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3. Adult Reconstruction (Hip & Knee) MCQs

Practice Set 109 of 326

This practice set contains high-yield board review questions covering key concepts in 3. Adult Reconstruction (Hip & Knee). Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 2161

Topic: 3. Adult Reconstruction (Hip & Knee)

During a complex revision total hip arthroplasty, an extended trochanteric osteotomy (ETO) is performed to aid in cement removal. To ensure optimal osseous healing of the osteotomized fragment, preservation of which of the following muscle attachments is most critical for its vascular supply?

. Gluteus maximus
. Gluteus medius
. Vastus lateralis
. Vastus medialis
. Iliopsoas

Correct Answer & Explanation

. Vastus lateralis

Explanation

The ETO fragment relies heavily on the vastus lateralis muscle pedicle and its blood supply from the first perforating branch of the profunda femoris. Preserving this attachment is critical to ensure osseous healing of the osteotomy site.

Question 2162

Topic: 3. Adult Reconstruction (Hip & Knee)

A 62-year-old male with a primary total hip arthroplasty (titanium stem, cobalt-chromium head, highly cross-linked polyethylene liner) presents 5 years postoperatively with vague groin pain. Radiographs show well-fixed components. Aspiration yields sterile fluid with a macrophage predominance. Blood tests show elevated cobalt but normal chromium levels. What is the most likely diagnosis?

. Mechanically assisted crevice corrosion at the head-neck taper
. Bearing surface wear of the highly cross-linked polyethylene
. Type IV delayed hypersensitivity to titanium
. Aseptic loosening of the acetabular component
. Galvanic corrosion at the stem-cement interface

Correct Answer & Explanation

. Mechanically assisted crevice corrosion at the head-neck taper

Explanation

Elevated serum cobalt with normal chromium in a metal-on-polyethylene THA indicates mechanically assisted crevice corrosion (trunnionosis) at the head-neck junction. This can cause adverse local tissue reactions (ALTR) presenting as pain and sterile effusions.

Question 2163

Topic: 3. Adult Reconstruction (Hip & Knee)

A 68-year-old female with a history of a multi-level lumbar fusion (L2-Pelvis) is undergoing a primary total hip arthroplasty. How should the acetabular cup positioning be altered to prevent impingement and posterior dislocation?

. Standard Lewinnek safe zone placement
. Increased anteversion and increased inclination
. Decreased anteversion and decreased inclination
. Standard anteversion but decreased inclination
. Increased anteversion but standard inclination

Correct Answer & Explanation

. Increased anteversion and increased inclination

Explanation

A fused lumbar spine reduces spinopelvic mobility, meaning the pelvis cannot naturally retrovert during sitting to increase acetabular anteversion. To prevent anterior impingement and posterior dislocation when sitting, the cup must be placed in greater anteversion and inclination than the traditional safe zone.

Question 2164

Topic: Total Hip Arthroplasty (THA)

An 81-year-old, low-demand female sustains a Vancouver B3 periprosthetic femur fracture around a cemented stem. Radiographs demonstrate a loose stem with profound loss of proximal femoral bone stock extending into the subtrochanteric region. What is the most appropriate surgical management?

. ORIF with a locking plate and cortical strut allografts
. Revision THA with a long cemented stem
. Proximal femoral replacement (megaprosthesis)
. Revision THA with a fully porous-coated cylindrical stem
. Impaction bone grafting with a standard length stem

Correct Answer & Explanation

. Proximal femoral replacement (megaprosthesis)

Explanation

A Vancouver B3 fracture is characterized by a loose stem and severely deficient proximal bone stock. In elderly, low-demand patients, a proximal femoral replacement provides immediate stability and allows for early, unrestricted weight-bearing.

Question 2165

Topic: 3. Adult Reconstruction (Hip & Knee)
When compared to patients with a body mass index (BMI) lower than 35, patients with a BMI above 40 who undergo primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) are likely to have
. smaller incisions.
. increased wound complications.
. fewer 30- and 90-day readmissions.
. lower rates of patient satisfaction.

Correct Answer & Explanation

. increased wound complications.

Explanation

Several clinical series as well as national database analyses have shown that morbidly obese patients undergoing THA/TKA are at increased risk for wound complications and 30- and 90-day readmissions. These patients’ incisions are typically larger because of the size of the soft-tissue envelope; although their clinical scores following successful THA/TKA often are lower than scores for controls, the overall change in clinical function and satisfaction is equivalent among nonobese and obese patients.

Question 2166

Topic: 3. Adult Reconstruction (Hip & Knee)
A 45-year-old woman has had progressive right shoulder pain for the past 6 months. She notes that the pain disrupts her sleep, she has pain at rest that requires the use of narcotic analgesics, and she has limited use of her left shoulder for most activities of daily living. History reveals the use of corticosteroids for systemic lupus erythematosus. Examination shows diminished range of motion. Radiographs of the right shoulder are shown in Figures 4a and 4b. Treatment should consist of
. core decompression of the humeral head.
. humeral arthroplasty.
. total shoulder arthroplasty.
. glenohumeral arthrodesis.
. vascularized fibular allograft.

Correct Answer & Explanation

. humeral arthroplasty.

Explanation

Humeral arthroplasty provides excellent pain relief and function for stage IV osteonecrosis with humeral collapse. In late disease with glenoid involvement (stage V), total shoulder arthroplasty is preferred. Some authors have reported satisfactory results with core decompression of the humeral head for early stages of osteonecrosis, but results for stage IV osteonecrosis are less satisfactory when compared with those for humeral arthroplasty.

Question 2167

Topic: 3. Adult Reconstruction (Hip & Knee)
Figures 57a through 57c show the radiographs of a patient who has pain, discomfort, and a popping sensation localized to the posterior aspect of the knee after undergoing primary left total knee arthroplasty 6 months ago. Examination reveals that the patient is able to ambulate without a limp. There is no significant swelling, erythema, or effusion. Range of motion is 0 degrees to 115 degrees, and a palpable crepitation or snapping is detected at the posterior lateral joint line. What is the most likely diagnosis?
. Popliteal snapping syndrome
. Patellar clunk syndrome
. Subluxation secondary to a tight posterior cruciate ligament
. Soft-tissue irritation secondary to retained polymethylmethacrylate
. Patellar subluxation secondary to a tight lateral retinaculum

Correct Answer & Explanation

. Popliteal snapping syndrome

Explanation

Popliteal snapping syndrome represents the most likely diagnosis. Barnes and Scott noted that the popliteus tendon can be a potential source of internal derangement after total knee arthroplasty. They noted that it can be subluxated anteriorly and posteriorly over a retained lateral femoral condyle osteophyte. Allardyce and associates described the condition as a popliteus condition, snapping as it rolls over a retained lateral femoral condylar osteophyte.

Question 2168

Topic: 3. Adult Reconstruction (Hip & Knee)

A 70-year-old man has a posterior dislocation 20 years after undergoing cementless THA with a metal-on-polyethylene bearing. Acetabular inclination is 55 degrees with neutral version. This is his third dislocation, and he has been treated with closed reduction 3 times during the past month. His ESR is 42 mm/h (reference range [rr], 0-20 mm/h) and CRP level is 16.2 mg/L (rr, 0.08-3.1 mg/L). Joint aspiration reveals a cell count of 865 cells (55% neutrophils).

. Isolated head and liner revision
. stage exchange
. Acute hemodialysis
. Femoral component revision
. Acetabular component revision
. Revision total hip (all components)

Correct Answer & Explanation

. Acetabular component revision

Explanation

DISCUSSIONTreatment options for various pathologic conditions after THA can be challenging, and there are often multiple potential options. Question 91 involves a patient who has fractured a modular ceramic acetabular liner, and an isolated head and liner exchange should be sufficient. Question 92 involves a patient with markedly elevated serum metal ions and abductor dysfunction, suggesting poor bearing function and a probable adverse local tissue reaction (ALTR). Additionally, the acetabular component position is suboptimal, and completeacetabular revision would be appropriate. Question 93 involves a patient with elevated serum metal ions, with cobalt disproportionately higher than chromium in a roughly 7:1 ratio, suggesting corrosive changes at the prosthetic femoral neck (trunnionosis). Cross-sectional imaging continues to be a key part of the evaluation and treatment of patients with metal reactions. This patient’s pain and Trendelenburg gait are suggestive of ALTR. An isolated head and liner exchange should be performed, typically using a ceramic head and titanium sleeve adapter. Question 94 involves late, recurrent instability, probably related to bearing surface wear and acetabular component position. Continued nonsurgical management is unlikely to succeed at this point, so it would be appropriate to proceed with acetabular component revision.

Question 2169

Topic: 3. Adult Reconstruction (Hip & Knee)

A large circumferential proximal femoral allograft is to be used in the reconstruction of a failed femoral component in a total hip arthroplasty. To enhance fixation of the graft to the implant, which of the following strategies should be used?

. Modern cement technique
. Porous-coated stem
. Nonporous press-fit stem
. Hydroxyapatite-coated stem
. Cerclage wire fixation

Correct Answer & Explanation

. Modern cement technique

Explanation

The optimum treatment is cementing the implant to the allograft. Press-fit stability is unreliable. Wires and screws may be used for an incomplete proximal femoral allograft but cannot be used to anchor a complete proximal femoral allograft. Allan DG, Lavoie GJ, Rudan JF, et al: The use of allograft bone in revision total hip arthroplasty, in Friedlaender GE, Goldberg VM (eds): Bone and Cartilage Allografts: Biology and Clinical Applications. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1991, pp 263-264. Gross AE, Lavoie MV, McDermott P, Marks P: The use of allograft bone in revision of total hip arthroplasty. Clin Orthop 1985;197:115-122.

Question 2170

Topic: 3. Adult Reconstruction (Hip & Knee)

A 60-year-old woman reports a painful hip arthroplasty after undergoing surgery 18 months ago. Radiographs show stable cementless implants without signs of ingrowth. Laboratory studies show an erythrocyte sedimentation rate of 50 mm/h. Management should now consist of

. a technetium Tc 99m scan.
. an indium scan.
. an ultrasound examination.
. aspiration.
. revision.

Correct Answer & Explanation

. aspiration.

Explanation

Significant elevation of the erythrocyte sedimentation rate in a patient with a painful hip arthroplasty mandates a complete work-up for infection prior to considering revision surgery. Reproducibility and reliability of ultrasonography as a diagnostic test still needs clarification. Aspiration is the easiest and most cost-effective test and should be performed prior to nuclear imaging. The latter is most valuable if the results are negative, strongly predicting the absence of infection. Barrack RL, Harris WH: The value of aspiration of the hip joint before revision total hip arthroplasty. J Bone Joint Surg Am 1993;75:66-76.

Question 2171

Topic: 3. Adult Reconstruction (Hip & Knee)

A 52-year-old woman has bicompartmental osteoarthritis following patellectomy. Treatment should consist of

. high tibial osteotomy.
. arthroscopic debridement.
. patella arthroplasty.
. total knee arthroplasty.
. knee arthrodesis.

Correct Answer & Explanation

. total knee arthroplasty.

Explanation

The patient has extensive degenerative changes in both the medial and lateral compartments within the knee; therefore, arthroscopic debridement or an osteotomy will not be helpful. A patellar arthroplasty will not address the medial and lateral compartments. Because the extensor mechanism provides a significant amount of anteroposterior stability, a posterior cruciate-substituting total knee arthroplasty is the treatment of choice for this patient. Martin SD, Haas SB, Insall JN: Primary total knee arthroplasty after patellectomy. J Bone Joint Surg Am 1995;77:1323-1330.

Question 2172

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 24 shows the radiograph of an otherwise healthy 56-year-old patient who reports hip pain after undergoing a primary cementless hip replacement 4 months ago. The next most appropriate step should consist of

Hip 2001 Practice Questions: Set 3 (Solved) - Figure 4

. indomethacin for 3 months.
. C-reactive protein and a sed rate.
. MRI scan.
. bone scan.
. follow-up radiograph in 3 months.

Correct Answer & Explanation

. C-reactive protein and a sed rate.

Explanation

Periosteal new bone formation is a warning sign of prosthetic infection. Indomethacin may prevent heterotopic ossification if given early enough; however, it is irrelevant in this patient. A C-reactive protein and a sed rate are useful screening studies that add to the predictive value of the radiographs and may be performed routinely if sepsis is suspected. A bone scan obtained 4 months after surgery would show increased uptake in all cases. If results of a sed rate and C-reactive protein are normal, then a biopsy should be considered to rule out a neoplasm.

Question 2173

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 24 shows the radiograph of a 47-year-old woman who has severe right hip pain and a limp. Management should consist of

Hip Board Review 2004: High-Yield MCQs (Set 4) - Figure 6

. acetabular osteotomy.
. femoral and acetabular osteotomy.
. total hip arthroplasty using standard trochanter osteotomy and cementless components.
. total hip arthroplasty using femoral shortening osteotomy and cementless components.
. total hip arthroplasty using femoral shortening osteotomy, a cemented socket, and a cementless femoral component.

Correct Answer & Explanation

. total hip arthroplasty using femoral shortening osteotomy and cementless components.

Explanation

Femoral shortening osteotomy for a Crowe type IV hip dislocation has been shown to provide superior results with minimal complications. Cementless fixation of the stem allows for modular implants that greatly simplify the reconstruction.

Question 2174

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 2 shows the AP radiograph of an 18-year-old woman with progressive and severe right hip pain. Nonsteroidal anti-inflammatory drugs no longer control her pain. What is the next most appropriate step in management?

Hip 2004 Practice Questions: Set 1 (Solved) - Figure 3

. Total hip arthroplasty
. Single innominate (Salter) osteotomy
. Chiari osteotomy
. Periacetabular osteotomy
. Varus intertrochanteric osteotomy

Correct Answer & Explanation

. Periacetabular osteotomy

Explanation

A concentric hip with acetabular dysplasia in a symptomatic patient is best treated by periacetabular osteotomy. The Salter osteotomy is less optimal because the method has limited correction, is uniaxial, cannot be tailored to the deformity, and lateralizes the entire hip joint, thereby increasing the joint reactive forces. Because the hyaline cartilage of the joint is histologically normal, rotating the hyaline cartilage into an optimal position is preferable to augmenting the acetabulum with a shelf or by Chiari osteotomy. Varus intertrochanteric osteotomy has no significant role in the treatment of acetabular dysplasia. Total hip arthroplasty may be required in the future but should not be the first choice.

Question 2175

Topic: 3. Adult Reconstruction (Hip & Knee)

Figures 11a and 11b show the radiographs of a 50-year-old man who was struck by a car. Treatment should consist of

. cemented bipolar hemiarthroplasty.
. cementless bipolar hemiarthroplasty.
. hybrid total hip arthroplasty.
. cementless total hip arthroplasty.
. open reduction and internal fixation.

Correct Answer & Explanation

. open reduction and internal fixation.

Explanation

The patient has a displaced femoral neck fracture. Although the treatment remains controversial, most clinicians advocate either a closed or open reduction in younger active patients. Achieving an anatomic reduction is necessary to avoid loss of reduction, nonunion, or osteonecrosis. An acceptable reduction may have up to 15 degrees of valgus angulation and 10 degrees of posterior angulation. Parallel multiple screws or pins are the most common method of internal fixation. Prosthetic replacement is generally reserved for older and less active individuals. Callaghan JJ, Dennis DA, Paprosky WG, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, pp 97-108.

Question 2176

Topic: 3. Adult Reconstruction (Hip & Knee)

A 35-year-old male laborer with isolated posttraumatic degenerative arthritis of the right hip undergoes the procedure shown in Figure 8. What is the most appropriate position of the right lower extremity?

Hip 2004 Practice Questions: Set 1 (Solved) - Figure 22

. 0 degrees of flexion, 10 degrees of abduction, 0 degrees of rotation
. 15 degrees of flexion, 20 degrees of abduction, 15 degrees of external rotation
. 20 degrees of flexion, 10 degrees of abduction, and 5 degrees of external rotation
. 30 degrees of flexion, 5 degrees of adduction, and 5 degrees of external rotation
. 45 degrees of flexion, 10 degrees of adduction, 0 degrees of rotation

Correct Answer & Explanation

. 30 degrees of flexion, 5 degrees of adduction, and 5 degrees of external rotation

Explanation

The primary indication for hip arthrodesis is isolated unilateral hip disease in a young, active patient. Avoiding abductor damage and preserving proximal femoral anatomy are imperative to allow conversion to a future total hip arthroplasty. Optimal positioning is 30 degrees of flexion to allow swing-through. Neutral abduction and adduction and slight external rotation allow the most efficient gait while allowing sufficient support in stance. A small degree of adduction is acceptable for a successful hip arthrodesis. Callaghan JJ, Brand RA, Pedersen DR: Hip arthrodesis: A long term follow-up. J Bone Joint Surg Am 1985;67:1328-1335.

Question 2177

Topic: 3. Adult Reconstruction (Hip & Knee)

A 57-year-old man with type I diabetes mellitus has had a tender, erythematous right sternoclavicular joint for the past 2 weeks. Radiographs reveal mild osteolysis without arthritic changes, within normal limits. Management should consist of

Upper Extremity 2005 Practice Questions: Set 1 (Solved) - Figure 28

. MRI.
. sternoclavicular joint aspiration.
. incision and drainage.
. IV antibiotics.
. nonsteroidal anti-inflammatory drugs.

Correct Answer & Explanation

. sternoclavicular joint aspiration.

Explanation

Sternoclavicular joint sepsis is a rare condition that is most often restricted to patients who are immunocompromised, diabetic, or IV drug abusers. Examination commonly reveals a tender, painful, and possibly swollen sternoclavicular joint. If suspicion remains high following a thorough history, physical examination, radiographs, and routine blood tests, joint aspiration should be performed prior to incision and drainage or administration of antibiotics. Bremner RA: Monarticular noninfected subacute arthritis of the sternoclavicular joint. J Bone Joint Surg Br 1959;41:749-753.

Question 2178

Topic: 3. Adult Reconstruction (Hip & Knee)

A 66-year-old woman who requires a cane for ambulation now notes increasing difficulty in using the cane after undergoing total elbow arthroplasty 3 months ago. AP and lateral radiographs are shown in Figures 15a and 15b. What is the most likely diagnosis?

. Ulnar nerve neuritis
. Triceps insufficiency
. Aseptic loosening
. Instability
. Infection

Correct Answer & Explanation

. Triceps insufficiency

Explanation

The lateral radiograph reveals a triceps avulsion with a small portion of bone. Triceps weakness and insufficiency can be a symptomatic problem after total elbow arthroplasty and is probably underreported. Ulnar nerve neuritis, aseptic loosening, instability, and infection are all complications of total elbow arthroplasty but would not account for the radiographic findings. Koval K (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orhthopaedic Surgeons, 2002, pp 323-327.

Question 2179

Topic: Total Hip Arthroplasty (THA)

A 44-year-old woman has bilateral knee pain, and history reveals bilateral hip replacements. Radiographs are seen in Figure 28a, and histopathologic specimens from the total hip replacement are shown in Figures 28b and 28c. Laboratory studies reveal anemia. What is the most likely diagnosis?

. Osteoarthritis
. Rheumatoid arthritis
. Pigmented villonodular synovitis
. Charcot arthropathy
. Paget's disease

Correct Answer & Explanation

. Rheumatoid arthritis

Explanation

Rheumatoid arthritis is an inflammatory arthritis that usually involves multiple joints. Radiologic findings of periarticular erosion, osteopenia, and minimal osteophyte formation favor rheumatoid arthritis over osteoarthritis. Pigmented villonodular synovitis and Charcot arthropathy are more often considered monoarticular diseases. There are no radiographic findings of Paget's disease.

Question 2180

Topic: 3. Adult Reconstruction (Hip & Knee)

A 56-year-old man underwent right total shoulder arthroplasty 2 months ago. Recently while reaching with his shoulder in a flexed and adducted position, he noted shoulder pain and afterwards he could not externally rotate his arm. An axillary radiograph is shown in Figure 30. What is the most likely cause of this problem?

Upper Extremity 2005 Practice Questions: Set 3 (Solved) - Figure 15

. Excessive anteversion of the humeral component
. Excessive anteversion of the glenoid component
. Excessive posterior capsular laxity
. Anterior capsular laxity
. Use of an oversized humeral head

Correct Answer & Explanation

. Excessive anteversion of the glenoid component

Explanation

Anteversion of the humeral component may result in anterior instability of the component. Posterior instability after total shoulder arthroplasty is usually the result of some combination of the following factors: untreated anterior soft-tissue contractures, excessive posterior capsular laxity, and excessive retroversion of the humeral and/or glenoid components. Cofield RH, Edgerton BC: Total shoulder arthroplasty: Complications and revision surgery. Instr Course Lect 1990;39:449-462.

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