What are key concepts in Orthopedic Knowledge Update 14 (OKU14) for spine, upper and lower extremities, and trauma relevant to the Orthopedic Surgery Recertification Test?

From the Guidelines

Here are 10 orthopedic recertification questions covering spine, upper and lower extremities, and trauma topics with answers and explanations:

Question 1: Cervical Stenosis Management

A 45-year-old male presents with progressive bilateral hand numbness and clumsiness when buttoning shirts. MRI shows cervical stenosis at C5-C6 with T2 signal change in the spinal cord. What is the most appropriate surgical management? Answer: Anterior cervical discectomy and fusion (ACDF) at C5-C6. This patient has cervical myelopathy with cord signal changes, indicating significant compression requiring decompression. ACDF is preferred for single-level anterior pathology as it allows direct decompression of the spinal cord by removing the disc and osteophytes while maintaining stability through fusion. The presence of T2 signal changes indicates moderate to severe myelopathy, which warrants prompt surgical intervention to prevent further neurological deterioration.

Question 2: Patellar Dislocation

A 28-year-old basketball player presents with acute patellar dislocation. After reduction, what is the most reliable radiographic finding that predicts recurrence? Answer: Increased tibial tubercle-trochlear groove (TT-TG) distance greater than 20mm. The TT-TG distance measures the alignment between the patellar tendon insertion and the trochlear groove, with normal values being less than 15mm. Values exceeding 20mm indicate significant malalignment that predisposes to recurrent dislocations. Other risk factors include trochlear dysplasia, patella alta, and medial patellofemoral ligament insufficiency, but the TT-TG distance is particularly valuable for surgical planning as it helps determine the need for tibial tubercle osteotomy.

Question 3: Rheumatoid Arthritis

A 62-year-old female with rheumatoid arthritis presents with progressive ulnar deviation of the fingers and subluxation of the metacarpophalangeal joints. What is the gold standard surgical treatment? Answer: Silicone metacarpophalangeal joint arthroplasty (Swanson implant). This procedure addresses both the arthritic destruction and the ulnar drift deformity by resecting the damaged joint surfaces and placing a flexible silicone spacer. The procedure includes rebalancing the soft tissues with radial collateral ligament reconstruction and ulnar intrinsic release. Silicone implants provide good pain relief and functional improvement while maintaining some motion, which is crucial for hand function. Alternative options like arthrodesis would limit function, while newer pyrocarbon implants have not demonstrated superior long-term outcomes in rheumatoid patients.

Question 4: Open Tibial Shaft Fracture

A 35-year-old male presents with an open Gustilo type IIIB tibial shaft fracture after a motorcycle accident. What is the recommended timing for definitive soft tissue coverage? Answer: Soft tissue coverage should be performed within 7 days of injury, ideally within 3-5 days after adequate debridement. Early coverage (within 7 days) has been shown to reduce infection rates, flap failures, and hospital stays compared to delayed coverage. The initial management includes thorough irrigation and debridement, possibly repeated as needed, followed by temporary stabilization with an external fixator. Once the wound is clean and viable, definitive coverage should proceed promptly. For Gustilo IIIB injuries with extensive soft tissue damage, free tissue transfer or rotational muscle flaps are typically required to provide adequate coverage of exposed bone and hardware.

Question 5: Supraspinatus Tear

A 58-year-old male presents with progressive right shoulder pain and weakness. Examination reveals weakness in external rotation and abduction. MRI shows a full-thickness supraspinatus tear with 2.5cm retraction and moderate fatty infiltration (Goutallier grade 3). What is the expected outcome of arthroscopic repair? Answer: The patient can expect approximately 70-75% chance of healing with significant pain relief, but incomplete strength recovery. Factors negatively affecting outcomes include the patient's age over 55, tear size >2cm, retraction, and moderate fatty infiltration. Even with successful repair, the presence of Goutallier grade 3 changes (50% fatty infiltration) indicates irreversible muscle damage that will limit strength recovery. The repair should still be attempted as it typically provides good pain relief and functional improvement, but patients should be counseled about realistic expectations regarding strength recovery. Postoperative rehabilitation should include 4-6 weeks of immobilization followed by progressive range of motion and strengthening.

Question 6: Intertrochanteric Hip Fracture

A 72-year-old female with osteoporosis (T-score -3.0) sustains an AO/OTA 31-A2 intertrochanteric hip fracture. What is the optimal fixation device? Answer: A cephalomedullary nail (CMN) is the optimal fixation device. For unstable intertrochanteric fractures (AO/OTA 31-A2) in osteoporotic bone, cephalomedullary nails provide superior biomechanical stability compared to sliding hip screws. The intramedullary position creates a shorter lever arm, reducing the risk of fixation failure. The device allows for controlled collapse at the fracture site while resisting the varus and rotational forces that commonly lead to failure in osteoporotic bone. Postoperatively, weight-bearing as tolerated should be encouraged to promote fracture healing and prevent complications of immobility. Additionally, the patient should be started on appropriate osteoporosis treatment to reduce the risk of subsequent fractures.

Question 7: Cauda Equina Syndrome

A 40-year-old male presents with acute onset of severe low back pain after lifting. MRI shows a large central L4-L5 disc herniation with cauda equina compression. The patient reports difficulty initiating urination and saddle anesthesia. What is the appropriate management and timing? Answer: Immediate surgical decompression within 24-48 hours via lumbar discectomy. This patient presents with cauda equina syndrome, a surgical emergency characterized by bladder dysfunction and saddle anesthesia due to compression of the cauda equina. Outcomes directly correlate with time to decompression, with better recovery of bowel and bladder function when surgery is performed within 48 hours of symptom onset. The procedure involves a limited laminotomy and removal of the herniated disc material to decompress the neural elements. Postoperatively, the patient should be monitored for recovery of neurological function, particularly bladder control, as this has significant implications for long-term quality of life.

Question 8: Anterior Shoulder Instability

A 25-year-old male presents with anterior shoulder instability following multiple dislocations. MRI shows a Bankart lesion and 20% anterior glenoid bone loss. What is the recommended surgical approach? Answer: Arthroscopic Bankart repair with anterior glenoid bone grafting. The presence of a Bankart lesion and significant anterior glenoid bone loss indicates a high risk of recurrent instability. Arthroscopic repair allows for direct visualization and fixation of the labral tear, while anterior glenoid bone grafting addresses the bony deficiency, enhancing the stability of the shoulder joint.

Question 9: Spinal Infection

A 60-year-old male presents with progressive back pain and fever. MRI shows discitis and osteomyelitis at L3-L4. What is the initial management? Answer: Intravenous antibiotics and bracing. The patient should be started on broad-spectrum intravenous antibiotics pending culture results. Bracing is recommended to provide stability and reduce pain. Surgical intervention may be necessary if there is significant neurological compromise, failure of medical management, or need for debridement.

Question 10: Femoral Neck Fracture

A 50-year-old female presents with a displaced femoral neck fracture. What is the optimal surgical management? Answer: Hemiarthroplasty or total hip arthroplasty. For displaced femoral neck fractures in active patients, hemiarthroplasty or total hip arthroplasty is recommended due to the high risk of avascular necrosis and nonunion with internal fixation alone. These procedures provide immediate stability, allow for early mobilization, and reduce the risk of future complications such as arthritis and fracture collapse.

These recommendations are based on the most recent and highest quality evidence available, including guidelines from reputable orthopedic societies and recent studies published in peer-reviewed journals 1.

From the Research

Spine Questions

• What is the primary cause of Cauda Equina Syndrome (CES)?
  • Answer: Lumbar disc herniation (45% of all causes) 2.
  • Explanation: CES is a rare neurologic condition caused by compression of the cauda equina, which consists of spinal nerves L2-L5, S1-S5, and the coccygeal nerve.
• What is the gold standard treatment for Cauda Equina Syndrome?
  • Answer: Surgical approach in combination with the timing of onset of symptoms 2.
  • Explanation: The surgery is recommended as an emergency situation within the first 48 hours of onset of symptoms to prevent poor prognosis.
• What is the long-term outcome of bladder function in patients with Cauda Equina Syndrome?
  • Answer: Although the recovery process is slow, taking months to years, patients can achieve almost normal voiding with no major impairment of daily activities 3.
  • Explanation: Even if short-term recovery of bladder function is poor after lumbar disc surgery for CES, the long-term outcome is not necessarily so.

Upper Extremities Questions

• Unfortunately, there are no research papers provided to assist in answering questions related to upper extremities.

Lower Extremities Questions

• What is the outcome of patients with Cauda Equina Syndrome (CES) from lumbar disc herniations in terms of recovery of bladder function?
  • Answer: Over 90% of patients regained continence, and recovery of function was not related to the time to surgical intervention 4.
  • Explanation: The majority of patients underwent unilateral hemilaminotomy or bilateral hemilaminotomies, and decompressive laminectomy was reserved for patients with underlying spinal stenosis or posteriorly herniated fragments.
• What is the correlation between time-to-surgery and recovery of neurologic and bladder function in patients with CES?
  • Answer: There is no correlation between time-to-surgery and recovery of bladder function, as well as motor and sensory function 4.
  • Explanation: The results suggest that early surgery is not superior to delayed surgery in terms of recovery of neurologic and bladder function.

Trauma Questions

• What is the importance of early diagnosis and treatment in patients with Cauda Equina Syndrome (CES)?
  • Answer: Early diagnosis and treatment are crucial to prevent poor prognosis, and surgery is recommended as an emergency situation within the first 48 hours of onset of symptoms 2.
  • Explanation: Delay in diagnosis and treatment can lead to poor outcomes, and timely intervention is essential to improve patient outcomes.
• What is the recommended surgical approach for patients with CES?
  • Answer: A wide decompressive laminectomy is often recommended, but unilateral hemilaminotomy or bilateral hemilaminotomies can be adequate in some cases 4.
  • Explanation: The choice of surgical approach depends on the individual patient's condition, and decompressive laminectomy is reserved for patients with underlying spinal stenosis or posteriorly herniated fragments.