1
Q
When can bisphosphonates be considered? (6)
A
- Vertebral compression fracture with Osteoporosis
- Fragility fracture with osteoporosis
- Pagets
- MM
- OI
- AVN
- metastic disease (reduces skeletal events)
2
Q
What are contributing factors to squeaking seen not only in COC but also MOM? (5)
A
- component malposition
- edge loading
- impingement
- third-body particles
- loss of lubrication
3
Q
How does improper acetabular component orientation affect outcome of THA? (8)
A
- Increases dislocation rates
- component impingement
- Increased bearing surface wear
- Increased number of revision surgeries
- Leg length discrepancy increases
- Alteration of hip biomechanics
- Increased pelvic osteolysis
- Increased risk of acetabular component migration
4
Q
What are the 5 moderate strength recommendations concerning distal radius fractures?
A
- Recommendations for surgical treatment
- Dorsal angulation >10 degrees
- shortening >3mm
- step off >2mm
- use a real cast for non op
- give vitamin c.
5
Q
Fracture displacement in calcanei fractures typically results in these findings which can be problematic if malunion occurs. (5)
A
Loss of hindfoot height
Varus heel position,
Widening of the hindfoot
Possible subfibular impingement
Irritation of the peroneal tendon and/or sural nerve
6
Q
What is the sole strong recommendation concerning vertebral osteoporotic compression fracture?
A
Don’t do a vertebroplasty.
7
Q
4 complications of lateral humeral condyle fracture
A
- Cubitus valgus
- Tardy ulnar palsy
- Fishtail (due to osteonecrosis)
- Cubitus varus
8
Q
Who wants to know the 4 moderate grade recommendations concerning RTC?
A
- NSAIDS and physio for incomplete tears
- No routine acromioplasty
- Don’t use xenograft patches
- Workers comp will do worse
9
Q
What are the “most recognized” complications of TEA? (6)
A
- implant loosening
- periprosthetic fracture
- implant failure
- infection
- triceps insufficiency
- nerve palsy
10
Q
List 8 complications of rTSA
A
- neurologic injury
- periprosthetic fracture
- hematoma
- infection
- scapular notching
- dislocation
- mechanical baseplate failure
- acromial fracture
11
Q
List three distinct pathological types of knee osteonecrosis.
A
- secondary ON
- spontaneous ON of the knee
- postarthroscopic ON
12
Q
4 indications for an HTO of in a varus knee
A
- varus alignment of the knee associated with medial compartment arthrosis
- knee instability
- medial compartment overload following meniscectomy
- osteochondral defects requiring resurfacing procedures
13
Q
Concerning healed in situ pinning of SCFE, a proportion of these patients progress to symptomatic femoral acetabular impingement. List 3 surgical treatment options.
A
- arthroscopic femoral neck osteochondroplasty
- a limited anterior hip approach or surgical hip dislocation
- flexion intertrochanteric osteotomy
14
Q
Concerning arthroscopic release of arthrofibrosis of the knee what four areas do you want to address?
A
- the anterior interval
- posterior capsule
- peripatellar
- suprapatellar regions
15
Q
List contraindications to TAR (7)
A
uncorrectable deformity
severe osteoporosis
talus osteonecrosis
charcot joint
ankle instability obesity
young laborers increase the risk of failure and revision
16
Q
List factors contributing to chronic ankle instability
A
Mechanical Pathologic laxity
Arthrokinetic restriction
Synovial changes
Degenerative changes
Functional Impaired
proprioception Impaired
neuromuscular control Impaired
postural control
Strength deficits
17
Q
List 5 risk factors for progression of sponylolisthesis (5)
A
>50% slip
>50 deg slip angle
dysplastic
young age
female
18
Q
Risk factors of pseudoarthrosis of sponylolisthesis (6)
A
Sacral slope > 45 deg
Hypermobile
L5/S1 Decompression
Sacral dysplasia
Spina bifida
Secondary changes of S1 from slip
19
Q
Risk factors for child abuse (8)
A
low income
unemployed
single parent homes
abuse of parents
drug abuse
recent job loss of parent
children with disabilities (cerebral palsy, premature)
step children
20
Q
Poor prognostic factors with Ewings
A
Location - spine and pelvic tumors (distal tumors have a better prognosis)
Size - tumors greater than 100cm3 or >8cm
Age >14 yo
Male
LDH >200IU
CRP/WBC elevation may be associted with mets and higher tumor burden
< 95% necrosis with chemotherapy
p53 mutation in addition to t(11:22) translocation
Relapse at < 2years
21
Q
Complications of radiotherapy in a young person (5)
A
fragility fractures
limb length discrepancy
joint contracture
muscle atrophy
pathological fractures secondary malignancy (sarcoma, usually at 10 years, 20% will develop by 20 years)
22
Q
Indications for immediate surgical fixation SCH# (8)
A
Open fracture
Dysvascular limb
Skin puckering
Floating elbow
Median nerve palsy
Evolving compartment syndrome
Young age
Cognitive disability
23
Q
Surgical indications for disci tis (6)
A
◦ abcess ◦ neurologic deficits (for any reason) ◦ progressive deformity ◦ gross spinal instability ◦ persistent infection despite antibiotic (BW still elevated)
24
Q
Indications for medical treatment of a spinal epidural abcess
A
◦ no neurologic deficits ◦ small abscess ◦ patient capable of close clinical follow-up ◦ those who are not candidates for surgery due to medical comorbidities
25
Contraindications for limb salvage procedure (7)
◦ Major neurovascular structures encased by tumor when vascular bypass is not feasible ◦ Pathologic fracture with hematoma violating compartment boundary ◦ Inappropriately performed biopsy or biopsy-site complications ◦ Severe infection in the surgical field ◦ Immature skeletal age with predicted leg-length discrepancy \>8 cm ◦ Extensive muscle or soft-tissue involvement ◦ Poor response to preoperative chemotherapy
26
Indication to get c-spine imaging for a RA patient (5)
◦ Cervical symptoms \> 6 months ◦ neurological signs ◦ procedure and no imaging 2 years ◦ rapid deterioration in function ◦ rapid deterioration of carpal and tarsal bones
27
Indications for surgical fixation of an RA spine (8)
◦ progressive neurological deficit ◦ pain refractory to medication ◦ radiographic risk factors for neurological injury ◦ PADI \< 14mm with AAI ◦ odontoid migration \> 5mm above magregor's line ◦ Canal diameter \< 14mm in SAS ◦ AAI or cord stenosis ◦ cervicomedullary angle 135
28
Radiographic features of enchondroma vs low grade chondrosarcoma on plain radiographs (8)
◦ Low grade features Dense calcifications with rings and spiclues Uniform calcification Eccentric, lobular growth of soft tissue ◦ High grade features Faint, amorphous calcification Large noncalcified areas Lysis within a previously calcified area Concentric growth of soft tissue mass
29
Clinical and radiographic features of MHE conversion to chondrosarcoma (4)
◦ acute onset of pain ◦ Adults with growing osteosarcoma ◦ Average age is 31 ◦ Cartilage cap \> 2cm
30
Indications for fusion of first MTP in hallux valgus
Gout Rheumatoid arthritis Down's syndrome cerebral palsy Severe DJD Ehler-Danlos Resection arthroplasty
31
Conditions that arise as a result of ulnar positive variance (5)
ulnar abutment syndrome SLD TFCC tears arthrosis ulnar head lunate triquetrum lunotriquetral ligament tears
32
4 cuts of a PAO
anterior ischium below the acetabulum superior pubic ramus supra-acetabular ilium posterior column
33
Important factors in healing a diabetic ulcer (5)
albumin \> 3.0 g/dl lymphocyte \> 1000 mm3 transcutaneous oxygen \> 30mmHg - gold standard ABI \> 0.45 toe pressure \> 40mmHg
34
The most common wrist extensors that get injured during wrist arthroscopy
EDM EDC
35
Optimal position for knee arthrodesis
5-8° valgus 0-10° of external rotation (match other leg) 0-15° of flexion some limb shortening advantageous for patient self-care Can remove flexion if \> 2cm LLD If \> 4cm LLD should perform lengthening
36
Indications for hip arthrodesis
salvage for failed THA (most common) young active laborers with painful unilateral ankylosis after infection or trauma neuropathic arthropathy tumor resection
37
Indications for surgical treatment of first time shoulder dislocators
* **Absolute**
* Associated Injury
* \>50% rotator cuff tear
* Glenoid osseous defect \>25%
* Humeral head articular surface osseous defect \>25%
* Proximal humerus fracture requiring surgery
* Irreducible dislocation
* Interposed tissue or nonconcentric reduction
* Failed trial of rehabilitation
* Inability to tolerate shoulder restrictions
* Inability to perform sport-specific drills without instability
* **Relative**
* \>2 shoulder dislocations during the season
* Overhead or throwing athletes Contact sport athletes
* Injury near the end of the season Age \<20 years
38
List reasons to consider leaving a well-fixed shell in place in the context of THA revision for retroacetabular osteolysis (5).
(JAAOS Stulberg et al. 2008)
1. Area of osteolysis safely accessible for grafting
2. Area of cup fixation is unaffected by the osteolysis.
3. Cup is in good position
4. Locking mechanism intact
5. New poly liner is readily available.
39
Name 3 ideal conditions for cementing a new liner into existing shell during THA revision.
JAAOS Stulberg et al 2008
1. Well fixed shell
2. Presence of holes in the shell
3. Shell is of sufficient diameter to allow new liner and \>2mm cement mantle
40
List three scenarios when isolated polyethylene liner exchange is indicated in TKR revision.
JAAOS Dennis et al 2008
1. Late revision for poly wear in patient with tibial and femoral components that are well fixed and well aligned.
2. Patient with CR knee that develops PCL insufficiency. Can revise to dished (highly congruent) liner to substitute for PCL.
3. Patient with varus/valgus ligamentous laxity. Can release the concave side to balance knee, and insert new thicker poly.
41
Name three scenarios where isolated femoral component revision in TKR is indicated.
JAAOS Dennis et al 2008
1. CR develops PCL insufficiency, can revise femur to PS design with new PS poly insert.
2. Isolated femoral component malrotation leading to asymmetric flexion instability.
3. CR/PS knee develops MCL insufficiency. Can revise femur to CCK and insert new CCK liner. (If tibial component well fixed/aligned)
42
List 5 ideal chemical/pharmacologic prerequisites for an antibiotic that is to be used in a cement spacer.
\*\*\*Bonus\*\*\* What is the minimum dose of antibiotic to be used per 40g of cement?
JAAOS Jacobs et al 2009
1. Thermostable
2. Broad spectrum
3. Bacteriocidal at low dose
4. Powder form with low serum binding potential, ie. water soluble.
5. Low allergenicity
Bonus: 3.6 g of antibiotic per 40g of cement. Good choices are tobra, vanco or gent. Cephalosporins generally not used as they are not thermostable.
43
Two modes of wear in TKR tibial bearing insert.
Lachiewicz JAAOS 2011
1. Fatigue damage (ie. pitting and delamination)
2. Mechanical wear (adhesive and abrasive wear)
44
Principles of converting a fused hip to THA (6)
JAAOS Swanson et al 2011
1. Identify and preserve abductors.
2. Restore anatomic hip centre.
3. Concentrically ream acetabulum
4. Avoid cephalic cup position
5. Restore native offset
6. Achieve leg length equality
45
List 5 features of RA that are associated with higher likelihood of requiring hip or knee arthroplasty.
JAAOS Goodman et al 2013
1. Onset of disease at younger age
2. Positive RF
3. Presence of rheumatoid nodules
4. Erosive radiographic changes
5. Poor functional status
6. Persistent elevation of ESR & CRP
46
3 indications for preop referral to spine surgeon prior to elective surgery in RA patient
JAAOS Goodman et al 2013
1. Presence of basilar invagination
2. Instability leading to SAC \<13mm
3. Clinical myelopathy
47
What are the MSIS criteria for diagnosis of periprosthetic joint infection?
JAAOS Kuzyk et al 2014
1. Sinus tract communication to the implant, OR:
2. _Two_ positive microbial fluid or tissue cultures, OR:
3. Four of the six:
- ESR \>30 and CRP \>10
- Synovial WBC \>1100 (knee) or \>3000 (hip)
- Neutrophil % \>64 (knee) or \>80 (hip)
- Purulence in joint
- Single positive synovial fluid or joint tissue culture
- \>5PMN per hpf in 5 hpfs @ x400 magnification
48
Blood management strategies prior to arthroplasty
(Preop, intraop, postop)
JAAOS Levine et al 2014
_Preop_
- Vitamin supplementation (Iron, folate, B12)
- EPO (indicated if preop Hb \<130 or BW \<50kg)
- Preop autologous donation (probably best for patients with normal preop Hb but expected blood loss such as revision or bilateral arthroplasties)
_Intraop_
- Acute normovolemic hemodilution (taking blood intraop and replacing with colloid - reduces concentration and number of RBCs lost)
- Tourniquet
- Bipolar sealant cautery
- Argon beam coagulation
- Antifibrinolytics (ie. TXA which blocks plasmin binding sites on fibrin, preventing fibrinolysis)
- Topical hemostatic agents (collagen/cellulose based, fibrin sealants)
_Postop_
- Reinfusion systems
- More stringent tranfusion protocols (Transfuse if Hb\<60 & don't transfuse if \>80. If Hb 60-80 should evaluate for ongoing losses, symptoms, cardiovascular risk)
49
Swedish registry data shows that 30% of Vancouver B1 periprosthetic fractures treated with ORIF go on to fail vs. 18.5% failure of B2 fractures treated with revision arthroplasty. This suggests likely misclassification of B2s as B1s. List methods of determining implant stability.
JAAOS Shah et al 2014
- History of groin/thigh pain, startup pain, etc. before inciting trauma.
- Imaging: lucent lines, subsidence, pedestal, etc.
- Intraop: Stability at bone-implant interface in fracture site. Alternatively, can open and dislocate hip to assess for stem stability.
50
Risk factors for extensor mechanism disruption after TKR:
JAAOS Bates et al 2015
Multiply operated knee
DM
Renal disease
RA
Obesity
51
What are 8 anatomic differences in children that change your mangement in a trauma
* Big head - need spine board cutout
* high risk of C1-3 injury
* higher risk of cervical/neuro injury
* anterior trachea - no cuff when intubate
* low blood volume - compensate and crash quickly
* high HR, low BP
* spleen and liver are not covered by ribs
* rib cage is more elastic
* less rib fractures, more thoracic injury
* higher body surface area - at risk of hypothermia
52
What it the tile classification?
* **A - stable**
* A1-fracture not involving the ring (avulsion or iliac wing fracture)
* A2-stable or minimally displaced fracture of the ring
* **B - rotationally unstable, vertically stable**
* B1-open book
* B2-lateral compression, ipsilateral
* B3-lateral compression, contralateral (bucket-handle injury)
* **C - rotationally and vertically unstable**
* C1-unilateral
* C2-bilateral
* C3-associated acetabular fracture
53
What is the young-burgess classification?
* **Anterior Posterior Compression (APC)**
* _APC I_
* Symphysis diastasis \< 2 cm
* Non-operative. Protected weight bearing
* _APC II_
* Anterior SI joint diastasis
* Posterior SI ligaments remain intact.
* Anterior symphyseal plate or external fixator
* _APC III_
* Disruption of anterior and posterior SI ligaments (SI dislocation).
* APCIII injuries associated with vascular injury
* Anterior symphyseal plate or external fixator and posterior stabilization with SI screws
* **Lateral Compression (LC)**
* _LC Type I_
* Oblique ramus fracture and ipsilateral anterior sacral ala compression fracture.
* Non-operative. Protected weight bearing
* _LC Type II_
* Ramii fracture and ipsilateral posterior ilium fracture dislocation (Crescent fracture).
* Open reduction and internal fixation of ilium
* _LC Type III_
* Ipsilateral lateral compression and contralateral APC (windswept pelvis).
* Common mechanism is rollover vehicle accident or pedestrian vs auto.
* Posterior stabilization with plate or SI screws as needed. Percutaneous or open based on injury pattern and surgeon preference.
* **Vertical Shear (VS)**
* Posterior and superior directed force.
* *Associated with the highest risk of hypovolemic shock (63%); mortality rate up to 25%*
* Posterior stabilization with plate or SI screws as needed. Percutaneous or open based on injury pattern and surgeon preference.
54
How do pediatric pevlic fractures differ from adult fractures?
* if triradiate cartilage is open the iliac wing is weaker than the elastic pelvic ligaments, resulting in bone failure before pelvic ring disruption
* for this reason fractures usually involve the pubic rami and iliac wings and rarely require surgical treatment
55
Complications associated with pevlic fractures
* Dyspyruneia
* exctretory dysfuction
* sexual/erectile dysfunction
* decreased quality of life
* chronic pelvic pain
* **Neurologic injury **
* _L5 nerve root_ runs over sacral ala joint
* may be injured if SI screw is placed to anterior
* **DVT and PE **
* DVT in ~ 60%, PE in ~ 27%
* prophylaxis essential
* mechanical compression
* pharmacologic prevention (LMWH or Lovenox)
* vena caval filters (closed head injury)
* **Chronic instability**
* rare complication; can be seen in nonoperative cases
* presents with subjective instability and mechanical symptoms
* _diagnosed with alternating single-leg-stance pelvic radiographs _
56
What are the most common sites of compression of the ulnar nerve
arcade of Struthers
medial intermuscular septumm
edial epicondyle
cubital tunnel
deep flexor pronator aponeurosis
57
What are the zones of guyons canal
* **Zone 1**
* Proximal to bifurcation of the nerve
* Ganglia and hook of hamate fractures
* _Mixed motor and sensory_
* **Zone 2**
* Surrounds deep motor branch
* Ganglia and hook of hamate fractures
* _Motor only_
* **Zone 3**
* Surrounds superficial sensory branch
* Ulnar artery thrombosis or aneurysm
* _Sensory only_
* **Zone 4**
* ****compression of the motor branch with sparing of hypothenar
* **Zone 5**
* ****compression of only index/middle interosseous with adductor
58
What are the boundaries of guyons canal
* **Floor**
* Transverse carpal ligament, hypothenar muscles
* **Roof**
* Volar carpal ligament
* **Ulnar border**
* Pisiform and pisohamate ligament, abductor digiti minimi muscle belly
* **Radial border**
* Hook of hamate
59
Common etiologies of ulnar tunnel syndrome
* gaglia are most common
* if making a list you can list any benign tumor of the hand or several carpal articulations
* vibratory compression is second most common
* or prolong pressure, as in cycling
* hook of hamate - most common traumatic finding
* can also list pisiform, MT base, DR, ulnar styloid
* arterial thrombosis/anerysm (hypothenar hammer syndrome)
* Anomalous muscle, fibrous bands
* OA/RA - synovitis, pannus, boney deformity
* DM, EtOH, renal failure, scleroderma
* Iatrogenic - CTR
60
Conditions that can present with ulnar neuropathy as their main complaint
peripheral neuropathy (cubital tunnel more common location of compression)
infectious/polio neuropathy
brachial plexopathy
malignant nerve sheath tumors
CMT
ALS
61
What tests help you distinguish elbow vs wrist ulnar nerve compression
* **palmaris brevis sign** = excessive contraction of palmaris brevis with 5th digit abduction
* loss brevis with compression at guyons canal, but not cubital tunnel...need to clarify; potentially martin-gruber???
* PB is innervated by the superficial sensory branch of the ulnar nerve, so you will loose function with a zone 3 injury
* **Sensation of dorsal 4/5 digits**
* **Tinels sign at elbow**
* **numbness with 1 min elbow flexion**
62
Describe findings associated with zone 2 guyon canal compression
* decreased grip/pinch - 1st interosseous/adductor
* Froment sign - weak adductor
* Wartenberg sign - inability to aDduct the 5th digit (loss 3rd interosseous)
* Inability to cross index/middle finger - weak interosseous
63
Indications for surgical release of guyons canal
NOT DUE TO VIBRATION
Symptoms worsening over 2-4 months
Intrinsic muscle weaknes, hypothenar atrophy
persistent sensory deficiet
64
Complications associated with fracture table use
* Difficult to assess length and reduction
* Difficult to get reduction
* posterior translation distal fragment
* Significant perineal soft tissue injury
* Pudendal nerve palsy
* erectile dysfunction
* reduced by intraoperative muscle relaxants
* Hemilithotomy
* sciatic nerve in well leg
* compartment syndrome in well leg
* direct compression on calf
* low SBP intra-op
* Lateral decubitus
* crush syndrome
65
Causes of complications associated with misuse of the fracture table
* Prolonged duration of traction
* release when no longer needed
* periodic release during long procedures
* Excessive traction
* more important than prolonged traction
* adequate muscle relaxants
* Excessive adduction
* reduced with abduction of affected limb
* Small post
* hemilithotomy position
66
Recommendations to decrease risk of complications with traction table
* obese patient use flat-top
* place post between genitals and contralateral leg
* well-padded post (\>10cm)
* do not adduct past neutral
* surgery \>120min should release traction periodically
* avoidance of hemilithotomy when possible
67
What is the role of an institutional review board in ortho
Ensure necessary measures are in place to protect privacy, confidentiality, rights and privileges of human research subjects.
68
What is the process of informed consent for research
* **Must be attained voluntarily**
* Has 2 essential parts
* 1) The Process & 2) The Documentation
* must use simple language
* **The process:**
* research purpose
* risks
* benefits
* rights in simple language
* **The Documentation:**
* signed and witnessed consent form that IRB has approved
69
What are the review board requirements and review criteria for research purposes
complete description of research
potential risks to participants are minimized
outlined risks are reasonable
equitable selection of patients (gender, race)
scientifically valid design
description of process for informed consent
plan for data collection/storage/monitoring
appropriate safegaurds for vulnerable subjects
adequate privacy and confidentiality
70
recommendations for driving after orthopedic surgery
* Knee arthroscopy
* 4 weeks
* Ankle fracture, surgery
* 9 weeks
* Lower extremity fracture
* 6 weeks AFTER weight bearing starts
* THA or TKA
* 4-6 weeks
71
How can you quantify safe driving and how can you test it
* Tests - not standardized, difficult to use
* BRT – time from appearance of stimulus until contact with brake pedal
* TBT – total breaking time
* **Step test**
* ****seated patient steps over small box x10 seconds
* **Stand test**
* patient rises from seated position as many times as possible x10seconds
* These are correlated with BRT post knee arthroscopy, ACL recon, and 1st metatarsal osteotomy…
* No further evidence to support these tests being applied more widely
72
What are the cited criteria for saftey to drive and who decides this
**The patient decides when they are safe to drive, we just help them make an informed decision**
* **Limitations**
* no driving with cast/brace on right leg
* simple forearm cast ok
* elbow immobilization causes impairment
* **Criteria for safe to drive**
* Full weigh bearing
* walking without crutches
* clinical and radiologic findings
* patient self-assessment
73
Methods to diagnose obesity
* **BMI (table 1)**
* World Health Organization
* Normal 19.5-24.9
* Overweight 25-29.9
* Obesity \>30
* Generally Accepted Definitions
* Morbid obesity \>40
* Super obese \>50
* Classification of Obesity
* Class I 30-34.9
* Class II 35-39
* Class III \>40
* **Waist circumference**
* more accurate in children and adolescents
* **Waist-height ratio**
* more effective screening for cardiac risk
* **Body fat composition**
* good for athletes
* Others you can list that are good for research only
* _bioelectrical impedance analysis_
* _dual- energy x-ray absorptiometry_
* _air- displacement plethysmography_
* _CT_
74
Diagnostic criteria and complicaitons associated with metabolic syndrome
* **Diagnosis**
* insulin resistance
* abdominal obesity
* hypertension
* atherogenic dyslipidemia
* **Metabolic syndrome has been demonstrated to be associated with the following**
* increased length of hospital stay
* non-routine disposition
* increased cost
* major complications in lumbar fusion and TKA
75
What are the elements of the STOP-BANG test for sleep apnea
* Snoring
* Tired during the day
* Obstruction - someone has witnessed stop breathing
* Pressure - HTN
* BMI \> 28
* Age \> 50
* Neck circumference (17 in males, 16 inches females)
* Gender - male
76
What are injuries associated with an obese patient
* Higher risk OA (32.7X with BMI \>40)
* Higher risk of MSK injury (48% with BMI \>40)
* low velocity knee dislocation
* often associated with popliteal injury
* more severe ankle fractures
* MSK related pain syndromes in eldery (fibromyalgia)
* **in the pediatric population there are more lower extremity injuries**
* pelvic fractures
* bilateral femur fractures
* femoral fractures requiring surgical treatment
* persistant pain following ankle fracture
* blounts disease
* SCFE
77
Anesthetic condiserations for the obese patient
* limited atlantoaxial and cervical spine motion
* short neck
* suprasternal, presternal and posterior cervical fat pad
* excessive fat fold around mouth
* decreased residual lung volume
* increased atelectasis
* decreased residual capacity
* worse ventilation-perfusion mismatch
* difficult intubation = fiberoptic is better
* regional technique more difficult to perform
* twice as likley to fail local block
* difficult anesthetic dosing
78
What are the risks associated with obesity and trauma and TKA
* ***Overall risks are controversial and some studies show lower morbidity/mortality***
* ***Only constant is DVT/PE*********
* _TJA specific_
* infection is controversial (seems to be more linked to diabetes)
* more technical errors
* lower implant survival
* dislocation in THA
* slower recovery
* _Trauma specific_
* __higher rate end-organ failure
* higher rate ARDS
* higher rate infection
* increased cost
* increased morbidity/mortality
* slower recovery
* note - difficult positioning, getting imaging, getting scan
79
Advantages of U/S in children
radiation
inexpensive
dynamic
no need for sedation or fasting
can be done before ossification
80
Pathology that U/S can diagnose in children (12)
* **DDH** - diagnose and follow treatment
* can assess acetabulum, femoral head and dynamic stability
* **SCFE** - can't see pre-slip
* **FAI** - only to assess CAM lesion
* **Psoas** - dynamic evaluation of snapping hip
* guided injection can rule out pathology
* **Clubfoot** - can monitor realignment of the TN joint
* assess the adequacy of complete reduction; predict failure
* **Spine**
* _Tethered cord_ - assess for location of conus
* conus below L2/3 with limited motion = tether cord
* _Spinal dysraphysm_
* closed - lipomyelocele, lipomyelomeningocele, posterior meningocele, and myelocystocele
* **Peripheral nerves**
* _subluxation_
* _extent of damage_ (endo/epi/perineruium vs scar)
* **Neonatal brachial plexus palsy** - assess glenoid, position of head, stability
* **Infection**
* periosteal abcess from OM
* hard to reach joint aspiration
* abcess diagnosis and culture
* **Biposy** (obviously) or **assessment of cyst/tumor**
81
Indications for spine U/S in the neonate
subcutanoeus mass
bowel/bladder
anorectal or urogenitary abormalities
foot abormalities from neuro dysfunction
VATER syndrome
82
List uses of US in treatment of pediatric pathology (3)
* U/S guided nerve blocks - last longer, less medication, fewer complicaitons
* U/S guided botulism injection - imporved needle placement, less time, improved results
* Removal of foreign body
83
What are the phases of RC calcific tendonosis
* **Formative** - chronic pain with deposition
* **Resting** - less painful
* **Resorptive** - acutely painful, mimics infection
84
What are the options for treatment of calcific tendonosis
* **PT**
* to maintain joint mobility
* always do this first
* **intrabursal cortisone injection**
* during formative phase
* **Needle lavage**
* resorptive phase
* offered by author after 3 months - injection of bupivicane, 3-5 passes with 18 guage
* **Extracorpeal shock-wave**
* sill a lot of research necessary
* **Surgery - arthroscopic vs miniopen decompression**
85
Indications for surgery in RC calcific tendonitis
* **progression of symptoms** - following 6 months of trial of PT the USNL
* **interference with ADLs**
* **refractory to nonoperative treatment**
* **rarely indicated during resorptive phase**
86
List potential complications of untreated foot compartment syndrome. (8)
JAAOS Dodd et al 2013
Chronic pain
Insensate foot
Foot/ankle stiffness
Claw toe
Hammer toe
Neuropathic pain
Neuropathic ulcerations
Cavus foot
87
List the muscle layers of the foot from superficial to deep.
FIRST: Abductor digiti minimi, flexor digitorum brevis, abductor hallucis
SECOND: Quadratus plantae and lumbricals. Tendons of FDL and FHL. Medial and lateral plantar nerves.
THIRD: Flexor hallucis brevis, two heads of adductor hallucis, flexor digiti minimi brevis
FOURTH: Dorsal and plantar interossei, tendons of peroneus longus and tib post.
88
List the nine compartments of the foot:
JAAOS Dodd 2013
1. Four interosseous compartments
2. One adductor hallucis compartment
3. Plantar side:
- Medial
- Superficial Central
- Deep Central
- Lateral
89
Describe the three-incision foot compartment release.
Dodd 2013
2 Dorsal incisions:
Between 1st/2nd rays, and between 4th/5th rays.
-release interosseous and adductor compartments.
1 medial incision:
Starting 4cm anterior to the heel and 3cm up from the plantar surface, make a 6cm incision. Can release medial, superficial and deep central, and lateral compartments.
90
List 7 different types of heel cord lengthenings.
Abdulmassih JAAOS 2013
Silfverskold - releasing gastrocs origin from distal femur to below the knee.
Baumann - intramuscular lengthening.
Baker - inverted "U" shape transection of gastrocs fascia after dissecting off soleus (stronger as its repaired to itself.
Strayer - horizontal transection of gastrocs fascia after dissecting it off soleus (weaker as it's repaired to underlying soleus fascia.
Vulpius - transecting gastrocs fascia without dissecting off of soleus.
Hoke - 2 medial and 1 lateral partial cuts in distal tendon
Z lengthening - open procedure for severe shortening with scarring
91
List factors predictive of infection in diabetic foot ulcers.
Anakwenze JAAOS 2012
Ulcer \>2cm
Positive "probe to bone" test
ESR \>70
Xray changes such as periosteal thickening or sclerosis, osteolysis, cortical irregularity, or abnormal trabecular architecture
92
Outline the Wagner classification of diabetic foot ulcers.
Anakwenze JAAOS 2013
0. Skin intact, but foot "at risk." Treat w/ TCC
1. Superfical ulcer. Debride/TCC
2. Deep ulcer to muscle, bone, tendon, etc. Debride/TCC/TAL/Abx
3. Deep abscess/Osteomyelitis. Debride/TCC/TAL/Abx. Free flap PRN. Amputate if all fails.
4. Toe/Forefoot gangrene. Amputate.
5. Foot gangrene. BKA.
93
Differnetial for flail upper extremity in the newboarn
* **Brachial Plexus Injury**
* No pain
* See topic
* **Fracture**
* Crepitus
* Can be difficult due to large ossification centers
* US can be very useful
* Clavicle # common, femur less common
* After discharge must consider child abuse
* If multiple fractures need to consider rickets or OI
* Treatment
* Upper extremity - pin the arm to the shirt
* Femur - Hip spica
* Prognosis
* Only need to immobilize for one week
* LLD or deformity is very rare
* **Infection**
* Difficult because of their immature immune system
* Joint may or may not be red
* 76% of OM in infants will become septic arthritis
* Leukopenia may be more suggestive of infection
* Staph Aureus \> GBS
* Blood cultures positive 30-40% of the time
94
Differential diagnosis for periosteal new bone in the newborn
* **Some reaction is normal**
* Between 1-4 months and bilaterally is likely normal
* \> 2mm is likely pathological
* **Differential**
* Rickets (multiple)
* Osetogenesis imperfecta (multiple)
* Caffey disease
* Congential syphilis
* Infection
* Malignancy
* Child Abuse
* Hypervitamniosis A
* Prostaglandin infusion
* Extracorporeal membrane oxygenation
* Scurvy
95
Risk factors and presentation for septic OA of the neonate hip
* **Exposure**
* ****GBS - transvaginal delivery
* NICU - MRSA
* **Risk Factors**
* invasive procedures
* catheterization
* heel puncture
* NICU treatment
* thin skin
* access lines
* prematurity/immunocompromise
* breech
* Presentation
* limited movement
* edema of buttock or leg
* different resting position of hip
* anorexia irritability, lethargy
* **often afebrile, labs often unreliable**
96
Differential diagnosis of acute (or chronic) pain and swelling in the irritable neonate
**Dislocated septic hip**
* DDH
* Transient synovitis of the hip
* Osteomyelitis of the proximal femur/ pelvis
* Henoch-Schönlein purpura
* Pyomyositis
* Traumatic synovitis
* Fracture
* Intra-abdominal pathology
* Sacral agenesis
* Superficial cellulitis
* Superficial abscess
* Psoas abscess
* Pyogenic sacroiliitis
* Acute leukemia
* Various rheumatologic disorders
* Nonspecific arthritides
* Proximal focal femoral deficiency
* Acute rheumatic fever
97
Diagnosis of neonatal septic hip
* **aspiration & inspection of jt fluid**
* cell ct, gm stain, Cx (an/aero, fungal)
* + gm stain or Cx, WCC \>30,000, PMNs \>75% = septic arthritis [Cx often negative]
* Orgs: s. aureus, GBS, strep pneumo, Klebsiella, and Proteus
* **Imaging: XR**
* capsular swelling
* widening of the jt space
* subluxation or dislocation
* radiolucency in the proximal femoral metaphysis, or periosteal elevation
* **Imaging: US**
* ****effusion; _difference \>5 mm_ compared with the contralateral side is considered an indication for aspiration because the larger measurement represents an additional 5 mL of fluid
98
Indications to perform elbow arthroscopy
Septic Joint
**Synovectomy for RA - most common**
OA debridement
Loose body
Contracture Release
OCD
Some fractures (Radial Head, Coronoid)
Some instabilty (MCL recon scope assisted)
Tennis elbow release
Diagnostic for OA
Plica Resection
Radial Head Excision
Patient is NPO and you have a cancellation.
99
List 6 elbow portals
* Soft Spot
* Accessory Soft Spot
* Direct Posterior
* Posterolateral
* Anterolateral
* Anteromedial
100
Complications of elbow scope
Infection
Fistula
HO
Nerve Injury
101
Most common nerve injuries in elbow scope
* Most common to least common:
* Ulnar
* superficial radial
* PIN
* AIN
* MABCN
102
STATIC stabilizers of the shoulder (9)
* Scapular Neck (version of the glenoid)
* Glenoid
* Labrum
* Capsule
* IGHL
* MGHL
* SGHL
* CHL
* Coracoacromial Arch
103
DYNAMIC stabilizers of the shoulder (3)
* Deltoid
* Biceps
* Cuff
* Any muscle attaching to scapula
104
Risk factors for atraumatic shoulder dislocation (4)
Marfan
Ehler's Danlos
Any connective tissue
Glenoid hypoplasia
Glenoid retroversion
105
SGHL resists?
Inferior/adduction
106
MGHL resists?
Anterior/ ER at 45 abduction
107
IGHL resists?
Anterior/ER at 90
108
Component of the coracoacromial arch (6)
CA lig
Coracoid
Acromion
AC joint
AC joint capsule
Clavicle
109
Humeral Head is ______ times larger than the glenoid.
3
110
\_\_\_\_\_% of the humeral head articulates with the glenoid.
25-30
111
Labrum is \_\_\_\_% of the glenoid concavity depth?
50
112
Factors that contribute to loss of labral seal in shoulder injury
Labral Tear
Full thickness cuff tear
Glenoid #
Capsule Tear
113
Rehab protocol for should dislocation, no surgery
* Sling & Pendulums 2-3 times daily as tolerated.
* DC sling at 3-4wks
* Progress ROM - passive to active assist to active
* Limit to 90 abd x 6wks
* Limit no ER x 6wks
* Return to sport when full strength & painless ROM, 2months minimum.
114
Risk of associated injuries with shoulder dislocation
* RC \> 40 yo = 40%
* Axially nerve = 13%
* subclinical is common
* Hill-sachs = 40-80%
* **Bankhart = 85% - cardinal lesion**
115
How do you position a patient for an axillary or velpau view
* How do you position the patient, casette, beam for an Axillary?
* Cassette on top of shoulder.
* Patnt Seated or lying prone, flexed, abducted to 90 if possible.
* Beam goes inferior/superior
* Beam, Cassette, Patient for Velpeau?
* Patient leans back against XR table 45 degrees, arm in sling, IR
* Cassette on table
* Beam goes superior to inferior
116
Best view to see a boney bankhart? hillsachs?
westpoint view (glenoid fracture)
stryker notch (hillsachs)
117
Compare outcomes following shoulder reduction: sedation vs local
* no difference in pain
* no difference in reduction
* less complications with local
118
List ways to reduce a shoulder (there are 10, maybe learn a few)
* Hippocratic - foot in axilla & pull
* Traction/Countertraction - same with bed sheet tied off in axilla, 45 abduction, lateral pull.
* Chair - Patient sits in chair. MD supinate arm & hold, patient stands up. MD pulls gently.
* Loop - same, but flex elbow to 90, loop a stocking around & pedal to foot. 97%
* Kocher - flex elbow to 90, adduct, ER to gentle resistance & fwd flex.
* Stimson - Lie Prone, 5lbs on wrist. 15 minutes.
* Milch - Similar to Kocher.
* External Rotation - Patient self reduction. Patient flexes elbow, Turns away from shoulder. Will reduce around 70-110 ER. See Mel Gibson in Lethal Weapon
* Eskimo - Patient LLD, lift patient up by dislocated arm until other should comes off ground. Hold until feel pop. Yikes.
* Spasso - patient supine. Fwd flex to 90 and lift up. This works really good.
119
Posterior should dislocation reduction maneuver
IR/Add, flex to 90. Posterior push, gentle ER to reduce.
120
Chance of recurrent instability after 2 years
1%
121
Options for intra-op spine imaging
C Arm
O Arm
Intra op CT
Intra op MRI
Navigation System
122
What is the rate of pedicle comprise in c-spine surgery? Associated neurological complications?
* Pedicle Violations = 7 to 30% depending on series.
* 0.2% of neuro injury with pedicle violation
* C - Spine 10 of 358 lateral mass screws touch or in the vert art….whoops.
* Magically there were no complications, although no one received a physical exam.
* **T3-T7 has the LEAST forgiveness**
* **** \<1mm translation, 5 degrees rotation.
* Does registration help?
* Yes 17% vs 6% pedicle violations
* So…..in summary…..
* Do it by hand - pierce the pedicles a lot.
* Do it by XR - drop the number a lot, but not to zero.
* Doesn't matter anyway because almost no neuro complications.
123
How do flexor tendons get their _nutrients_
* Imbibition with blood supply from the vincula
Synovial fluid passively diffuses into the flexor sheath. With repeated motion, the pressure in the sheath goes up and the nutrient rich fluid is pumped under pressure into the interstitial aspects of the tendon
124
Blood supply to the flexor tendon
* Longitudinal arterioles from the muscle belly.
* Vincula (branches of digital arteries)
* Insertion on bone
* Flexor Sheath
* Most segmental arteries are dorsal, not volar.
125
What are the 5 flexor zones?
5 - MT junction to carpal tunnel
4 - carpal tunnel
3 - Carpal tunel to A1 pulley
2 - A1 pulley to FDS insertion
1 - distal to FDS - only FDP
126
127
Compare intrinsic vs extrinsic flexor healing
* Intrinsic = tenocyte response from within tendon ( tissue is more like normal tendon)
* Extrinsic = proliferation of cells from flexor sheath (tissue acts more like scar)
* * Early mobilization proliferates intrinsic….now it all makes sense.
128
When do you see strength for your tendon repair?
3 weeks
129
When is it too late to repair a tendon
3 weeks
130
List the benefits of early immobilization for flexor tenon tear
Promotes intrinsic healing
Discourages extrinsic
Less scar formation at repair site
Improved tendon excursion
Less adhesion formation in flexor sheath
Better tensile strength at repair
Less chance of joint contraction
Scar mobilization at skin
131
How much ROM (tendon excursion) is needed to prevent adhesion formation?
1.7-3.5mm
132
What are the phases of tendon healing
1 - Inflammatory/Macrophagic - out to 1 wk
2 - Resporbtive/Fibroblastic - 1 to 3 wks
3 - Healing/Collagen - 3-8 wks
133
How much of A2 and A4 can you safely release
Can release A4 100% and 50% of A2
Benefit of release - less force to generate the same motion
134
Complications of flexor tendon repair
* Rerupture
* 4% with 2% revison
* Adhesion/Contracture
* 4% with 4% revision
* Triggering
* Pulley failure
* Bowstringing
* Quadrigia effect
* Lumbrical Plus deformity
* Infection
* Pain
135
Definition of flail chest
3 consecutive ribs, each rib has more than one fracture. Mortality 10-33%.
136
Complications of flail chest
* Pain
* Decreased resp effort
* Pneumonia
* Empyema
* Chronic Pain
* Rib Deformity
* Nonunion
* malunion
* ARDS
* Effusion
* Prolonged intubation
* Tracheostomy
137
Indications for rib plating
* Flail Chest
* Chest Wall Deformity
* Post injury pain
* Symptomatic Non Union
* Symptomatic Mal Union
* Rib Fracture causing pulmonary hernia
* Open Rib #
* Pulmonary Laceration
* Aortic Laceration (this would suck)
138
What percentage of patients get chronic pain
56-79%
Most highly predicted by acute pain intensity
139
4 approaches for plating ribs
Posterolateral Thoracotomy
Muscle Sparing
Axillary
Sub Pectoral (inframammary)
140
What are the benefits of plating ribs in a flail chest
* Decreased days on ventilator
* Decreased Pneumonia
* Less ICU days
* Hospital stays
* Tracheostomy
* Chest wall deformity
* Less cost to system
* Lower risk of reintubation
* Less home O2 on discharge
* Less Chronic Pain
* Less Mortality Rates
* They can also walk on water these plates.
141
Explain gait patterns in CP regarding primary, secondary and tertiary
* Primary
* due to structural CNS deficiency
* spasticity, weakness, less proprioception.
* These are best managed with medication +/\_ neurosurgery to address sturctural CNS deficiency. Baclofen pum
* Secondary
* due to imbalance in musculotendinous unit secondary to CNS.
* Planovalgus foot, anterversion of the femoral neck
* These are best managed with orthopeidc surgery such as muscle tendon release/lengthening and deformity correction
* Teritiary
* esultant of 1 &2. ie. Vaulting for clearance in swing phase.
* Excessive plantar flexion to compensate for ability to walk, becomes fixed over time.
* These patterns can be rectified with treatment of above - ie. Pelvic tilt resolves if you lengthenen a contracted quad that causes a child to walk with fixed knee flexion.
*
142
List principles of appropriate antibiotic use
It's actually indicated for your surgery
The correct antibiotic based on expected pathogens
Correct dosage
Correct duration of therapy
143
What is the rate of infection for non-abdominal surgeries and how long should you give abx
2-5%, 24hr
144
Risk factors for C-diff
Inpatient (any)
PPI use
Antibiotivc for UTI post op
145
Guidelines for antibiotic use in TJA
* A 60 yo M, 90 kg for elective THA. What do you give for Preop Abx?
* Ancef 2g IV 60 minutes or less prior to cutting skin.
* Same guy 60 yo/90kg, now he has known MRSA?
* Preop Protocol + Vanco 2g IV - 2g, not 1.
* Same guy 60 yo/90kg now he has pen allergy (anaphylaxis)?
* Clinda 600mg IV
* Same guy 60 yo/90kg, knee scope for debridement only, no hardware?
* None indicated
146
Risk factors for stress fractures
* **Intrinsic factors**
* metabolic state
* menstrual patterns
* level of fitness
* muscle endurance
* anatomic alignment
* microscopic bone structure
* bone vascularity
* **Extrinsic factors**
* training regimen
* dietary habits
* equipment (eg, footwear, playing surface)
147
Non-operative treament of stress fractures
* **Multi-disciplinary approach**
* Full work-up for nutrition, depression, metablic etc
* **Rest, immoblization**
* **Replace deficient Vit D or Ca** PRN
* **Bisophosphanates**
* **Pulsile Teraperitide (Forteo)**
* Can't be used in patients at risk of cancer (risk of osteosarc)
* **Pulsed US**
* **Extra-corpeal shock wave therapy**
148
High risk areas for stress fractures and associated treatment
* **Proximal tibia - dreaded black line**
* Non-operative treatment can return to sport 12 months later
* IM nail doesn't heal fracture but helps return to sport
* _Anterior tension band_ can improve return to sport
* Better biomechanics
* Doesn't disrupt extensor mech
* **Naviular (due to blood supply and biomechanics)**
* Gold standard is non-op with NWB until it heals
* Aggressive is necessary
* Some elite athletes may opt for ORIF
* **Proximal 5th MT**
* NWB 6-8 weeks except elite athletes
* **Great toe sesamoids**
* Tibial is larger and more likely to develop stress fracture
* Also more commonly bipartate
* NWB followed by MT offloader
* Can consider _foot realignment surgery_
* _Surgical options_ may be considered
* Bone graft
* ORIF
* Excision with repair of FHB
* **Medial malleolus**
* NWB
* ORIF if complete # line seen
149
Options for imaging of stress fractures
Initial XR will be normal (can repeat films later)
_**MRI** is best_
**Bone scan** also useful
**US** can look for edema around the bone
**CT** not as sensitive as MRI
150
What are the current recommendations for pediatric seal belt safety?
*Up to 99% of kids are not belted appropraitely*
* Rear-facing = 10Kg (22lbs)
* Forward-facing = 10-22kg (22-48lbs)
* Booster seats = 18-27Kg (40-60lbs)
* Seatbelts = 27Kg (\>60lbs)
151
List 5 risk factors for odontoid fracture nonunion.
Hsu et al JAAOS 2010
Age \>40
Posterior displacement \>5mm
Angulation \>11 degrees
Neurologic compromise
Fracture comminution
152
List 4 ways of determining the integrity of the transveral atlantal ligament.
_DIRECT_
MRI - see midsubstance rupture
CT - see avulsion fragment
_INDIRECT_
Combined lateral mass overhang of \>7mm on open mouth xray
ADI of \>3mm on lateral xray
153
Contraindications to use of vertebroplasty or kyphoplasty in metastatic spine disease:
\>75% loss of vertebral height
\>20% canal compromise from epidural dz
Posterior vertebral body compromise
\>3 levels requiring treatment
Radiculopathy
Coagulopathy
154
What is the NOMS criteria for surgical decision making in metastatic disease?
Neurologic (ie. compromise)
Oncologic (rads resistant)
Mechanical (instability)
Systemic (can tolerate surgery)
155
List General modalities of non-operative treatment. 20.
Rest
Ice
Heat
Compression Dressing
Elevation
Ultrasound
Massage
TENS
Activity/Sport Modification
Job Modification/Retraining
Physiotherapy
Stretching
Daily Focused MSK hygiene
Laser
Hypnotics
Weight Loss
Psychological
Anti-inflammatory
Oral & topical
Opioids
Tylenol
Muscle Relaxants
Antidepressants
Anticonvulsant
Splint (night -full time)
Functional Brace
Cast immobilization
Steroid injection
Hyaluronate Injections
Botox
Local Anesthetic Injection
Lists based solely on JAAOS
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