There are certain thought barriers involved in making diagnostic-classifcation criteria in diseases of unknown origin. Among these are a lack of appreciation of the issue of circular logic, the basic oneness of diagnostic and classifcation criteria, the lack of appreciation as to why we make such criteria in the frst place, and the lack of importance informing our patients that we do as well as should treat them without a frm diagnosis in many instances. The relevance of these thought barriers to the new American College of Rheumatology/European Union League Against Rheumatism (ACR/EULAR) Rheumatoid Arthritis (RA) classifcation criteria are also discussed.

“Treat-to-target” of rheumatoid arthritis (RA) is similar in many respects to hypertension and diabetes. All three diseases involve a dysregulation of normal physiologic functions, which results in long-term organ damage if not treated. “Treat-to-target” strategies, based on values of specific quantitative measures, lead to improved outcomes, including longer survival. However, RA differs from hypertension and diabetes in at least fve important respects: 1. the absence of a single “gold standard” measure in RA for all individual patients necessitates indices; 2. the rarity of acute emergency situations in RA leads to underestimation of its natural history, which includes increased mortality rates similar to hypertension and diabetes; 3. the patient with hypertension or diabetes goes to the doctor to learn how she or he is doing, based on a “gold standard” quantitative measure, while the patient with RA goes to the doctor to tell the doctor how she or he is doing; 4. the history and physical examination in hypertension or diabetes may be recorded as narrative, nonquantitative information, as a vital sign or laboratory test provides the crucial information for clinical care but should be recorded as quantitative, standardized “scientifc” data on patient questionnaires and formal joint counts because of their importance in RA; and 5. patient mood or distress may impact directly RA indices used as quantitative measures in a “treat-to-target” strategy, which is not seen in hypertension or diabetes. These matters may be addressed through three global scales completed by health professionals concerning infammation, damage, or neither infammation nor damage as a basis for symptoms.

Since the main objective of therapies in rheumatology is not only to improve the patient condition but also to prevent a further disability and because of the emergence of new and very effective therapies, the outcome measures used to evaluate treatments in rheumatology have been revisited. The major changes are that in addition to the concept of improvement (achievement of a relevant level of change), other concepts have been recognized as important, such as status (achievement of an acceptable condition), onset of action (the quickest is the better), and sustainability. In order to evaluate these concepts, new tools have been recently elaborated (for example, the ACR-EULAR remission criteria in rheumatoid arthritis) and several statistical approaches can be used for an optimal presentation of the data observed in clinical trials (in particular to assess the concepts of onset of action and sustainability).

The prognosis of patients with recent onset arthritis may vary from self-limiting disease to severe destructive rheumatoid arthritis (RA). In order to improve outcomes, a great deal of effort has been put into applying a diagnosis that will allow rapid initiation of treatment. The diagnosis of undifferentiated arthritis (UA) for these patients as well as the new ACR-EULAR 2010 criteria for rheumatoid arthritis (RA) are reviewed in the context of pathogenetic and clinical data available from this group of patients.

The purpose of this pilot study was to evaluate the cytokine profle of human knee synovial fuid and correlate this with the subject’s degree of articular cartilage degradation, radiographic score, and synovial histology. Materials and Methods: Synovial fuid was withdrawn before knee meniscectomy in 12 subjects with varying degrees of osteoarthritis and assayed for 21 cytokines, using a multiplex cytokine assay and fow cytometry instrumentation. Articular cartilage surfaces were scored by a single orthopaedic surgeon on the basis of the International Cartilage Repair Society (ICRS) classifcation during the arthroscopy, and posterior-anterior knee radiographs were graded using the Kellgren-Lawrence (KL) classifcation. Synovial biopsies were taken in four zones at the time of surgery for histological analysis. Results: Signifcant concentration differences in IL-2, IL-5, MCP-1, and MIP-1 were found between subjects with advanced arthritis and subjects with little or no arthritis on the ICRS scale (p < .05). No such differences could be appreciated using KL scores. There was no correlation between histology samples and visualized surface osteoarthritis. Conclusion: This data suggests a molecular basis of disease progression, with higher levels of cytokines indicative of greater degrees of osteoarthritis. These results add pilot data that can assist investigators in conducting a comparative observational study of the levels of infammatory cytokines with radiologic and arthroscopic assessments of osteoarthritis.

Background: Dislocation of the sternoclavicular joint is a rare injury that has a low incidence of signifcant long-term symptoms. Surgical reconstruction of the joint is indicated in patients with symptomatic, chronic anterior instability or with irreducible or recurrent posterior instability. There have been many reported techniques for stabilization of the joint, but few investigators have reported more than several cases. The ideal reconstruction has not been identifed. Purpose: The purpose of this investigation was to perform a systematic review of the available literature with the objective of identifying one technique of sternoclavicular reconstruction that could be recommended. Methods: A systematic review of literature pertaining to treatment of sternoclavicular joint injuries was performed, focusing on clinical reports with at least six patients and 1 year of follow-up. We also reviewed biomechanical reports pertaining to sternoclavicular reconstruction. Results: Six clinical reports and two biomechanical studies were identifed that met our inclusion criteria. Treatments described in the clinical reports included conservative treatment with a sling, repair of the joint capsule with provisional stabilization, and joint reconstruction with local tissue or graft tissue. One biomechanical study compared the strength of three reconstruction techniques. Conclusion: Reconstruction with tendon tissue woven in a figure-of-eight pattern through drill holes in the manubrium and clavicle is stronger than reconstructions with local tissue. The review of clinical reports suggests excellent outcomes with this technique, and it is recommended in cases of chronic instability. In cases of acute instability requiring open reduction or inability to maintain a reduction in a posterior dislocation, there is evidence that repair of the joint capsule is suffcient surgical treatment.

Rheumatoid arthritis (RA) is a chronic, systemic infammatory disorder affecting multiple organ systems, joints, ligaments, and bones and commonly involves the cervical spine. Chronic synovitis may result in bony erosion and ligamentous laxity that result in instability and sublux-ation. Anterior atlantoaxial subluxation (AAS) is the most frequently occurring deformity, due to laxity of the primary and secondary ligamentous restraints. Additional manifestations of RA include cranial settling, subaxial subluxation, or a combination of these. Although clinical fndings can be confounded by the severity of multifocal joint and systemic involvement, a careful history is critical to identify symptoms of cervical disease; serial physical examination is the best noninvasive diagnostic tool. Thorough physical and neurologic examinations should be performed in all patients and serial functional assessments charted. Radiographs of the cervical spine with lateral fexion-extension dynamic views should be obtained periodically and used to “clear” the cervical spine before elective surgery requiring general anesthesia. Advanced imaging, such as magnetic resonance imaging (MRI) or myelography and computed tomography (CT), may be necessary to evaluate the neuraxis. Early initiation of pharmacotherapy may slow progression of rheumatoid cervical disease. Operative intervention before the onset of advanced myelopathy results in improved outcomes compared to the surgical stabilization of patients whose conditions are more advanced. A multidisciplinary approach involving rheumatology, surgery, and rehabilitation is benefcial to optimize outcomes.

The popularity of snowboarding has brought awareness to injuries sustained during the sport. Wrist injuries are among the most common injuries, and there is an interest in using protective equipment to prevent these injuries. The purpose of this study was to review the literature on wrist guard use, injury prevention, the biomechanical effects of wrist guards, and the various types of wrist guards commercially available for consumers. A literature search was done using MEDLINE® Ovid (1950 to January 2009), MEDLINE® PubMed® (1966 to January 2009), and EMBASE® (1980 to January 2009) for studies on snowboard injuries and wrist guards. References from the studies found were also reviewed. Two randomized controlled studies (Level I), one meta-analysis (Level II), eight prospective case control studies (Level II), one cross-sectional study, and four biomechanical-cadaveric studies were found from the literature search. Based on the review of this literature, wrist injuries are among the most common injury type, and wrist guard use may provide a protective effect in preventing them. There is no consensus as to what type or design of wrist guard is the most effective and which wrist guards are available for use by the consumer.

The objective of this study was, in chondrosarcoma (CHS) of the femur, to evaluate by radiologic-pathologic correlation, the degree of tumor growth, cortical destruction, periosteal reaction, and soft tissue extension present. Materials and Methods: Eight cases of histologically proven CHS of the femur were studied. All cases were resected, evaluated histologically with coronal slabs, and compared with radiographs and magnetic resonance imaging (MRI) scans. In two resected specimens, the tumors were studied in more detail; along with coronal slabs, axial sections of the remaining anterior and posterior halves of both tumors were taken, and the bone specimens were X-rayed and examined histologically. Results: CHS initially involved the medullary cavity and subsequently destroyed the cortex; first, by endosteal scalloping and, second, by subsequent invasion and destruction of the cortex. During this process, there was periosteal new bone formation (PNBF), with increased cortical thickness, the degree of which often correlated with the degree of cortical destruction. In the areas of cortical thickening of three cases, a “grey line” was seen on MRI that separated the cortex from the periosteal new bone; the line, in reality,is a space between the two structures. The presence of this line suggests that the tumor does not extend beyond the cortex. PNBF occurred in all cases and varied in thickness. It frequently developed independent of direct periosteal tumor involvement. The periosteum of one case contained porotic bone with interposed marrow fat, which was easily misinterpreted as tumor extension on MRI. Expansion and remodeling of the femoral diaphysis in CHS, with widening of the medullary cavity, is usually due to extensive cortical destruction with PNBF. Soft tissue extension was present in five cases and apparently occurred by two different mechanisms: direct tumor destruction of the cortex and periosteum, with extension into the soft tissues; and subtle MRI occult tumor permeation through the periosteum. As far as we know, a first literature histologic description of the thickened CHS periosteum also was accomplished. Conclusion: PNBF is a common imaging manifestation of CHS of the femur, which correlated with the degree of cortical destruction. A grey line between the cortex and periosteum is an MRI finding described in this study and may facilitate the evaluation of periosteal thickening and tumor invasion in CHS. PNBF often occurs in the absence of direct periosteal involvement. Periosteal imaging abnormalities suggestive of tumor infltration should be interpreted with caution on MRI, and early soft tissue extension in CHS may be difficult to determine on MRI.

The Orthopaedic In-Training Examination (OITE) provides a standardized measure to assess the knowledge of orthopaedic residents regarding knee reconstruction surgery. However, there currently are limited resources for residents who are preparing for the knee reconstruction questions on the OITE. The present study assessed the character of the knee reconstruction questions tested and which literature resources may be recommended for residents preparing for this examination. Materials and Methods: All knee reconstruction-related questions found during a 5-year period (2002 to 2006) on the OITE were characterized by the diagnosis and treatment discussed. The most frequently referenced journals were identifed from the OITE exam key. The character of the OITE questions was compared to the literature in terms of overall proportion of articles and questions that were related to knee reconstruction, as well as to categories of diagnosis and treatment modality. Results: There were 59 out of 1375 questions (4%) on the OITE over the 5 years that were related to knee reconstruction. Over half of the questions (54%) were related to primary total knee arthroplasty, with osteoarthritis being the most frequently tested diagnosis (30%). The top three referenced orthopaedic journals were The Journal of Bone and Joint Surgery-American, Clinical Orthopaedics and Related Research, and The Journal of Arthroplasty. Compared to the OITE, these journals covered higher percentages of overall knee reconstruction-related questions (18% versus 4%). In addition, the journal literature had a greater focus on treatment modalities (65% versus 41%) and less emphasis on biomechanics, materials, and basic science (18% versus 34%) than the OITE, respectively. The two most frequently cited textbooks represented approximately 78% of the total number of provided textbook references: Orthopaedic Knowledge Update (39%) and Instructional Course Lectures (39%). Discussion: The results of this study suggest that residents may beneft from using general orthopaedic journals such as The Journal of Bone and Joint Surgery-American in preparation for the OITE. However, residents and residency directors who are preparing their educational programs should be aware that clinical journals may not refect the OITE in terms of the proportion of basic science and biomechanics articles and additional study resources may be necessary.

The pivot shift test is a cornerstone in the clinical diagnosis of anterior cruciate ligament (ACL) defciency. It can be diffcult to perform in overweight patients or in those with long or bulky legs. We present an alternative method to perform the pivot shift test that recalls the judo technique of fgure-of-four knee lock and eases the examination of the patient with anterior cruciate ligament deficiency. This modality of execution also makes the surgeon able to perform varus-valgus tests with small changes in hand positions. The surgeon, embracing with one arm the tibia of the affected limb, grasps with this hand the wrist of his free arm opposite to the affected limb. Then the surgeon hooks onto the posterior surface of the leg with his free hand. In this way, the surgeon can exert a moment on the limb of the patient, and can apply combined internal rotation, fexion, and valgus stress to perform the pivot shift test or simply varus or valgus force to perform the varus-valgus tests.

A case is presented of arteriovenous malformation of the thumb, requiring thumb amputation and free fap coverage for curative treatment. The thumb was reconstructed by pollicization of the index fnger as a secondary operation. The patient remains free of recurrence after 2 years and uses the pollicized thumb for daily activities.

A 75-year-female with a history of Isoniazid (INH) therapy for latent tuberculosis, was admitted with a 4-week duration of dyspnea, cough, and pleuritic chest pain. She was treated with intravenous antibiotics for a diagnosis of pneumonia. Her stay was complicated by development of recurrent, exudative eosinophilic pleural effusions (EPEs). When symptoms continued to worsen and she developed joint pain and anasarca and did not respond to the antibiotics, a rheumatologic work-up was performed. She was found to have positive anti-double stranded-DNA antibodies and anti-histone antibodies; thus, a diagnosis of drug-induced lupus, secondary to INH, was made. INH was discontinued, and the patient was started on prednisone; within weeks her symptoms resolved. This case illustrates a unique side effect of INH that caused exudative EPEs and drug-induced lupus with positive anti-dsDNA

SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) is a rare chronic infammatory musculoskeletal disorder of unknown etiology observed in children and young adults, which involves both osteo-articular infammation and skin abnormalities. We review the case of a 22-year-old male, who presented with a 5-year history of hidradenitis suppurativa (HS), acne vulgaris, joint stiffness, and pain. Previous ineffective treatments included isotretinoin and oral antibiotics. Marked improvement of all cutaneous features was noticed after the frst dose of infliximab and methotrexate; continued treatment resulted in the complete remission of the arthritis and enthesopathy. This case report demonstrates the effcacy and safety of infiximab and methotrexate in refractory SAPHO syndrome.

Metallosis following open reduction and internal fxation (ORIF) for fracture, usually presenting as a soft tissue mass, is barely discussed in the literature. In this case report, the imaging and pathological fndings of metallosis after ORIF for a humeral fracture are presented and comprehensively discussed.

There are certain thought barriers involved in making diagnostic-classifcation criteria in diseases of unknown origin. Among these are a lack of appreciation of the issue of circular logic, the basic oneness of diagnostic and classifcation criteria, the lack of appreciation as to why we make such criteria in the frst place, and the lack of importance informing our patients that we do as well as should treat them without a frm diagnosis in many instances. The relevance of these thought barriers to the new American College of Rheumatology/European Union League Against Rheumatism (ACR/EULAR) Rheumatoid Arthritis (RA) classifcation criteria are also discussed.

“Treat-to-target” of rheumatoid arthritis (RA) is similar in many respects to hypertension and diabetes. All three diseases involve a dysregulation of normal physiologic functions, which results in long-term organ damage if not treated. “Treat-to-target” strategies, based on values of specific quantitative measures, lead to improved outcomes, including longer survival. However, RA differs from hypertension and diabetes in at least fve important respects: 1. the absence of a single “gold standard” measure in RA for all individual patients necessitates indices; 2. the rarity of acute emergency situations in RA leads to underestimation of its natural history, which includes increased mortality rates similar to hypertension and diabetes; 3. the patient with hypertension or diabetes goes to the doctor to learn how she or he is doing, based on a “gold standard” quantitative measure, while the patient with RA goes to the doctor to tell the doctor how she or he is doing; 4. the history and physical examination in hypertension or diabetes may be recorded as narrative, nonquantitative information, as a vital sign or laboratory test provides the crucial information for clinical care but should be recorded as quantitative, standardized “scientifc” data on patient questionnaires and formal joint counts because of their importance in RA; and 5. patient mood or distress may impact directly RA indices used as quantitative measures in a “treat-to-target” strategy, which is not seen in hypertension or diabetes. These matters may be addressed through three global scales completed by health professionals concerning infammation, damage, or neither infammation nor damage as a basis for symptoms.

Since the main objective of therapies in rheumatology is not only to improve the patient condition but also to prevent a further disability and because of the emergence of new and very effective therapies, the outcome measures used to evaluate treatments in rheumatology have been revisited. The major changes are that in addition to the concept of improvement (achievement of a relevant level of change), other concepts have been recognized as important, such as status (achievement of an acceptable condition), onset of action (the quickest is the better), and sustainability. In order to evaluate these concepts, new tools have been recently elaborated (for example, the ACR-EULAR remission criteria in rheumatoid arthritis) and several statistical approaches can be used for an optimal presentation of the data observed in clinical trials (in particular to assess the concepts of onset of action and sustainability).

The prognosis of patients with recent onset arthritis may vary from self-limiting disease to severe destructive rheumatoid arthritis (RA). In order to improve outcomes, a great deal of effort has been put into applying a diagnosis that will allow rapid initiation of treatment. The diagnosis of undifferentiated arthritis (UA) for these patients as well as the new ACR-EULAR 2010 criteria for rheumatoid arthritis (RA) are reviewed in the context of pathogenetic and clinical data available from this group of patients.

The purpose of this pilot study was to evaluate the cytokine profle of human knee synovial fuid and correlate this with the subject’s degree of articular cartilage degradation, radiographic score, and synovial histology. Materials and Methods: Synovial fuid was withdrawn before knee meniscectomy in 12 subjects with varying degrees of osteoarthritis and assayed for 21 cytokines, using a multiplex cytokine assay and fow cytometry instrumentation. Articular cartilage surfaces were scored by a single orthopaedic surgeon on the basis of the International Cartilage Repair Society (ICRS) classifcation during the arthroscopy, and posterior-anterior knee radiographs were graded using the Kellgren-Lawrence (KL) classifcation. Synovial biopsies were taken in four zones at the time of surgery for histological analysis. Results: Signifcant concentration differences in IL-2, IL-5, MCP-1, and MIP-1 were found between subjects with advanced arthritis and subjects with little or no arthritis on the ICRS scale (p < .05). No such differences could be appreciated using KL scores. There was no correlation between histology samples and visualized surface osteoarthritis. Conclusion: This data suggests a molecular basis of disease progression, with higher levels of cytokines indicative of greater degrees of osteoarthritis. These results add pilot data that can assist investigators in conducting a comparative observational study of the levels of infammatory cytokines with radiologic and arthroscopic assessments of osteoarthritis.

Background: Dislocation of the sternoclavicular joint is a rare injury that has a low incidence of signifcant long-term symptoms. Surgical reconstruction of the joint is indicated in patients with symptomatic, chronic anterior instability or with irreducible or recurrent posterior instability. There have been many reported techniques for stabilization of the joint, but few investigators have reported more than several cases. The ideal reconstruction has not been identifed. Purpose: The purpose of this investigation was to perform a systematic review of the available literature with the objective of identifying one technique of sternoclavicular reconstruction that could be recommended. Methods: A systematic review of literature pertaining to treatment of sternoclavicular joint injuries was performed, focusing on clinical reports with at least six patients and 1 year of follow-up. We also reviewed biomechanical reports pertaining to sternoclavicular reconstruction. Results: Six clinical reports and two biomechanical studies were identifed that met our inclusion criteria. Treatments described in the clinical reports included conservative treatment with a sling, repair of the joint capsule with provisional stabilization, and joint reconstruction with local tissue or graft tissue. One biomechanical study compared the strength of three reconstruction techniques. Conclusion: Reconstruction with tendon tissue woven in a figure-of-eight pattern through drill holes in the manubrium and clavicle is stronger than reconstructions with local tissue. The review of clinical reports suggests excellent outcomes with this technique, and it is recommended in cases of chronic instability. In cases of acute instability requiring open reduction or inability to maintain a reduction in a posterior dislocation, there is evidence that repair of the joint capsule is suffcient surgical treatment.

Rheumatoid arthritis (RA) is a chronic, systemic infammatory disorder affecting multiple organ systems, joints, ligaments, and bones and commonly involves the cervical spine. Chronic synovitis may result in bony erosion and ligamentous laxity that result in instability and sublux-ation. Anterior atlantoaxial subluxation (AAS) is the most frequently occurring deformity, due to laxity of the primary and secondary ligamentous restraints. Additional manifestations of RA include cranial settling, subaxial subluxation, or a combination of these. Although clinical fndings can be confounded by the severity of multifocal joint and systemic involvement, a careful history is critical to identify symptoms of cervical disease; serial physical examination is the best noninvasive diagnostic tool. Thorough physical and neurologic examinations should be performed in all patients and serial functional assessments charted. Radiographs of the cervical spine with lateral fexion-extension dynamic views should be obtained periodically and used to “clear” the cervical spine before elective surgery requiring general anesthesia. Advanced imaging, such as magnetic resonance imaging (MRI) or myelography and computed tomography (CT), may be necessary to evaluate the neuraxis. Early initiation of pharmacotherapy may slow progression of rheumatoid cervical disease. Operative intervention before the onset of advanced myelopathy results in improved outcomes compared to the surgical stabilization of patients whose conditions are more advanced. A multidisciplinary approach involving rheumatology, surgery, and rehabilitation is benefcial to optimize outcomes.

The popularity of snowboarding has brought awareness to injuries sustained during the sport. Wrist injuries are among the most common injuries, and there is an interest in using protective equipment to prevent these injuries. The purpose of this study was to review the literature on wrist guard use, injury prevention, the biomechanical effects of wrist guards, and the various types of wrist guards commercially available for consumers. A literature search was done using MEDLINE® Ovid (1950 to January 2009), MEDLINE® PubMed® (1966 to January 2009), and EMBASE® (1980 to January 2009) for studies on snowboard injuries and wrist guards. References from the studies found were also reviewed. Two randomized controlled studies (Level I), one meta-analysis (Level II), eight prospective case control studies (Level II), one cross-sectional study, and four biomechanical-cadaveric studies were found from the literature search. Based on the review of this literature, wrist injuries are among the most common injury type, and wrist guard use may provide a protective effect in preventing them. There is no consensus as to what type or design of wrist guard is the most effective and which wrist guards are available for use by the consumer.

The objective of this study was, in chondrosarcoma (CHS) of the femur, to evaluate by radiologic-pathologic correlation, the degree of tumor growth, cortical destruction, periosteal reaction, and soft tissue extension present. Materials and Methods: Eight cases of histologically proven CHS of the femur were studied. All cases were resected, evaluated histologically with coronal slabs, and compared with radiographs and magnetic resonance imaging (MRI) scans. In two resected specimens, the tumors were studied in more detail; along with coronal slabs, axial sections of the remaining anterior and posterior halves of both tumors were taken, and the bone specimens were X-rayed and examined histologically. Results: CHS initially involved the medullary cavity and subsequently destroyed the cortex; first, by endosteal scalloping and, second, by subsequent invasion and destruction of the cortex. During this process, there was periosteal new bone formation (PNBF), with increased cortical thickness, the degree of which often correlated with the degree of cortical destruction. In the areas of cortical thickening of three cases, a “grey line” was seen on MRI that separated the cortex from the periosteal new bone; the line, in reality,is a space between the two structures. The presence of this line suggests that the tumor does not extend beyond the cortex. PNBF occurred in all cases and varied in thickness. It frequently developed independent of direct periosteal tumor involvement. The periosteum of one case contained porotic bone with interposed marrow fat, which was easily misinterpreted as tumor extension on MRI. Expansion and remodeling of the femoral diaphysis in CHS, with widening of the medullary cavity, is usually due to extensive cortical destruction with PNBF. Soft tissue extension was present in five cases and apparently occurred by two different mechanisms: direct tumor destruction of the cortex and periosteum, with extension into the soft tissues; and subtle MRI occult tumor permeation through the periosteum. As far as we know, a first literature histologic description of the thickened CHS periosteum also was accomplished. Conclusion: PNBF is a common imaging manifestation of CHS of the femur, which correlated with the degree of cortical destruction. A grey line between the cortex and periosteum is an MRI finding described in this study and may facilitate the evaluation of periosteal thickening and tumor invasion in CHS. PNBF often occurs in the absence of direct periosteal involvement. Periosteal imaging abnormalities suggestive of tumor infltration should be interpreted with caution on MRI, and early soft tissue extension in CHS may be difficult to determine on MRI.

The Orthopaedic In-Training Examination (OITE) provides a standardized measure to assess the knowledge of orthopaedic residents regarding knee reconstruction surgery. However, there currently are limited resources for residents who are preparing for the knee reconstruction questions on the OITE. The present study assessed the character of the knee reconstruction questions tested and which literature resources may be recommended for residents preparing for this examination. Materials and Methods: All knee reconstruction-related questions found during a 5-year period (2002 to 2006) on the OITE were characterized by the diagnosis and treatment discussed. The most frequently referenced journals were identifed from the OITE exam key. The character of the OITE questions was compared to the literature in terms of overall proportion of articles and questions that were related to knee reconstruction, as well as to categories of diagnosis and treatment modality. Results: There were 59 out of 1375 questions (4%) on the OITE over the 5 years that were related to knee reconstruction. Over half of the questions (54%) were related to primary total knee arthroplasty, with osteoarthritis being the most frequently tested diagnosis (30%). The top three referenced orthopaedic journals were The Journal of Bone and Joint Surgery-American, Clinical Orthopaedics and Related Research, and The Journal of Arthroplasty. Compared to the OITE, these journals covered higher percentages of overall knee reconstruction-related questions (18% versus 4%). In addition, the journal literature had a greater focus on treatment modalities (65% versus 41%) and less emphasis on biomechanics, materials, and basic science (18% versus 34%) than the OITE, respectively. The two most frequently cited textbooks represented approximately 78% of the total number of provided textbook references: Orthopaedic Knowledge Update (39%) and Instructional Course Lectures (39%). Discussion: The results of this study suggest that residents may beneft from using general orthopaedic journals such as The Journal of Bone and Joint Surgery-American in preparation for the OITE. However, residents and residency directors who are preparing their educational programs should be aware that clinical journals may not refect the OITE in terms of the proportion of basic science and biomechanics articles and additional study resources may be necessary.

The pivot shift test is a cornerstone in the clinical diagnosis of anterior cruciate ligament (ACL) defciency. It can be diffcult to perform in overweight patients or in those with long or bulky legs. We present an alternative method to perform the pivot shift test that recalls the judo technique of fgure-of-four knee lock and eases the examination of the patient with anterior cruciate ligament deficiency. This modality of execution also makes the surgeon able to perform varus-valgus tests with small changes in hand positions. The surgeon, embracing with one arm the tibia of the affected limb, grasps with this hand the wrist of his free arm opposite to the affected limb. Then the surgeon hooks onto the posterior surface of the leg with his free hand. In this way, the surgeon can exert a moment on the limb of the patient, and can apply combined internal rotation, fexion, and valgus stress to perform the pivot shift test or simply varus or valgus force to perform the varus-valgus tests.

A case is presented of arteriovenous malformation of the thumb, requiring thumb amputation and free fap coverage for curative treatment. The thumb was reconstructed by pollicization of the index fnger as a secondary operation. The patient remains free of recurrence after 2 years and uses the pollicized thumb for daily activities.

A 75-year-female with a history of Isoniazid (INH) therapy for latent tuberculosis, was admitted with a 4-week duration of dyspnea, cough, and pleuritic chest pain. She was treated with intravenous antibiotics for a diagnosis of pneumonia. Her stay was complicated by development of recurrent, exudative eosinophilic pleural effusions (EPEs). When symptoms continued to worsen and she developed joint pain and anasarca and did not respond to the antibiotics, a rheumatologic work-up was performed. She was found to have positive anti-double stranded-DNA antibodies and anti-histone antibodies; thus, a diagnosis of drug-induced lupus, secondary to INH, was made. INH was discontinued, and the patient was started on prednisone; within weeks her symptoms resolved. This case illustrates a unique side effect of INH that caused exudative EPEs and drug-induced lupus with positive anti-dsDNA

SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) is a rare chronic infammatory musculoskeletal disorder of unknown etiology observed in children and young adults, which involves both osteo-articular infammation and skin abnormalities. We review the case of a 22-year-old male, who presented with a 5-year history of hidradenitis suppurativa (HS), acne vulgaris, joint stiffness, and pain. Previous ineffective treatments included isotretinoin and oral antibiotics. Marked improvement of all cutaneous features was noticed after the frst dose of infliximab and methotrexate; continued treatment resulted in the complete remission of the arthritis and enthesopathy. This case report demonstrates the effcacy and safety of infiximab and methotrexate in refractory SAPHO syndrome.

Metallosis following open reduction and internal fxation (ORIF) for fracture, usually presenting as a soft tissue mass, is barely discussed in the literature. In this case report, the imaging and pathological fndings of metallosis after ORIF for a humeral fracture are presented and comprehensively discussed.