Insertion of blocking screws lateral and posterior to the nail, Insertion of blocking screws medial and posterior to the nail, Insertion of blocking screws lateral and anterior to the nail, Insertion of blocking screws medial and anterior to the nail, Insertion of blocking screws medial, lateral, and posterior to the nail. Incomplete is more common than complete type, Long-term degenerative changes are similar between arthroscopic saucerization, partial, and complete meniscectomy, Saucerization with repair results in inferior clinical outcomes compared to saucerization alone, A 6-8mm peripheral rim is recommended following saucerization. A 22-year-old female is struck by a truck and sustains the injury seen in figure A. The Gustilo Anderson classification, also known as the Gustilo classification, is the most widely accepted classification system of open (or compound) fractures.. Deep vein thromobosis. WebTHA Dislocation THA Sciatic Nerve Palsy THA Leg Length Discrepancy Patellar Clunk Syndrome pseudo-lateral (oblique) views of the pelvis designed to evaluate the columns and walls of the acetabulum. fracture. A radiograph taken 6 weeks after surgery and before the fall is shown in Figure 10a. Figures A through E are paired diagrams depicting the anteroposterior and lateral profiles of the proximal tibia. MRI studies can be helpful for central or foraminal stenosis. Prognosis. Thermal ablation of the posterior capsule, (SAE07HK.23) Softening of the overlying articular cartilage with intact articular surface, Failure of apoptosis during in-utero development, Landing biomechanics and neuromuscular activation patterns, Relative quadriceps strength over hamstrings. Based on the angles X,Y, and Z shown in Figure A, B, and C, which of the following most accurately determines the Pelvic Incidence (PI) in this patient? Patellar dislocations occur with significant regularity, particularly in young female athletes. A 13-year-old girl presents with lateral knee pain after a twisting injury during basketball. Ligaments. CT of the pelvis can assist with assessing for implant malpositioning. She returns to clinic 3 years post-operatively with signifcant thigh pain. L3 and L4 nerve root compression. Posterolateral portal (PL) function. Webpatella dislocation. dislocation rates may be higher than anterior exposures. Which of the following statements is true? A 60-year-old male had a total hip replacement 8 years ago. 295 plays. flexion, internal rotation, adduction of hip, ideal positioning of acetabular component is, in general, excessive anteversion increases risk of anterior hip dislocation; excessive retroversion increases risk of posterior hip dislocation, spastic or neuromuscular disease (Parkinson's), decreased femoral offset (decreases tissue tension and stability), prior spinal fusion or fixed spinopelvic alignment, common cause of late instability occuring >5 years after procedure, often reports activity that puts patient in a position that provokes dislocation (hip flexion, adduction, internal rotation), two-thirds of early dislocations can be treated with closed reduction and immobilization, immobilize with hip spica cast, hip abduction brace, or knee immobilizer, stable well-aligned implants with extensive polyethylene wear thought to be sole reason for dislocation, indicated if 2 or more dislocations with evidence of, for soft tissue deficiency or dysfunction, contraindicated if acetabular bone is compromised, older technique rarely used with development of dual mobility implants, significant bone loss and soft tissue deficiency, techniques to prevent future dislocation during THA include, indicated if malalignment explains dislocation, places abductor complex under tension which increases hip compression force, conversion to a constrained acetabular component. Demographics. will show patella baja. Which of the following hip positions would put the patient at the greatest risk for dislocation? Copyright 2022 Lineage Medical, Inc. All rights reserved. He has noticed intermittent episodes of gait imbalance and difficulty with buttoning his shirt over the past 3 months. Which of the following complications has been associated with this fixation construct? AP and lateral of knee. (OBQ06.269) Patellar. She has 5 of 5 motor strength in all muscles groups in her lower extremities and symmetric patellar and Achilles reflexes. This is an AAOS Self Assessment Exam (SAE) question. This is her third dislocation in the last 6 months. The problem most likely occurred as a result of. torsional injury (spiral oblique fracture), severity of muscle injury has the greatest impact on need for amputation, fracture into apex anterior, or procurvatum, intracompartmental pressure measurement if indicated, proximal fracture extended, apex anterior, varus, varus due to pes anserinus + anterior compartment, question of intra-articular fracture extension, diagnosis confirmed by clinical presentation and radiographs, closed low energy fractures with acceptable alignment, < 10 degrees anterior/posterior angulation, shortening is most difficult to control with nonoperative management, angulation and rotational control are difficult to achieve by closed methods, extent of shortening and translation on injury radiographs should be expected at time of union, fractures with extensive soft-tissue compromise, higher incidence of malalignment than IMN, enough proximal bone to accept two locking screws (5-6 cm), high rates of malunion with improper technique, inadequate proximal fixation for IM nailing, best suited for transverse or oblique fractures, lateral plating with medial comminution can lead to varus collapse, long plates may place superficial peroneal nerve at risk, higher infection rate that IMN for open fractures, place in long leg cast and convert to functional brace at 4 weeks, bi-planar and multiplanar pin fixators are useful, circular frames indicated for very proximal fractures, can be safely converted to IMN within 7-21 days, helps maintain reduction for proximal 1/3 fractures, medial parapatellar approach may lead to valgus deformity, facilitates nailing in semiextended position, proximal to the anterior edge of the articular margin, use of a more lateral starting point may decrease valgus deformity, use of a medial starting point may create valgus deformity, prevents apex anterior (procurvatum) deformity, place in posterior half of proximal fragment, place on lateral concave side of proximal fragment, enhance construct stability if not removed, short one-third tubular plate placed anteriorly, anteromedially, or posteromedially across fracture, secure both proximally and distally with 2 unicortical screws, Schanz pins inserted from medial side, parallel to joint, pin may additionally be used as blocking screws, may help to prevent apex anterior (procurvatum) deformity, neutralizes deforming forces of extensor mechanism, statically lock proximally and distally for rotational stability, no indication for dynamic locking acutely, must use at least two proximal locking screws, straight or hockey stick incision anterolaterally from just proximal to joint line (if intra-articular extenion) to just lateral to the tibial tubercle and extend distally as needed, better soft tissue coverage laterally makes lateral plating safer, superficial peroneal nerve injuy with use of a longer plate, varus collapse if lateral only plate used with medial comminution, occurs in more than 30% of cases treated with IMN, resolves with removal of IMN in 50% of cases, 20-60% rate of malunion following intramedullary nailing (valgus/procurvatum), laterally based starting point and anterior insertion angle, entry of IMN should be in line with the medial border of the lateral tibial eminence, blocking screws placed in metaphyseal segment on the concave side of the deformity, place laterally to prevent valgus and posterior to prevent procurvatum in proximal fragment, this narrows the available space for the IMN, direct the nail toward a more centralized position, High rate of malunion following intramedullary nailing, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. An Insall-Salvati ratio of < 0.8 indicates patella baja. If seen on pelvic radiographs when moving from standing to sitting, which of the following parameter changes would increase her risk for postoperative THA dislocation the most? acts as primary ligamentous restraint to lateral patellar translation. [12][13], "Kneecap" redirects here. Trans-sacral fibula (Bohlman's procedure) for High Grade Spondylolisthesis, Spine Conference lecture: isthmic adult spondylolisthesis, L5-S1 Pseudoarthrosis with Adjacent Level Spondylolisthesis in 44F, L5-S1 first degree spondylolithesis with bilateral pars interarticularis fracture. Each of the following operative interventions will increase the stability of the hip EXCEPT: Revising the acetabular component to a more medialized position, Advancing the trochanter distal on the femur, Converting to a femoral component with extended offset, Replacing the acetabular polyethylene with a constrained liner, Replacing the femoral head with a larger size. It is pointed in shape, and gives attachment to the patellar ligament. A 75-year-old female wishes to proceed with total hip arthroplasty (THA) for osteoarthritis. WebMedial parapatellar arthrotomy avoiding the patellar tendon. A 26-year-old male presents with chronic back and bilateral leg pain that has not improved with extensive nonoperative management including physical therapy, oral medications, and corticosteroid injections. A 34-year-old female sustains a proximal third tibia fracture as an isolated injury and elects to undergo operative treatment with intramedullary nailing. He denies any past history of pain, clicking, or locking. Most commonly involves the medial meniscus, Asymptomatic discoid meniscus should undergo saucerization, Radiographs will commonly show a hyperplastic lateral intercondylar spine, Radiographs will commonly show squaring of affected condyle with cupping of tibial plateau. (OBQ12.6) Which of the following operative techniques would have helped to best avoid the procurvatum deformity? Patient unable to reliably exert effort or muscle unavailable for testing due to factors such as immobilization, pain on effort, or contracture. Symptoms. Tibial nailing with increased knee flexion, Lateral blocking screw in the proximal fragment, Medial blocking screw in the proximal fragment, Anterior blocking screw in the proximal fragment, Posterior blocking screw in the proximal fragment. Neutral and flexion radiographs are shown in Figures A and B. What is the most appropriate first line of treatment? 10/21/2019. inserts anteriorly on tibial tubercle . (SBQ12TR.22) WebAn anterior-posterior (AP) X-ray of the pelvis and a cross-table lateral X-ray of the effected hip are ordered for diagnosis. (OBQ13.197) You can rate this topic again in 12 months. posterior hip joint access and instrumentation. Imaging is shown in Figure A. Patella fractures are usually treated with surgery, unless the damage is minimal and the extensor mechanism is intact.[7]. All of the following techniques can help to prevent apex-anterior angulation during intramedullary nailing of proximal one-third tibia fractures EXCEPT: Posterior blocking screw in the proximal segment, Interlocking the nail in a semi-extended knee position. 1% (40/6066) 5. A 38-year-old male sustains the closed injury shown in Figures A and B. What is the most appropriate treatment for the recurrent dislocations? MRI. [citation needed] Partite patellas occur almost exclusively in men. A 59-year-old woman who underwent a total hip arthroplasty 5 years ago now has recurrent dislocation following bariatric surgery and a weight loss of 200 lb. Treatment is closed reduction of the hip. increased signal intensity, thickening, and cysts within and adjacent to ACL are common findings, and clinically insignificant (no instability quadriceps tendon. (OBQ10.140) Pathophysiology. The tests include, a. Superficial - pain with light touch to skin, b. WebLateral thigh, anterior knee, and medial leg. The lower part of the posterior surface has vascular canaliculi filled and is filled by fatty tissue, the infrapatellar fat pad. (OBQ09.189) Webquadriceps tendon rupture is more common than patellar tendon rupture. Fatigue fracture of the pars interarticularis, Degenerative instability with intact pars interarticularis, Traumatic fracture with intact pars interarticularis. The patient is at significantly increased risk for. Toe dorsiflexion. A 34-year-old male presents with a closed left leg injury after falling off a 20ft ladder. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. There is evidence of eccentric polyethylene wear and some retroacetbular osteolysis. Four main types of articular surface can be distinguished: In the patella an ossification centre develops at the age of 36 years. 698 plays. (OBQ05.166) WebNormal limits of knee range of motion include extension from 0 to 10 and flexion to 135. He is otherwise healthy, with no birth or developmental issues. Which angle in Figure A-E best illustrates the measurement of pelvic incidence. high energy. posteromedial buttress plate for coronal fracture not captured with lateral plate only . Web(OBQ20.108) A 21-year-old recreational hockey goalie presents to your clinic with 6 weeks of right hip and groin pain. Traumatic Spondylolisthesis of Axis (Hangman's Fracture), Cervical Lateral Mass Fracture Separation, Extension Teardrop Fracture Cervical Spine, Clay-shoveler Fracture (Cervical Spinous Process FX), Chance Fracture (flexion-distraction injury), Osteoporotic Vertebral Compression Fracture, Ossification Posterior Longitudinal Ligament, DISH (Diffuse Idiopathic Skeletal Hyperostosis), Atlantoaxial Rotatory Displacement (AARD), Pediatric Intervertebral Disc Calcification, Pediatric Spondylolysis & Spondylolisthesis. Spine Infections, Tumors, & Systemic Conditions. What affect does this have on the biomechanics of her THA? instability. Figures A and B show pre- and post-operative radiographs of a sedentary 75-year-old female who underwent surgery on her left hip. Diagnosis can be suspected with a knee effusion and a positive dial test but MRI studies are required for confirmation. Thank you. (SBQ16HK.10) A lateral radiograph and axial CT scan are shown in Figures A and B, respectively. Diagnosis is made with lateral radiographs. Her past medical history is significant for hypertension, hypothyroidism, and lumbar degenerative disease. (OBQ04.64) The apex is the most inferior (lowest) part of the patella. Knee immobilizer and non weight bearing for 6 weeks, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course. Osteology. Her clinical mechanical alignment, patellar tracking, meniscal examination, and ligamentous examination are all equivocal on physical examination. (SAE09SN.23) She has no neurologic deficits. Which of the following is the cause of this type of spondylolisthesis? Lateral blocking screws in proximal tibia fragment, Use of a radiolucent triangle to flex the knee, Anterior blocking screw in the proximal tibia fragment, Medial parapatellar arthrotomy avoiding the patellar tendon. A radiograph taken after the fall is shown in Figure 10b. findings. Surgical management is indicated for progressive disabling pain that has failed nonoperative management, and/or progressive neurological deficits. Owing to the great stress on the patellofemoral joint during resisted knee flexion, the articular cartilage of the patella is among the thickest in the human body. A 62-year-old woman presents for her 1-year follow-up after a revision right total hip arthroplasty. (OBQ06.106) An attempt at converting to a larger head size and trochanteric advancement has failed. (OBQ09.176) patella instability. A 46-year-old male presents with the radiographs in Figure A following a skiing accident. The front and back surfaces are joined by a thin margin and towards centre by a thicker margin. Which of the following figures has arrows that correspond to the ideal entry point for intramedullary nailing of a proximal third diaphyseal tibial fracture? Copyright 2022 Lineage Medical, Inc. All rights reserved. Physical examination reveals mild effusion, lateral sided tenderness, and range of motion from 10-85 degrees without any signs of instability. This page was last edited on 15 November 2022, at 13:55. chronic injury. The patella is found in many tetrapods, such as mice, cats, birds and dogs, but not in whales, or most reptiles. What is the most appropriate course of action? (OBQ06.201) You decide to treat this injury with an intramedullary nail. gluteal n.), Peptic ulcer disease, cholecystiits, nephrolithiasis, PID, pancreatitis, looking for prior scars, cafe au lait spots, hairy patches in the lower lubmar spine, Active movement, full range of motion, gravity eliminated, Active movement, full range of motion, against gravity, Active movement, full range of motion, against gravity and provides some resistance, Active movement, full range of motion, against gravity and provides normal resistance. The retinacular fibres of the patella also stabilize it during exercise. (OBQ13.22) His injury radiographs are shown in Figure A. A 34-year-old man is involved in a motorcycle accident and sustains a closed tibia fracture and multiple rib fractures. Treatment generally consists of surgical open reduction and internal fixation (ORIF) versus intramedullary nail fixation. Periprosthetic acetabular fracture with resulting pelvic discontinuity, Chronically infected total hip arthroplasty, Recurrent dislocations in a patient whose femoral component is positioned in 15 retroversion, Recurrent dislocations in a patient whose cup is positioned in 10 retroversion and 60 abduction, Recurrent dislocations in a patient whose cup is positioned in 20 anteversion and 40 abduction. An attempt at converting to a larger head size and trochanteric advancement has failed. 4/20/2020. Web(SAE13HK.10) A healthy, active 72-year-old man tripped and fell, landing on his left hip 10 weeks after an uncomplicated left primary uncemented total hip replacement. i.e. Pain with running, point tenderness over fracture site, "dreaded black line" on lateral x-ray. You can rate this topic again in 12 months. What technique can be utilized to avoid the characteristic deformity seen in this fracture pattern if an intramedullary nail is used for treatment? 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, 2019 Winter SKS Meeting: Shoulder, Knee, & Sports Medicine, Patellofemoral Lesion: Why These are Different and Tricks for Managing - Andreas Gomoll, MD, Keynote: Rehabilitation After Patellofemoral Instability Surgery - Michael Matthews, PT, DPT, Case Presentations: Patellofemoral Instability Surgery - Matthew Provencher, MD. After extensive nonoperative management fails to provide any significant pain relief, surgical intervention is performed. Lumbar decompression with L5 to S1 posterior lumbar fusion, Lumbar decompression, L4 to S1 posterior lumbar fusion, and anterior column support, Minimally invasive direct lateral interbody fusion with percutaneous pedicle screw placement, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Posterior Laminectomy and Instrumented Fusion, Single Level Lumbar Decompression and Fusion (TLIF), Type in at least one full word to see suggestions list. His symptoms have remained persistent and both he and his parents are concerned as this limits his performance. Treatment should include: Revision of the femoral component to a modular stem with retention of the acetabular component, Revision to a constrained liner with retention of the acetabular and femoral prostheses. WebHer pain is located directly over her medial femoral condyle (MFC). For other uses, see, "On the presence of the patella in frogs", "patella - Origin and meaning of patella by Online Etymology Dictionary", https://en.wikipedia.org/w/index.php?title=Patella&oldid=1122033912, Short description is different from Wikidata, Articles with unsourced statements from July 2015, Creative Commons Attribution-ShareAlike License 3.0, present at the joint of femur and tibia fibula. The upper three-quarters of the patella articulates with the femur and is subdivided into a medial and a lateral facet by a vertical ledge which varies in shape. What course of action will you recommend? When treating this injury with an intramedullary nail, addition of blocking screws into which of the following positions can prevent the characteristic malunion deformity? (OBQ09.126) Additionally, she describes intermittent episodes of an inability to fully extend her knee. MRI. Biomechanically complex articulation between the, bony constraint of the patella within the trochlear groove, diameter of lateral femoral condyle > medial femoral condyle, bony constraint of groove is the primary constraint to lateral patellar instability when knee flexion is > 30 degrees, originates from the adductor tubercle to insert onto the superomedial border of the patella, primary constraint to lateral patellar instability with knee flexion 0 to 20 degrees, vastus lateralis = lateral restraint to medial translation, angular difference between the quadriceps tendon insertion and patella tendon insertion creates a valgus axis (, creates a laterally directed force across the patellofemoral joint, leads to increased contact pressures in lateral patellar facet between 40-90 degrees, superior, medial and lateral, geniculate arteries, inferior, medial and lateral, geniculate arteries, transmits tensile forces generated by the quadriceps to the patellar tendon, increases lever arm of the extensor mechanism, patellectomy decreases extension force by 30%, patella moves caudally during full flexion, maximum contact between femur and patella is at 45 degrees of flexion, passive restraints to lateral subluxation, primary passive restraint to lateral translation in 20 degrees of flexion, line drawn from the anterior superior iliac spine --> middle of patella --> tibial tuberosity, patellar height (e.g. Current radiographs, shown in Figure B, demonstrate femoral subsidence. (OBQ11.161) Her ankle-brachial index (ABI) for her right posterior tibial artery is 0.4. Modified Bohlman Technique: Multi-Surgeon Results - Robert Hart, M.D. good results At the time of the revision surgery shown in Figure 14, the acetabular component was found to be stable. A standing PA and lateral radiograph is shown in Figures A and B. Webmedial/lateral - traction and medial or lateral translation. Copyright 2022 Lineage Medical, Inc. All rights reserved. may be treated with exostosis excision, ulnar lengthening and radial closing wedge osteotomy. (OBQ08.260) Which of the following correctly combines techniques used to decrease the incidence of the most common deformities associated with this fracture pattern? [3] The patella can be tracked back into the groove with an extension of the knee, and therefore sometimes returns into the proper position on its own.[3]. Radiographs show a Tonnis angle of 15 degrees and a lateral center-edge angle of 15 degrees. [1] The patella originates from two centres of ossification which unite when fully formed. An 11-year-old soccer player presents with a 6 month history of snapping and discomfort along the lateral joint line of the knee. He complains of right leg pain, and physical exam reveals no evidence of an open fracture. A patella baja is a low-riding patella. These fractures usually cause swelling and pain in the region, bleeding into the joint (hemarthrosis), and an inability to extend the knee. During insertion of your nail, it's decided that blocking screws are needed. A 65-year-old male with chronic right hip pain undergoes the procedure seen in Figure A utilizing a posterior approach. acute associated soft tissue injuries (patellar tendon rupture, periarticular avulsion, or displaced menisci) may benefit from acute repair. A 6-year-old boy complains of a 'clunking' sensation in his left knee. What is the most appropriate next step in treatment? She underwent uncomplicated L5-S1 posterior lumbar fusion 5 years ago. usually medial-sided plateau fractures . An AP radiograph is shown in Figure A. Radiographs are shown in Figure A. L3/4 central disc herniation with impingement on the bilateral descending nerve roots, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Spine | Lower Extremity Spine & Neuro Exam. Webrefers to a shortened patellar tendon which decreases the distance of the patellar tendon from the inferior joint line can cause bony impingement of patella on tibia. Surgical management with possible revision THA is indicated for irreducible dislocations, recurrent instability, and implant malposition. After extensive nonoperative management fails to provide any significant pain relief, surgical intervention is performed. Diagnosis can be suspected on radiographs with (squaring of lateral condylewithcupping of lateral tibial plateau) but require MRI for confirmation. Classification. A 68-year-old woman who underwent a right total hip arthroplasty 1 year ago has dislocated her hip five times since surgery. A 45-year-old male sustains a proximal third tibia fracture as an isolated injury and elects to undergo operative treatment with intramedullary nailing. A radiograph is provided in figure A. Radiographs show a retroverted acetabular component. True Patellar "J Sign" Jonathan Cohen Pediatrics - Accessory Navicular Orthobullets Team Pediatrics - Accessory Navicular ; Listen Now 14:0 min. Polyethylene exchange with a standard ultra-high molecular weight polyethylene liner and grafting was performed. Tripartite and even multipartite patellas occur. Proximal Tib-Fib Dislocation Knee Overuse injuries Patellar Tendinitis 3.0 T MRI has accuracy, sensitivity, and specificity of >90% for detecting medial and lateral meniscus tears. Babies are born with a patella of soft cartilage which begins to ossify into bone at about four years of age. A 73-year-old female undergoes a total hip arthroplasty (THA) using a cemented stem design shown in Figure A. Thank you. posterior knee pain. He has no associated pain and denies trauma. MRI is significant for an anterosuperior labral tear. Copyright 2022 Lineage Medical, Inc. All rights reserved. spondylolysis is seen in 4-6% of population, increased prevalence in sports that involve, due to forces in the lumbar spine being greatest at these levels and the facet being more coronal, adult isthmic spondylolisthesis at L5/S1 often leads to radicular symptoms caused by compression of the exiting L5 nerve root in the L5-S1 foramen, hypertrophic fibrous repair tissue of the pars defect, uncinate spur formation of the posterior L5 body, caused by facet arthrosis and hypertrophic ligamentum flavum, rare due to fact that these slips are usually only Grade I or II, - pars elongation due to multiple healed stress fx, Degenerative: facet instability without a pars fx, Traumatic: acute posterior arch fx other than pars, Neoplastic: pathologic destruction of pars, pain usually has a long history with periodic episodes that vary in intensity and duration, usually a L5 radiculopathy usually caused by foraminal stenosis at the L5-S1 level, characterized by buttock and leg pain worse with walking, symptoms of neurogenic claudication rare because these slips rarely progress beyond Grade II, rare because these slips rarely progress beyond Grade II, obtain AP, lateral, obliques, and flexion-extension views, will see spondylolisthesis and pars defect, pelvic incidence = pelvic tilt + sacral slope, a line is drawn from the center of the S1 endplate to the center of the femoral head, a second line is drawn perpendicular to a line drawn along the S1 endplate, intersecting the point in the center of the S1 endplate, the angle between these two lines is the pelvic incidence (see angle X in figure above), pelvic incidence has direct correlation with the MeyerdingNewman grade, sacral slope = pelvic incidence - pelvic tilt, a second vertical line (parallel with side margin of radiograph) line is drawn intersecting the center of the femoral head, the angle between these two lines is the pelvic tilt (see angle Z in figure above), pelvic tilt = pelvic incidence - sacral slope, a line is drawn parallel to the S1 endplate, a second horizontal line (parallel to the inferior margin of the radiograph) is drawn, the angle between these two lines is the sacral slope (see angle Y in the figure above), T2 parasagittal images are best study to evaluate for foraminal stenosis and compression of neural elements, bracing may be beneficial especially in the acute phase, L5-S1 decompression and instrumented fusion +/- reduction, L5-S1 low-grade spondylolisthesis with persistent and incapacitating pain that has failed 6 months of nonoperative management (most common), risk of stretch injury to L5 nerve root with reduction, decompression and instrumented fusion +/- reduction, L5-S1 high-grade spondylolithesis with persistent and incapacitating pain that has failed 6 months of nonoperative management, can be used successfully to treat low-grade isthmic spondylolisthesis even when radicular symptoms are present, cannot be used to treat high grade isthmic spondylolisthesis due to translational and angular deformity, studies have shown good to excellent results in 87-94% at 2 years, indicated in adult with leg pain below knee, usually involves Gill laminectomy and foraminal decompression, removal of loose lamina and scared pars defect allows decompression of nerve root, a Gill decompression is destabilizing and should be combined with fusion, interbody fusion (PLIF/TLIF) commonly performed, posterior lumbar interbody fusion (PLIF) involves insertion of device medial to facets, transforaminal lumbar interbody fusion (TLIF) requires facetectomy and more lateralized and transforaminal approach to the disc space, interbody fusion has increased operative time with greater blood loss and longer hospitalizations, usually done through trans-retroperitoneal approach, decompression of nerve root done indirectly by foraminal distraction via restoration of disc height, grafts used include autologous iliac crest, structural allograft, and cages of various materials, may increase chance of union by more complete discectomy and endplate preparation, allows improved restoration of disc height, retrograde ejaculation and sexual dysfunction, persistent radiculopathy due to inadequate indirect foraminal decompression, persistent low back pain may be caused by nociceptive pain fibers in pars defect that are not removed in an anterior procedure alone, preferred treatment is surgeon dependent with each technique having similar outcomes, Relatively few patients (5%) with spondylolysis with develop spondylolisthesis, Slip progression usually occurs in adolescence and rare after skeletal maturity, Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar. Bone. WebOrthobullets Team Knee & Sports - Patellar Instability Technique Guide. [6], The kneecap is prone to injury because of its particularly exposed location, and fractures of the patella commonly occur as a consequence of direct trauma onto the knee. The affected femoral head will appear larger if the dislocation is anterior, and smaller if posterior. patella emarginata, a "missing piece") are common laterally on the proximal edge. Wrisberg (lack of posterior meniscotibial attachment to tibia), mechanical symptoms most pronounced in extension, study of choice for suspected symptomatic meniscal pathology, 3 or more 5mm sagittal images with meniscal continuity, sagittal MRI will show abnormally thick and flat meniscus, coronal MRI will show thick and flat meniscal tissue extending across entire lateral compartment, Symptomatic cases may reveal underlying meniscus tear, asymptomatic discoid meniscus without tears, obtain anatomic looking meniscus with debridement, repair meniscus if detached (Wrisberg variant), meniscal instability is frequently present, recent literature suggest anterior horn instability is most common, Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Concussions (Mild Traumatic Brain Injury). most effective from 0-30 of flexion before patella engages trochlear groove. What is the best treatment for this patient? An adult patient with a grade I isthmic spondylolisthesis at L5-S1 is most likely to have weakness of the. patellofemoral joint arthritis. During surgical treatment of this fracture, which of the following techniques will help facilitate a successful reduction and intramedullary fixation? A 64-year-old healthy female patient underwent right total hip replacement (THR) through a posterior approach 6 months ago. A radiograph is provided in Figure A. Emarginations (i.e. A laminectomy and instrumented fusion is performed and shown in Figure C. What would be the most likely neurologic deficit found in the postoperative period? A 56-year-old male undergoes a total hip arthroplasty (THA). The grading system is used to guide management of compound fractures, with higher grade injuries associated with higher risk of complications. The lateral femoral condyle remains stationary on the lateral tibia plateau during knee flexion from 0 to 120 degrees. Which of the following is true of his pathology? He is unable to bear any weight on the left leg. Hyperflexion to help prevent apex anterior angulation, A medial parapatellar incision to help prevent valgus angulation, Starting point just lateral to the medial tibial eminence to help prevent valgus angulation, A medially placed blocking screw to help prevent valgus angulation, Suprapatellar nailing technique to help prevent apex anterior angulation. The upper third of the front of the patella is coarse, flattened, and rough, and serves for the attachment of the tendon of the quadriceps and often has exostoses. The patient has attempted physical therapy, bracing, and steroid injections but continues to have constant pain. He can elicit the sensation when moving his knee from flexion into full extension. In order to prevent the most common deformity associated with intramedullary nailing of this injury, where should blocking screws be placed and what deformity are they trying to prevent? A post-operative radiograph is provided in Figure B. compression of lower lumbar nerve roots (L4-S1), important to distinguish from hamstring tightness, considered positive if symptoms produced with leg raised to 40, performing straight leg raise in uninvolved leg produces symptoms in involved leg, positive findings suggests upper motor neuron lesion, associated with upper motor neuron lesion, positive reflex with anal sphincter contraction with squeezing of glans penis or clitorus, can alternatively tug on foley catheter to stimulate reflex, Irritation of saphenous division of femoral nerve, Meralgia paresthetica (lateral femoral cutaneous nerve palsy), Compression of LFCN (patient positioning), Common peroneal nerve palsy or sciatic nerve compression, Waddell identified 5 exam findings that correlated with non-organic low back pain. Deep - nonanatomic widespread deep pain, a. Her components are well aligned. Team Orthobullets (J) (SBQ13PE.10) Tibialis posterior (tibial n.) EHL (DPN), EDL (DPN) Hip dislocation. A 25-year-old man sustains a left leg injury during a motorcycle accident. 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 The black arrow in the radiograph indicates she is at higher risk for which of the following? may be normal. [1] The tendon of the quadriceps femoris muscle attaches to the base of the patella.,[1] with the vastus intermedius muscle attaching to the base itself, and the vastus lateralis and vastus medialis are attached to outer lateral and medial borders of patella respectively. Tendons. L5-S1 posterior spinal fusion with instrumentation has the highest fusion rates, L4-S1 posterior spinal fusion with instrumentation and spondylolisthesis reduction has the lowest L5 nerve root injuries, L5-S1 anterior lumbar interbody fusion has the best functional outcomes, L5-S1 transforaminal lumbar interbody fusion has the lowest dural tear rates, Surgeon preference with most techniques having similar outcomes. [2] It involves the patella sliding out of its position on the knee, most often laterally, and may be associated with extremely intense pain and swelling. [1] The posterior surface is divided into two parts.[1]. Examination shows a 10 degree loss of active extension. A correlation has been found between Pelvic Incidence (PI) and spondylolisthesis. She has no complaints of pain and has returned to all her activities of daily living. (SBQ13PE.9) What is the best course of action? Thank you. In the adult the articular surface is about 12cm2 (1.9sqin) and covered by cartilage, which can reach a maximal thickness of 6mm (0.24in) in the centre at about 30 years of age. WebProximal Tib-Fib Dislocation Knee Overuse injuries Lateral Patellar Compression Syndrome all made lateral to anterior portal and medial the anterolateral portals. Achilles, bone-patellar tendon-bone, hamstring, and anterior tibialis. Discoid Lateral Meniscus Saucerization and Stabilization, Type in at least one full word to see suggestions list, Saucerization of a discoid lateral meniscus, Knee & SportsMeniscal Injuries & Discoid Meniscus (ft. Dr. Raymond H. Kim). WebTKA Patellar Prosthesis Loosening lateral femoral cutaneous nerve paresthesias. indications. (OBQ18.192) You are seeing a 28-year-old female for lower back pain after she fell off a horse 2 days ago. The patient was referred to your office for a consultation. (OBQ13.149) OCD lesions. An AP radiographs is shown in Figure A. Sequential sagittal MRI images of the lateral compartment of the knee are shown in Figure B. He denies any acute traumatic injuries. (OBQ10.236) WebOrthobullets Team Spine - Adult Isthmic Spondylolisthesis An AP and lateral radiograph in extension are shown in Figures A and B respectively. A 28-year-old female is struck by a motor vehicle while crossing the street and suffers the injury seen in Figure A. A CT scan is obtained which shows intra-articular extension of the fracture, and lateral locked plating with intercondylar lag screw fixation is planned. Anterior to the nail in the proximal segment; medial to the nail in the proximal segment, Anterior to the nail in the proximal segment; lateral to the nail in the proximal segment, Posterior to the nail in the proximal segment; lateral to the nail in the proximal segment, Anterior to the nail in the distal segment; lateral to the nail in the distal segment, Posterior to the nail in the distal segment; medial to the nail in the proximal segment. A 37-year-old male sustains the closed injury seen in figure A. (SBQ12SP.3) A 17-year-old gymnast presents with increasing lower back pain and lower extremity radiculopathy over the course of 1 year. Web(OBQ09.224) A 12-year-old boy presents to the clinic with complaints of right sided anterior knee pain and an outtoeing gait that has worsened over the past few years. A 75-year-old-male presents after being struck by a vehicle while crossing the street. What is the most common complication of isolated polyethylene exchange with bone grafting that should be disclosed? The size of the head of the femur is then compared across both sides of the pelvis. Most commonly the medial articular surface is smaller than the lateral. Observation, mobilization, and further treatment based on symptoms, Thoracolumbosacral orthosis for 6-8 weeks, L5 to S1 posterior spinal fusion with instrumentation. (OBQ09.202) In more primitive tetrapods, including living amphibians and most reptiles (except some Lepidosaurs), the muscle tendons from the upper leg are attached directly to the tibia, and a patella is not present. She elects to undergo an amputation. Treatment is closed reduction and casting or surgical fixation depending on the degree of displacement. operative 6%. (OBQ11.193) Arthroscopic meniscectomy and saucerization may be indicated for patients with continued pain and mechanical symptoms. more common in lateral opening wedge osteotomy and lateral closing wedge osteotomy. This raises the possibility that the kneecap arose 350 million years ago when tetrapods first appeared, but that it disappeared in some animals. His pediatrician ordered an MRI which is shown in Figure A. Weblateral support. Figure 27 shows the AP radiograph of a patient who has late instability. Physical exam shows normal strength in all four extremities and hyper-reflexic patellar tendons. indications. Team Orthobullets 4 [10][11], The word patella originated in the late 17th century from the diminutive form of Latin patina or patena or paten, meaning shallow dish. (OBQ07.129) The fracture is treated in a minimally invasive manner with a lateral locking plate and percutaneous screw fixation. On Adams forward bending, she measures 6 degrees. What would be the most likely diagnosis? quadriceps tendon rupture. incidence . Webknee valgus (because of shortened fibula) and patellar dislocation. The patella is attached to the tendon of the quadriceps femoris muscle, which contracts to extend/straighten the knee. (OBQ09.5) [1] Bipartite patellas are the result of an ossification of a second cartilaginous layer at the location of an emargination. A 68-year-old male 2 weeks status post left total hip arthroplasty experiences a painful clunk getting out of bed in the morning. Imaging studies are depicted in Figures A and B. His knee exam is unremarkable. THA Dislocation is a complication following THA and may occur due to patient noncomplicance with post-operative restrictions, implant malposition, or soft-tissue deficiency. 2% (154/6433) 3. Previously, bipartite patellas were explained as the failure of several ossification centres to fuse, but this idea has been rejected. In which position should they be placed to prevent the most common malunion? Anatomy. Lateral and posterior to the nail in the proximal segment; procurvatum and valgus, Medial and posterior to the nail in the proximal segment; procurvatum and varus, Lateral and posterior to the nail in the proximal segment; recurvatum and varus, Medial and anterior to the nail in the proximal segment; recurvatum and valgus, Anterior and posterior to the nail in the proximal segment; recurvatum. [5], The Insall-Salvati ratio helps to indicate patella baja on lateral X-rays, and is calculated as the patellar tendon length divided by the patellar bone length. Which of the following is most accurate about the etiology of her diagnosis? She has now dislocated posteriorly 3 times, each followed by closed reduction under anesthesia in the operating room. (OBQ20.3) Which of the following techniques has not been shown to prevent valgus angulation during intramedullary nailing of proximal one-third tibia fractures? ligament tear. Foot inversion. (OBQ09.269) usually occurs in patients > 40 years of age. Hyperflexed Pavlik harness. Physical examination reveals mild effusion, lateral sided tenderness, and range of motion from 10-85 degrees without any signs of instability. A radiograph is provided in Figure A. Treatment is generally observation for patients who are asymptomatic. Spine Infections, Tumors, & Systemic Conditions. A 12-year-old basketball player reports frequent and moderately painful popping in his left knee during his games. The lower third culminates in the apex which serves as the origin of the patellar ligament. You discuss treatment options of acetabular revision if the component is found to be loose intra-operatively versus isolated polyethylene exchange if the acetabular component is stable intra-operatively with the patient. The upper three-quarters of the patella articulates with the femur and is subdivided into a medial and a lateral facet by a vertical ledge which varies in shape. An AP and lateral radiograph in extension are shown in Figures A and B respectively. WebPosterolateral corner (PLC) injuries are traumatic knee injuries that are associated with lateral knee instability and usually present with a concomitant cruciate ligament injury (PCL > ACL). (SBQ16SM.92) (SBQ16SM.35) Which of the following would increase the patient's risk for dislocation or instability? Figures A and B show a 33-year-old man with axial back pain and bilateral leg pain. (OBQ10.8) nonoperative 9%. A Trendelenburg gait would most likely be caused by which of the following lumbar conditions. A post-operative radiograph is provided in Figure B. Webfracture dislocation . Which of the following situations is appropriate for revision of a total hip arthroplasty to a constrained acetabular liner? risk reduced with repair of capsule A long-standing patella baja may result in extensor dysfunction. Femoral nerve palsy. This is an AAOS Self Assessment Exam (SAE) question. joint pain. 5.0 (6) See More See Less. Hip Extension. An exostosis is the formation of new bone onto a bone, as a result of excess calcium formation. Agenesis of the anterior cruciate ligament. (OBQ05.255) The patella is stabilized by the insertion of the horizontal fibres of vastus medialis and by the prominence of the lateral femoral condyle, which discourages lateral dislocation during flexion. continued expansion of the lytic defects. (SBQ16SM.13) (SAE07HK.26) WebProximal Tib-Fib Dislocation Knee Overuse injuries lesions in lateral femoral condyle and patella have poorer prognosis. Initial radiographs are shown in Figures A and B, and intramedullary nailing of the fracture is planned. Adult Isthmic Spondylolisthesis is a common adult spinal condition characterized by subluxation of one vertebral body anterior to the adjacent inferior vertebral body, caused by a defect in the pars interarticularis. Web(SAE07HK.26) A 59-year-old woman who underwent a total hip arthroplasty 5 years ago now has recurrent dislocation following bariatric surgery and a weight loss of 200 lb. [citation needed]. The fracture is treated in a minimally invasive manner with a lateral locking plate and percutaneous screw fixation. (OBQ10.98) WebHe denies any recent trauma. A radiograph is provided in Figure A. Copyright 2022 Lineage Medical, Inc. All rights reserved. Diagnosis is made with orthogonal radiographs of the tibia withCT scan often required to assess for intra-articular extension. The patella is a sesamoid bone roughly triangular in shape, with the apex of the patella facing downwards. What deformities are most commonly seen in treating this injury with an intramedullary nail? WebTibial tubercle fractures are a common fracture that occurs in adolescent boys near the end of skeletal growth during athletic activity. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Physical therapy with a focus on concentric knee strengthening, Arthroscopic saucerization of the lateral meniscus and/or meniscal repair, Arthroscopic microfracture treatment of the defect on the lateral femoral condyle. The middle third has numerous vascular canaliculi. Websuture the patellar tendon to the patella with a #5 non-absorbable transosseous suture drill 2 trans-patellar bony tunnels and pass the sutures through tunnels and tie over the top of patella can be protected with a cerclage wire or nonabsorbable tape (OBQ09.124) He is taken for intramedullary nail (IMN) fixation. In humans, the patella is the largest sesamoid bone (i.e., embedded within a tendon or a muscle) in the body. Quadriceps weakness. WebProximal Tib-Fib Dislocation Knee Overuse injuries patellar tendon insertion at the inferior pole of the patella. He is evaluated and the decision is made to proceed with arthroscopic saucerization. An attenuated patella alta is an unusually small patella that develops out of and above the joint. chondromalacia patellae. The patient opts to proceed with surgery. Based on the radiographic findings, what was the most likely indication for revision surgery? The primary functional role of the patella is knee extension. She completed 6 weeks of physical therapy following her first dislocation. Radiographs reveal no failure of the hardware and an acetabular component that has an abduction angle of 40 degrees and a version of 10 degrees retroverted. intraoperative fracture rate thought to be higher. failure of the fixation between the liner and the acetabular shell. Compartment syndrome. Flexion and extension lateral lumbar radiographs can identify the degree of instability. 3 or more 5mm sagittal images with meniscal continuity). (OBQ06.275) Examination reveals an external foot-progression angle of 25 degrees, a thigh-foot axis of +30 degrees, and a positive apprehension test for lateral patellar subluxation on the right side. [8] A patella is also present in the living monotremes, the platypus and the echidna. This can be the cause of chronic pain when formed on the patella. Webknee dislocation. Note: The table below is a simplification as muscles are often innervated by multiple nerve root, ankle dorsiflexion usually has a contribution from both L4 and L5, Anterior thigh, medial thigh and medial knee, Lateral thigh, anterior knee, and medial leg, Hamstrings (tibial) & gluteus max (inf. Proximal third tibia fractures are relatively common fractures of the proximal tibial shaft that are associated with high rates of soft tissue compromise and malunion (valgus and procurvatum). An 8-year-old boy was playing at school and took a direct blow to his knee causing pain and swelling. Peroneal nerve palsy. Which statement is true regarding discoid menisci? [9] In 2017 it was discovered that frogs have kneecaps, contrary to what was thought. (OBQ18.156) L5. Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. Web(SBQ16SM.92) A 13-year-old girl presents with lateral knee pain after a twisting injury during basketball. may show spur at inferior pole of patella. Starting point in Figure B with blocking screw in Figure D, Starting point in Figure B with blocking screw in Figure E, Starting point in Figure C with blocking screw in Figure D, Starting point in Figure C with blocking screw in Figure E, Starting point in Figure C with blocking screw in Figure F. 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