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A 40-year-old orthopedic surgeon felt a pop while lowering the bar to his chest during a bench pressing session. There was sudden pain and loss of strength in his left arm. Physical exam shows ecchymosis over the anterior biceps. There is a palpable defect and a deformity of the anterior axillary fold. There are no neurologic deficits. 

   In addition to Xrays, what additional imaging studies would you obtain to determine treatment?

	None - Xrays are enough
	Ultrasound
	CT Scan
	MRI
	CT Scan and MRI
	CT and Ultrasound

 How would you treat this patient considering the MRI shows a tendon avulsion from the bone?

	Nonoperative (Sling with eventual PT)
	Operative

  If you choose Operative treatment, what fixation technique would you use on the humerus?

	Transosseous suture repair with cortical trough
	Suture Anchor - Biocomposit/PEEK Screw
	Suture Anchor - All-suture (e.g. JuggerKnot)
	Cortical Button Fixation
	I would Not perform operative treatment

  If you choose Operative treatment, would you augment it with biologics?

	No - I would not use biologics
	Yes - PRP
	Yes - BMAC
	Yes - Amnion
	Yes - PRP and BMAC
	I would Not perform operative treatment

  If you choose Operative fixation, how long would you keep the patient in the sling?

	2 weeks
	3 weeks
	4 weeks
	5 weeks
	6 weeks
	I would Not perform operative treatment

  If you choose Operative treatment, when would you allow return to sport and athletics that require contact and forceful abduction?

	3 months
	4 months
	5 months
	6 months
	I would Not perform operative treatment

DISTAL CLAVICLE FRACTURE IN 27M

A 27-year-old male, right hand dominant, presents with left shoulder pain after a motorcycle accident. The patient works in an office and is recreationally active, playing basketball among other activities. On physical exam there is some tenting, he has no neurovascular deficits. He is a non-smoker with no significant PMH. 

 Would you use a classification system to help determine treatment?

	No - a classification system does not help me
	Yes - Neer Classifications System
	Yes - AO Classification
	Yes- OTA classification
	Outside my area of expertise - best if I don't vote

  How would you treat this injury?

	Nonoperative (Sling)
	Operative (ORIF)
	Outside my area of expertise - best if I don't vote

   If you choose Operative Treatment (ORIF), what would you do?

	Fracture (Interfragmentary) Fixation Alone
	Coracoclavicular Stabilization/Augmentation Alone
	Fracture (Interfragmentary) Fixation AND Coracoclavicular Stabilization/Augmentation
	I would not choose operative treatment
	Outside my area of expertise - best if I don't vote

 If you choose Fracture (Interfragmentary) Fixation, what fixation technique would you use?

	Intramedullary fixation
	Hook plate
	Dynamic compression plate
	T Plate
	Small Fragment Plate
	K-wire plus tension band wiring
	I would NOT perform Operative treatment
	Outside my area of expertise - best if I don't vote

 If you choose Coracoclavicular Stabilization/Augmentation, how would you do it?

	Cortical flip button
	Suture Anchors
	CC screw (Bosworth)
	Loop Suture (suture passed around the base of the coracoid)
	CC ligament reconstruction with coracoacromial (CA) ligament (Modified Weaver-Dunn)
	CC ligament reconstruction with free tendon graft
	I would NOT perform Operative treatment
	Outside my area of expertise - best if I don't vote

ACETABULAR FRACTURE IN 63M   

A 63-year-old male fell 2 meters from a ladder at work onto a concrete floor. He presents to an outside hospital and was then transferred to our ED with right hip pain. He works as a carpenter. The patient complains of right hip pain only. He denies any other injuries and pain elsewhere, and denies loss of consciousness. The patient smokes 1 pack per day smoker for the last 40 years. On physical exam there are no open wounds in his pelvis and right lower extremity. He is tender to palpation around the right hip with no overt ecchymosis. His ROM is limited by pain. Distally his neurovascular status is intact.

 How would you classify this acetabular fracture?

	Anterior column
	Transverse
	Transverse plus posterior wall
	T-Type
	Posterior column
	Posterior wall
	Both column
	Outside my area of expertise - best if I don't vote

  What would be your definitive treatment approach for this patient?

	Nonoperative - Protected Weight Bearing
	Nonoperative - Closed treatment with Skeletal Traction
	Operative - Closed Reduction & Percutaneous Screw Fixation
	Operative - Open Reduction and Internal Fixation

  If choosing Open Reduction and Internal Fixation, which Surgical Approach would you use?

	Ilioinguinal
	Iliofemoral
	Modified stoppa (Anterior intrapelvic approach)
	Modified stoppa (Anterior intrapelvic approach) with a lateral window
	Posterior Kocher-Langenbach
	Extensile - Extended iliofemoral
	I would not perform Open Reduction and Internal Fixation in this patient

 If you performed a Modified stoppa (Anterior Intrapelvic Approach) with a lateral window, would you perform an ASIS Ostetomy

	No
	Yes - ASIS osteotomy - fixation with an independent lag screw(s)
	Yes - ASIS osteotomy - fixation with recon plate
	I would not perform a Modified stoppa (Anterior intrapelvic approach)

 If choosing Open Reduction and Internal Fixation, assuming you obtained adequate fixation when would you typically allow weight bearing as tolerated?

	Within 2 weeks
	3-4 weeks
	5-6 weeks
	7-8 weeks
	9-12 weeks
	>12 weeks
	I would not perform Open Reduction and Internal Fixation in this patient

 If choosing Open Reduction and Internal Fixation, what would you use for DVT Prophylaxis?

	Mechanical compression (SCDs) only
	Aspirin
	Low molecular weight heparin (ie., Lovenox)
	Coumadin
	Factor Xa inhibitor (ie., Xarelto)
	I would not perform Open Reduction and Internal Fixation in this patient

 Would you provide heterotopic ossification (HO) prophylaxis? If so, which type?

	No - I would not prescribe HO prophylaxis
	Yes - Radiation therapy
	Yes - Indomethacin
	Yes - Oral NSAIDs only
	Yes - IV Toradol then oral NSAIDs
	I would not perform Open Reduction and Internal Fixation in this patient

PERSISTENT BACK PAIN, URINARY RETENTION
18-MONTHS AFTER L2 FRACTURE

18 months ago
A 41-year-old male fell from ladder in May of 2018. At that time he presented to the ER with back pain only. He denied subjective weakness in his lower extremity or bowel or bladder symptoms. His physical exam showed no deficits. After a discussion regarding treatment options, he elected to proceed with nonoperative treatment in a TLSO.

17 months ago
He was watched radiographically and clinically over first 8 weeks and there was no progression of his kyphosis or onset of neurologic symptoms.

5 months ago
The patient presents with persistent back pain, and some feeling of weakness to hip flexion and pain in anterior thighs. He denies any bowel or bladder symptoms. Physical exam shows some trace weakness to b/l hip flexion only, full strength in all other motor groups. Transforaminal selective nerve root injections a L2/3 improved his pain in the anterior thighs.

1 weeks ago
In December 2019, the patient presents to the emergency room with back pain and some bladder symptoms, and he is told he has urinary retention due to his fracture. 

Current Exam
Current physical exam shows he has 4-5 of 5 hip flexion weakness b/l. He has some trace weakness to knee extension on left, normal knee extension on right. Normal ankle dorsal flexion and ankle plantar flexion bilaterally. He has normal patellar reflexes.


   Now that it is 18 months years after his initial fracture, and he has progressive back pain, some hip flexion weakness, and reports of urinary retention, how would you treat this patient at this time?

	Nonoperative
	Operative

 If you choose operative treatment at this time, how would you approach this?

	Anterior Only
	Posterior Only
	Anterior-Posterior (L2 corpectomy)

  If you choose an Anterior-Posterior (L2 corpectomy), what anterior approach would you use?

	Standard Retroperitoneal
	Direct Lateral (e.g., XLIF)
	Oblique Lateral (e.g, OLIF)
	I would NOT do a Anterior-Posterior (L2 corpectomy)

  If you choose an Anterior-Posterior (L2 corpectomy), how would you do your decompression for stenosis at L2?

	Indirect Decompression only (no laminectomy, leave posterior cortex of L2)
	Decompress from front (remove posterior cortex during corpectomy)
	Decompress from back (L2 laminectomy, do not remove posterior cortex during corpectomy)
	Decompress from front and back (L2 laminectomy, remove posterior cortex during corpectomy)
	I would NOT do a Anterior-Posterior (L2 corpectomy)

  If you choose an Anterior-Posterior (L2 corpectomy), how would you instrument and fuse from the back?

	Instrument & Fusion TWO levels above and below
	Instrument & Fusion ONE level above and below
	Instrument TWO levels above and below, fuse ONE level above and below (instrument long, fuse short)
	I would NOT do a Anterior-Posterior (L2 corpectomy)

   If you choose an Anterior-Posterior (L2 corpectomy), would you do the anterior or posterior first, and would you do it all in the same day?

	Anterior First - then posterior - same day
	Posterior first - then anterior - same day
	Anterior First - then posterior - different days
	Posterior first - then anterior - different day
	I would NOT do a Anterior-Posterior (L2 corpectomy)

   If you performed an Anterior-Posterior (L2 corpectomy + cage), would you put BMP in the cage?

	No - I would not use BMP in the cage
	Yes - I would put BMP in the cage
	I would NOT do a Anterior-Posterior (L2 corpectomy)

 If you performed an Anterior-Posterior (L2 corpectomy + cage), how much would you distract/expand your cage (assuming expandable cage)?

	Leave at existing height - do not distract
	Distract to pre-fracture vertebral body height
	Over distract by 10% above pre-fx height to get extra lordosis and open foramen
	I would NOT do a Anterior-Posterior (L2 corpectomy)

 If you did a Posterior Only approach, what would you do?

	Posterior Fusion Only (No Decompression with laminectomy)
	Posterior Fusion and L2 Laminectomy only
	Posterior Fusion and Corpectomy with Cage (from back by removing partial pedicle)
	I would not do a Posterior Only approach

  If performing posterior instrumentation 2 levels above and below, how would you do it?

	Percutaneous Screws - Using Fluoro
	Percutaneous Screws - Using Inraop CT Navigation
	Open Screws - Using Fluoro
	Open Screws - Using Intraop CT Navigation
	Open Screws - Using Anatomic Technique
	I would not instrument posterior 2 levels above and below

Distal Radius Fracture in 32M

A 32-year-old male presents with left wrist pain following a fall down the steps at home onto an out-stretched left hand. He has localized pain at the left wrist. He denies numbness in his hand.

He is otherwise healthy and works as a manual laborer.

On physical examination, the injury is isolated, closed, with moderate swelling and tenderness about the wrist. His neurovascular exam is normal.

 How would you manage this injury?

	Nonoperative (closed reduction, immobilization)
	Operative

 If you choose Operative management, when would you take this patient to surgery?

	I would not choose Operative management
	Same-day
	<1 week
	1-2 weeks
	>2 weeks

 If you choose Operative management, what surgical technique would you use?

	I would not choose Operative management
	External fixation only (ExFix)
	Closed reduction percutaneous pinning only (CRPP)
	Open reduction internal fixation only (ORIF)
	Dorsal bridge plate only (DBP)
	ExFix + CRPP
	ORIF + CRPP
	DBP + CRPP

 If you choose Open reduction internal fixation (ORIF), what approach would you use?

	I would not choose ORIF
	Volar only
	Dorsal only
	Volar + Radial
	Dorsal + Radial
	Dorsal + Volar
	Volar + Radial + Dorsal

Ankle Arthritis s/p Ankle Fx ORIF in 52M

A 52-year-old male presented with chronic ankle pain. He had an ankle fracture that was fixed 4 years prior. He has global ankle pain and profound stiffness. He had a bone scan and CT scan rule that showed no evidence of osteomyelitis.

PMH: Unremarkable. No history of diabetes or peripheral vascular disease. 

PE: LLE shows gross deformity, antalgic gait, and intact skin w/o changes, TTP globally about ankle, NVID w/ SILT and W/WP foot.


 Would you obtain any additional infection work-up?

	No - this would not affect my management
	Serum labs (CBC, ESR, CRP) only
	Aspirate (gram stain, cell count, etc.) only
	Open biopsy (gram stain, cultures) only
	Serum labs + Aspirate
	Serum labs + Open biopsy
	Aspirate + Open biopsy
	Serum labs + Aspirate + Open biopsy

 If you choose Operative management, in addition to possible hardware removal (HWR) what surgery would you perform?

	I would not choose Operative managementI would not choose to use Autograft
	I would perform HWR only
	Revision ORIF
	Arthrodesis
	Arthroplasty
	Amputation

 If you choose Tibiotalocalcaneal (TTC) Arthrodesis, what implant(s) would you use?

	I would not choose TTC Arthrodesis
	External fixation only (includes monoplanar, ringed circular fixation, etc.) (Includes limited internal fixation)
	Percutaneous fixation (screws) only
	Plate and screws
	Intramedullary nail (IMN)

 If you choose Tibiotalocalcaneal (TTC) Arthrodesis, would you prepare the tibiotalar and/or subtalar joints?

	I would not choose TTC Arthrodesis
	No - I would not prepare either joint
	Yes - Subtalar joint only
	Yes - Tibiotalar joint only
	Yes - Tibiotalar + Subtalar joints

 If you choose Operative management and attained the construct shown below, what would your immediate post-operative weight-bearing status be?

	I would not choose Operative management
	Non-weight-bearing (NWB)
	Toe-touch/Foot-flat weight-bearing (TTWB/FFWB)
	Partial/protected (25-50%) weight-bearing (PWB)
	Weight-bearing as tolerated (WBAT)

Proximal Both Bone Forearm
Fracture in 28M

A 28-year-old male involved in a high-energy mountain bike jump with direct impact onto the arm presents with pain and deformity of the dominant right arm. He  denies LOC or head injury. This is an isolated injury and he denies pain in the other extremities.  He also denies numbness in the hand.

His past medical history is unremarkable. He is otherwise active and healthy.

On physical exam the injury is closed, with minor superficial overlying abrasions. There is moderate swelling and deformity about the forearm. The extremity is otherwise neurovascularly intact distally with no motor or sensory deficits. The hand is warm and well-perfused with a 2+ symmetric radial pulse.


  If you choose Operative management, how would you plan to definitively manage this injury?

	I would not choose operative management
	External fixation
	Percutaneous pinning (include post-op casting)
	Flexible IM rods
	Open reduction internal fixation (ORIF)

 If you choose ORIF, which bone would you fix first?

	I would not choose ORIF
	Ulna
	Radius

 If you choose ORIF of the radius, what implant would you use??

	I would not choose ORIF of the radius
	2.7mm plate
	3.5mm LC/DCP plate
	3.5mm recon plate
	1/3rd tubular plate

 If you choose ORIF, what approach would you use for the radius?

	I would not choose ORIF
	Volar Henry
	Dorsal Thompson
	Lateral elbow approach (Kaplan)

COMMINUTED PROXIMAL HUMERUS FX IN 72M   

 How would you treat this injury?

	Nonoperative (sling)
	Operative
	Outside my area of expertise - best if I don't vote

 If you choose Operative Treatment, what would you do?

	Closed Reduction Percutaneous Pinning (CRPP)
	ORIF
	Intramedullary Nail (proximal humerus nail)
	Arthroplasty
	I would not choose operative treatment

  If you choose Arthroplasty, what procedure would you perform?

	Hemiarthroplasty
	Total shoulder Arthroplasty (TSA)
	Reverse Total Shoulder Arthroplasty (rTSA)
	I would not choose Arthroplasty
	Outside my area of expertise - best if I don't vote

  If you choose reverse TSA, would you attempt to repair the tuberosities?

	Absolutely - it is very important for clinical outcomes
	I would try - it is somewhat important
	No - it is not important
	I would not choose Reverse TSA
	Outside my area of expertise - best if I don't vote

  If you choose ORIF, what type of fixation would you choose to use?

	Heavy Nonabsorbable Sutures Only (no hardware)
	Isolated Screw Fixation +/- heavy sutures
	Locking Plate +/- heavy sutures
	I would not perform ORIF
	Outside my area of expertise - best if I don't vote

 If you choose ORIF with a locking plate, would you use an intramedullary Fibular Allograft?

	Yes - Fibular Allograft
	No
	I would not perform ORIF with locking plate
	Outside my area of expertise

CHRONIC ZONE 1 FLEXOR TENDON
LACERATION IN 17M

A 17-year-old male presents with a history of a sharp laceration in Zone I of his left middle, ring, and small fingers 4 months prior. He was told "everything was fine" at an outside hospital. He now presents 4 months after the injury with no flexion at the DIP joint on the left middle, ring, and small digit. He has no past medical or surgical history.

On physical exam, he has transverse scars on the volar middle, ring, and small fingers just proximal to the level of DIP joints. He has no flexion at the DIP joints. His neurovascular exam is intact.

Exploration at surgery found the FDP tendons to be 100% cut in Zone 1 and the proximal tendon retracted to roughly the level of the PIP joints. The tendons were fairly mobile and could be approximated at the laceration site as seen in the image on the left. 



 Considering his flexion deficit on physical exam, what imaging studies would you require to determine treatment?

	None - physical exam is sufficient
	Xrays
	CT hand
	MRI hand
	Ultrasound

 If you choose Operative Management, and intraoperative exploration found 100% rupture with retraction to the PIP joints but fairly mobile tendons (see images), how would you treat this injury?

	I would not choose Operative Management
	Irrigation and debridement of tendon edges only
	Flexor tendon Repair (Repair)
	Flexor tendon Reconstruction (Reconstruction)

 If you choose Flexor tendon Repair, what type of repair would you perform?

	I would not choose Flexor tendon repair
	Epitendinous suture repair only
	Core suture only
	Epitendinous suture repair + Core suture repair

 5) If you choose Core suture repair, how many strands would you cross the repair site?

	I would not choose Core suture repair
	2 strands
	4 strands
	6 strands

 If you choose Operative Treatment, what type of anesthesia would you perform?

	I would not choose Operative Treatment
	Wide awake (tumescent local anesthesia)
	Peripheral nerve block
	General anesthesia

 If you choose Epitendinous or Core Suture repair, what type of ROM protocol would you use?

	I would not choose Epitendinous or Core Suture Repair
	Duran protocol
	Kleinert protocol
	Mayo Synergistic Splint protocol
	St John protocol

Interprosthetic Femur Fracture in 74F

A 74 year-old female fell from standing height after tripping over a carpet. She lives with her brother and ambulates with a wheeled walker. On presentation she has pain at the left knee and hip. She denies numbness/tingling/weakness in her left lower extremity. She denies pain elsewhere.

Her PMH is significant for CVA with left sided deficits, provoked DVT and now on eliquis, HTN, HLP, OA, and breast cancer.

Her PSH is significant for left hip hemiarthroplasty, left total knee arthroplasty, cataracts, and mastectomy.

Social: She is a community ambulator with a cane.

Physical exam of her LLE shows:
Inspection: Open wound at base of fifth toe on left foot. No skin breakdown on left knee.
Palpation: TTP at distal femur, compartments soft and compressible.
Neuro exam: intact.
Vascular: DP pulse is palpable. Capillary refill time is less than 3 seconds.
 

 In addition to AP and LAT radiographs of the knee and femur, would you obtain additional imaging to guide management?

	No - AP and LAT radiographs of hip and knee are sufficient
	Yes - additional radiographic views (XR)
	Yes - CT scan of the femur (CT)
	Yes - MRI scan of the femur (CT)
	Yes - CT + XR
	Yes - MRI + XR
	Yes - MRI + CT
	Yes - MRI + CT + XR

 If you choose Operative management, what is the PRIMARY method by which would you assess implant stability?

	I would not choose Operative management
	I would NOT assess implant stability - it would not change my management
	Pre-operative imaging (includes stress films, CT scan)
	Intra-operative imaging (includes fluoroscopic stress films)
	Intra-operative direct visualization of bone-implant interface

 If you choose Operative management, which surgery would you perform?

	I would not choose Operative management
	Open reduction internal fixation (ORIF)
	Intramedullary nail fixation (IMN)
	ORIF + IMN
	Revision Arthroplasty (includes supplementary fixation)

 If you choose Open reduction internal fixation (ORIF), which construct would you use?

	I would not choose ORIF
	Lateral plate fixation only
	Lateral + medial plate fixation
	Other

 If you choose Lateral plate fixation, what type of plate would you select?

	I would not choose Lateral plate fixation
	Condylar buttress plate (non-locking)
	Locking supracondylar/periarticular plate (locking)
	Blade plate
	Dynamic condylar screw

SCAPHOID WAIST FRACTURE IN 17M ATHLETE

A 17-year-old right hand dominant male was playing basketball and sustained a ground level fall onto his outstretched right hand. He felt immediate radial-sided wrist pain with painful range of motion and pain with lifting. 

On physical exam there is mild ecchymosis over the radial wrist. Wrist range of motion is limited due to pain. He can make a composite fist with grip strength limited by pain. He is tender to palpation in the anatomic snuffbox. Radial, median, ulnar motor nerves are intact, SILT, and 2+ radial and ulnar pulses.


 Would you obtain additional imaging studies other than standard wrist and navicular view radiographs to determine treatment?

	No - current radiographs are sufficient
	Yes - CT scan of the wrist in plane of the scaphoid
	Yes - MRI of the wrist
	Yes - CT scan and MRI of the wrist
	Outside my area of expertise - best if I don't vote

 How would you manage this patient?

	Nonoperative (Immobilization)
	Operative

 If you choose Nonoperative Management, what technique would you use?

	I would not choose Nonoperative Managment
	Short arm cast, thumb free
	Short arm cast, thumb immobilized (spica)
	Long arm cast, thumb free
	Long arm cast, thumb immobilized (spica)

 If you choose Operative Management, what surgery and approach would you perform?

	I would not choose Operative Management
	ORIF with Screw fixation - Volar
	ORIF with Screw fixation - Dosal
	ORIF with Plate fixation - Volar
	ORIF with Plate fixation - Dorsal
	Percutaneous screw fixation - Volar
	Percutaneous screw fixation - Dorsal
	Outside my area of expertise - best if I don't vote

 Assuming you performed Percutaneous screw fixation and obtained the fixation seen, how long do you immobilize post-operatively?

	I would not choose Percutaneous screw fixation
	No immobilization
	1-2 Weeks
	3-4 Weeks
	5-6 Weeks
	7-8 Weeks
	>8 Weeks
	Outside my area of expertise - best if I don't vote

FEMORAL SHAFT FX IN 2F

A 2-year-old female fell while walking in the kitchen. It was a witnessed fall. She was brought to ER 30 minutes after the fall. There was no discrepancy on her history from the family. 

Her Past Medical History is negative. She lives locally with both parents. There is no history of prior fractures.

On physical exam she weighs 15 kg. She refuses to walk. She is swollen and tender to palpation over the right femur. She has no other areas of focal tenderness in her extremities. She has no abnormal skin lesions on a careful exam of her extremities.
 

 What additional work-up would you obtain to rule out child abuse assuming there are no red flags in the history (burn marks, inconsistent history, prior fractures)?

	History & Physical Alone if no red flags for abuse are found
	Skeletal survey
	Skeletal survey + head CT
	Skeletal survey + head CT + eye exam
	Skeletal survey + head CT + eye exam + child protective services evaluation
	Child protective services evaluation ONLY
	Outside my area of expertise - best if I don't vote

 How would you manage this patient?

	Nonoperative (includes Pavlik or Spica Cast application in any location)
	Operative (skin incision made)

 If you choose Nonoperative Management, how would you treat this patient?

	I would not choose Nonoperative Management
	Pavlik harness
	Spica Casting - Delayed after Traction
	Spica Casting - Immediate

 If you choose immediate or delayed Spica casting, what Type of Cast would you apply?

	I would not choose Immediate or Delayed Spica Casting
	Single-leg Spica Cast
	One-and-half-leg Spica Cast
	Double-leg Spica Cast

 If you choose Immediate Spica Casting, Where would you apply it?

	I would not choose Immediate Spica Casting
	Clinic (office)
	Emergency room
	Sedation unit
	Operating room

 If you choose Spica Casting in the Operating Room, what Type of Anesthesia would you use?

	I would not choose Spica Casting the the Operating Room
	Conscious sedation
	General anesthesia WITHOUT muscle relaxation
	General anesthesia WITH muscle relaxation
	Outside my area of expertise - best if I don't vote

Medial Knee Pain and Genu Varum in a 45M

The patient is a 45-year-old male who presents with severe right medial-sided knee pain which has been present for a number of years and progressively worsening. He notes pain is activity-related and associated with mechanical symptoms to include catching and locking, with no feelings of instability. He denies any inciting trauma. He is active duty military and has been on restricted activities for over 3 years, avoiding running or heavy lifting. He feels improvement with medial off-loader brace. He has also had multiple rounds of directed physical therapy and two prior corticosteroid injections prior to being referred to my office.

He is otherwise healthy with no past medical history. 

Focused physical examination demonstrates a profound clinical varus deformity, mildly antalgic gait with no varus thrust, moderate tenderness isolated over the medial joint line and otherwise full range of motion. Strength is 5/5 for knee flexion and extension. The knee is ligamentously stable, with genus varum that does not correct to neutral on manual stress, and the limb is neurovascularly intact. Positive McMurray and Thessaly localizing to the medial joint line. Rotational profile symmetric and within normal limits.

Radiographic parameters: Anatomic lateral distal femoral angle is 84 degrees. Mechanical lateral distal femoral angle is 90 degrees. Anatomic/mechanical medial proximal tibial angle is 81 degrees. Posterior tibial slope is 3 degrees.

 If you choose Operative management, what surgery would you perform?

	I would not choose Operative management
	Arthroscopy only (with interventions as indicated)
	Osteotomy only
	Arthroscopy + Osteotomy
	Arthroplasty

 If you choose to perform an Osteotomy, what technique would you use?

	I would not choose to perform an Osteotomy
	Medial opening-wedge high tibial osteotomy (HTO)
	Lateral closing-wedge HTO
	Focal dome HTO
	Distal femoral osteotomy (DFO)

 If you choose to perform a Medial opening-wedge high tibial osteotomy (HTO), how would you perform your cut?

	I would not choose a Medial opening-wedge HTO
	Free-hand
	Cutting guide/jig
	Computer navigated
	Robotic

 If you choose to perform a Medial opening-wedge high tibial osteotomy (HTO), how would you stabilize the osteotomy site?

	I would not choose a Medial opening-wedge HTO
	Wedge only (includes screws)
	Plate and screws (w/wo partial wedge)
	External fixation (includes ringed circular fixation)

Painful Lytic Lumbar Lesion in 16F

A 16-year-old female with long-standing low back pain presents with significantly increased pain in the past 3-5 months. She also recently developed left leg radicular pain mainly in the S1 dermatomal pattern.

On physical exam she is a healthy appearing female, appropriately developed. She has tenderness to palpation at the lumbosacral junction. She has no nerve tension signs and 5/5 motor in bilateral lower extremities. Sensation is intact in all dermatomes, Reflexes are equal and symmetric. She has no skin lesions.

Imaging obtained and CT guided biopsy performed. Core biopsy was consistent with Giant Cell Tumor. 


  How would you treat this patient?

	Medical Management Only (Denosumab +/- Bisphosphonates)
	Operative Resection & Reconstruction
	Combined Operative and Medical (Denosumab +/- Bisphosphonates)
	Outside my area of expertise - best if I don't vote

  If choosing Operative Resection & Reconstruction, what approach would you do?

	Posterior Only Procedure
	Anterior Only Procedure
	Combined Anterior and Posterior Procedure
	Outside my area of expertise - best if I don't vote

	Ethanol
	Phenol
	Hydrogen Peroxide
	Argon Laser
	Multiple of above
	I would not perform adjuvent treatment
	Outside my area of expertise - best if I don't vote

	Bone cement in vertebral body only
	Posterior Spinal Fusion from L5 to S1 Only (no cage or cement)
	Bone cement in vertebral body and Posterior Spinal Fusion from L5 to S1 Only
	Corpectomy, Expandable Cage, Posterior Spinal Fusion from L5 to S1
	I would not perform operative treatment
	Outside my area of expertise - best if I don't vote

  If you choose an Anterior Approach in this patient, would you also do an anterior approach if the patient was male?

	Yes - I would still do a Anterior Approach if the patient was male
	No - in a male I would not due to the risk of retrograde ejaculation
	I would not perform an Anterior Approach in either sex
	Outside my area of expertise - best if I don't vote