Lumbar spinal stenosis is a narrowing of the spinal canal and neural foramina resulting in nerve root compression. This condition effects most individuals over the age of 60 years old. Compression on the nerve roots can often cause a varying degree of lower back and leg pain. Unlike symptoms of lumbar herniated disc, symptoms of lumbar stenosis rarely follow a dermatomal distribution. Pain associated with lumbar stenosis usually radiates to both thighs when walking. Prolonged standing or walking increases pain down the buttock and thighs. Patients with symptomatic lumbar stenosis have a distinct gait pattern. This pattern is classically described as a hunched over wide based gait and stance. Lumbar stenosis causes compression of the proprioceptive fibers in the spine resulting in poor balance with gait. The Romberg test is often positive with lumbar stenosis. The Romberg test involves having the patient stand in one spot, feet together, and arms out to the side. The patient is then asked to stay balanced with the eyes open and then with the eyes closed. The Romberg test counts the number of seconds a patient can stay balanced with their eyes closed. A positive Romberg is found when patients are unable to maintain balance with their eyes closed.

References
1. Katz JN, Dalgas M, Stucki G, Katz NP, Bayley J, Fossel AH, Chang LC, Lipson SJ. Degenerative lumbar spinal stenosis. Diagnostic value of the history and physical examination. Arthritis Rheum. 1995 Sep;38(9):1236-41.

Non-operative treatment including a trial of activity modification, physical therapy, and NSAIDS are the first line treatment for FAI and labral tears of the hip.  Since young and active patients are often affected, any prolonged activity modification may not be acceptable.  Physical therapy can be beneficial in correcting overall mechanics, however range of motion exercises can make symptoms worse or aggravate FAI.  As previously described, continued mechanical impingement can lead to chondral wear and arthritis. Therefore, patients are instructed not to push through pain and avoid positions during activities that cause discomfort. Intra-articular cortico-steriods can be used, however the age of patient and associated risk factors should be taken into consideration.  Intra-articular injections with local anesthetic can be used for diagnostic value, and serve to confirm the hip as the pain generator, since the differential diagnosis, as previously mentioned, can be extensive.

In the prescence of FAI with an associate labral tear, bony impingement must be addressed to prevent further damage to the labrum. Repair of isolated labral tears without bony impingement lesions is also recommended if conservative treatment has failed. Isolated labral tears require a detailed history and physical ensuring other conditions in the differential are excluded. Clinical correlation is important with hip MRI, as some studies have reported high incidence (up to73%) of asymptomatic labral tears.  In other words, a labral tear on MRI may not be the source of the patient’s pain.

Operative Treatment
Both open and arthroscopic treatments are available for FAI, each with specific indications.  The open procedure involves a surgical dislocation with trochanteric osteotomy, making this a significant operation.  The advantage is that it does allow for 360 degree visualization of the femoral head. Large posterior or posterolateral CAM deformities, extra-articular impingement (ischiofemoral impingement or trochanteric impingement), and morphology that is associated with hip instability including coxa valga are often treated by open approach.  Acetabular sided morphology including dysplasia, severe acetabular retroversion, coxa profunda, and protrusio are also sometimes best addressed through an open surgical approach.

Arthroscopy is a minimally invasive approach, allowing for quicker rehab. It is typically done on an outpatient basis.  Technique can be challenging and has an associated learning curve, and does require specialized equipment.  This paper will focus on arthroscopic treatment, as this is growing in popularity.

Hip Arthroscopy
Hip Arthroscopy is one of the fastest growing fields in orthopedics.  This minimally invasive technique can be effective for treating intra-articular pathology of the hip including loose body removal, labral debridement/repair, and correction of FAI bony changes, and is usually favored to open surgical dislocation.  Hip arthroscopy has been shown to have higher functional outcome scores than open procedures with lower rates of complications.

Surgical Technique
The patient is placed supine on the operating table.  Using a hip distractor system and well-padded perineal post, approximately 10-12 mm of distraction is achieved.  Fluoroscopy is used to evaluate distraction, as well as to guide spinal needles to obtain intra-articular access. A series of dilators are used to create arthroscopic portals, taking care to avoid injury to neurovascular structures.  The most commonly described portal sites are anterior, anterolateral and distal lateral accessory portal.  A 70 degree arthroscope allows for visualization of intra-articular structures. Labral debridement may be performed if tissue is not viable, however long term results appear to be better with labral repair. Labral repair is performed using anchors and suture .  In cases of significant labral deficiency, labral reconstruction may be performed to restore labral function.  Pincer lesions can be corrected, again using fluoroscopy to evaluate bony resection .  Care is taken to keep traction time under 2 hours to avoid neurovascular injury. CAM deformities are addressed via the peripheral compartment, which can be accessed off traction, resecting bone to create a more spherical femoral head.

Rehabilitation Protocol
The post-operative course following hip arthroscopy will vary by the procedure performed and surgeon preferences.  Rehab for isolated labral debridement typically includes immediate weight bearing as tolerated and a gradual return to activities to tolerance. FAI and labral repair patients are typically on crutches, allowing for partial weight bearing for 4-6 weeks. Flexion with internal rotation should be approached cautiously.  Some surgeons elect to use post operative bracing systems, however patients will often self regulate motion.  Range of motion is progressed through weeks 2-4, along with early strengthening of quad, hamstring and gluteal muscle groups.  Lumbopelvic muscle dysfunction is often present in these patients, and should be addressed.  Functional progression occurs as weight bearing, strength, and stability allow.  Elliptical machines and jogging are often incorporated at 12-16 weeks.  Return to play for athletes varies from 12-32 weeks.  Patient education is very important when discussing returning to high level sports and repetitive impact activities, such as distance running.  The risk of exacerbating underlying chondral pathology should be taken into consideration, with emphasis on long term chondral health.

Patients should be advised of the risks and potential complications of hip arthroscopy.  Major risks that are unique to hip arthroscopy include; femoral neck fracture during application of traction, sciatic nerve injury/footdrop, pudendal nerve palsy, compartment syndrome of the leg, compartment syndrome of the abdomen from arthroscopic fluid extravasation, subsequent hip instability, AVN of the femoral head and septic arthritis.  A recent review of 6962 hip arthroscopies reported a 0.58% major complication rate, and minor complication rate of 7.5%.  Minor complications include:  re-tear of the labrum, persistent pain from degenerative arthritis, transient numbness in foot from traction boots, lateral femoral cutaneous nerve irritation, heterotopic ossification, and iatrogenic chondral injury.

Positive clinical outcomes have been reported following hip arthroscopy, ranging from 67-93% good to excellent results at 26 months. Return to play rates for athletes have been reported at 92%.  As mentioned, results of labral repair tend to be better than debridement.  Outcomes are less favorable when other underlying conditions are present including degenerative osteoarthritis, acetabular dysplasia, large posterior CAM lesions, extra-articular impingement, significant coxa valga, coxa profunda and protrusio.While these are not necessarily contraindications to arthroscopy, care should be taken to thoroughly evaluate these conditions and adjust treatment accordingly.

References
Philippon, MJ Prevalence of Abnormal Hip Findings in Asymptomatic Participants American Journal of Sports Medicine 2012 Dec;40(12):2720-4.

Beaule Three-dimensional computed tomography of the hip in the assessment of femoroacetabular impingement Journal of Orthopedic Research Nov 2005 23(6) 1286-92
Parvizi, Leunig, Ganz Femoroacetabular Impingement Journal American Academy of Orthopedic Surgeons 2007 (15) 561-70.

Pre-operative intra-articular hip injection as a predictor of short term outcome following arthroscopic management of femoroacetabular impingement  Knee surgery, sports traumatology, arthroscopy April 2014 22(4) 801-5.

Boster IB, Smith TJ, Nasser R, Domb B  Open Surgical Dislocation Versus Arthroscopy for Femoroacetabular Impingment: A Comparison of Clinical Outcomes American Journal or Orthopedics May 2014 43(5) 209-14.

Zaltz I, Kelly B, Larson C, Leunig M, Bedi A  Surgical Treatments of Femoroacetabular Impingement: What are the Limits of Hip Arthroscopy? Arthroscopy Jan 2014 30(1) 99-110.

Boster IB, Jackson TJ, Smith TW, Leonard JP, Stake CE, Domb BG Open Surgical Dislocation versus arthroscopic Treatment of FAI American Journal of Orthopedics 2014 May 43(5) 209-14.

The Learning Curve for Hip Arthroscopy: A Systematic Review Hoppe DJ, Larson CM  Arthroscopy 2014 March 30(3) 389-97.

Trends in Hip Arthroscopy Colvin AC, Harrast J, Harner C Journal of Bone and Joint Surgery 2012 Feb 15, 94(4).

Arthroscopic Labral Repair in the Hip: Surgical Technique and Review of the Literature Kelly BT, Weiland DE, Schenker ML, Philippon MJ Arthrosocpy Dec 2005 21(12) 1496-504.

Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement: mean 3.5-year follow-up  Larson CM, Giveans MR, Stone RM American Journal of Sports Medicine 2012 May 40 (5) 1015-21.

Arthroscopic Management of Femoroacetabular Impingement Osteoplasty Technique and Literature Review Philippon, MJ, Stubbs AJ, Schenker Ml, Maxwell BR, Ganz R, Leunig M  The American Journal of Sports Medicine 2007 Sept 35(9) 1571-80.

Rehabilitation After Arthroscopic Decompression for Femoroacetabular Impingement Enseki KR, Martin R, Kelly BT. Clin Sports Med. 2010 Apr;29(2):247-55.

Abdominal Compartment Syndrome After Hip Arthroscopy Justin Fowler, M.D., and Brett D. Owens, M.D. Arthroscopy 2010 Jan 26 (1) 128-30.

Osteonecrosis of the Femoral Head after Hip Arthroscopy Danielle L. Scher MD, Philip J. Belmont Jr MD, Brett D. Owens MD Clinical Orthopedics and Related Research 2010 Nov 468(11) 3121-5.

Hip Subluxation as a Complication of Arthroscopic Debridement Benali Y, Katthagen BD Arthroscopy 2009 Apr 25(4) 405-7.

A review of femoroacetabular impingement and hip arthroscopy in the athlete Tranovich MJ, Salzler MJ, Enseki KR, Wright VJ The Physician and sports medicine 201 Feb 42(1) 75-87.

Femoroacetabular impingement. Bedi A1, Kelly BT. Journal of Bone and Joint Surgery Jan 2 95(1) 82-92.

Return to Preinjury Activity Levels After Surgical Management of Femoroacetabular Impingement in Athletes.  Alradwan H, Philippon MJ, Farrokhyar F, Chu R  Arthrosocpy 2012 Oct 28(10) 1567-76.

The patient has a decreased acromiohumeral interval noted on AP x-ray of the shoulder. This distance can be measured from the undersurface of the acromion to the superior portion of the humerus. An increased distance suggests inferior subluxation which can result from a shoulder dislocation or proximal humerus fracture. A decreased distance suggests a rotator cuff tear. An intact rotator cuff places an inferiorly directed force to the humeral head relative to its position on the glenoid. A balance of an intact supraspinatus, infraspinatus, teres minor, and subscapularis tendons allows for concentric rotation of humeral head in the glenoid. A massive rotator cuff tear causes superior humeral head migration from the unopposed contraction of the deltoid. A rotator cuff tear also causes loss of negative pressure in the glenohumeral joint and escape of normal synovial fluid out of the joint that is important for healthy articular cartilage. With chronic massive rotator cuff tearing the acromion can often articulate with the humeral head. A decreasing acromiohumeral interval on serial x-rays is a sign of progressive rotator cuff disease. A decreased acromiohumeral interval is the start of the rotator cuff arthropathy cascade where articular cartilage is gradually lost and arthritis becomes evident on x-ray. A loss of dynamic stabilization of the shoulder causes repetitive trauma to the articular cartilage resulting in arthritis. 1,2
Answer B.
References
1. Nam DN, Maak TG, Raphael BS, Kepler CK, Cross MB, Warren RF. Rotator Cuff Tear Arthropathy: Evaluation, Diagnosis, And Treatment. The Journal Of Bone & Joint Surgery – Scientific Articles: 21 March 2012 – Volume 94 – Issue 6 – p. e34.
2. Ecklund, Kier J.; Lee, Thay Q.; Tibone J. Rotator Cuff Tear Arthropathy. JAAOS – Journal of the American Academy of Orthopaedic Surgeons. 15(6):340-349, June 2007.

Freiberg’s disease is a poorly understood condition in which the articular surface of the second metatarsal head begins to collapse causing pain at the second metatarsophalangeal (MTP) joint. Although less common, the condition can occur in the third and fourth metatarsal heads as well. The cause is thought to be from a disruption in the blood supply of the metatarsal head. This is why the condition is also referred to as a Freiberg’s infarction. On x-ray Freiberg’s starts with a subchondral fracture and collapse (which may only be seen on MRI) and later may progress to further collapse, joint space narrowing, and arthritis. Patients may present initially with little to no changes on x-ray and an MRI is often necessary to establish the diagnosis. Symptoms include forefoot pain that is made worse with activities and localized pain to the second metatarsal head.
Initial treatment aims at taking pressure off the effected metatarsal head. Patients can be placed in a walking boot or use a stiff shoe insert with a metatarsal pad. Activity modification and NSAIDs can help manage symptoms. A metatarsophalangeal (MTP) joint steroid injection may provide temporary relief and is particularly useful with advanced arthritic changes. If conservative treatments fail the most common operative treatment is an MTP joint arthrotomy with removal of loose bodies and osteophytes. The metatarsal head can be drilled or bone grafted to treat the collapsed metatarsal head. Metatarsal head resection is usually avoided as it increases the weight bearing load on the adjacent metatarsal heads.
References
1. Freiberg’s disease. http://www.orthobullets.com. Accessed on 10/21/2017.
2. Freiberg’s disease. http://www.aofas.org. Accessed on 10/21/2017.

AP and lateral radiographs above show a left greater trochanteric fracture. Isolated fractures of the greater trochanter usually result from direct impact. Controversy exists as to the best way to treat isolated greater trochanter fractures. It is difficult to establish a definitive diagnosis when plain films cannot rule out a possible occult fracture extension to the lesser trochanter. CT or MRI should be performed to rule out fracture extension; if negative, immediate weight-bearing as tolerated can be initiated. Fracture extension seen on MRI or CT identifies an unstable fracture pattern and open reduction and internal fixation should be performed with a sliding hip screw or intramedullary nail.  Follow-up radiographs should be obtained to monitor for displacement of non-operative greater trochanter fractures secondary to the pull of the gluteus medius and gluteus minimus muscles.

References
Lalond B, Fenton P, Campbell A, Wilson P, Yen D. Immediate weight bearing in suspected isolated greater trochanter fractures as delineated by MRI. Iowa Orthop J. 2010; 30. 201-204.