Observation with follow-up ESR, CRP, and repeat aspiration in 1-2 days, Oral cephalosporin and follow-up in 10 days, Surgical arthrotomy, debridement, and irrigation procedure. 19% (OBQ13.50)
What is the most common organism in this scenario? A 65-year-old man presents with aseptic loosening 3 years after total knee arthroplasty. (OBQ05.62)
displacement of femoral neck fracture will disrupt the blood supply and cause an intracapsular hematoma (effect is avoid multiple cortical perforations during guide pin or screw placement to avoid development of lateral stress riser. Sequestrum is defined as which of the following? tarsal fracture.
(OBQ11.146)
Diagnosis and etiology of TKA failure can be determined by a combination of physical examination, labs, and radiographs.
axial load. Treatment is nonoperative with antibiotics in the absence of an abscess.
Calcium phosphate Osteoconduction and osteointegration. This system divides tibial plateau fractures into six types: Schatzker I: wedge-shaped pure cleavage fracture of the lateral tibial plateau, originally defined as having less than 4 mm of depression or displacement Schatzker II: splitting and depression of the lateral tibial plateau; namely, type I fracture with a depressed component (generally considered commonest 5) (OBQ05.149)
Orthobullets Team Spine - Adult Isthmic Spondylolisthesis Traumatic fracture with intact pars interarticularis. A 2-year-old girl has had a 2-day history of fever and refuses to move her left shoulder following varicella. Two months later, she is deemed to be free of infection and is taken to the operating room for the second stage operation. Advanced imaging is obtained and reveals a 1.5x1.5cm abscess in the distal tibia. Figure 25 shows the radiograph of an 84-year-old woman who has pain and is unable to extend her knee. He reports falling off his bicycle 5 days prior. fracture length. A joint aspiration yields 2 mL's of synovial fluid demonstrating a cell count of 2,500 and no organisms on gram stain. Classification. (OBQ08.50)
extends from the anteroinferior border of the fibula to the neck of the talus. After surgical decompression and antibiotics, which of the following is the best indicator of response to treatment? Diagnosis and etiology of TKA failure can be determined by a combination of physical examination, labs, and radiographs. An active 73-year-old male presents with progressive pain and instability 15 years after undergoing a left total knee arthroplasty. Laboratory studies show an erythrocyte sedimentation rate of 75 mm/h and a peripheral WBC count of 18,000/mmP3P. freezing the graft twice and packaging the tissue without solution at minus 80 degrees C. freezing the graft in water without an antibiotic solution soak during quarantine, with final storage in liquid nitrogen. valgus load . Radiographs taken at the time of explantation are seen in Figure B. A 40-year-old man complains of increasing groin pain. An aspirate of the knee was performed successfully with a scant amount of clear synovial fluid with a cell count of 1,000. His mother notes that he has had a fever of 39.0. core decompression or vascularize free-fibula graft. Physical exam shows focal tenderness over his tibia. Examination shows no knee effusion but there is tenderness to palpation over the proximal tibia. useful to diagnosis syndesmosis injury in high ankle sprain.
He has a moderate effusion, positive Lachman, positive pivot shift, negative quadriceps active test, and medial sided knee pain with a positive Mcmurray test. Increased complications due to serous drainage, Improved clinical outcomes as shown by more rapid time to healing, Improved clinical outcomes as shown by SF-36 scores, Increased complications due to autoimmune reactions and graft rejection, Equivalent complication rates and clinical outcomes. external rotation stress test. Presence of Group A Streptococcus infection, Presence of Group B Streptococcus infection.
Following surgery, serial evaluations of which of the following studies is the most expeditious method to determine the early success of treatment? Treatment is generally observation with management of the underlying systemic condition. Copyright 2022 Lineage Medical, Inc. All rights reserved.
MR imaging demonstrates osteomyelitis of the proximal tibia without an abscess. Hip motion is painless, but knee motion is painful. Lab results include a C-reactive protein level of 12mg/L (normal 0-3.2 mg/L), erythrocyte sedimentation rate of 38mm/h (normal 0-20mm/h) and a white blood cell count of 12.3 K/mm3(normal 4.3 -11.4 K/mm3). varus load. What is the most likely diagnosis? Hip Osteonecrosis, also known as avascular necrosis of the hip,represents a condition caused by reduced blood flow to the femoral head secondary to a variety of risk factors such as a traumatic event, sickle cell disease, steroid use, alcoholism, autoimmune disorders, and hypercoagulable states. core decompression or vascularize free-fibula graft. (OBQ07.184)
Reestablishment of the central meniscal blood supply. Treatment. He has a moderate effusion, positive Lachman, positive pivot shift, negative quadriceps active test, and medial sided knee pain with a positive Mcmurray test. The most expeditious method to determine the early success or failure of treatment is by serial evaluations of which of the following studies? The surgeon is balancing the tibial and femoral cuts with sizing blocks and finds that the knee has valgus instability greater than 1cm in full extension. younger patient with crescent sign or more advanced femoral head collapse, +/- acetabular DJD A 47-year-old man presents with 1 week of left leg pain. TKA Revision is most commonly performed to address aseptic loosening, fracture, instability, or infection associated with a prior TKA. The ligament connecting the anterolateral tibial to the anteromedial fibula. (OBQ11.253) A 17-year-old ballet dancer presents with 5 months of pain in the posterior aspect of the right lower extremity that is exacerbated with the ballet position shown in Figure A. A 67-year-old female falls off of a step ladder while changing a lightbulb in her kitchen and sustains the injury shown in Figures A and B. (OBQ11.267)
The ligament connecting the anterolateral tibial to the anteromedial fibula. This is an AAOS Self Assessment Exam (SAE) question. A recent radiograph is shown in Figure A. tibial stress fracture from side graft is taken.
lateral meniscus.
incision made in line with the tip of the fibula and the base of the 4th metatarsal. This can occur in all the following joints EXCEPT? Which of the following graft materials has the least potential to elicit an immune response? Current WBC and ESR is normal and CRP is elevated. Gaucher's disease), virus (CMV, hepatitis, HIV, rubella, rubeola, varicella), protease inhibitors (type of HIV medication), coagulation of the intraosseous microcirculation , due to injury of femoral head blood supply (, hip dislocation: 2-40% (2-10% if reduced within 6 hours of injury), higher risk of AVN with greater initial displacement and poor reduction, decompression of intracapsular hematoma may reduce risk, quicker time to reduction may reduce risk, advanced stages similar to hip OA (limited motion, particularly internal rotation), classification systems based largely on radiographic findings (see below), highest sensitivity (99%) and specificity (99%), order when radiographs negative and osteonecrosis still suspected, presence of bone marrow edema on MRI is predicitve of worsening pain and future progression of disease, indicated for precollapse AVN (Ficat stages 0-II), trials have shown that alendronate prevents femoral head collapse in osteonecrosis with subchondral lucency, However, other studies have also shown no benefit of preventing collapse with bisphosphonates, core decompression with or without bone grafting, for early AVN, before subchondral collapse occurs, drill an 8-10 mm hole through the subchondral necrosis, pass a 3.2 mm pin into the lesion two to three times for decompression, relieves intraosseous hypertension equals less pain, stimulates a healing response via angiogenesis, only for small lesions (<15%) in which the lesion can be rotated away from a weight bearing surface, typically performed through intertrochanteric region, reported success rate of 60% to 90%, mainly in Japan, distorts the femoral head making THA more difficult, lightbulb - through the cortex of the femoral neck-head junction to access the necrotic area of the femoral head and place bone graft, for both pre-collapse and collapsed AVN in young patient, remove the necrotic area with large core hole, fibular strut is placed under subchondral bone to help prevent collapse or tamp up small areas of collapse, some centers demonstrating 80% success at 5 to 10-year follow-up, tibial stress fracture from side graft is taken, younger patient with crescent sign or more advanced femoral head collapse, +/- acetabular DJD, irreversible etiology (chronic steroid use), care must be taken while preparing the femur as there are high rates of femoral canal perforation, in young patients with osteonecrosis, there is a higher rate of linear wear of the polyethylene liner and a higher rate of osteolysis than compared to older patients who have THA for osteoarthritis, most reliable means to provide pain relief and immediate return of function, in advanced DJD with small, isolated focus of AVN, requires adequate bone to support resurfacing component, contraindicated in underlying disease process or chronic steroid use causing AVN (poor bone quality) and renal disease (metal ions from metal-on-metal implant), medium-term follow-up showing problems with acetabular erosion and pain, only consider in the very young patient in a, Risk of femoral head collapse with osteonecrosis is based on the, calculated by adding the arc of the femoral head necrosis on a mid-sagittal and mid-coronal MR image, Moderate-risk group = combined necrotic angle, High-risk group = combined necrotic angle of. Allograft reconstruction with a tendon graft from 89% (3286/3694) L 1
He has not done any physical therapy nor received a corticosteroid injection. His temperature is currently 101.2 degrees F. Radiographs are provided in Figures A and B. stairs, level ground, rising from chair), gait (stiff legged gait, inability to fully extend during stance phase), skin changes, presence of effusion, warmth (infection vs. complex regional pain syndrome (CRPS)), Serial AP and lateral radiographs to provide timeline of TKA, Weight bearing radiographs can provide evaluation of any asymmetric wear, Standing leg length views to assess overall alignment, Femoral version study can aide in assessing component rotation when also compared to the femoral neck, Can also aide in assessing severity and location of bony defects, Can be positive for up to 2 years after primary TKA, can indicate loosening, infection, or stress fracture, Knee aspiration to rule out infection via cell count and culture, Unconstrained Posterior Cruciate Retaining, always have a PCL substituting implant available as it is difficult to evaluate the integrity of the PCL prior to surgery, Unconstrained Posterior Cruciate Substituting, large central post substitutes for MCL/LCL function, MCL attenuation or deficiency (controversial because load may lead to breaking of central post), Constrained Hinged with rotating platform, tibial component is allowed to do internal/external rotation within a yoke, reduces rotational forces that would otherwise be on prosthesis-bone interface, MCL attenuation or deficiency (deficiency of MCL is controversial because load may lead to breaking of central post), flexion gap laxity with component mismatch, resection of the knee for tumor or infection, relatively indicated for charcot arthropathy, extraction of components with minimal bone loss and destruction, when compared to the standard medial parapatellar approach for revision total knee arthroplasties, the oblique rectus snip approach shows no difference in outcomes, tibial side first by establishing tibial joint line, tibial joint line should be 1.5 to 2 cm above head of fibula (use xray of contralateral knee to determine exact distance), after tibia joint line established proceed with femoral side to match the tibia, keep patellar thickness >12mm to avoid fracture, Anderson Orthopaedic Research Institute (AORI) Classification, Minor bone defects with intact metaphyseal bone that do not compromise stability, Metaphyseal bone damage that involves 1 femoral condyle or tibial plateau, Metaphyseal bone damage that involves both femoral condyles or tibial plateaus, Massive bone loss comprising a large portion of condyle/plateau, and can involve the collateral ligaments/patellar tendon, Bulk allografts, custom implants, megaprosthesis, porous tantalum, metaphyseal sleeves, rotating hinge, Metaphyseal bone in TKR is often severely deficient due to, classification systems not used as commonly as revision THA, long stems to promote load sharing to the femoral and tibial diaphysis, usually done with a long intramedullary stem, can use in scenarios of excessive femoral bow, increases complexity of any future revision, cement is adequate for small defects, structurally better than allograft, efficient, simple, can be used as cutting guides, variety of shapes/sizes with custom shaping/contouring is possible, trials/specific instrumentation available, compatible with several different implant companies, satsifactory survivorship in mid-to-long term, long-term failure due to graft resorption, pain scores less favorable than primary TKR, activity related pain can be expected for 6 months, peroneal nerve subject to injury with correction of valgus and flexion deformity, upwards of 4-7%, double the risk of primary TKA, prior scars should be incorporated into skin incision whenever possible, bloody supply to anterior knee is medially based, so lateral skin edge is more hypoxic, extensor mechanism allograft using achilles tendon bone block, residual lag due to attenuation is common, - TKA Postoperative Rehabilitation & Outpatient Management. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. 19% He returns to clinic with persistent right ankle pain. (OBQ08.65) A 25-year-old man sustains an open forearm fracture from an auger as depicted in Figures A and B. Saphenous Nerve. Stress fracture.
(SAE07HK.53)
core decompression or vascularize free-fibula graft. When performing surgery, if calcium sulfate is used as the primary bone substitute void filler, an increase in which of the following outcomes may be expected as compared to autograft? Treatment. Standing, full-length, bilateral lower extremity roentgenogram to evaluate for growth disturbance of the distal femur, MRI of the hip to evaluate for progression of osteonecrosis and allow for staging, MRI of the femur to evaluate for recurrence of osteosarcoma, Positron emission tomographic scan of the body to evaluate for the presence of metastasis, Parathyroid hormone serology to evaluate for secondary hyperparathyroidism. What is the most appropriate next step in treatment? Anterolateral soft-tissue impingement. Superficial peroneal nerve palsy. (OBQ16.173)
Inheritance Patterns of Orthopaedic Syndromes, General and Regional Anesthesia in Orthopaedics, Legal Considerations in Orthopaedic Practice.
(SBQ13PE.95.1) A 3-year-old patient fell out of a tree and sustained a closed right tibial shaft fracture. Aspiration and studies for infection are negative. This is an AAOS Self Assessment Exam (SAE) question. His ESR is 68 mm/hr (normal <15) and CRP is 14 mg/dL (normal <1).
Figures A and B are the AP and lateral radiographs of a 10-year-old female who presents to the office with 1-2 months of worsening left ankle pain. Current images are shown in Figure A and Figure B. A 20-year-old male is involved in motor vehicle collision and sustains a depressed tibial plateau fracture. Clinical photos of the elbow and wrist are shown in Figures A and B, and radiographs in Figures C and D. His parents report that he has had night sweats and a loss of appetite, and physical examination is notable for bilateral axillary lymphadenopathy. (SBQ11PA.55)
With comparison to his father, the patient should be informed of the following risk? Orthobullets Team Spine - Adult Isthmic Spondylolisthesis Traumatic fracture with intact pars interarticularis. The injury is closed, and the patient is neurovascularly intact.
total hip replacement . After being fully treated for this condition, what study may be needed in late-term follow-up if clinically indicated? unlikely with incomplete stress fracture.
Methicillin-resistant staphylococcus aureus, Fever of greater than 38.5 degrees Celsius.
tarsal fracture. indications. He presents with complaints of groin pain for the past 6 weeks.
pain over syndesmosis is elicited with external rotation/dorsiflexion of the foot with knee and hip flexed to 90 degrees. Radiographs show femoral head avascular necrosis with subchondral lucency but without femoral head collapse. Discharge home on non-steroidal anti-inflammatory drug (NSAID) and short leg non-weightbearing cast, Discharge home on oral antibiotics with serial ESR and CRP in an outpatient setting, Admit to hospital for percutaneous aspiration for culture and intravenous antibiotics with serial ESR and CRP, Admit to hospital for percutaneous biopsy and referral to orthopaedic oncologist, Admit to hospital for percutaneous screw fixation of distal tibia fracture. The child undergoes a diagnostic biopsy shown in Figure E. What is the most likely diagnosis? The splint is removed revealing intact skin integrity with notable swelling and erythema overlying the distal fibula.
This system divides tibial plateau fractures into six types: Schatzker I: wedge-shaped pure cleavage fracture of the lateral tibial plateau, originally defined as having less than 4 mm of depression or displacement Schatzker II: splitting and depression of the lateral tibial plateau; namely, type I fracture with a depressed component (generally considered commonest 5)
Knee pain affects approximately 25% of adults, and its prevalence has increased almost 65% over the past 20 years, accounting for nearly 4 million primary care visits annually.
Allograft reconstruction with a tendon graft from tibial metaphysis. What is the most appropriate treatment? Approximately 30 hours after the injury, the floor nurse calls stating the patient is complaining of severe right leg and foot pain despite adequate analgesia with
Septic arthritis in pediatric patients may occur secondary to direct intra-articular spread from metaphyseal osteomyelitis. You are considering using a frozen allograft distal femoral condyle in your reconstruction of a massive giant-cell tumor of the knee. 5%
Diagnosis is generally made with MRI studies to evaluate for bone marrow edema or subperiosteal abscess. None, by 5 years the allograft cartilage will be completely acellular. axial load. Epidemiology. medial plateau.
An aspiration is performed and demonstrates a synovial WBC count of 26k. ER rotation stress view. external rotation stress test. a base plate with an offset tibial stem attachment. 29% (222/766) 3.
Surgical debridement is indicated in the presence of an abscess. (OBQ12.266)
She undergoes 2-stage revision total knee arthroplasty. 8% (218/2875) 5.
A lateral radiograph from the day of presentation is shown in Figure A. WBC, ESR, and CRP are all within normal limits. Lab results include a C-reactive protein level of 12mg/L (normal 0-3.2 mg/L), erythrocyte sedimentation rate of 38mm/h (normal 0-20mm/h) and a white blood cell count of 12.3 K/mm3(normal 4.3 -11.4 K/mm3). collapse. History reveals that she underwent total knee arthroplasty 8 years ago. Figures A and B are the radiographs of a 68-year-old man who is well known to you for having undergone a previous two stage revision for infection. ORIF of distal fibula fx (especially Weber C) At risk with ankle inversion injuries. (OBQ06.273)
His right knee is warm to the touch and an effusion is noted. Approximately 30 hours after the injury, the floor nurse calls stating the patient is complaining of severe right leg and foot pain despite adequate analgesia with
In which of the following patients with osteomyelitis of the tibia is surgical debridement the next best step in treatment? lateral meniscus.
An articulating antibiotic spacer is placed. 89% (3286/3694) L 1 Pathologic local bone disease. Alumina ceramic bonds bind to bone in response to stress and strain. (OBQ04.148) A 34-year-old male presents with right knee pain, swelling, and symptoms of buckling 3 months after being involved in a motorcyle accident. (OBQ05.147)
extends from the anteroinferior border of the fibula to the neck of the talus.
(SBQ18BS.12)
abnormal lateral tibiofibular ratio is reliable way of diagnosing Achilles tendon repair - especially percutaneous technique. may show fracture of proximal fibula. The pain is located at the level of his donor site and is worse with weight-bearing and relieved by rest. lateral plateau. The ESR and CRP are elevated and blood cultures have been drawn and are pending. Proximal femoral resection and reconstruction. Exposure to place the distal femoral cutting guide is difficult due to poor knee flexion following a standard medial parapatellar arthrotomy. After debridement of nonviable bone, a 10cm bone defect is left. pain over syndesmosis is elicited with external rotation/dorsiflexion of the foot with knee and hip flexed to 90 degrees. A 7-year-old boy complains of worsening left knee pain over the last 2 weeks.
She reports a decreased appetite.
A 14-year-old boy presents 6 months after spraining his right ankle. He denies any recent trauma to the leg. A 9-year-old boy presents to clinic with 3 month history of left ankle pain. varus load. Which of the following has been shown to have highest early compressive strength? C-reactive protein (CRP) is 72 mg/L (rr 0-9 mg/L). using chemicals to remove cellular water and controlled rate freezing to prevent ice crystal formation. normal deltoid ligament. (OBQ09.175)
Which implant offers the most appropriate level of constraint while limiting the amount of implant-host interface stresses? (OBQ08.65) A 25-year-old man sustains an open forearm fracture from an auger as depicted in Figures A and B. tibial stress fracture from side graft is taken. Calcaneal osteomyelitis caused by a puncture wound has an increased rate of which of the following compared to hematogenous osteomyelitis? (OBQ06.261)
Unlinked constrained (varus-valgus constrained), Fixed bearing PCL-substituting (posterior-stabilized), Mobile bearing PCL-substituting (posterior-stabilized). (SBQ13PE.95.1) A 3-year-old patient fell out of a tree and sustained a closed right tibial shaft fracture. An MRI is obtained and shown in Figure C. The patient undergoes CT-guided biopsy and the histology slides are shown in figures D and E. What is the most likely diagnosis? Selective estrogen receptor modulator therapy. gravity stress view can identify medial clear space widening. Musculoskeletal Infection Society (MSIS) Type C host. mark out lateral malleolus and anterior and posterior borders of fibula; mark estimated location of fracture site (check with C-arm if unsure) straight longitudinal incision 4-6cm in length centered on fracture . Current ankle radiographs are normal and T1 and T2 MRI images are shown in Figures A and B, respectively. After debridement of nonviable bone, a 10cm bone defect is left. more common with displaced FNSFs (9-44%) Radiographs show no evidence of a stress fracture, an alpha angle of 45 degrees, and a lateral center edge angle of 30 degrees. During the work-up in the ER, the patient became hypotensive. Figures A, B and C show axial T1 fat saturated, sagittal T1 fat saturated and coronal short tau inversion recovery magnetic resonance imaging (MRI) images of the left femur.
Infection is now the most frequent cause for late revision, Polyethylene wear is no longer the major cause for revision, Aseptic loosening is now the most frequent cause for early revision, The percentage of revisions for instability and malalignment has increased, Stiffness is an uncommon reason for revision procedures. Which of the following medical treatments have been shown to decrease the risk of subsequent femoral head collapse?
(OBQ05.177)
Hemiarthroplasty. valgus load .
(SBQ07HK.5)
He is exquisitely tender over the 1st metatarsal. Initial radiographs on the day of injury were negative, and the patient was placed into a knee immobilizer by his pediatrician.
Achilles tendon repair - especially percutaneous technique.
The ligament connecting the first metatarsal base to the medial cuneiform. 19% After debridement of nonviable bone, a 10cm bone defect is left. In patients with sickle cell disease and asymptomatic osteonecrosis of the femoral head identified with magnetic resonance imaging, what percentage will eventually go on to femoral head collapse?
Which of the following substances is most osteoinductive? A 64-year-old female with rheumatoid arthritis is undergoing a left total knee arthroplasty. (OBQ04.274)
3% (26/766) 4. and etiology of TKA failure can be determined by a combination of physical examination, labs, and radiographs. Treatment. pain over syndesmosis is elicited with external rotation/dorsiflexion of the foot with knee and hip flexed to 90 degrees. Calcium phosphate Osteoconduction and osteointegration. The patient subsequently undergoes formal open surgical debridement, without complications. Fresh irradiated corticocancellous bulk allograft. Which of the following is often associated with this diagnosis and requires close surveillance in the acute setting? The ligament connecting the first metatarsal base to the medial cuneiform. valgus load . (OBQ11.196)
Treatment is nonoperative versus operative based on fracture displacement and alignment, associated soft tissue injury, and patient risk factors. The splint is removed revealing intact skin integrity with notable swelling and erythema overlying the distal fibula. Intraoperatively, it is noted that the collaterals are intact and the previous tibial tubercle osteotomy had healed. A decrease in erythrocyte sedimentation rate (ESR). abnormal lateral tibiofibular ratio is reliable way of diagnosing
younger patient with crescent sign or more advanced femoral head collapse, +/- acetabular DJD A 47-year-old man presents with 1 week of left leg pain. 29% (222/766) 3. ER rotation stress view. The ligament is not able to be repaired. (SBQ13PE.95.1) A 3-year-old patient fell out of a tree and sustained a closed right tibial shaft fracture. more common with displaced FNSFs (9-44%) Radiographs show no evidence of a stress fracture, an alpha angle of 45 degrees, and a lateral center edge angle of 30 degrees.
Saphenous Nerve. tibial stress fracture from side graft is taken. Periprosthetic fracture distal to the implant, Iatrogenic fracture causing pelvic discontinuity, Cardiac arrest from fat embolization to lungs. A current bone scan and MRI is shown in Figure A and B. (OBQ18.19)
covers larger portion of articular surface associated fibula fracture. (OBQ11.253) A 17-year-old ballet dancer presents with 5 months of pain in the posterior aspect of the right lower extremity that is exacerbated with the ballet position shown in Figure A. Group A Streptococcus is the most common infecting organism, A history of trauma is reported in 20-40% of patients, It typically occurs in the epiphysis via hematogenous seeding, CT scan is the advanced imaging study of choice, Blood cultures are positive in 75-80% of patients.
Synthetic calcium sulfate and tri-phosphate mixture, (SAE07SM.94)
Biodegrade very slowly fibula and ribs are most common sources of vascularized autografts. However he is still having persistent anterior shoulder/arm pain that worsens with most activities.
Which of the following is the most appropriate next step? incidence. 8% (218/2875) 5. Hemiarthroplasty. 89% (3286/3694) L 1 A clinical photograph is shown in Figure A. Superficial peroneal nerve palsy. The patients physical exam is limited secondary to pain.
1% (26/2875) L 3 B Trans-sacral fibula (Bohlman's procedure) for High Grade Spondylolisthesis A 10-year-old male presents with refusal to bear weight on his right lower extremity. Her symptoms returned with ballet activity following a 1 month course of full rest, nonsteroidal anti-inflammatory medication, and physical therapy. Two years earlier, she had had mild trauma followed by a bone infection and had received short courses of oral antibiotics. bone cement to smooth the outline of the proximal medial tibia. Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Flexible Pes Planovalgus (Flexible Flatfoot), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease). You can rate this topic again in 12 months. metatarsal stress fracture. He has not done any physical therapy nor received a corticosteroid injection. Delayed union or nonunion.
allograft bone instead of metal augments. Increased risk for polyethylene wear and osteolysis, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list.
A 13-year-old girl reported left ankle pain after falling while playing soccer 3 weeks ago. Radiographs are included in Figures A and B. MRI images include T1, T2 and post-contrast in Figures C-E, respectively. The injury is closed, and the patient is neurovascularly intact. (OBQ06.80)
This is an AAOS Self Assessment Exam (SAE) question. A material with either osteoconductive, osteoinductive, and/or osteogenic properties, almost 1 million bone grafting procedures performed in US each year, with a growth of almost 13% per year, healing of fractures, delayed unions, or nonunions, replace bone defects from trauma or tumor, relative resorption rates of bone graft substitutes, calcium sulfate > tricalcium phosphate > hydroxyapatite, retrieval studies are helpful in understanding the body's response to allografts, allograft articular cartilage is completely acellular, Bone graft has aspects of one or more of these three properties, material acts as a structural framework for bone growth, the various three-dimensional makeups of the material dictate the conductive properties, material contains factors that stimulate bone growth and induction of stem cells down a bone-forming lineage, material directly provides cells that will produce bone including primitive, mesenchymal stem cells, osteoblasts, and osteocytes, mesenchymal stem cells can potentially differentiate down any cell line, osteoprogenitor cells differentiate to osteoblasts and then osteocytes, cancellous bone has a greater ability than cortical bone to form new bone due to its larger surface area, autologous bone graft (fresh autograft and bone marrow aspirate) is the only bone graft material that contains live mensenchymal precursor cells, Allograft is a composite material and therefore has many potential antigens (cell surface glycoproteins), Class I and Class II antigens on graft are recognized by host T lymphocytes and elicit an immune response, immunogenic cells are marrow-based, endothelium, and retinacular-activating cells, bone marrow cells elicit the greatest immune response, extracellular matrix also acts as an antigen, type I collagen stimulates both humoral and cell-mediated responses, noncollagenous matrix (proteoglycans, osteocalcin), hydroxyapatite has not been shown to elicit an immune response, primary rejection is cell-mediated related to the major histocompatibility complex (MHC) incompatibility, Rapid incorporation via creeping substitution, Slower incorporation due to need to remodel existing Haversion canals, 25% of massive grafts sustain insufficiency fractures, Technically challenging with quicker union and cell preservation, Examples include: free fibula strut graft (peroneal artery), free iliac crest (deep circumflex iliac arteries), distal radius used for scaphoid fx (1-2 intercompartmental superretinacular artery branch of radial artery), BMP preserved and therefore osteoinductive, Alumina ceramic bonds bind to bone in response to stress and strain, Many prepared as ceramics (heated to fuse into crystals), Examples include: tricalcium phosphate, Norian (Synthes), hydroxyapatitie (tradename Collagraft by Zimmer), MONTAGE, Examples include: OsteoSet (Wright medical), Calcium carbonate skeleton is converted to calcium phosphate via a thermoexchange process (Interpore), Examples include: Biocora (Inoteb, france), Contains: collagen, bone morphogenetic proteins, transforming growth factor-beta, residual calcium, Does NOT contain mesenchymal precursor cells, Bone graft transferred from one body site to another in the same patient, osteogenic, osteoinductive, and osteoconductive, cortical, cancellous, or corticocancellous, source of osteogenic mesenchymal precursor cells, iliac crest and vertebral body most common sites, variable number of cells depending on patient age, provides both cancellous and cortical graft, higher complication rate with anterior versus posterior harvesting, stem cell concentration with posterior harvesting, injury to lateral femoral cutaneous or cluneal nerves, the degree of osteoconduction available depends on the processing method (fresh, frozen, or freeze-dried) and type of graft (cortical or cancellous), cortical, cancellous, corticocancellous, and osteoarticular (tumor surgery), preserved with glycerol or dimethyl sulfoxide (DMSO), cryogenically preserved (few viable chondrocytes remain), tissue-matched (syngeneic) grafts decrease immunogenicity, debridement of soft tissue, wash with ethanol (remove live cells), gamma irradiation (sterilization), dose-dependent higher doses of irradiation kills bacteria and viruses but may impair biomechanical properties, cleansing and processing removes cells and decreases the immune response improving incorporation, rarely used due to disease transmission and immune response of recipient, reduces immunogenicity while maintaining osteoconductive properties, two years for fresh frozen stored at -20 degrees C, five years for fresh frozen stored at -70 degrees C, removes the minerals and leaves the collagenous and noncollagenous structure and proteins, interproduct and interlot variability is common, Various compositions available (see summary above), Level I evidence shows that calcium-phosphate bone substitutes allow for bone defect filling, early rehabilitation, and prevention of articular subsidence in distal radius and tibial plateau fractures, stimulates undifferentiated perivascular mesenchymal cells to differentiate into osteoblasts through, Platelet rich plasma (PRP) (like other BMPs) solely osteoinductive, Provides large volume of bone graft from intramedullary source, femoral shaft fracture due to eccentric reaming, Differentiates from mesenchymal precursor cells, Stimulation of osteoblast and osteoclast function, risk of hepatitis B disease transmission in musculoskeletal fresh-frozen allograft transplantation is 1 in 63,000, risk of hepatitis C disease transmission in musculoskeletal fresh-frozen allograft transplantation is 1 in 100,000, risk of transmission of HIV in fresh-frozen allograft bone is 1 in 1,000,000 to 1,670,000, allografts are tested for HIV, HBV, HCV, HTLV-1, and syphilis, calcium sulfate bone graft substitute associated with increased serous wound drainage. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, ICJR 9th Annual Revision Hip & Knee Course, Revision of UKA to TKA: Video-based Tips and Tricks - Rafael J. Sierra, MD, Outpatient Revision TJAs: When Is It Safe, If Ever! Diagnosis can often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture.
(OBQ04.148) A 34-year-old male presents with right knee pain, swelling, and symptoms of buckling 3 months after being involved in a motorcyle accident. Osteochondral talar dome fracture. CRP and WBC are normal. In counseling your patient regarding the risks of allografts, you explain that 5 years after transplantation, what percentage of donor chondrocytes will be present and viable in the allograft? Which of the following bone-graft substitutes disappears most quickly in vivo? indications. Meniscus. (SAE07HK.51)
The pain initially improved, but for the past 10 days she has had increased pain. Current radiographs and MRI images are shown in Figures B, C, and D. What is the next most appropriate step in management? (SAE07SM.44)
During fixation, the surgeon elects to use an osteoconductive bone graft substitute. maintaining maximum cellular viability of fresh tissue without long-term storage. 5%
(OBQ08.212)
Injury to the medial ankle may even lead to fracture of the medial malleolus without a significant sprain to the deltoid ligament. Stress fracture. Approximately 30 hours after the injury, the floor nurse calls stating the patient is complaining of severe right leg and foot pain despite adequate analgesia with 8% (218/2875) 5. primary restraint to varus stress at 30 deg. cast immobilization for 8 weeks. Allograft reconstruction with a tendon graft from (SAE07HK.100)
(OBQ06.131)
6 months prior he underwent a vascularized free-fibula bone graft from his left leg to his right hip for avascular necrosis. Epidemiology.
MRI. (OBQ12.254)
What is the most appropriate surgical strategy at this point? The surgeon reviews radiographs of his knee and takes him to the operating room for revision total knee arthroplasty. Which of the following osteoconductive bone graft substitutes resorbs faster than the rate at which bone growth occurs? The injury is closed, and the patient is neurovascularly intact. normal deltoid ligament. Examination revealed a small, pus-secreting wound on the anterior aspect of her left thigh.
After three days of treatment, he fails to show any clinical improvement. What do the blue arrowheads identify in both of these imaging studies? Osteochondral talar dome fracture. During revision surgery, management of the tibial bone loss should consist of. Which of the following factors is most critical to the success of a meniscal allograft transplantation? A biopsy is obtained and is shown in figures B and C. All of the following statements are true for this condition EXCEPT: Patients often present afebrile, with mild pain, and a normal WBC count, Radiographs characteristically show a solitary, localized radiolucency with sclerotic margins, Treatment consist of wide surgical resection and chemotherapy, Treatment consists of surgical debridement and postoperative antibiotics. He has been unable to bear weight through the left lower extremity for the past 24 hours. Physical exam is notable for focal tenderness over the distal femur without a palpable fluid collection. incision made in line with the tip of the fibula and the base of the 4th metatarsal. Diagnosis can be made with plain radiographs in moderate/late disease but MRI may be required to detect early or subclinical osteonecrosis.
She undergoes CT-guided biopsy and culture.
(SBQ18FA.18) A 60-year-old woman with a history of well-controlled diabetes and hypertension sustained a fall into a ditch yesterday and presents with persistent left ankle pain and deformity. ER rotation stress view.
(OBQ13.44)
An afebrile 8-year-old Ethiopian girl presented with a limp. (OBQ09.8)
fracture length. tibial metaphysis.
(SBQ10HK.58.1)
He presents 10 days later with increasing pain and fevers up to 39 degrees C over the last 3 days. make incision along posterior fibula if access to the posterior malleolus is needed; Soft Tissue Dissection . A tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures. A radiograph of her knee is seen in Figure A. Lab results include a C-reactive protein level of 12mg/L (normal 0-3.2 mg/L), erythrocyte sedimentation rate of 38mm/h (normal 0-20mm/h) and a white blood cell count of 12.3 K/mm3(normal 4.3 -11.4 K/mm3). Saphenous Nerve. Copyright 2022 Lineage Medical, Inc. All rights reserved. The ligament connecting the first metatarsal base to the medial cuneiform.
tibial metaphysis.
A clinical photograph is shown in Figure A. varus load. Which of the following bone graft material contains live mesenchymal osteoblastic precursor cells? A 30-year-old patient has had severe left hip pain and difficulty ambulating, necessitating the use of a cane, for the past 6 months.
Figures 9a and 9b show the radiographs of a 75-year-old man who underwent a revision total knee arthroplasty with a long-stemmed tibial component. (OBQ14.138)
Leukocyte count is normal but the ESR is elevated.
Despite being non-weightbearing on crutches, his pain has continued to worsen, and he presented to the ER with a low grade fever and irratibility. Superficial peroneal nerve palsy. Which of the following is the most appropriate next step in management?
MRI. Injury to the medial ankle may even lead to fracture of the medial malleolus without a significant sprain to the deltoid ligament. A 10-year-old boy complains of two days of worsening right knee pain. Classification. After debridement of nonviable bone, a 10cm bone defect is left. (OBQ08.65) A 25-year-old man sustains an open forearm fracture from an auger as depicted in Figures A and B. A 5-year-old boy presents with temperature of 104 degrees Fahrenheit and painful weight bearing on the left lower extremity for one day. Less severe postoperative pain at the surgical site, Decreased postoperative gait abnormalities, Increased complication rates as compared to posterior harvesting. 5th Metatarsal Base Fracture Metatarsal FX screw placement for stress fx of proximal 5th MT. (SAE07PE.36)
Classification.
(OBQ05.2)
(SBQ04PE.24.1)
Aspiration reveals 1,000 WBC with 30% PMNs.
Urgent irrigation and debridement of the right knee, Close monitoring with repeat labs in 24 hours, Oral antibiotics with office follow-up the next day, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Pediatrics Pediatric Osteomyelitis (ft. Dr. Lindsay Andras), Question SessionOsteomyelitis - Pediatric, Post-septic arthritis of the knee sequelae in an 8 year old patient. What is the next most appropriate initial step in management? Radiographs of the knee are normal.
Diagnosis can often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture.
(OBQ13.76)
The splint is removed revealing intact skin integrity with notable swelling and erythema overlying the distal fibula. (OBQ06.167)
Calcium phosphate Osteoconduction and osteointegration. Nonoperative. Oral antibiotic therapy, with outpatient follow-up in 6 weeks. Anterolateral soft-tissue impingement.
3% (26/766) 4. unlikely with incomplete stress fracture. mark out lateral malleolus and anterior and posterior borders of fibula; mark estimated location of fracture site (check with C-arm if unsure) straight longitudinal incision 4-6cm in length centered on fracture . This is an AAOS Self Assessment Exam (SAE) question. Treatment is nonoperative versus operative based on fracture displacement and alignment, associated soft tissue injury, and patient risk factors. incidence.
Biodegrade very slowly fibula and ribs are most common sources of vascularized autografts. (OBQ18.141) A 48-year-old male returns to your office 8 months after sustaining a proximal humerus fracture that was successfully treated nonoperatively. A radiograph of the affected hip is shown in Figure A. 3% (26/766) 4. (OBQ11.253) A 17-year-old ballet dancer presents with 5 months of pain in the posterior aspect of the right lower extremity that is exacerbated with the ballet position shown in Figure A. However he is still having persistent anterior shoulder/arm pain that worsens with most activities. Vector of applied load, amount of energy, and quality of bone determine type of fracture. covers larger portion of articular surface associated fibula fracture. Weightbearing foot radiographs demonstrate no fracture. A pediatric patient has just been diagnosed with osteomyelitis of the femur. hip arthroplasty . Which of the following interventions has been shown to have the best outcomes in this patient population?
(SBQ18FA.18) A 60-year-old woman with a history of well-controlled diabetes and hypertension sustained a fall into a ditch yesterday and presents with persistent left ankle pain and deformity. unlikely with incomplete stress fracture. What is the next best step in management to confirm the diagnosis? Weightbearing foot radiographs demonstrate no fracture. Which of the following is the most common intraoperative complication in a patient with sickle cell disease undergoing a total hip arthroplasty? metatarsal stress fracture. Osteomyelitis in the pediatric population is most often the result of hematogenous seeding of bacteria to the metaphyseal region of bone. Her blood count was normal, but her erythrocyte sedimentation rate was 48 mm. fracture length. This system divides tibial plateau fractures into six types: Schatzker I: wedge-shaped pure cleavage fracture of the lateral tibial plateau, originally defined as having less than 4 mm of depression or displacement Schatzker II: splitting and depression of the lateral tibial plateau; namely, type I fracture with a depressed component (generally considered commonest 5)
In rehabilitation, he reports fullness and tenderness in the proximal medial leg (at the knee). (OBQ06.150)
covers larger portion of articular surface associated fibula fracture. A knee aspiration is performed. extends from the anteroinferior border of the fibula to the neck of the talus. Polyethylene liner exchange and bone grafting. He has not done any physical therapy nor received a corticosteroid injection. A synovial fluid aspirate of the hip demonstrates < 500 cells (60% PMN). medial plateau. A clinical photograph is shown in Figure A. Which of the following statements regarding acute hematogenous osteomyelitis in pediatric patients is true? Knee pain affects approximately 25% of adults, and its prevalence has increased almost 65% over the past 20 years, accounting for nearly 4 million primary care visits annually. During surgery, the exposure technique shown in Figure A is used. Meniscus. Which of the following is the most appropriate treatment at this time? (OBQ12.270)
(SBQ04PE.28)
Anterolateral soft-tissue impingement. 5th Metatarsal Base Fracture Metatarsal FX screw placement for stress fx of proximal 5th MT. (OBQ06.216)
Achilles tendon repair - especially percutaneous technique. displacement of femoral neck fracture will disrupt the blood supply and cause an intracapsular hematoma (effect is avoid multiple cortical perforations during guide pin or screw placement to avoid development of lateral stress riser. He denies any recent trauma. Treatment depends on etiology of failure, prior surgery and patient activity demands. collapse. 1% (26/2875) L 3 B Trans-sacral fibula (Bohlman's procedure) for High Grade Spondylolisthesis total hip replacement .
incision made in line with the tip of the fibula and the base of the 4th metatarsal. mark out lateral malleolus and anterior and posterior borders of fibula; mark estimated location of fracture site (check with C-arm if unsure) straight longitudinal incision 4-6cm in length centered on fracture . A radiograph is provided in Figure A. A 6 year-old boy develops tenderness at the right heel and avoids putting weight on the right extremity after stepping on a nail 2 weeks ago while wearing tennis shoes. (OBQ04.220)
Management with a knee immobilizer for 3 months, Revision of tibial component with LCL reconstruction, Revision of tibial and femoral components with stems and/or augments, Revision of tibial and femoral components without stems and/or augments, (SAE07HK.45)
incidence. make incision along posterior fibula if access to the posterior malleolus is needed; Soft Tissue Dissection . (OBQ16.270)
(OBQ14.254)
(OBQ07.151)
more common with displaced FNSFs (9-44%) Radiographs show no evidence of a stress fracture, an alpha angle of 45 degrees, and a lateral center edge angle of 30 degrees.
useful to diagnosis syndesmosis injury in high ankle sprain. After debridement of nonviable bone, a 10cm bone defect is left. After debridement of nonviable bone, a 10cm bone defect is left. The ligament connecting the anterolateral tibial to the anteromedial fibula. external rotation stress test.
Her symptoms returned with ballet activity following a 1 month course of full rest, nonsteroidal anti-inflammatory medication, and physical therapy. Lab results include a C-reactive protein level of 12mg/L (normal 0-3.2 mg/L), erythrocyte sedimentation rate of 38mm/h (normal 0-20mm/h) and a white blood cell count of 12.3 K/mm3(normal 4.3 -11.4 K/mm3). cast immobilization for 8 weeks. Address epiphyseal defects with impaction particulate bone grafting, Address metaphyseal defects with structural allograft and uncemented, unstemmed implants, Address metaphyseal defects with uncemented, porous metaphyseal sleeves and uncemented, stemmed implants, Address diaphyseal defects with porous metal cones and uncemented, stemmed implants, Address diaphyseal defects with cemented stemmed implants. 1% (18/1949) 4.
(SAE07HK.15)
Serum laboratory values are WBC-8.0, ESR-20, CRP-0.5. Compared to historical causes of revision after total knee replacement which of the following statements is most accurate? What is the approximate risk of transmission of HIV in fresh-frozen allograft bone? He has been unable to ambulate on the leg since waking up this morning. He has a temperature of 103.4F and his laboratory values are remarkable for elevated ESR, CRP, and WBC. replacing water in the tissue with alcohol to a moisture level of 5% and then using a vacuum process to remove the alcohol from the tissue. A 47-year-old man presents with 1 week of left leg pain. gravity stress view can identify medial clear space widening. Copyright 2022 Lineage Medical, Inc. All rights reserved. Final cultures reveal methicillin-resistant staphylococcus aureus (MRSA). younger patient with crescent sign or more advanced femoral head collapse, +/- acetabular DJD A 47-year-old man presents with 1 week of left leg pain. Pathologic local bone disease. A tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures. TKA Revision is most commonly performed to address. After reduction of the joint surface you plan to fill the void with a bone-graft substitute to prevent joint collapse. Orthobullets Team Spine - Adult Isthmic Spondylolisthesis Traumatic fracture with intact pars interarticularis. Vector of applied load, amount of energy, and quality of bone determine type of fracture. ORIF of distal fibula fx (especially Weber C) At risk with ankle inversion injuries.
Her symptoms returned with ballet activity following a 1 month course of full rest, nonsteroidal anti-inflammatory medication, and physical therapy. Stress fracture. Delayed union or nonunion.
(OBQ08.97)
indications. reconstruction with a metal augmented revision tibial implant. normal deltoid ligament. A 45-year-old with a history of sickle cell anemia reports hip pain for the past 6 months. (OBQ12.95)
A photomicrograph of the femoral head sectioned at the time of surgery is shown in Figure 31. They have high resistance to shear forces, They have high resistance to torsional forces, They are contraindicated in spinal fusion, They provide a scaffold for bone progenitor cells, They are not biocompatible with stainless steel orthopedic implants.
Binding to penicillin-specific binding proteins in the bacterial cell wall, Binding to the D-Ala-D-Ala residues in the bacterial cell wall, Inhibition of bacterial topoisomerase and DNA gyrase. A 7-year-old boy presents with right elbow and left wrist swelling for the past 3 months. Collagen-based matrix with hydroxyapatitie coating. During the tibial cut, a ligament is transected by a reciprocating saw. What is the mechanism of action of the empiric antibiotic appropriate for this patient? A 63-year-old patient presents with periprosthetic joint infection 3 years after primary total knee arthroplasty. A 65-year-old patient was treated with an open reduction/internal fixation for a left femoral neck fracture sustained 25 years ago. (OBQ08.239)
Cytomegalovirus, Hepatitis A, Hepatitis B, Hepatitis C, HIV, Syphillis, Cytomegalovirus, Hepatitis A, Hepatitis B, Hepatitis C, HIV, Hepatitis A, Hepatitis B, Hepatitis C, HIV, Syphillis. subacute osteomyelitis) and need to rule out malignancy, early disease with no subperiosteal abscess or abscess within the bone, surgery is not indicated if clinical improvement obtained within 48 hours, generally, nafcillin or oxacillin, unless high local prevalence of MRSA (then use clindamycin or vancomycin), mechanism of action for vancomycin involves binding to the D-Ala D-Ala moiety in bacterial cell walls, if gram stain shows gram-negative bacilli - add a third generation cephalosporin, convert to organism-specific antibiotics if organism identified, treatment for initial 1 year is multiagent antibiotics and rarely surgical debridement due to risk of chronic sinus formation, often a case by case decision with input from infectious disease consultation, surgical drainage, debridement, and antibiotic therapy, hemodynamic instability, as patients should be stabilized first - however sometimes operative treatment of the underlying infection helps stabilize the patient, example of institution algorithm treatment pathway, evacuate all purulence, debride devitalized tissue, and drill as needed into intraosseous collections, send tissue for culture and pathology to rule out neoplasm, close wound over drains or pack and return to OR in two to three days, is an infrequent complication in children, bones with intra-articular metaphysis are at risk (shoulder, elbow, hip, ankle), Growth disturbances and limb-length discrepancies from growth plate involvement, observation and possible corrective surgery depending on severity or projected severity, Mortality decreased from 50% to <1% with development of antibiotics.
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