Hi, I am preparing for the swiss board exam with questions from old exams. One of the questions is related to suprascapular neuropathy. It asks which of MRI and EMG should be obtained first in the diagnostic workup. I couldn`t find a conclusive answer in my references (Orthobullets, Miller 7th ed., pubmed). Any thoughts?
Knee Lesion in a 40M (C2731)
40 / M - 40 year old male presents with an ongoing history of right knee pain. He describes a 2 year history of aching knee pain that has recently gotten worse after injuring his knee while lifting a heavy object at work. He works as a general laborer in a warehouse. He does not describe any mechanical symptoms related to the knee (no clicking, catching, popping, or locking). His MRI does not reveal a meniscal tear. He isolates his pain to the medial aspect of his knee.
What is the diagnosis?
a spontaneous ON is more likely as a result of either repetitive loadings or excessive torsional forces applied in one incident and I would go for unloading the medial compartment by HTO and decompression and grafting the lesion at wt.bearing area,I would postpone unicondylar replacement as a second line of surgery
I thinks this is a chondral lesion of the MFC, possibile related to the previous knee surgery (medial meniscectomy?). It would be interesting to know the dimensione of the lesion measured on MRI. I think it's mandatory to performe a long standing weight bearing x-ray to check the alignment and after decide the treatment (from this x-rays the knee seems to be varus). Conservative treatment would be the first line with crutches for 6-8 week and PRP injection. After repeat MRI. If the lesion and the symptoms are better Ok, otherwise knee arthroscopy to check and visualize the lesion, measure the dimension and decide the treatment (MF or OATS +/- HTO). The patient has 40 yo and is a sportsman so the UKA it is not recommendable!
I think it is SONK.I will first give it a fair trial of conservative mgmt.and if it doesn't work I will go ahead with osteochondral allograft plug and if that also fails I will go with UKA.
A patient presents to your office for evaluation of arm pain. Upon evaluation, a diagnosis of rupture of the long head of the biceps tendon is made. Which of the following photographs would best corroborate this diagnosis?
If a patient in his thirties presents with traumatic rupture of the LHB and insists on surgery just for cosmesis. Would you perform surgery even is he accepts all the Risk and benefits and long terme pain of a tenodesis of the myotendinous junctions above the inferior portion of the Pec major tendon?
Looks like an isolated chondral lesion on the MFC. Certainly conservative treatment would be the first line but my guess is in this case it would be unsuccessful. I would consider a scope to characterize the lesion and knee and likely drill the lesion as suggested. Depending on it's size you could consider OATS or ACI. From an arthroplasty standpoint a hemicap or uni is an option but I would not start with that. Also I agree you need a standing xray to assess overall limb alignment.
I think this patient has a small focal cartilage flap. This is causing a one way valve effect with synovial fluid being pumped behind the cartilage as he walks through the flap. This is causing a giode type phenomena behind the cartilage flap. I would perform an arthroscope and debride the cartilage flap and decompressing the giode. If the defect behind is small, microfracture can help and a period of NWB will hopefully heal the bony defect. If it is large, then it becomes more controversial.
HemiCAP - a local prosthetic for cartilage lesions is worth of thinking. It can be used for lessions up to 20 mm of diameter.
I would diagnosis this as spontaneous osteonecrosis of the knee. I don't think there is sufficient evidence from the literature to further implicate arthroscopy or testosterone as causative factors, although both are plausible. Also, the literature is generally not conclusive on the optimal treatment.My personal preference is to drill these lesions from the normal bone into the necrotic area using flouro and having a scope in the knee to insure the joint surface is not violated. Whether stem cells or graft should be added has not been determined (both seem reasonable). I would be less likely to add stem cells or graft in a small lesion like this one. If the lesion collapses I believe arthoplasty is superior to osteotomy. Unloading the hemi-joint with a substantial defect with an osteotomy still leaves a substantial defect.
I think this is an osteochondral defect of the MFC. Possible relationship to previous arthroscopy. Start with conservative rx. Surgery would be arthroscopy and likely osteochondral allograft. Tibial osteotomy a possibility but in this case not that bad a varus deformity.
Hi,The MR is VERY consistent with Outerbridge 4 disease and subchondral marrow changes. This is not SONK (subchondral fracture) and not likely to be OCD.Seems like a trial of conservative care could make sense. Unloader brace, knee injections, and consider PRP or stem cells...
Chondral management with chondroplasity and microfracture plus knee malaligment correcction with HTO.
Also can you include a full length WB view of the legs to assess limb alignment.Assessing Lower Limb Alignment: Comparison of Standard Knee Xray vs Long Leg View.Zampogna B, Vasta S, Amendola A, Uribe-Echevarria Marbach B, Gao Y, Papalia R, Denaro VIowa Orthop J. 2015. 35. :49-54PMID: 26361444 (Link to Abstract)
Can you please measure list the size dimensions of the defect on the MRI? This would be helpful to decide treatment of the lesion
In my opinion , This is a focal lesion of the medial femoral condyle mainly affecting the subcondral bone, the cartilage looks at least in the given cuts that it is not breached, also you can see small osteophytes developing on the medial joint line and a varus alignment which should be confirmed by a long leg film. For me, This is a medial compartment overload disease that should be addressed and treated from this point of view , osteochondral therapy alone will fail greatly unless the axis is corrected.I will do first arthroscopy to document the cartilage status then outside-in drilling and valgus high tibial osteotomy fixed by Tomofix.
Surgical Treatment of Long Thoracic Nerve Palsy
Case example of a pectoral is tendon transfer for long thoracic nerve palsy.
A 35-year-old construction worker presents with medial-sided knee pain. He has no instability complaints but at age 18, he sustained a Grade 1 PCL injury that was treated non-operatively. A radiograph is shown in Figure A. What surgical treatment is the best option given his age and occupation?
Unicompartmental knee replacement
Total knee replacement
Lateral closing wedge osteotomy of the proximal tibia
Medial opening wedge osteotomy of the proximal tibia
HTO is about correcting early wear secondary to a bony deformity. There are no mechanical axis xrays and the limited radiographs dont show significant tibia vara. So an HTO is not indicated here. Also as he is a manual labourer he is going to stress his HTO. If he did have a varus deformity and this was corrected by a medial opening wedge osteotomy then he would perhaps be at higher risk of collapse/recuurence of deformity?
COMPLETE AVULSIÓN OF HAMSTRINGS (C1533)
62 / F - 62yo female, no sports, retired. After fall in hiperflexión of hip with extended knee, presents pain, haematoma in posterior thigh
What treatment would you choose?
AS long as we are sharing, I had a partial tear during a sprint in tennis, two heads off completely and opted to treat myself non operatively at the age of 63 It has taken me one year to return to tennis, for myself this was a good decision again my fear as others have articulated was the fear of time off from a busy surgical practice.
The classification is still listed incorrectly
Women athletes have a higher rate of ACL tears than male athletes in the same sport. While the cause is likely multi-factorial, which of the following factors has been shown to contribute most significantly to this observation?
Neuromuscular coordination and training
Intra-articular notch size
Valgus leg alignment
While it is clear that neuromuscular training/conditioning can have a positive/protective effect you fail to provide any evidence to support the question that poor neuromuscular coordination and training has been proven to be the most significant risk factor.