UKITE 2020 Flashcards
An 11 year old boy presents to fracture clinic having sustained a fall the day before and knee pain.
X-ray shows a lytic lesion proximal third tibial shaft. Narrow zone transition, expansive,, cortical thinning)
Which of the following statements describes this condition?
A. A benign condition of childhood which is treated with curettage
B. A benign condition of childhood which almost always spontaneously disappears in adulthood
C. A locally aggressive condition which requires curettage and adjuvant treatment to halt local progression and recurrence
D. A malignant primary bone tumour, commoner in childhood, chemotherapy is mainstay of treatment
E. A malignant primary bone tumour, seen in all age groups, wide excision and attempted limb salvage is the main treatment
B
Simple bone cyst: A non-neoplastic, serous fluid-filled bone lesion thought to result from temporary failure of medullary bone formation near the physis - Usually found in patients <20 years of age in the proximal humerus but can be found in other locations including proximal femur, distal tibia, ilium, calcaneus, and occasionally metacarpals, phalanges, or distal radius.
Arises in the metaphysis adjacent to physis and progresses toward the diaphysis with bone growth.
As a patient approaches skeletal maturity, often decrease in size and may heal after growth is complete. Fracture healing usually does not lead to cyst resolution
requires close follow up while in active phase due to recurrence and risk of fracture or growth arrest.
Radiographs: central, lytic, well-demarcated metaphyseal lesion (2-3% cross physis), cystic expansion with symmetric thinning of cortices, “fallen leaf” sign (pathologic fracture with fallen cortical fragment in base of empty cyst is pathognomonic). May have trabeculated appearance after multiple fractures.
Histology: cyst with thin fibrous lining containing fibrous tissue, giant cells, and hemosiderin pigment
A patient with a history of metastatic renal cancer presents to an elective clinic with left hip pain. His xray shows a left THR with multiple acetabular metastatic deposits and superior and medial migration of the acetabular component.
Choose the incorrect statement:
A: Pelvic disease should be addressed during surgery to revise THR
B: Pre-op workup should include serum albumin, corrected calcium and haemoglobin
C: He should undergo embolisation to reduce intraop blood loss
D: An associated soft tissue mass would not change your surgical management
E: There should be a discussion with the patients oncologist prior to surgery
D
MBD BOOS guidelines:
PRESENTATION TO THE ORTHOPAEDIC SURGEON.
4.1 This is typically in one of three modes:
a. Acute admission with pathological fracture or neurological compromise
b. Referral from oncologist/surgical oncology team (surgeon, radiologist or oncologist).
c. Referral to an orthopaedic clinic with unexplained musculoskeletal pain The presentation with MBD may be the first manifestation of malignancy.
4.2 Pain is the most frequent clinical symptom, ranging from a dull ache to a deep intense pain that is exacerbated by weight bearing, and is sometimes worse at night. The aetiology of this pain is not fully understood, but probably involves the release of chemical mediators of pain including substance p, prostaglandins, growth factors, bradykinin and histamine. Fracture occurring after a period of antecedent pain and a relatively low energy injury should raise the suspicion of pathological fracture.
5.1 The role of the orthopaedic surgeon in the management of MBD falls into four principal categories:
a. Establish the diagnosis of MBD
Biopsy is considered further in section 6.
b. Surgical treatment of metastatic deposits for pain and to prevent fracture
c. Stabilisation or reconstruction following pathological fracture.
d. Decompression of spinal cord and nerve roots and/or stabilisation for spinal
instability.
6.1 Biopsy of a suspicious lesion of bone should always be performed if there is doubt about the underlying pathology, and in particular where there is a solitary lesion in bone. Biopsies are not usually necessary if there is previously diagnosed disseminated malignancy in bone.
Any patient with a suspicious solitary bone lesion should be investigated with a full clinical history and examination, followed by investigation with routine blood tests (FBC, U&E, LFT, Bone Profile, ESR / PV, CRP and tumour markers) and radiological investigations including CT chest, abdomen and pelvis, MRI scan of the lesion and isotope bone scanning. If a staging CT shows bone metastases then isotope bone scanning to assess the peripheral skeleton may be appropriate [Krammer 2013]. In some cases bone scan may be indicated even if a CT does not demonstrate skeletal metastases. Following this work-up, biopsy (usually percutaneous) should be carried out and then discussed at an MDT before definitive surgery is performed.
6.3 Bone biopsies should be performed with image guidance (fluoroscopy or CT) and with percutaneous instruments. If biopsy is carried out by a radiologist (eg CT guided), there should be prior discussion with the surgical team, so that the creation of inappropriate biopsy tracts can be avoided. Soft tissue lesions or soft tissue extension of a bony lesion may be suitable for Tru-cut biopsy under local anaesthetic in the out- patient clinic.
7. AIMS OF SURGERY.
7.1 Patients with MBD have simple priorities - to remain ambulant, pain free, independent and out of hospital [Harvie 2013].
The general orthopaedic principles underlying the management of impending or actual pathological fractures through metastases are as follows:
a. A primary bone tumour should be excluded.
b. The procedure should provide immediate absolute stability, allowing weight
bearing.
c. The surgeon must assume that the fracture will not unite.
d. The fixation should last the lifetime of the patient (therefore choice of implant
and an awareness of life expectancy are essential).
e. All lesions in the affected bone should be stabilised if reasonable to do so.
Treatments should, where possible, be appropriate for the stage of disease and general condition of the patient, and should reflect the patient’s preferences for treatment.
8. NON-SURGICAL THERAPY.
8.1 Radiotherapy may be effective both on its own and in the adjuvant setting in the treatment of MBD [Hartsell 2005]. External beam radiotherapy (EBRT) effectively relieves pain from localised sites of skeletal metastases [Chow 2013] It is usually given as a single fraction for pain relief although multiple fractions may be used for a solitary metastasis or following surgical fixation. Radiotherapy can produce effective bone healing and sclerosis and can prevent pathological fracture, especially in more radiosensitive cancers (myeloma, lymphoma, small cell lung, prostate and breast cancer).
Radiotherapy will not cure pain of a ‘mechanical’ nature, and only 30-40% of pathological fractures will unite even after radiotherapy [Gainor 1983].
It is recommended that following surgical procedures in patients with MBD, radiotherapy to the affected bone and operative field (unless field sizes are excessive) should be considered by a clinical oncologist within the context of the site-specific multidisciplinary team [Townsend 1994,1995; Chow 2012]. Where the medullary canal has been broached or an intramedullary nail inserted into a long bone, the whole bone should be irradiated.
In the treatment of metastatic spinal cord compression, radiotherapy should be given after decompression and stabilisation. In patients not fit for surgery, or with extensive disease precluding reliable mechanical stabilisation, or who have a prognosis of less than three months, radiotherapy alone is recommended and can improve pain, mobilisation and patient function.
8.2 Endocrine therapy, bisphosphonates, chemotherapy and newer cancer biological agents (such as denosumab) all have a role in the management of patients with MBD. The indications are beyond the scope of this document but should be addressed by the multi-disciplinary team.
8.3 Denosumab is a fully human monoclonal antibody that binds to RANK ligand, a protein found on osteoclasts and involved in bone breakdown. It has been shown to be more effective than zoledronic acid in preventing skeletal related events in patients with bone metastases from solid tumours (but not multiple myeloma) and recently approved by NICE for this indication [NICE Technology Appraisal Guidance 265]. This has been further supported by a systematic review in which denosumab was more effective than zoledronic acid in reducing the incidence of Skeletal Related Events (SRE), and delayed the time to SRE [Peddi 2013].
8.4 Percutaneous cryoablation is a safe and effective treatment to achieve local tumour control and short-term complete disease remission in patients with limited metastatic disease to the musculoskeletal system [Woodrun 2013, Nicholas Kurup 2013]. High-Intensity Focussed Ultrasound (HIFU) has also shown promising results for pain relief [Halani 2014].
9.5 In an effort to provide a more reliable and reproducible measure of the risk of pathological fracture, Mirels devised a scoring system (Table 1) which we
regard as a useful aid to management, both for the orthopaedic surgeon, and
for oncologists monitoring patients with MBD [Mirels 1989]. For scores of nine or above consideration should be given to prophylactic fixation prior to radiotherapy being administered. Functional pain is the most important single clinical sign (Healey 2000)
11.7 Pre-operative embolisation: Tumours at risk of haemorrhage (renal and thyroid) should be considered for pre-operative embolisation. This has been shown to significantly reduce blood loss, packed cell transfusion volume and operative time. Embolisation should ideally be performed less than 48 hours before surgery. [Chatziioanou 2000, Pazionis 2014]
12.4 Proximal Femur
One third of bone metastases occur in the proximal femur and as reflected in the Mirels scoring system risk of fracture is higher than in other locations
Prognosis, site of tumour within the bone and extent of bone loss determine the appropriate management plan.
• Femoral head. Where destruction is limited to the femoral head a cemented hemiarthroplasty or total joint replacement is recommended as a primary procedure. Long stem femoral implants should be considered when there are concomitant metastases further down the femur.
27
• Femoral neck. Lesions in the femoral neck are usually best managed with cemented hemiarthroplasty or total hip replacement.
• Pertrochanteric. In patients with a good prognosis or extensive bone loss at this site proximal femoral replacement should be considered. If prognosis is poor (eg <6 months) then cement augmented internal fixation may be appropriate if there is sufficient bone stock.
• Subtrochanteric. Patients with a good prognosis or with extensive subtrochanteric bone loss are often best managed with endoprosthetic replacement (Chandrasekar 2008). Metastatic deposits at this site are amongst the most frequent causes of implant failure. In patients with limited subtrochanteric bone loss with limited life expectancy may be best stabilised by cephallo-medullary nails with locking screws in the femoral neck or internally fixed with plate and screws (eg DHS) with cement augmentation.
• Periprosthetic metastases. Disease occurring beneath a hip prosthesis needs to be managed with careful consideration of the patients prognosis and risk of implant failure if the metastasis cannot be controlled locally. Management may consist of stabilization with a plate +/- cement augmentation or endoprosthetic replacement.
• There is no role for bone grafting in the management of appendicular pathological fractures. Reconstructions should provide immediate stability and should not rely on the ability of the grafted area to heal, particularly if there has been radiotherapy or there is a risk of local recurrence. Cement can be useful where there are bone defects.
Pelvic disease not involving the acetabulum is usually treated by radiotherapy alone
• Patients who have undergone radiotherapy to this area may occasionally suffer pain due to radiation necrosis of the femoral head or articular cartilage.
The Harrington Classification (Harrington 1981) is a four-grade system which is most widely employed to describe acetabular defects associated with metastatic disease. Type II - IV defects should be considered for referral to a specialist centre.
Type I defects are characterized by an acetabulum with intact anterior and posterior columns, superior dome and medial wall with only punctuate disease of the floor of the acetabulum.
These lesions uncommonly present for surgical intervention. Careful curettage of the metastatic tumour is required and occasionally ‘prophylactic’ medial wall mesh augmentation is required. Definitive reconstruction is with a standard cemented total hip replacement. Cement provides immediate stability and has the theoretical advantage of a thermonecrotic effect on tumour tissue.
Type II defects are characterized by a loss of medial wall with potential for true migration of the femoral head medially into the pelvic cavity.
After removal of tumour the principle of surgery is to reconstruct and thus protect the medial wall from further protrusion and if feasible restore the normal hip centre. This can be achieved with mesh or anti-protrusio cages depending on the defect severity. Anti-protrusio cages necessitate good exposure to ensure that during initial cementation that the ischial flange is intimately seated, and the superior iliac flanges exposed sufficiently well to facilitate screw insertion. A polyethylene liner is then cemented into the cage.
Type III defects are the most challenging because of defects that involves the medial wall, lateral margin and superior dome of the acetabulum. One or both columns are often involved.
These are the most difficult defects to address and represent a spectrum from intermediate to severe loss of native bone stock. Defects at the less severe end of the spectrum can be managed as previously detailed above.
Where medial defects are more extensive the Harrington technique provides an excellent solution which biomechanically facilitates the transfer of stresses across the defect from acetabulum to strong proximal bone [Tillman 2008]. As above the medial defect is meshed and threaded Steinmann pins passed from the iliac crest into the acetabulum bridging the defect. Wires placed anteriorly on the iliac crest can be directed posteriorly into the acetabulum and secured within the ischium. Similarly, pins with a more posterior entry point on the iliac crest can be directed anteriorly into the pubis creating a lattice deep to and above the level of the true acetabulum to provide support for an anti-protrusio cage which is implanted as documented above.
Simply filling such defects with cement will result in medialisation of the ‘cementoma’ due to lack of structural support. This then necessitates further complex revision surgery emphasizing the importance of adequate preoperative planning.
Type IV defects are rare and were originally classified as solitary lesions that were amenable to en-bloc resection.
The spine is the commonest site for MBD accounting for approximately 50% of bone metastases. Whilst not all spinal metastases are symptomatic, pain from the expanding tumour tissue and/or a pathological fracture, is frequently disabling. Paresis or paralysis may be the presenting feature. Untreated, high levels of dependency result, with high human and financial costs.
Indications for Surgery
• Spinal instability evidenced by pathological fracture, progressive deformity,
and/or neurological deficit
Clinically significant neurological compression.
• Tumour insensitive to radiotherapy, chemotherapy or hormonal manipulation
• Patients who have reached spinal cord tolerance after prior radiotherapy
• Intractable pain unresponsive to non-operative measures (eg. radiotherapy,
chemotherapy or hormonal manipulation.)
d. Metastasis completely encircling the cord
SINS SCORE
Spine Instability Neoplastic Score
Location
• 3 points: Junctional (C0-C2, C7-T2, T11-L1, L5-S1)
• 2 points: Mobile spine (C3-C6, L2-L4)
• 1 point: Semi-rigid (T3-T10)
• 0 points: Rigid (S2-S5)
Pain relief with recumbency and/or pain with movement/loading of the spine
• 3 points: Yes
• 1 point: No (occasional pain but not mechanical)
• 0 points: Pain free lesion
Bone lesion
• 2 points: Lytic
• 1 point: Mixed (lytic/blastic)
• 0 points: Blastic
Radiographic spinal alignment
• 4 points: Subluxation / translation present
• 2 points: De novo deformity (kyphosis / scoliosis)
• 0 points: Normal alignment
Vertebral body collapse
• 3 points: >50% collapse
• 2 points: <50% collapse
• 1 point: No collapse with >50% body involved
• 0 points: None of the above
Posterolateral involvement of the spinal elements (facet, pedicle or costovertebral joint fracture or replacement with tumor)
• 3 points: Bilateral
• 1 point: Unilateral
• 0 points: None of the above •
• Interpretation
• sum score 0-6: stable
• sum score 7-12: indeterminate (possibly impending) instability
• sum score 13-18: instability
SINS scores of 7 to 18 warrant spinal surgical consultation.
A 41 year old patient with a known renal cell cancer presents with a lytic lesion in the distal femur. Pre-op work-up would not include which of the following:
A; Biopsy
B: Embolisation
C: Up to date staging
D: Discussion with the regional orthopaedic oncology centre
E: Radiotherapy
E
MBD BOOS guidelines:
PRESENTATION TO THE ORTHOPAEDIC SURGEON.
4.1 This is typically in one of three modes:
a. Acute admission with pathological fracture or neurological compromise
b. Referral from oncologist/surgical oncology team (surgeon, radiologist or oncologist).
c. Referral to an orthopaedic clinic with unexplained musculoskeletal pain The presentation with MBD may be the first manifestation of malignancy.
4.2 Pain is the most frequent clinical symptom, ranging from a dull ache to a deep intense pain that is exacerbated by weight bearing, and is sometimes worse at night. The aetiology of this pain is not fully understood, but probably involves the release of chemical mediators of pain including substance p, prostaglandins, growth factors, bradykinin and histamine. Fracture occurring after a period of antecedent pain and a relatively low energy injury should raise the suspicion of pathological fracture.
5.1 The role of the orthopaedic surgeon in the management of MBD falls into four principal categories:
a. Establish the diagnosis of MBD
Biopsy is considered further in section 6.
b. Surgical treatment of metastatic deposits for pain and to prevent fracture
c. Stabilisation or reconstruction following pathological fracture.
d. Decompression of spinal cord and nerve roots and/or stabilisation for spinal
instability.
6.1 Biopsy of a suspicious lesion of bone should always be performed if there is doubt about the underlying pathology, and in particular where there is a solitary lesion in bone. Biopsies are not usually necessary if there is previously diagnosed disseminated malignancy in bone.
Any patient with a suspicious solitary bone lesion should be investigated with a full clinical history and examination, followed by investigation with routine blood tests (FBC, U&E, LFT, Bone Profile, ESR / PV, CRP and tumour markers) and radiological investigations including CT chest, abdomen and pelvis, MRI scan of the lesion and isotope bone scanning. If a staging CT shows bone metastases then isotope bone scanning to assess the peripheral skeleton may be appropriate [Krammer 2013]. In some cases bone scan may be indicated even if a CT does not demonstrate skeletal metastases. Following this work-up, biopsy (usually percutaneous) should be carried out and then discussed at an MDT before definitive surgery is performed.
6.3 Bone biopsies should be performed with image guidance (fluoroscopy or CT) and with percutaneous instruments. If biopsy is carried out by a radiologist (eg CT guided), there should be prior discussion with the surgical team, so that the creation of inappropriate biopsy tracts can be avoided. Soft tissue lesions or soft tissue extension of a bony lesion may be suitable for Tru-cut biopsy under local anaesthetic in the out- patient clinic.
7. AIMS OF SURGERY.
7.1 Patients with MBD have simple priorities - to remain ambulant, pain free, independent and out of hospital [Harvie 2013].
The general orthopaedic principles underlying the management of impending or actual pathological fractures through metastases are as follows:
a. A primary bone tumour should be excluded.
b. The procedure should provide immediate absolute stability, allowing weight
bearing.
c. The surgeon must assume that the fracture will not unite.
d. The fixation should last the lifetime of the patient (therefore choice of implant
and an awareness of life expectancy are essential).
e. All lesions in the affected bone should be stabilised if reasonable to do so.
Treatments should, where possible, be appropriate for the stage of disease and general condition of the patient, and should reflect the patient’s preferences for treatment.
8. NON-SURGICAL THERAPY.
8.1 Radiotherapy may be effective both on its own and in the adjuvant setting in the treatment of MBD [Hartsell 2005]. External beam radiotherapy (EBRT) effectively relieves pain from localised sites of skeletal metastases [Chow 2013] It is usually given as a single fraction for pain relief although multiple fractions may be used for a solitary metastasis or following surgical fixation. Radiotherapy can produce effective bone healing and sclerosis and can prevent pathological fracture, especially in more radiosensitive cancers (myeloma, lymphoma, small cell lung, prostate and breast cancer).
Radiotherapy will not cure pain of a ‘mechanical’ nature, and only 30-40% of pathological fractures will unite even after radiotherapy [Gainor 1983].
It is recommended that following surgical procedures in patients with MBD, radiotherapy to the affected bone and operative field (unless field sizes are excessive) should be considered by a clinical oncologist within the context of the site-specific multidisciplinary team [Townsend 1994,1995; Chow 2012]. Where the medullary canal has been broached or an intramedullary nail inserted into a long bone, the whole bone should be irradiated.
In the treatment of metastatic spinal cord compression, radiotherapy should be given after decompression and stabilisation. In patients not fit for surgery, or with extensive disease precluding reliable mechanical stabilisation, or who have a prognosis of less than three months, radiotherapy alone is recommended and can improve pain, mobilisation and patient function.
8.2 Endocrine therapy, bisphosphonates, chemotherapy and newer cancer biological agents (such as denosumab) all have a role in the management of patients with MBD. The indications are beyond the scope of this document but should be addressed by the multi-disciplinary team.
8.3 Denosumab is a fully human monoclonal antibody that binds to RANK ligand, a protein found on osteoclasts and involved in bone breakdown. It has been shown to be more effective than zoledronic acid in preventing skeletal related events in patients with bone metastases from solid tumours (but not multiple myeloma) and recently approved by NICE for this indication [NICE Technology Appraisal Guidance 265]. This has been further supported by a systematic review in which denosumab was more effective than zoledronic acid in reducing the incidence of Skeletal Related Events (SRE), and delayed the time to SRE [Peddi 2013].
8.4 Percutaneous cryoablation is a safe and effective treatment to achieve local tumour control and short-term complete disease remission in patients with limited metastatic disease to the musculoskeletal system [Woodrun 2013, Nicholas Kurup 2013]. High-Intensity Focussed Ultrasound (HIFU) has also shown promising results for pain relief [Halani 2014].
9.5 In an effort to provide a more reliable and reproducible measure of the risk of pathological fracture, Mirels devised a scoring system (Table 1) which we
regard as a useful aid to management, both for the orthopaedic surgeon, and
for oncologists monitoring patients with MBD [Mirels 1989]. For scores of nine or above consideration should be given to prophylactic fixation prior to radiotherapy being administered. Functional pain is the most important single clinical sign (Healey 2000)
11.7 Pre-operative embolisation: Tumours at risk of haemorrhage (renal and thyroid) should be considered for pre-operative embolisation. This has been shown to significantly reduce blood loss, packed cell transfusion volume and operative time. Embolisation should ideally be performed less than 48 hours before surgery. [Chatziioanou 2000, Pazionis 2014]
12.4 Proximal Femur
One third of bone metastases occur in the proximal femur and as reflected in the Mirels scoring system risk of fracture is higher than in other locations
Prognosis, site of tumour within the bone and extent of bone loss determine the appropriate management plan.
• Femoral head. Where destruction is limited to the femoral head a cemented hemiarthroplasty or total joint replacement is recommended as a primary procedure. Long stem femoral implants should be considered when there are concomitant metastases further down the femur.
27
• Femoral neck. Lesions in the femoral neck are usually best managed with cemented hemiarthroplasty or total hip replacement.
• Pertrochanteric. In patients with a good prognosis or extensive bone loss at this site proximal femoral replacement should be considered. If prognosis is poor (eg <6 months) then cement augmented internal fixation may be appropriate if there is sufficient bone stock.
• Subtrochanteric. Patients with a good prognosis or with extensive subtrochanteric bone loss are often best managed with endoprosthetic replacement (Chandrasekar 2008). Metastatic deposits at this site are amongst the most frequent causes of implant failure. In patients with limited subtrochanteric bone loss with limited life expectancy may be best stabilised by cephallo-medullary nails with locking screws in the femoral neck or internally fixed with plate and screws (eg DHS) with cement augmentation.
• Periprosthetic metastases. Disease occurring beneath a hip prosthesis needs to be managed with careful consideration of the patients prognosis and risk of implant failure if the metastasis cannot be controlled locally. Management may consist of stabilization with a plate +/- cement augmentation or endoprosthetic replacement.
• There is no role for bone grafting in the management of appendicular pathological fractures. Reconstructions should provide immediate stability and should not rely on the ability of the grafted area to heal, particularly if there has been radiotherapy or there is a risk of local recurrence. Cement can be useful where there are bone defects.
Pelvic disease not involving the acetabulum is usually treated by radiotherapy alone
• Patients who have undergone radiotherapy to this area may occasionally suffer pain due to radiation necrosis of the femoral head or articular cartilage.
The Harrington Classification (Harrington 1981) is a four-grade system which is most widely employed to describe acetabular defects associated with metastatic disease. Type II - IV defects should be considered for referral to a specialist centre.
Type I defects are characterized by an acetabulum with intact anterior and posterior columns, superior dome and medial wall with only punctuate disease of the floor of the acetabulum.
These lesions uncommonly present for surgical intervention. Careful curettage of the metastatic tumour is required and occasionally ‘prophylactic’ medial wall mesh augmentation is required. Definitive reconstruction is with a standard cemented total hip replacement. Cement provides immediate stability and has the theoretical advantage of a thermonecrotic effect on tumour tissue.
Type II defects are characterized by a loss of medial wall with potential for true migration of the femoral head medially into the pelvic cavity.
After removal of tumour the principle of surgery is to reconstruct and thus protect the medial wall from further protrusion and if feasible restore the normal hip centre. This can be achieved with mesh or anti-protrusio cages depending on the defect severity. Anti-protrusio cages necessitate good exposure to ensure that during initial cementation that the ischial flange is intimately seated, and the superior iliac flanges exposed sufficiently well to facilitate screw insertion. A polyethylene liner is then cemented into the cage.
Type III defects are the most challenging because of defects that involves the medial wall, lateral margin and superior dome of the acetabulum. One or both columns are often involved.
These are the most difficult defects to address and represent a spectrum from intermediate to severe loss of native bone stock. Defects at the less severe end of the spectrum can be managed as previously detailed above.
Where medial defects are more extensive the Harrington technique provides an excellent solution which biomechanically facilitates the transfer of stresses across the defect from acetabulum to strong proximal bone [Tillman 2008]. As above the medial defect is meshed and threaded Steinmann pins passed from the iliac crest into the acetabulum bridging the defect. Wires placed anteriorly on the iliac crest can be directed posteriorly into the acetabulum and secured within the ischium. Similarly, pins with a more posterior entry point on the iliac crest can be directed anteriorly into the pubis creating a lattice deep to and above the level of the true acetabulum to provide support for an anti-protrusio cage which is implanted as documented above.
Simply filling such defects with cement will result in medialisation of the ‘cementoma’ due to lack of structural support. This then necessitates further complex revision surgery emphasizing the importance of adequate preoperative planning.
Type IV defects are rare and were originally classified as solitary lesions that were amenable to en-bloc resection.
The spine is the commonest site for MBD accounting for approximately 50% of bone metastases. Whilst not all spinal metastases are symptomatic, pain from the expanding tumour tissue and/or a pathological fracture, is frequently disabling. Paresis or paralysis may be the presenting feature. Untreated, high levels of dependency result, with high human and financial costs.
Indications for Surgery
• Spinal instability evidenced by pathological fracture, progressive deformity,
and/or neurological deficit
Clinically significant neurological compression.
• Tumour insensitive to radiotherapy, chemotherapy or hormonal manipulation
• Patients who have reached spinal cord tolerance after prior radiotherapy
• Intractable pain unresponsive to non-operative measures (eg. radiotherapy,
chemotherapy or hormonal manipulation.)
d. Metastasis completely encircling the cord
SINS SCORE
Spine Instability Neoplastic Score
Location
• 3 points: Junctional (C0-C2, C7-T2, T11-L1, L5-S1)
• 2 points: Mobile spine (C3-C6, L2-L4)
• 1 point: Semi-rigid (T3-T10)
• 0 points: Rigid (S2-S5)
Pain relief with recumbency and/or pain with movement/loading of the spine
• 3 points: Yes
• 1 point: No (occasional pain but not mechanical)
• 0 points: Pain free lesion
Bone lesion
• 2 points: Lytic
• 1 point: Mixed (lytic/blastic)
• 0 points: Blastic
Radiographic spinal alignment
• 4 points: Subluxation / translation present
• 2 points: De novo deformity (kyphosis / scoliosis)
• 0 points: Normal alignment
Vertebral body collapse
• 3 points: >50% collapse
• 2 points: <50% collapse
• 1 point: No collapse with >50% body involved
• 0 points: None of the above
Posterolateral involvement of the spinal elements (facet, pedicle or costovertebral joint fracture or replacement with tumor)
• 3 points: Bilateral
• 1 point: Unilateral
• 0 points: None of the above •
• Interpretation
• sum score 0-6: stable
• sum score 7-12: indeterminate (possibly impending) instability
• sum score 13-18: instability
SINS scores of 7 to 18 warrant spinal surgical consultation.
When a patient with a clinically indeterminate 3cm enlarging soft tissue lump on the forearm which has been present for 2 years to the GP, the next step is:
A: Direct 2WW referral to the local sarcoma centre
B. Urgent USS and 2WW to local sarcoma centre if it is indeterminate on USS
C. Urgent MRI and 2WW to the sarcoma centre before the report is back
D. Needle biopsy by the GP
E. Excision biopsy by the nearest surgical centre
B
- Which one of the following is a typical histological report of Osteosarcoma?
A: Pleomorphic cells surrounded by a bizarre osteoid matrix
B: Pleomorphic cells surrounded by complex chondroid matrix
C: Plump osteoblasts in a mature osteoid matrix
D: Sheets of small round blue cells
E: Scant fibroblasts in a severly sclerotic osteoid matrix
A
Which option best fits with the x-ray description of a non-ossifying fibroma
A: A cenral, well demarcated lytic lesion within the metaphysis, no periosteal reaction or soft tissue reaction. Pathological fracture may show a fallen leaf sign.
B. An expansile eccentric lytic lesion with a thin rim of periosteal new bone, within the metaphysis. Contains bony septae, Alternate imaging shows fluid levels
C: An expansile ‘bubbly’ lytic lesion, arising in the metaphysis. May migrate to the diaphysis. No periosteal reaction.
D. A central, well demarcated, lucent lesion, arising in the metaphysis. May migrate to the diaphysis. Calcify over time.
E: An anterior eccentric lytic lesion with a sclerotic rim, usually in the diaphysis, located in the tibia. There is no periosteal reaction.
C
The joints fused in a 4 corner fusion include all of these except:
A: Capitolunate
B: Scapholunate
C: Lunotriquetral
D: Capitohamate
E: Triquetrohamate
B
Four corner fusion, or partial wrist arthrodesis, is a procedure which involves resection/removal of the scaphoid bone and fixation of the remaining wrist bones with a plate or wires. 4-corner arthrodesis (lunate, capitate, hamate, and triquetrum). The procedure is usually performed due to wrist arthritis or due to scaphoid collapse.
Scaphoid Lunate Advanced Collapse (SLAC) describes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate.
Pathoanatomy
Chronic SL ligament injury creates a DISI deformity: scaphoid is flexed and lunate is extended as scapholunate ligament no longer restrains this articulation:
- Scapholunate angle > 70 degrees
- Lunate extended > 10 degrees past neutral
Resultant scaphoid flexion and lunate extension creates abnormal distribution of forces across midcarpal and radiocarpal joints, and malalignment of concentric joint surfaces
Initially affects the radioscaphoid joint and progresses to capitolunate joint.
Notably the radiolunate joint is spared
Watson classification (Stages I-III) describes the predictable progression of degenerative changes from the radial styloid, to the entire scaphoid facet and finally to the unstable capitolunate joint as the capacitate subluxes dorsally in the lunate.
Key finding is that the radiolunate joint is spared, unlike other forms of wrist arthritis, since there remains a concentric articulation between the lunate and the spheroid lunate fossa of the distal radius.
Stage I: arthritis between scaphoid and radial styloid. XR: Radial styloid beaking, sclerosis and joint space narrowing between scaphoid and radial styloid.
Tx: radial styloidectomy and scaphoid stabilisation, PIN & AIN denervation (can also be used in combo with treatment options described for Stage II & III).
Stage II: arthritis between scaphoid and entire scaphoid facet of radius. XR: sclerosis and joint space narrowing between scaphoid and entire scaphoid fossa of distal radius.
Tx: Proximal row capectomy (Contraindicated in capitolunate arthritis i.e. stage III, because capitate articulates with lunate fossa of the distal radius, or if there is an incompetent radioscaphocapitate ligament). Involves excising the entire proximal row of the carpal bones (scaphoid, lunate and triquetrum), whilst preserving radioscaphocapitate ligament (to prevent ulnar subluxation after proximal row carpectomy).
Scaphoid Excision and 4-corner fusion - provides relative preservation of strength and motion. Wrist motion occurs through the preserved articulation between the lunate and distal radius (lunate fossa).
Stage III: Arthritis between capitate and lunate. XR: sclerosis, joint space narrowing between lunate and capitate, and the capitate will eventually migrate proximally into the space created by the scapholunate dissociation.
Tx: 4CF or wrist fusion - indicated for any form of pan carpal arthritis.
Wrist fusion gives best pain relief and good grip strength at the cost of wrist motion.
Lateral XR will show DISI deformity and subluxation of capitate dorsally onto lunate.
Subsequent description - Stage IV: pan carpal arthritis where radiolunate joint is affected (remains controversial).
Watson scaphoid shift test may be positive in early stages of the disease, but will not be positive in more advanced cases as arthritis changes stabilise the scaphoid.
What is NOT attached to the coracoid?
A: conoid ligament
B: Coracobrachialis
C: Pec Major
D: Short head biceps
E: Trapezoid ligament
C
The coracoid also serves as a critical anchor for many tendinous and ligamentous attachments. These include the tendons of the pectoralis minor, coracobrachialis, and short head of the biceps brachii muscles, and the coracoclavicular, coracohumeral, coracoacromial, and transverse scapular ligaments.
Whereas pectoralis major is the superior most and largest muscle of the anterior chest wall. It is a thick, fan-shaped muscle that lies underneath the breast tissue and forms the anterior wall of the axilla.
The pectoralis major’s primary functions are flexion, adduction, and internal rotation of the humerus.
Origin is composed of a sternocostal and clavicular head, inserting into the lateral lip of the bicipital groove of the humerus (anteromedial proximal humerus).
What is the most important restraint to inferior displacement with the arm in 0 degrees abduction and external rotation?
A: Inferior glenohumeral ligament anterior band
B: Inferior glenohumeral ligament posterior band
C: Long head of biceps
D: Middle glenohumeral ligament
E: Superior glenohumeral ligament
E
Which of these tests is used to identify Teres Minor weakness specifically?
A; Belly press test
B: Hornblower’s sign
C: Jobe’s empty can test
D: Lift off test
E: Pain with cross body abduction
B
The most common location for an os acromiale is between which parts of the acromion?
A: Basi-acromion and meso-acromion
B: Basi-acromion and meta-acromion
C: Meso-acromion and meta-acromion
D: Pre-acromion and meso-acromion
E: Pre-acromion and meta-acromion
C
Which nerve innervates Rhomboid muscles?
A: Axillary
B: Dorsal scapular
C: Lower subscapular
D: Long thoracic
E: Thoracodorsal
B
The borders of the quadrangular space include
A: Teres minor, teres major, lateral head of triceps, long head of triceps
B: Teres minor, teres major, latissimus dorsi and humerus
C: Teres major, long head of triceps, subscapularis and latissimus dorsi
D: Teres major, lateral head of the triceps, humerus and infraspinatus
E: Teres minor, teres major, long head of the triceps and the humerus
E
Teres minor, teres major, long head of the triceps and the humerus
The quadrangular space (also known as the quadrilateral space) is an anatomic interval formed by the shaft of the humerus laterally, the long head of the triceps medially, the teres minor muscle superiorly, and the teres major muscle inferiorly.
The quadrangular space transmits the axillary nerve, and the posterior humeral circumflex artery.
Triangular space: formed by the lower margin of terms minor superiorly, tires major inferiorly and long head of the triceps laterally. Contains the scapular circumflex artery.
Triangular interval: formed by the terms major superiorly, lateral head of the triceps of humerus laterally, and long head of the triceps medially. Contains the radial nerve and profunda brachiia artery.
Which one of the following is not a cause of thoracic outlet syndrome
A: abnormal anterior scalene muscle
B: abnormal pectoralis major insertion
C: Costoclavicular ligament
D: Cervical rib
E: Subclavian artery aneurysm
B
Thoracic outlet syndrome is a neurovascular disorder resulting from compression of the brachial plexus and/or subclavian vessels in the interval between the neck and axilla.
Diagnosis can be suspected clinically with specific provocative tests and supplemented with radiographs or vascular studies. showing anatomic causes of compression.
Treatment may be nonoperative or include surgical decompression or a vascular procedure depending on the specific etiology.
Pathophysiology
Most cases are thought to stem from anatomic predisposition with superimposed neck trauma (acute or chronic repetitive stress).
Anatomically, can be organized into soft tissue (70%) and osseous (30%) abnormalities.
Soft tissue
- Scalene muscle abnormalities: hypertrophy of anterior scalene, passage of the brachial plexus through the anterior scalene muscle (rather than posterior within the interscalene triangle), Variable origin and insertion e.g. anterior insertion of the middle scalene muscle on the 1st rib, Accessory scalenus minimus (found in 30-50% of patients with TOS - originates from cervical transverse process and inserts onto 1st rib between the subclavian artery and T1 root)
Anomalous ligaments or bands:
- Fibromuscular bands: increase stiffness and decrease compliance of the thoracic outlet
- Costoclavicular ligament: abnormal insertion implicated in Paget-Schroetter syndrome
Soft tissue tumors
- Pancoast tumor: tumor of the pulmonary apex. 1-3% of lung cancer cases- generally lack typical symptoms of lung cancer (cough, hemopytsis and dyspnea)
- Neuroblastomas
- Schwannoma of the brachial plexus
- Abnormal pectoralis minor
Osseous
- Cervical rib ( occur in < 1% of the population) - arise from the 7th cervical vertebra
type 1: complete rib that articulates with the first rib or manubrium
type 2: incomplete rib with a free distal bulbous tip
type 3: incomplete rib with distal attachment via fibrous band
type 4: short bar of bone (millimeters) extending beyond the C7 transverse process
- Prominent C7 transverse process
- Abnormal clavicle or first rib: acute fracture displacement, hypertrophic fracture callus formation, fracture mal-union.
- Acromioclavicular (AC) or sternoclavicular (SC) joint injury or dislocation
- Osseous tumors: bone metastasis to first rib (breast, prostate, kidney, lung)
- Osteoid osteoma
Chronic overuse
- Repetitive shoulder use: frequent lifting above the level of the shoulder, extreme arm positions, including hyperabduction
Athletes at risk: weight lifting, rowing, swimming,
Vascular
Repetitive compression over time can result vessel damage: aneursym formation, thrombosis, embolic events, limb-threatening ischemia
Associated conditions
Paget-Schroetter syndrome: type of venous thoracic outlet syndrome seen in well-developed young athletes
intermittent obstruction of the subclavian vein in the costoclavicular space by abnormal costoclavicular ligament and anterior scalene muscle hypertrophy -results in upper extremity deep vein thrombosis
Which of the following is not part of Dupuytren’s diathesis?
A: Early onset
B: Bilateral hands involvement
C: Ledderhose disease
D: Epileptic
E: Male
D
The term diathesis refers to a condition that might predispose a person to a particular illness or disease. Dupuytren’s disease diathesis describes specific characteristics of the disease that might indicate a more aggressive course and possibly higher recurrence rate after surgical treatment.
Dupuytren’s DISEASE is a benign proliferative disorder characterized by decreased hand function caused by hand contractures and painful fascial nodules.
Anatomic location
ring > small > middle > index
Pathophysiology
- Myofibroblast is the dominant cell type (differs from fibroblast as the myofibroblast has INTRACELLULAR ACTIN filaments aligned along long axis of cell)- adjacent myofibroblasts connect via EXTRACELLULAR FIBRONECTIN to act together to create contracted tissue.
- Type III collagen predominates (> type I collagen)
- Cytokines have been implicated: TGFbeta1, TGFbeta2, epidermal growth factor, PDGF, connective tissue growth factor
Ectopic manifestations
- Ledderhose disease (plantar fascia) 10-30%
- Peyronie’s disease (dartos fascia of penis) 2-8%
- Garrod disease (knuckle pads) 40-50%
Associated conditions
HIV, alcoholism, diabetes, antiseizure medications
Anatomy:
Nodules and Cords make up the pathologic anatomy - nodules appear before contractile cords
Normal fascial bands become pathologic cords
- Palmar = pretindinous cord
- Palmodigital transition = natatory cord & spiral cord
- Digital = central cord (distal extent of the pretendinous cord), lateral cord, digital cord, retrovascular cord
Spiral cord = most important cord. Cause of PIP contracture. Typically inserts distally into the lateral digital sheet then into Grayson’s ligament. Composed of pretendinous band, spiral band, lateral digital sheet and Grayson’s ligament.
Travels under the neurovascular bundle displacing it central and superficial therefore at risk during surgical resection. Best predictors of displacement are:
- PIP joint flexion contracture (77% positive predictive value)
- interdigital soft-tissue mass (71% positive predictive value)
Central cord
- Arises from disease involving pretendinous band.
- Inserting into flexor sheath at PIPJ level and causes MCP contracture
- Forms palmar nodules and pits between distal palmar crease and palmar digital crease
NOT involved with neurovascular bundle
Retrovascular cord
- Runs dorsal to the neurovascular bundle distally
- Originates from proximal phalanx, inserts on distal phalanx
and causes DIP contracture.
Natatory cord (from natatory ligament) causes web space contracture
NOT involved in Dupuytren’s disease
Cleland’s ligament
transverse ligament of the palmar aponeurosis
Stages of Dupuytrens (Luck):
Proliferative Stage: Hypercellular with large myofibroblasts and immature fibroblasts - this is a nodule. Very vascular with many gap junctions. Minimal extracellular matrix.
Involutional Stage: Dense myofibroblast network. Fibroblasts align along tension lines and produce more collagen. Increase ratio of type III to type I collagen
Residual Stage: Myofibroblast disappear (acellular) leaving fibrocytes as the predominate cell line. Leaves dense collagen-rich tissue/scar.
An engineer sustains a laceration to the volar aspect of their ring finger, directly over their PIPJ. Which flexor tendon pulley are they most likely to have injured?
A: A2
B: A3
C: A4
D; A5
E: C3
B
Which finger tendon pulley can be safely divided without causing flexor bowstringing?
A: A2, A4
B: A1, A3, A5
C: A1, A2, A3
D: C2, C4
E: A3, A4, A5
B
Annular ligaments: A2 & A4 are the biomechanically most important to prevent bowstringing.
A1, A3, and A5 overlie the MP, PIP and DIP joints respectively (originate from palmar plate).
A1 pulley most commonly involved in trigger finger.
Cruciate pulleys function to prevent sheath collapse and expansion during digital motion, facilitates approximation of annular pulleys during flexion.
3 total at the level of the joints.
Which of the following will reduce the JRF of a THR?
A: A bag full of shopping in the contralateral hand
B: Instruct the patient to use a walking stick in the ipsilateral hand
C: Placing the acetabular component in a more lateral position
D: Placing the femoral component in varus
E: Using an uncemented implant
D
Which of the following is not a component of the ‘superior shoulder suspensory complex’?
A. Acromioclavicular ligaments
B. Coracoclavicular ligaments
C. Coracoid process
D. Distal third of clavicle
E. Superior glenohumeral ligament
E.
Which of the following statements regarding diathermy is true?
A: Bipolar never has any effect on a pacemaker heart lead system
B: “Coagulation” setting uses continuous current
C: “Cutting” setting has a sinus waveform
D: Diathermy applied to an implant is likely to results in significant heating of the implant and surrounding tissues
E: Diathermy is always contra-indicated when a patient has a cardiac device in situ
C
Diathermy uses very high frequencies (around 0.5-3 MHz) of electrical current. This allows diathermy to avoid the frequencies used by body systems generating electrical current, such as skeletal muscle and cardiac tissue, allowing body physiology to be broadly unaffected during its use.
The radio-frequencies generated by the diathermy heat the tissue to allow for cutting and coagulation, by creating intracellular oscillation of molecules within the cells. Depending on the temperature reached, different results occur: at 60oc, cell death occurs (fulgurate), between 60-99oc, dehydration occurs and the tissues coagulate, and at around 100 oc, the tissues vaporise (cutting).
Due to the small surface area at the point of the electrode, the current density is high, producing a focal effect and allowing the tissues to heat up rapidly. In monopolar diathermy, as the current passes through the body, the current density decreases rapidly as the surface area the current acts across increases. Consequently, this allows for focused heating of tissues at the point of use, without heating up the body systemically.
In monopolar action, the electrical current oscillates between the surgeon’s electrode, through the patient’s body, until it meets the ‘grounding plate’ (typically positioned underneath the patient’s leg) to complete the circuit.
In bipolar diathermy, the two electrodes are found on the instrument itself. The bipolar arrangement negates the need for a dispersive electrode, instead a pair of similar sized electrodes are used in tandem. The current is then passed between the electrodes.
Bipolar is most commonly used in operations of the digits (to avoid monopolar current focused over a smaller region), in patients with pacemakers (to avoid electrical involvement with the pacemaker), or in microsurgery.
The main two settings of diathermy* are cutting and coagulation.
Cutting uses a continuous waveform with a low voltage. In cutting mode, the electrode reaches a high enough power to vaporise the water content. Hence it is able to perform a clean cut but is less efficient at coagulating. The cutting mode focuses heat at the surgical site, using sparks being the more focussed way to distribute heat; the cutting mode should therefore be used with the tip slightly away from the tissue.
Coagulation alternatively uses a pulsed waveform with a high voltage. In coagulation, the waveform is at a lower average power, not generating enough heat for explosive vaporisation, but enough for thermal coagulation. The tip should be held slightly away from the tissue, however the sparks are spread over a wider area causing charring rather than cutting.
*There is also a mixed (or blend) mode, acting in between as both cutting and coagulating, however this is not widely used
The impact of patient reported penicillin allergy on SSI risk:
A: Increases SSI risk in elective surgery
B: Increases risk of C.diff infection
C: No correlation between SSI and patient reported penicillin allergy
D: SSI rate is decreased in patients undergoing elective surgery with reported penicilin allergy owing to stronger 2nd line antibiotics
E: SSI rate is related to true penicillin allergy and not reported penicillin allergy
A
A patient presents with thoracic back pain and whole spine MRI demonstrating MSCC at T10. Radiologists is of opinion that it is lymphoma. Which of the following statements is true?
A: Administer 16mg dexamethasone as per NICE guideline
B: Do not give dexamethasone as lymphoma is highly sensitive to steroid and it affects biopsy confirmation of lymphoma
C: Administer 300mg of aspirin instead of dex in case of suspected lymphoma -> MSCC as per NICE guidelines
D: Transfer patient to theatre for emergency spinal decompression
E: Discharge patient home with OP appointment with haematology, MSCC due to lymphoma is rarely progressive and emergency treatment is not indicated
B
Calcitonin was prescribed to a patient with Paget’s who is intolerant to bisphonates, what is the mechanism of action of calctionin?
A: Promotes renal reabsorption of phosphate
B: Inhibits osteoclastic function
C: Promotes intestinal absorption of calcium
D: Stimulates osteoblastic formation
E: Promotes mineralisation of osteoid
B
Kaplan-Meier survival analysis is used to determine the revision rate of hip resurfacing vs THR for 10 years following surgery in male patients aged less than 50 years. What statistical test is used to compare the survival distribution of these two samples?
A: Non-parametric regression
B: Log-rank test
C: Cox-regression
D: Paired t-test
E: Chi-squared test
B
Articular cartilage is a heterogenous composition. In which of the following layers do we see the highest concentration of proteoglycans?
A: Superficial (gliding)
B: Middle (transitional)
C: Deep (Radial)
D: Tidemark
E; Calcified
C
The initial phase of collagen synthesis occurs intra-cellulary by rough endoplasmic reticulum. A deficiency on Vitamin C, manifesting in Scurvy, is due to what defective physiological process?
A: Glycosylation
B: Cross-linking
C: Oxidation
D: Hydroxylation
E: Exocytosis
D
Collagen is the main organic constituent of bone and cartilage. It has many subtypes. What collagen type is mainly expressed in hypertrophic chondrocytes in cartilage, usually limited to the hypertrophic zone of the growth plate and in the calcified zone of articular cartilage of long bones, where it seems to facilitate calcification?
A: II
B: VI
C: IX
D: X
E: XI
D
There are differences in composition of normal, ageing and arthritic articular cartilage. Which of the following is true of ageing articular cartilage?
A: Water content reduces
B: Collagen cross linking decreases
C: Collagen content decreases
D: Chondrocyte density increases
E: Young’s modulus decreases
A
Which of the following shows an autosomal dominant mendelian inheritance pattern?
A: Hunter Syndrome
B: Vitamin D Resistant Rickets
C: Haemophilia B
D: Duchenne Muscular Dystrophy
E; Charcot-Marie Tooth Disease
E
A: Hunter Syndrome - Xlinked Recessive
B: Vitamin D Resistant Rickets - AR
C: Haemophilia B - X-linked Recessive
D: Duchenne Muscular Dystrophy - X-linked recessive
An 18 year old female presents with recurrent patellar dislocation. Her knee MRI shows patella alta, a shallow trochlear groove and a tibial tuberosity trochlear distance (TT-TG) distance of 12mm.
What is the most appropriate surgical intervention ?
A: Lateral retinacular + medial capsule plication
B: Tibial tuberosity distalisation + medial patello-femoral ligament (MPFL) reconstruction
C: Lateral retinacular release ++ MPFL reconstruction
D: Tibial tuberosity distalisation + trochleoplasty
E: Tibial tuberosity distalisation + medialisation
B
An 18 year old male presents with a painful, swollen knee after a twisting injury whilst playing football. This is a sagittal cut of his MRI……(PCL visible)
Which is the most appropriate given MRI findings?
A: Hinged knee brace 6/52
B: Knee arthroscopy and medial meniscal repair
C: Arthroscopic PCL reconstruction
D: MPFL reconstruction
E: Arthroscopic removal of a loose body
B
A 65 year old female presents with chronic pain post TKR?
Which of the following criteria alone is considered enough to meet diagnostic criteria for PJI according to the International Consensus Meeting (ICM) for PJI?
A: A single positive culture from knee aspirate
B: Elevated CRP
C: Sinus tract communicating with joint
D: Elevated synovial WCC
E: Positive histological analysis of peri-prosthetic tissue
C
A 70 year old male presents with groin pain one year after a THR. On examination, the pain is reproduced with resisted hip flexion. CRP & WCC are normal. X-ray shows not signs of loosening or wear. CT scan shows a retroverted cup.
Which is the most appropriate next step of management?
A: Aspiration of hip joint
B: MRI scan of the lumbosacral spine
C: Revision of the acetabular component
D: Steroid injection into the iliopsoas bursa
E: Triphasic bone scan
D
A 65 year old male presents with numbness on the lateral aspect of his thigh following anterior approach THR. Which nerve is most likely to have been damaged?
A: Femoral nerve
B: Iliohypogastric nerve
C: Ilioinguinal nerve
D: Lateral femoral cutaneous nerve
E: Obturator nerve
D
The NICE guideline for joint replacement, based upon current evidence (Dec 2020) does not recommend patella resurfacing for all primary knee replacements over secondary resurfacing nor selective resurfacing………..which of these statements best supports current evidence?
A: Better functional outcome with patella resurfacing
B: Better quadriceps function with patella resurfacing
C: Better ROM with patellar resurfacing
D: Less incidence patellar fractures with patella resurfacing
E: Patella resurfacing is more cost effective over 10 years
E
The sciatic nerve exits the pelvis via the …………… and passes between the ………………and ………………….
Blanketey blank!
A: Greater sciatic notch, inferior gemellus, obturator externus
B: Greater sciatic notch, piriformis, superior gemellus
C: Obturator foramen, obturator internus, obturator externus
D: Lesser sciatic notch, piriformis, superior gemelluls
E: Lesser sciatic notch, superior gemellus, inferior gemellus
B
Compared to metal-on-polyethelene total hip bearing surfaces, the wear particles generated from a metal-on-metal bearing are:
A: larger and less numerous
B: larger and more numerous
C: Smaller and less numerous
D: Smaller and more numerous
E: Not detectable
D
A 75 year old female presents to an arthroplasty clinic - THR 8 years ago, XR: osteopenia proximal femur, most notably n Gruen zone 7. Has pain upon transition from sitting to standing.
What is most likely responsible for this?
A: Uncemented titanium stem
B: Cemented stainless steel stem
C: Uncemented stainless steel stem
D: Uncemented cobalt chrome stem
E: Cemented titanium stem
D
most common complication in total hip arthroplasty and most common cause of component failure;
- osteolysis is a time dependent process which arises from inflammatory reaction against polyethylene particulate debris;
- patho-biology:
- osteolysis is mediated primary by macrophages (fibroblasts and endothelial cells also play a role);
- these cells are activated by wear debris (primarily polyethylene, but also metal and polymethylmethacrylate debris);
- chemical mediators include: interleukin-1 (bone-resorbing cytokine) and tumor necrosis factor;
- in the report by Bi Y, et al (2001), the authors present study showed that titanium particles induced both murine marrow cells and human peripheral blood monocytes to produce factors that stimulated osteoclast differentiation;
- mean increase in osteoclast differentiation was 29.3 ± 9.4-fold.
- they showed that titanium particles stimulate in vitro bone resorption primarily by inducing osteoclast differentiation;
A 55 year old female with knee pain is referred to the arthroplasty clinic.
She has medial knee pain and a varus deformity. XR: medial compartment OA.
Which is a contraindication to unicompartmental arthroplaty?
A: FFD 5 degrees
B: Previous ACL reconstruction
C: Fixed varus deformity 15 degrees
D: Age
E: Flexion to 100 degrees
C
A 65 year old male, 1 year post cemented THR falls from a ladder.
ATLS etc, only injury is periprosthetic fracture at midportion of a cemented taper slip stem.
Acetabular component is well fixed, but the stem is loose and cement is poorly fixed to the bone, bone stock is good.
Which is the most appropriate option?
A: Proximal femoral replacement
B: Uncemented revision & ORIF
C: ORIF only
D: Non-op Mx with protected weight bearing
E: ORIF & cement in cement revision
B
A 74 year old male suffers a dislocation THR 4 months post surgery.
In the absence of infection, which of the following is MOST likely to contribute to his dislocation risk?
A: Use of a lateral approach
B: History of Parkinson’s disease
C: Use of 56mm acetabular component
D: Cup inclination of 40 degrees
E: Male sex
B
A 50 years old male presented with Schatzker III tibial fracture. This was treated with ORIF with a bone graft.
Which of the following bone graft/substitute incorporates by creeping substitution?
A: Autogenous cancellous bone graft
B: Autogenous cortical bone graft
C: Bone marrow injection
D: Calcium phosphate
E: Calcium carbonate
A
AP radiograph of an 18year old male, who presented following a twisting injury of his knee……….XR - small bony lesion proximal to fibula
What structure is most frequently injured in association with this injury?
A: ACL
B: Biceps femoris
C: LCL
D: PCL
E: Popliteus tendon
A
With regards to IM nailing tibial fractures:
A: In extra-articular distal third fractures, IM nails have been shown to confer superior outcomes to plates at one year
B: The suprapatellar approach offers most benefit when addressing more distal fractures
C: Reamed nails confer no benefit over unreamed nails in fractures with critical-sized defects
D: The optimal diameter of the tibial nail lies between 80% and 99% of the isthmus
E: To correct a valgus deformity, blocking screws should be placed medial to the centre of the axis in the coronal plane
D
A 10 year old child sustain and isolated elbow injury pictured on XR (olecranon fracture, radial head dislocation). Which answer is most appropriate?
A: The radial head dislocation usually results from the radial head slipping out from under an intact annular ligament
B: In children, the resultant growth abnormality is usually a short radius
C: Bado 4 (anterior dislocation with radial fracture) injuries are predominatly seen in adults
D: When treating a child’s missed injury at 3/12, open reduction alone will be sufficient to treat the injury
E: The acute management of the injury usually requires both stabilisation of the ulna and repair of the annular ligament
c
Which of the following is not an accepted mode of plate fixation in trauma?
A: Compression
B: Neutralisaton
C: Tension Band
D: Cerclage
E: Buttress
D
What term best describes a property on bone grafting that involves live cells stimulating and enabling bone growth?
A: Osteoconductive
B: Osteogenic
C: Freeze dried
D: Osteoinductive
E: Strut graft
B
Fractures of wha are described using the Ideberg classification?
A: Clavicle
B: Glenoid
C: Distal humerus
D: Proximal ulna
E: 5th Metacarpal
B
A fracture of the talus with dislocation of the subtalar and ankle joint is described as?
A: Hawkins 1
B: Hawkins 2
C: Hawkins 3
D: Hawkins 4
E: Hawkins 5
C
When applying an external fixator, which of the following will not increase the stability of the construct?
A: Near-near, far-far construct
B: Increased number of pins
C: Avoiding the zone of injury
D: Increasing pin diameter
E: Adding extra bars to the construct
C
An adult patient sustains a both-bone forearm fracture, and decision is made to proceed to ORIF with plates and screws. With regards to these implants:
A: The bending rigidity of a plate is proportional to the second power of it’s thickness
B: A plate is most effective when plated on the tension side of the fracture
C: The elastic modulus of stainless steel is closer to that of cortical bone than titaniums
D: A convex bend on a plate may help achieve compression in transverse fractures
E: The pullout strength of a screw has a proportional relationship with it’s core diameter
B
A 69 year old male who underwent fixation of an ankle fracture 3/52 ago re-presents via A&E concerned his wound has opened up and leaking pus.
With regards to assessment of fracture related infection, which of the following is NOT a standard of care?
A: Blood cultures in all febrile and/or systemically septic patients
B: Plain XR to assess implant loosening, periosteal reaction and bone lysis
C: Clinical photography of wound, with images available in patients records for subsequent review
D: Documentation of prompt consideration of early deep sampling radiologically or surgical debridement
E: For stable patients the optimum antibiotic free duration before sampling should be discussed with micro. In non-acute infections this should be a minimum of 1 week
E
A patient sustained a segmental humeral fracture with fracture lines at the junction of proximal and middle thirds, and within the distal third of the humerus. If plating this fracture, the appropriate approach
A: Has no internervous plane and an intermuscular plane between the long and lateral heads of triceps
B: Has no internervous plane and an intermuscular plane between the medial and lateral head of triceps
C: Has an internervous plane between radial and musculocutaneous nerves and an intermuscular plane between brachialis and biceps
D: Has an internervous plane between radial and musculocutaneous nerves and no intermuscular plane
E: Presents risk primarily to the median nerve at the elbow
D
In a clinically stable patient, what is the role of tissue biopsy in the management of pyogenic spinal infection?
A: CT or fluoroscopy guided tissue biopsy should be performed to confirm the diagnosis and identify the pathogen prior to commencing abx treatment
B: Sensitivity of tissue biopsy is very low therefore it should not be performed routinely
C: There is high complication of spinal tissue biopsy therefore should not be performed
D: Blood culture is more than sufficient to identify pathogen and therefore tissue biopsy should not be performed
E: Pyogenic spinal infection are treated based on CRP & MRI findings, therefore tissue biopsy is an unnecessary procedure
A
A young girl presents to OPD for FU. She has a Cobb angle of 30 degrees thoracic curve and is Risser grade 2. What is the best management for the patient?
A; Observe
B: Repeat XR in 6/12 to document progression
C: Offer brace Tx
D: Offer posterior instrumented deformity correction and spinal fusion
E: Offer anterior release and posterior instrumented deformity correction and spinal fusion
C
Which of the following nerve roots form the sciatic nerve?
A: L2-L4
B: L4-S3
C: L2 - S3
D: L5 - S1
E: L2 - S1
B
