAC, SNAC) DRUJ

Instability Pathomechanics Rationale for Treatment Treatment Options Arthroplasty New evolving concepts Rationale for Treatment Indications and Options Outcomes/Evidence TFC Update: Anatomy/Biomechanics Diagnosis and Classification Treatment Options/Rationale Kienbocks Classification Schemes New adjuncts to classification Classification based Treatments Outcomes Thumb CMC Reconstruction Update on Treatment Options Evidence Nerve Reconstruction: New options for treatment Conduits Autogenous

Synthetic Allograft Outcomes/Evidence

RickF.Papandrea,MD OrthopaedicAssociatesofWI AssistantClinicalProfessor,MedicalCollegeofWI

Elbow 1. Intro a. Anatomy i. Collaterals 1. Isometricpoints[13] a. Nottrulyisometric[4] b. Laterallyatcenterofcapitellum c. Mediallyatinferiorepicondyle ii. Fossae 1. Coronoid/Olecranon 2. Dontforgetradialhead iii. Medialfacetofcoronoid 1. Adjacenttosublimetubercle a. AttachmentofMCLanteriorband b. Functionalrequirements i. ROM 1. Flex/ext a. 30to130Morrey[5] b. 75to120Vasen[6] i. withadjacentjointcompensation 2. Supination/pronation a. 50to50[5] i. Accommodatelossofpronation 1. Shoulderabduction c. History i. Symptoms 1. Pain a. Endarcimpingment b. midarcincongruityofjoint(worsewithload) c. restsynovitis d. Imaging i. Xrays 1. Radialheadviewlimitsoverlapfromulna 2. Neutralrotationfullforearm a. Radialbow[7] i. Losslimitsrotation b. DistalRadioulnarjoint i. Assessrelativeulnalengthcomparedtocontralateral ii. CT 1. 3Dreconstruction a. OsirixallowspostCTreconstrucion[8] i. Surgeoncontrolled iii. MRI 1. Indications a. Biceps

i. FABSview[9] 1. Flexion,Abduction,Supination 2. Allowsvisualizationfrommuscletoinsertioninsame image 3. Lesssensitiveforpartialtears[10] e. Exposure i. Skin 1. Universalposterior a. nervesparing[11] i. lesschanceofnumbess b. largeflaps i. riskofseroma/hematoma/necrosis 1. limitingmotionfor2448hrsmayhelp 2. Direct a. Mayneedmultipleincisionsdependingonpathology ii. Deep 1. Kocher a. ImplicationstoLCL i. IfdeepincisioniscarriedinlinebetweenanconeusandECU,the UCLwillbecut 2. Kaplan a. Limitationradialnerve i. Ifdissectiongoesdistaltoradialneck,supinatorsplitandRadial nervedissected b. Canextendupcolumn i. Allowsincreasedaccesstocapitellum 3. LateralColumn a. FirstdescribedbyHastings/Cohen[12,13] b. NamedbyMorrey 4. Overthetop,a.k.a.MedialColumn a. Hotchkiss i. SplitFlexor/Pronatormass ii. Proximalupcolumn 5. BryanMorrey[14] a. Maybeproblemswithhealingandtricepsweaknes[15] 6. TRAP[16] a. TricepsReflectingAnconeusPedicle i. BryanMorreycombinedwithmuscularportionofKocherdeep ligamentsleftintact 7. Olecranonosteotomy 8. AFT[17] a. OlecranonosteotomycombinedwithTRAP 9. Lateralepicondylarosteotomy a. canallowforincreasedaccesstolateraljoint b. repairwithrigidfixationallowformoreaggressiverehab i. canbehelpfulwithradialheadreplacements,capitellarfractures 2. Arthroscopy a. Specialequipment i. Positioningsupports ii. Dedicated30degree4mmsleeve

1. Nofenestrations iii. Multipleswitchingsticks b. Positioning i. Prone/lateraldecubitus 1. Armoverbolster/support 2. Mustbe90degreesfrombody 3. Antecubitalregionwithnopressure ii. Supine 1. Maybemoredifficulttoworkposteriorly c. Indications i. OCD ii. Loosebody iii. DJD iv. Plica[18,19] v. LateralEpicondylitis[20,21]Risks[22] d. Risks i. Mayodataover470elbowswithnopermanentinjuries[22] ii. Nerveshavebeencut 1. Greatestriskradial? a. DontforgetUlnarnerveposteriorly 3. Stiffness a. Nonoperativemanagement i. Bracing 1. Staticvs.dynamic a. Teachingdynamicirritates 2. Sciencenodifference[23] 3. Protocol? a. Noscience[24] 4. Windowofopportunity a. 36months b. noscience b. Operative i. Open 1. Lateral a. Column[12,13] b. Hastings/Cohen(ref) c. Safe,reproducible,simple d. DoesnotallowaccesstoUlnarnerve 2. Medial a. Overthetop b. ConcomitantUlnarnerve c. Noradialheadaccess 3. Both a. Startononeside,gototheotherifneeded 4. TardyUlnarnervesymptoms a. Releaseortransposeifflexiongained i. Absolutenumbers? 1. Mostsurgeonsreleaseifflexiononlyto90 2. Somesurgeonsreleasingall ii. Problemsafterincreasedflexion

1. TardyUlnarnervemaypresentonlywithlossof motionorvaguepain ii. Arthroscopic 1. Releasev.Excisionofcapsule a. Experiencedbased b. Outcomesunknownforsuperiortech c. Postoperativemanagement i. Noscience 1. CPM[25] 2. Formaltherapy 3. Selfdirectedexercises 4. Splints 4. Stability a. PrimacyofCoronoidMorrey i. Withoutadequatecoronoidtheelbowwillbeunstable b. Collateralanatomy i. LCLcritical ii. NonthrowerscantolerateMCLinsufficiency 1. Ifotherconstrainsareinplace c. RadialheadImportantsecondary[26] i. Criticalinpersistentinstability(failedattemptsatORIFoffxdislocations)[2729] 5. Instability a. Test i. Pivotshift ii. Drawer iii. Pushup/off b. Simpleelbowdislocation i. PLRImechanism ii. Recurrent 1. ReconstructLCL[30,31] 2. MCLmaybeintactandusuallydoesnotneedtobereconstructed c. Fracturedislocation i. Coronoidfracture 1. Morrey/Regan[32,33] a. TypeItip(shear,previouslyavulsion) b. TypeIIlessthan50%height c. TypeIIIMorethan50%height 2. ODriscoll a. Correlationwithinjurypattern[34] Andthereforetreatmentrecommendations 1. TipPLRI(posterolateralrotatoryinstability) a. FixLCL[35] b. Singlebundlecanwork[36] c. RepairorreplaceRadialHead d. AssessMCL a. Mostdontneedrepair b. Willhealifelbowisstable e. Successfulpublishedprotocol[37] f. Nowtherearequestionsifalltipsneedtoberepaired g. Casereportof4casestreatednonop[38]

a. Alignedwithsmallfrxandnoblocktomotion 2. MedialVPMRI(Varusposteromedialrotatoryinstability) a. Image b. 3DCT c. AssessLCL a. Usuallyneedsrepair d. Assessmedialcoronoid a. Usuallyneedsrepair 3. Base(transolecranonfxdislocation) a. Securecoronoidtoulna a. Easiestaccessisthrougholecranonfx b. Plateolecraonon c. Fixorreplaceradialhead 4. EXfixcanbeconsideredtosupporttenuousfixation a. Dynamicorrigid a. Nosciencesupportsoneoverother b. DynamiccanprotectLCLinjuriesor recon[39] d. Medialcollateralligament i. Clinicaldx 1. Lossofvelocity,oftenafterpop 2. Movingvalgusstresstest[40] ii. Throwers(pitchers,catchers,javelin) iii. Somewrestlers/MMA/gymnast iv. Lookforulnansymptoms v. Mayberepairedwithsinglebundle[41] vi. Dockingtechnique[42] e. Valgusextensionoverload[43] i. Dontremovemorethantheosteophyte f. Rehab i. Importanceofvarusstresswithshoulderabduction a. Forearmpositioneffectsoncollateralstress[44,45] i. SupinationstressesLCL ii. PronationstressesMCL ii. Acutesimpledislocation 1. Immediateorearlymotion a. Immobilizeonlyifstaticsubluxation 2. Avoidvarus a. Supineexercises 6. Arthritis a. Primary i. Osteophytesfillingfossae 1. ridgeosteophyte a. early b. distalolecranonfossae c. impingeswithextension 2. Treatment a. Removeosteophytes

i. Open 1. OuterbrideKashiwagiorulnohumeralarthroplasty[46] a. Doesnotaddressradialheadfossa b. Doesnotremovemedialorlateralboneoffulna 2. Lateralormedialapproach a. MaycombinewithOuterbridge b. Stilldifficulttoremovemediallateralbonefrom olecranon ii. Arthroscopic(OCAosteocapsulararthroplastyODriscoll) b. Addressulnarnerve i. Noscience 1. Releasev.transpose 2. Onlyifflexionincreased? 3. Onlyifflexionlessthan90? b. Posttrauma c. Inflammatory i. Earlysynovectomy ii. Questionroleofradialheadexcision 1. Classicteachingtoremove 2. Arthroscopyallowssynovectomywithretention 7. ElbowArthroplasty a. Partialreplacement i. offlabeluse 1. hemiarthroplastyofdistalhumerus[47] a. acutefracture b. delayedreconstruction i. salvage b. TotalElbowArthroplasty i. History 1. Currentsuccessinlowdemand[48] 2. Higherfailureinotherpts[49] ii. Risks 1. Infection a. AbxinPMMA b. RegionalAbx[50] iii. Linked 1. Termpreferredoversemiconstrained iv. Unlinked v. Convertible[51] vi. Hemisphericalbearings 1. Dotheymatter? vii. Roleofradialhead(ref?) c. Interposition[5254] i. Typicallyunsuccessfulifpreoperativelyunstable ii. Withpreoperativestabilitystilla50:50surgery 8. Fusion[55,56] a. Durableoncefused b. Ifptacceptsthedisabilitycanprovidepainlessfunction 9. Tendinopathy a. Medial/lateral

b. Naturalhistory c. Currentscience(thereisnotmuch) i. Bracing[57] 1. LevelIevidencethatwristextensionsplintissuperiortoforearmstrap ii. Shockwave iii. Injections 1. Steroids[58] a. Shorttermbenefit b. Longertermdetriment 2. Botox 3. Blood 4. Plateletgel 5. Mayweakentissue(pix) iv. Surgery 1. Debride/release a. Noneedtotxepicondyle[59] i. Randomizeddoubleblindstudy!LEVEL1 b. Percutaneous c. Open d. Scope[60] d. Biceps i. Partialv.full[61] 1. MRrarelyneeded 2. Hooktest[62] ii. Tofixornottofix[63] 1. 30%lossofflexionand40%lossofsupinationstrengthwithoutrepair iii. Technique 1. Oneincision 2. Twoincision[64] 3. Anchors/buttons/interferencescrews/tunnels iv. Rehab 1. Immediatemotion[65] e. Triceps[66] i. Rare ii. Steroids? iii. Lookforfleck iv. Canoccurinadultsandkids 1. Youngerwithradialheadfracture v. Repair 10. Fractures a. Distalhumeral i. Dualplateconfiguration[67,68] 1. parallelplatesatleastasgoodas9090 ii. Shorteningosteotomyforboneloss[69] iii. Prostheticforirreparable a. Totalelbow[70]Mustbelinked b. Tricepslefton 2. Hemiarthroplasty[47] a. Offlabel b. Olecranon

c. Coronoid i. Seeabove,underfracturedislocation d. Radialhead i. IndicationsforORIF[71] ii. ORIFvs.Replace?(needreferences) iii. Implants 1. overstuffing[7274] a. bestassessmentisvisualizingthelateralUHjoint i. radiographicwideningofthejointmaybenormal,compare tocontralatral 2. spacerv.anatomic[75] a. nocomparitivedata b. mostdataonspacers 3. roleofbipolars? a. polyethylene 11. Ulnarnerve a. Releasev.transpositionforCubitalTunnel[76] 12. OsteochondritisoftheCapitellum a. Lateralmarginshouldbeintactorreconstructed[77] 13. HeterotopicOssification a. PostopXrayTherapy(700cGy/Rads)increasednonunioninACUTETRAUMA[78] Forearm I. Anatomy a. Diarthrodialjoint b. Longseparation(IOM)b/tjointcompartments II. Monteggia III. Galeazzi IV. Bothbones a. Dontrodboth(ref) i. Malunion ii. nonunion Essexlopresti V. a. Recognizeandtreatacutely i. Fixorreplaceradialhead ii. StabilizeDRUJ 1. Pinningenough? iii. ?roleofIOMsurgery b. Anconeus[79] i. salvage c. IOMreconstruction i. Bonetendonbone[80,81] ii. Pronatorteresrerouting[82] d. CementedMonoblockradialheadsdidnotwork i. 8patientscaseseries[83] VI. Malunion a. Poorrotation b. Lateinadolescent,youngadultwithh/odistalradiusfxyearsprior i. ClinicallyshowsupasDRUJinstability

VII.

HeterotopicOssification a. Testing i. Noneedforlabsorbonescan ii. Lookforwellmarginatedbone b. Timingforremoval[84] i. Consensusat6mos ii. ?34mos c. Recurrenceprevention i. Preopv.postopXRT 1. Singlefraction 2. 700Rads ii. IndocinorotherNSAIDs

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44.

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Shoulder & Humerus Review Safran, Page 1

SHOULDER & HUMERUS

Whats Hot & Whats Not

ORTHOPAEDIC REVIEW COURSE February 18, 2011 San Diego, California

MARC R. SAFRAN, MD
Professor, Orthopaedic Surgery Associate Director, Sports Medicine Stanford University msafran@stanford.edu

Disclaimers: (1)

This talk is not intended specifically as a board review but rather an update on current, evidenced- and experienced-based practice of shoulder surgery. This handout is more extensive than the lecture as 25 minutes is not enough time to review all the hot topics in the shoulder

(2)

1)

Clavicle
a. Clavicle Fractures
i. Whats HOT 1. Early Plating Of Displaced Midshaft Clavicle Fractures (1) a. Younger and more active patients b. Poorer outcomes if >1.5cm overlap or increased comminution, minimal bony contact, segmental fracture or transversely displaced butterfly fragment (2) c. Increase risk for non union, neurologic injury, cosmetic issues, weakness and endurance deficits d. Consider ORIF i. Plate stronger (2, 3) Pre contoured Locked or DCP Superior surface of clavicle ii. Hage Pin Less invasive Less periosteal stripping Must remove

NOTES:

Shoulder & Humerus Review Safran, Page 2

ii. Whats NOT 1. Observation of Comminuted and/or shortened midshaft clavicle fractures particularly in young, active patients (1,2) 2. K-wires (2,3) 3. Intramedullary devices for comminution

B. Distal Clavicle Fracture

i. Whats HOT 1. Surgical Plate and Screw Fixation of Type IIB Distal Clavicle Fractures (4) a. Unstable: High rate of non-union / malunion ii. Whats NOT 1. Suture Fixation 2. Plating Across AC Joint 3. K Wires / Threaded Steinmann Pin Across AC Joint (5) a. Infection b. Migration c. AC Arthritis d. Shoulder Stiffness 4. Hook Plate (6) a. Migrate Into Acromion / Acromial Fracture b. Subacromial adhesions / impingement / Stiffness c. Rotator Cuff Injury

2)

AC Joint
a. AC Separation (7,8)
i. Whats HOT 1. Surgical Repair of CC Ligaments (7) 2. Augmentation or Reconstruction for Type III & V Lesions with Soft Tissue (7) 3. Semitendinosis Graft (7) 4. Avoiding Anteriorization of Clavicle By Cerclage Fixation ii. Whats NOT 1. Routine Surgery for Grade III AC Separation (8) 2. Plating Across The AC Joint 3. Non-Anatomic Repairs a. Weaver Dunn 4. Bosworth Screw

b. AC Osteolysis or Arthritis
i. Whats HOT 1. Injection with steroids 2. Distal clavicle resection if symptoms persist a. Remove only 5 10mm ii. Whats NOT 1. Removal of > 1cm of distal clavicle NOTES:

Shoulder & Humerus Review Safran, Page 3

3)

Rotator Cuff
a. Impingement
i. Whats HOT 1. Secondary Causes a. Scapular Dyskinesis (9) b. Old trauma c. Stiffness 2. Most Always Secondary if < 30 y/o (10) a. Instability b. Stiffness i. Global vs Posterior Capsule c. Scapular dysfunction d. Os Acromiale e. Overuse 3. Treatment of Impingement (9, 10) a. Rehabilitation ii. Whats NOT 1. Attribute All Impingement to Acromial Morphology 2. Arthroscopic Subacromial Decompression a. Though, when needed, results the same as open b. 70 95% success c. Spare the Deltoid Insertion iii. CONTROVERSIAL 1. Role Of Corticosteroid Injections (11) a. Accuracy (12) b. Efficacy (13)

b. Internal Impingement (14)

i. Whats HOT 1. Physiologic 2. Increased with Increased External rotation and hyperabduction 3. Associated with tight Posterior Capsule vs Anterior Laxity (15-19) 4. Associated with SLAP Lesions 5. Treatment (20,21) a. Stretch posterior capsule b. May require posterior inferior capsular release ii. Whats NOT 1. Rotational Osteotomy of Humerus (22) 2. Anterior Shoulder Stabilization iii. CONTROVERSIAL 1. Posterior Capsular Release for Internal Impingement NOTES:

Shoulder & Humerus Review Safran, Page 4

c. Partial Thickness Rotator Cuff Tears

i. Whats HOT 1. Primary Repair of PASTA Lesions (23, 24) 2. Repair of Lesions > 50% Thickness ii. Whats NOT 1. Take down of Partial Tears with Primary Repair 2. Repair Partial Tears < 50% Thickness loss 3. Debridement (25)

d. Full Thickness Rotator Cuff Tears

i. Whats HOT 1. Earlier Repair 2. Arthroscopic Double Row / Transosseous Equivalent a. Stronger repair vs single row (26) b. Less slippage c. Larger Footprint restoration (27) d. Limitations i. Effect on Blood Supply ii. Outcomes poor with Massive Tears 3. Arthroscopic repairs approach open and mini-open with regard to symptomatic improvement and clinical rating scales (28-30) a. Integrity of cuff repair for large / massive tears worse with large / massive tears arthroscopically repaired vs small and vs open. 4. Mason-Allen Stitch or Equivalent (31) 5. Understanding Tear Pattern (32) a. Allow for Marginal Convergence b. Reduce Stress on Repair 6. Subscapularis tears (33) a. Unique Management More aggressive i. Early Surgical Repair b. Chronic cases may require pectoralis major transfer. ii. Whats NOT 1. Open Repairs a. Though, Open repair, acromioplasty, cuff mobilization, results = 85-90% good to excellent b. Mini open repair and arthroscopic repairs results parallel open repair 2. Debridement (34) a. Outcomes deteriorate with time b. Indicated in old, sedentary individuals when involves nondominant arm c. Non compliant patients iii. CONTROVERSIAL 1. Arthroscopic Repair for All Tears vs Small and Medium Size NOTES:

Shoulder & Humerus Review Safran, Page 5

e. Massive Rotator Cuff Tears

i. Whats HOT 1. Reverse Total Shoulders in Elderly (35,36) 2. Arthroscopic Partial Repairs (37) 3. Tendon transfers (38) a. Latissimus transfer for irreparable massive (supraspinatus and infraspinatus tears) (39,40) b. Pectoralis major transfer for irreparable subscapularis tear (41) 4. Rehabilitation of the anterior deltoid and teres minor particularly important (42,43) ii. Whats NOT 1. Debridement (34) 2. Biceps Tenotomy (44, 45) 3. Allograft or Bridging Soft Tissue Substitute (46)

f. Cuff Arthropathy
i. Whats HOT 1. Reverse Total Shoulders in Elderly (35, 36) ii. Whats NOT 1. Debridement (34) 2. Hemiarthroplasty a. Especially if Cannot Actively Abduct > 90 degrees (47) 3. Reverse Shoulder Arthroplasty in young patients

4)

Shoulder Instability
a. Anterior Instability
i. Whats HOT 1. Arthroscopic Anterior Stabilization (48) a. Bankart w/ Capsular Tightening b. Success in athletes 89 93% (49) i. 90% of non throwing athletes RTS ii. 68% of throwing athletes RTS iii. Recurrence rate for contact athletes 9.5% iv. Recurrence rate for non-contact athletes 6% c. Advantages over open i. Avoid injury / detachment to subscapularis ii. Less likely loss of external rotation iii. More full assessment of intra-articular pathology 2. Bony Defects (50) a. Glenoid Based Bony Loss i. > 20 % ii. Latarjet Procedure b. Humeral / Hill Sachs Lesion i. Engaging Lesion ii. Osteochondral Allograft iii. Reverse McLaughlin

NOTES:

Shoulder & Humerus Review Safran, Page 6

ii. Whats NOT 1. Arthroscopic Stabilization for Bony defects (50) 2. Thermal Capsular Shrinkage (51) iii. CONTROVERSIAL 1. Surgery For First time anterior dislocator (52-54) 2. Sling Immobilization in ER a. MRI coaptation of Labrum to Glenoid by Subscapularis in ER (55) b. Benefit clinically Itoi studies (56, 57) c. Not reproduced in US Studies

b. Posterior instability
i. Not all patients have psychological issues

ii. Posterior Dislocation (58)

1. Whats HOT a. Must Get Orthogonal Views i. Axillary view ii. Velpeau Axillary b. 3D CT Scan For Full Evaluation of Bony Defects c. Treatment i. If acute closed reduction 1. Often associated with Posterior Bankart Lesion 2. Rehabilitation a. Strengthen Rotator Cuff b. Strengthen Scapular Stabilizers c. Proprioception training ii. If Recurrent & failed rehabilitation 1. Open or Arthroscopic posterior Bankart Repair iii. If subacute or chronic, avoid closed reduction 1. Open reduction iv. If Defect 20 45% of head 1. Consider McLaughlin 2. Osteochondral Allograft v. If Defect 50 60% 1. Hemiarthroplasty 2. If young, consider Osteochondral Allograft vi. If glenoid involvement and old patient, consider TSR 2. Whats NOT a. Early Surgery if not locked b. Thermal Shrinkage NOTES:

Shoulder & Humerus Review Safran, Page 7

iii. Posterior Subluxation

1. Whats HOT a. Positive jerk test, or load-and-shift test. (59) b. Kim Test c. Kim Lesion (60) d. Arthroscopic Posterior Bankart Repair (61-66) i. After Failed Rehab ii. Stability restored arthroscopically 88% to 100% of shoulders and a high rate of return to preinjury sporting activities (67% to 90%) 2. Whats NOT a. Early Surgery b. Open Posterior Capsulolabral repair c. Rotator Interval Closure

iv. Multidirectional instability

1. Whats HOT a. Rehabilitation is key (65,67) i. Make sure to evaluate scapular mechanics b. Outcomes of surgery, open or arthroscopic, less optimal as compared with anterior instability, even with newest techniques (65,67) c. Arthroscopic Capsular Plication (567,68) 2. Whats NOT a. Thermal Capsular Shrinkage (51,69) b. Rotator Interval Closure (68, 70)

5)

Glenohumeral Arthritis
a. Young Patient
i. Whats HOT 1. Arthroscopic Debridement (71, 72) 2. Arthroplasty with Short or No Stem (73) a. Cap b. Non-traditional short stem 3. Hemiarthroplasty with Interposition Graft (74) a. Meniscus b. Allograft / Autograft Fascia Lata c. Allograft Achilles d. Ream & Run (75)

NOTES:

Shoulder & Humerus Review Safran, Page 8

i. Whats NOT (76) 1. Resurfacing Glenoid with Cap arthroplasty a. Hard to Ream Concentrically b. Meniscus Allografts Do not Seem To Work well with Cap 2. Hemiarthroplasty a. Erosion of Glenoid Bone Stock b. Incomplete Pain Relief c. TSR Post HA not as good results 3. Total Shoulder Arthroplasty

b. Older Populations
i. Whats HOT 1. Total Shoulder (77, 78) a. Glenoid: All-poly, cemented (79) b. Press Fit Stem (80) 2. Prosthetic Infection a. Think Proprionabacter Acnes i. Slow to grow, keep cultures 14 days 3. Reverse Shoulder Replacement a. Cuff Arthropathy b. > 70 years old (35, 36, 81) ii. Whats NOT 1. Hemiarthroplasty (77, 78, 82) 2. Total Shoulder a. Metal Backed Glenoid (79) b. Cemented Stem NOTES:

Shoulder & Humerus Review Safran, Page 9

6)

Humerus Fractures
a. Proximal Humerus
i. Whats HOT 1. CT Scan Evaluation of Fracture Parts and Displacement (83) a. Radiographs with poor inter & intra-observer reliability 2. Treatment based on age and activity level of patient, comorbidities, bone quality and fracture type (84, 85) a. Salvage bone in young, active patients with good bone quality 3. Greater tuberosity fractures (86) a. More aggressive for surgical intervention i. Displacement ii. Secondary Impingement iii. Poorer results with osteotomy for malunion b. Repair if 5mm displacement / above level of apex of head, subacromial crowding c. Soft Tissue Fixation (suture through cuff insertion into tuberosity) with or without screw as post in cortical humeral bone 4. 2 and 3 part Fractures (85, 87, 88) a. Locking Plate (87) b. Suture Fixation (85) 5. Getting Greater Tuberosity Fracture To Heal 6. Knowledge of AVN Risk to determine viability of repair a. Anatomic neck fracture with (89) i. Posteromedial metaphyseal extension < 8 mm ii. Disruption of the medial hinge 1. Displacement of the humeral shaft > 2 mm iii. 97% PPV for humeral head ischemia 7. Hemiarthroplasty for 4 part fracture factors for success (90, 91) a. Anatomic humeral height i. Humeral prosthetic head should be placed approximately 3 to 5 mm above the tip of the anatomically reduced greater tuberosity fragment. b. Anatomic Humeral version i. Forearm is pointed straight ahead in neutral position and the humeral head is turned to face the glenoid Approximately 20 of retroversion relative to the transepicondylar axis of the elbow c. Anatomic Tuberosity reconstruction i. Tuberosities rigidly fixed with horizontal cerclage suture fixation around the medial neck of the prosthetic stem as well as with vertical tension-band suture fixation through drill holes in the humeral shaft d. Early Surgical Intervention (<4 weeks) (92)

NOTES:

Shoulder & Humerus Review Safran, Page 10

ii. Whats NOT 1. Non-operative treatment of Greater Tuberosity Fractures with > 5mm displacement 2. Treatment based solely on fracture pattern 3. Screw fixation of Greater Tuberosity 4. Percutaneous Pinning of proximal humerus fractures in elderly pts and 4 part fractures(93, 94) 5. Rush Rods 6. Hemiarthroplasty for < 4 part fractures (95, 96) 7. Delayed Surgery iii. CONTROVERSIAL 1. Closed reduction and Percutaneous Pinning 2. Locked External Fixaiton 3. Intrameduallary Rodding a. Rotator Cuff complaints and dysfunction 4. Reverse Shoulder Arthroplasty in Elderly (97)

b. Humeral Shaft
i. Whats HOT 1. Non-op Treatment (98) a. Most treated in coaptation splint, Velpeau dressing, cuff and collar or hanging arm cast. b. Convert to functional arm fracture brace c. Alignment considered acceptable (99) i. 20 of anterior angulation ii. 30 of varus angulation iii. 3 cm of shortening. 2. If Surgery: Method of choice: Locked Plating (100,101) a. Less Nerve Risk b. > 95% union 3. Management of Radial Nerve injury (102-104) a. If no radial nerve function from injury, does not affect management i. Transection of nerve may occur with open fracture ii. Closed fracture extremely rarely associated with transaction iii. Primary repair of radial nerve transaction from humeral shaft fracture no recovery b. If radial nerve intact and function lost due to manipulation (closed reduction and/or rodding), then need to explore nerve to ensure it is not entrapped. ii. Whats NOT 1. Intramedullary Rod Fixation (100,101) a. High incidence of shoulder stiffness and rotator cuff complaints, even after removal of nail NOTES:

Shoulder & Humerus Review Safran, Page 11

7)

SLAP Lesions
a. Whats HOT i. Physical Examination (105-107) 1. No 1 Clinical Examination is Diagnostic a. Assess for Glenohumeral Internal Rotation Deficit (GIRD) (16,17) i. Posterior Capsular Tightness b. Dynamic Shear Test ii. Mechanism of Injury 1. Peel Back (16 - 18) 2. Posterior capsular tightness leading to posterosuperior humeral head migration 3. Degenerative fraying from mechanical contact of labrum and rotator cuff iii. MRI arthrogram diagnostic tool of choice iv. Treatment of Type II (108-110) 1. Repair to Glenoid if < 40 years old 2. Tenodesis vs Leave Alone if > 40 b. Whats NOT i. Repair of SLAP in Older Patients (109) 1. ? Unrelated to symptoms ii. Need for Thermal Shrinkage Augmentation c. CONTROVERSIAL i. Type IV Tenotomy vs biceps repair ii. Repair of SLAP at same time as Rotator Cuff Repair and/or Subacromial Decompression - Risk Stiffness (109)

8)

Biceps
a. Whats HOT i. Arthroscopic Biceps Tenodesis (111 - 113) ii. Biceps tendon subluxation in to joint = Pathognomonic for Subscapularis tear b. Whats NOT i. Isolated Biceps Tendinitis as a Primary Pathology (113) ii. Biceps Tenotomy c. CONTROVERSIAL i. Role In Shoulder Function

9)

Adhesive Capsulitis
a. Whats HOT i. Rehabilitation ii. Focal Capsular Release of Isolated Area of Contraction (114,115) iii. Brisement b. Whats NOT i. Thermal Capsulotomy of Inferior Capsule ii. Early Surgery iii. Expecting Full Range of Motion regardless of treatment (116)

Shoulder & Humerus Review Safran, Page 12

10) Pain Management

a. Whats HOT i. Interscalene Blocks (117 - 119) 1. Indwelling Catheters b. Whats NOT i. Intra-articular Pain Pumps 1. Marcaine 2. Chondrotoxicity (120, 121)

Shoulder & Humerus Review Safran, Page 13

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69) Miniaci A, Codsi MJ.Thermal capsulorrhaphy for the treatment of shoulder instability. Am J Sports Med. 2006; 34(8): 1356-1363. 70) Provencher MT, Dewing CB, Bell SJ, McCormick F, Solomon DJ, Rooney TB, Stanley M An analysis of the rotator interval in patients with anterior, posterior, and multidirectional shoulder instability. Arthroscopy. 2008; 24(8): 921-929. 71) Safran MR, Baillargeon D: The Role of Arthroscopy in the Treatment of Glenohumeral Arthritis. Sports Med Arthrosc 12: 139145, 2004. 72) Richards DP, Burkhart SS. Arthroscopic debridement and capsular release for glenohumeral osteoarthritis. Arthroscopy. 2007; 23(9): 1019-22. 73) Levy O, Copeland SA. Cementless surface replacement arthroplasty (Copeland CSRA) for osteoarthritis of the shoulder. J Shoulder Elbow Surg. 2004; 13(3): 266-271. 74) Adams JE, Steinmann SP. Soft tissue interposition arthroplasty of the shoulder. J Shoulder Elbow Surg 2007;16(5 Suppl):S254-60. 75) Lynch JR, Franta AK, Montgomery WH Jr, Lenters TR, Mounce D, Matsen FA 3rd. Self-assessed outcome at two to four years after shoulder hemiarthroplasty with concentric glenoid reaming. J Bone Joint Surg Am. 2007; 89(6): 1284-1292. 76) Sperling JW, Steinmann SP, Cordasco FA, Henshaw DR, Coons DA, Burkhead WZ. Shoulder arthritis in the young adult: arthroscopy to arthroplasty. Instr Course Lect. 2006; 55: 67-74. 77) Bryant D, Litchfield R, Sandow M, Gartsman GM, Guyatt G, Kirkley A. A comparison of pain, strength, range of motion, and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder. A systematic review and meta-analysis. J Bone Joint Surg Am. 2005; 87(9): 1947-1956. 78) Edwards TB, Kadakia NR, Boulahia A, Kempf JF, Boileau P, Nmoz C, Walch G. A comparison of hemiarthroplasty and total shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: results of a multicenter study. J Shoulder Elbow Surg. 2003; 12(3): 207-213. 79) Taunton MJ, McIntosh AL, Sperling JW, Cofield RH. Total shoulder arthroplasty with a metal-backed, bone-ingrowth glenoid component. Medium to long-term results. J Bone Joint Surg Am. 2008; 90(10): 2180-2188 80) Norris TR, Iannotti JP: Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study. J Shoulder Elbow Surg. 2002; 11(2): 130-135. 81) Frankle M, Levy JC, Pupello D, Siegal S, Saleem A, Mighell M, Vasey M. The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. a minimum two-year follow-up study of sixty patients surgical technique. J Bone Joint Surg Am. 2006; 88 Suppl 1 Pt 2: 178-190. 82) Lo IK, Litchfield RB, Griffen S, Faber K, Patterson SD, Kirkley A: Quality of life outcome following hemiarthroplasty or total shoulder arthroplasty in patients with osteoarthritis: A prospective, randomized trial. J Bone Joint Surg Am 2005; 87: 2178-2185. 83) Robinson BC, Athwal GS, Sanchez-Sotelo J, Rispoli DM. Classification and imaging of proximal humerus fractures. Orthop Clin North Am. 2008; 39(4): 393-403. 84) Shrader MW, Sanchez-Sotelo J, Sperling JW, Rowland CM, Cofield RH. Understanding proximal humerus fractures: image analysis, classification, and treatment. J Shoulder Elbow Surg. 2005; 14(5): 497-505.

Shoulder & Humerus Review Safran, Page 15 85) Williams GR Jr, Wong KL. Two-part and three-part fractures: open reduction and internal fixation versus closed reduction and percutaneous pinning. Orthop Clin North Am. 2000; 31(1):1-21. 86) George MS Fractures of the greater tuberosity of the humerus. J Am Acad Orthop Surg. 2007; 15(10): 607-613. 87) Ring D. Current concepts in plate and screw fixation of osteoporotic proximal humerus fractures. Injury. 2007; 38 Suppl 3:S59-68. 88) Kitson J, Booth G, Day R A biomechanical comparison of locking plate and locking nail implants used for fractures of the proximal humerus. J Shoulder Elbow Surg. 2007; 16(3):362-6. 89) Hertel R, Hempfing A, Stiehler M, Leunig M: Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg 2004;13: 427-433. 90) Boileau P, Krishnan SG, Tinsi L, Walch G, Coste JS, Mole D: Tuberosity malposition and migration: Reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg 2002;11:401-412. 91) Frankle MA, Greenwald DP, Markee B, Ondrovic LE, Lee WE III: Biomechanical effects of malposition of tuberosity fragments on the humeral prosthetic reconstruction for four-part proximal humerus fractures. J Shoulder Elbow Surg 2001; 10: 321-326. 92) Bosch U, Skutek M, Fremerey RW, Tscherne H: Outcome after primary and secondary hemiarthroplasty in elderly patients with fractures of the proximal humerus. J Shoulder Elbow Surg 1998; 7: 479-484. 93) Fenichel I, Oran A, Burstein G, Perry Pritsch M. Percutaneous pinning using threaded pins as a treatment option for unstable twoand three-part fractures of the proximal humerus: a retrospective study. Int Orthop. 2006; 30(3): 153-157. 94) Calvo E, de Miguel I, de la Cruz JJ, Lpez-Martn N. Percutaneous fixation of displaced proximal humeral fractures: indications based on the correlation between clinical and radiographic results. J Shoulder Elbow Surg. 2007; 16(6):774-81. 95) Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br. 2008; 90(11):1407-13 96) Antua SA, Sperling JW, Cofield RH. Shoulder hemiarthroplasty for acute fractures of the proximal humerus: a minimum five-year follow-up. J Shoulder Elbow Surg. 2008; 17(2): 202-9. 97) Wall B, Walch G: Reverse shoulder arthroplasty for the treatment of proximal humeral fractures. Hand Clin. 2007 23: 42530. 98) Ekholm R, Tidermark J, Trnkvist H, Adami J, Ponzer S. Outcome after closed functional treatment of humeral shaft fractures. J Orthop Trauma. 2006; 20(9): 591-596. 99) Koch PP, Gross DF, Gerber C: The results of functional (Sarmiento) bracing of humeral shaft fractures. J Shoulder Elbow Surg 2002; 11: 143-150. 100) Bhandari M, Devereaux PJ, McKee MD, Schemitsch EH Compression plating versus intramedullary nailing of humeral shaft fractures--a meta-analysis. Acta Orthop. 2006; 77(2): 279-84. 101) Chapman JR, Henley MB, Agel J, Benca PJ. Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates. J Orthop Trauma. 2000;14(3):162-6.

102) Ekholm R, Ponzer S, Trnkvist H, Adami J, Tidermark J. The Holstein-Lewis humeral shaft fracture: aspects of radial nerve injury, primary treatment, and outcome. J Orthop Trauma 2008 22(10): 693-697. 103) Shah A, Jebson PJ Current treatment of radial nerve palsy following fracture of the humeral shaft. J Hand Surg 2008 33(A):1433-4. 104) Heckler MW, Bamberger HB Humeral shaft fractures and radial nerve palsy: to explore or not to explore...That is the question. Am J Orthop. 2008; 37(8): 415-419. 105) Pandya NK, Colton A, Webner D, Sennett B, Huffman GR. Physical examination and magnetic resonance imaging in the diagnosis of superior labrum anterior-posterior lesions of the shoulder: a sensitivity analysis. Arthroscopy. 2008;24(3):311-7. 106) Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT 3rd, Cook C. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med. 2008; 42(2): 80-92. 107) Jones GL, Galluch DB. Clinical assessment of superior glenoid labral lesions: a systematic review. Clin Orthop Relat Res. 2007 455: 45-51. 108) Barber FA, Field LD, Ryu RK. Biceps tendon and superior labrum injuries:decision making. Instr Course Lec 2008;57:527-38. 109) Franceschi F, Longo UG, Ruzzini L, Rizzello G, Maffulli N, Denaro V. No advantages in repairing a type II superior labrum anterior and posterior (SLAP) lesion when associated with rotator cuff repair in patients over age 50: a randomized controlled trial. Am J Sports Med. 2008; 36(2): 247-253. 110) Park HB, Lin SK, Yokota A, McFarland EG Return to play for rotator cuff injuries and superior labrum anterior posterior (SLAP) lesions. Clin Sports Med. 2004; 23(3): 321-334. 111) Frost A, Zafar MS, Maffulli N Tenotomy versus tenodesis in the management of pathologic lesions of the tendon of the long head of the biceps brachii. Am J Sports Med. 2009; 37(4): 828-833

Shoulder & Humerus Review Safran, Page 16 112) Wolf RS, Zheng N, Weichel D. Long head biceps tenotomy versus tenodesis: a cadaveric biomechanical analysis. Arthroscopy. 2005; 21(2): 182-185. 113) Friedman DJ, Dunn JC, Higgins LD, Warner JJ Proximal biceps tendon: injuries and management. Sports Med Arthrosc. 2008; 16(3): 162-169. 114) Beaufils P, Prvot N, Boyer T, Allard M, Dorfmann H, Frank A, Kelbrine F, Kempf JF, Mol D, Walch G. Arthroscopic release of the glenohumeral joint in shoulder stiffness: a review of 26 cases. French Society for Arthroscopy. Arthroscopy. 1999; 15(1): 49-55 115) Ticker JB, Beim GM, Warner JJ Recognition and treatment of refractory posterior capsular contracture of the shoulder. Arthroscopy. 2000; 16(1): 27-34. 116) Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. A longterm follow-up. J Bone Joint Surg Am. 1992; 74(5): 738-746. 117) Fredrickson M, Borgeat A. Continuous interscalene block is preferable to the 'shoulder block' for postoperative analgesia following shoulder surgery. Anaesth Intensive Care 2008 36:11920. 118) Beaudet V, Williams SR, Ttreault P, Perrault MA. Perioperative interscalene block versus intra-articular injection of local anesthetics for postoperative analgesia in shoulder surgery. Reg Anesth Pain Med. 2008; 33(2): 134-138. 119) Bryan NA, Swenson JD, Greis PE, Burks RT Indwelling interscalene catheter use in an outpatient setting for shoulder surgery: technique, efficacy, and complications. J Shoulder Elbow Surg. 2007; 16(4): 388-395. 120) Dragoo JL, Korotkova T, Kanwar R, Wood B. The effect of local anesthetics administered via pain pump on chondrocyte viability. Am J Sports Med. 2008; 36(8): 1484-1488. 121) Gomoll AH, Yanke AB, Kang RW, Chubinskaya S, Williams JM, Bach BR, Cole BJ. Long-term effects of Bupivacaine on cartilage in a rabbit shoulder model. Am J Sports Med 2009; 37(1): 72 - 77

Pediatrics

PediatricOrthopaedics Moderator:LoriA.Karol,MD 12:50 PM HipProblemsinChildren WilliamC.WarnerJr.,MD 1:20PM Infection/Congenital and DevelopmentalProblems/Miscellaneous JeffreyR.Sawyer,MD 1:50PM FracturesoftheUpperandLower Extremities JohnM.Flynn,MD 2:20 PM LowerExtremityProblemsin Children LoriA.Karol,MD

PEDIATRIC HIP REVIEW W. C. WARNER, JR. CAMPBELL CLINIC

DEVELOPMENTAL DYSPLASIA OF THE HIP

Definition DDH is a spectrum of disorders in the developing hip joint. Name changed from CDH to DDH to reflect spectrum of disease Terminology o Dysplasia shallow or underdeveloped acetabulum o Subluxation femoral head can be partially displaced from acetabulum o Dislocatble femoral head can be displaced from acetabulum with stress but can be easily relocated o Dislocation femoral head is completely displaced from acetabulum o Teratologic dislocation are dislocated in utero an is not reducible on neonatal examination. These hip are stiff and have limited range of motion

Growth and Development of Hip Acetabulum and proximal femur develops from 1 cartilage 11th week hip joint is formed Proximal femur o One growth plate that develops into 3 main components 1. Physeal plate of femoral head 2. Growth plate of Greater trochanter 3. Femoral neck isthmus growth plate Largest determinant of actetabular development reduced femoral head Neolimbus o Hypertrophied ridge of acetabular cartilage in the superior, posterior and inferior aspect of the acetabulum Accessory center of Ossification o Present in only 2 to 3% of normal hips o Present in 60% of pts treated for DDH

Incidence o Dyspalsia of the hip or some form of instability of the hip 1 in 100 births o True hip dislocations 1 to 2 in 1000 births o Reported incidence of late dislocations is 4 per 10,000 births o 2% of all hip dislocations are Teratologic Risk Factors 1. Breech presentation a. Only 2-4% of deliveries are breech but of DDH cases 17%-20% are breech presentation b. 1 out of 15 girls with Breech presentation had DDH 2. Female a. 80% of DDH cases female b. Other report a 6:1 ratio of female: male 3. Family History a. + family Hx. In 12% to 33% b. risk of subsequent pregnancies i. 6% neither parent has DDH ii. 12% when one parent had DDH iii. 36% when both parents had DDH 4. Ethnic Background a. Increase in native Americans b. Decrease in African descent 5. First born increased incidence 6. Oligohydramnios 7. Packing syndrome a. Torticollis b. Metatarsus adductus 8. Left hip more commonly dislocated a. Due to left hip against sacrum in the most common presentation Diagnosis CLICK vs., CLUNK Early Diagnosis 1. Ortalani positive 2. Barlow positive Late Diagnosis 1. Galeazzi positive 2. Adduction contracture 3. Asymmetric skin folds Diagnostic imaging Ultrasound 2 methods

1. Morphologic assessment 2. Dynamic assessment Morphologic assessment < 4 months of age 1. Alpha angle measurement of slope of the superior part of the bony acetabulum 2. Beta angle evaluates the cartilaginous component of the acetabulum 3. % acetabular coverage of the femoral head 4 to 6 weeks of age alpha angle is 60 degrees beta angle is < 55 degrees Dynamic assessment Joint evaluated while being stressed with a Barlow and Ortolani maneuvers Instability is measured by displacement of the femoral head from acetabulum Clarke found in high-risk infants the use of U/S did not decrease the incidence of late presentation of DDH Plain radiographs Ossific nucleus does not appear until about 4 - 6 months of age Radiographic measurements Acetabular index Shenton line Delayed ossification of femoral head Perkins line Center edge angle Arthrography Useful in assessment of an adequate reduction Medial joint fluid Thorn sign Cartilaginous coverage CT Scan Role in assessment of reduction post op Define anatomy of acetabular dysplasia MRI role still evolving

Obstacles to Reduction 1. Muscle a. Psoas muscle b. Adductor longus muscle 2. Ligamentum teres 3. Transverse acetabular ligament 4. Constricted joint capsule 5. ? inverted labrum more likely the Neolimbus

Natural History Newborn variable but tendency to stabilize o Barlow reported that 1- 60 unstable o 60% stabilize in 1 week o 88% stabilize in 1 - 2 months Adult o If false acetabulum present 24% have good result o If no false acetabulum - >50% good results Treatment Pavlik Harness 95% effective in Ortolani positive hips if worn for 6 weeks Incidence of osteonecrosis is <5% Contraindications o Neuromuscular o Teratologic Effectiveness decreases with age Harness is not effective in children > 6 months of age Risk factors for adverse outcome of the harness o Ortaloni negative o Bilateral o Age > 7 weeks start of treatment o U/S with less that 20% coverage will not have a successful outcome with harness 2-3 % treated successfully in harness will have residual acetabular dysplasia Pavlik harness disease o Failure of harness after 6 weeks Proper application of harness o Ant straps o Posterior straps o Chest straps Complication of harness o Inferior dislocation o Femoral nerve palsy o Brachial plexus palsy o Skin problems Closed reduction Traction ? of benefit o Gage and Winter o Schoenecker o Kutil Closed reduction

Safe Zone o Is 15 degrees less that the limits of motion defined as the stable zone Adequacy of reduction by arthrogram o Less than 5 mm of medial contrast o No interposed limbus Cast immobilization for 12 weeks

Open reduction 6month to 2 years of age AVN and presence of ossific nucleus o Pro o Con Anterior approach Ferguson approach o Between adductor brevis and adductor magnus Anterior Medial approach o Between femoral neurovascular bundle and pectineus muscle Pros and Cons of different approaches Potential for acetabular remodeling is up to 4 to 8 years of age Open reduction - > 2 years of age 2 to 3 years is grey area for need of femoral shortening > 3years of age will need a femoral shortening ? When an acetabular procedure should be done Proximal femoral osteotomies Role of proximal femoral osteotomy o Must be <4 years to expect acetabular remodeling Pelvic Osteotomy For rotational osteotomy 1. Concentric reduction 2. Release of muscle contractures 3. Congruous hip joint 4. Good range of motion 4 types of osteotomies o Redirectional osteotomy Salter Most likely to succed if CE angle > 10 degrees Sutherland Tonis/Steele Ganz Wagner/Eppright o Acetabularplasties Pemberton Dega

o Reconstructive by placing Bone over hip joint capsule Chiari Shelf o Hybrid Salter + shelf

SLIPPED CAPITAL FEMORAL EPIPHPYSIS

Definition Displacement of the femoral head relative to the femoral neck and shaft Epidemiology Male > female 1.4 :1 or 2:1 male:female ratio Annual incidence is 2 to 13 per 100,000 Risk o Male is 1 per 1000 to 1 per 2000 o Female is 1 per 2000 to 1per 3000 Increased incidence with higher mean body weight Most SCFE occur in the peripubertal period o Male 13.5 years of age o Female 12 years of age Obesity is reported in 51% to 77% of SCFE o 50% will be > 90th percentile in wt. o 70% will be > 80th percentile in body wt. Etiology mechanical insufficiency of the proximal femoral physis to resist the load across it Lab studies o Testosterone weaken physis o Estrogen Strengthens physis Endocrinopathies account for 5-8% of SCFE Most common causes of Endocrinopathies o Hypothyroidism o Panhypopituitarism o Growth Hormone abnormalities o Hypogonadism Increased prevalence of hypothyroidism in Downs Syndrome patients explains increased risk of SCFE in Downss pts. Indications for endocrine work-up in SCFE o <10 years of age o > 15 years of age o < 10th percentile for height (short stature)

Other systemic disease o Radiation therapy o Renal Osteodystrophy Have a six fold to eightfold increased risk of SCFE Highest in patients on dialysis and receiving GH Due to secondary hyperparathyroidism Often will slip through metaphysis and not the physis Immunology o ? Findings o ? Association with chondrolysis Genetics o 3 to 7% of cases have a second member of family affected Mechanical factors o Possible association with decreased femoral anteversion or femoral retroversion o Chung reported the mechanical forces across the femoral head during gait can be 6.5 time body and that such forces may be enough to cause a SCFE in an obese patient with a normal physis

Classification two classification systems Based on time o Acute Symptoms less than 3 week o Chronic Symptoms > 3 weeks o Acute on chronic Acute exacerbation of symptoms that have been present for > 3 weeks o Preslip Symptomatic hip with evidence of physiolysis prior to true movement of the femoral neck to the femoral head o Acute slip had a AVN rate of 10 -15 % Based on Stability o Unstable Slip only 5 to 10% of slips Unable to bear weight with or without crutches o Stable Slip Able to bear weight o Unstable slips had a 47% incidence of AVN o Stable slip had a 0% incidence of AVN Presentation Pain o Groin pain o Often referred pain to knee or distal thigh 23 to 46% of cases Limp o Antalgic limp

o Trendelenburg gait Decreased range of motion o Decreased flexion and extension o Decreased abduction o Loss of internal rotation o Obligate external rotation of hip on flexion

Radiographic Evaluation AP and Lateral views Must always image both hips (20% bilateral) AP view o Widening and irregularity of physis o Decreased height of the capital femoral epiphysis o Metaphyseal Blanch - increased radiodensity of the proximal metaphysis o Kleins Line o Cowell noted that displacement may not be evident in 14% of the AP radiographs Lateral view o Cross table vs. frog leg later Degree of slip o Mild less than 33% o Moderate 33- 50 % o Severe > 50 % Other Imaging methods o CT scan Useful to determine if there is physeal closure and anatomy of slip Detection of Pin penetration o Ultrasound of little benefit o MRI Pre slip Physeal widening Edema Evaluation of AVN o Bone scan Evaluation of AVN Pathoanatomy Have disorganization of Proliferative and hypertrophies zone o The hypertrophic zone is much larger than usual 80% of the physeal width compared to the normal 15 to 30% of physeal width SCFE occurs through the proliferative and hypertrophic zones of the physis Once slip is stabilized the pathologic changes seen in the physis will return to normal architecture

Natural History 20% will have bilateral slips at time of presentation a reported additional 10 to 20% will have a contralateral SCFE after diagnosis of SCFE The true frequency of Bilateral SCFE at long term follow up appears to be approximately 60% From this data, then of the 80% of pts. who present with a unilateral SCFE will ultimately have a contralateral SCFE Contralateral slip occurs it within 18 months of the diagnosis of the first slip. Pts. With endocrinopathies - will have bilateral slips in 61 to 100% of the cases. Therefore the recommendation to do prophylactic pinning Longer term SCFE puts the hip at significant risk of Osteoarthritis Treatment Goals of treatment Early detection Prevention of further slipping Avoidance of complications. Manipulation No role for forceful manipulation in the treatment of SCFE A serendipitous reduction with patient positioning does not appear to negatively affect outcome Spica cast Associated with high complication rates o Chondrolysis Reported in 14 to 53% of cases o AVN o Progressive slip 5 to 18% of cases Immobilization was for 3 to 4 months In Situ Fixation Goal - to prevent slip progression Fracture table vs. radiolucent table Inadvertent reduction do not appear to cause AVN Unrecognized pin penetration blind spot Approach withdraw phenomenon described by Moseley Center-center pins are left 5 go 6 mm from subchondral bone, pins that are not center-center should be at lest 10 mm from subcondral bone Posterior and superior portion of the femoral neck and head should be avoided o Risk of compromise of the intraosseous blood supply Single vs. two screws Stable vs. unstable

Physeal closure generally occurs within 6 to 12 months following in situ fixation Complication o AVN More common in unstable slips Role of aspiration or capsular decompression Treatment within 24 hour May be beneficial in unstable slips o Chondrolysis Persistent pin penetration Location above fovea o Progressive slip o Growing off the screw o Proximal femur fracture o Leg length inequality o Impingement o Osteoarthritis Screw removal not routinely recommended

Bone graft epiphysiodesis Role of bone graft epiphysiodesis is to hastening the physeal closure Physeal closures occurs at 4 to 6 months Is an alternative to in situ pinning but is not recommended as primary treatment Proximal Femoral Osteotomy Early vs. Late Location o Subcapital o Femoral neck o Intertrochanteric Subcapital o Gives greatest correction o High rates of AVN Femoral neck o Less power of correction but also has less AVN o Osteotomy may be intracapsular or extracapsular Intertrochanteric osteotomy o Southwick Valgus, flexion and internal rotation o Imhauser Flexion and internal rotation o Greatest correction but not anatomic Trantrochanteric rotational osteotomy o Sugioka o High complication rate Femoral neck Osteoplasty

Indicated for impingement

Complications Long term studies of untreated slips o Carney Weinstein o Ordeberg Osteoarthritis o Appears to be a universal sequela of both treated an untreated SCFE because of biomechanical derangement of the hip joint o Hagglund noted that no hip with a mild to moderate slip treated with in situ pinning developed arthritis before 50 years of age o 2 to 9% of those with end stage OA have been reported to have a history of SCFE AVN o Canale paper long term follow up of AVN in slip 38% had salvage procedures Remaining 42% had osteoarthritis Chondrolysis o Hip is usually held in abduction o Joint space narrowing o Premature closure of trochanteric apophysis Decreased bone scan activity in trochanter in 47 % of affected hips Salvage Procedures Hip arthroplasty Hip arthrodesis o Back pain 57% o Ipsilateral knee pain 45% -57% o Contralateral hip pain in 17 -27% o Conversion to THA in 13-21% Redirectional osteotomy

Legg-Calve-Perthes Disease
Definition is osteonecrosis of the femoral head in children Epidemiology Age ranges 4 to 8 years o Reported cases as young as 2 years of age and in late teenagers Male: Female ratio o 4:1 to 5:1

Bilateral in 10 to 12% More common in o Urban areas o ADHD pts o Skeletal age lagged behind chronological age 89% had delayed bone age Average delay in skeletal maturity was 21 months but tended to catch up in the healing phase o Shorter in stature Male 1 inch shorter Females 3 inches shorter compared to healthy children Potential abnormalities with Somatodmedin C insulin like growth factor 1 (IGF1) o Associated with regulation of growth hormone

Etiology Historical proposed etiologies o Infection Aseptic TB Viral Rubella o Trauma o Congenital o Hormonal Hypothyroid IGF1 deficiency o Transient Synovitis o Mechanical Increase femoral neck anterversion Most accepted etiologic theories vascular embarrassment to the femoral head o Incomplete anastomotic network between medial and lateral femoral circumflex arteries o Double infarction theory o Increased blood viscosity o Thrombophilia induced by low levels of protein C or Protein S Pro Con Pathogenesis Data suggest that Perthes disease is a generalized process affecting other epiphyses o Irregular ossification of other epiphyses o Increased association with Kohlers disease May be a localized manifestation of a generalized disorder of epiphyseal cartilage in the susceptible child

Radiographic Stages Initial o Failure of femoral ossific nucleus to increase in size o Widening of the medial joint space o Radiodense ossific nucleus o Physeal plate irregularity Fragmentation o Crescent sign o Fragmentation with areas of increase radiodensity and increased radiolucency Reossification o Radiographic normal bone returns to areas that were previously radiolucent Healed Patterns of deformity Coax magna Premature physeal arrest patterns o Central arrest o Lateral arrest Irregular femoral head formation Osteochondritis dissecans o Only 3% incidence Natural history Caterall 97 untreated pts using grading system of Sundt o Group 1 and 2 92% good results o Group 3 and 4 91 % poor results 20 to 30 year follow up o 80 to 85 % pain free o Only 40 to 33% have normal radiographs 40 year follow up o 40% had undergone THA o 10% had disabling OA

Prognostic factors Residual head deformity and hip joint incongruity - most important prognostic factor o Stulberg classification Class 1 normal hip Class 2 spherical but coax magna Class 3 Mushroom shaped but not flat Class 4 flat head and abnormal acetabulum

Class 5 flat head and normal acetabulum Class 5 deteriorate by 4th decade Class 4 and 3 deteriorate by 5th and 6th decade The more out of round the femoral head the greater chance of early DJD o Catterall classification 90 % good results in Group 1 and 2 90% poor results in group 3 and 4 Takes up to 8 months for hip to be far enough into the fragmentation phase to show the extent of epiphyseal involvement o Salter and Thompson Extent of subchondral fracture line Group A < 50% Group B > 50% o Herring Classification Lateral pillar of femoral head on AP radiographs Type A no involvement of lateral pilar Type B - > 50% of lateral pilar preserved Type C - < 50 % of lateral pilar preserved o Head at risk signs Gages sign radiolucency in the lateral epiphysis and metaphysis Lateral calcification Metaphyseal lesions Lateral subluxation Horizontal growth plate o Duration of disease is related to the extent of epiphyseal involvement o Poorer prognosis in girls than boys Age of onset of the disease is the second most significant factor o Age at healing is probably a more important factor o The more immature the patient at the time of entering the reossification stage the greater potential for remodeling Physeal arrest o 90% have some physeal involvement o 25% have premature physeal closure 33% of hips will show some improvement in anatomical grade Once reossification stage there should not be any further femoral head deformity

Clinical Presentation Insidious onset of a limp Pain with activity and relieved with rest Pain localized to groin or referred to anterior medial thigh or ant knee Physical exam Limited hip range of motion o Abduction o Internal rotation Trendelenburg test

 Limb length inequality Imaging Plain radiographs o AP and frog lateral Bone scan MRI Arthrography CT scan Differential diagnosis Infection Bilateral involvement o Multiple epiphyseal dysplasia o Hypothyroidism Meyer dysplasia o Benign self resolving condition in children younger than 4 years of age Treatment Treatment is considered only for those patient who have an otherwise known poor prognosis based on prognostic factors o No treatment needed in pts. With good prognosis Catterall I Salter Thompson type A Lateral pillar type A disease The two most important prognostic factors are o Deformity of the femoral head o Age of the patient Cornerstone of treatment is containment o Containment is an attempt to reduce the forces through the hip joint by actual or relative varus positioning Femoral head represents more than of the sphere and the acetabulum only of the sphere First principle of treatment is to restoration of motion o Bed rest at home o Nonsteroidal anti-inflammatory drugs o Home traction o Abduction cast o Physical therapy o Crutches o Adductor tenotomy Nonoperative treatment o Braces ? Benefit o Petrie cast May be used as temporary method to regain motion Surgical treatment - hip must be containable (relative full range of motion, congruent)

o Varus osteotomy Should not exceed a neck shaft angle of less than 110 degree Limb shortening o Innominate osteotomy Persistent acetabular configuration change in a previously normal acetabulum Loss of flexion ? Increase pressure on femoral head o Combined procedure varus and innominate osteotomy o Shelf arthroplasty o Triple Innominate osteotomy o Arthordiastasis Treatment of Noncontainable hip and late present pt with deformity o Abduction extension osteotomy o Shelf arthroplasty o Chiari osteotomy o Cheilectomy

Femoral Acetabular Impingement

Source of hip pain with subtle abnormalities on radiographs Abnormal contact between femoral neck and acetabular rim during terminal motion of the hip Abnormal contact leads to labral pathology and adjacent chondral lesions 2 types of femoral acetabular impingement Cam Type Pincer Type Cam Type Impingement from abnormal shaped femoral head (ex. Slipped Epiphysis) that abuts the acetabular rim Have separation of labrum and cartilage in the anterior superior portion of the acetabulum Pincer Type Have normal femoral head Have abnormal contact between acetabulum and femoral neck that is due to overcoverage of the acetabulum (ex Acetabular retroversion) Have lesions in o Anterior superior labrum o Femoral neck o Countrecoupe lesion posterior inferior acetabulum History Intermittent groin pain Pain after physical activity Pain after prolonged sitting

Physical exam Impingement test o Pain on internal rotation, adduction and flexion of hip Grab sign Radiographs True AP pelvis o Coccyx points at symphysis pubis with a distance of 1 to 2 cm between them o Cross over sign o Femoral head deformity o Cystic changes in femoral neck and acetabulum Lateral of hip o Evaluate femoral head deformity MRI arthrogram with gadolinium Treatment Nonsurgical treatment usually ineffective Surgical treatment o Surgical dislocation of hip o Arthroscopy

References
DDH
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Albinana, J.; Dolan, L. A.; Spratt, K. F.; Morcuende, J.; Meyer, M. D.; and Weinstein, S. L.: Acetabular dysplasia after treatment for developmental dysplasia of the hip. Implications for secondary procedures. J Bone Joint Surg Br, 86(6): 876-86, 2004. Bohm, P., and Brzuske, A.: Salter innominate osteotomy for the treatment of developmental dysplasia of the hip in children: results of seventy-three consecutive osteotomies after twenty-six to thirty-five years of follow-up. J Bone Joint Surg Am, 84-A(2): 178-86, 2002. Castelein, R. M., and Korte, J.: Limited hip abduction in the infant. J Pediatr Orthop, 21(5): 668-70, 2001. Chmielewski, J., and Albinana, J.: Failures of open reduction in developmental dislocation of the hip. J Pediatr Orthop B, 11(4): 284-9, 2002. Grudziak, J. S., and Ward, W. T.: Dega osteotomy for the treatment of congenital dysplasia of the hip. J Bone Joint Surg Am, 83-A(6): 845-54, 2001. Hedequist, D.; Kasser, J.; and Emans, J.: Use of an abduction brace for developmental dysplasia of the hip after failure of Pavlik harness use. J Pediatr Orthop, 23(2): 175-7, 2003.

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Ito, H.; Matsuno, T.; and Minami, A.: Chiari pelvic osteotomy for advanced osteoarthritis in patients with hip dysplasia. J Bone Joint Surg Am, 86-A(7): 1439-45, 2004. Lorente Molto, F. J.; Gregori, A. M.; Casas, L. M.; and Perales, V. M.: Three-year prospective study of developmental dysplasia of the hip at birth: should all dislocated or dislocatable hips be treated? J Pediatr Orthop, 22(5): 613-21, 2002. Luhmann, S. J.; Bassett, G. S.; Gordon, J. E.; Schootman, M.; and Schoenecker, P. L.: Reduction of a dislocation of the hip due to developmental dysplasia. Implications for the need for future surgery. J Bone Joint Surg Am, 85-A(2): 239-43, 2003. Mladenov, K.; Dora, C.; Wicart, P.; and Seringe, R.: Natural history of hips with borderline acetabular index and acetabular dysplasia in infants. J Pediatr Orthop, 22(5): 607-12, 2002. Paton, R. W.; Hossain, S.; and Eccles, K.: Eight-year prospective targeted ultrasound screening program for instability and at-risk hip joints in developmental dysplasia of the hip. J Pediatr Orthop, 22(3): 338-41, 2002. Roovers, E. A.; Boere-Boonekamp, M. M.; Mostert, A. K.; Castelein, R. M.; Zielhuis, G. A.; and Kerkhoff, T. H.: The natural history of developmental dysplasia of the hip: sonographic findings in infants of 1-3 months of age. J Pediatr Orthop B, 14(5): 325-30, 2005. Shipman, S. A.; Helfand, M.; Moyer, V. A.; and Yawn, B. P.: Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics, 117(3): e557-76, 2006. Tien, Y. C.; Su, J. Y.; Lin, G. T.; and Lin, S. Y.: Ultrasonographic study of the coexistence of muscular torticollis and dysplasia of the hip. J Pediatr Orthop, 21(3): 343-7, 2001. Vengust, R.; Antolic, V.; and Srakar, F.: Salter osteotomy for treatment of acetabular dysplasia in developmental dysplasia of the hip in patients under 10 years. J Pediatr Orthop B, 10(1): 30-6, 2001. Weinstein, S. L.; Mubarak, S. J.; and Wenger, D. R.: Developmental hip dysplasia and dislocation: Part I. Instr Course Lect, 53: 523-30, 2004. Weinstein, S. L.; Mubarak, S. J.; and Wenger, D. R.: Developmental hip dysplasia and dislocation: Part II. Instr Course Lect, 53: 531-42, 2004. Wenger, D. E.; Kendell, K. R.; Miner, M. R.; and Trousdale, R. T.: Acetabular labral tears rarely occur in the absence of bony abnormalities. Clin Orthop Relat Res, (426): 145-50, 2004. Westberry, D. E.; Davids, J. R.; and Pugh, L. I.: Clubfoot and developmental dysplasia of the hip: value of screening hip radiographs in children with clubfoot. J Pediatr Orthop, 23(4): 503-7, 2003. Wirth, T.; Stratmann, L.; and Hinrichs, F.: Evolution of late presenting developmental dysplasia of the hip and associated surgical procedures after 14 years of neonatal ultrasound screening. J Bone Joint Surg Br, 86(4): 585-9, 2004.

Slipped Capital Femoral Epiphysis

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Barrios, C.; Blasco, M. A.; Blasco, M. C.; and Gasco, J.: Posterior sloping angle of the capital femoral physis: a predictor of bilaterality in slipped capital femoral epiphysis. J Pediatr Orthop, 25(4): 445-9, 2005. Carney, B. T.; Birnbaum, P.; and Minter, C.: Slip progression after in situ single screw fixation for stable slipped capital femoral epiphysis. J Pediatr Orthop, 23(5): 584-9, 2003. Carney, B. T.; Weinstein, S. L.; and Noble, J.: Long-term follow-up of slipped capital femoral epiphysis. J Bone Joint Surg Am, 73(5): 667-74, 1991. Chung, S. M.; Batterman, S. C.; and Brighton, C. T.: Shear strength of the human femoral capital epiphyseal plate. J Bone Joint Surg Am, 58(1): 94-103, 1976. Dewnany, G., and Radford, P.: Prophylactic contralateral fixation in slipped upper femoral epiphysis: is it safe? J Pediatr Orthop B, 14(6): 429-33, 2005. Gordon, J. E.; Abrahams, M. S.; Dobbs, M. B.; Luhmann, S. J.; and Schoenecker, P. L.: Early reduction, arthrotomy, and cannulated screw fixation in unstable slipped capital femoral epiphysis treatment. J Pediatr Orthop, 22(3): 352-8, 2002. Hagglund, G.: The contralateral hip in slipped capital femoral epiphysis. J Pediatr Orthop B, 5(3): 158-61, 1996. Kennedy, J. G.; Hresko, M. T.; Kasser, J. R.; Shrock, K. B.; Zurakowski, D.; Waters, P. M.; and Millis, M. B.: Osteonecrosis of the femoral head associated with slipped capital femoral epiphysis. J Pediatr Orthop, 21(2): 189-93, 2001. Kenny, P.; Higgins, T.; Sedhom, M.; Dowling, F.; Moore, D. P.; and Fogarty, E. E.: Slipped upper femoral epiphysis. A retrospective, clinical and radiological study of fixation with a single screw. J Pediatr Orthop B, 12(2): 97-9, 2003. Kocher, M. S.; Bishop, J. A.; Hresko, M. T.; Millis, M. B.; Kim, Y. J.; and Kasser, J. R.: Prophylactic pinning of the contralateral hip after unilateral slipped capital femoral epiphysis. J Bone Joint Surg Am, 86-A(12): 2658-65, 2004. Kocher, M. S.; Bishop, J. A.; Weed, B.; Hresko, M. T.; Millis, M. B.; Kim, Y. J.; and Kasser, J. R.: Delay in diagnosis of slipped capital femoral epiphysis. Pediatrics, 113(4): e322-5, 2004. Krahn, T. H.; Canale, S. T.; Beaty, J. H.; Warner, W. C.; and Lourenco, P.: Long-term follow-up of patients with avascular necrosis after treatment of slipped capital femoral epiphysis. J Pediatr Orthop, 13(2): 154-8, 1993. Loder, R. T.: Unstable slipped capital femoral epiphysis. J Pediatr Orthop, 21(5): 694-9, 2001. Loder, R. T.; Starnes, T.; and Dikos, G.: Atypical and typical (idiopathic) slipped capital femoral epiphysis. Reconfirmation of the age-weight test and description of the height and age-height tests. J Bone Joint Surg Am, 88(7): 1574-81, 2006.

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Loder, R. T.; Starnes, T.; and Dikos, G.: The narrow window of bone age in children with slipped capital femoral epiphysis: a reassessment one decade later. J Pediatr Orthop, 26(3): 300-6, 2006. Loder, R. T.; Starnes, T.; Dikos, G.; and Aronsson, D. D.: Demographic predictors of severity of stable slipped capital femoral epiphyses. J Bone Joint Surg Am, 88(1): 97-105, 2006. Maeda, S.; Kita, A.; Funayama, K.; and Kokubun, S.: Vascular supply to slipped capital femoral epiphysis. J Pediatr Orthop, 21(5): 664-7, 2001. Mooney, J. F., 3rd; Sanders, J. O.; Browne, R. H.; Anderson, D. J.; Jofe, M.; Feldman, D.; and Raney, E. M.: Management of unstable/acute slipped capital femoral epiphysis: results of a survey of the POSNA membership. J Pediatr Orthop, 25(2): 162-6, 2005. Ordeberg, G.; Hansson, L. I.; and Sandstrom, S.: Slipped capital femoral epiphysis in southern Sweden. Long-term result with no treatment or symptomatic primary treatment. Clin Orthop Relat Res, (191): 95-104, 1984. Poussa, M.; Schlenzka, D.; and Yrjonen, T.: Body mass index and slipped capital femoral epiphysis. J Pediatr Orthop B, 12(6): 369-71, 2003. Puylaert, D.; Dimeglio, A.; and Bentahar, T.: Staging puberty in slipped capital femoral epiphysis: importance of the triradiate cartilage. J Pediatr Orthop, 24(2): 144-7, 2004. Sanders, J. O.; Smith, W. J.; Stanley, E. A.; Bueche, M. J.; Karol, L. A.; and Chambers, H. G.: Progressive slippage after pinning for slipped capital femoral epiphysis. J Pediatr Orthop, 22(2): 239-43, 2002. Schultz, W. R.; Weinstein, J. N.; Weinstein, S. L.; and Smith, B. G.: Prophylactic pinning of the contralateral hip in slipped capital femoral epiphysis : evaluation of long-term outcome for the contralateral hip with use of decision analysis. J Bone Joint Surg Am, 84-A(8): 1305-14, 2002. Seller, K.; Raab, P.; Wild, A.; and Krauspe, R.: Risk-benefit analysis of prophylactic pinning in slipped capital femoral epiphysis. J Pediatr Orthop B, 10(3): 192-6, 2001. Tokmakova, K. P.; Stanton, R. P.; and Mason, D. E.: Factors influencing the development of osteonecrosis in patients treated for slipped capital femoral epiphysis. J Bone Joint Surg Am, 85-A(5): 798-801, 2003.

Perthes Disease
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Aksoy, M. C.; Caglar, O.; Yazici, M.; and Alpaslan, A. M.: Comparison between braced and non-braced Legg-Calve-Perthes-disease patients: a radiological outcome study. J Pediatr Orthop B, 13(3): 153-7, 2004. Balasa, V. V.; Gruppo, R. A.; Glueck, C. J.; Wang, P.; Roy, D. R.; Wall, E. J.; Mehlman, C. T.; and Crawford, A. H.: Legg-Calve-Perthes disease and thrombophilia. J Bone Joint Surg Am, 86-A(12): 2642-7, 2004.

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Bennett, J. T.; Stuecker, R.; Smith, E.; Winder, C.; and Rice, J.: Arthrographic findings in Legg-Calve-Perthes disease. J Pediatr Orthop B, 11(2): 110-6, 2002. Carney, B. T., and Minter, C. L.: Nonsurgical treatment to regain hip abduction motion in Perthes disease: a retrospective review. South Med J, 97(5): 485-8, 2004. Catterall, A.: The natural history of Perthes' disease. J Bone Joint Surg Br, 53(1): 37-53, 1971. Gigante, C.; Frizziero, P.; and Turra, S.: Prognostic value of Catterall and Herring classification in Legg-Calve-Perthes disease: follow-up to skeletal maturity of 32 patients. J Pediatr Orthop, 22(3): 345-9, 2002. Guille, J. T.; Lipton, G. E.; Tsirikos, A. I.; and Bowen, J. R.: Bilateral LeggCalve-Perthes disease: presentation and outcome. J Pediatr Orthop, 22(4): 458-63, 2002. Herring, J. A.; Kim, H. T.; and Browne, R.: Legg-Calve-Perthes disease. Part I: Classification of radiographs with use of the modified lateral pillar and Stulberg classifications. J Bone Joint Surg Am, 86-A(10): 2103-20, 2004. Herring, J. A.; Kim, H. T.; and Browne, R.: Legg-Calve-Perthes disease. Part II: Prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am, 86-A(10): 2121-34, 2004. Herring, J. A.; Neustadt, J. B.; Williams, J. J.; Early, J. S.; and Browne, R. H.: The lateral pillar classification of Legg-Calve-Perthes disease. J Pediatr Orthop, 12(2): 143-50, 1992. Hresko, M. T.; McDougall, P. A.; Gorlin, J. B.; Vamvakas, E. C.; Kasser, J. R.; and Neufeld, E. J.: Prospective reevaluation of the association between thrombotic diathesis and legg-perthes disease. J Bone Joint Surg Am, 84A(9): 1613-8, 2002. Kitoh, H.; Kitakoji, T.; Katoh, M.; and Takamine, Y.: Delayed ossification of the proximal capital femoral epiphysis in Legg-Calve-Perthes' disease. J Bone Joint Surg Br, 85(1): 121-4, 2003. Lappin, K.; Kealey, D.; and Cosgrove, A.: Herring classification: how useful is the initial radiograph? J Pediatr Orthop, 22(4): 479-82, 2002. Maxwell, S. L.; Lappin, K. J.; Kealey, W. D.; McDowell, B. C.; and Cosgrove, A. P.: Arthrodiastasis in Perthes' disease. Preliminary results. J Bone Joint Surg Br, 86(2): 244-50, 2004. Rowe, S. M.; Chung, J. Y.; Moon, E. S.; Yoon, T. R.; Jung, S. T.; and Lee, K. B.: Computed tomographic findings of osteochondritis dissecans following Legg-Calve-Perthes disease. J Pediatr Orthop, 23(3): 356-62, 2003. Segev, E.; Ezra, E.; Wientroub, S.; and Yaniv, M.: Treatment of severe late onset Perthes' disease with soft tissue release and articulated hip distraction: early results. J Pediatr Orthop B, 13(3): 158-65, 2004. Wiig, O.; Terjesen, T.; and Svenningsen, S.: Inter-observer reliability of radiographic classifications and measurements in the assessment of Perthes' disease. Acta Orthop Scand, 73(5): 523-30, 2002.

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Femoral acetabular impingement

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1. Beaule PE, Allen DJ, Clohisy JC, Schoenecker PL, Leunig M. The young adult with hip impingement: deciding on the optimal intervention. Instr Course Lect 2009;58:213-22. 2. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 2003(417):112-20. 3. Gautier E, Ganz K, Krugel N, Gill T, Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br 2000;82(5):679-83. 4. Guanche CA, Bare AA. Arthroscopic treatment of femoroacetabular impingement. Arthroscopy 2006;22(1):95-106. 5. Keogh MJ, Batt ME. A review of femoroacetabular impingement in athletes. Sports Med 2008;38(10):863-78. 6. Leunig M, Beaule PE, Ganz R. The concept of femoroacetabular impingement: current status and future perspectives. Clin Orthop Relat Res 2009;467(3):616-22. 7. Leunig M, Podeszwa D, Beck M, Werlen S, Ganz R. Magnetic resonance arthrography of labral disorders in hips with dysplasia and impingement. Clin Orthop Relat Res 2004(418):74-80. 8. Parvizi J, Leunig M, Ganz R. Femoroacetabular impingement. J Am Acad Orthop Surg 2007;15(9):561-70. 9. Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am 2003;85-A(2):278-86. 10. Sink EL, Gralla J, Ryba A, Dayton M. Clinical presentation of femoroacetabular impingement in adolescents. J Pediatr Orthop 2008;28(8):806-11.

CHILDHOOD BONE AND JOINT INFECTIONS, CONGENITAL, DEVELOPMENTAL PROBLEMS, & MISCELLANEOUS

Jeffrey R. Sawyer MD Assistant Professor of Orthopaedics University of Tennessee-Campbell Clinic Memphis, Tennessee USA

AAOS Review Course 2011 Jeffrey Sawyer MD

Basic concepts Pediatric orthopaedics with many rare and unusual syndromes. Test questions tend to be on major topics. Rare diseases/conditions appear.
Genetic/molecular defect known Pathognomonic phenotype (OI) Associated conditions that need to be evaluated for (Wilms tumor-hemihypertrophy) 2-3 year delay from papers to exam questions. Mainstream concepts. Conservative treatment in children best

Bone and Joint infections in Children

Acute Osteomyelitis 3 routes: hematogenous contiguous direct innoculation most common type is hematogenous rich blood supply to metaphysis blood supply to epiphysis end arterioles in metaphysis, phagocytosis increased trauma in children Demographics: 2:1 male:female 25% cases < 1 yr old, 50% < 5 years old 68% cases in long bones Differential diagnosis: trauma, septic arthritis, toxic synovitis, rheumatoid, malignancy Organisms: most common: 1 S. aureus 61-89% 2 Group A -hemolytic strep 10% 3 H. influenza incidence rapidly due to immunization other: Kingella kingae underreported-harder to culture PCR testing previous upper resp infection Salmonella sickle cell Pseudomonas shoe puncture
2

AAOS Review Course 2011 Jeffrey Sawyer MD

Diagnosis: pain, limp, inability to bear weight, swelling, warmth neonates-pseudoparalysis radiographs typically not helpful MRI highly sensitive (97%) bone scan good for multifocal disease needle aspirate-definitive (positive 66% cases) blood cultures-positive 36-65% of cases laboratory ESR and CRP elevated (peak 2-5 after treatment) Follow response with CRP Treatment: antibiotics mainstay first generation cephalosporin consider vancomycin or clindamycin in MRSA endemic areas based on blood/bone cultures follow response with CRP surgical indications failure to improve with antibiotics (48 hrs) gross pus on aspiration abcess on MRI tissue for pathology (biopsy the culture, culture the biopsy) Length of antibiotics controversial 2 weeks of IV then change to PO 6 weeks total continue until CRP normal Chronic Osteomyelitis occurs in 10-20% of children with acute osteomyelitis most commonly following: open fracture, inadequately treated acute treatment is extensive, repeated debridements removal sequestrum abcess drainage

AAOS Review Course 2011 Jeffrey Sawyer MD

Chronic recurrent multifocal osteomyelitis typically older children (mean age 14) recurrent multifocal episodes of inflammation/remission cultures negative antibiotics not effective symptomatic treatment, no need for surgical treatment Pamidronate may be beneficial Septic Arthritis 3 routes:

hematogenous (trauma) contiguous direct inoculation

most common type is hematogenous Mechanism transphyseal vessels allow spread into joints several joints with intra-articular metaphysis hip, elbow, shoulder, ankle
enter due to vascular synovium with no basement membrane proteolytic enzymes cause cartilage destruction release of cytokines including TNF, IL-1 loss of proteoglycan (5 days) and cartilage (9 days)

Demographics: 2:1 male:female peak children < 3 years 80% in lower extremity (hip) Differential diagnosis: trauma, osteomyelits, Lyme disease, toxic synovitis, rheumatoid, malignancy Organisms: most common: S. Aureus age-related: <12 months 6mo-5 yrs 5-12 years 12-18 yrs S. aureus, Streptococcus S. aureus, Streptococcus, H. influenza ( immunization) Kingella kingae S. aureus S. aureus, N. gonorrhoeae
4

AAOS Review Course 2011 Jeffrey Sawyer MD

other:

Kingella kingae underreported-harder to culture prior upper resp infection Salmonella sickle cell Pseudomonas shoe puncture pain, limp, inability to bear weight, swelling, warmth symptoms progress more rapidly than osteomyelitis neonates-pseudoparalysis, pain with diaper change radiographs typically not helpful early widened joint space r/o other causes of limp (SCFE, Perthes, Fracture) ultrasound-useful for detecting and aspirating joint effusions MRI-can detect effusion, associated osteomyelits laboratory WBC > 12,000, 40-60% PMNs, ESR > 55 mm/hr suggestive Follow response with CRP Strains and PVL status (PVL+ and USA3000 strains virulence) needle aspirate gold standard Infection: > 50,000 wbc, > 75% PMNs, + gram stain Cultures positive 60%

Diagnosis:

Treatment: antibiotics mainstay first generation cephalosporin consider vancomycin or clindamycin in MRSA endemic areas based on blood/joint cultures follow response with CRP surgical indications surgical emergency arthroscopic drainage effective length of antibiotics controversial trend is shorter courses 2 weeks of IV then change to PO 6 weeks total continue until CRP normalizes complications: joint stiffness, growth arrest
5

AAOS Review Course 2011 Jeffrey Sawyer MD

Septic arthritis versus toxic synovitis Toxic synovitis Typically following viral illness (GI, URI) Temp, WBC, ESR, CRP not as elevated as septic arthritis Self limiting-NSAIDs helpfu

Kocher criteria: Fever, Inability to bear weight, WBC > 12,000, ESR > 40 4 present: 99.8% predictive of septic arthritis 3 present: 93-95% predictive of septic arthritis 2 present: 33.8-62% predictive of septic arthritis 1 present: 0.1% predictive of septic arthritis CRP added and may increase sensitivity

Congenital
General concepts many with associated features conservative approach children with unilateral upper extremity deformities do well w/ no surgery Spine Klippel Feil Syndrome low posterior hairline, short neck (ROM), congenital vertebral fusion Associated with deafness, cardiopulmonary, limb deficiency, urinary defects patients develop hypermobile segments cranial/caudal to fusion lifestyle modification (no contact sports) cervical fusion for significant instability Shoulder Sprengels Failure of scapular descent during development 50% with omovertebral bone (connects scapula and spine) Associated with torticollis, Klippel-Feil, pulmonary and renal disorders Surgical treatment for functional impairment Woodward procedure-detach/advance scapular muscules Cavicular osteotomy for older patients (plexus injury)

AAOS Review Course 2011 Jeffrey Sawyer MD

Forearm Radial neck dislocation Appears in late childhood/adolescence Bony prominence, little functional problems May be associated with unrelated trauma Associated with Klippel-Feil, arthrogryposis, Nail-Patella syndrome Flat capitellum, convex radial head, bowed ulna - dif. from traumatic No role for radial head relocation, radial head excision if painful Radial deficiency Failure of formation of radial side of forearm, hand, wrist Associated with TAR(thrombocytopenia-absent radius), Fanconis anemia, VACTERRL (used to be VATER) dx life saving in Fanconis and TAR PT/bracing early Surgery (centralization) recurrence and function not indicated for older children who have adapted to deformity Hand Syndactyly Most common congenital hand disorder Associated with Poland (chest wall) and Apert (skull/face) syndromes May be associated with functional loss Surgical resection one digit per procedure to avoid necrosis skin grafting necessary Polydactyly (tends to show up on exams) Male > Female Pre-axial(Thumb) Over-expression of sonic hedgehog protein Underexpression Gli3 protein (down regulates sonic hedgehog)

Most common: duplicated proximal phalanges (Wassel IV) duplicated distal phalanges (Wassel IV) Surgical treatment: Simple excision contraindicated except pedunculated Reconstruct radial collateral ligaments, advance thenar m. +/- osteotomies Late deformity common (20%)
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AAOS Review Course 2011 Jeffrey Sawyer MD

Post-axial(Ulnar side 6th digit) Autosomal dominant African American > Caucasian more often syndrome-related in caucasian Surgical treatment excision Thumb deficiency May be part of spectrum of radial deficiency Commonly bilateral Associated with Fanconis, TAR, VACTERRL Severe deform- thumb ablation and index pollicization indicated Unilateral deformities controversial Knee Congenital knee dislocation Females > males, can be unilateral or bilateral Associated with hip dysplasia (50%), clubfoot, congenital vertical talus, myelomenigocele, arthrogryposis, Larsen syndrome History of packing disorders (breech birth, oligohydramnios) Conservative treatment and orthotic (Pavlik) Surgery for fixed dislocation or significant contracture Patellar dislocation Rare Irreducible lateral dislocation May have genu valgum +/- flex contracture, hypotrophic/aplastic trochlea Conservative treatment not indicated Surgery-lateral release/VMO advancement, medialization patella Discoid meniscus Many children asymptomatic (? true incidence) Lateral >> medial, 20% bilateral Treatment based on symptoms, tear, meniscofemoral ligaments Conservative treatment mainstay for asymptomatic children Surgery (saucerization) symptomatic, tears total and near total meniscectomy results poor

Developmental/Aquired
Brachial Plexus Palsy 4:1000 births most common with large babies, shoulder dystocia, forceps, breech, long labor poor prognosis: no return of bicep function at 6 months + Horners root avulsion for spinal cord
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AAOS Review Course 2011 Jeffrey Sawyer MD

Type
Erb-Duchenne

Roots
C5-6 (Upper)

Deficit
Deltoid,biceps,wrist extensors, hand extensors Wrist flexors, hand intrinsic Flaccid arm, sensory defecits

Prognosis
Good

Other
Waiters tip

Klumpke Total

C8-T1 (Lower) C5-T1

Poor Bad

Horners

Early surgical treatment: Brachial plexus reconstruction technically challenging, complete plexus w/ no return at 3 months Reconstructive treatment: Early anterior capsular relesase (can be arthroscopic) prevents glenoid deformity (think DDH of the shoulder) Younger patients-lastissimus/teres transfer Older patients- humeral external rotation osteotomy Amniotic Bands Amniotic disruption leads to constrictive bands 90% distal to wrist Associated with: clubfoot, cleft palate, craniofacial defects Spectrum: skin dimpling complete amputation Most patients can acutely be observed (rare vascular insufficiency) Surgery for vascular insufficiency, late reconstruction of amputations

Genetics
I. General concepts Autosomal dominant Heterozygotes manifests condition Normal offspring do NOT transmit disease Usually structural defects Autosomal recessive Heterozygotes do not manifest condition Usually biochemical/enzymatic diseases Sex linked dominant Heterozygotes manifest disease (XY or XX) Sex linked recessive Heterozygote male manifests disease (XY) Heterozygote female unaffected (XX) *many genetic diseases are due to new mutations and may not follow above patterns Questions tend to target: Common diseases
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II.

AAOS Review Course 2011 Jeffrey Sawyer MD

Diseases where the gene defect, structural product and phenotype known:
Achondroplasia FGFR3 geneFGF receptorProliferative zone of physis

Molecular Basis of Common Orthopaedic Conditions

Disease Dysplasias
Achondroplasia FGF receptor 3 AD Proliferative zone Rhizomelic Dwarfism Joint instability Spinal stenosis Short limb Disproportionate

Molecular Basis

Mode

Tissue/Physiologic

Orthopaedic Manifestations

Multiple epiphyseal dysplasia

Cartilage Oligomeric Protein

AD

Epiphysis

Metabolic
OI Vitamin D-dependent rickets Vitamin D resistant rickets Collagen genes Renal 25 hydroxylase 1,25 OH D receptor AD (I,IV) AR (II,III) AR XD Bony fragility Physis-abnormal ossification Physis -abnormal ossification Connective tissue Connective tissue Bone Muscle Muscle Frequent fractures Scoliosis Bony deformity Osteomalacia Bony deformity Osteomalacia Joint laxity-subluxation Scoliosis Joint laxity Fibrous lesions Progressive weakness Scoliosis Weakness Lifespan > Duchennes (20s) Hemarthrosis Hemophilic arthropathy Bone pain/infarcts Salmonella osteomyelitis C spine instability Joint laxity Finger deformity Halothane/succinylcholine Inc. in neuromuscular pts Radial head dislocation Angular deformity-lower ext Radial/thumb deficiency Thrombocytopenia

Connective Tissue
Marfan Ehlers-Danlos Fibrous Dysplasia Fibrillin gene Col 1A2 gene G protein (GNAS) Dystrophin gene Dystrophin gene* AD AD AD XR XR

Muscular Dystrophy
Duchennes Beckers

Hematologic
Hemophilia A Sickle cell Factor VIII gene Hemoglobin S gene XR AR Complement cascade Hemoglobin

Chromosomal
Down Syndrome Clinodactyly Trisomy 21 Trisomy 8 and 12 Ryanodine receptor EXT genes ? N/A N/A AD AD AR Increased joint laxity ? Skeletal musclesarcoplasm/Ca++ Physis Radial forearm

Miscellaneous
Malignant Hyperthermia Multiple hereditary osteochondromas TAR (Thrombocytopeniaabsent radius)

*Same gene-different mutation location ** For a comprehensive list see Dietz & Mathews JBJS 1996 1583-98.
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AAOS Review Course 2011 Jeffrey Sawyer MD

Diseases that show up on exams

Achondroplasia Defect in FGF receptor 3 gene-majority are spontaneous mutation Most common type of disproportionate dwarfism Failure of proliferative zone in physis Phenotype: normal trunk/short limbs Frontal bossing Trident hands Thoracic kyphosis-resolves w/ ambulation Lumbar stenosis-most common cause of disability Decreasing intrapedicular distance L1-S1 Radial head subluxation Champagne glass pelvis Normal intelligence Treatment: weight loss, bracing Surgical: lumbar decompression and fusion Osteotomies for genu varum Limb lengthening (upper and lower) controversial Osteogenesis Imperfecta Defect in Type I collagen-abnormal cross-linking leads to easy fracture Phenotype: short stature scoliosis tooth defects (dentinogenesis imperfecta) hearing defects ligamentous laxity classic description of 4 types: now with molecular biology-spectrum fractures common with normal healing, no remodeling Treatment: early bracing to prevent fracture prophylactic intramedullary nailing of long bones no proven medical therapy scoliosis-bracing ineffective, surgery difficult due to osteopenia candidate for gene therapy Duchennes Muscular Dystrophy Non-inflammatory disorder of muscle weakness (progressive) Defect in Dystrophin gene Diagnosis: Young male with clumsy walking motor skills Gowers sign calf hypertrophy (pseudohyertrophy)
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AAOS Review Course 2011 Jeffrey Sawyer MD

Laboratory: increased CPK, absent dystrophin DNA Biopsy: absent dystrophin Most patients lose independent ambulation by 10 Scoliosis progresses rapidly fusion for curves 25-30 Death of respiratory complications by 20 Different from Beckers which is less severe, associated w/ red-green color blindness and lifespan >20 years w/o respiratory support. Marfan Syndrome Disorder of Fibrillin gene Pheontype: arachnodactyly long arms, fingers Pectus Scoliosis 50% with heart (valve) and eye (superior lens dislocations) problems Joint laxity treated non-operatively with bracing Scoliosis treated surgically. Bracing ineffective Down Syndrome Trisomy 21- most common chromosomal abnormality Phenotype: characteristic facial features ligamentous laxity hypotonia mental retardation 50% with heart disease, endocrine disorders (hypothyroid, diabetes) common Orthopaedic problems: pes planus C1-C2 instability Scoliosis Hip instability Asymptomatic children with C1-2 instability should avoid contact sports, diving, gymnastics- Special Olympics Mucopolysaccharidosis Defect in hydrolase enzyme deficiency in carbohydrate metabolism Phenotype: proportionate dwarfism Diagnosis: complex sugars in urine diagnostic

Four main types: Morquios, Hunters, Hurlers, Sanfilippos Classified by inheritance, mental retardation, urine sugar Morquios-commonly on exams Waddling gait, 2 years of age
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AAOS Review Course 2011 Jeffrey Sawyer MD

Phenotype:

Genu valgum thoracic kyphosis wide ribs C1-C2 instability (odontoid hypoplasia) Urinary Excretion Keratin sulfate Dermatan/heparin sulfate Dermatin/heparin sulfate Heparin sulfate Notes Most common Worst Normal until 2yo

Syndrome Morquios Hurlers Hunters Sanfilippos

Inheritance AR AR XR AR

Intelligence Normal Retardation Retardation Retardation

Exam tips: very confusing and at most this will be one question Morquios-classic disease, most common, only one w/ Keratin and nl intelligence All are recessive transmission Cerebral Palsy Non-progressive to brain before the age of 2 Cause most often is not identifiable Classification: Physiologic: Spastic- most common, best response to surgery Athetoid-associated w/ kernicterus, poor response to surgery Ataxia- wide based gait, poor response to surgery Mixed- spastic and athetoid Anatomic: Hemiplegia-upper and lower same side, almost all walk Diplegia-LE involvement > UE, usually walk (late) Quadriplegia-UE and LE involvement, low IQ, rare to walk Physical examination: Persistence of primitive reflexes Increased spasticity Treatment: Pharmacologic Baclofen - decrease spasticity Botulinum A toxin (postsynaptic blockade at NM junction) Bracing early to prevent deformity Soft tissue procedures early before contracture/bony deformity Bony procedures for joint subluxation/dislocation
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AAOS Review Course 2011 Jeffrey Sawyer MD

Hip: Stage Hip at risk Hip subluxation

ROM (abduction) < 45 degrees < 20 degrees

Xrays May be normal Subluxation (migration index) Dislocated

Hip dislocation

None

Hip dislocation (late)

None

Dislocated Degenerative changes

Treatment Adductor tenotomy Adductor tenotomy +/- VDRO +/- pelvic osteotomy Open reduction Femoral shortening Femoral VDRO Pelvic osteotomy Girdlestone Abduction osteotomy

VDRO = varus derotational osteotomy Pelvic osteotomy = most common is Dega Exam points: trend is toward not reducing hip unless patient: has pain that limits ADLs (diapering, transfer) has significant ambulatory potential Spine: risk for scoliosis is highest in children with severe disease bracing ineffective spinal fusion for progressive curves that interfere with care, sitting. Usually involves fusion to pelvis to control obliquity High complication rate (up to 10x idiopathic scoliosis) Important to assess nutritional status: Albunin < 3.5 g/dL, WBC < 1500 consider g-tube due to infection Knees: Usually hamstring contractures quadriplegia > diplegia > hemiplegia Bracing Hamstring release helpful +/- rectus femoris transfer (to increase knee flexion) Feet: Diplegia: equinovalgus due to spastic peroneals, tight heelcords Calcaneal lengthening osteotomy for severe deformity equinovarus feet due to overpull of tib ant and tib. post. Achilles tendon lengthening +/- split tendon transfer (tib ant) high rate of failure with standard adult procedures MTP joint fusion best
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Hemiplegia Bunions:

AAOS Review Course 2011 Jeffrey Sawyer MD

Upper extremity: Limited role for UE surgery High functioning children tendon transfers around wrist to improve hand function Severely involved children- soft tissue release to prevent skin breakdown Myelomeningocele Disorder of incomplete spinal cord closure (spina bifida occulta rachischisis) Folate deficiency in utero Diagnosed in utero ultrasound increased -fetoprotein levels Associated with Type II Chiari Malformation, hydrocephalus, tethered cord Pathologic fractures common often confused with DVT, infection fractures heal with abundant callus Ambulation/function dependent on level Above L3 non-ambulator L3-L4 household ambulatory L5-S1 community ambulatory Hip: most common level for dislocation L3-4 L2 and cranial do not treat hip dislocations-painless, no ambulatory potential L4 and caudal treat hip dislocations surgically maintain braceable, plantagrade foot soft tissue releases to maintain balance clubfoot common triple arthrodesis for severe deformity and sensate feet most patients will develop scoliosis/kyphosis ( with cranial spinal level) bracing not effective rapid curve progression tethered cord fixation to pelvis necessary kyphectomy for severe kyphosis

Ankle foot:

Spine:

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AAOS Review Course 2011 Jeffrey Sawyer MD

References Infection
Arnold, S.R., et al., Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus. J Pediatr Orthop, 2006. 26(6): p. 703-8. Caird, M.S., et al., Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am, 2006. 88(6): p. 1251-7.

Congenital/Developmental/Genetic
Ballock, R.T., Molecular and genetic approaches to musculoskeletal diseases. J Pediatr Orthop, 2003. 23(1): p. 131-7.

Common Diseases
Avivi, E., et al., Skeletal manifestations of Marfan syndrome. Isr Med Assoc J, 2008. 10(3): p. 186-8. Borges, J.L., et al., Modified Woodward procedure for Sprengel deformity of the shoulder: long-term results. J Pediatr Orthop, 1996. 16(4): p. 508-13. Arnold, S. R., D. Elias, et al. (2006). "Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus." J Pediatr Orthop 26(6): 703-8. Avivi, E., H. Arzi, et al. (2008). "Skeletal manifestations of Marfan syndrome." Isr Med Assoc J 10(3): 186-8. Ballock, R. T. (2003). "Molecular and genetic approaches to musculoskeletal diseases." J Pediatr Orthop 23(1): 131-7. Borges, J. L., A. Shah, et al. (1996). "Modified Woodward procedure for Sprengel deformity of the shoulder: long-term results." J Pediatr Orthop 16(4): 508-13. Caird, M. S., J. M. Flynn, et al. (2006). "Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study." J Bone Joint Surg Am 88(6): 1251-7. Catalano-Pons, C., A. Comte, et al. (2008). "Clinical outcome in children with chronic recurrent multifocal osteomyelitis." Rheumatology (Oxford) 47(9): 1397-9. Ceroni, D, Cherkauoi, A, Ferey S, Kaelin, A, Schrenzel, J (2010) Kingella Kingae Osteoarticular Infections in Young Children: Clinical Features and Contributions of a New Specific Real Time PCR assay to the Diagnosis. J. Pediatric Orthop 30(3):301-4. Chapurlat, R. D. and P. Orcel (2008). "Fibrous dysplasia of bone and McCune-Albright syndrome." Best Pract Res Clin Rheumatol 22(1): 55-69. Crandall, R. C., R. C. Birkebak, et al. (1989). "The role of hip location and dislocation in the functional status of the myelodysplastic patient. A review of 100 patients." Orthopedics 12(5): 675-84. Dao, K. D., A. Y. Shin, et al. (2004). "Surgical treatment of congenital syndactyly of the hand." J Am Acad Orthop Surg 12(1): 39-48. Dietz, F. R. and K. D. Mathews (1996). "Update on the genetic bases of disorders with orthopaedic manifestations." J Bone Joint Surg Am 78(10): 1583-98.
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AAOS Review Course 2011 Jeffrey Sawyer MD

Dormans, J. P. and D. S. Drummond (1994). "Pediatric Hematogenous Osteomyelitis: New Trends in Presentation, Diagnosis, and Treatment." J Am Acad Orthop Surg 2(6): 333-341. Drennan, J. C. (1993). "Congenital dislocation of the knee and patella." Instr Course Lect 42: 517-24. Driscoll, S. W. and J. Skinner (2008). "Musculoskeletal complications of neuromuscular disease in children." Phys Med Rehabil Clin N Am 19(1): 163-94, viii. Girschick, H. J., C. Zimmer, et al. (2007). "Chronic recurrent multifocal osteomyelitis: what is it and how should it be treated?" Nat Clin Pract Rheumatol 3(12): 733-8. Green, N. E. (1987). "The orthopaedic management of the ankle, foot, and knee in patients with cerebral palsy." Instr Course Lect 36: 253-65. Greene, W. B. (1999). "Treatment of hip and knee problems in myelomeningocele." Instr Course Lect 48: 563-74. Herman, M. J. and P. D. Pizzutillo (1999). "Cervical spine disorders in children." Orthop Clin North Am 30(3): 457-66, ix. Horton, W. A., J. G. Hall, et al. (2007). "Achondroplasia." Lancet 370(9582): 162-72. Karol, L. A. (2004). "Surgical management of the lower extremity in ambulatory children with cerebral palsy." J Am Acad Orthop Surg 12(3): 196-203. Karol, L. A. (2007). "Scoliosis in patients with Duchenne muscular dystrophy." J Bone Joint Surg Am 89 Suppl 1: 155-62. Klimo, P., Jr., G. Rao, et al. (2007). "Congenital anomalies of the cervical spine." Neurosurg Clin N Am 18(3): 463-78. Kocher, M. S., K. Klingele, et al. (2003). "Meniscal disorders: normal, discoid, and cysts." Orthop Clin North Am 34(3): 329-40. Kocher, M. S., D. Zurakowski, et al. (1999). "Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm." J Bone Joint Surg Am 81(12): 1662-70. Kozin, S. H. (2003). "Upper-extremity congenital anomalies." J Bone Joint Surg Am 85-A(8): 1564-76. Light, T. R. (1992). "Treatment of preaxial polydactyly." Hand Clin 8(1): 161-75. Lourie, G. M. and R. E. Lins (1998). "Radial longitudinal deficiency. A review and update." Hand Clin 14(1): 85-99. Maschke, S. D., W. Seitz, et al. (2007). "Radial longitudinal deficiency." J Am Acad Orthop Surg 15(1): 41-52. McCarthy, J. J., L. P. D'Andrea, et al. (2006). "Scoliosis in the child with cerebral palsy." J Am Acad Orthop Surg 14(6): 367-75. McCarthy, J. J., J. P. Dormans, et al. (2005). "Musculoskeletal infections in children: basic treatment principles and recent advancements." Instr Course Lect 54: 515-28. Mellado Santos, J. M. (2006). "Diagnostic imaging of pediatric hematogenous osteomyelitis: lessons learned from a multi-modality approach." Eur Radiol 16(9): 2109-19. Mik, G., P. A. Gholve, et al. (2008). "Down syndrome: orthopedic issues." Curr Opin Pediatr 20(1): 30-6. Mikles, M. and R. P. Stanton (1997). "A review of Morquio syndrome." Am J Orthop 26(8): 533-40. Moran, S. L., M. Jensen, et al. (2007). "Amniotic band syndrome of the upper extremity: diagnosis and management." J Am Acad Orthop Surg 15(7): 397-407. Morcuende, J. A. (1993). "Orthopedic aspects of skeletal dysplasia in children." Curr Opin Pediatr 5(3): 363-7.
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Novacheck, T. F. and J. R. Gage (2007). "Orthopedic management of spasticity in cerebral palsy." Childs Nerv Syst 23(9): 1015-31. Rauch, F. and F. H. Glorieux (2004). "Osteogenesis imperfecta." Lancet 363(9418): 1377-85. Renshaw, T. S., N. E. Green, et al. (1996). "Cerebral palsy: orthopaedic management." Instr Course Lect 45: 475-90. Richette, P., T. Bardin, et al. (2008). "Achondroplasia: from genotype to phenotype." Joint Bone Spine 75(2): 125-30. Sachar, K. and A. D. Mih (1998). "Congenital radial head dislocations." Hand Clin 14(1): 39-47. Sarwark, J. F. (1999). "Kyphosis deformity in myelomeningocele." Orthop Clin North Am 30(3): 4515, viii-ix. Scott, R. J., M. R. Christofersen, et al. (1990). "Acute osteomyelitis in children: a review of 116 cases." J Pediatr Orthop 10(5): 649-52. Spiegel, D. A. and J. M. Flynn (2006). "Evaluation and treatment of hip dysplasia in cerebral palsy." Orthop Clin North Am 37(2): 185-96, vi. Stieber, J. R. and J. P. Dormans (2005). "Manifestations of hereditary multiple exostoses." J Am Acad Orthop Surg 13(2): 110-20. Strombeck, C., L. Krumlinde-Sundholm, et al. (2007). "Long-term follow-up of children with obstetric brachial plexus palsy I: functional aspects." Dev Med Child Neurol 49(3): 198-203. Tassone, J. C. and A. Duey-Holtz (2008). "Spine concerns in the Special Olympian with Down syndrome." Sports Med Arthrosc 16(1): 55-60. Tedeschi, E., F. Antoniazzi, et al. (2006). "Osteogenesis imperfecta and its molecular diagnosis by determination of mutations of type I collagen genes." Pediatr Endocrinol Rev 4(1): 40-6. Vekris, M. D., M. G. Lykissas, et al. (2008). "Management of obstetrical brachial plexus palsy with early plexus microreconstruction and late muscle transfers." Microsurgery 28(4): 252-61.

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Pediatric Upper and Lower Extremity Fractures

John (Jack) M. Flynn, MD
Orthopaedic Trauma Director Associate Chief of Orthopaedics Childrens Hospital of Philadelphia, Associate Professor of Orthopaedics University of Pennsylvania

AAOS Review Course 2010 Pediatric Fractures John M. Flynn, MD

Notes Essential pediatric fracture principles

Remodeling based on: Age (younger = better) Distance from the physis (closer = better) Amount of angulation (more = better) Know where to be aggressive Late puberty/nearly adult kids Elbow, Hip Intra-articular fractures Femur fractures: school age and older Know where non-operative is usually the best option Almost all distal radius Most diaphyseal forearm (90%) Humeral shaft/proximal humerus Clavicle Femur and tibia in very young Most pediatric pelvic fractures Compartment syndrome Sentinel finding: increasing pain Often the next day in LE fractures Remove any cast if there is increasing pain Knee and elbow get stiff with intra-articular fractures, esp in older kids Growth arrest risk and problems high: distal femur (25-50%), distal ulna (60%) Growth arrest risk and problems low: distal radius, distal humerus, ankle Dont forget child abuse Femur fx and not yet walking SH II distal humerus in baby Corner fracture

Upper Extremity
Wrist
Know remodeling/natural history: dont over treat! Acceptable reduction Bayonet apposition Sagittal plane angulation up to 30 if > 5 yrs. of growth remaining 5 less for each year less than 5 Frontal plane angulation looks bad, remodels slowly ~ 10-15 if > 5 yrs. of growth remaining

AAOS Review Course 2010 Pediatric Fractures John M. Flynn, MD

Indications to pin peds distal radius Unstable distal radius and ipsilateral distal humerus Cant CR/cast (extremely swollen/skin/compartment syndrome)

Diaphyseal Forearm
Principles Most are rotational injuries The ulna shows you the angulation; the radius shows you the rotation Look for a second injury if just one diaphyseal fracture Diaphyseal fractures heal more slowly Malunion can be a problembe more aggressive than distal radius Acceptable reduction Up to 10-20 angulation in kids < 10 y/o No more than 10 angulation >10 y/o Bayonet apposition 30 malrotation Distal fractures more forgiving than proximal fractures Treatment pearls Make a good cast Dont accept a crooked arm OK to reduce or re-reduce in OR (even @ 2-3 weeks post-injury) Avoid re-fracture: splint or cast a couple extra weeks if necessary Use single bone fixation if necessary Fracture site often must be opened for IM nailing Treat older adolescents like adults

Monteggia injuries
Principles Dont accept forearm images that dont show the elbow Radiocapitellar line in all views Treatment based on Stability of ulna fracture Monteggia type Age of patient Time from injury to treatment (missed or failed treatment) Bado types I: radial head anterior Most common type in kids Often CR cast OK; flex to reduce, but cast at 90 K-wire or plate on ulna, depending on stability II: radial head posterior Relatively rare Teens Hard to cast in extension; usually fix these III: radial head lateral 2nd most common in kids

AAOS Review Course 2010 Pediatric Fractures John M. Flynn, MD

Look for associated radial nerve injury Greenstick proximal ulna can be hard to control Ulnar IM k-wire commonly used IV: radial head anterior, radial shaft fracture Late/Missed Monteggia Management very controversial Results often poor, even in experienced hands Treatment determined by amount of delay < 2 weeks May still be able to get CR and use cast Fixation often helps 2 weeks to about 6 months Often need ulnar osteoclasis or osteotomy Restore ulnar length May need to open radiocapetellar joint May need to repair/reconstruct annular ligament > 6mo Results often poor, even in experienced hands Ulnar osteotomy, with plate v. ex fix Open reduction radiocapetellar joint Repair/reconstruct annular ligament (Bell-tawse)

Proximal radius and ulna

Radial head/neck Unusual5% peds elbow fx Metaphyseal or physeal Usually valgus injuries Displaced fractures: high rate of poor results in literature 15-30% poor results overall 50% poor results in high energy injuries Results are worse if there is another fx (esp prox ulna) Satisfactory CR usually better than anatomic OR Acceptable reduction criteria 0-20 angulation, no translation: accept as is, LAC for 3 weeks >20angulation, translation: attempt ER closed reduction Post reduction If translation corrected and angulation < 30, cast If > 30, try OR reduction Percutaneous manipulation works 95% of time Avoid opening fracture site if at all possible A CR to < 45 will do better than anatomic ORIF Complications Motion lossesp. pronation Radial head overgrowth20-40% Myositis ossificans

AAOS Review Course 2010 Pediatric Fractures John M. Flynn, MD

Esp. after surgical treatment: AVN10-20% Non-union (Waters JPO 2001) Radioulnar synostosis Olecranon/prox. Ulna Apophyseal (seen in OI tarda) Metaphyseal Flexion Extension Shear Treatment Non-displaced/min displaced cast for 3-4 wks 30 elbow flexion Operative indications: Unstable fractures Articular step-off Younger kids Suture tension band Leave wires out to pull in clinic Older adolescents: treat like adults

Elbow fracture principles

Posterior fat pad sign predictive of occult fx (53% Supracondylar) Anterior humeral line should intersect the capitellum Carrying angle ~ 5-7 degrees Baumanns angle 10-20(or 70-80, the official way to measure) Very little remodeling at distal humerus High rate of complications from injury/treatment

Supracondylar humerus
10-20% associated NV injury Anterior interosseous n. palsy the most common Most nerve palsies recover in 2-4 months 1% brachial artery occlusion ~ 95% extension type, 5% flexion type(ulnar n. can be injured) Lots of low level evidence that fixing the next day is safe (unless NV risk) Beware of medial impactioncan cause cubitus varus malunion Classification and treatment Gartland I: non-displaced, crack in anterior cortex, cast 3 weeks Gartland II: displaced but hinged, most get CR/pins(2pins) & cast for 3 weeks Gartland III: completely displaced, all get CR/pins(3pins) & cast for 3 weeks Open reduction Rarely needed in most centers (< 5%) Indications to open Something trapped in fracture site Need to address vascular compromise

AAOS Review Course 2010 Pediatric Fractures John M. Flynn, MD

Anterior approach generally preferred Vascular compromise Absent pulse, well perfused hand Proceed urgently to OR, CR and pin If pulse returns, usual treatment If pulse does not return Hand well perfused: observe as inpatient, splint Hand not well perfused, vascular team assess and treat Absent pulse, poorly perfused hand Proceed urgently to OR, CR and pin If hand perfusion well restored: observe as inpatient, splint If hand not well perfused, vascular team assess and treat

Lateral condylar humerus

Milch 1: SH IV Milch II: SH II (most common, by far) Surgical management usually recommended if > 2 mm of displacement (>60 %) Stages of displacement classification best for determining treatment I: Intact hinge of trochlear cartilage: cast x 6 weeks (watch for progressive displacement!) II: Disrupted hinge, but minimally displaced: cast v. perc pin v. ORIF III: Completely displaced: ORIF Use Kocher approach, stay anterior (blood supply posterior) Non-union Can lead to cubitus valgus Early: ORIF, dont strip soft tissue to improve reduction Late: Fixation in situ, +/- bone graft, sometimes osteotomy

Distal humeral physeal separation

Most before age 6 May occur as birth injury Consider child abuse Diagnosis can be challenging Can look like lateral condyle fracture EUA, +/- arthrogram can be helpful Treatment principles Manipulative closed reduction if fresh Fresh means a few days after injury CRPP just as for supracondylar 2-3 weeks of immobilization Splint in situ if late (osteotomy better than risking growth arrest)

Medial epicondyle fractures of humerus

Apophyseal injury Peak age 11-12 y/o, boys 4:1 Associated with elbow dislocation (50%) Fragment trapped in the joint (15%) Flexor mass, ligaments attached Evaluate the ulnar nerve carefully Minimally displaced: splint Operative indications

AAOS Review Course 2010 Pediatric Fractures John M. Flynn, MD

Incarcerated fragment Ulnar nerve completely out Controversy: displacement > 5mm Non-operative Strong support in older literature (1982-2002) Fibrous union likely, but asymptomatic in many ORIF Currently used at many centers, esp for athletes Screw fixation and early motion

Proximal humerus
< 5% of all peds fx prox humerus physeal < 1% of all peds fx < 5 y/o: SH I 5-12 y/o: metaphyseal fx predominate > 12 y/o: SH II most common Extraordinary remodeling potential universal joint rapidly growing physis Immobilization only is treatment for most Operative indications Open NV injury Intra-articular Unacceptable displacementvery controversial < 12 y/o: can accept up to 70 and 100% displacement Teenage: controversial. 30-40, 50% displacement

Clavicle
99%+: treated with sling or figure of 8 Trend towards adult ORIF philosophy extending to teens, esp athletes and re-fractures ORIF also with open fractures, NV injury Sternoclavicular physeal fracture/dislocations Anterior: closed reduction if very displaced Posterior can threaten mediatstinal structures get CT scan reduce in OR with CT surgery on standby trend towards suture fixation through drill holes

AAOS Review Course 2010 Pediatric Fractures John M. Flynn, MD

Lower Extremity
Pelvis
Look for associated injury: >50% Head, abdominal, urologic, other fractures Mortality/morbidity usually from other injuries, not pelvic fx Complicationsmost are rare Premature triradiate cartilage closure Leg-length discrepancies Nerve palsy Heterotopic ossification

Femoral Neck Fractures

Classification-Delbet

Type I: like acute SCFE (very high AVN risk) Type II: transcervical (moderate AVN risk) Type III: cervicotrochanteric(low AVN risk) Type IV: intertrochanteric (very low AVN risk)
Treatment principles Displaced Type I-III: relative surgical emergency Some form of capsular decompression recommended Rigid internal fixation (screws, not pins) If child is too young to fix across physis, use a spica for 4-6 weeks Complications AVN Coxa vara Non-union Growth disturbance/arrest

Traumatic Hip Dislocations

Children under age 5: trivial trauma, low risk of problems Older children/teens: significant trauma, more risks: Be alert for fragements trapped in the joint Avascular Necrosis About 10% of hip dislocations Reduce within 24 hours Risk of AVN is probably related to the severity of initial trauma

AAOS Review Course 2010 Pediatric Fractures John M. Flynn, MD

Femoral Shaft Fractures

Management principles Most heal without long-term sequelae Consider abuse in children who are not yet walking Treatment is age-related Infants: Pavlik harness, +/- splint Infant to < 6 y/o: early spica cast in most cases Skeletally mature: antegrade IM nail 6 y/o to maturity: many options Elastic nailing Submuscular plating External fixation Trochanteric-entry nailing Traction/casting Acceptable Alignment 2-10 y/o 11y/o Varus/valgus 15 5-10 Anterior/posterior 20 10 Malrotation 30 30 Acceptable shortening Under 10 y/o: 1.5-2.0 cm Over 10 y/o: 1.0 cm Treatment options Casting / Traction & Casting Best option for most kids 5 y/o; rarely used in children > 8 y/o Traction: + Telescope test (EUA > 25 mm shortening) or child > 6 y/o Complications under appreciated Risk of leg compartment syndrome Flexible intramedullary nails Good option for length-stable fractures ages 6-12 y/o TEN poor results increase in kids 11 y/o, wt 50 kg Select more stable fracture patterns/protect unstable patterns External Fixation Best for: severe soft tissue injury, comminuted/spiral/unstable fx pattern Very distal/proximal fractures Submuscular Plate Fixation Recent surge in popularity Length unstable fractures Long plate, limited number of screws Solid antegrade IM nail Trochanteric starting point Avoid piriformis fossa

AAOS Review Course 2010 Pediatric Fractures John M. Flynn, MD

Knee Fractures
Distal Femoral Physeal Fractures Look for occult fxs in pediatric knee sprain If fracture displaced or unstable: Use internal fixation if fracture, smooth K-wires across physis for 3 weeks: ok Peroneal nerve injury: avoid excess stretch through traction or excessive varus Vascular injury reportedcarefully check vascular status Knee joint instability: check ligaments when fracture healed Growth arrest: Very common: 25-50% after displaced fractures MRI at 4-6 months after trauma to detect growth disturbances Patellar Fractures Principles for patellar fx same as for adult Strong suture (rather than wire) tension band effective in kids

Patellar sleeve fractures

Entire injury can be missedfeel for defect, look for patella alta Usually massive soft tissue injury Be sure fixation allows early motion Loss of flexion, extensor lag possible Tibial Spine Myers and McKeevers I: non-displaced Myers and McKeevers II: intact posterior hinge Myers and McKeevers III: completely displaced Meniscus can be entrapped in the fracture Complications Late anterior instability in 64% patients, not a functional problem Unrecognized injuries of the collateral ligaments Malunion may cause mechanical impingement Non-union, re-fracture Knee stiffness: warn pre-op, move post-op as soon as its safe Proximal tibial physeal fractures These can be surprisingly unstable: fix if there is any question of instability Joint step-off rare, plateau diastasis more commonfix if >2mm Vascular injury a major risk Vessels tethered at trifurcation: can injure popliteal artery Compartment syndrome Physeal arrest Often no leg-length discrepancy if less than 3 years growth remaining

Watch for varus/valgus deformity

Tibial Tubercle avulsion Compartment syndrome: ant tibial artery tear Genu recurvatum after growth arrest Loss of knee flexionextensor mechanism contracture Proximal tibial metaphyseal fractures Usually 3-6 y/o, heal rapidly Post-fx genu valgum (Cozens fracture) Cause unknown, usually resolves spontaneously

Be certain there is no tissue trapped in fx site

10

AAOS Review Course 2010 Pediatric Fractures John M. Flynn, MD

Diaphyseal Tibia/Fibula Fractures

Accept: 5 valgus, 5-10 varus and ant. angulation, 5 post. Angulation Be vigilant for compartment syndrome Often a next day problem in children Earliest sign may be increased narcotic requirements Malrotation Rotational malalignment of the tibia does not spontaneously correct More than 10 degrees may produce significant functional impairment Leg length discrepancy Beware of occult physeal injury in diaphyseal tibia fracture

Distal Tibial Physeal Fractures

Physis closes central to medial to posterior to anterolateral Tillaux Ext. rotation injury Anterior tibfib ligament pulls off fragment of anterolateral tibial physis Triplane 2, 3 and 4-part fractures < 2mm joint displacement: CR with IR, LLC > 2mm joint displacement: ORIF vs. percutaneous with interfrag screws Non-unions rarereported in SHIII (medial mal. fx) Growth arrest Entrapped periosteum has been implicated Usually occurs after Salter-Harris types III and IV fractures Varus deformity Leg length discrepancy rarely a problem

Foot fractures
AVN in talus fracturesuse MRI for early diagnosis, NWB if possible Beware of occult tarsometatarsal injury in children Be vigilant for compartment syndromeesp. the run-over or crushed foot Seymours fracture (occult open physeal fx/nailbed injury of the toe) Beware when there is blood under the nail bed Give antibiotics in ED ORIF may be necessary to free entrapped tissue

11

References

Upper Extremity
General Principles 1. Kocher MS, Kasser JR: Orthopaedic aspects of child abuse. J Am Acad Orthop Surg 2000;8:10-20. 2. Marsh JL, Buckwalter J, Gelberman R, Dirschl D, Olson S, Brown T, Llinias A: Articular fractures: Does an anatomic reduction really change the result? J Bone Joint Surg Am. 84-A:1259-1271, 2002. 3. Carey J, Spence L, Blickman H, Eustace S: MRI of pediatric growth plate injury: correlation with plain film radiographs and clinical outcome. Skeletal Radiol. 27:250-255., 1998. 4. Flynn J, Skaggs D, Sponseller P, et al: The operative management of pediatric lower extremity fracture. Journal of Bone and Joint Surgery Am. 84:2002. Wrist 5. Cannata G, De Maio F, Mancini F, Ippolito E: Physeal fractures of the distal radius and ulna: Long-term prognosis. J Orthop Trauma 2003;17:172-179. 6. McLauchlan GJ, Cowan B, Annan IH, Robb JE: Management of completely displaced metaphyseal fractures of the distal radius in children: A prospective, randomized controlled trial. J Bone Joint Surg Br 2002;84:413-417. 7. Proctor MT, Moore DJ, Peterson JM: Redisplacement after manipulation of distal radial fractures in children. J Bone Joint Surg Br 1993;75:45:3454. Forearm 8. Bado JL: The Monteggia Lesion. Clin Orthop Relat Res 1967;50:71-86. 9. Price CT, Scott DS, Jurzner ME, Flynn JC: Malunited forearm fractures in children. J Pediatr Orthop 1990;10:705-712 10. Tarr RR, Garfinkel AI, Sarmiento A: The effects of angular and rotational deformities of both bones of the forearm. J Bone Joine Surg Am 1984;66:65-70. 11. Van der Reis WL, Otsuka NY, Moroz P, Mah J: Intramedullary nailing versus plate fixation for unstable forearm fractures in children. J Pediatr Orthop 1998;18:9-13. Elbow 12. Skaggs DL, Hale JM, Bassett J, Kaminksy C, Kay RM, Vernon TT: Operative treatment of supracondylar fractures of the humerus in children: The consequence of pin placement. J Bone Joint Surg Am 2001;83:735-740. 13. Archibeck MJ, Scott SM, Peters CL: Briachialis muscle entrapment in displaced supracondylar humerus fractures: A technique of closed reduction and report of initial results. J Pediatr Orthop 1997;17:298-302. 14. Campbell CC, Waters PM, Emans JB, et al: Neurovascular injury and displacement in type III supracondylar humerus fractures. J Pediatr Orthop 1995;15:47-52. 15. Gicquel PH, DeBilly B, Karger CS, Clavert JM: Olecranon fractures in 26 children with mean follow-up of 59 months. J Pediatr Orthop 2001;21:141-147. 16. Mintzer CM, Waters PM, Brown DJ, et al: Percutaneous pinning in the treatment of displaced lateral condyle fractures. J Pediatr Orthop 1994;14:462-465. 17. Flynn JC: Nonunion of slightly displaced fractures of the lateral humeral condyle in children: An update. J Pediatr Orthop 1989;9:691-696. 18. Iyengar SR, Hoffinger SA, Townsend DR: Early versus delayed reduction and pinning of type III displaced supracondylar fractures of the humerus in children: A comparative study. J Orthop Trauma 1999;13:51-55. 19. Bernstein SM, McKeever P, Bernstein L: Percutaneous reduction of displaced radial neck fractures in children. J Pediatr Orthop 1993;13:85-88. 20. Metaizeau JP, Lascombes P, Lemelle JL, et al: Reduction and fixation of displaced radial neck fractures by closed intramedullary pinning. J Pediatr Orthop 1993;13:355-360. Clavicle 21. Waters PM, Kadiyala R: Short-term outcomes after surgical treatment of traumatic posterior sternoclavicular fracture-dislocations in children and adolescents. J Pediatr Orthop 2003;23:464-469. Pelvis and Hip 22. Silber JS, Flynn JM: Changing patterns of pediatric pelvic fractures with skeletal maturation: implications for classification and management. J Pediatr Orthop. 22:22-26., 2002. 23. Silber JS, Flynn JM, Katz MA, et al: Role of computed tomography in the classification and management of pediatric pelvic fractures. J Pediatr Orthop. 21:148-151., 2001. 24. Schwarz N, Posch E, Mayr J, al e: Long-term results of unstable pelvic ring fractures in children. Injury. 29:431-433, 1998. 25. Smith WR, Oakley M, Morgan SJ: Pediatric pelvic fractures. J Pediatr Orthop 2004;24:130-135 26. Silber J, Flynn J, Koffler K, Dormans J, Drummond D: An analysis of the cause, classification and associated injuries of 166 consecutive pediatric pelvic fractures. J Pediatr Orthop. 21:446-450, 2001. 27. Karunakar MA, Goulet JA, Mueller KL, Bedi A, Le TT: Operative treatment of unstable pediatric pelvis and acetabular fractures. J Pediatr Orthop 2005;25:34-38 28. Flynn JM, Wong KL, Yeh GL, Meyer JS, Davidson RS: Displaced fractures of the hip in children. Management by early operation and immobilization in a hip spica cast. J Bone Joint Surg Br. 84:108-112., 2002. 29. Hughes LO, Beaty JH: Fractures of the head and neck of the femur in children. J Bone Joint Surg Am. 76:283-292., 1994. 30. Morsy HA: Complications of fracture of the neck of the femur in children: A long-term follow-up study. Injury 2001;32:45-51 31. Song KS, Kim YS, Sohn SW, Ogden JA: Arthrotomy and open reduction of the displaced fracture of the femoral neck in children. J Pediatr Orthop B 2001;10:205-210 Femur 32. Flynn JM, Schwend RM: Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;12:347-359. 33. Schwend RM, Werth C, Johnston A: Femur shaft fractures in toddlers and young children: Rarely from child abuse. J Pediatr Orthop 2000;20:475-481. 34. Shapiro F: Fractures of the femoral shaft in children: The overgrowth phenomenon. Acta Orthop Scand 1981;52:649-655 35. Podeszwa DA, Mooney JF 3rd, Cramer KE, Mendelow MJ: Comparison of Pavlik harness application and immediate spica casting for femur fractures in infants. J Pediatr Orthop 2004;24:460-462. 36. Smith NC, Parker D, McNicol D: Supracondylar fractures of the femur in children. J Pediatr Orthop 2001;21:600-603. 37. Hutchins CM, Sponseller PD, Sturm P, Mosquero R: Open femur fractures in children: Treatment, complications, and results. J Pediatr Orthop 2000;20:183-188. 38. Illgen R II, Rodgers WB, Hresko MT, Walters PM, Zurakowski D, Kasser JR: Femur fractures in children: Treatment with early sitting spica casting. J Pediatr Orthop 1998;18:481-487. 39. Gordon JE, Khanna N, Luhmann SJ, Dobbs MB, Ortman MR, Schoenecker PL: Intramedullary nailing of femoral fractures in children through the lateral aspect of the greater trochanter using a modified rigid humeral intramedullary nail: Preliminary results of a new technique in 15 children. J Orthop Trauma 2004;18:416-422.

AAOS Review Course 2010 Pediatric Fractures John M. Flynn, MD

40. Kanlic EM, Anglen JO, Smith DG, Morgan SJ, Pesantez RF: Advantages of submuscular bridge plating for complex pediatric femur fractures. Clin Orthop Relat Res 2004;426:244-251. 41. Flynn JM, Luedkte L, Ganley TJ, Dawson J, Davidson, RS, Dormans JP, Ecker ML, Gregg JR, Horn BD, Drummond DS. A prospective cohort study comparing titanium elastic nailing to traction and spica casting for pediatric femur fractures. J Bone Joint Surg Am. 2004 Apr;86-A(4):770-7. 42. Flynn JM, Luedtke L, Ganley TJ, Pill SG: Titanium elastic nails for pediatric femur fractures: lessons from the learning curve. Am J Orthop. 31:71-74., 2002. 43. Moroz, LA, Launay F, Kocher MS, Newton PO, Frick SL, Sponseller PD, Flynn JM. Titanium elastic nailing of fractures of the femur in children: predictors of complications and poor outcome. J Bone Joint Surg Br. 2006 Oct;88-B(10):1361-6. 44. Flynn J, Hresko T, Reynolds R, et al: Titanium elastic nails for pediatric femur fractures: initial results of a U.S. multicenter study. J Pediat Orthop. 21:4-8, 2001. 45. Gregory P, Pevny T, Teague D: Early complications with external fixation of pediatric femoral shaft fractures. J Orthop Trauma. 12:191198., 1996. 46. Luhmann SJ, Schootman M, Schoenecker PL, Dobbs MB, Gordon JE. Complications of titanium nails for pediatric femoral shaft fractures. J Pediatr Orthop. 23:443-7. 2003.11. 47. Raney EM, Ogden JA, Grogan DP: Premature greater trochanteric epiphysiodesis secondary to intramedullary femoral rodding. J Pediatr Orthop. 13:516-520., 1993. 48. Skaggs DL, Leet AI, Money MD, et al: Secondary fractures associated with external fixation in pediatric femur fractures. J Pediatr Orthop. 19:582-586., 1999. 49. Rohde RS, Mendelson SA, Grudziak JS. Acute synovitis of the knee resulting from intra-articular knee penetration as a complication of flexible intramedullary nailing of pediatric femur fractures: report of two cases. J Pediatr Orthop. 23:635-8. 2003. 50. Large TM, Frick SL. Compartment syndrome of the leg after treatment of a femoral fracture with an early sitting spica cast. A report of two cases. J Bone Joint Surg Am. 2003 Nov;85-A(11):2207-10. 51. OMalley DE, Mazur JM, Cummings RJ: Femoral head avascular necrosis associated with intramedullary nailing in an adolescent. J Pediatr Orthop 1995;15:21-23. Knee 52. Zionts LE: Fractures around the knee in children. J Am Acad Orthop Surg 2002;10:345-355. 53. Mosier SM, Stanitski CL: Acute tibial tubercle avulsion fractures. J Pediatr Orthop 2004;24:181-184. 54. Riseborough EJ, Barrett IR, Shapiro F: Growth disturbances following distal femoral physeal fracture-separations. J Bone Joint Surg Am. 65:885-893., 1983. 55. Hunt DM, Somashekar M: A review of sleeve fractures of the patella in children. Knee 2005;12(1):3-7. 56. Hresko MT, Kasser JR: Physeal arrest about the knee associated with non-physeal fractures in the lower extremity. J Bone Joint Surg Am. 71:698-703., 1989. 57. Baxter MP, Wiley JJ: Fractures of the tibial spine in children. An evaluation of knee stability. J Bone Joint Surg Br. 70:228-230., 1988. 58. Burstein DB, Viola A, Fulkerson JP: Entrapment of the medial meniscus in a fracture of the tibial eminence. Arthroscopy. 4:47-50., 1988. 59. Janarv PM, Westblad P, Johansson C, Hirsch G: Long-term follow-up of anterior tibial spine fractures in children. J Pediatr Orthop. 15:6368., 1995. 60. McLennan JG: Lessons learned after second-look arthroscopy in type III fractures of the tibial spine. J Pediatr Orthop. 15:59-62., 1995. 61. Pape JM, Goulet JA, Hensinger RN: Compartment syndrome complicating tibial tubercle avulsion. Clin Orthop. 201-204., 1993 62. Willis RB, Blokker C, Stoll TM, et al. Long-term follow-up of anterior tibial eminence fractures. J Pediatr Orthop1993;13::361-364. 63. Wessel LM, Scholz S, Ruch M, et al: Hemarthrosis after trauma to the pediatric knee joint: What is the value of magnetic resonance imaging in the diagnostic algorithm? J Pediatr Orthop 2001;21:338-342. 64. Kocher MS, Forman ES, Micheli L: Laxity and functional outcome after arthroscopic reduction and internal fixation of displaced tibial spine fractures in children. Arthroscopy 2003;19:1085-1090. Tibia 65. Morton K, Starr D: Closure of the anterior protion of the upper tibial epiphysis as a complication of tibial-shaft fracture. J Bone Joint Surg Am. 46:570, 1964. 66. Cozen L. Fracture of the proximal portion of the tibia in children followed by valgus deformity. Surg Gyecol Obstet 1953;97:183. 67. Jackson DW, Cozen L: Genu Valgum as a complication of proximal tibial metaphyseal fractures in children. J Bone Joint Surg Am 1971;53(8):1571-1578. 68. McCarthy JJ, Kim DH, Eilert RE: Posttraumatic genu valgum: Operative versus nonoperative treatment. J Pediatr Orthop 1998;18(4):518521. 69. Jordan SE, Alonso JE, Cook FF. The etiology of valgus angulation after metaphyseal fractures of the tibia in children. J Pediatr Orthop 1987;7:450. 70. Kubiak EN, Egol K, Scher D, Wasserman B, Feldman D, Koval K: Operative Treatment of tibial fractures in children: Are elastic stable intramedullary nails an improvement over external fixation? J Bone Joint Surg Am 2005;87(8):1761-1768. 71. Yue JJ, Churchill RS, Cooperman DR, et al: The floating knee in the pediatric patient: Nonoperative versus operative stabilization. Clin Orthop Relat Res 2000;376:124-136. 72. Barmada A, Gaynor T, Mubarak SJ: Premature physeal closure following distal tibia physeal fractures: A new radiographic predictor. J Pediatr Orthop 2003;23(6):733-739. 73. Brown SD, Kasser JR, Zurakowski D, Jaramillo D: Analysis of 51 tibial triplane fractures using CT with multi-planar reconstruction. AJR AM J Roentgenol 2004;183:1489-1495. 74. Buckley SL, Smith G, Sponseller PD, Thompson JD, Griffin PP: Open fractures of the tibia in children. J Bone Joint Surg Am 1990;72(10):1462-1469. Foot and Ankle 75. Caterini R, Farsetti P, Ippolito E: Long-term followup of physeal injury to the ankle. Foot Ankle. 11:372-383. 1991. 76. Kensinger DR, Guille JT, Horn BD, Herman MJ. The stubbed great toe: importance of early recognition of open fractures of the distal phalanx. J Pediatr Orthop 21:31-4. 2001. 77. Ertl JP, Barrack RL, Alexander AH, VanBuecken K: Triplane fracture of the distal tibial epiphysis. Long-term follow-up. J Bone Joint Surg Am. 70:967-976. 1988.

AAOS REVIEW COURSE 2011 PEDIATRIC SECTION: LOWER EXTREMITY Lori A. Karol, M.D. Texas Scottish Rite Hospital Dallas, Texas

I.

ANGULAR DEFORMITIES OF LOWER EXTREMITIES A. Normal development 1. Birth: 10-15 deg varus 2. Age 18-24 months: neutral alignment 3. Age 3-4 years: 8 deg valgus 4. Age 6-7 years: normal adult alignment 6 deg valgus B. Varus deformity 1. Infantile Blounts disease a. Etiology -Growth disturbance to medial proximal tibial physis b. History -Usually present as toddlers -Can be unilateral or bilateral -More prevalent in heavy children and early walkers -More prevalent in black children c. Physical examination -Genu varum -Internal tibial torsion -Lateral thrust during gait d. Radiographs -Long leg standing xray with knee straight ahead -Varus angulation in metaphysic with physeal irregularity -Medial beaking -Langenskiold stages subdivide Blounts *1= normal xray with genu varum *6=bony bar across medial tibial physis -Metaphyseal diaphyseal angle in borderline cases *difficult to reliably measure * >11 degrees likely to develop blounts e. Treatment -Observation *appropriate for infants < 2 yr of age *borderline radiographs -Bracing *useful in age 2-3 yo children *best if Langenskiold 3 or less

* 65% success (no surgery) *success better in unilateral cases *KAFO with elastic band to apply valgus force *stop before 4th birthday if unsuccessful -Surgery *Best results if performed prior to age 4 *Proximal tibial and fibular osteotomy *Watch for tibial tubercle and stay distal *Overcorrect 10 degrees *If older, may require bar excision (stage 5 and 6) *Epiphyseal osteotomy with elevation described in extreme cases 2. Adolescent Blounts disease a. Etiology -Disturbance to medial proximal tibial physis -Usually preexisting mild varus b. History -May be uni or bilateral -Usually painful -Cosmetic complaints c. Physical examination -Usually obese teens -Obvious varus deformity of knee -Thrust during gait d. Radiographs -Varus alignment -Proximal medial tibial physeal widening -Variable physeal changes in distal femur -Scanogram may show LLD -Hand xray for bone age e. Treatment -Hemiephyseodesis Benefit: Small operation in large child Can be performed if skeletally immature Successful in 1/3, improvement in 1/3, fail 1/3 *Temporary: remove when corrected --stapling --growth modulation with plate *Permanent --Phemister technique --may need completion of epiphyseodesis Look at femur to see if there is deformity there too -Osteotomy Benefit: Immediate realignment of extremity Difficult to make perfect Internal fixation versus external fixation

II.

Immediate correction versus gradual correction Do NOT overcorrect because valgus unsightly! Risks: loss of fixation, under or overcorrection, compartment syndrome 3. Metabolic bone disease a. Nutritional rickets Suspect black breastfed children Still occurs in USA Due to vitamin D deficiency Radiograph: widened metaphyses, blurry wide physes, metaphyseal cupping b. Vitamin D resistant rickets Looks like rickets on xray Short stature Family history Labs diagnostic 4. Skeletal dysplasias a. Chondrometaphyseal dysplasias (Schmid) Looks like rickets on xray Labs normal Autosomal dominant b. Achondroplasia C. Valgus deformity 1. Cozens fracture a. Tibial metaphyseal fracture in young child b. Overgrowth phenomena with max deformity 1yr s/p injury c. Treatment observation d. Warn parents at time of injury e. Tibial osteotomy can lead to recurrent valgus 2. Idiopathic a. Usually bilateral b. Cosmetic problem c. If adolescent, can manipulate growth via hemiepiphyseodesis 3. Skeletal dysplasia (family hx, see on xray) a. Multiple epiphyseal dysplasia b. Renal rickets c. Multiple hereditary osteochondromatosis ROTATIONAL DIFFERENCES of LOWER EXTREMITIES A. Intoeing 1. Tibial torsion a. Presents usually between ages of 1 and 3 b. Almost always bilateral c. Bimalleolar angle < 20 degrees external d. Foot-thigh angle internal e. Internal foot progression angle

III.

f. Treatment parental reassurance g. Remodelling until age 5 h. No functional sequellae 2. Femoral anteversion a. Usually presents ages 3-7 years b. Usually bilateral c. Hip internal rotation > external rotation d. Foot-thigh angle normal e. Internal foot progression angle with patellae pointing in f. If unilateral, consider CP (birth hx, PE spasticity) g. Can be measured by CT (but not necessary) h. Treatment parental reassurance i. Remodelling until age 10-12 j. No functional sequellae (?? If also ext tibial torsion) B. Out-toeing a. Common in babies due to increased hip external rotation b. Also seen in flat feet c. Watch for DDH d. No treatment needed e. Less worrisome to parents LEG LENGTH DISCREPANCY A. History 1. Trauma 2. Infection 3. Age of onset B. Physical examination 1. Galleazzi test Flex hips with patient supine Can approximate femoral length 2. Allis test Can approximate tibial length 3. Standing pelvic obliquity (use blocks to level) 4. Angular deformity 5. Gait a. Toe-walking b. Vaulting c. Bend long hip and knee C. Radiographic study 1. Scanograma. Assess precise amount of discrepancy in each bone b. Calculate % shortening c. Use length and bone age to prognosticate difference at maturity (1) Green Anderson growth remaining charts (2) Mosely graphs (3) Paley multiplier method

IV.

2. Long leg AP radiograph (r/o DDH, coxa vara, hemimelia, congenital short femur, skeletal dysplasia) 3. Hand for bone age 4. Abdominal ultrasound in young children R/O neuroblastoma D. Treatment 1. Observation a. Appropriate for small discrepancies <2-2.5 cm b. Young children prior to preferred age for treatment 2. Shoe lift a. When discrepancy begins to disturb gait b. Useful prior to femoral shortening in questionable cases 3. Epiphyseodesis a. Best for discrepancies in 2-5 cm range b. Timed based on growth remaining and bone age c. Open vs. percutaneous techniques 4. Acute femoral shortening a. Useful in skeletally mature adolescents b. Can be done via closed IM nail with IM saw c. Usually contraindicated for LLD > 5cm d. Postop quad weakness e. Immediate weight-bearing 5. Gradual lengthening a. Useful for LLD > 5cm or with coexistant angular deformity b. Ring fixator vs. Taylor spatial frame vs. monolateral fixator c. Indications vary between centers d. Usually requires 1 month in frame per centimeter lengthened e. Difficulties with joint motion and muscle tolerance f. Contractures and dislocations/subluxations possible especially with femoral lengthening g. Regenerate fracture problematic, intramedullary protection proposed but controversial KNEE DISORDERS A. ACL injuries 1. Increasing incidence 2. Nonoperative treatment often results in continued instability 3. Extra-articular augmentations not isometric 4. Usual technique violates the physis 5. Typical ACL reconstruction should be delayed til close to skeletal maturity 6. Epiphyseal tunnels reported in younger patients to prevent growth arrest B. Osteochondritis dissecans 1. Usually lateral side of medial femoral condyle of femur 2. Pathology- avascular necrosis of fragment

V.

3. Presents with nonspecific knee pain aggravated by activity 4. May be tender to palpation 5. Radiographs a. Tunnel view best b. MRI shows stability of fragment c. Bone scan activity may predict healing potential 6. Treatment a. Activity restrictions -may take months to heal b. Casting c. Arthroscopy -Indications are fail conservative rx or unstable fragment -If intact lesion, drilling can promote healing -If early-separated lesion, can pin plus drill -If separated but bed fresh, can replace fragment -If detached and bed not salvageable, options limited C. Osgood Schlatter 1. Traction-induced inflammation of patellar tendon and tibial tubercle 2. Presents in adolescents 3. Pain aggravated by activities, esp jumping 4. Tubercle painful, may be enlarged 5. Xrays show fragmentation or ossicles in area of tibial tubercle 6. Treatment nonoperative LEG DISORDERS A. Posteromedial bow of the tibia 1. Present at birth 2. Associated with calcaneus position of foot 3. Angulation usually resolves with growth til age 2 years 4. Leg length discrepancy will require treatment with epiphyseodesis or lengthening 5. No increased risk of pseudarthrosis B. Congenital pseudarthrosis of the tibia 1. Seen in anterolateral bowing of the tibia 2. Associated with neurofibromatosis (55%) 3. Classification a. Crawford: nondysplastic, failure of tubularization, cystic, and frank pseudarthrosis b. Broken vs. not broken 4. Clinical features a. Bowing frequently noted at birth b. Motion at pseudarthrosis c. Shortened leg d. Limp 5. Treatment a. GOAL: to obtain and maintain union

b. PRINCIPLES: maintain alignment, permanent IM fixation c. Bracing to prevent fracture in walking children d. Debridement of pseudarthrosis, intramedullary fixation of tibia and fibula with bone grafting e. External fixation f. Vascularized fibular graft g. Amputation 6. Outcome a. Refracture or persistant pseudarthrosis very common b. Leg length discrepancy c. Ankle valgus C. Tibial hemimelia 1. Only familial form of limb deficiency (but usually sporadic) 2. Complete or partial absence of tibia (Jones classification) a. Type 1 complete absence (1)1a-complete absence and no cartilaginous prox tibia (2)1b-proximal tibia present but not ossified b. Type 2 proximal tibia ossified at birth c. Type 3- proximal tiba absent, distal tibia present (rare) d. Type 4 distal tib/fib diastasis 3. Physical examination a. Inability to extend knee implies absence of proximal tibia b. Varus foot due to lack of malleolus c. Extreme shortening d. Possible polydactyly 4. Treatment a. If no proximal tibia (cannot extend knee)-knee disarticulation b. If proximal tibia ossified or seen on imaging-proximal tib/fib synostosis and Symes amputation c. Diastasis of type 4 treated either by Symes or by ankle reconstruction/fusion + multiple lengthenings D. Fibular hemimelia 1. more common than tibial hemimelia 2. Defined as complete or partial absence or hypoplasia of fibula a. Can classify based on amount of fibula missing b. Clinically useful classification based on status of foot (#rays) 3. Physical examination a. Shortening of limb b. Associated femoral shortening c. Tibial bow with pucker anteriorly d. Possible absence of lateral rays of foot e. Ankle equinovalgus in complete deficiency f. ACL insufficiency 4. Associated Abnormalities

VI.

a. congenital short femur b. subtalar tarsal coalition c. ACL insufficiency d. Knee valgus 5. Treatment a. If no fibula and foot unstable with < 3 rays: symes or boyd amputation b. If foot 3 or more rays and ankle reconstruction possible, can consider multiple lengthenings FOOT DISORDERS A. Metatarsus adductus 1. Packaging disorder 2. Differentiated from clubfoot because no equinus, ankle ROM nl 3. Bean-shaped foot 4. R/O DDH 5. Flexibility decides if treatment needed a. If flexible, stretching b. If moderate, reverse last shoes if desired c. If severe, may require casts d. Surgery not indicated B. Calcaneovalgus 1. Excessive dorsiflexion of the ankle with limited plantarflexion 2. Packaging disorder 3. R/O DDH 4. Check spine 5. Treatment stretching 6. Resolves spontaneously C. Clubfoot 1. Etiology 2. Types a. Idiopathic : 1-2/1000 live births b. Neuromuscular -Spina bifida -Spinal cord abnormalities c. Syndromic/teratologic -Arthrogryposis -Larsens syndrome -Diastrophic dwarfism 3. Physical examination a. Forefoot adducted b. Hindfoot in varus c. Cavus d. Ankle equinus-heel pad feels empty e. Smaller foot f. Thinner calf 4. Radiographs

a. Not needed for diagnosis b. Parallelism of calcaneus and talus on lateral c. Equinus of calcaneus on lateral 5. Treatment a. Nonoperative treatment -Begins in newborn period -Casting most prevalent -Ponseti technique -LLC -Perc tenotomy of Achilles at 6 weeks -Denis Browne bar after casts for 3 mos -Night-time DB bar thereafter for 3 years b. Surgical treatment -Posteromedial and lateral release most common -Cincinnati incision -Lengthening of shortened tendons -Transects pathologic ligaments and capsules -Postop problems with stiffness and weakness -Recurrence a problem -Lateral column shortening 6. Complications a. Overcorrection b. Recurrence c. DJD D. Congenital vertical talus 1. Description a. Equinus of ankle (1) Contracted tendoachilles b. Fixed dorsal dislocation of navicular on talus (1) Navicular articulates with dorsal aspect of neck of talus (2) Spring ligament attenuated (3) Anterior tendons, toe extensors tight c. Also known as congenital pes valgus 2. Etiology a. Most often associated with syndrome b. Can be seen in neurologic disorders 3. Radiographs a. Lateral radiograph of foot shows ankle equinus b. Stress plantarflexion lateral shows dorsiflexion of 1st metatarsal relative to the axis of the talus c. Navicular nonossified d. Talus vertical on lateral view 4. Treatment a. Cast treatment usually ineffective

b. Surgical release via PMR (1) Releases equinus (2) Direct reduction of navicular onto talar head (3) Ant tib transfer to talus (4) Dorsal tendon lengthenings E. Flatfeet 1. Flexible flatfeet a. Arch normally flexible in young children b. Reconstitutes with sitting or standing on toes c. Signs of ligamentous laxity throughout child d. Rarely symptomatic e. Treatment unnecessary 2. Rigid flatfeet a. Tarsal Coalition (0.03-1% population) (1) History -usually present in second decade -pain with activity -usually hurts in area of coalition -often bilateral but symptoms asymmetric -may be familial (2) Physical examination - Limited hindfoot range of motion - Ankle stiffness - External foot progression angle - Peroneal spastic flatfoot - No arch when stand on toes (3) Radiographs - Plain film oblique for calcaneonavicular coalition * anteater sign - Harris view for subtalar coalition of limited use - CT scan diagnostic look for multiple fusions - MRI can show fibrous coalition (4) Treatment - Conservative treatment with orthotics/cast - Surgical excision of coalition if possible *All calcaneonavicular coalitions -interpose EDB muscle *Subtalar coalitions that are not massive i.e. only middle facet or < post facet -interpose fat - Triple arthrodesis if massive or fail resection

b. Accessory navicular (1) common but rarely symptomatic (2) Ossicle within the insertion site of the post tibialis (3) Seen on oblique or AP foot xrays (4) Treatment unnecessary if asymptomatic (5) Soft pads/orthotics for initial treatment of foot pain (6) Surgical excision of fragment for persisant pain (7) Surgery does not correct pes planus F. Cavus feet 1. Etiology a. Usually neurologic- r/o CP, Friedreichs ataxia, spina bifida, Charcot Marie Tooth, spinal cord pathology b. Results from muscle imbalance (1) Weak tib ant and peroneus brevis (2) strong post tib and peroneus longus (3) Weak intrinsics of foot c. Can result from clubfoot d. Sequellae of compartment syndrome 2. Clinical presentation a. Elevated arch b. Hindfoot varus c. Increased pressure over lateral midfoot and 1st MT head d. Usually no ankle equinus e. Clawing of toes f. May complain of ankle sprains g. Foot shortened if unilateral 3. Physical examination a. Calluses b. Neuro exam incl spine c. Leg atrophy d. Flexibility of hindfoot varus **Coleman Block Test** (1) Put lift beneath the heel and lateral forefoot (2) Let 1st MT head fall medial to lift (3) Look to see if varus corrects 4. Radiographs a. Lateral radiograph shows dorsiflexion of calcaneus b. Calcaneal-1st MT (Mearys) angle increased on lat xray -Normal Mearys angle zero c. Parallelism of subtalar joint d. MRI neural axis! 5. Treatment a. Conservative treatment only for very mild b. Surgery for flexible hindfoot cavovarus (1) plantar fascia release (2) 1st metatarsal dorsiflexion osteotomy (3) Poss peroneus longus to brevis transfer

(4) No TAL usually needed c. Surgery for rigid hindfoot cavovarus (1) soft tissue surgery as above (2) Possible metatarsal osteotomies (3) Calcaneal osteotomy (4) OR midfoot dorsiflexion osteotomy (5) Triple arthrodesis if very severe-last resort VII. TOE DISORDERS A. Hallux valgus (Bunion) 1. Lateral deviation of great toe with apex of deformity 1st MTP joint 2. Girls>>boys 3. Positive family history common 4. c/o pain over bump 5. Xray: may show metatarsus primus varus a. Intermetatarsal angle should not exceed 10 degrees b. Distal metatarsal articular angle > 15 degrees 6. Treatment a. Conservative treatment emphasized b. Recurrence seen after surgery in up to 33% c. 1st MT crescentic osteotomy with distal realignment d. Double osteotomy 1st Metatarsal e. MTP fusion in neuromuscular patients B. Polydactyly (1.7/1000 live births) 1. Postaxial (5th toe) >>> preaxial (1st toe) 2. Postaxial genetic 3. Preaxial associated with syndromes 4. Usually remove border digit to enable shoe wear 5. Preop xray to assess metatarsals

Spine

 Spine Moderator:DavidL.Skaggs,MD 3:00PM Spine Trauma JensR.ChapmanMD 3:30PM DegenerativeSpine ToddJ.Albert,MD 4:00PMPediatricSpine DavidL.Skaggs,MD

AAOS Board Review Course 2010 New Orleans, LA

SPINE TRAUMA
A Comprehensive Review Jens R. Chapman, M.D. Professor Chief of Spine Service HansJrg Wyss Endowed Chair Department of Orthopaedic Surgery and Sports Medicine Joint Professor of Neurological Surgery Harborview Medical Center, University of Washington School of Medicine (206) 744-3466 jenschap@u.washington.edu

CONTENTS 1. 2. 3. Evaluation and Treatment principles Spinal Cord Injury Cervical Spine (for each injury category) - Classification - Management TL - Spine - Classification - Management Sacrum - General overview References

NOTES

4.

5. 6.

Note: This Handout follows the lecture but offers expanded content in the interest of providing more comprehensive review of principles of Spine Trauma.

1. Evaluation and Treatment principles 1.1 Resuscitation / retrieval Suspect Spine trauma with: Focal neurologic deficits Polytrauma Head -/ facial injuries Intoxication and/or sedation Suspect injury mechanism back pain Postraumatic spinal deformity with pain Tenderness to palpation and percussion of posterior midline Apply ATLS principles ! Follow expanded ABCs Airways Breathing Circulation and C-Spine Initial Immobilization Protocol Collar +/- sand bags / head taped Backboard Children < 6y..: Standard backboard causes C-Spine flexion. Use custom pediatric backboard or place torso on folded sheets. Resuscitation: Airway Intubation under manual traction (MILT), nasotracheal or fiberoptic Standard oral intubation causes excessive neck extension Maintain log roll and spinal precautions until spine cleared Trauma C-Spine lateral in ER (with arms pulled down) (Part of routine ATLS Trauma XR: Chest, Pelvis, C-Spine) Resuscitation: Neurogenic vs. spinal vs. hemorrhagic shock a) Neurogenic shock : Caused by disrupted sympathetic cardiac input Usually injury occurs in T4 8 region Differential diagnosis: Hemorrhagic and spinal shock Treat with IV Norepinephrine or Dopamine drip Avoid overinfusion (risk of pulmonary edema, CHF) b) Spinal shock: Temporary depolarization of neural elements Duration: Minutes to days 99 % resolution within 48 hours Return of bulbocavernosus reflex (BCR) indicative of recovery
Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 2

c) Hemorrhagic shock: Loss of intravascular volume Hypotension Tachycardia Oliguria / anuria Cold, clammy skin Differential diagnosis Blood pressure Heart rate Urine output Skin color / temp Mental status 1.2 Physical Examination Definition Spine Clearance: Spine clearance is a combination of clinical assessment and radiographic studies to be obtained as clinically indicated with the purpose of establishing spinal stability. Examination: Inspection skull to coccyx Palpation (log roll: skull to coccyx) Neurologic Evaluation (ASIA principles) Motor evaluation Reflexes (with bulbocavernosus, clonus, Babinski) Sensory Pain (pin prick) Proprioception Rectal examination: 1. Perianal sensation 2. Perianal wink 3. Spontaneous anal sphincter tone 4. Maximal voluntary anal sphincter contractility Prerequisites for clinical clearance of C-Spine without radiographs: NEXUS study group (National Emergency X-Ray utilization study) No X-Rs necessary if all of the following 5 points are fulfilled: Cognitively unimpaired patient (includes mind-altering meds, drugs etc.) No midline cervical tenderness No focal neurologic deficits Normal alertness No painful distracting injury Also suggested:
Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 3

Hemorrhagic shock < 100 mm Hg > 110/ min decreased Pale and clammy Decreased / agitated

Neurogenic shock < 100 mm Hg < 80/min normal Pink / warm unaffected

Low velocity, blunt injury mechanism (i.e.: speed < 35 mph, fall < 10 ft.). Full ROM C-Spine in all directions

1.3 Radiographic Evaluation

Concept of Spine clearance: Combination of clinical evaluation and radiographic clearance Communication and integration of information essential for success Problems: Cognitively impaired ( i.e. severely head injured patients) with limited examinability, and normal screening images. Goal: No missed injuries Missed injuries Causes of missed injuries: Failure to order appropriate tests Failure to interpret clinical or radiographic manifestations Failure of patient to seek medical assistance Failure of tests to identify relevant pathology (true exception) Patients at risk for missed injuries Cognitively impaired (i.e. head injured, mind altering drugs etc) High energy polytrauma o Speed > 35mph o Fall >10 feet o Death at scene o Pelvis or long bone fractures o Facial fractures Atypical anatomy Geriatric patients Imaging Techniques Plain radiographs: Lateral C-spine remains diagnostic for 78 - 85 % of C-spine trauma Open mouth XR can increase number to 95% Remember that 50% of TL trauma occurs at TL junction. This may be inadequately visualized on conventional T-, and L- spine radiographs. Consider coned-down TL junction radiograph if clinical suspicion warrants. Easily missed injuries: elderly, osteopenic skeleton, ankylosing disorders, type II odontoid fractures. Increasingly, helical CT and reformatted views have replaced conventional radiographs. However, there remains no substitute for alignment assessment and flexion-extension stability assessment with plain radiographs.
Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 4

CT: Spiral CT new imaging standard for patients with any cognitive impairment or who receive head CT for suspected trauma. CT C-spine to follow head scan. Assess reformats for transition zones. Also indicated following myelography. CT-Angiography: For suspected vertebral artery injury or disruption of transverse process by 2 mm or more. MRI: Indicated for any cervical SCI. Optional for suspected ligament disruption (look for high signal intensity on fat suppressionT2 weighted image). Aids in assessment of soft tissues, disc herniation, cord signal changes, presence of blood and integrity of ligaments (note high sensitivity and much lower specificity). Most effective screening tool for infection and tumors MRAngiography most sensitive tool for vertebral artery injury screening Bone Scan (TC-99 with SPECT) Indicated for occult pediatric trauma, unclear fractures. May need 720 to turn positive

2. Spinal Cord Injury

2.1 Cord anatomy Medulla oblongata: Foramen magnum - C2 Spinal cord: Occiput - T11/L1 (L3 in peds) Conus Medullaris T11/L1 (adult) Cauda equina L2-S3 Cross sectional anatomy a. Anterior-lateral cortical spinal tracts (motor) - Laminated so that cervical tracts closer to midline, sacral out lateral, (central cord syndrome) - Ipsilateral trajectory b. Anterior spinal - thalamic tracts - pain/temperature
Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 5

Laminated as above - sacral sparing Decussation (crossover) at around Occ - C2 (crossed fibers) Hemiplegia with ipsilateral loss of pinprick suggestive of hysteria/?brain lesion c. Posterior column - proprioception, vibration, light touch, deep pain - Touch - spared in anterior cord syndrome - Ipsilateral trajectory 2.2 Neural injury response 3 main mechanisms: contusion, compression and distraction 1. Contusion: Initial neural tissue trauma o Primary irreversible axon and cell deaths o Secondary Effects o Lyoszymal enzymes o Ischemia o Inflammation/edema o Toxins 2. Compression: Residual mass effects on neural tissue o Restriction of cell regeneration o Restriction of axonal flow o Restriction of vascular supply 3. Distraction: Highly destructive to neurons o Actual cord separation very uncommon o Very poor recovery potential 2.3 Biochemical changes of SCI 1. Accumulation of Na+ within neurons within seconds of injury. 2. Resulting depolarization of neural membranes 3. Further Na+ influx Ca++ pumped into cells 4. Na+ efflux into extracellular environs 5. Na+/Ca++ exchange enzymes destroyed 6. Phospholipid cell membranes destroyed Histopathology of SCI

2.4

Zone of primary injury Region of direct insult and cell destruction Zone of secondary injury Posttraumatic propagation of injury through several mechanisms: o Cell apoptosis o Membrane unraveling o Electrolyte imbalance o Inflammation o Hypoxia o Vascular insult
Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 6

Gray matter < nerve cell response > after injury: Immediate very sensitive injury response White matter < axon response > after injury: Delayed compared to gray Axonal death after 24 hours compression Timeline neurologic injury Timelines established for cord contusion models (Tator, Ducker, Bohlmann, Carlson) Impact: Bioelectrical depolarization 1 0: Biochemical release 2 0: Alterations in blood flow 3 0: Tissue perfusion changes 4 0: Changes in cells 7-8 0 : Tissue necrosis PMN infiltration 50 0: Pathologic scarring, syrinx formation Timelines established for compression and contusion effects in several dog and rat models. (Delamarter et al 95) Immediate effect: Wallerian degeneration % SSEP recovery One hour: Isolated necrosis 72 % SSEP recovery 6 hours: Severe central necrosis, cell loss 29 % SSEP recovery 24 hours 1 week: Severe necrosis, cellular disorganization 9 % SSEP recovery Conclusions: For effective intervention if compression is primary injury mechanism decompression within 24 hours is desired based upon animal models. Human correlation is not well established. Cauda equina decompression recommended within 48 hours based on prevalent clinical data. Cord decompression for incomplete injuries recommended within 24 hours based on weak clinical evidence. 2.3 Neurologic Injury Types:

Formal classification: Frankel / ASIA Classification (1996) A: No motor or sensory function B: No motor function, but sensory intact C: Sensory intact, motor present but not useful
Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 7

D: Sensory intact, motor weakened (4/5) E: Sensory and motor intact E-R: Sensory and motor intact. Nerve root deficit ASIA motor score is used for quantification of motor function 100 points maximum, 5 points maximally for each of the 5 key muscle groups of each extremity Complete / incomplete / intact Complete - No preservation of motor and sensory function below level of injury (sensory level within 3 levels of SLI) , absence of sacral preservation (sacral sparing) after 48 hours, completion of spinal shock True complete injuries have very poor prognosis Root recovery at level of injury or below possible Incomplete any motor or sacral preservation, any sensory function below 3 segments of skeletal level of injury Concept of sacral preservation: Sparing of most central motor and sensory fibers in corticospinal and afferent tracts (sacral elements) may indicate incomplete SCI! Signs of sacral sparing are: 1. Hallux longus flexors functional 2. Perianal sensory function + S1, S2 dermatomes 3. Anal sphincter tone (spontaneous and resting) Cord syndromes o Complete spinal cord injuries o Incomplete spinal cord injuries o Central Cord Syndrome o Anterior Cord Syndrome o Posterior Cord Syndrome o Brown-Sequard o Root injuries 2.4 Incomplete Cord Injury Syndromes

Cervicomedullary syndrome Complete or incomplete paralysis Respiratory arrest Hypotension Loss of facial sensation Similar to Bells cruciate paralysis Mimics central cord syndrome Greater upper than lower extremity weakness Proximal weakness more pronounced than distal
Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 8

Variant: Hemiplegia cruciata (Wallenberg) Ipsilateral arm Contralateral leg weakness Central cord syndrome Usually affects cervical spine Arms worse than legs Recovery of ambulation Poor residual hand function Common mechanism: hyperextension in cervical spondylosis Anterior cord syndrome Posterior column function preserved Variable loss of motor function, pain sensation Ischemic mechanism (i.e. occlusion of Spinal artery) hypothesized Poor prognosis Posterior cord syndrome Extremely rare Motor, pain and light touch preserved Proprioception lost Brown Sequard lesion Hemi cord injury Penetrating injury mechanism common Ipsilateral motor loss and pain, contralateral loss of pain and sensation Conus medullaris syndrome Injury around thoracolumbar junction Areflexic bowel and bladder function Variable prognosis on recovery Frequently incomplete SCI Cauda equina syndrome Frequently incomplete lesion Chance for recovery (lower motor neuron) Return of bowel/bladder control variable Root injuries As lower motor neuron injury in general good prognosis with postganglionic injury Recovery particularly favorable for compressive lesions Repair of torn roots controversial
Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 9

2.5

Principles of SCI Treatment

Rogerss rules (1956) Avoid additional neurologic damage Stabilize injury Reduce deformity Decompress compressed neural elements Basic principles (2004) AIRWAY: Oxygenation BLOOD: Restore hematocrit CIRCULATION: Treat hypotension Implement Rogerss rules! Pharmacologic Treatment High dose I.V. steroids (methylprednisolone) administered within 8 0 from injury are considered treatment option for acute SCI management, but are neither standard of care, nor FDA approved for this indication. Purported benefit: Stabilization of neural membranes Decrease of secondary neurologic injury zone Potential to limit neurologic injury by halting neural membrane destruction Risks: Increased wound infection Increased GI-bleeding Diabetogenic Pulmonary distress Steroid psychosis Use of steroids for root injuriesor cauda equina syndrome is not supported by literature. Use of steroids for penetrating trauma is associated with higher complication rates and has been shown to have no neurologic benefit. Suggested dose (Bracken, NASCIS II trials) : IVPB Methylprednisolone if given within 3 8 hours from injury 30mg/kg loading 5.4 mg/kg/hr for 23 hours Lazaroids (membrane protective) and Gangliosides (nucleoproliferative) are investigational drugs with unclear efficacy. Current research is aimed at reducing neural cell apoptosis, neural gliosis and preventing neural regeneration blockade (no-go inhibitors).

Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 10

Sodium channel blockers stabilize neural membranes and aid in restoring electrolyte balance. Medications such as Riluzole have been shown to slow disease progression in amyotrophic lateralsclerosis. Hypothermia (systemic or local) , Naloxone, anticoagulants, CA-channel blockers are unproven and therefore not recommended. Stem cell therapy and nerve cable grafts as well as nano scaffoldings are some of many experimental undertakings that are being studied in a variety of settings without regular clinical applications. 2.7 Functional SCI Outcomes (This section is not part of the lecture due to time constraints, however is included as courtesy to the audience and for completeness sake) C 1-4 Level Mechanical ventilation support (C1-3 pentaplegia) C-4 level commonly can use CPAP or BiPAP. C1-2 level patient has no headcontrol Early extubation and upright position may lead to pulmonary deterioration due to decrease of vital capacity with denervated diaphragm Mobility: Power wheelchair with tilt back Mouthsticks for C3-4 ok sip and puff devices for computer access 24o personal care maintenance necessary Manual wheelchair for back-up C 5 Tetraplegia Minimum 3/5 strength in biceps Mobility aids: - Opponens splint for feeding - Ratchet orthosis for patients with strong shoulder abduction - Freehand system (8-channel implanted stimulator) for grasp - Not able to transfer - Can operate power wheelchair with hand control - Driving modified van can be possible C 6 Tetraplegia Minimum 3/5 strength of ECRL and ECRB Can perform self catheterization, sometimes bowel program Mobility aids: - Partial assistance necessary - Consider for wrist-driven flexor hinge splint (tenodesis splint) - Writing with static splint possible
Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 11

Can get dressed in upper body, not lower body Independent transfers with sliding board can be achieved Manual wheelchair with knobs etc. for short distances Power wheelchair for longer distances Can be considered for tendon transfers, Freehand system

C 7 and C 8 Tetraplegia Minimum 3/5 strength in triceps (C 7) Minimum 3/5 strength in finger flexors (C 8) Mobility: - Possible to be independent with ADLs, transfers - Manual wheelchair useable - Able to live alone - Tenodesis splints not suitable (limit hand function) T 1 T12 Paraplegia Upper extremities and intercostals functional (T1-5) Abdominals functional from T6 caudalwards Mobility: - With good abdominal control limited ambulation possible - KAFO (cumbersome, household range) - IRGO (isocentric reciprocating gait orthosis) less energy consuming - FES (functional electrical stimulation) can be considered with upper motor neuron lesions L 1 L 3 Paraplegia Iliopsoas and quadriceps lowest functional motor units Mobility: - Manual wheelchair usual mode of transport - Short distance ambulation with KAFOs or IRGOs possible - Bladder / bowel function impaired L 4 Sacral levels Various levels of bowel and bladder control impairment Management of B/b is independent Mobility: - Ambulation with AFOs +/- crutches frequently possible Driving car without hand controls possible

Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 12

3. Cervical Spine Trauma

Anatomically and functionally C-spine consists of 2 regions: Upper C-spine (Occiput C2 vertebral body) Lower C-spine (C2/3 disc T1 vertebral body)

3.1 Imaging Basic C-spine radiology skills and norm values Standard views: - AP - Lateral (skull base to upper endplate T-1) - Open mouth odontoid - Trauma oblique (left and right) - Swimmers (if lateral insufficient) Specialized views: b. Flexion- extension (nonacute setting only) c. Pillar view (stable spine only) C-spine lateral :

Prevertebral soft tissue shadow : C2-3 < 6mm C5-7 > 14 mm Altered by intubation, crying

Dens angulation : Odontoid should be parallel to the atlas. Angulation implies transverse atlantal ligament (TAL) insufficiency.
Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 13

Wackenheims line : Screening study to assess cranio-cervical proportions. Drawn as caudal continuation from the clivus. Odontoid tip should be within 1 2 mm distance of this line. C1-3 spinolaminar line : Laminae of the atlas, axis and C-3 segments should form straight line with < 2 mm deviation. If abnormal consider Hangmans fracture or TAL disruption.

ADI (atlas-dens interval): Adult < 3 mm Child < 5 mm SAC (space available for cord): Adult > 13mm (Post. dens ant. lamina) DBI (dens basion interval): Adult < 12 mm in PAL (posterior axis line): < 4 mm anterior and < 12 mm posterior to the basion. Open mouth odontoid:

Visualizes: Occipital condyles C2-3 facet joints LADI (lateral atlas dens interval): < 2mm deviation left to right. Joint spaces: C 0-1 and C1-2 should be symmetric Rule of Spence: No overhang of C-1 lateral masses > 6,9mm overhang: TAL torn Odontoid: Helpful in identifying Type I and II fractures

Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 14

C-Spine AP:

Visualizes: C3-T3 Uncovertebral joints: Symmetric Alignment: straight Transverse processes: No Fx (Vertebral artery C1-C6) Lower C-Spine lateral: Basic principle: AAIA: Adequacy. Alignment, Interval, Angulation,

ALL (anterior longitudinal line): Homogeneous continuity PVL (Posterior vertebral body line): Translation < 3.5mm PLL (Posterior laminar line): No splaying or stepoffs Spinous processes: No interspinous splaying Facet joints: No unroofing Inferior vertebral body endplates: Angulation < 11o Limitations of plain X-rays -Transition zone injuries (Occipitocervical , cervico-thoracic) most frequently missed! -Visualize cervico-thoracic junction (pull-down, swimmers or CT) -CT with sagittal and coronal reformats for unclear odontoid -Prefer no flexion/extension XRs in ER setting -Stability exam with F/E in postprimary F/U CT-Scan (Indications)
Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 15

Any Fx / ligamentous injury Inability to visualize area of spine radiographically Unclear anatomy on radiographs Suspected occipitocervical trauma Unclear cervico-thoracic junction Unexplained neuro deficit Attempt to date injury Post myelography SPIRAL CT (aka helical) as screening study (less definition than conventional CT) Conventional CT for known fxs (1.5 - 2 mm thickness) MRI (Indications) For all incomplete deficits Skeletal level of injury (SLI) different from neurologic injury level (NLI) Suspected spinal canal mass (i.e. HNP) prior to reduction Spinal cord injury without radiographic abnormalities (SCIWORA) Suspected neoplastic or infectious disorder Prediction of SCI severity (Cotler 92) Assessment of ligament disruption (Cohen 94) TC-99 Bone scan Rare indication Pediatric indication most common (i.e. physeal fracture) Not sensitive before 48 72o postinjury Useful to assess for occult fractures 3.2 Upper C-Spine Injuries (Occiput - C2) Osseous Structures Occiput Atlas Axis / Odontoid Key Cranio - cervical Ligaments Tectorial membrane Alar ligaments Anterior Occipito-atlantal and atlanto-axial membrane Transverse atlantal ligament Joint capsules Occipital condyle Fxs Classification: Anderson and Montesano 90 Type 1: Basilar skull Fx into condyle
Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 16

Type 2: Type 3:

Comminuted impaction fx Avulsion alar ligament

Clinical pointers: Frequently missed CT diagnosis on skull CT Types I, II usually stable Type III may infer AO dissociation Treatment Mostly stable Halo or brace for Types I or II Consider occult AOD in Type III avulsions Atlanto - occipital dissociation Traynelis '73 Types: Anterior Posterior Vertical Mixed Clinical pointers: Frequently not survived Frequently missed (60 %) High incidence of 2nd neuro deficit in case of missed injuries Look for unusual neurologic injury presentation Cranial nerve, brainstem lesions Completely unstable > 1mm displacement Do not apply traction (Sandbags preferable) Treatment : Commonly fatal Traction contraindicated Frequently missed Increasing survival rates at trauma centers Emergent rigid occipitocervical fusion preferred

Atlas fracture
Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 17

Levine 91

o o o o o o

Isolated bony apophysis fracture Isolated posterior arch fracture (stable) Isolated anterior arch fracture (stable) Comminuted lateral mass fracture Burst fracture, three or more fragments (aka Jefferson) Anterior ring blowout (unstable)

Clinical pointers: Atlas serves as washer between occiput and axis TAL insufficient if > 6.9mm lat. mass overhang C1 on C2 (Rule of Spence) Indicator fracture: If atlas fractured 50% incidence of other spine fx Treatment: Isolated anterior or posterior ring Fxs are usually stable, can be treated with collar Remember to look for additional spine trauma (50% incidence, sentinel Fx) Burst Fx ( 3- or 4 part) usually are treated with traction followed by Halo. ORIF or decompression very rarely, if ever, indicated. If TAL is insufficient (Rule of Spence) choice is either Halo for 3-4 months followed by F/E XR, or primary C1-2 arthrodesis. Anterior ring blow-out requires C1-2 fusion Lateral mass Fxs commonly are treated nonoperatively. If nondisplaced treat with brace, if displaced closed reduction with traction followed by Halo. Risk of late pain, malunion and arthrosis.

Odontoid fracture Anderson, dAlonzo, 73

Type I: Fracture of odontoid tip (Congenital dysplasia vs. trauma)

Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 18

Type II:

Type III:

Waist Fx (Initial displacement important) Nonunions up to 75% described with cons. Rx Body Fx (cancellous surface)

Clinical pointers: Type I: potential AOD (alar ligament avulsion) Type II: Up to 30 % miss rate reported Always unstable fracture Without treatment nonunion is expected outcome Important treatment modulators: - Initial Fx displacement >5mm (Only consistent factor) - Fx angulation > 9mm (inconsistent factor) - Age > 60 y.o. (inconsistent factor) Treatment: Type I Rule out AOD, os odontoideum True Type I very, very rare. Nonop Rx for true Type I (brace) Type II High nonunion rates with any form of nonop Rx (20 85%) Halo most common nonop modality. Check recumbent and upright XR for stability Accept closed reduction only if > 60% Fx site overlap, and no distraction ROM reduced by 50% or more after successful nonop Rx Decreased chances of successful nonop Rx with distraction > 5mm Anterior odontoid screw fixation favored for: Simple transverse Fx pattern at odontoid waist Acute Fx (<3 months) Choice of 1 or 2 screws (Sasso97) Good bone quality Primary C1-2 fusion favored for: Comminuted, oblique Fx pattern Geriatric patients Highly displaced Fx Nonunion or delayed union Type III If minimally displaced, brace acceptable. For displaced Fxs closed reduction and Halo recommended. Union rate is high Surgery rarely indicated (C1-2 fusion).

Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 19

Traumatic spondylolisthesis of the axis ( Hangmans Fx ) (Should be named Hanged mans Fx) Effendi,73, Levine and Edwards, 89

Type I: Nondisplaced fracture of the pars interarticularis Type II: Displaced fracture of the pars interarticularis Type II a): Displaced fracture of the pars interarticularis with disruption of the C2/3 discoligamentous complex Type III: Dislocation of C2-3 facets joints with fractured pars interarticularis Clinical pointers: Types IIa and III unstable injury pattern Neurologic injury risk generally low Healing rates of Type I and II injury types high Treatment Type I and II Brace or with increasing instability Halo Type IIa Preferred Rx is controversial Closed reduction with traction recommended. Attempted mobilization with Halo versus anterior cervical discectomy and fusion with instrumentation. For nonop Rx prolonged recumbency and traction may be necessary. Secondary neurologic deterioration is rare. Nonop Rx may lead to C2-3 instability and kyphosis Type III Posterior open reduction, internal fixation, C2-3
Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 20

Atlanto-axial Disruption 3 Subtypes based on disruption pattern (rotatory, sagittal and vertical) Group A: Rotatory atlanto-axial disruption Fielding and Hawkins 77

A B C D

Type I, rotation without translation Type II, unilateral lateral mass subluxation of 3 5 mm Type III, unilateral subluxation of greater than 5 mm Type IV, posterior displacement C1-2

Clinical pointers: Pediatric versus adult patient group Acute versus chronic timeline Differential Dx: Trauma versus retropharyngeal infection (Grisel syndrome) versus habitual or congenital deformity Integrity of TAL key to treatment Group B: Transverse atlantal ligament disruption (TAL) Dickman 96 Type I: Bony avulsion Type II: Midsubstance ligament tear Clinical pointers: Chances for healing of ligamentous tear with nonoperative treatment are poor. Group C: Distractive atlanto-axial disruption Vertical or rotatory dissociation Clinical pointers: Variant of AOD Traumatic tear of alar ligaments, atlanto-axial facet capsules, TAL High degree of associated mortality, high SCI Treatment: Group A (rotatory) If TAL intact closed reduction, inpatient observation, collar and FW XR to rule out instability. If TAL torn closed reduction followed by fusion
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Group B (TAL injury) Type I injuries (bony avulsion of TAL) can be treated with closed reduction, Halo, follow-up FE-Xr to assess stability Type II injuries (midsubstance ligament tears) usually require C1-2 fusion Group C (atlanto-axial dissociation) If survived C1-2fusion or Occipitocervical fusion

3.3 Lower C- Spine Injuries (C3-C7) Classification: Multiple classification systems, concepts. No consensus Low interobserver reliability. Poor relationship of classification to stability Skeletal Systems - Anatomic Holdsworth 70 Denis 83 Louis 85 Mechanistic Allen and Ferguson 82 Combined Bohlman 79 AO/ASIF/OTA 96 Moore and Anderson 06 SLIC 07

OTA 95: Suggested nomenclature / system Minor fractures and ligament injury - Spinous process fractures - Tear drop/extension avulsion - Undisplaced lateral man. fx - Isolated lamina fx - Ligament strain Facet Injuries - Perched Unilateral Bilateral - Dislocated Unilateral
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Bilateral - Fx Dislocation Unilateral Bilateral Severe Injuries - Flexion tear drop - Severe ligament injury - Compression fx - Burst fx AO/ASIF 97 A: AXIAL LOADING: Compressive lesions ( i.e. compression, burst Fxs ) B: BENDING INJURIES: Lesions with posterior distraction or extension injuries (i.e. facet dislocations) C: CIRCUMFERENTIAL INJURIES: Rotational injuries (i.e. complex fracure dislocations) Ligamentous Instability White, Southwick and Panjabi 76, 90 Element Ant. elements injured Post. element injured Sag. plane translation > 3.5 mm Sag. plane rotation > 110 Positive stretch test Medullary cord damage Root damage Abnormal disc narrowing Dangerous loading anticipated Point Value 2 2 2 2 2 2 1 1 1

Total of 5 points or more = unstable Three column concept: Louis, 1985 Anterior column = vertebral body Posterior left and right column facet joimts with lateral masses either side. Never validated anatomic model. Cervical Spinal Column Injury Severity Score (CISS) Four column concept Anderson and Moore, 2006, Spine Trauma Study Group (Vacarro 2007) There are 4 columns, anteriorly vertebral body and disc, left and right pillars and posteriorly interspinous ligaments and spinous processes. Each of four columns is
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assigned a severity 0-5 on intuitive basis. Combined (additive score of 10 or more is unstable injury and will likely require surgical stabilization.

Moore and Anderson, Spine 2006

Treatment: Cervical skeletal traction: Most efficacious initial management for cervical fracture-dislocations, indirect reduction of spinal canal compression and temporary stabilization of injury. Indications: Unilateral or bilateral facet dislocations with or without fracture Burst fractures Contraindications: AOD (see above) Distractive ligamentous injuries Patients with temporal or parietal skull fractures Patients with ankylosing spondylits or DISH Concern: Neurologic deterioration post reduction due to potential disc herniation compressing spinal cord. Disc herniation risk (Grant 99): Unilateral facet dislocation: 23 % Bilateral facet dislocation: 13 % Risk of neurologic deterioration: <1% Success of closed reduction: 92 % Suggested pathway: Neuro intact: MRI first (if readily available) Neuro deficit: Reduce first, then MRI Neuro unknown: MRI first (if readily available)
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Technique: Graphite Gardner Wells Tongs Use Halo ring for definitive Rx or in pediatric patients (<6 years) Make sure there is NO skull fracture or distractive spine injury 2.5 kg per level per increment in adults 5-10kg initial traction, after check proceed with 5 kg inreases Incremental XR and MD neuro check Total weight < 70% body weight No manipulation Early reduction with SCI preferred MRI prior to reduction in neuro intact suggested Goal: Decompression of spinal canal (indirect or direct) within 8o of injury or less Determination for surgical intervention based upon success of reduction Basic decision making Primarily ligamentous injuries usually heal poorly with nonop Rx Fxs with large cancellous surfaces usually heal well nonop Most patients with SCI require surgical stabilization consisting of decompression and fusion with rigid internal fixation (except SCIWORA, central cord injuries etc.) Poor nonop Rx prognosis: - Fx with ankylosing spondylitis - Patients with pulmonary disease - Geriatric patients - Patients with significant traumatic deformity - Displaced Type 2 odontoid Fxs - Patients with ligamentous injuries Soft neck collar No stability to neck For stable neck sprains etc. Neck collar (i.e. Philadelphia, Miami J, Aspen etc.) Suitable for postop care, stable, minimally displaced Fxs Cervico-thoracic orthoses (Minerva, SOMI) Improved cervico-thoracic stability Halo / vest - Most rigid external immobilization device - Stability most influenced by snug vest fit - Reduces motion of normal C-spine by 98 % - Snaking and loss of reduction common (48%) - Pins:
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Adults: 4 pins, 6 - 8 inch pounds Retighten once Children < 8 years: 6-8 pins 2 4 inch pounds Pin infection: Retighten once, if unsuccessful exchange Complications Supraorbital nerve injury Temporal fossa penetration (temporal artery!) Frontal sinus penetration Pin tract infection 12 42% (Garfin)

Surgery: - Simple principle: Treat anterior lesions anteriorly Treat posterior lesions posteriorly - Laminectomy alone destabilizes C-spine and is ineffective for decompression (Tencer89) - Surgeon preference - Multilevel surgery needed: treat posteriorly - Most unstable lower C-spine trauma can be stabilized anteriorly - Most unstable upper C-spine trauma is treated posteriorly (exception odontoid screw) - Combined anterior and posterior surgery is rarely indicated Indications for emergent surgery - Irreducible Fx-Dl with neural compromise - Residual mass effect on neural tissue with neurologic compromise: - HNP - Epidural hematoma - Depressed lamina Fx - Low velocity projectile in canal (controversial) Surgical timing - Emergent Rx rarely indicated - Mandatory 72o delay of surgery ( Marshall '86) no longer required - Safety of early management established (McLain99, Mirza99) 3.5 General C-spine Injury Treatment Algorithm
General Classification Occipital condyle Fx (Anderson, Montesano) Subtype
Type 1 Type 2 Type 3 R/o AOD

Subclass.

Recommended Rx
Brace, Halo Halo, fusion Fusion, Halo

Comment
If AOD fusion Traction test? Traction test

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Atlanto-occipital dissociation (AOD) (Traynelis)

Not relevant for treatment

Infant

Halo + Rotorest, Fusion + Halo Fusion +/- Halo Occ - C2 if transarticluar screw Occ - C3 if no transarticular screw "Sentinel" fracture Posttraumatic osteoarthritis ? Stability Reassess stability after Rx Treatment decision often delayed Variant of atlantoaxial dislocation Patient survival

Not relevant for treatment Adolescent,Adult

Atlas fractures

Posterior arch Isolated lateral mass Burst (Jefferson) Fx Transverse lig. Intact TAL bony avulsion TAL Ligament tear Atlanto-axial subluxation Subluxation vs. dislocation Type 1 Type 2 Type 3 Type 4 Age

Brace, Halo Brace, Halo Brace, traction - Halo Halo C1-2 Fusion C1-2 fusion

Anterior arch blowout

Atlanto-axial dissociation Atlanto-axial rotatory subluxation (Fielding)

C1-2 fusion,Occ-2 fusion Brace, NSAID, PT Traction, bracing Traction, brace, halo, fusion ORIF+ C1-2 fusion Brace C1-2 fusion Halo, Brace

R/o infection, Grisel's syndrome Delayed diagnosis, nonunion rate DDx: dysplasia Unreducible if ring fractured F/E XR's after brace

Transverse ligament ADI within "stable" zone tear

"Unstable" Type 1 Type 2 Type 3 Type 2 a (Hadley) Type 1 Type 2 Type 2 a (Levine) Type 3 Displacement

Odontoid fractures (Anderson, d'Alonzo)

R/o AOD Osteoporosis

Halo, ORIF with screw(s), C1-2 Fusion, brace Halo, brace, fusion (rare) C1-2 fusion Brace Brace,+/-traction,ORIF, ACDF C2-3 ACDF C2-3 ORIF, post fusion C2-3, PCF C1-3

Differentiate from type III Fx

Traumatic C-2 spondylolisthesis (Effendi)

Displaces more with traction

Axis vertebral body fractures

"Teardrop" Fx Lateral mass Fx

R/o occult ligament injury

Brace, Halo Brace, Halo,+/-traction

R/o hyperextensions Fx Posttraumatic osteoarthritis

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4. THORACOLUMBAR SPINE INJURIES 4.1 Clinical Assessment See Chapter on C-spine Trauma. Same principles apply. Note that 50% of TL Trauma occurs at TL junction Palpation of posterior midline is important component of assessment. Disruption of posterior elements is important diagnostic insight in regards to Rx choice. Remember that cord, conus and cauda equina injuries can have different consequences in terms of injury severity, management and prognosis 4.2 Radiographic Assessment Conventional Radiographs Primary radiographic workup and injury screening tool. Basic views: AP/Lat T-Spine AP/Lat L-Spine Pelvis ap Specific views: Transitional zone views: Swimmers view (increasingly substituted by helical (spiral CT) with reformats Coned down AP and lateral view T12/L1 L5/S1 lateral Pelvic views Pelvic in- and outlet views Judet projections (left and right) Sacrum lateral Computed Tomography (CT) Indicated in : Any trauma! Suspected neoplasia, infection Post-myelography Dating of injury

Obtain with sagittal and, if deemed helpful, coronal reformatted views. 3D CT reformats are rarely helpful. Myelography Always together with postmyelography study
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Suitable for patients requiring neuroimaging study if MRI contraindicated MRI unavailable Magnetic Resonance Imaging Indicated in: - Unexplained neuro deficit - Discongruous skeletal level of injury (SLI) and neurologic level of injury (NLI) - Screening tool in ankylosing spondylitis with possible fracture - Differential diagnosis trauma, neoplasia, infection - Assessment of posterior ligament injury (controversial in TL-Spine) Not necessary for routine TL Fx workup, even in presence of neuro deficit

4.3 CLASSIFICATION Concept of Stability Stable vs. Unstable (Nicoll, 49) Unclear prognostic characteristics Definition of Stability: White and Panjabi 77 and 90i: .. the loss of the spine under physiologic conditions to maintain relationships between vertebrae in such a way that there is neither damage nor subsequent irritation to the spinal cord or nerve root, and in addition, there is no development of incapacitating deformity or pain from structural changes. (White AA, Panjabi MM. Clinical Biomechanics of the Spine. W.B. Saunders, 1982, pp.219-244. Factors of Instability Neurologic status Pain Deformity Displacement Structural defects Compliance Prognostic factors Morphologic Systems: Column - concept (2-columns):Whitesides 77 (3-column): Denis 88 Theory:
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Anterior column = compression Posterior column = tension Middle column= no actual anatomic entity Injury to 2 or 3 of 3 columns = potential for instability Three Column concept (Denis)

POSTERIOR ANTERIOR Two Column system (Whitesides, Holdsworth) CT based classification system (AAOS preferred) McAffee 83 Wedge compression Stable burst Unstable burst Chance Fx Flexion-distraction Translational AO/ASIF (similar concept to C-Spine) Type A: Compressive Type B: Flexion distraction and extension Type C: Rotational Thoracolumbar Injury Classification and Severity Score (TLICS) (Vaccaro et al. 2005) Three major variables 1) Injury morphology (0-4 points) 2) Integrity of posterior ligament complex (PLC) (0-3 points)
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3) Neurologic status (0-3 points) Add point scores of each entity. Final score suggests treatment: Nonoperative treatment: 3 or less Operative Treatment: 5 or more TLICS 4: equivocal management

4.4

TREATMENT

Modulating Factors Neurologic status/development Strict spine precautions until disposition / Rx Associated injuries/age Body size (obesity) Bone mineral health (i.e. osteoporosis) Preexistant spinal conditions Anticipated patient compliance Comorbidity Compression Fxs T2-10: single level: observation multiple levels < 60 degrees CTLSO > 60 degrees PSIF T11-L5: Jewett / TLSO Stable Burst Fx Ongoing controversy as to definition Criteria for stable injury < 15 kyphosis, < 50% stenosis, < 40% wedging Ant/middle column failure Post. column intact Neurologically intact Level of injury Nonoperative Rx with hyperextension cast, TLSO Unstable Burst Fx Presence of any related neurodeficit Generally accepted characteristics (but not necessarily scientifically validated): > 50 % canal compromise > 50 % loss of vertebral body height > 30 o focal kyphosis
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Disrupted posterior elements (i.e. facet joint Fx) Treatment options Bedrest (Rotorest bed + DVT prophylaxis (6-12 weeks) Custom hyperextension TLSO (+/- period of bedrest) Risser cast Surgery Alternatives: Posterior, anterior or posterior/ anterior staged Flexion-distraction Injury Center of rotation in vertebral body Frequently misread as compression injuries Unstable injuries due to failure of posterior elements Conservative Rx commonly fails Posterior reduction and short segment fixation successful 30 60 % association with GI injuries (look for lap-belt sign)! Chance Injury Center of rotation anterior to vertebral body Lap-belt injury common Risk of higher level SCI High incidence of pediatric patients R/o GI injuries !!! Assess posterior elements -Pure ligamentous injury -Pure bony injury (pedicle, spinous process) -Mixed Conservative Rx (Hyoerextension cast): Neuro intact No GI injuries Mainly bony posterior injury Surgery If prerequisistes for nonop Rx are not met Interspinous wire in small children In older patients posterior spinal instrumentation / fusion Translational Injury (Shear Fx) Very unstable Usually associated with paraplegia Stable fixation important (may require anterior and posterior surgical stabilization)

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4.5 General TL Injury Treatment Principles Nonoperative measures Basically stable fractures can be mobilized in external support: Jewett brace for simple compression fractures CTLSO for T1-6 compression or burst Fxs Custom-molded TLSO for stable burst fractures (T6-L3) TLHSO for lower lumbar burst fractures (L4-S1) Bilateral pantaloon spica for nonop RX of complex sacral Fxs (controversial) Risser hyperextension cast suitable for nonop Rx of some unstable burst fractures, bony Chance injuries etc. If more unstable fracture consider prolonged bedrest (i.e. Rotorest bed) of 3-6 weeks with DVT prophylaxis prior to mobilization into upright Braces / casts / prolonged Rotorest bed care in general unsuitable for patients with severe chest injuries, sternal Fxs, very obese patients etc. Basic instrumentation concepts Goal of surgery: Complete decompression, anatomic realignment Most TL spine trauma can be initially treated with posterior instrumentation and fusion +/- neural decompression Posterior instrumentation options: - Conventional posterior multisegmental fixation: 3 levels above, 2 below injury - Short segment fixation: 1 level above, 1 below injury - Rod long, fuse short: Fusion extends one segment above, and one below, instrumentation goes beyond this, but requires removal 1 2 years later - Rod long / fuse short concept largely outdated - Short segment fixation associated with higher failure rates - Stable segmental fixation concepts generally preferred (i.e. pedicle screws or multisegment hook assembly) Neuromonitoring for patients with unknown neurostatus Early mobilization Bracing - TLSO helpful for SCI (trunk control) Early rehab for SCI Repeat neuroimaging for incomplete SCI Anterior surgery Indications: High grade burst fracture Insufficient anterior column Supplemental fusion for highly unstable fracture (rarely needed)

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Concept: Pros: Con: Traditional approaches: Higher bloodloss, longer surgery time than posterior Less biomechanical stiffness than most posterior constructs As stand-alone less suitable for osteopenic conditions Approach morbidity Multilevel surgery neither feasible nor realistic Possibly better neurologic recovery rates than posterior surgery alone (inconsistent findings) Anterior column reconstruction Anterior decompression Strutgrafting (ICBG, Allograft, Cage) Stabilization

Transthoracic (T4 T12) Thoracolumbar subpleural (T11-L1) Retroperitoneal (L1-S1) Transperitoneal approaches are NOT recommended for trauma Minimally invasive surgery is not Board Standard Posterior surgery: Indications: Most TL-fractures can be treated with posterior procedures High grade burst fractures, require either long posterior instrumentation and fusion or supplemental anterior decompression and fusion Short segment fixation for simple bending injuries Long segment fixation for highly unstable injuries (burst, dislocations etc.) Posterior decompression: Indirect (via distraction, realignment) Direct (laminectomy with ventral fragment disimpaction) Segmental fixation strongly favored Pedicle screw systems superior in biomechanics Caveat: Suspect trapped nerve roots and dural tear with displaced lamina fracture Standard, well tolerated approach Multilevel surgery readily possible Superior biomechanical stiffness to anterior stand-alone

Concept: Technique: Pros: Con:

Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 34

Indirect decompression via distraction is insufficient, destabilizing Posterior decompression of anterior canal compression is incomplete

Combined anterior decompression and posterior stabilization: Indications: - High grade burst fracture - Fracture dislocation - Corrective osteotomy of posttraumatic kyphosis Concept: - Staged surgery - Same day surgery in trauma impractical, rarely if ever necessary - Repeat plain CT - Anterior surgery on delayed basis

5. Sacral Fractures (This segment is provided as a courtesy to the audience and is not part of the lecture due to time constraints) Classification Three-Zone system (Denis 1988) This system correlates with incidence and type as well as frequency of neurologic injury Zone I injury: Alar fracture, injury lateral to sacral neuroforamina. L-5 root injury Zone II injury: Transforaminal fracture Zone III injury: Any sacral fracture extending into the spinal canal

Sublassification of Denis Zone III sacral fractures by Roy-Camille modified by Strange-Vognsen - Type 1: simple flexion deformity of the sacrum - Type 2: flexion and translational deformity - Type 3: complete translation of the upper to the lower sacral elements - Type 4 (Strange-Vognsen): Segmentally comminuted S1 vertebral body
Jens R. Chapman, M.D., University of Washington AAOS BoardReview Course, New Orleans, LA Review of Spine Trauma PAGE 35

5.2 Goals:

Treatment

Optimize chances for patient survival Assure pelvic ring and lumbosacral stability Protecting neural structures or optimizing their recovery potential in the presence of deficits.

Nonoperative management Options: Activity modification Bed-rest Brace or cast immobilization with unilateral or bilateral hip spica extensions Recumbent skeletal traction Duration: 8 to 12 weeks Decompression Techniques - Direct (fragment removal, laminectomy etc.) - Indirect (fracture reduction, ventral disimpaction, sacral kyphectomy) Surgical Stabilization Techniques - Assess anterior fixation needs first - Posterior pelvic ring stabilization - Transiliac threaded compression rods (largely outdated) - Iliac tension band plates (requires bilateral parasagittal approaches) - Sacral alar plating (small fragment plates inserted into ala lateral to posterior neuroforamina) limited usefulness due to frequent comminution and limited biomechanical stiffness - Open or percutaneous sacro-iliac screw fixation (for a wide variety of mildly and moderately displaced sacral fractures) - Galveston-type lumbo-iliac fixation techniques (for complex sacral H and U type fractures); newer systems allow for segmental screw fixation to ileum instead of rod placement. - Segmental lumbo-screw screw/rod fixation for lumbo-sacral dislocation
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6. REFERENCES Spinal cord injury Anderson PA, Bohlman HH. Anterior decompression and arthrodesis in patients with traumatic, complete motor cervical spine cord injury. Long term neurologic recovery in 51 patients. Part II. JBJS 74-A: 683-91, 1992. Bohlman HH, Eismont FJ. Surgical techniques of anterior decompression and fusion for spinal cord injuries. Clin Orthop 154:57-67, 1981. Bohlman HH, Anderson PA. Anterior decompression and arthrodesis of the cervical spine: long term motor improvement. Part I-Improvement in incomplete traumatic quadriparesis. J Bone Joint surg Am 1992;74:671-82. Bracken MB ea: A randomized controlled clinical trial of methylprednisolone in acute spinal cord injury: results of the second NASCIS. N Engl J Med 322:1405-1411, 1990 Bracken MB, Shepard MJ, Holford TR, et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlle Cardenas DD: Current concepts of rehabilitation of spinal cord injury patients. Spine: state of the art reviews Vol 13, No3: 53- 585, 1999 Chen TY, Dickman CA, Eleraky M, Sonntag VK. The role of decompression for acute incomplete cervical spinal cord injury in cervical spondylosis. Spine. 1998;23:2398-40 Frankel, HL, Hancock DO, Hyslop G, et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. Paraplegia 7:179-92, 1969. Gertzbein SK, Court-Brown CM, Marks P, Martin C, Fazl M, Schwartz M, Jacobs RR. The neurological outcome following surgery for spinal fractures. Spine 13:641-4, 1988. Heinemann AW, Yarkony GM, Roth EJ et al: Functional outcome following spinal cord injury: A comparison of specialized spinal cord injury center vs. general hospital shortterm care. Arch Neurl 46:1098-1102, 1989 La Rosa G, conti A, Cardali S et al.: Does early decompression improve neurological outcome of spinal cord injury patients? Appraisal of the literature using meta-analytical approach. Spinal Cord 2004; 42:503-12.

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Marshall LF, Knowlton S, Garfin SR, et al. Deterioration following spinal cord injury. A multicenter study. J Neurosurg. 1987;66:400-4. Mirza SK, Krengel WF, Chapman JR et al. Early versus delayed surgery for acute cervical spinal cord injury. Clin Orthop 1999;104-14. Oektenoglu BT, Benzel EC: Postinjury support in spinal cord injuries. Spine: State of the Art Reviews Vol 13, 451-468, 1999 Tator CH. Review of experimental spinal cord injury with emphasis on the local and systemic circulatory effects. Neurosurgery. 1991;37:291-302. Tator CH, Dunca EG, Edmonds VE et al: Complications and cost of management of acute spinal cord injury. Paraplegia 31:700-714, 1993 Vaccaro AR, Daugherty RJ, Sheehan TP et al. Neurologic outcome of early versus late surgery for cervical spinal cord injury. Spine 1997;22:2609-13. Waters RL, Adkins RH, Yajkura JS: Definition of complete spinal cord injury. Paraplegia 9:573-581, 1991 Cervical spine injuries Aebi M, Etter C, Coscia M: Fractures of the odontoid process. Treatment with anterior screw fixation. Spine, 14(10):1065-70, 1989. Alander DH, Andreychik DA, Stauffer ES: Early outcome in cervical spinal cord injured patients older than 50 years of age. Spine, 19(20):2299-301, 1994. Allen BL,Jr., Ferguson RL, Lehman TR et al.: A mechanistic classification of closed , indirect fractures and dislocations of the lower cervical spine. Spine 1982;7:1-27. Anderson LD, D'Alonzo RT: Fractures of the odontoid process of the axis. J Bone Joint Surg [Am], 56(8):1663-74, 1974. Anderson PA ea: Failure of the Halo vest to prevent in-vivo motion in patients with injured cervical spines. Spine 16: 501-505, 1991 Anderson PA, Montesano PX: Morphology and treatment of occipital condyle fractures. Spine, 13(7):731-6, 1988. Bellabarba C, Mirza SK, West GA, Mann FA, Dailey AT, Newell DW, Chapman JR. Diagnosis and treatment of craniocervical dislocation in 17 consecutive survivors during a 8 year period. J Neurosurg Spine 2006, 4(6): 429-440

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Blackmore CC. Evidence-based imaging evaluation of the cervical spine in trauma. Neuroimaging Clin N Am 2003;13:283-91 Bohlmann HH: Acute fractures and dislocations of the cervical spine, JBJS 61B:11191142, 1979 Brodke DS, Dailey AT: Upper cervical spine fractures in patients with spinal cord injury. Spine: State of the Art Reviews, 13(3):70-83, 1999. Brunette DD, Rockswold GL. Neurologic recovery following rapid spinal realignment for complete cervical spinal cord injury. J Trauma. 1987;27:445-7. Chapman JR, Anderson PA: Cervical spine trauma. In Frymoyer J. W., (ed.). The Adult Spine: Principles and Practice. Lippincott-Raven, hiladelphia, 1997. Chen TY, Dickman CA, Eleraky M, Sonntag VK. The role of decompression for acute incomplete cervical spinal cord injury in cervical spondylosis. Spine. 1998;23:2398-40 Clark CR, White AAd: Fractures of the dens. A multicenter study. J Bone Joint Surg [Am], 67(9):1340-8, 1985. Delamarter RB, Sherman J, Carr JB. Pathophysiology of spinal cord injury. Recovery after immediate and delayed decompression. J Bone Joint Surg Am. 1995;77:1042-9. Deliganis AV, Mann FA, Grady MS: Rapid diagnosis and treatment of a traumatic atlantooccipital dissociation. AJR Am J Roentgenol, 171(4):986, 1998. Dickman CA, Greene KA, Sonntag VK: Injuries involving the transverse atlantal ligament: classification and treatment guidelines based upon experience with 39 injuries. Neurosurgery, 38(1):44-50, 1996. Ducker TB ea : Timing of operative care in cervical spinal cord injury. Spine 9: 525-531, 1984 Effendi B, Roy D, Cornish B, Dussault RG, Laurin CA: Fractures of the ring of the axis. A classification based on the analysis of 131 cases. J Bone Joint Surg [Br], :319-27, 1981. Fehlings MG, Cooper PR, Errico TJ. Posterior plates in the managemnt of cervical instability: long term results in 44 patients. J Neurosurge 1994;81:341-9. Fielding JW, Hawkins RJ: Atlanto-axial rotatory fixation. (Fixed rotatory subluxation of the atlanto-axial joint). J Bone Joint Surg [Am], 59(1):37-44, 1977. Garfin SR, Botte MJ, Waters RL, Nickel VL. Complications in the use of the halo fixation device. J Bone Joint Surg [Am]. 1986;68:320-5.
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Garfin SR, Shackford SR, Marshall LF, Drummond JC. Care of the multiply injured patient with cervical spine injury. Clin Orthop. 1989;239:19-29. Grant GA, Mirza SK, Chapman JR, et al. Risk of early closed reduction in cervical spine subluxation injuries. J Neurosurg (Spine 1). 1999;90:13-18. Harris JH, Carson GC, Wagner LK: Radiologic diagnosis of traumatic occipitovertebral dissociation: 1. Normal occipitovertebral relationships on lateral radiographs of supine subjects. AJR Am J Roentgenol, 162(4):881-6, 1994. Harris JH, Jr., Carson GC, Wagner LK, Kerr N: Radiologic diagnosis of traumatic occipitovertebral dissociation: 2. Comparison of three methods of detecting occipitovertebral relationships on lateral radiographs of supine subjects. AJR Am J Roentgenol, Hoffman JR et al: Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. NEXUS Study Group. N Engl. J Med 343, 2000 Jeanneret B, Magerl F: Primary posterior fusion C1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation. J Spinal Disord, 5(4):464-75, 1992. Johnson RM, Hart DL, Simmons EF, Ramsby GR, Southwick WO: Cervical orthoses. A study comparing their effectiveness in restricting cervical motion in normal subjects. J Bone Joint Surg [Am], 59(3):332-9, 1977. Levine AM, Edwards CC: Fractures of the atlas. J Bone Joint Surg [Am], 73(5):680-91, 1991. Lieberman IH, Webb JK: Cervical spine injuries in the elderly. J Bone Joint Surg Br, 76(6):877-81, 1994. Loius R: Spinal stability as defined by the three-column spine concept. Anatomia Clinica 1985; 7:33-42 Magerl F, Seeman PS: Stable posterior fusion of the atlas and axis by transarticular screw fixation. In Weidner P. A., (ed.). Cervical Spine. Springer Verlag, New York, 322-7, 1987. Marshall LF, Knowlton S, Garfin SR, et al. Deterioration following spinal cord injury. A multicenter study. J Neurosurg. 1987;66:400-4. McGuire RA, Jr., Harkey HL: Primary treatment of unstable Jefferson's fractures. J Spinal Disord, 8(3):233-6, 1995. Mirza SK, Krengel 3rd WF, Chapman JR, et al. Early versus delayed surgery for acute cervical spinal cord injury. Clin Orthop. 1999
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Moore TA, Anderson PA: Classification of Lower cervical spine Injuries. Spine 2006, Supplement March 2006 ( in press) Nesathurai S. Steroids and spinal cord injury: revisiting the NASCIS 2 and NASCIS 3 Trials. J Trauma. 1998;45:1088-1093. Rizzolo SJ, Piazza MR, Cotler JM, Balderston RA, Schaefer D, Eismont FJ, Arena MJ, Green BA. Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets. Case report. J Bone Joint Surg Am. 1991;73:1555-60. Sasso R, Doherty BJ, Crawford MJ, Heggeness MH: Biomechanics of odontoid fracture fixation. Comparison of the one- and two-screw technique. Spine, 18(14):1950-3, 1993. Scher AT. Cervical spinal cord injury without evidence of fracture or dislocation. An assessment of the radiological features. S Afr Med J. 1976;50:962-5.. Standards for Neurological and Functional Classification of Spinal Cord Injury, Revised 1992. . Chicago: American Spinal Injury Association; 1992. Sutterlin CE, McAfee PC, Warden KE, Rey RM, Jr., Farey ID: A biomechanical evaluation of cervical spinal stabilization methods in a bovine model. Static and cyclical loading. Spine, 13(7):795-802, 1988. Tator CH. Review of experimental spinal cord injury with emphasis on the local and systemic circulatory effects. Neurosurgery. 1991;37:291-302. Traynelis VC, Marano GD, Dunker RO, Kaufman HH: Traumatic atlanto-occipital dislocation. Case report. J Neurosurg, 65(6):863-70, 1986. Vaccaro AR, Daugherty RJ, Sheehan TP, et al. Neurologic outcome of early versus late surgery for cervical spinal cord injury. Spine. 1997;22:2609-13. White AA, Southwick WO and Panjabi MM: Clinical instability of the lower cervical spine. a review of past and current concepts. Spine 1: 15-26, 1976. Thoracolumbar Spine Benson DR, Burkus JK, Montesano PX et al: Unstable thoracolumbar and lum,bar burst fractures treated with an AO fixateur interne. J Spinal Disorder 5:335-343, 1992 Bransford R, Bellabarba C, Thompson JH, Henley MB, Mirza SK, Chapman JR. Tha safety of fluoroscopy-assisted thoracic pedicle screw instrumentation for spine trauma. J Traum. 2006 60(5):1047-52.
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Chan DPK, ung NK, Kaan KT: Nonoperative treatment in burst fractures of the lumbar spine (L2-5) without neurologic deficit. Spine 18:320-325, 1993 Chapman JR, Anderson PA: Thoracolumbar spine fractures with neurologic deficit. Orthop Clin N Am 25: 595-612,1994 Denis F: Spinal instability as defined by the three-column spine concept in acute spinal trauma. Clin Ortho 189:65-76, 1984 Edwards CC, Levine AM: Early rod-sleeve stabilization of the injured thoracic and lumbar spine. Orthop Clin North Am 17:121, 1986 Gertzbein SD, Court-Brown CM: Flexion-distraction injuries of the l;umbar spine; mechanisms and classification. Spine 227:52, 1988 Holdsworth F: Fractures and fracture- dislocations of the spine. JBJS 52: 1534-1551, 1970 Jacobs RR, Asher MA, Snider RK. Thoracolumbar spinal injuries, a comparative study of recumbent and operative treatment in 100 patients. Spine 5:463-77, 1980. Levine AM, Bosse M, Edwards CC: Bilateral facet dislocations in the thoracolumbar spine. Spine 13: 630-640. 1988 Mirza SK, Mirza AJ, Chapman JR et al: Classifications of thoracic and lumbar fractures: rationmale and supporting data. JAAAOS 2003;20:364-77 McAfee ea: The value of CT in thoracolumbar fractures. JBJS 65: 461-473, 1983 McAffee PC, Bohlmann HH, Yuan HA: Anterior decompression of traumatic thoracolumbar fractures with incomplete neurologic deficit using a retroperitoneal approach. J Bone Joint Surg 67-A89, 1985 McHenry TP, Mirza SK, Wang J, Wade CE, OKeefe GE, Dailey AT, Schreiber MA, Chapman JR. risk factors for respiratory failure follwing operative stabilization of thoracic and lumbar spine fractures. J Bone Joint Surg Am. 2006 88(5): 997-1005. McLain RF, Spoiling E, Benson DR: Early failure of short segment pedicle screw instrumentation for thoracolumbar fractures. J Bone Joint Surg 75-A:162-167, 1993 Vaccaro AR, Lehman RA, Hurlbert J et al: A new classification of thoracolumbar injuries. The importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status Sacral Injuries
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Bellabarba C, Schildhauer TA, Vaccaro A, Chapman JR: complications associated with surgical stabilization of high-grade sacral fractures with spin-pelvic instability. Spine 2006;31 (11 Suppl) S80-88. Denis F, Davis S, Comfort T: Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop 227:67-81, 1988 Gibbons KJ, Soloniuk DS, Razack N: Neurogical injury and patterns of sacral fractures. J Neurosurg 72:889-893, 1990 Isler B: Lumbosacral lesions associated with pelvic ring injuries. J Orthop Trauma 4:1-6, 1990 Nork S, CB Jones, SP Harding, SK Mirza, MLC Routt Jr: Percutaneous stabilization of U-shaped sacral fractures using iliosacral screws: technique and early results. J Orthop Trauma 15: 1236-tbd, 2001 Routt MLC Jr, Nork SE, Mills WJ: Percutaneous fixation of pelvic ring disruptions. Clin Orthop 375:15-29, 2000 Roy-Camille R, Saillant G, Gagna G et al: Transverse fracture of the upper sacrum: Suicidal jumpers fracture. Spine 10: 88-845, 1985 Schildhauer TA, Josten Ch, Muhr G: Triangular osteosynthesis of vertically unstable sacrum fractures: A new concept allowing early weight-bearing. J Orthop Trauma 12: 307-314, 1998 Schildhauer TA, Bellabarba C, Nork SE, Barei DP, RouttML, Chapman JR. Decompression and lumbopelvic fixation. J Orthop Trauma 2006. 20:447-57. Simonian PT, Routt MLC Jr: Biomechanics of pelvic fixation. Orthop Clin N. America 28 (3): 351-368, 1997

Jens R. Chapman, M.D., University of Washington AAOS Board Review Course 2010

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Introduction 30%-60% of adults experience significant neck or radicular pain during lifetime Point prevalence 5-10% History of previous trauma to cervical spine increases risk of developing significant axial neck pain or radiculopathy 1. Axial Neck Pain Epidemiology o 30%+ of population has significant neck pain in lifetime o ~15% of population with chronic neck pain of > 6 months o ~5% of population has disabling symptoms Pathophysiology o Afferent nociceptors in facet joint synovium and degenerative intervertebral discs likely responsible for most neck pain o Loss of disc height, facet arthrosis, osteophyte formation, and listhesis can all contribute to pathological loading of facet joints and intervertebral disc o Fibromyalgia may be perceived as neck pain, often localizes to trapezium, associated with decreased blood flow, high resting muscle tension and intramuscular metabolic derangement o Although controversial because of the potential for secondary gain, cervical injury including whiplash as a risk factor for axial neck pain Presentation/Diagnosis o Cervical injury may precede onset of neck pain Significant neck pain after trauma common even in patients who have already settled resulting litigation presumably decreasing secondary gain o Axial neck pain should not be painful to palpation, and is likely to be worse in extension and/or rotation o Suboccipital pain suggests involvement of the occiput-C1 or C1-C2 level o Trigger points associated with fibromyalgia in the region of the cervical spine are located in the: occiput, lateral aspect of low cervical spine, trapezius and medial origin of the supraspinatus o Directed physical examination Range of motion of cervical spine often limited by spondylosis Palpation of trigger points as mentioned above to evaluate for fibromyalgia Also: lateral condyle, medial knee joint line, greater trochanter, medial 2nd rib and upper, outer quadrant of buttocks Complete sensory, strength, gait and reflex evaluation Although a patients pain may be predominantly in the neck, this does not preclude myelopathy or an unrecognized motor deficit o Anteroposterior, lateral, and lateral flexion and extension radiographs establish baseline evaluations and may show dynamic instability

o MRI is gold standard for evaluation of disc pathology such as annular injury, disc dessication and facet arthrosis but caution needed because of high prevalence of findings in asymptomatic population o Cervical discography is controversial but may provide guidance Obtaining negative control in adjacent, normal appearing disc essential to reliance on positive discogram to indicate surgery Multiple positive controls without a negative control should discourage surgical intervention, especially in young patients Treatment options o Natural History At 15 year follow-up with nonoperative care, 79% of patients had symptom improvement in comparison to pain level at presentation 43% were pain-free, 32% had moderate/severe pain Factors associated with persistent pain: severe pain on presentation, history of related injury Axial neck pain rarely progresses to myelopathy ~20% of patients presenting with severe pain will still be significantly disabled at 5 years o Conservative treatment ill-defined but successful given natural history May include: steroids, NSAIDs, narcotics, muscle-relaxants, PT Traction has not been shown to offer any benefit o Surgery Axial neck pain is a contraindication to cervical disc replacement Anterior cervical discectomy and fusion is the procedure of choice for carefully selected patients who fail nonoperative treatment Retrospective studies report good/excellent results in 60-80% with poor results in 5-20% Similar results extend to treatment of neck pain from cervical pseudoarthrosis if workup identifies no other pain generator Complications specific to condition o Adjacent level disease after cervical fusion may be unrelated to surgery and instead due to the natural history of multilevel cervical spondylosis

2. Cervical Radiculopathy Epidemiology o Lifetime prevalence 3.5/1000 o Yearly incidence ~ 8/10,000 o F>M o Incidence peaks in 50s and 60s and then declines Decline due to dessicated disc, reduced likelihood of herniation? Pathophysiology o Mechanical compression of nerve roots can result from several causes: Loss of disc height, facet arthritis, uncovertebral joint osteophytes, ligamentum flavum hypertrophy and disc herniation o Chemical irritation of nerve roots occurs with exposure to herniated nucleus pulposus

Mediated by TNF-alpha contained within degenerative disc o Foraminal stenosis and associated instability can cause symptom worsening with extension or rotation to the ipsilateral side as the neural foramen cross-sectional area decreases in these positions o Conversely, arm abduction causes relative lengthening of cervical roots and may result in pain relief Presentation/Diagnosis o Patients typically present with pain in a dermatomal distribution in upper extremity o Pain may be burning, sharp or electric, can be accompanied by motor weakness or sensory changes o Positional changes in foraminal area may lead patients to turn their head to the opposite side or abduct their arm overhead (shoulder abduction sign) o Neck pain also present in 80% o Directed physical examination Important to identify dermatomes/myotomes affected through history and physical examination to treat only symptomatic levels Spurlings test exacerbation of pain with extension and rotation of head toward painful side Complete sensory, strength, gait and reflex evaluation Patients may present with concomitant myelopathy Pain, motor and sensory dysfunction can also result from peripheral nerve entrapment and thoracic outlet syndrome which must be ruled out o MRI is gold standard for evaluation of nerve compression, pathology must correlate with dermatomal complaints when indicating surgery o EMG useful to differentiate cervical from peripheral nerve compression, Treatment options o Natural History 70-90% of patients have good outcome with nonoperative care Pain typically resolves within 6-12 weeks o Conservative treatment Early treatment brief course of narcotics if necessary, brief immobilization with soft collar, short steroid course may be helpful Later treatment may include: NSAIDs, muscle-relaxants, physical therapy and stretching o Surgery Anterior Approach - Fusion Indicated for soft disc herniation, bilateral symptoms, significant neck pain, kyphotic cervical alignment Usually not performed when addressing more than 3 levels as nonunion rates rise unless posterior instrumentation used Anterior plating increases stiffness, decreases nonunion rate, and allows earlier postoperative range of motion without a protective collar

Intervertebral spacer can be autologous or allograft structural bone graft, PEEK or mesh cages Good/excellent results in 70-90% of patients Worse results in smokers, females, patients with decreased cervical range of motion or worse preoperative disability Anterior Approach Cervical Disc Replacement FDA approved in 2007 although reimbursement difficult Surgical approach similar to ACDF Theoretical benefit of reducing adjacent level disease o Elimination of increased load seen by motion segment adjacent to fusion, not yet proven clinically Motion retained 2 years after surgery Similar clinical results to ACDF although better studies necessary Posterior Approach Indicated for soft posterolateral HNP, lateral recess or foraminal stenosis, facet arthropathy with posterior compression, > 3 level surgery Must have cervical lordosis for decompression to be effective (> 10) Decompression via laminectomy, laminoforaminotomy, or laminoplasty Posterior fusion/instrumentation can be performed using lateral mass screws or wiring o Lateral mass/pedicle screws not FDA approved o Complications specific to anterior approach Dysphagia common, usually self limited Esophageal perforation rare (<0.25%) but high mortality rate, especially when not recognized at time of surgery Recurrent laryngeal nerve palsy (up to 10% although often asymptomatic), left sided approach may be safer as nerve protected within tracheoesophageal interval o Complications specific to posterior approach Neck pain if fusion not performed secondary to spondylosis, preserved motion Wound complication rates higher than for anterior approach Postoperative kyphosis after laminectomy without instrumentation Nerve root palsy after posterior decompression, C5 most common 3. Cervical Myelopathy Epidemiology o Degenerative changes in the cervical spine are ubiquitous with aging o True incidence of cervical myelopathy is unknown and likely higher than expected because of the insidious and subtle nature of symptoms in early disease Pathophysiology

o Myelopathy likely with cord narrowing >40% or banana-shaped cord on axial MRI images o While degenerative changes often cause myelopathy in older population (most common at C5-6 and C6-7), younger patients may become myelopathic due to untreated HNP o Congenital stenosis (canal diameter <13mm) predisposes patients to myelopathy o Gait and bladder disturbances likely secondary to spinothalamic and pyramidal tract compression Presentation/Diagnosis o May present with isolated myelopathy or with radicular pain plus signs of cord compression o Typical history often includes: difficulty writing, trouble with buttons or zippers, dropping objects, gait disturbances or clumsiness, and falls o Directed physical examination very important in diagnosing myelopathy Evaluation of gait and balance Repetitive tasks such as rapid tapping of thumb and index finger pads or slapping thigh alternating between palm and dorsum of hand will be difficult and slow in patients with myelopathy Complete sensory, strength, and reflex evaluation May see clonus or hyperactive reflexes Radicular and myelopathic symptoms often coexist so can find sensory or motor deficiencies on examination Special signs Lhermittes sign electric pain in back of neck on flexion Babinskis sign great toe dorsiflexion on plantar stroke Hoffmans reflex thumb IP flexion with flicking of 3rd or 4th fingernail o Anteroposterior, lateral, and lateral flexion and extension radiographs Pavlov ratio to screen for congenital stenosis AP diameter canal/AP diameter body <0.8 is pathologic o MRI is gold standard for evaluation of neural impingement and may demonstrate cord signal changes with severe compression Prognostic value of cord signal changes unclear, however Treatment options o Natural History Insidious onset of symptoms with long periods of stability without deterioration These stable periods are punctuated by episodic worsening of symptoms after which a new functional baseline is established and function rarely regained ~5% have rapid onset of symptoms with no further progression Delay of 1 year in mild cases does not affect surgical outcome o Conservative treatment possible for elderly patients with minimal symptoms and in patients with severe medical co-morbidities May include: NSAIDs, physical therapy

Patients with myelopathy should avoid activities that will put them at risk for spinal cord injury given the reduced tolerance for trauma o Surgery Patients with mild symptoms may not benefit from surgery, especially in the elderly Indications based around level of disability, degree of pain Milder symptoms may be indication in younger patients, those with evidence of congenital canal stenosis on imaging Anterior surgical indications (ACDF or corpectomy): One to three affected levels Any number of levels with loss of cervical lordosis Should not be used for congenital stenosis or posteriorbased cord compression Significant axial neck pain Posterior surgical indications (laminectomy or laminoplasty): More than 3 affected levels with preserved lordosis Cervical kyphosis with concomitant anterior procedure Need wide decompression so laminoforaminotomy not indicated Technique and surgical considerations same as for radiculopathy Recovery of function depends on severity of preoperative myelopathy Complications specific to condition o Failure to decompress spinal cord if lordosis not preserved or iatrogenic kyphosis develops o Nerve root palsy related to posterior decompression, C5 most likely

3. Ossification of the Posterior Longitudinal Ligament (OPLL) Epidemiology o Predominantly found in patients of Japanese heritage but has been described in Caucasian and other Asian populations o Occurs in ~3% of adult Japanese, has been described in as many as 1.3% of patients in study performed in US o M>F o Incidence highest in sixth decade Pathophysiology o Human leukocyte antigen (HLA) haplotype is an important risk factor for development of OPLL indicating a strong genetic basis of disease o OPLL causes ossification with development of mature lamellar bone, not calcification as previously thought o No correlation with degenerative disc disease although OPLL can occur with diffuse idiopathic skeletal hyperostosis o Associated with diabetes mellitus Presentation/Diagnosis o Often asymptomatic o Presenting symptoms usually include mylopathic features but radiculopathy may also be present

o Directed physical examination Evaluation of gait, balance and repetitive tasks Complete sensory, strength, and reflex evaluation May see clonus or hyperactive reflexes Radicular and myelopathic symptoms often coexist Special signs associated with myelopathy: Lhermittes sign, Babinskis sign, Hoffmans reflex o Anteroposterior, lateral, and lateral flexion and extension radiographs Characteristic radiodense strip along posterior vertebral bodies with disc space preservation Occupation of >60% by OPLL carries high risk of myelopathy o CT useful because of bony nature of lesion o MRI is necessary for evaluation of neural impingement although OPLL itself not always easily distinguished on MRI Treatment options o Natural History Degree of spinal compression may not change over long periods of follow-up Only ~15% of patients with OPLL with become myelopathic o Conservative treatment often employed for asymptomatic OPLL or with mild symptoms because of slow progression May include: Cervical orthosis, physical therapy o Surgery Indicated with significant or progressive myelopathy or in patients in whom OPLL occupies >60% of spinal canal Anterior surgery with corpectomy for removal or decompression of OPLL, especially with convex-posterior OPLL lesions or kyphosis Posterior surgery using laminectomy or laminoplasty in patients with involvement of multiple levels or congenital stenosis Complications specific to condition o C5 nerve palsy seen in ~10% after anterior or posterior decompression o Iatrogenic kyphosis after laminectomy, laminoplasty to lesser degree

Introduction >70% of adults in developed countries suffer from back pain at some point in their lives Annual incidence 15-45% M=F; most common 35-55 y/o Total cost of LBP in US >$100 billion annually including treatment, lost wages Only 5% of patients develop chronic pain, these patients represent 85% of cost 1. Lumbar Herniated Nucleus Pulposis (HNP) Epidemiology o 2% of general population will experience symptomatic HNP o 5% recover in 1 month o 96% fully functioning by 6 months (surgical and nonsurgical) o 19% of patients with sciatica ultimately require surgery Pathophysiology o Annulus fibrosis and posterior longitudinal ligament cannot contain NP o 3 potential pain generators: Mechanical breech/stretch of annulus innervated by sinuvertebral nerve of Lushka low back pain at site of HNP Mechanical compression of nerve root Referred pain into buttocks, down leg Chemical irritation of nerve root TNF- mediated Referred pain into buttocks, down leg o HNP can be: central, posterolateral, foraminal, extraforaminal Presentation/Diagnosis o Low back pain may precede HNP as disc degeneration often present o Referred pain is sharp, lancing pain along dermatomes or myotomes that classically radiates distally from buttocks o Pain worsens with activities that increase intradiscal pressure (i.e. bending forward in seated or standing position) o May be accompanied by paresthesias, weakness, bowel/bladder symptoms o HNP can present as cauda equine syndrome large central herniation o Directed physical examination Loss of lumbar lordosis Paravertebral muscle spasm Percussion of sciatic notch may reproduce sciatica Complete sensory, strength, and reflex evaluation to document/localize abnormalities Straight leg raise or Laseques Test nerve root stretch between 30 and 70, foot dorsiflexion increases sciatic nerve excursion Contralateral straight leg raise test highly suggestive of HNP if positive, may be best test to identify contralateral axillary HNP o MRI is gold standard for imaging, gadolinium if previous spinal surgery Treatment options o Natural History 70-90% of patients have full recovery within one month

Herniated material decreases in size with time based on long-term imaging studies o No decline in results after surgery if observe for 3 mo, worse results after 1 year of observation o Conservative treatment ill-defined but should not include bedrest May include: steroids, NSAIDs, narcotics, muscle-relaxants, PT o Surgery Decompressive Technique: laminectomy vs. laminotomy vs limited exposure laminotomy microdiscectomy Discectomy vs. limited discectomy SPORT HNP Trial Patients treated with laminotomy or in nonsurgical arm o Nonsurgical arm: PT, home exercise, NSAIDS o High rates of patient crossover between groups As treated analysis: Surgical benefit at 4 years vs. nonsurgical arm for ODI (~13 pt difference) and SF36 scores (~16 pt difference for PF and BP subscores) o Difference exceeded previously established Minimum Clinically Important Differences (MCID) Complications specific to condition o Recurrence common (~10% at same level)

2. Lumbar Stenosis Epidemiology o Incidence increases in 5th and 6th decade of life for degenerative stenosis, most commonly seen in 4th decade for patients with congenital stenosis o M=F o Prevalence in population >50 years old as high as 0.5% o Most common preoperative diagnosis for spine surgery in US Pathophysiology o Canal shape influences central canal volume, 3 described normal variants: Round, Ovoid, Trefoil (least volume 15% of population) o Degenerative/acquired stenosis most common Most common at L3-4 and L4-5 Later presentation due to acquired morphologic changes: Facet hypertrophy from degenerative joint disease Ligamentum flavum thickening Disc bulging/herniation o Congenital stenosis Pedicles shortened, lamina and facet joints thickened Earlier presentation Common in achondroplasia because of limited physeal growth o Combination of degenerative and congenital stenosis Patients with short pedicles have less room to spare before degenerative changes cause neural compression

Presentation/Diagnosis o Asymptomatic patients commonly have radiographic evidence of stenosis so nature of symptoms critical for diagnosis o Insidious onset of diffuse back pain o Leg pain typically develops later May present as cramping, sharp pain, burning, pins & needles Pseudoclaudication walking exacerbates pain, improves with rest Radicular pain seen with lateral recess stenosis, localizes to affected nerve roots o Leaning forward classically improves pain by increasing canal diameter o Other less common symptoms: weakness, incontinence, UTI, priapism, perineal numbness, urinary retention (rare) o Directed physical examination Forward posture when walking/standing Complete sensory, strength, and reflex evaluation If present, weakness common in L5/S1, sensory changes in L4/L5 Asymmetric reflexes more common in central stenosis patients Often have paucity of physical exam findings o MRI is gold-standard imaging method to evaluate neural impingement o Radiographs with flexion, extension helpful in evaluating associated listhesis, instability for treatment decisions Treatment options o Natural History At medium-term follow-up, 15-25% of patients worse, 50-70% unchanged with conservative treatment of mild/moderate stenosis o Pharmacologic therapy: NSAIDs, gabapentin, narcotics (acute pain only) o Epidural steroids have been reported to provide relief at 1 year in 50-60% of patients with less reliable long-term results o No definitive studies of therapeutic exercise but weight loss helpful o Surgery Laminectomy Laminotomy SPORT Lumbar Spinal Stenosis Trial Patients treated with laminectomy or in nonsurgical arm High rates of patient crossover between groups As-treated analysis: benefit to surgery vs. nonsurgical arm at 2 years, sustained at 4 years for ODI (~9 pt difference) and SF36 scores (~13 pts difference for BP, ~9 pts for PF) o Differences exceeded MCID Complications specific to condition o Instability preserve as much of facet as possible, fuse if more than 50% of both facets removed or if take one joint entirely during decompression o Postoperative neurological injury more common with laminotomy vs. laminectomy but uncommon in both types of surgery

3. Lumbar degenerative spondylolisthesis

Epidemiology o Rarely seen in patients younger than 40 years old, typically in 6th decade o Predominantly occurs in women, ~ 6:1 female to male ratio Pathophysiology o Reason for female predominance unclear, proposed explanations: Ligamentous laxity Hormonal effect o Facets are more sagittally oriented in patients with degenerative spondylolisthesis Unclear if this is a primary or secondary effect o Most common at L4-5 (85% of cases) o Anterior translation of one vertebral body on another results in an effective stenosis as spinal canals no longer line up o Degenerative spondylisthesis rarely progresses beyond Grade I slip which represents <25% translation of one body on the next Presentation/Diagnosis o Symptoms and presentation often identical to that of spinal stenosis o Patients typically have neurogenic claudication or radicular symptoms with antecedent back pain o Directed Physical Examination same as for spinal stenosis When present, weakness and sensory changes most often localize to L4-5 level as this is most common spondylolisthesis level o MRI valuable to evaluate degree and source of neural element compression o Radiographs with flexion/extension useful for documenting the amount of listhesis and associated instability to guide treatment options o Radiographic evidence of listhesis and clinical symptoms often have little correlation - radiographic pathology must match clinical impression Treatment options o Natural history At medium term follow-up, most patients do not deteriorate clinically and most do not have progression of listhesis o Conservative therapy: NSAIDs, gabapentin, narcotics, PT, steroids o Surgery Decompression is mainstay of surgical intervention Laminotomy, laminoforaminotomy, laminectomy Preoperative imaging will help determine if decompression alone is sufficient or if patient will also require fusion Factors which may suggest fusion should be performed: Wide bilateral decompression necessary which may lead to instability if level not fused Preoperative instability on flexion/extension films Severe associated degenerative changes If necessary, fusion with instrumentation (vs. fusion in situ) is associated with higher fusion rates and better long-term results despite higher early complication rates

SPORT Spondylolisthesis Trial Patients with single-level spondylolisthesis treated with laminectomy fusion or in nonsurgical arm Fusion either instrumented or in situ per surgeons decision High rates of patient crossover between groups As treated analysis: Significant benefit at 4 years for surgical intervention as measured by ODI (~14 pt difference) and SF36 (~15 pt difference BP, ~19 pt for PF) o Differences exceeded MCID o Complications specific to condition Slip progression and clinical deterioration in patients with instability or who undergo wide decompression without fusion Neurologic deficit in high grade slips (rare) that undergo reduction

4. Degenerative scoliosis Epidemiology o Prevalence unknown because often asymptomatic, estimated up to 6% o Mean age >60 years old o M=F for de novo degenerative scoliosis Pathophysiology o Adult degenerative scoliosis can be due to: Untreated AIS with degenerative progression De novo from degenerative disease asymmetric disc wear and facet joint incompetence o Associated stenosis common due to degenerative changes: 90% of de novo adult scoliosis patients have stenosis symptoms vs. 30% in adult AIS patients not due to scoliosis alone Presentation/Diagnosis o Symptoms are same as for lumbar spinal stenosis back pain and claudicatory leg pain, radiculopathy often related to foraminal stenosis on concave side of curve o With extreme deformity, ribs may abut iliac crest o Sagittal and coronal imbalance create gait difficulty, reliance on cane o Directed Physical Examination Posture often demonstrates loss of lumbar lordosis Radicular symptoms may be relieved when patient holds their trunk in straightened position using arms Assess coronal and sagittal balance with plumb line Complete sensory, strength, and reflex evaluation although as for spinal stenosis, neurologic findings rare o MRI valuable to evaluate degree of neural element compression o Standing full-length spine radiographs with bending/traction films o DEXA scan can be useful in preoperative planning Treatment options o Natural History:

Well-studied in untreated AIS Thoracic curves >50 progress ~1 per year Thoracolumbar and lumbar curves >50 progress ~0.5 per year Progress not well characterized for de novo degenerative scoliosis Association between curve magnitude and symptoms controversial o Decision regarding operative vs. nonoperative treatment should consider: Symptoms/quality of life General health - complication rates very high compared to other degenerative conditions/surgical intervention o Nonoperative treatment symptomatic use of NSAIDs, general conditioning, treatment of osteoporosis, use of brace (symptomatic relief only, will not prevent progression) o In addition to symptoms, surgical indications may include: cosmesis, and coronal or sagittal imbalance o Surgical decision making should consider symptoms, curve flexibility, osteoporosis, other degenerative changes at levels adjacent to curve, comorbidities o Goals in order of priority: correct imbalance, pain relief, reduce risk of subsequent degenerative deformity o Surgical options: Decompression alone (rarely) Posterior-only fusion (increasingly common with all-pedicle screw constructs) Anterior-posterior fusion may be necessary with rigid deformity or when anterior column support is necessary to restore lordosis Consider pelvic fusion Complications specific to condition o Medical complication rates high in patients who undergo long fusions because of magnitude of surgery and relative postoperative immobility during lengthy recovery period o Adjacent level disease can be prevent by not ending fusion at degenerative disc in middle of thoracic kyphosis if thoracic spine included in fusion o Nonunion Iliac fixation for fusions to sacrum increases fusion rate, especially important with a long construct or poor bone quality

5. Discogenic pain Epidemiology o As many as 90% of patients 50+ have radiographic evidence of lumbar disc degeneration but little correlation with symptoms o Degenerative disc disease accounts for ~25% of lumbar fusions in US Pathophysiology o Traditionally, environmental factors such as heavy lifting, vibration exposure and smoking have been implicated as causative factors

o Role of genetics being increasingly recognized, probably provides most of individual susceptibility to disease o Posterior aspect of intervertebral disc innervated by sinuvertebral nerve, nociceptive nerve ingrowth into normally aneural disc with degeneration o Intradiscal environment undergoes variety of molecular changes Decreased collagen II, aggrecan production Extracellular matrix degradation due to upregulation of matrix metalloproteinases Increased cell senescence, apoptosis o Little capacity for repair because of low disc cellularity and vascularity Presentation/Diagnosis o Low back pain with radiation into buttocks, posterior thighs, nondermatomal o Symptoms may be worse with sitting and prolonged walking, relieved with supine position o No neurogenic claudication unless concomitant lumbar stenosis o Directed Physical Examination Range of motion of lumbar spine limited, painful No relief with forward flexion, may exacerbate pain because of increase in intradiscal pressure in this position Otherwise, physical examination often normal o MRI will show disc dessication with loss of T2 signal, loss of disc integrity and disc height These findings are nonspecific, widespread in asymptomatic population especially in age 50+ Endplate changes (Modic) have been associated with painful degeneration but this relationship is not well-established o Discography controversial but is the only diagnostic modality which helps determine whether a degenerative appearing disc is actually painful Obtaining negative control in adjacent, normal appearing disc essential to reliance on positive discogram to indicate surgery Poor instrument in patients with secondary gain because of test subjectivity Treatment options o Interventional procedures Intradiscal electrothremal therapy, intradiscal radiofrequency thermocoagulation No evidence of significant therapeutic benefit over sham treatment o Lumbar fusion Meta-analyses comparing fusion with nonoperative treatment for isolated degenerative disc disease have had mixed results, some favoring surgery and some finding no difference o Lumbar total disc replacement (TDR) Studies comparing lumbar fusion and total disc replacement including the IDE trials prior to TDR approval found no significant differences in outcome between groups at medium term

Long term results, however, not yet known Complications specific to condition o Lack of clinical success Clinical success rates as defined by FDA for the IDE trails of TDR was achieved by only ~55% of patients, ~45% for fusion group Success= no device failure, no major complications, no neurologic deterioration, >25% decrease in ODI for Charite trial, similar for ProDisc trial

Annotated Bibliography Lumbar Spine: Herniated Nucleus Pulposus 1. Bozzao A, Galucci M, Masciocchi C et al. Lumbar disk herniation: MR imaging assessment of natural history in patients treated without surgery. Radiology 1992; 185:135141. Repeat MRI 11 months after initial MRI in 69 patients treated conservatively for HNP demonstrated >70% HNP resorption in ~48%, 30%-70% resorption in 15%, no change in 29% and increased disc fragment size in 8%. 2. Olmarker K, Rydevik B. Selective inhibition of tumor necrosis factor-alpha prevents nucleus pulposus-induced thrombus formation, intraneural edema, and reduction of nerve conduction velocity: possible implications for future pharmacologic treatment strategies of sciatica. Spine. 2001; 26(8):863-869. A series of investigations in a porcine model established the role of TNF-alpha as the principle agent in HNP which causes chemical irritation of the nerve roots. TNF-alpha blocking agents were demonstrated to mitigate the effects of HNP on nerve roots. 3. Wang JC, Line E, Brodke DS et al. Epidural injections for the treatment of symptomatic lumbar herniated discs. J Spinal Disord 2002; 15:269-272. This retrospective study of patients who had failed noninvasive conservative treatment and were amenable to surgical treatment for HNP demonstrated good short-term results of transforaminal steroid injections with 77% of patients avoiding surgery at 1.5 years after enrollment. 4. Weinstein JN, Tosteson TD, Lurie JD et al. Surgical vs. Nonoperative Treatment for Lumbar Disk Herniation The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial. JAMA. 2006; 296(20): 2441-2450. The initial report from the SPORT HNP trial presents only intention-to-treat analysis which was limited by patient crossover. Significant improvements for primary outcome measures were seen in both operative and non-operative treatment groups, demonstrating non-significant trends toward improved outcomes in the operative group. 5. Weinstein JN, Tosteson TD, Lurie JD et al. Surgical Versus Nonoperative Treatment for Lumbar Disc Herniation: Four-Year Results for the Spine Patient Outcomes Research Trial (SPORT). Spine. 2008; 33(25): 27892800. The as-treated four-year follow-up for the SPORT trial demonstrated significantly improved results in SF36, ODI for the operative group vs. the non-operative group.

Lumbar Stenosis 1. Cuckler JM, Bernini PA, Wiesel SW et al. The use of epidural steroids in the treatment of lumbar radicular pain: A prospective, randomized, double blind study. J Bone Joint Surg Am 1985;67:63-66. A blinded RCT found equivalent results between epidural steroid injection and placebo injection in patients with lumbar stenosis at follow-up of 1 year with 75% of patients in the steroid group reporting significant residual pain at 1 year follow-up. 2. Johnsson KE, Rosn I, Udn A. The natural course of lumbar spinal stenosis. Clin Orthop Relat Res 1992; 279:82-86. Patients untreated for lumbar spinal stenosis were followed out to 4 years; ~70% of patients had stable symptoms, ~15% improved and ~15% worsened without intervention. 3. Boden SD, Davis DO, Dina TS et al. Abnormal magnetic-imaging scans of the lumbar spine in asymptomatic subjects: A prospective investigation. J Bone Joint Surg Am 1990; 72:403-408. This study established the high rate (21%) of asymptomatic subjects older than 60 with evidence of spinal stenosis on MRI emphasizing the importance of history, physical examination and clinical correlation in the diagnosis of spinal stenosis. 4. Weinstein JN, Tosteson TD, Lurie JD et al. Surgical versus Nonsurgical Therapy for Lumbar Spinal Stenosis. N Engl J Med 2008;358:794-810. The first SPORT lumbar spinal stenosis report demonstrated improved results for surgical treatment in terms of SF-36 bodily pain scores in the intention-to-treat analysis and improved results for both SF-36 and ODI scores in the as-treated analysis at 2 years after surgery. 5. Weinstein JN, Tosteson TD, Lurie JD et al. Surgical Versus Nonoperative Treatment for Lumbar Spinal Stenosis Four-Year Results of the Spine Patient Outcomes Research Trial. Spine 2010; 35(14):1329-1338. The 4 year SPORT follow-up study found advantages for surgical treatment using astreated analysis with respect to SF-36 and ODI scores.

Lumbar Degenerative Spondylolisthesis 1. Matsunaga S, Sakou T, Morizono Y et al. Natural history of degenerative spondylolisthesis: Pathogenesis and natural course of the slippage. Spine 1990; 14;12041210. This study reports the natural history of untreated lumbar degenerative spondylolisthesis over follow-up of more than 8 years on average and demonstrates clinical deterioration in only 10% of patients and little slip progression. 2. Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis: A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 1991; 73:802-808. A prospective study that first established the superior results obtained when patients with spondylolisthesis are treated with fusion as opposed to decompression alone. 3. Kornblum MD, Fischgrund JS, Herkowitz HN et al. Degenerative lumbar spondylolisthesis with spinal stenosis: A prospective long-term study comparing fusion and pseudoarthrosis. Spine 2004; 29:726-733. Patients treated for spondylolisthesis with posterolateral fusion and developed pseudoarthrosis had inferior results to those achieved solid fusion. 4. Weinstein JN, Tosteson TD, Lurie JD et al. Surgical versus Nonsurgical Treatment for Lumbar Degenerative Spondylolisthesis. N Engl J Med 2007;356:2257-70. The 2 year follow-up data from the SPORT spondylolisthesis trial found no significant differences between surgical and non-surgical treatment in the intention-to-treat analysis likely due to patient cross but significant advantage to surgical treatment in terms of SF36 and ODI scores. 5. Weinstein JN, Tosteson TD, Lurie JD et al. Surgical Compared with Nonoperative Treatment for Lumbar Degenerative Spondylolisthesis: Four-Year Results in the Spine Patient Outcomes Research Trial (SPORT) Randomized and Observational Cohorts. J Bone Joint Surg Am. 2009;91:1295-304. Four years after the SPORT trial began, the as-treated analysis demonstrated maintenance of the benefit to surgery at 4 year follow-up in all primary outcome measures (SF-36, ODI).

Degenerative Scoliosis 1. Kostuik JP, Bentivoglio J: The incidence of low-back pain in adult scoliosis. Spine 6:268273, 1981. A correlation between curve magnitude and back pain was established although for the population of patients with curves > 10 on the whole, incidence of back pain is similar to the general population it becomes more prevalent at higher curve magnitudes. 2. Lenke LG, Bridwell KH, Blanke K, Baldus C: Prospective analysis of nutritional status normalization after spinal reconstructive surgery. Spine 1995; 20:13591367. Adult patients who underwent surgery for spinal deformity at an average of ~6 levels took 6 weeks to return to their baseline nutritional status where patients who underwent surgery at an average of 12 levels took ~13 weeks to return to baseline nutritional status. 3. DeWald CJ, Stanley T: Instrumentation-related complications of multilevel fusions for adult spinal deformity patients over age 65: Surgical considerations and treatment options in patients with poor bone quality. Spine 31:S144S151, 2006. Complications in patients older than age 65 who underwent 5 level fusions are reviewed. A ~25% rate of junctional kyphosis was reported and >10% of patients suffered early complications related to bone quality including pedicle or compression fractures. 4. Kim YJ, Bridwell KH, Lenke LG et al. Pseudarthrosis in long adult spinal deformity instrumentation and fusion to the sacrum: Prevalence and risk factor analysis of 144 cases. Spine 2006; 31:23292336. Factors identified to be associated with pseudoarthrosis in the adult deformity population included: thoracolumbar kyphosis, osteoarthritis of the hip joint, thoracoabdominal approach, positive sagittal balance 5 cm at 8 weeks postoperatively, age 55 years and incomplete sacropelvic fixation. 5. Schwab F, Farcy JP, Bridwell K et al. A clinical impact classification of scoliosis in the adult. Spine 2006;31:21092114. A classification system for adult-onset scoliosis was created in which scores correlate with measures of disability and rates of surgical intervention. Parameters considered by the classification include curve location (e.g. thoracic, thoracolumbar etc.), degree of lumbar lordosis, lateral vertebral subluxation and sagittal balance.

Discogenic Pain 1. Boden SD, Davis DO, Dina TS et al. Abnormal magnetic-imaging scans of the lumbar spine in asymptomatic subjects: A prospective investigation. J Bone Joint Surg Am 1990; 72:403-408. 35% of asymptomatic patients between 20 and 39 and 100% of asymptomatic patients older than age 60 had signs of disc degeneration on MRI emphasizing the importance of clinical judgement in treating degenerative disc disease in the lumbar spine. 2. Huang RC, Lim MR, Girardi FP, et al. The prevalence of contraindications to total disc replacement in a cohort of lumbar surgical patients. Spine 2004;29(22):253841. This retrospective study demonstrated that very few patients are eligible for lumbar total disc replacement when strict guidelines are applied to potential candidates. 3. Freeman BJ, Fraser RD, Cain CM et al. A Randomized, Double-Blind, Controlled Trial: Intradiscal Electrothermal Therapy Versus Placebo for the Treatment of Chronic Discogenic Low Back Pain. Spine 2005; 30(21): 23692377. This RCT found no difference between IDET and sham procedure at 6 months and no benefit to either treatment over baseline for 5 different validated outcome measures. 4. Freemont AJ. The cellular pathobiology of the degenerate intervertebral disc and discogenic back pain. Rheumatology 2009;48:510. This review article presents the biological basis for disc degeneration and identifies strategies to leverage our knowledge of disc biology in the development of new treatment. 5. van den Eerenbeemt KD, Ostelo RW, van Royen BJ et al. Total disc replacement surgery for symptomatic degenerative lumbar disc disease: a systematic review of the literature. Eur Spine J 2010;19:12621280. Results from 3 RCTs and 16 prospective studies comparing total disc replacement and lumbar fusion are analyzed. Overall, results are similar between TDR and lumbar fusion for degenerative disc disease and have low success rates overall for this challenging disease entity.

Cervical Spine: Axial Neck Pain 1. Bogduk N, Windsor M, Inglis A. The innervation of the cervical intervertebral discs. Spine 1998; 13:2-8. Dissection provided insight into the innervation of the disc by the sinuvertebral nerve adjacent to the canal and by the vertebral nerves further laterally. Histologic staining demonstrated innervation of only the outermost 1/3 of the annulus fibrosis. 2. Gore D, Sepic S, Gardner G, Murray P. Neck pain: A long term follow-up of 205 patients. Spine 1987; 21:1-5. A long-term retrospective study of patients treated conservatively for greater than 10 years after presenting with neck pain demonstrated decrease in pain compared with on presentation in 79%. 32% still had moderate/severe pain and 43% were pain free. 3. MacNab I. Acceleration injuries of the cervical spine. J Bone Joint Surg Am 1964; 46:1707-1799. This classic article established a high rate of neck pain in post-whiplash patients (45%). Interestingly, this group of patients had all definitively settled litigation related to their accident a minimum of 2 years prior to evaluation, a factor hoped to eliminate secondary gain influences on the reporting of symptoms. 4. Zheng Y, Liew SM, Simmons ED. Value of magnetic resonance imaging and discography in determining the level of cervical discectomy and fusion. Spine 2004; 29(19):2140-5. MRI was found to have a high rate of false negative and false positive results based on discography. 59% of both discs with HNP and discs with annular tears had positive discography. Use of clinical suspicion, MRI and discography together is recommended. 5. Palit M, Schofferman J, Goldthwaite N, et al. Anterior discectomy and fusion for the management of neck pain. Spine 1999;24:2224-8. This retrospective study of patients treated for axial neck pain demonstrates 79% of patients were satisfied postoperatively. Although significant improvement in VAS and ODI were reported, ~40% could not work postoperatively - expectations must be tempered in comparison to patients treated for radiulopathy. 6. Zdeblick TA, Hughes SS, Riew KD, Bohlman HH. Failed anterior cervical discectomy and arthrodesis. Analysis and treatment of thirty-five patients. J Bone Joint Surg Am. 1997; 79(4):523-32. A series of patients undergoing revision ACDF included 23 patients with nonunion and 16 of these with significant neck pain who failed conservative treatment. Results were excellent in 20/23 demonstrating that appropriately indicated patients who failed initial surgical treatment and present with neck pain can do well after revision fusion surgery.

Cervical Radiculopathy 1. Muhle C, Resnick D, Ahn JM et al. In vivo changes in the neuroforaminal size at flexion-extension and axial rotation of the cervical spine in healthy persons examined using kinematic magnetic resonance imaging. Spine 2001; 26: e287-93. MRI was used to visualize neuroforaminal area increase of 31% with neck flexion, decrease of 20% with neck extension and decreases of 15% and 23% with 20 and 40 of rotation, respectively. 2. Murata Y, Onda A, Rydevik B et al. Changes in pain behavior and histologic changes caused by application of tumor necrosis factor-alpha to the dorsal root ganglion in rats. Spine. 2006;31:530-5. A series of investigations established the role of TNF-alpha as the principle agent in HNP which causes chemical irritation of the nerve roots demonstrated in this paper by both behavioral and histologic data in rats. 3. Henderson CM, Hennessy RG, Shuey HM, Shakelford EG. Posterior-lateral foraminatomy as an exclusive operative technique for cervical radiculopathy: A review of 846 consecutively operative cases. Neurosurgery 1983; 13:504-512. In addition to reporting 91% good/excellent results, this large study reports presenting symptoms of cervical radiculopathy as a reminder of the symptom diversity: 99% arm pain, 85% sensory deficit, 80% neck pain, 70% reflex changes, 68% motor weakness, 52% scapular pain, 18% chest pain, 10% headache, 6% anterior chest/arm pain. 4. Robinson R, Walker A, Ferlic D. The results of anterior interbody fusion of the cervical spine. J Bone Joint Surg 1962; 44:1569-1587. This classic paper is the first large series describing outcomes after ACDF using the technique described by Robinson & Smith and reports 73% good/excellent resultswith 22% fair and 6% poor. These numbers have largely been confirmed in subsequent series. 5. Wang JC, McDonough PW, Endow KK, Delamarter RB. Increased fusion rates with cervical plating for two-level anterior cervical discectomy and fusion. Use of anterior plates in 2 level ACDF was associated with decreased rate of pseudarthrosis and less graft collapse in comparison to ACDF performed without anterior plating in this retrospective study. A similar conclusion was found in a subsequent paper for 3 level ACDF. 6. Krupp W, Schattke H, Muke R. Clinical results of the formainotomy as described by Frykholm for the treatment of lateral cervical disc herniation. Acta Neurochir 1990; 107:22-29.

Retrospective evaluation of 230 patients demonstrated good results in: 98% of patients treated for soft disc lesions, 91% of patients with mixed hard/soft lesion, and 84% of patients treated for hard disc lesions.

Cervical Myelopathy 1. Lees FT, Turner JW. Natural history and prognosis of cervical spondylosis. BMJ 1963; 2:1607-1610 . The natural history of 44 patients treated nonoperatively is described. Patients presenting with severe myelopathy remained severely disabled, and the overall natural history was characterized by shorter periods of symptom progression with intervening periods of symptom stability. 2. Hukuda S, Wilson CB. Experimental cervical myelopathy: effects of compression and ischemia on the canine cervical cord. J Neurosurg. 1972; 37: 631-652. Cervical spinal cords in dogs were compressed to determine the amount of compression which would cause myelopathic-like symptoms 45%. This study also demonstrated the role that restriction of blood flow during cord compression plays in cord injury. 3. Pavlov H, Torg JS, Robie B, Jahre C. Cervical spinal stenosis: determination with vertebral body ratio method. Radiology. 1987;164:771-5. Measurement of cervical spine lateral radiographs in athletes who suffered transient neuropraxia established a spinal canal diameter/vertebral body diameter ratio of 1.0 as normal and <0.8 as consistent with cervical spinal stenosis and an elevated injury risk. 4. Emery SE, Bohlman HH, Bolesta MJ, Jones PK. Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy. Two to seventeen-year follow-up. J Bone Joint Surg Am. 1998;80:941-51. Results after operative treatment are heavily dependent on preoperative function. The strongest predictive factor for recovery from myelopathy was the severity of the myelopathy before the operative intervention. 5. Hilibrand AS, Fye MA, Emery SE et al. Increased rate of arthrodesis with strut grafting after multilevel anterior cervical decompression. Spine 2002; 27: 146-151. A comparison of multi-level ACDF with corpectomy and strut grafting demonstrated higher fusion rates in corpectomy and strut grafting. The authors attributed this to fewer bony interfaces to heal and greater healing/stability with strut recession into a trough. 6. Imagama S, Matsuyama Y, Yukawa Y et al. C5 palsy after cervical laminoplasty: a multicentre study. J Bone Joint Surg Br. 2010; 92(3):393-400. This study identified factors associated with C5 palsy in a cohort of 43 patients who developed postoperative C5 palsy out of 1858 total patients (2.3%) treated with laminoplasty. Factors identified were smaller C5 neural foramen, larger superior articular process and more postoperative posterior shift of the cord after decompression.

Ossification of the Posterior Longitudinal Ligament 1. Matsunaga S, Sakou T, Taketomi E et al. The natural course of myelopathy caused by ossification of the posterior longitudinal ligament in the cervical spine. Clin Orthop. 1994; 305:158-177. This study with an average follow-up of greater than 10 years demonstrated 66% of patients remained free of myelopathy and ~40% of patients who were myelopathic on presentation demonstrated symptom progression. 2. Harsh GR 4th, Sypert GW, Weinstein PR et al. Cervical spine stenosis secondary to ossification of the posterior longitudinal ligament. J Neurosurg. 1987; 67(3):349-57. Although OPLL is often considered an exclusively Japanese disease, this report documents OPLL in 17 non-Asian Americans seen over 3 years at two hospitals in California and Florida, 10% of the myelopathic patients seen during that time period. 3. Ono K, Yonenobu K, Miyamoto S, Okada K. Pathology of ossification of the posterior longitudinal ligament and ligamentum flavum. Clin Orthop Relat Res. 1999;(359):18-26. A description of the pathophysiology of OPLL is provided and the role of BMP and TGF in pathogenesis is discussed. 4. Matsunaga S, Sakou T, Hayashi K et al.Trauma-induced myelopathy in patients with ossification of the posterior longitudinal ligament. J Neurosurg 2002; 97(supp2):172-175. Out of a cohort of patients with OPLL, the only patients who developed myelopathy without a history of trauma had >60% of their canal occupied by OPLL confirming this amount of compression as a threshold for the development of neurological symptoms. 5. Yamaura I, Kurosa Y, Matsuoka T et al. Anterior floating method for cervical myelopathy caused by ossification of the posterior longitudinal ligament. Clin Orthop 1999; 359:27-34. This technique paper describes the floating method and reports 71% rate of neurological recovery in a cohort of Japanese patients treated for OPLL.

Pediatric Spine AAOS Review Course

David L. Skaggs, MD,
Professor and Chief of Orthopaedic Surgery Childrens Hospital Los Angeles University of Southern California School of Medicine Endowed Chair of Pediatric Spinal Disorders

www.childrensorthopaediccenter.com
4650 Sunset Blvd, #69 Los Angeles, California, 90027 323-361-4658 fax 323-361-1310

I.

Idiopathic scoliosis a. Definition = coronal plane deformity of >10 degrees by Cobb method with no known cause. i. Normal thoracic kyphosis is 20-45 degrees with normal lumbar lordosis of 30-60 degrees. ii. Genetics: autosomal dominance with variable penetrance. b. Infantile Idiopathic scoliosis = Age 0-2 years at onset i. Males>female ii. Risk of progression overall 10%. Those curves with apical rib-vertebra angle difference (RVAD) or Mehta angle greater than 20 degrees, and apical rib phase 2 (overlap of the rib head with the apical vertebral body) are at the greatest risk of progression. iii. Most common curve location is in thoracic spine with 75% of curves being left convex, iv. 22% of patients with curve >20 degrees have neural axis abnormality, of which approximately 80% will require neurosurgical care. v. can dramatically impair alveolar growth and thoracic cage development causing significant cardiopulmonary impairment with restrictive lung disease, and possibly cor pulmonale. vi. AVOID long spine fusion <8years vii. Patients with RVAD >20 degrees and Cobb angle >30 degrees are at high risk of progression. Bracing or casting should be considered when the Cobb is >20-30 degrees. viii. Growing implants may help pulmonary function, weight gain, etc

To measure the rib-vertebra angle difference (RVAD), a line is drawn perpendicular to the end plate of the apical vertebrae (a). Next, a line is drawn from the midpoint of the neck of the rib through the midpoint of the head of the rib to the perpendicular on the convex side (b). The resultant angle is calculated. The angle on the concave side is calculated in a similar manner. Concave convex = RVAD. Mehta MH: The rib-vertebra angle in the early diagnosis between resolving and progressive infantile scoliosis. J Bone Joint SurgBr 1972;54:230-243.)

ix.

Spine problems in children

David L. Skaggs, MD

i.

Thoracic insufficiency syndrome (TIS) is defined as the inability of the thorax to support normal respiration or lung growth, and is usually associated with significant scoliosis (idiopathic or congenital), a shortened thorax, rib fusions or rib aplasia, or poor rib growth (Jeunes syndrome) . Jarco-Levin syndrome, extensive congenital fusions of the thoracic spine, is a common cause of TIS, with two important subtypes: spondylothoracic dysplasia (primarily vertebral involvement) and spondylocostal dysplasia (fused or missing ribs). Left untreated TIS can cause significant cardiopulmonary insufficiency or an early demise.

c.

Juvenile Idiopathic scoliosis = Age 3-10 years at onset i. 95% of curves will progress. Incidence of neural axis abnormalities is 20-25%; hence MRI necessary. ii. Bracing is usually started for juveniles with curves >20 degrees, and adolescents >25 degrees; smaller curves are treated with observation.

d. Adolescent Idiopathic scoliosis i. Polygenetic interaction is suspected ii. Female:male ratio is 1:1 for small curves, but increases to 10:1 for curves >30 degrees. 1. Risk of progression related to curve size and remaining skeletal growth, 2. Girls at greatest risk for progression are premenarchal, Risser grade 0, with open triradiate cartilage. 3. Peak height velocity generally occurs prior to Risser 1. Peak height velocity in adolescence is approximately 10 cm/year and occurs just prior to the onset of menses in females. iii. Long-term implications of scoliosis is dependent upon the size of curve at skeletal maturity. Thoracic curves >50 degrees and lumbar curves >45 have been shown progress up to a mean of 1 degree/year after skeletal maturity. iv. Larger curves >60 degrees can have a negative impact on pulmonary function tests but symptomatic cardiopulmonary impact traditionally develops in curves >90 degrees. v. A mild increase incidence of backpain is likely in significant curves in adulthood e. Evaluation i. Scoliometer measurement >5 degrees, 2-5% false negative rate of missing curve >20 degrees and a 50% false positive rate (curve <20 degrees) ii. Physical examination should include detailed neurological examination of lower extremities (sensory exam, motor exam and reflexes). Skin evaluation should inspect for caf-au-lait spots (neurofibromatosis).. Lower extremity evaluation should rule out cavovarus feet (associated with neural axis abnormalities), and document normal strength, gait and coordination. Hairy patches, dimples, nevi, tumors, over the spine or may be indicative of spinal dysraphism. Dimples outside of the gluteal fold are generally benigh. Asymmetrical abdominal reflexes are associated with a syrinx, and an indication for an MRI of the spine. iii. iv. Plain radiographic evaluations include 36 inch cassettes in the posterioanterior (PA) and lateral projections in the upright position. Bending or traction films are useful for surgical planning. v. Indications for MRI of spine to rule out an intraspinal anomalies (tethered cord, syringomyelia, dysraphism, and spinal cord tumor) include atypical curve patterns (e.g. left thoracic curve, short angular curves, absence of apical thoracic lordosis, absence of rotation and congenital scoliosis), patients <10 years of age with a curve >20 degrees, abnormal neurologic finding on examination, abnormal pain, rapid progression of curve (>1 degree/month). Intraspinal anomalies are referred for evaluation by neurosurgeon.

Spine problems in children

David L. Skaggs, MD

f.

Classification 1.

Adolescent (>10 years of age): Accounts for 80% of IS. Prevalence is 2-3% for curves 10-20 degreees and 0.3% for curves greater than 30 degrees. ii. Curve location: cervical (C2-C6), cervicothoracic (C7T1), thoracic (T2-T11/12 disc), thoracoluumbar (T12-L1) and lumbar (L1-2 disc to L4). iii. Classification of adolescent idiopathic scoliosis 1. King - not commonly used 2. Lenke classification has 6 major curve types with modifiers for the lumbar curve and amount of thoracic kyphosis (T5-T12).

Spine problems in children

David L. Skaggs, MD

g.

Treatment recommendations are based on the natural history of scoliosis. i. Non-operative 1. Bracing is used for skeletally immature patients (Risser 0, 1 or 2) and recommended for 16-23 hours/day and continued until completion of skeletal growth or curve progresses to greater than 45 degrees (at which point bracing is no longer considered effective). Aim of bracing is to halt progression of curve during growth, not to correct scoliosis. Thoracic hypokyphosis is relative contraindication for bracing. Underarm brace or thoracolumbosacral orthosis (TLSO) is most effective when curve apex at T7 or below. The efficacy of brace treatment is controversial. ii. Operative 1. Thoracic curves >45-50 degrees. 2. Lumbar Curves > 45 degrees or marked trunk imbalance with curve >40 degrees (relative) 3. Spine fusion with spinal implants and bone graft is gold standard. Posterior more common than anterior. 4. Complications a. Crankshaft phenomena: Progression of spine deformity after a solid posterior fusion due to continued anterior spinal growth. Can be avoided by concomitant anterior spine fusion at the time of posterior fusion. b. Infections occur in up to 5% of cases. Early infection (<6 months post-op) is treated with irrigation and debridment, and antibiotics, without removal of implants as fusion is assumed to not have occurred. Chronic deep infections of the spinal implants are treated with implant removal and intravenous antibiotics, though progression of deformity over time may occur. c. Neurologic injury has an incidence of up to 0.7%as a result of compressive, tensile or vascular phenomenon. Current recommendations are for intra-operative spinal cord monitoring of SSEP and NMEPs. d. Decreased pulmonary function has been reported following anterior fusions and posterior thoracoplasties. Thoracoscopic approaches to the thoracic spine have less negative impact on pulmonary function than open thoracotomy. Similarly open anterior thoracolumbar fusions have less impact than open thoracic fusion. 5. Spinal cord monitoring a. Spinal-cord monitoring is current standard of care utilizing both somatosensory evoked potentials (SSEP), which will detect many but not all neurologic difficulties, and motor evoked potentials (MEP), which can detect neurologic injury earlier than SSEPs. Monitoring of the upper extremities with SSEPs can identify positional injury to the upper extremity, which is the most likely intraoperative neurologic deficity to be reversible. b. When spinal cord monitoring suggests neurologic injury: i. suspect technical problems 1. loose electrodes 2. uses inhalational agents ii. real neurological problems

Spine problems in children

David L. Skaggs, MD

1. 2. 3. 4. 5. 6.

if changes occurred following deformity correction, reverse or lessen the correction raise blood pressure if hematocrit is low give a blood transfusion give intravenous steroids (i.e. solumedrol 30 mg/kg bolus, and 6.5mg/kg x 23 hours wake-up test if all else fails, remove instrumentation if spine is stable.

II.

Congenital scoliosis a. Overview (Epidemiology) i. Genetics: No specific inheritance pattern; isolated occurrences. ii. Estimated incidence in general population is 1-4%. b. Pathoanatomy i. Divided into three categories: failure of formation, failure of segmentation and mixed. 1. Unilateral unsegmented bar associated with a contralateral hemivertebra has the worst prognosis for development of scoliosis. 2. Best prognosis are the block vertebra (bilateral failure of segmentation). 3. Presence of congenital vertebral anomaly in thoracolumbar region with fused ribs have a high risk of progression. 4. Incarcerated hemivertebrae do not cause scoliosis as deficiencies above and below the hemivertebrae compensate.

ii. Progression of deformity correlates with growth which is rapid the first 3 years of life.

Spine problems in children

David L. Skaggs, MD

c.

Evaluation i. Associated systemic abnormalities are present in up to 61% of patients with vertebral anomalies: congenital heart defects (26%), congenital urogenital defects (21%), limb abnormalities (hip dysplasia, limb hypoplasia, Sprengels deformity), anal atresia, hearing deficits, and facial asymmetry. Approximately 38-55% of patients with vertebral anomalies present with a constellation of defects that constitute a syndrome, such as VACTERL (formally called VATER) (vertebral anomalies, anorectal anomalies, cardiac defect, tracheoesophageal fistula, renal and vascular anomalies, and limb defects) and Goldenhar syndromes (dysplastic or aplastic ears, eye growths or absent eye, asymmetric mouth/chin, usually affecting one side or face). Work-up of patient with congenital scoliosis includes renal evaluation (MRI or ultrasound) and cardiology evaluation. ii. MRI is indicated for patients with congenital spinal deformity due to the incidence of neural axis abnormality in 20-40% (Chiari type 1 malformation, diastematomyelia, tethered spinal cord, syringomyelia, low conus and intradural lipoma). MRI in young children who would require general anesthesia may be delayed if the curve is not progressive or requiring surgery. Treatment i. Non-operative: Bracing has no effect on the congenital scoliosis. . ii. Operative 1. Indications: significant progression of scoliosis, or known high risk of progression such as a unilateral bar opposite a hemi-vertebrae, declining pulmonary function and neurologic deficit. 2. Contraindications to operative intervention includes poor skin at operative site, minimal soft tissue coverage over spine, and significant medical comorbidities. 3. Procedures a. Unilateral unsegmented bars with minimal deformity are best treated with early in situ arthrodesis, either anterior and posterior or posterior alone., . b. Progressive fully segmented hemivertebra in children <5 years of age with <40 degree curve without notable spinal imbalance have traditionally been treated with an in situ anterior and/or posterior contralateral hemiepiphyseodesis with hemiarthrodesis. c. Hemivertebra excision is recommended for patients with progressive curve with marked trunk imbalance caused by a hemivertebra This technique has the best results when patients <6 years of age with flexible curves<40 degrees. d. Anterior and/or posterior osteotomy/vertebrectomy approaches for more severe, rigid deformities, fixed pelvic obliquity or decompensated deformities that present late. e. Growing rod constructs may attach to the spine and/or ribs and attempt to control deformity and encourage spinal growth. Better results are reported with lengthening the construct about every 6 months 4. Complications a. Iatrogenic shortening of spinal column due to fusion. Younger age at surgery and more levels fused creates greater impact on growth. The goal of growth constructs is to optimize spinal growth. b. Neurologic injury can occur secondary to overdistraction or overcorrection, harvesting of segmental vessels, spinal implant intrusion into the canal

d.

Spine problems in children

David L. Skaggs, MD

III.

Soft-tissue problems over the spinal implants. These children often have minimal subcutaneous tissue volume to safely pad the implants, especially those with pulmonary compromise. Pre-operative nutrition maximization is vital. 5. Pearls and pitfalls. a. Due to the significant number of children with congenital scoliosis which have concomitant cardiopulmonary, renal and neurological issues a multi-disciplinary approach is commonly necessary particularly pulmonary. b. Operative treatment is prone to complications due to multiple factors. Preoperative discussions are essential to convey the complexity of the childs spinal problem and its treatment. c. The importance of nutrition in this population can not be overemphasized. iii. Klippel-Feil syndrome is characterized by failure of segmentation in the cervical spine with a short, broad neck, torticollis, scoliosis, low hairline posteriorly, high scapula, and jaw anomalies. 1. Sprengel deformity seen in 33% of patients with Klippel-Feil. 2. 70% will develop scoliosis Kyphosis a. Overview (Epidemiology) i. Most common types are postural, Scheuermanns and congenital kyphosis. ii. Incidence of Scheuermanns kyphosis is 1-8% with a male:female ratio between 2:1 and 7:1. iii. Scheuermanns kyphosis is defined as thoracic hyperkyphosis due to three consecutive vertebra with >5 degrees of anterior wedging (Sorensens criteria). An increased kyphosis with gibbus on clinical exam may be considered diagnostic. b. Pathoanatomy i. Scheuermanns kyphosis is believed to be a developmental error in collagen aggregation leading to disturbance of enchondral ossification of the vertebral end plates. This leads to wedge-shaped vertebra and increased kyphosis. Most common in thoracic spine; less common in lumbar spine. The natural history of Scheuermanns kyphosis in adults with mild forms of the disease (mean 71 degrees) is more back pain than controls, but the back pain rarely interferes with daily activities or professional careers. More severe deformities (>75 degrees) are more likely cause severe thoracic pain. Genrally pulmonary compromise is not a conern unless kyphois reaches >100 degrees . ii. Congenital kyphosis divided into failure of formation (type I), failure of segmentation (type II), mixed (type III) and rotatory/congenital dislocation of spine (type IV). Type III (mixed) has worst prognosis for sagittal plane deformity. Rate of progression is 7-9 degrees/year for type I and 5-7 degrees for type II. Greatest risk of neurologic injury in type I (failure of formation) and type III (mixed). c. Evaluation i. Normal thoracic kyphosis is 20-45 degrees with no kyphosis at thoracolumbar junction. ii. Presentation is usually due to cosmetic concerns or pain which can be at thoracic region or in hyperlordotic lumbar spine. Thoracolumbar is typically painful, whereas thoracic is typically not painful. Patients with congenital and Scheuermanns kyphosis will clincally demonstrate an acute gibbus at the site of pathology. iii. Patients with postural kyphosis have more gentle, rounded contour (without gibbus) of the back and may have up to 60 degrees of kyphosis.

c.

Spine problems in children

David L. Skaggs, MD

d.

iv. Classic plain radiographic findings in Scheuermanns are vertebral endplate abnormalities, loss of disc height, Schmorls nodes and wedged vertebra. The lumbar spine needs to be evaluated to rule out concomitant spondylolisthesis. v. MRI indicated for all congenital kyphosis, which has a 56% incidence of intraspinal anomalies. vi. MRI may be indicated preoperatively in Scheuermanns kyphosis to rule potential thoracic disc herniation, epidural cyst or spinal stenosis which may cause neurologic symptoms at the time of deformity correction. Classification. Kyphosis is generally Scheuermanns may be (thoracic or thoraco lumbar), or congenital. Les commonly, it may be secondary to trauma, infection, or at the junction of spine instrumentation. Treatment i. Non-operative 1. Congenital kyphosis: Bracing is ineffective. 2. Bracing of Scheuermanns kyphosis can be effective if >1 year of growth remaining and kyphosis is between 50 and 70 degrees with apex at or below T7. Bracing is continued for minimum of 18 months. Pain can respond to physiotherapy and non-steroidal anti-inflammatory medications. Patient noncompliance with bracing is common. 3. ii. Operative 1. Indications: a. In congenital kyphosis surgery is indicated for most with failure of segmentation or mixed, especially those with neurologic deficits. For those with failure of formation, an indication for surgery is progressive local kyphosis over 40 degrees or neurologic symptoms.. b. Scheuermanns kyphosis relative indications for surgery are kyphosis >75 degrees, deformity progression, cosmesis, neurologic deficits, and significant pain unresponsive to nonsurgical management. 2. Procedures a. In congenital kyphosis, children with failure of segmentation who are < 5 years of age with <55 degrees kyphosis, posterior fusion is recommended to stabilize the kyphosis and permit some correction. Anterior decompression (which may be performed through a posterior approach) is performed for compromised neural structures.. b. Scheuermanns kyphosis surgery is a posterior spinal fusion with instrumentation. Anterior release has been recommended for deformities which do not correct to >50 degrees on hyperextension lateral radiograph over an apical bolster. Newer thoracic pedicle screw constructs withmulitple posterior osteotomies may obviate need for anterior releases. Traditional recommendations are to limit correction to <50% of deformity to prevent proximal or distal junctional kyphosis or implant pull-out 3. Complications a. Neurologic injury (paralysis, nerve root deficit) can occur due mechanical impingement or stretch of cord, by spine implants or bony/soft-tissue structure, or vascular. Anterior approaches to the thoracic spine can injure the artery of Adamkiewicz, the main blood supply to the T4-T9 spinal cord, generally arising in the variable position from T8-L2 on the left.

e.

Spine problems in children

David L. Skaggs, MD

4.

Junctional kyphosis occurs in 20-30% of patients, though this is usually not clinically significant Pearls and pitfalls a. do not try to correct more than 50% b. the lower end of the instrumentation should include the first vertebrae crossed by verticle line from posterior-superior corner of S1 c. winds segmental pedicle screws are used in combination with multiple posterior osteotomies, anterior approaches may generally be avoided

b.

IV.

Spondylolysis/Spondylolisthesis a. Overview (Epidemiology) i. Incidence of spondylolysis is 6% (males > females). Incidence of 53% in eskimos. Or a ii. 25% of spondylolysis have associated spondylolisthesis. iii. Primarily effects L5 (in 87% to 95% of patients) and less frequently L4 (in up to 10%) and L3 (in up to 3%). b. Pathoanatomy i. Spondylolysis is an acquired condition presumed to be a stress fracture through pars interarticularis. ii. Spondylolisthesis is anterior slippage of one vertebra relative to another and is most common in lumbar spine. iii. Progression associated with adolescent growth spurt, lumbosacral kyphosis (slip angle >40 degrees), higher Meyerding grade (>2 or >50% translation), younger age, female gender, dysplastic posterior elements and dome-shaped sacrum. c. Evaluation i. Back pain is usually localized to the lumbosacral area though may run down the legs ii. Pain is exacerbated lumbar extension activities and improved with rest. iii. Physical examination findings include paraspinal muscle spasms, tight hamstring and limited lumbar mobility. High-grade spondylolisthesis can have waddling gait and hyperlordosis of lumbar spine. Most common nerve root affected by a spondylolisthesis at L5-S1 is the L5 nerve root. iv. Oblique radiographs, in addition to AP and lateral views, may aid in identifying pars defects which has been described as the Scotty dog sign, but radiographs may miss up to 50% of spondys. CT is best for assessing bone involvement. Single photon emisssion CT (SPECT) is highly sensitive for active pars defects. MRI is suboptimal for evaluating pars defect, but they have a role in assessing nerve entrapment

Spine problems in children

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Classification v. Wiltse system based on etiology: dysplastic (congenital) (type 1), isthmic (acquired )(type 2), degenerative, traumatic, pathologic, iatrogenic. Most common in adolescents is the isthmic type (type 2) which occurs 85-95% of time at L5, with 5-15% of time at L4. vi. Meyerding grade: based on amount of forward slippage of superior vertebra on inferior vertebra and reported in quadrants. Grade 5 is spondyloptosis, or 100% translation anteriorly of the superior vertebra. d. Treatment i. Non-operative 1. Asymptomatic patients with spondylolysis and grade 1-2 spondylolisthesis do not require treatment or activity restrictions. 2. Symptomatic patients (spondylolysis and grade 1-2 spondylolisthesis) are treated with lumbosacral orthoses for up to 4-6 months. a. Return to sports after core strengthening ii. Operative 1. Indications for surgery include uncontrolled pain (after nonoperative management), neurologic symptoms (ie. radicular symptoms or cauda equina syndrome), > grade 2 slip or progressive slip to grade 2 (50% slip). 2. Procedures a. Spondylolysis can be treated with pars repair. If disc dessication present (dark disk) then L5-S1 fusion should be performed. b. Posterolateral fusion (with or without instrumentation) may be performed for spondylolysis and spondylolisthesis. The deformity in uninstrumented fusions may progress over many years. . Pedicle screw constructs may increase fusion rates and decrease postoperative slip progression. c. In the presence of neurologic deficit,nerve decompression is generally recommended, though neurological improvement has been demonstrated by in situ fusion alone. d. Indications for reduction are controversial with no universallyaccepted guidelines. Reduction of spondylolistheses of greater than 50% is associated with L5 nerve root stretch and neurological injury! Complications

3.

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4.

a. Drop foot - L5 nerve root injury Pearls and pitfalls a. 5% of the population has this condition, and most are asymptomatic. i. Even though a patient has spawned a spondy, continue to look for other causes of back pain if the clinical picture is not typical. ii. The endpoint of treatment in a slip less than 50% is lack of pain, not necessarily radiographic demonstration of healing

V.

C-spine a. Torticollis i. Congenital Muscular 1. Think hips - 5 % DDH 2. x-ray to look for congenital 3. resolves with PT in first year of life 95% 4. release sternocleidomastoid bipolar if needed. ii. Acquired torticollis 1. most often muscle strain/spasm and self resolving 2. non-resolving, severe or traumatic often from C1C2 subluxation a. many causes including trauma (even minor), Grisel's syndrome, ophthalmologic, vestibular, CNS tumor or dysfunction. Its etiology is presumed secondary to compartment syndrome. b. If a tight sternocleidomastoid is not present, look for other causes c. Dx: dynamic CT d. Treatment i. < 1 wk soft collar ii. 1-4 wks traction iii. >4wks surgical fusion iv. Can be reduced safely with pinless halo with pt awake Trauma i. 87% C3 and above at <8years - different from adults ii. 33% with neruologic injury iii. SCIWORA - may be delayed iv. Pseudo subluxation of C2-C3. Swischuks line connects the spinolaminar junction of C1 to C3. As long as the spinolamiar junction of C2 is no more than 1mm anterior to this line the subluxation is physiologic. v. Anterior soft-tissue welling normal from crying. On a lateral radiograph the retropharyngeal space should be less than 6 mm at C2 and less than 22mm at C6, though these both may be enlarged due to crying, and is not necessarily a sign of underlying injury in children. vi. Atlanto Dens interval 1. Children <4.5 mm normal 2. Downs Syndrome a. <10 mm OK if no symptoms b. 25% mortality in two surgical series vii. Os Odontoidium 1. Very common 2. ? Old trauma? 3. OK if stable

b.

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c.

pitfall:Posterior cervical fusions in children have high union rate with iliac crest bone grafting, and nonunions reported with allograft.

VI.

Disc Conditions in Children . a. Endplate fractures i. often missed on MRI - remember disc problems uncommon in children/adolescents ii. VERY painful b. Intervertebral disc calcification -most common in cervical spine. i. present with neck pain, fevers, increased ESR and DRP ii. normal neurologic examination. iii. treated with analgesics. Biopsy and antibiotics not needed. Calcifications usually resolve over 6 months. c. Discitis i. ii. Pathoanatomy: Presumed infection likely begins by seeding the vascular vertebral endplate and then extending into disc space iii. Evaluation 1. Symptoms: fever, back pain, abdominal pain, refusal to ambulate, painful limp and lower extremity discomfort. 2. 25% will be febrile. 3. Laboratory studies of erythrocyte sedimentation rate and C-reactive protein will be elevated. 4. Radiographs can demonstrate disc space narrowing with vertebral endplate irregularities. Further imaging generally not needed. typical organism is Staphylococcus aureus. Must consider histiocytosis X (the great imitator) v. Treatment 1. Non-operative treatment typically parenteral antibiotics (to cover Staphylococcus aureus) for 7-10 days then switch to oral antibiotics for several more weeks. Failure to respond to antibiotics should undergo biopsy for cultures and pathologic tissue evaluation 2. Think of salmonella in the setting of sickle cell anemia. a. Back pain i. Overview (Epidemiology): Over 50% of children will experience back pain by the age of 15 years with 80-90% resolving within 6 weeks. Table 1, JAAOS, vol 13, no6, oct 2005 p373 differential diagnosis ii. Pathoanatomy 1. in children less than 10 years of age, consider serious underlying pathology, although standard mechanical back pain is still most common. 2. Older children and adolescents will commonly suffer suffer adult low-back pain. 3. Spinal deformities (scoliosis and kyphosis) can cause pain. 4. Consider intra-abdominal pathology such as pyelonephritis, pancreatitis, and appendicitis. 5. Studies suggest more weight in a backpack is associated with a higher incidence of backpain. 6. iii. Evaluation 1. Pain at night traditionally associated with tumors. 2. Visceral pain is not relieved by rest or exacerbated by activity. iv.

VII.

Spine problems in children

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13

Detailed musculoskeletal, abdominal and neurologic exam Imaging studies a. Plain radiographs b. Technetium bone scan: helpful to localize tumor, infection or fracture c. CT scan best for bone problems (spondylolysis) d. MRI recommended for any neurologic signs or symptoms. 5. Laboratory studies such as complete blood counts, C-reactive protein, erythrocyte sedimentation rate, peripheral smear are indicated for patients with back pain and constitutional symptoms. iv. Classification 1. Possible specific causes include discitis, spinal deformity (scoliosis and kyphosis), neoplasms, spondylolysis/spondylolisthesis, disc herniations and vertebral apophyseal end-plate fracture. 2. Posteriorly, common tumors include osteoid osteoma, osteoblastoma, and aneurysmal bone cyst.. Anteriorly, histiocytosis X has predilection for vertebral body causing vertebrae plana 3. Figs 2,4 &5, JAAOS, vol 13, no6, oct 2005 p374 differential diagnosis note although this is a lot, these are pics likely to show up on tests. 4. 5. Most common malignant cause of back pain is leukemia. v. Treatment 1. Non-operative a. b. Osteoid osteomas are initially treated with NSAIDs and observation. 2. Operative a. Indications i. Lumbar disc herniation with neurologic symptoms or is unresponsive to nonoperative management for minimum of 6 weeks. ii. Osteoid osteomas: failure of nonoperative pain management. Radioablation is not commonly used in the spine for fear of him? risking neurologic injury iii. Osteoblastomas do not respond to nonoperative interventions b. Contraindications c. Procedures i. Benign bone lesions can be marginally excised. d. Complications e. Pearls and pitfalls-included in the table below f. Table: red flags for pathologic back pain i. History 1. pain is well localize-positive finger testpatient points to pain in one location with one finger 2. pain is progressively worsening over time 3. pain not associated with activities, and present at rest or nighttime 4. bowel or bladder incontinence ii. physical exam 1. tight hamstrings-popliteal angle over 50 2. localized bony tenderness 3. neurologic abnormalities 3.

3. 4.

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VIII.

Spine trauma Addendum: MORE DETAIL THAN IN TALK - JUST FYI - THIS SUBJECT FREQUENTLY APPEARS ON TESTS a. Overview (Epidemiology) i. Cervicall spine accounts for 60% of pediatric spinal injuries. ii. Mortality from cervical injury in pediatric trauma victims is 16-17%. iii. Overall the most common mechanism of injury are motor vehicle crashes. Toddlers and school-age children are injured most commonly in falls, while adolescents also suffer sports-related injuries. Pathoanatomy: i. Increased risk of cervical spine injuries in children <8 years of agedue to larger head-to-body ratio, increased ligamentous laxity, relatively horizontal facet joints. ii. 87% of children <8 years have injuries at C3 or higher and have a higher mortality rate compared to children >8 years of age. Mortality rates range from 17% at C1 to 3.7% at C4. iii. The immature spinal column can stretch up to 5 cm without rupture; the spinal cord ruptures at 5-6 mm of traction. iv. 33% of children with cervical spine injury will manifest evidence of neurologic deficit. v. 42% of children with spinal injury have injuries to other organ systems. Evaluation i. Initial management: Transport on backboard with cutout for occiput or mattress to elevate body to prevent inadvertent flexion of cervical spine due to disproportionately large head. ii. Physical examination consists of detailed neurologic examination to include sensation (look for sacral sparing) and motor function, reflexes (absence of anal wink indicates spinal shock). Upper cervical spine injuries should be suspected in young children with facial fractures and head trauma iii. Imaging starts with plain radiographs of the injured region. iv. Atlantoaxial instability is evaluated with and the ADI (atlanto-dens interval). ADI should be <5mm in children . When ADI >10mm all ligaments have failed, creating cord compression due to negligible SAC. Instability of the subaxial cervical spine should be suspected with intervertebral angulation of >11 degrees or translation of >3.5 mm. It is crucial to always visualize the C7-T1 junction on the lateral view. 3-dimensional imaging: CT and MRI help to assess injury and amount of spinal canal intrusion. v. Atlanto-occipital junction injuries are assessed with Powers ratio, C1-C2:C2-C3 and BAI (Basion-Axial Interval). Powers ratio is determined by the ratio of the line from the basion to the posterior arch of the atlas and a second line from the opisthion to the anterior arch of the atlas. Ratio of >1.0 or less than 0.55 respresents disruption of atlanto-occipital joint. The C1-C2:C2-C3 ratio (interval between the posterior arches) which is <2.5 in normal children. The BAI is the distance from the basion to the tip of the odontoid and should be less than 12 mm in all children. vi. Classification i. Cervical 1. Atlanto-occipital junction are rare, but commonly fatal injuries which are highly unstable ligamentous injuries. Common mechanism are motor vehicle crashes and pedestrian-vehicle. 2. Atlas fractures (aka Jefferson fractures) are uncommon injuries which are usually due to axial loading. Neurologic dysfunction atypical. Widening of lateral masses of more than 7 mm beyond the

b.

c.

d.

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e.

borders of the axis on the AP view indicates injury to travsverse ligament 3. Atlantoaxial injuries are usually ligamentous injuries to the main stabilizers (transverse ligament) or secondary stabilizers (apical and alar ligaments). 4. Odontoid fractures usually occur through synchondrosis by a flexion moment causing anterior displacement. 5. Hangmans fractures are usually due to hyperextension causing angulation and anterior subluxation of C2 on C3. 6. Lower (C3-7) cervical spine are more common in adolescents. ii. Thoracolumbar 1. Flexion injuries: result in compression or burst fractures. Compression fractures rarely exceed more than 20% of vertebral body. When loss of vertical height >50% consider burst fracture, and obtain CT scan. 2. Distraction and Shear: highly unstable and usually associated with spinal cord injury. 3. Chance fractures: caused by hyperflexion over automobile lap belt and frequently associated with intra-abdominal injuries. 4. Spinal Cord Injury Without Radiographic Abnormality (SCIWORA): MRI is study of choice, but may be normal in 25%. Is the cause of paralysis in approximately 20-30% of children with injuries of the spinal cord. Approximately 50% have delayed onset of neurologic symptoms or late neurologic deterioration. Children <10 years are more likely to have permanent paralysis than older children. Treatment i. Non-operative: 1. Cervical a. Intervertebral disc calcification treated with rest and NSAIDs b. Atlas fractures: treat with cervical collar or halo 2. Thoracolumbar a. Compression fractures: Bracing for 6 weeks. b. Burst fractures: If stable, then bracing. c. Chance fractures with <20 degrees of segmental kyphosis can be treated in a hyperextension cast. d. SCIWORA: Immobilization for 6 weeks to prevent further spinal cord injury. ii. Operative 1. Indications: a. Cervical i. Craniocervical instability ii. Atlantoaxial instability with ADI >5mm iii. Odontoid fracture displaced iv. Displaced and angulated hangmans fracture b. Thoracolumbar burst fractures with neurologic injury and canal compromise. c. Distraction and shear injuries with displacement. d. Chance fractures which are purely ligamentous injuries and bony injuries with >20 degrees kyphosis. 2. Contraindications 3. Procedures a. Craniocervical instability is treated with an occiput to C2 fusion with halo stabilization, preferably with internal fixation. b. Atlantoaxial instability requires a C1-C2 posterior fusion with transarticular C1-C2 screw with a Brooks-type posterior fusion or lateral mass screws.

Spine problems in children

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4.

5.

Odontoid: Reduction of displacement with extension or hyperextension with halo immobilization for 8 weeks. d. Hangmans fractures with minimal angulation and translation can be treated with closed reduction in extension with immobilization in a Minerva cast or halo device for 8 weeks. Fractures with significant angulation or translation requires a posterior fusion or anterior C2-C3 fusion. e. Halo placement: In toddlers and children <8 years, use multiple pins (8-12 pins) with only finger tightness (2-4 inchpounts). Anterior pins should be placed lateral enough to avoid the frontal sinus, and supraorbital and supratrochlear nerves. Place pins anterior enough to avoid temoralis muscle. The posterior pins should be placed opposite side of ring from anterior pins. f. Thoracolumbar burst fractures with canal compromise require canal decompression, fusion and instrumentation. Indirect canal decompression is accomplished by operative distraction of injured level. g. Distraction and shear injuries are treated with reduction with decompression, instrumentation and arthrodesis. h. Chance injuries which are purely ligamentous injuries should be surgically stabilized with instrumentation and arthrodesis. Bony injuries with >20 degrees kyphosis or inadequate reduction, are treated with posterior compression instrumentation and arthrodesis. Complications a. Os odontoideum: caused by nonunion of an odontoid fracture which may have episodic or transient neurologic symptoms. Instability when >8 mm of motion; requires C1-2 fusion. b. Post-traumatic kyphosis usually does not remodel and may worsen. c. Pseudarthrosis d. Implant failure Pearls and pitfalls a. Ligament injuries do not heal, and usually require operative stabilization. b. Boney fractures without significant angulation may be treated nonoperative flick c. ecchymosis in the distribution of the seatbelt should alert one to the possibility of a chance fracture and/or inter abdominal injuries d. children under eight years of age tend to have cervical injuries C3 and above, children under eight tend to have injuries below C3

c.

6.

IX.

References a. Gillingham BL, Fan RA, Akbarnia BA. Early Onset Idiopathic Scoliosis. J Am Assoc Orthop Surg 2006;14:101-112. b. Hedequist D, Emans J. Congenital Scoliosis. J Am Assoc Orthop Surg 2004;12:266275. c. Lenke LG, Betz RR, Harms J, et al. Adolescent idiopathic scoliosis: A new classification to determine extent of spinal arthrodesis. J Bone Joint Surg [Am] 2001;83:1169-1181.

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d.

e. f.

Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ, Ponseti IV. Health and function of patients with untreated idiopathic scoliosis: A 50-year natural history study. JAMA 2003;289:559-567. Copley LA, Dormans JP. Cervical spine disorders in infants and children. J Am Assoc Orthop Surg 1998;6:204-214. Wenger DR, Frick SL. Scheuermanns Kyphosis. Spine 1999;24:2630-2639.

X.

Top Testing Facts: a. Idiopathic Scoliosis i. MRI for atypical pattern or neruo signs/SXS ii. Surgical indications 45-50o b. Congenital Scoliosis i. Early fusion for hemi-vertebrae opposite unilateral bar c. Spondylolysis and Spondylolisthesis i. In 5% of population usually not painful ii. L5 nerve root at risk with >50% reduction at surgery d. Spine Trauma i. Atlanto dens interval <5mm OK ii. C2-C3 pseudo-subluxation is normal

Tumors and Metabolic Bone Disease

 TumorsandMetabolicBoneDisease Moderator:AlbertJ.Aboulafia,MD 4:40PMTumors AlbertJ.Aboulafia,MD 5:10PMMetabolicBoneDisease JosephM.Lane,MD

AAOS Board Maintenance of Certification Preparation and Review #490 February 18th 2011 San Diego, California
Albert J. Aboulafia, MD FACS MBA Sinai Hospital of Baltimore University of Maryland

Tumors

I.

General Introduction: a. Benign Bone Tumors b. Malignant Bone Tumors c. Benign Soft Tissue Tumors d. Malignant Soft Tissue Tumors e. Principles of diagnosis (imaging and biopsy) f. Principles of treatment All primary bone and soft tissue tumors fall into one of the following categories. For the purposes of examinations you must be able to recognize what type of tumor you are presented with and in many cases the appropriate diagnostic evaluation and subsequent treatment.

II.

Classification of Benign Bone Tumors (Histology) a. Chondrogenic i. Osteochondroma 1. hallmark: cortical and medullary continuity of host and lesion

This is a common tumor and shows up on many exams. Radiographic imaging is diagnostic. The primary differential diagnosis includes parosteal osteosarcoma and secondary chondrosarcoma. A CT scan demonstrating cortical and medulary continuity of the lesion with the host bone confirms the diagnosis. ii. Enchondroma 1. hallmark: stippled calcifications, geographic, no endosteal scalloping The most common clinical scenario is distinguishing an enchondroma from a chondrosarcoma. A cartilage lesion within the bone that demonstrates aggressiveness (breakthrough cortical bone with a soft tissue component) is malignant and not an enchondroma. Enchondromas can be a source of pain and may be moderately hot on bone scan. iii. Chondromyxoid fibroma 1. hallmark: location, age, lobular Favored location: Fibula and Tibia iv. Chondroblastoma 1. hallmark: epiphyseal location Location, Location, Location. Well defined but may extend into adjacent joint. b. Osteogenic i. Osteoblastoma ii. Osteoid Osteoma 1. hallmark: nidus, reactive cortical bone Radiofrequency Ablation is the less invasive method of treatment and very effective. c. Fibrogenic i. Non ossifying fibroma 1. hallmark: eccentric, well defined, cortical rim May require prophylactic curettage and bone grafting in cases of impending fracture. If fracture occurs, allow it to heal and then treat as neede. ii. Osteofibrous dysplasia 1. hallmark: diaphyseal tibia iii. Fibrous Cortical Defect 1. hallmark: see NOF but cortically based
2

iv. Fibrous Dysplasia 1. hallmark: well defined, ground glass, cortical remodeling, expansion: No perisosteal new bone unless associated with fracture 2. Polyostotic or Monostotic 3. May be associated with endocrine abnormalities 4. ?Role of bisphosphonates for aggressive conditions d. Vascular i. Hemangioma Treatment options include observation, resection or embolization. May be symptomatic (pain). Clinically, look for discoloration of the skin and/or a mass that gets bigger and smaller (especially when in a dependent position). e. Lipogenic i. Intraosseous lipoma ii. Liposclerosing myxiod fibrous tumor (LSMFT) On X-ray well defined with sclerotic border. MRI shows all fat. LSMFT favored location-proximal femur f. Unknown Origin i. Anuerysmal Bone Cyst ii. Unicameral Bone Cyst iii. Giant Cell Tumor iv. Langehans Cell Histiocytosis These tumors have little in common with respect to their radiographic and clinical presentation or treatment.

III.

Classification of Benign Bone Tumors (Enneking) a. Based on Clinical and Radiographic Criteria b. Arabic numerals (1,2 or 3) c. Treatment based on tumor type and stage

IV.

Stage 1 Tumors a. Osteochondroma i. Imaging characteristic/diagnostic ii. DDx includes parosteal osteosarcoma, chondrosarcoma, exostosis bursata iii. Treatment based on symptoms and clinical behavior b. Osteoid Osteoma i. Imaging studies and clinical history largely diagnostic (X-ray, CT, bone scan) ii. DDx includes infection/Brodies abscess iii. Treatment may be medical or surgical (NSAID/open vs. closed surgical i.e. RFA)

V.

Stage 2 Tumors a. Enchondroma (may be stage 1 or 2) i. Must distinguish symptomatic from other causes ii. Distinguish from Grade 1 chondrosarcoma b. Juxtacortical Chondroma i. Diagnosis largely based on imaging studies ii. Treatment based on natural history c. Unicameral Bone Cyst i. 50% present as pathologic fracture ii. Most common location proximal humerus iii. Remember classic fallen leaf sign iv. Allow fracture to heal then treat v. Treatment options vary (no one best answer) vi. Lesions in proximal femur usually require fixation to prevent path fx. Stage 2or 3 Tumors a. CMF, Osteoblastoma, Chondromyxoid Fibroma, ABC, GCT i. All require treatment ii. Treatment options depend on location, patients age, proximity to growth plate iii. Simple curettage, extended curettage with or without physical/chemical adjuvants, resection

VI.

VII.

Malignant Bone Tumors a. Hematopoietic b. Chondrogenic c. Osteogenic d. Fibrogenic e. Vascular f. Notochordal g. Unknown Origin Multiple Myeloma/Plasmacytoma: a. Most common malignant primary bone tumor. b. Biology: cells produce macrophage inflammatory protein 1alpha which stimulates osteoclast production. In conjunction with parathyroid hormone related peptide (PTH-rp) and osteoclast activating factors there is increase expression of receptor activating factor of nuclear factor kB (RANKL). Some treatments i.e bisphosponates, RANKL inhibitors etc. target these pathways. c. Work-up: SPEP/UPEP, CBC, ESR, Ca, renal function and B2 microglobulin, skeletal survey. d. Treatment: primarily systemic chemo and XRT. Surgery for impending fractures, some established fractures or those that do not respond to chemo/rads. Staging a. MSTS (Enneking) i. Low and intermediate and high grade (I=low grade II=intermediate and high grade) ii. A=intracompartmental; B=extra compartmental C= metastatic

VIII.

IX.

b. Histologic Grade i. Measure of biologic potential (1-3 or 1-4) ii. Potential for metastases and/or local recurrence

X.

Evaluation: Pre op a. X-ray b. CT chest c. MRI d. Bone Scan Biopsy a. First stage of limb salvage surgery b. First do no harm c. Open vs. Closed i. FNA/Core ii. Incisional/Excisional

XI.

XII. Limb Sparing Surgery a. Biopsy b. Resection of Tumor c. Reconstruction of Skeletal Defect d. Soft Tissue Reconstruction

XIII. The Basics a. Osteosarcoma and Ewings Sarcoma i. Chemotherapy well established ii. Limb Sparing surgery in 90% of patients iii. Chemo+Surgery (wide resection) iv. Radiation rarely used for primary bone tumors v. Surgery requires WIDE surgical excision (a cuff of normal tissue completely surrounding the tumor) XIV. Benign Soft Tissue Tumors a. Histologic Subtypes i. Fibrous ii. Synovial iii. Vascular iv. Lipomatous v. Neurogenic vi. Muscular

b. Treatment i. Leave alone or take out (once dx established) ii. MRI is key 1. can diagnose many b9 tumors (Be careful: Dont trust reports from someone without experience) if you are going to recommend observation a. lipoma b. PVNS c. Nerve sheath tumors d. Infection e. Ganglion iii. Locally aggressive tumors require treatment 1. desmoids tumors/PVNS 2. desmoids tumors are very prone to local recurrence. Treatment options include surgery with or without pre or post op radiation and even lowdose chemotherapy. It is difficult to ask questions about the most appropriate treatment for desmoids tumors. You should simply be able to recognize it and know that it is locally aggressive and requires treatment. XV. Malignant Soft Tissue Tumors a. Histologic Subtypes i. Fibrous ii. Synovial iii. Lipomatous iv. Neurogenic v. Muscular vi. Uncertain Origin b. Evaluation i. Clinical/Radiographic and Histologic correlation ii. MRI characteristics (well defined, heterogeneous) iii. Any soft tissue mass deep to fascia greater than 5cm (assume sarcoma) iv. Regional nodes: especially epthelioid sarcoma and synovial sarcoma

XVI. Staging STS AJC 1997 a. Low vs. High Grade b. Size > or< 5cm c. Deep vs. Superficial d. Regional nodes + or Soft tissue tumors that have a relatively high incidence of nodal metastases include epitheleoid sarcomas and rhabdomyosarcoma. The latter is more common in children and adolescents. Epitheleoid sarcomas are the most common primary soft tissue sarcoma in the hand. XVII. Biopsy a. Closed i. FNA ii. Core needle b. Open i. Incisional ii. Excisonal (small, superficial when wide excision adds no additional morbidity) So there are 4 types of biopsy. 2 closed: FNA and Core, and 2 open: incisional and excisional c. Remember to have tissue available for flow cytometry and genetic studies. Send some tissue fresh. Be familiar with translocations associated with specific tumor types i.e Ewings, Dermatofibrosarcoma protuberans, extraskeletal myxoid chondrosarcoma, myxoid/round cell liposarcoma and synovial sarcoma Ewings: t(11;22)(q22;q12)or t(11;22)(q24;q12) DFSP: t(17;22)(q22;q13) EMCS: t(9:22)(q22-31;q12) M/RCLS: t(12;16)(q13;p11) Synovial Sarcoma: t(X;18)(p11.2:q11.2) d. Immunohistochemisty: i. Keratin: stains epithelial markers i.e carcinomas (may also be present in epitheloid sarcoma, synovial sarcoma and adamantinoma.

ii. Desmin: Muscle marker i.e rhabdomyosarcoma, a. skeletal muscle: myogenin (Myo-D) b. smooth muscle: actin (leiomyosarcoma, desmoid tumors iii. CD31 and CD34: Vascular marker iv. S-100: Neural marker XVIII. Treatment STS a. Wide local excision b. Role of chemotherapy not well defined (very controversial so they cant ask you that) c. Preop radiation vs. post op radiation i. Radiation improves local control ii. Preop associated with high incidence of local wound complications

XIX: Metastatic Disease: a. Lead Kettle (P,B,K,T,L) Prostate, Breast, Kidney, Thyrod (75% or more) b. Consider first in pt over 40 with destructive bone lesion c. Favored location axial skeleton and proximal long bones. Bone met may be first presentation in nearly 25% of patients with metastatic disease to bone. d. Indications for prophylactic fixation. A bit of a moving target. Open segment: 1/3 circumf. of bone decreases rigidity 30%. General principle for long bones-protect the entire bone. (See Mirels H. CORR 1989) e. Treatment: Depends on extent of bone destruction and anticipated response or prior response to radiation and or chemotherapy. Bisphosphonates play a critical role. f. Spine Mets: Kostuik system 3+ right and left. 3 or more segments destroyed suggests instability. Indications for surgerymechanical instability, progressive deficit. Anterior or posterolateral approaches that allow anterior vertebral body reconstruction is preferred to posterior approach alone (Patchell RA et al. Lancet 2005)

Parting thoughts: 2 Minute Review (OK maybe 5 minute review) 1. Most common primary malignant bone tumor: Myeloma Evaluation includes X-ray, labs (CBC, Chem 25, SPEP, UPEP, immunofixation Beta-2 microglobulin) look for anemia, elevated calcium, proteinuria Bone scan may not demonstrate lesions (not reliable). Bone/Skeletal Survey more accurate. 2. Biopsy: Be careful. If you suspect a malignant bone or soft tissue tumor first choice is to refer it prior to biopsy. If you do biopsy must have all imaging studies completed prior to biopsy Biopsy options include FNA, core, incisional or excisional: Know the advantages and disadvantages of each. Special Studies: FISH (fluorescent in situ hybridization), flow cytomety, electron microscopy) and culture for infection. Need fresh tissue Ewings Sarcoma: look for chromosomal translocation T(11:22)(q24;q12) or T(11;22)q(22;q12) Lymphoma (flow cytometry) 3. Osteosarcoma and Ewings Sarcoma most common primary bone tumor in children and adolescents Treatment includes Chemotherapy and Wide Resection Same is true for most other primary malignant bone tumors other than myeloma.

10

4. Soft Tissue Sarcomas By definition malignant Suspect any deep tumor greater than 5cm as being malignant MRI characteristics are: Well defined, heterogeneous Treatment always includes wide excision. Chemo is controversial, therefore they cant ask you about chemo. Preop radiation improves local control but at the expense of higher wound complications. 5. In a patient over 40 years of age with a malignant appearing bone lesion think mets and myeloma. 6. Benign bone tumors are common in children. Fibrous cortical occur in 30-40% of all children. Therefore: this is fair game. Know them and how to treat them. Recognize the common ones: FCD, osteochondroma, UBC, osteoid osteoma, etc. 7. Benign aggressive bone tumors have high incidence of local recurrence. GCT are treated with aggressive mechanical curettage, use of a physical adjuvant (phenol, cryo) and cementation or bone grafting). 8. Quick guide to imaging studies:
Purpose: Develop a differential diagnosis, define extent of disease and plan treatment in a cost effective and efficient manner. A. X-ray 1. The "gold standard" for diagnostic criteria in bone tumors. Most valuable imaging study (and not expensive). May be useful in soft tissue lesions i.e fat or vascular lesions or identify associated bone pathology. Myxoma and fibrous dysplasia Mazenbrauds syndrome. 2. Note: A. Location: metaphyseal, diaphyseal or epiphyseal

11

B: Pattern: well defined, ill defined, permeative, destructive, moth eaten... C. What is the bone doing to the lesion and what is the lesion doing to the bone? Sclerotic border, fading borderpresence or absence of periosteal new bone, endosteal scalloping D. Matrix Is the tumor making a matrix like bone i.e osteogenic B. CT scan 1. Study of choice to assess presence of pulmonary mets.

2. Identifies areas of mineralization, provides superior imaging of cortical bone (and risk for path fracture), subtle pathologic fracture. 3. Indicated when lesion may be metastatic. CT chest, abdomen and pelvis to identify primary. 4. Use in evaluating soft tissue lesions largely replaced by MRI (except when MRI is contraindicated) 5. May be helpful in evaluating osteochondromas C. MRI 1. The primary imaging modality for evaluating soft tissue lesions. Extremely valuable: a. Can identify tissue types, i.e fat, fibrous, pertinacious material, fluid, cystic, hematoma, heterogeneity etc. 2. Defines medullary extent and soft tissue extension of bone lesions and skip lesions. More sensitive and specific than bone scan. 3. Used in evaluating primary bone lesions when wide resection is anticipated. 4. Not usually necessary for metastatic lesions 5. REMEMBER: STS are typically: 1.WELL DEFINED and 2. HETEROGENEOUS

12

D. Radionuclide scan 1. Especially important to identify if patient has a solitary lesion, possibly a primary bone tumor, or multiple lesions and likely to be metastatic i.e patient with a path fx who is over 40. Must be sure it is not a primary before proceeding with fixation. 2. May identify skip lesions (MRI is better) 9. Surgical Principles: Dont try to memorize the treatment for each and every tumor. Understand the stage of the tumor and the treatments follow: i.e High grade bone tumors: wide excision. Benign bone tumors: stage 1 observation or local excision. Stage 2. intralesional excision. Stage 3 extended curettage frequently with physical adjuvant A. Surgical Choices: The surgeon may remove a lesion in one of four ways; 1. by entering the lesion ( intralesional excision), 2. by removal through the reactive pseudocapsule (marginal excision), 3. by removing a cuff of normal tissue beyond the reactive pseudocapsule (wide excision), 4. by removing the entire compartment (radical resection). B. Intralesional Surgery 1. Appropriate for stage 1 or 2 benign bone lesions though there is some risk of recurrence with stage 2 lesions. a. Chondroblastoma b. Giant cell tumor c. Osteoid osteoma d. Unicameral bone cyst e. Aneurysmal bone cyst 2. And for Stage 3 lesions (usually with physical and chemical adjuvants a. GCT extended curettage with phenol/cement/liquid nitrogen

13

B. Marginal (local) Excision (within the reactive pseudocapsule) 1. Appropriate for some benign soft tissue (lipoma) tumors and stage 2 benign bone lesions. a. Neurilemmoma b. Ganglion c. Osteochondroma C. Wide Excision (a cuff of normal tissue surrounding the entire tumor and pseudocapsule ) 1. Used in cases of low grade malignancy, selected stage 3 benign lesions that can not be treated with marginal procedures

2. High grade bone and soft tissue tumors

a. Osteosarcoma following chemotherapy b. Soft tissue sarcomas c. Ewings sarcoma following chemotherapy D. Radical (compartmental) Excision (removes the entire anatomic compartment) 1. Rarely used except in very advanced massive tumors or when there has been extensive contamination from prior surgery. 2. How wide is wide? As much as you can get. At times plane may be 1-2mms. Depends on border i.e fascia or loose areolar tissue. 10. Chemotherapy A. Chemotherapy for osteosarcoma (A must. Well established. Not controversial) 1. Historical 20% five year survival with surgery alone. 2. Adjuvant (post-op) chemotherapy 40-50% five year survival. 3. Confirmed by controlled randomized studies 1970's.

14

4. Neo-adjuvant (pre surgical) chemotherapy a. Reduced primary tumor size b. Allowed assessment of drug efficacy c. Did not increase mortality rate d. Originally used to buy time to make custom endoprosthesis 5. Currently a. Neo-adjuvant chemotherapy allows for limb salvage in 80-90% of patients b. 60-65% five year disease free survival c. Amputation in <20% (non-responders, pathologic fracture, certain anatomic sites) d. % necrosis has prognostic significance Huvos index) d. Even patients with pulmonary mets can have long term survival/cure (20%) B. Chemotherapy in Ewing's Sarcoma 1. Surgery alone resulted in 5% five year survival 2. Chemotherapy - increased survival a. With radiation therapy - 34% five year survival b. With surgery >65% five year survival (+RT)

15

OSTEOPOROSIS
JOSEPH M. LANE, MD
HOSPITAL FOR SPECIAL SURGERY NEW YORK, NY

JOSEPH M. LANE, MD
Does have a financial interest or relationship with the manufacturers of products or services: Consulting Fees: Amgen, Arthrocare, Biomimetics, DFine, Inno ati e DFine Innovative Clinical Solutions, Kuros Sol tions K ros Biosurgery AG, Osteotech, Orthovita, Soteira, Zelos, Zimmer Speakers Bureaus: Eli Lilly, Novartis, Orthovita, Proctor and Gamble, Roche, Sonofi - Aventis Presentation will not include discussion of off label or investigational use of products or treatments

GOALS
DISCUSS PATHOPHYSIOLOGY OP FRAGILITY FRACTURES DIAGNOSIS/RISK FACTORS TREATMENT ANTI-RESORPTION ANABOLIC
NIH (2001)

OSTEOPOROSIS
DECREASED BONE STRENGTH RATHER THAN REDUCED BMD

OSTEOPOROSIS
DECREASED BONE MASS MICROARCHITECTURAL DETERIORATION ALTERED QUALITY FRAGILITY FRACTURE

Relevance of Architecture to Structural Strength

Normal Quantity and Architecture

Loss of Quantity

Loss of Architecture

RISK OF VERTEBRAL FRACTURE OSTEOPOROSIS AFFECTS 45% WOMEN AGED 50 OR OLDER LIFETIME RISK OF FRACTURE OF HIP, WRIST AND SPINE 40%
5x GREATER WITH PRIOR VERTEBRAL FRACTURE

VERTEBRAL FRACTURE
2x RISK OF HIP FRACTURE

FRACTURE

MORE FRACTURES
(NEVITT 1999)

OSTEOPOROTIC FRACTURES POSE A LIFETIME RISK OF DEATH COMPARABLE TO BREAST CANCER

CUMMINGS, Arch. Inter. Med. (1989)

High Bone Turnover Leads to Development of Stress Risers and Perforations

Osteoclasts

Bone Stress Risers

Perforations

CALCIUM SOURCE
CHILDREN - YOUNG ADULTS INTESTINAL ABSORPTION ELDER ADULTS BONE RESORPTION

DAILY CALCIUM REQUIREMENTS

CHILD TEEN - YOUNG ADULT ADULT PREGNANCY LACTATION POST MENOPAUSAL MAJOR FRACTURE 700 mg 1300 mg 800 mg 1500 mg 2000 mg 1500 mg 1500 mg

DRUGS WHICH DECREASE CALCIUM RETENTION

ISONIAZID CORTICOSTEROIDS HEPARIN LUPRON TETRACYCLINE FUROSEMIDE CAFFEINE? NICOTINE ALUMINUM CONTAINING ANTACIDS

MECHANICAL EFFECTS
NO LOAD LOW LOAD HIGH LOAD VERY HIGH LOAD LOSE BONE MAINTAIN BONE REMODEL BONE BONE FAILURE

EXERCISE IN GROWING CHILD 30

BONE MASS AND STRUCTURE

EXERCISE IN POST MENOPAUSAL WOMEN

NO CHANGE IN BONE DENSITY FRACTURES BETTER BONE QUALITY LESS FALLS

LOW BONE MASS IS THE SINGLE MOST ACCURATE PREDICTOR OF INCREASED FRACTURE RISK

WHO CRITERIA FOR OP

NORMAL OSTEOPENIA OSTEOPOROSIS SEVERE OP 1 SD 1 SD TO 2.4 SD 2.5 SD 2.5 SD AND Fx

BIOCHEMICAL MARKERS
BONE RESORPTION : COLLAGEN BREAKDOWN PRODUCTS - N -TELO AND C TELO C-TELO PEPTIDES, PYRODINOLINE BONE FORMATION : BONE ALKALINE PHOSPHATASE, OSTEOCALCIN, AND PINP

OP RISK FACTORS INDEPENDENT OF BONE MASS

LOW BODY WEIGHT (127 pounds) RECENT LOSS OF BODY WEIGHT PERSONAL HX OF FRAGILITY Fx MATERNAL HX OF FRAGILITY Fx SMOKING

PREDICTORS OF NON-SPINE NONFRACTUERS IN ELDERLY MEN

Tricyclic antidepressant use Previous fracture I bilit t walk narrow path Inability to lk th Falls in previous year Age 80 years Depressed mood
LEWIS JBMR 2007

FRAX

WHO Fracture Risk Assessment Tool

Calculate the ten year probability of fracture with BMD About the risk factors

Country: US (Caucasian) Name / ID: Questionnaire:

1. Age (between 40-90 years) or date of birth Age: Y: 2. Sex 3. Weight (Kg) 4. Height (cm) 5. Previous fracture 6. Parent fractured hip 7. Current smoking 8. Glucocorticoids 9. Rheumatoid arthritis No No No No No Yes Yes Yes Yes Yes Male Date of birth: M: Female

10. Secondary Osteoporosis 11. Alcohol 3 more units per day 12. Femoral neck BMD D: Select

No

Yes

Clear

Calculate

R/O OSTEOMALACIA
Alkaline Phosphatase PTH Ca PO4 25(OH) Vit.D 60+% Hip Fracture Patients 45% General Orthopaedic HSS

COMMON CAUSES OF OSTEOMALACIA

NUTRITIONAL VITAMIN D DEFECIENCY DISORDERS OF INTESTINAL ABSORPTION OF VITAMIN D DEFECTS OF VITAMIN D METABOLISM RENAL OSTEODYSTROPHY RENAL TUBULAR ACIDOSIS HYPOPHOSPHATEMIC (RENAL TUBULAR)

METABOLIC BONE DISEASE WORKUP FOR OSTEOPENIA

BONE MARROW CBC OSTEOMALACIA SED RATE CALCIUM, PHOS, IMMUNOELECTRO IMMUNOELECTROALK PTASE, ALK-PTASE PTH PHORESIS 25 HYDROXY VIT D ENDOCRINOPATHY HYPER THYROID, HYPER PTH, OSTEOPOROSIS CUSHINGS, JUVENILE HIGH vs. LOW DIABETES TURNOVER NTX

HIP FRACTURE
IN FALLS FROM STANDING HEIGHT IMPACT FORCES: EXCEED FEMORA STRENGTH BY 50% IN ELDERLY BELOW FEMORA STRENGTH BY 20% IN YOUNG
COURTNEY (JBJS, 1995)

HIP FRACTURES
FALL TO SIDE FEMORAL NECK BONE DENSITY POTENTIAL ENERGY BODY MASS INDEX ODDS RATIOS NURSING AMBULATORY HOME 5.7 21.7 2.7 2.8 2.2

3.3 4.2

(GREENSPAN & HAYES)

SYMPTOMATIC VERTEBRAL FRACTURE OVER AGE 60 50% FALL 20% CONTROLLED ACTIVITY REACHING BENDING LIFTING
MYERS (J Bone Min Res 1996)

REPAIR POTENTIAL

BONE QUALITY

BONE MASS BONE STRUCTURE

GENERAL HEALTH AGE

TRAUMA

FRACTURE PROTECTION CONTINUES UP TO 10 YEARS 1 3yrs 7 10yrs 7-10yrs 3.2% 5.0% Fracture Rate Fracture Rate Fracture Rate after d/c drug

CONTROVERSIES ON BISPHOSPHONATES

RISK OF FRACTURE IF TOO SUPPRESSED FATIGUE FRACTURE

1-5yrs drug 6.6% no drugs 5-10

(PAK CY)
BONE (NEJM 2004)

Subtrochanteric Fracture

PROLONGED BISPHOSPHONATES
TURNOVER MICROFRACTURE FROZEN BONE BRITTLE FRACTURE

(PAK)

Alendronate Fracture

ST/S Fracture

83 year old female with no history of alendronate use

60 year old female with no history of alendronate use

Alendronate Fracture
HIP FRACTURE BISPHOSPHONATE 11% SUBTROCH FX BISPHOSPHONATE 38%

PAMIDRONATE (IV) RECLAST IBANDRONATE

COMPARABLE BONE MASS ACCRETION FRACTURE DATA - HIP/VERT FRACTURE WHEN ORAL BISPHOSPHONATES CONTRAINDICATED OSTEONECROSIS JAW MORTALITY 20%
LYLES NEJM 2007

BONE MASS CHANGE ACCOUNTS FOR APPROXIMATELY 18% OF FRACTURE RISK PREVENTION TURNOVER QUALITY REMAINING FACTORS

PTH (1-34) ANABOLIC AGENT (1BONE MASS ALL FRACTURES ? ENHANCES FRACTURE HEALING SPINE FUSION (20 ANIMAL STUDIES)

PTH (1-34) INDICATIONS (1BONE MASS DECLINE ON BISPHOSPHONATE FRACTURES ON BISPHOSPHONATES STEADY STATE < 3 5 SD 3.5 LOW TURNOVER OSTEOPOROSIS

PREMENOPAUSAL WOMEN ACTIVE LONG BONE FRACTURE

Biochemical Markers of Bone Turnover Contrasted Data on Mechanism of Action1

Alendronate
Mean % Change SE
250 200 150 100 50 0 -50 0 1 3 6 - 68 - 70 12 250

FORTEO (teriparatide
[rDNA origin] injection)

Fracture Healing: PTH vs. Bisphosphonates

197

PINP NTx

200 150 100 50 0 -50 -100 0 1 3 6

Animal

40

Bisphosphonate Callus Size

PTH

-100

12

Months

Months

Maturation Biomechanics -

Information regarding mechanisms of action does not provide evidence of comparative fracture protection.

1. Arch Intern Med. 2005;165:1762-1768.

See Boxed Warning and Important Safety Information for FORTEO. See full Prescribing Information for FORTEO.

New Osteoporotic Fracture

Initiate Calcium/Vitamin D Hold Bisphosphonate 3 6 Weeks Consider PTH Depending on Host/Site/Character

PREVENTION OP
PHYSIOLOGICAL CALCIUM 800-2000 UNITS VITAMIN D + / - ESTROGEN (MENOPAUSAL SYMPTOMS) EXERCISE

EXERCISE
IMPACT STRENGTHENING BALANCE (DANCING, TAI CHI)

HIP FRACTURE PREVENTION USING HIP PROTECTORS

LAUPITZEN 1993 HORADA 2001

DXA TEST OF CHOICE NTX DXA NTX APPARENT BONE MASS RATE OF BONE TURNOVER

FALLS
MAJOR CAUSE HIP FRACTURES OSTEOPOROTIC INDIVIDUALS WAITING TO FALL TO FRACTURE THEIR HIPS
HAYES (HARVARD)