2017

Question 1

DVT prophylaxis in total ankle arthroplasty

A. Everyone should get it
B. Only if patient has risk factors
C. If patient is casted give it

Answer 1

B

Barg et al. Risk factors for symptomatic DVT after TAA JBJS 2011

• Routine prophylaxis is not indicated.
  4% incidence.
• Low Incidence of Symptomatic
• Thromboembolic Events After Total Ankle Arthroplasty Without Routine Use of Chemoprophylaxis
  -Our results suggest that clinically detectable VTE after TAA is uncommon. Patients without identifiable risk factors do not appear to require chemoprophylaxis following TAA. We recommend continuation of antiplatelet or anticoagulation therapy in patients who are taking these medications preoperatively and the initiation of chemoprophylaxis postoperatively in patients with known risk factors for VTE.

Question 2

DVT prophylaxis in below knee trauma?

A. All patients should have it until fully weight bearing
B. All patients should have it until starting ROM
C. No role

Answer 2

C

Thrombosis Canada Guidelines 2018
- DVT prophylaxis is not required for below knee trauma.

Adrichem NEJM 2017
- Prophylaxis did not decrease VTE following arthroscopy of knee and casting of lower leg

Prevention of VTE after Isolated Lower Leg Fractures. JOT 2015 (*Canadian Study)
- Overall incidence of clinically important VTE low no observed differences between dalteparin and placebo group.

Question 3

Femoral acetabular impingement surgery scope vs open?

A. Pain after 2 weeks is similar
B. Scope associated with higher infection rate
C. Scope is better for patient reported health outcome and QoL scores
D. Scope is unable to address the pathology

Answer 3

C

AJSM 2016
- Both hip arthroscopy and open surgical hip dislocation demonstrate excellent and comparable hip survival rates at medium-term follow-up.
- Clinical outcome measures similarly demonstrate equivalence, although hip arthroscopy results in a significantly improved general HRQoL.
- Continued research is needed to demonstrate the long-term benefits of surgical treatment of FAI and to improve our understanding of the natural history of the disease.

Neppel et al. Overview of Treatment Options, Clinical Results, and Controversies in the Management of Femoroacetabular Impingement. JAAOS 2013
- Infection rates are not listed.
- The study noted similar alpha angle corrections in the anterior and anterosuperior quadrants with both techniques but significantly greater correction in the superior quadrant with open techniques, as seen on AP pelvis radiographs.

https://doi.org/10.1016/j.arthro.2010.11.008. Arthroscopy 2011. Open Surgical Dislocation versus Arthroscopy for Femoroacetabular Impingement: A comparison of Clinical Outcomes
- 1.7% complications in arthroscopic, 9.2% open surgical dislocation
- Faster recovery with arthroscopic

Question 4

Proximal humerus GT fracture, what is an indication for surgery?

A. 45° angulation
B. 3 mm sup migration
C. 5 mm posterior migration
D. 30° anterior angulation

Answer 4

C

JAAOS 2017
- 5 mm of displacement may benefit from surgical fixation to reduce the risk of subacromial impingement.
- Posterior displacement leads to worse outcomes than superior displacement.

Question 5

Volar PIP dislocation causes of it being irreducible?

A. Collateral band
B. Lateral band
C. Volar plate
D. Oblique retinacular ligament

Answer 5

B

Treating PIP Joint Dislocations. Hand Clinics 2018

• In volar rotatory PIP dislocations, the proximal phalanx button-holes between lateral band and central slip. The lateral band gets stuck in the joint blocking reduction.
• In rotatory volar dislocation, reduce by applying traction to finger with MCP and PIP joints in 90° of flexion relaxes volarly displaced lateral band, allowing it to slip back dorsally.
• If failed closed reduction, in closed dorsal dislocations, reduction is usually prevented by volar plate interposition.
• In open dorsal dislocations, reduction is usually prevented by dislocated FDP tendon.
• In lateral dislocations, reduction is usually prevented by lateral band interposition.

Question 6

Best test to assess going ahead with DCO in a trauma patient?

A. Blood pressure
B. Heart rate
C. Urine output
D. Base deficit

Answer 6

D

Indicators of adequate resuscitation are:
- Urine output 0.5-1.0 ml/kg/hr (30 cc/hr)
- Serum lactate levels
»Most sensitive indicator to assess if circulatory beds remain inadequately perfused (normal < 2.5 mmol/L
- Gastric mucosal pH
- Base deficit normal -2 to +2

The review article by Elliott (J Am Coll Surg) argues that serum lactate levels are the most reliable indicator of peripheral organ perfusion and tissue oxygenation. A base deficit between -2 and +2 is also an appropriate end point however may be non-specific in older patients with medical comorbidities leading to acid/base disturbances.

Question 7

When comparing the outcomes of ankle arthrodesis and ankle arthroplasty with those of a control group, all of the following are true except?

A. Ankle arthroplasty group has same plantar flexion strength as the control group
B. Both Ankle arthroplasty and ankle arthrodesis demonstrate a weaker gait than the control group
C. Arthrodesis and ankle arthroplasty patients report similar patient reported outcomes
D. Ankle arthroplasty gives a range of motion that is similar to that of the control group

Answer 7

A

Singer et al. Ankle arthroplasty and ankle arthrodesis: gait analysis compared with normal controls. JBJS Am 2013 (Canadian study)

• Power is decreased in both replacement and fusion compared to controls.
• Gait patterns are not completely normalized compared to controls.
• Improvements in patient-reported AOS and SF-36 scores were similar for both treatment groups.
• With respect to ROM, arthroplasty had equivalent dorsiflexion compared to controls, while arthrodesis was significantly lower.
• There were significant differences between all groups in plantarflexion: control > arthroplasty > arthrodesis.

Question 8

What is an advantage of ceramic bearings?

A. Unusually low wear
B. More resistant to 3rd body particles
C. Smells good
D. Pretty color

Answer 8

A

Lachiewicz et al. Bearing Surfaces in Total Hip Arthroplasty third body wear- particles in joint space cause abrasion and wear. JAAOS 2018

• Article states that in general harder bearing have lower wear. They are also hydrophilic and more easily establish a fluid-film which further decreases contact between the bearing surfaces.
• Highly cross linked poly has much lower wear rates than standard poly - approximately 8x less.
• Ceramic on cross linked poly has even lower wear rates than metal on cross linked poly.
• Ceramic on ceramic has virtually no wear at all, not even measurable in most of the 10 year follow-up studies.

Question 9

Pediatric patient has a flexible flat foot, which is true?

A. Commonly need calcaneal osteotomy
B. Insole improve symptoms
C. Soft tissue procedure is adequate
D. 1/3 tendo-achilles contracture

Answer 9

D

Bouchard and Mosca. JAAOS 2014

• Most children with flatfeet are asymptomatic and will never require treatment.
• In general, flatfoot deformity is flexible and will not cause pain or disability; it is a normal variant of foot shape.
• Indications for flatfoot surgery are strict: failure of prolonged nonsurgical attempts to relieve pain that interferes with normal activities and occurs under the medial midfoot and/or in the sinus tarsi.
• In nearly all cases, an associated contracture of the heel cord is present.
• Osteotomies with supplemental soft-tissue procedures are the best proven approach for management of rigid flatfoot.
• Most children with flatfeet will never require treatment. Surgery is rarely indicated.

Question 10

DDH what indicates early surgery with PAO?

A. CEA <5°, with BMI >30
B. CEA <25°, with BMI >30
C. CEA <5°, active patient
D. CEA <25°, active patient

Answer 10

C

Matheney et al. Activity Level and Severity of Dysplasia Predict Age at Bernese Periacetabular Osteotomy for Symptomatic Hip Dysplasia. JBJS 2016

• A high activity level and severe dysplasia lead to the development of symptoms and presentation for PAO at significantly younger ages.
• The combination of these 2 factors has an even greater effect on decreasing the age at presentation for hip-preserving surgery.
• An increased BMI was not independently associated with a younger age at surgery.

Question 11

Biceps procedure 1 vs 2 incision question, what is true?

A. Complications rate of the 2 incision technique has <10% complication
B. Radial nerve is the most common injury
C. Bone tunnel has more complications than suture anchors
D. Both techniques (1 & 2 incision) have same complication rate

Answer 11

D

JAAOS 2018

• LABCN is most commonly injured nerve
• LABCN is the terminal sensory branch of the musculocutaneous n.
• Bone tunnel and cortical button have lower complication rate than suture anchor and interference screw.
• No difference in complication rate between single and double incision: 24% single and 26% double (p=0.3).
  Comparison:
• Single incision higher risk LABCN injury
• Double incision higher risk of synostosis and HO
  Separate point: Double incision gives more flexion strength (HULC paper 2012), single incision more supination strength (2019 UBC paper stockton et al)

Question 12

60F with an olecranon fracture with failure of tension band, what is the most likely cause of failure?

A. Patient stopped smoking 4 years ago
B. Splint removed too early
C. Pins not inserted adequately into triceps aponeurosis
D. Early ROM

Answer 12

C

Tension band wiring in olecranon fractures: the myth of technical simplicity and osteosynthetical perfection. SICOT 2012

10 common technical error in tension banding:
- Nonparallel K-wires
- Long K-wires
- K-wires extending radially outwards
- Insufficient fixation of the proximal ends of the K-wires
- Intramedullary K-wires
- Perforation of the joint surface
- Single wire knot
- Jutting wire knot(s)
- Loose figure-of-eight configuration
- Incorrect repositioning.

Question 13

All of the following are treatment for Swan Neck deformity except?

a. FDS partial tenodesis
b. DIP fusion
c. Oblique retinaculum repair
d. Intrinsic cross transfer

Answer 13

D

DY: Intrinsic cross transfer is for MCP ulnar deviation/dislocation without arthritis to rebalance forces

Question 14

What is the treatment plan of adamantinoma?

a. Wide resection
b. Wide resection + Chemo
c. Wide resection + Radiation
d. Wide resection + Chemo + Radiation

Answer 14

A

JAAOS 2010 - Osteofibrous Dysplasia and Adamantinoma

Adamantinoma:
- Low grade malignant tumor, low recurrence but can get mets to lungs (25%).
- Treatment involves wide resection only in most cases.
- As adamantinoma is a low-grade malignancy, radiotherapy and/or chemotherapy is not typically used for local control of disease.
31% local recurrence rate at average of 4.7 years
- Risk factors for recurrence:
> Shorter duration of symptoms (<1 year)
> Initial treatment with intra-lesional curettage or marginal resection
> Age < 20 years
> 87.2% survival at 10 years

Question 15

What is a contraindication to give oxygen in a trauma patient?

a. COPD with a high PaCO2
b. COPD with low PaCO2
c. Patient with high oxygen
d. There is no contraindication

Answer 15

D

DY: Asked anesthesia friend “A is basically a myth, the teaching was that high oxygen would decrease their drive to breath etc etc. But in reality, there are other things in play like the haldane effect etc. D is the best answer, especially in the context of trauma”

For most patients with known chronic obstructive pulmonary disease (COPD) or other known risk factors for hypercapnic respiratory failure (eg, morbid obesity, chest wall deformities or neuromuscular disorders), a target saturation range of 88–92% is suggested pending the availability of blood gas results

Question 16

Decompression in lumbar stenosis - all are true except?

A. Surgery isn’t beneficial in those with only motor findings
B. Get imaging to determine location
C. Bilateral laminectomy is an absolute indication to fuse
D. One other true thing.

Answer 16

C

Question 17

Os trigonum syndrome associated with all except?

A. Rarely FHL tenosynovitis
B. Stieda process fracture
C. Painful plantar flexion
D. Sx should be considered if 3-6 months non op rx completed in an athlete

Answer 17

A

Nault, Marie-Lyne MD, PhD; Kocher, Mininder S. MD, MPH; Micheli, Lyle J. MD. Os Trigonum Syndrome. Journal of the American Academy of Orthopaedic Surgeons 22(9):p 545-553, September 2014. | DOI: 10.5435/JAAOS-22-09-545

• Os trigonum syndrome often coexists with FHL tenosynovitis in the same patient population.11Repetitive plantar flexion leads to constant pressure exerted on the os trigonum by the FHL tendon, leading to tenosynovitis.
• Failure of a 3- to 6-month course of nonsurgical treatment is an indication for surgery, particularly in athletes or dancers who wish to continue training.
• Surgical excision of the os trigonum can be performed using an endoscopic, arthroscopic, or open technique.

Question 18

Which is not a treatment option for a cerebral palsy patient with a 45° flexion contracture of elbow?

A. Biceps lengthening
B. Brachialis lengthening
C. Flexor-pronator slide
D. Selective neurectomy

Answer 18

D

Flexor pronator slide is a procedure for the wrist. However, based on one sentence, it can be considered in an elbow contraction. Neurectomy can only be done in an elbow that has full passive ROM. So in this case, with a 45 degree contracture, that is the most wrong answer.

Lomita et al. JAAOS 2010

Treatment for elbow flexion contacture
involves:
- Curvilinear release of skin
- Biceps Z-lenthening
- Intramuscular lengthening of brachialis and brachioradialis release off origin.
- In a few select patients, musculocutaneous neurectomy of the biceps and brachialis muscles may be an option. Such treatment must be done only in patients with spastic deformity who have full passive ROM of the elbow. This surgery will not correct deformity caused by joint contracture. However, in the appropriate patient, this procedure can significantly alter the resting position of the extremity.

Question 19

All of the following are risk factors for re-dislocation after arthroscopic Bankart repair, except? [REPEAT]:

a. Age < 40 years
b. Hyperlaxity
c. Hill Sachs on AP radiograph
d. Contact Sports

Answer 19

A

Question 20

All of the following complications regarding unicameral bone cysts of the proximal humerus or femur are true, except?

A. Limb Length Discrepancy
B. Varus Angulation
C. Physeal Arrest
D. Malignant Transformation

Answer 20

D

No malignant potential

Question 21

What is true regarding unicameral (simple) bone cysts?

A. Cross sectional area of the lesion corresponds to fracture risk
B. 15-20% of UBC will resolve after fracture
C. Healing is the same or better for bone marrow injection versus steroids
D. There is a higher chance of malignant degeneration in an adult presenting with a UBC

Answer 21

A

Pireau N, De Gheldere A, Mainard-Simard L, Lascombes P, Docquier PL: Fracture risk in unicameral bone cyst: Is magnetic resonance imaging a better predictor than plain radiography? Acta Orthop Belg 2011;77(2):230–238

• The bone cyst index was found to be the best predictor for the risk of fracture.
• Bone cyst index (BCi) described by Kaelinand MacEwen (6) is often used as an easy method to assess the mechanical resistance of the cyst wall.The BCi is obtained by dividing the cyst area by the diameter of the diaphysis squared.

Question 22

50 year old female with 3 part proximal humerus. All are accepted methods of fixation except.

A. Percutaneous pinning with C-arm imaging
B. Open reduction with pins and tension bands
C. ORIF with a plate
D. Hemi

Answer 22

B

Kancherla et al. Management of Acute Proximal Humerus Fractures. JAAOS 2017

• This article does not describe the use of tension bands in the proximal humerus.
• The other three options are viable for management of a 3-part proximal humerus fracture.
• Older outcome studies of CRPP suggest that patients in general are satisfactory.
• The complication rate is higher than with ORIF, hemi, and reverse.

Question 23

Enchondroma in the hand. All are true except?

a. After curettage it is controversial whether or not to put bone graft in
b. Transformation to chondrosarcoma is rare
c. Pathologists accept more atypia in a hand enchondroma then elsewhere in the body
d. Recurrence after curettage is >10%

Answer 23

D

Lubahn et al. Enchondroma of the Hand: Evaluation and Management. JAAOS 2016

• High-grade chondrosarcoma of the hand is very rare and also has a low risk of metastasis.
• Enchondroma of the hand is unique because it may exhibit hypercellularity and cytologic atypia, which are generally consistent with chondrosarcoma in the long bones.
• Although surgical curettage of enchondromas typically results in favorable outcomes and low complication rates, controversy exists regarding immediate versus delayed treatment of pathologic fractures, the role of surgical adjuncts after curettage, and the role and effect of void fillers.
• There is no consensus on use of bone graft after curretage.
• Local recurrence rate after curettage in the hand is ~5%.

Question 24

C5/6 quad, maxilla and mandible fracture, closed reduced with 15 lbs traction, starts developing vertigo, diplopia, nystagmus, tinnitus, difficulty swallowing, something to do with palate elevation being asymmetric. What is the cause? [REPEAT]

1. Vertebrobasilar insufficiency syndrome
2. Subdural hematoma
3. Unrecognized ocular trauma
4. Ascending c-spine syndrome
5. Patient is coning

Answer 24

A

Findings associated with vertebral artery injury/kinking (Vertebrobasilar insufficiency) are:

Altered LOC
Syncope
Dysarthria
Ataxia
Dysphagia
Headache
Vertigo
Tinnitus
Visual field defects

Question 25

With regards to massive bone loss (>6cm) in open fractures, which is true? [Repeat]

A. Should be treated with amputation if bone loss greater than 10cm
B. Most common in femur
C. Most common in diaphyseal region of bone
D. Must be stabilized with a plate to maintain alignment and length

Answer 25

C

OTA international 2020: 10.1097/OI9.0000000000000059

68% in tibia
22% in femur
metaphyseal fragments are much less commonly loose or free given ST attachments and rich periosteum

Question 26

25M comes in 5 months post injury to right wrist after FOOSH. Given XR with proximal pole of scaphoid fracture - not united, no signs of SNAC or degeneration. Best treatment?

A. Immobilize in cast
B. PT/rehab
C. Volar approach with bone graft
D. Dorsal approach with ORIF

Answer 26

D

JAAOS 2003 Trumble Management of Scaphoid Nonunions

• Surgical management of established scaphoid nonunions is necessary given the strong likelihood of eventual development of radiocarpal arthrosis with a persistent nonunion

JAAOS 2007 Waitayawinyu, Scaphoid Non-union surgical techniques

• Nonunion of the proximal pole of the scaphoid, with or without osteonecrosis, should be addressed via a dorsal approach.

Question 27

What is true regarding arthrofibrosis following a TKA?

A) Anterior interval scarring can be a block to extension
B) Manipulation under anesthesia is necessary after 16 weeks if has not regained ROM
C) Hoffa test can be used to assess suprapatellar scarring
D) Flexion contracture of 20° is well tolerated

Answer 27

A

Arthrofibrosis of the knee. JAAOS 2007

• Extension loss is poorly tolerated and can be more difficult to manage than loss of flexion. As little as 5° of extension loss can produce a noticeable limp during ambulation, strain the quadriceps muscle, and contribute to patellofemoral pain.
• Hoffa’s syndrome is an uncommon complication following knee surgery or injury which results in knee stiffness.
• Hoffa test is done by placing the thumb at the inferior lateral aspect of patella and pushing on the fat pad while the knee is brought from flexion to extension. Pain is a positive result. It tests intra-patellar fibrosis. The development of patella baja on lateral radiographs is a common sequela and also a poor prognostic sign.
• Hoffa Test = for INFRApatellar scarring
• The resulting stiffness limits both active and passive ROM and usually results in loss of flexion, extension, and patellar mobility.

Question 28

Given a picture and x-rays of an infant born with posteromedial bowing. Treatment?

A. Serial casting followed with bracing
B. Osteotomy of tibia at age 4
C. Surgical correction of foot
D. Long term follow up as child may develop LLD

Answer 28

D

Question 29

A 24 year old punches another person in the mouth region and has an open injury at the knuckle. What antibiotic should you prescribe for prophylaxis? [REPEAT]

A. Amoxicillin and Clavulonate
B. Cephalexin and Clavulonate
C. Amoxicillin
D. Cephalexin

Answer 29

A

JAAOS 2015 Human and other mammalian bite injuries of the hand

• The unique bacteria in a human bite is Eikenalla corrodens.
• Other bacteria in human bites are Strep viridans, Staph aureus, and gram negatives.
• Dog and cat bites tend to grow Pasteurella, which requires 1 week to grow in cultures. You might have to notify lab regarding this requirement.
• Up to 80% of cat bites grow Pateurella.
• Amoxicillin and Clavulonate is also effective against Pasteurella.

Question 30

What is the important obstacle in treating obese orthopedic patients? [REPEAT]:

a) Implant durability with total hip and knee replacements is not sufficient for this patient population.
b) Anesthetic concerns for this population
c) Surgeons attitude towards these patients
d) Post-operative medical concerns in these patients

Answer 30

C

JAAOS 2014 - Obesity and Orthopedics

“The biggest obstacle to optimal orthopaedic care of obese patients is not the patient’s body habitus but the attitude of the physician.”

Question 31

Hand and wrist tendonopathies, which one is correct?

A. DeQuervain’s tenosynovitis is caused by repeated radial and ulnar deviation of the wrist.
B. With surgical treatment of trigger finger there is a 20% chance of recurrence
C. Following a distal radius fracture when extensor pollicis longus ruptures it is almost exclusively due to a displaced bone fragment.
D. The pathology for trigger finger is found at the A2 pulley.

Answer 31

A

JAAOS 2015 - Tendinopathies of the Hand and Wrist

• Dequervain’s tenosynovitis is associated with repetitive radioulnar deviation such as hammering, cross-country skiing, or lifting a child/pet

Wheeless

• EPL is tendon that is most frequently ruptured from distal radius frx;
• Ruptures occur most often just distal to the extensor retinaculum (at Lister’s tubercle)
• Rupture is far more common in assoc w/ undisplaced fracture than in associated w/ displaced fractures, and it has been reported in patients who had wrist injury w/o a fracture;
• Rupture of this tendon after minimally displaced frx suggests ischemic etiology rather than attritional rupture over an osseous spike

Question 32

Regarding the distal humerus, relative to the shaft.

a) 10 degree anterior, 6 degree valgus, 5 degrees IR
b) 10 degree anterior, 6 degrees varus, 5 degree ER.
c) 30 degrees anterior, 6 degree valgus, 5 degrees IR
d) 30 degrees anterior, 6 degrees varus, 5 degree ER.

Answer 32

C

Question 33

Which of the following is not an indication for fixation in an acute scaphoid fracture? [REPEAT]

A. Intrascaphoid angle of >35°
B. Scapholunate angle of 45°
C. Displacement of >1.5 mm
D. Proximal pole fracture

Answer 33

B

Indications for surgical intervention of scaphoid fractures
Unstable fractures as shown by:

• Proximal pole fractures
• Displacement > 1 mm
• 15° scaphoid humpback deformity
• Radiolunate angle > 15° (DISI)
• Intrascaphoid angle of > 35°
• Scaphoid fractures associated with perilunate dislocation
• Comminuted fractures
• Unstable vertical or oblique fractures

Normal scapholunate angle is 47degrees (range 30-60)

Question 34

This type of acetabular fracture is most likely to have secondary congruence?

A. T-type
B. Associated both column
C. Transverse
D. Anterior wall, posterior hemitransverse

Answer 34

B

“Secondary Congruence” can be present in ABC Acetabular fractures

• In ABC fracture patterns, entire acetabular surface is separated from ilium and columns rotate away from each other→ head is medialized.
• If columns maintain congruent relationship with femoral head (i.e. sitting congruently under the roof) then this is called “Secondary Congruence”.

Question 35

Gunshot to the right side of the neck, presenting with brown-sequard, what do you find? [REPEAT]

A. Ipsilateral motor, contralateral pain, sensation, vibration, proprioception
B. Contralateral motor, ipsilateral pain and temperature
C. Ipsilateral motor, contralateral pain and temperature
D. Contralateral motor, sensation & pain, Ipsilateral vibration and proprioception

Answer 35

C

Question 36

75 male, presents with bowel and bladder symptoms with anterior soft tissue mass, no matrix, the lesion is mid-sacral lesion?

A. Chondrosarc
B. Osteosarc
C. GCT
D. Chordoma

Answer 36

D

Chordoma of the Sacrum and Vertebral Body. JAAOS 2008

• Chordoma are central in upper sacrum. GCT are eccentric and lower sacral.
• 50% occur in the sacrum and coccyx
• CT will show midline bone destruction and soft tissue mass

Question 37

Talar neck fracture that you have done a dual incision approach for, but remains unreducible. Your next step:

A. Medial malleolar osteotomy
B. Lateral malleolar osteotomy
C. Inline traction
D. Femoral distractor

Answer 37

D

AO Surgical Reference describes: first elevators and joysticks, second ex fix and distractors, and third medial malleolar osteotomy

Question 38

Chronic osteomyelitis with malignant transformation what is treatment?

A. Wide resection
B. Wide resection and radiation
C. Wide resection and chemo
D. Requires amputation

Answer 38

D

JAAOS 2014

• Increasing smell, pain, and increased drainage are the most common presenting complaints of Marjolin’s ulcers.
• Is most commonly squamous cell carcinoma, but can be other cancers.
• Lesions are aggressive and carry a poor prognosis with a high rate of recurrence.
• Usually have regional mets, high grade, and high mortality.
• Any suspicious nonhealing or ulcerative lesion that appears in a chronic scar should be biopsied to confirm the diagnosis.
• Definitive treatment of choice has been amputation.
• The definitive treatment of choice as suggested by most clinicians has been amputation proximal to the tumor
• Recently, wide complete local excision has also been proposed in selected patients and before any distant metastasis is evident.
• They therefore recommended a wide local excision for grade I lesions (low-grade tumour) and amputation for grade II and III lesions (high-grade tumour).
• Mets are mainly to lymph nodes

Question 39

The MOST important factor in planning for surgery on a polyostotic fibrous dysplasia lesion is [REPEAT]:

A. Bone graft using allograft
B. Bone graft using autograft
C. Bone graft using fibular strut grafts
D. Maintain normal bone mechanics with implant support

Answer 39

D

Leet AI, et al. Bone Grafting in Polyostotic Fibrous Dysplasia. JBJS 2016

• Bone-grafting, including both allograft and autograft, is of limited value in ablating the lesions of fibrous dysplasia.
• If graft is used it should be allograft (cortical better than cancellous)
• The expectations of patients and surgeons should include the high probability of graft resorption over time with return of bone characteristics of fibrous dysplasia, particularly in younger patients.
• This suggests the maintenance of normal bone mechanics with implant support should be the priority of any surgical intervention.
• Our current recommended practice (albeit without peer-reviewed evidence of its effectiveness) is to utilize intramedullary nailing in the surgical procedure for severe fibrous dysplasia involvement of weight-bearing long bones.

Question 40

X-Ray of lateral distal humerus with double bubble sign. Which of the following is true [REPEAT]:

A. The capitellum is intact and the trochlea is fractured
B. The capitellum is fractured and the trochlea is intact
C. An olecranon osteotomy is required
D. A direct anterior approach is contraindicated

Answer 40

D

• They describe an anterolateral approach on the JAAOS, NOT a direct anterior approach

McKee MD (JBJS 1996) Coronal Shear Fractures of the Distal End of the Humerus

• Fracture line was observed to extend in the coronal plane across the capitellum to include most of the lateral trochlear ridge and the lateral half of the trochlea.
• A pathognomic radiographic feature of these injuries is the so-called double-arc sign, best seen on the lateral radiograph of the elbow for the patients in this series.