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3. Adult Reconstruction (Hip & Knee) MCQs

Practice Set 112 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 2221

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 17 shows the AP radiograph of a 75-year-old man with right hip pain. The femoral component is loose. The mechanism of loosening is most likely secondary to

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 2) - Figure 5

. osteolysis.
. fatigue failure of the implant.
. failure of bone ingrowth.
. wear debris from cerclage wire.
. trochanteric impingement.

Correct Answer & Explanation

. failure of bone ingrowth.

Explanation

The femoral construct shown in the radiograph has failed to produce ingrowth of the stem. The stem has subsided and rotated. Impingement of the trochanter did not occur until after the stem subsided. There is no evidence of osteolysis or third-body wear debris from the cerclage wire. A larger femoral stem needs to be implanted to achieve rigid fixation. Pelicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 217-238.

Question 2222

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 30 shows the MRI scan of a 68-year-old woman who has left hip pain. What is the most appropriate treatment?

Hip & Knee Reconstruction 2007 Practice Questions: Set 3 (Solved) - Figure 1

. Open reduction and internal fixation
. Total hip arthroplasty
. Incisional biopsy
. Proximal femoral resection and reconstruction
. Arthrodesis

Correct Answer & Explanation

. Total hip arthroplasty

Explanation

The patient has a large zone of osteonecrosis of the left femoral head. The wedge-shaped zone of decreased signal intensity on the T1 image in the subchondral region of the femoral head is typical. Based on these findings, total hip arthroplasty is the most appropriate treatment. Open reduction and internal fixation will not help this condition. Incisional biopsy is indicated only if the MRI scan shows a probable neoplasm. Resection of the proximal femur is indicated only for aggressive malignancy. Arthrodesis may be considered in a younger patient but not in a 68-year-old individual. Other treatments, not listed, such as core decompression, vascularized fibular transplant, and osteotomy may be options in selected patients. Urbaniak JR, Jones JP Jr (eds): Osteonecrosis: Etiology, Diagnosis, and Treatment. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 213-223.

Question 2223

Topic: 3. Adult Reconstruction (Hip & Knee)

A patient with a previously pain-free knee replacement now reports a sudden inability to ambulate. Radiographs of the knee are shown in Figures 33a and 33b. Management should consist of

. bracing and physical therapy.
. insertion of a thicker polyethylene insert.
. revision with a cementless modular prosthesis.
. revision with a cemented semiconstrained prosthesis.
. reconstruction of the extensor mechanism.

Correct Answer & Explanation

. reconstruction of the extensor mechanism.

Explanation

The radiographs show a patellar tendon rupture following a total knee replacement. This infrequent, but serious, complication is reported to occur in 0.17% to 1.4% of patients after total knee arthroplasty. Although the radiographs show concerning features such as incomplete tibial and femoral periprosthetic lucencies, it is most important for the surgeon to recognize extensor mechanism disruption. Insall J, Salvati E: Patella position in the normal knee joint. Radiology 1971;101:101-104. Lynch AF, Rorabeck CH, Bourne RB: Extensor mechanism complications following total knee arthroplasty. J Arthroplasty 1987;2:135-140.

Question 2224

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 8 shows the radiograph of a 76-year-old man who has knee pain and swelling. History reveals that he underwent total knee arthroplasty 18 years ago. What is the most likely diagnosis?

Anatomy 2008 Practice Questions: Set 1 (Solved) - Figure 18

. Loose femoral component
. Loose tibial component
. Particle-mediated osteolysis
. Polyethylene failure
. Infection

Correct Answer & Explanation

. Polyethylene failure

Explanation

The radiograph reveals complete loss of joint space with particulate metal debris consistent with total polyethylene failure and metal-on-metal articulation. The components appear to be well fixed and minimal osteolysis is evident. Kilgus DJ, Moreland JR, Finerman GA, et al: Catastrophic wear of tibial polyethylene inserts. Clin Orthop Relat Res 1991;273:223-231.

Question 2225

Topic: 3. Adult Reconstruction (Hip & Knee)

A 50-year-old woman who underwent a joint replacement of the hallux metatarsophalangeal joint 6 months ago now has pain and swelling about the great toe. Radiographs are shown in Figures 39a and 39b. What is the next most appropriate step in management?

. Removal of the implant alone
. Amputation of the hallux
. Revision of the implant with a Silastic joint replacement
. Arthrodesis of the hallux metatarsophalangeal joint with interposition bone graft
. Rocker bottom steel shank shoe with orthosis

Correct Answer & Explanation

. Arthrodesis of the hallux metatarsophalangeal joint with interposition bone graft

Explanation

The radiographs show displacement of the prosthesis, and there has been large amounts of bone resected to insert the implant. Arthrodesis is indicated with interposition bone graft to stabilize the joint and restore length to the first ray.

Question 2226

Topic: 3. Adult Reconstruction (Hip & Knee)

Metal-on-metal articulation has been reintroduced because of concern about polyethylene wear. This type of articulation is considered favorable because

. metal particles are inert.
. metal particles are larger than polyethylene particles.
. the surfaces can now be fabricated with low carbon, machined cobalt-chromium.
. less than 0.6 mm3 of metallic debris are generated per year.
. electrochemical problems of the articulation have now been solved through passivation.

Correct Answer & Explanation

. the surfaces can now be fabricated with low carbon, machined cobalt-chromium.

Explanation

The improvements in metal-on-metal bearing surfaces come from the nonlinear wear rate and smaller particle size of the high carbon wrought material. Extremely low rates of wear have been demonstrated with high carbon metal-on-metal implants. There is no significant electrochemical effect of mating two like materials in vivo.

Question 2227

Topic: 3. Adult Reconstruction (Hip & Knee)

A 37-year-old laborer falls 12 feet and sustains a comminuted tibial plafond fracture. Three years after treatment using standard techniques, what will be the most likely outcome?

. Need for ankle fusion or arthroplasty
. Return to normal function
. Ankle stiffness without pain
. Severe constant pain and inability to work
. Adversely affected general health status and posttraumatic arthritis

Correct Answer & Explanation

. Adversely affected general health status and posttraumatic arthritis

Explanation

Two recent studies by Pollak and associates and Marsh and associates have focused on function after high-energy tibial plafond fractures. Findings are unfavorable even when anatomic reduction is performed in the best centers and patients are provided excellent rehabilitation. Function improves up to 2 years after injury, but even basic walking skills remain adversely affected. Virtually all patients have long-term adverse general health effects compared to their gender and age-matched peers. Posttraumatic degenerative arthritis is present in most ankles. Patients should be told early about the long-term prognosis, and early vocational/psychological counseling should be given. Despite these adverse outcomes, only a minority of patients require fusion or arthroplasty. Pollak AN, McCarthy ML, Bess RS, et al: Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am 2003;85:1893-1900.

Question 2228

Topic: Total Knee Arthroplasty (TKA)

A 63-year-old woman reports giving way of the knee and pain after undergoing primary total knee arthroplasty (TKA) 1 year ago. Examination reveals that the knee is stable in full extension but has gross anteroposterior instability at 90 degrees of flexion. The patient can fully extend her knee with normal quadriceps strength. Studies for infection are negative. AP and lateral radiographs are shown in Figures 12a and 12b, respectively. What is the appropriate management?

. Anti-inflammatory drugs
. Knee brace
. Physical therapy for quadriceps strengthening
. Revision to a thicker polyethylene insert
. Revision to a larger, posterior stabilized implant

Correct Answer & Explanation

. Revision to a larger, posterior stabilized implant

Explanation

The radiographs show posterior flexion instability that is the result of a flexion-extension gap imbalance and posterior cruciate ligament incompetence after a posterior cruciate ligament-retaining TKA. The femur is anteriorly displaced on the tibia, with lift-off of the femoral component from the tibial polyethylene. Revision to a larger femoral component will address the larger flexion gap relative to the extension gap, and a posterior stabilized implant will address the posterior cruciate ligament insufficiency. Pagnano and associates, reporting on a series of painful TKAs previously diagnosed as pain of unknown etiology, showed that the pain was secondary to flexion instability. Pain relief was achieved by revision to a posterior stabilized implant. Pagnano MW, Hanssen AD, Lewallen DG, et al: Flexion instability after primary posterior cruciate retaining total knee arthroplasty. Clin Orthop 1998;356:39-46. Fehring TK, Valadie AL: Knee instability after total knee arthroplasty. Clin Orthop 1994;299:157-162.

Question 2229

Topic: 3. Adult Reconstruction (Hip & Knee)

A patient is scheduled to undergo total knee arthroplasty (TKA) following failure of nonsurgical management. History reveals that she underwent a patellectomy as a teenager as the result of a motor vehicle accident. Examination reveals normal ligamentous stability. For the most predictable outcome, which of the following implants should be used?

Hip & Knee Reconstruction 2007 Practice Questions: Set 1 (Solved) - Figure 1

. Mobile-bearing knee
. Posterior cruciate ligament-sparing knee
. Posterior cruciate ligament-substituting knee
. Semiconstrained-style knee
. Triaxial hinged knee

Correct Answer & Explanation

. Posterior cruciate ligament-substituting knee

Explanation

Paletta and Laskins performed a retrospective study of the results of TKA with cement in 22 patients who had a previous patellectomy. Nine of the patients had insertion of a posterior cruciate ligament-substituting implant. Thirteen patients had insertion of a posterior cruciate ligament-sparing implant. The 5-year postoperative knee scores were 89 for the posterior cruciate ligament-substituting knee versus 67 for the posterior cruciate ligament-sparing knee (P < 0.01). The patella functions to increase the lever arm of the extensor mechanism and to position the quadriceps tendon and the patellar ligament roughly parallel to the anterior cruciate ligament and posterior cruciate ligament, respectively. The patellar ligament thereby provides a strong reinforcing structure that functions to prevent excessive anterior translation of the femur during flexion of the knee. The absence of the patella results in the patellar ligament and the quadriceps tendon being relatively in line with one another. After a patellectomy, the resultant quadriceps force is no longer parallel to the posterior cruciate ligament. This results in loss of the reinforcing function of the patellar ligament. The authors believe this loss of reinforcing function may place increased stresses on the posterior cruciate ligament and posterior aspect of the capsule, which may result in stretching of these structures over time. They found a high rate of anteroposterior instability, a high prevalence of recurvatum, and a high rate of loss of full active extension compared with passive extension in the posterior cruciate ligament-sparing group, which supports their theory. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 559-582.

Question 2230

Topic: 3. Adult Reconstruction (Hip & Knee)

A 72-year-old woman who underwent right total hip arthroplasty 7 years ago now reports right hip pain and limb shortening. Studies for infection are negative. AP and lateral radiographs are shown in Figures 13a and 13b. What is the most appropriate management?

. Observation only
. Nonsteroidal anti-inflammatory drugs and protected weight bearing
. Revision of the acetabular component with a jumbo cup with screws
. Revision of the acetabular component with a reinforcement cage and bone grafting
. Resection arthroplasty

Correct Answer & Explanation

. Revision of the acetabular component with a reinforcement cage and bone grafting

Explanation

Current literature supports the use of reinforcement cages for the reconstruction of failed, loosened acetabular components associated with major bone loss as seen in this patient. Although results of revision using the so-called jumbo cup with screws generally have been good, the amount of bone loss and medial wall penetration shown here and the likelihood of pelvic discontinuity precludes the use of that technique. With either technique, bone grafting of remaining defects is recommended. Sporer SM, O'Rourke M, Paprosky WG: The treatment of pelvic discontinuity during acetablular revision. J Arthroplasty 2005;20:79-84.

Question 2231

Topic: Total Hip Arthroplasty (THA)

Design and manufacturing of a metal-on-metal articulation has an important influence on the tribology. Which of the following statements best characterizes the type of contact that is best for metal-on-metal articulations?

. Equatorial contact should exceed polar contact.
. Polar contact should exceed equatorial contact.
. Polar and equatorial contact should be equal by exactly duplicating radii.
. The "bedding in" process makes consideration of polar equatorial contact unimportant.
. The stiffness of metal-on-metal articulations makes consideration of polar equatorial contact unimportant.

Correct Answer & Explanation

. Polar contact should exceed equatorial contact.

Explanation

It is important that the radii of a metal-on-metal head to cup articulation be such that there is polar contact. As the radii become closer to equal, conditions favor higher frictional torque and equatorial seizing. The "bedding in" of metal-on-metal surfaces and their stiffness are both components of the properties considered in the design of polar contact surfaces.

Question 2232

Topic: 3. Adult Reconstruction (Hip & Knee)

Figures 9a and 9b show the radiographs of a 75-year-old man who underwent a revision total knee arthroplasty with a long-stemmed tibial component. In rehabilitation, he reports fullness and tenderness in the proximal medial leg (at the knee). The strategy that would best limit this postoperative problem is use of

. a base plate with an offset tibial stem attachment.
. a bone ingrowth surface on the augment.
. a nonstemmed tibial base plate.
. allograft bone instead of metal augments.
. bone cement to smooth the outline of the proximal medial tibia.

Correct Answer & Explanation

. a base plate with an offset tibial stem attachment.

Explanation

The problem with this reconstruction is the medial protrusion of the base plate. The use of a base plate with an offset stem can prevent the protrusion and thus the impingement and pain. Allograft bone or smoothing the outline with cement would be just as prominent and likely to cause pain. An ingrowth surface may improve soft-tissue attachment but would still leave the implant protruding medially and likely to cause pain. A nonstemmed tibial base plate would lead to less medial protrusion but at the expense of a smaller area for load carriage on the proximal tibia.

Question 2233

Topic: 3. Adult Reconstruction (Hip & Knee)

A patient who underwent total knee arthroplasty 6 years ago now reports knee pain for the past 3 days following dental surgery. Cultures of the aspirate are positive for Staphylococcus epidermidis. Management should consist of

Hip 2004 Practice Questions: Set 1 (Solved) - Figure 10

. IV antibiotics.
. arthroscopic irrigation and debridement, following by IV antibiotics.
. irrigation and debridement, polyethylene exchange, and IV antibiotics.
. one-stage component removal and reimplantation, followed by IV antibiotics.
. two-stage component removal and reimplantation, with IV antibiotics in the interim period.

Correct Answer & Explanation

. irrigation and debridement, polyethylene exchange, and IV antibiotics.

Explanation

The patient has an early prosthesis infection as a result of hematogenous seeding from dental surgery. Irrigation and debridement with polyethylene exchange and IV antibiotics have been successful in early postoperative infections; it is less likely to be effective for a late hematogenous infection. Immediate total component exchange also may be effective, but it should be reserved for failure of irrigation and debridement. Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 323-337.

Question 2234

Topic: 3. Adult Reconstruction (Hip & Knee)

A direct lateral (Hardinge) approach is used during total hip arthroplasty. The structure labeled A in Figure 7 is the

Anatomy 2005 Practice Questions: Set 1 (Solved) - Figure 20

. superior gluteal nerve.
. inferior gluteal nerve.
. obturator nerve.
. medial femoral circumflex artery.
. lateral femoral circumflex artery.

Correct Answer & Explanation

. superior gluteal nerve.

Explanation

The superior gluteal nerve is located approximately 7.82 cm above the tip of the greater trochanter as it courses through the gluteus medius. This anatomic consideration is relevant during a Hardinge approach to the hip, where excessive proximal dissection or retraction could result in nerve injury. A split of the gluteus medius of no more than 4 cm above the greater trochanter is considered safe. Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, pp 333-335.

Question 2235

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 23 shows failure of the femoral stem in a patient. What is the most likely reason for the failure?

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 2) - Figure 17

. Torsional loading
. Cantilever bending
. Pistoning
. Subsidence
. Torque

Correct Answer & Explanation

. Cantilever bending

Explanation

A two-dimensional stress analysis has been used to study the effects of some of the factors leading to early fatigue failure of the femoral stem in total hip arthroplasty. It has been demonstrated that loss of proximal stem support at the level of the calcar femorale and subsequent stem stress can lead to fatigue failure. In addition, the role of body weight and range of cyclic stress fluctuation play an important role in fatigue life under conditions where the stem has lost proximal support. These results indicate that stem design could be improved by incorporating some means of adequate support at the calcar femorale where maximum tensile stresses are found to occur. Femoral component fracture is a rare but well-documented complication after total hip arthroplasty. Historically, most stem fractures occur at the middle third of the implant where proximal stem loosening and solid distal stem fixation result in cantilever bending and eventual fatigue failure. The component shown is a modular fluted cementless stem that occasionally fractures at the modular junction in patients with poor proximal bone support. Andriacchi TP, Galante JO, Belytschko TB, et al: A stress analysis of the femoral stem in total hip prostheses. J Bone Joint Surg Am 1976;58:618-624.

Question 2236

Topic: 3. Adult Reconstruction (Hip & Knee)

A 65-year-old woman has nausea, vomiting, and abdominal distention after undergoing total knee arthroplasty 48 hours ago. An abdominal radiograph is shown in Figure 14. Associated risk factors for this disorder include

Hip 2004 Practice Questions: Set 3 (Solved) - Figure 2

. hypokalemia.
. administration of warfarin.
. administration of antibiotics.
. general anesthesia.
. early mobilization and physical therapy.

Correct Answer & Explanation

. hypokalemia.

Explanation

The prevalence of postoperative ileus associated with total joint arthroplasty has been reported to be as high as 3%. Metabolic abnormalities such as hypokalemia are believed to contribute to the onset of ileus and Ogilvie's syndrome (acute pseudo-obstruction of the colon). Prolonged bed rest also has been associated with the development of ileus and Ogilvie's syndrome. Untreated Ogilvie's syndrome can result in cecal perforation. Ileus usually is not accompanied by mechanical obstruction. Antibiotic administration and the type of anesthesia used have not been correlated with development of ileus. Administration of warfarin has been associated with elevated prothrombin time/partial thromboplastin time and international normalized ratio levels when ileus is managed with a nasogastric tube and suction. Metabolic imbalances must be corrected to reverse the ileus process. Iorio R, Healy WL, Appleby D: The association of excessive warfarin anticoagulation and postoperative ileus after total joint replacement surgery. J Arthroplasty 2000;15:220-223.

Question 2237

Topic: 3. Adult Reconstruction (Hip & Knee)

A 67-year-old patient seen in the emergency department reports the acute onset of pain and is unable to ambulate. History reveals that the patient underwent surgical treatment for a periprosthetic femoral fracture 6 months ago. A radiograph is shown in Figure 41. What is the best treatment option at this time?

Hip & Knee Reconstruction 2007 Practice Questions: Set 3 (Solved) - Figure 15

. Open reduction and internal fixation with cortical onlay strut grafts and bone morphogenic protein
. Resection arthroplasty
. Revision hip arthroplasty with an allograft prosthetic composite
. Revision hip surgery with distal stem fixation using a long stem implant with strut grafts
. Revision hip arthroplasty with a proximally coated implant

Correct Answer & Explanation

. Revision hip surgery with distal stem fixation using a long stem implant with strut grafts

Explanation

The radiograph reveals a periprosthetic fracture at the tip of the stem with a stable cemented implant. This is classified as a Vancouver type B1 periprosthetic fracture. An attempt at internal fixation has already failed; therefore, the most predictable results would be achieved with distal fixation. After removal of the well-fixed cemented implant, the proximal bone may not be suitable for proximal fixation. Adequate bone stock is available such that an allograft prosthetic composite or a tumor prosthesis is not necessary. The best option is a long stem implant with distal fixation, which serves as an intramedullary device to restore alignment and increase the likelihood of union. Cortical onlay strut grafts are used as an adjunct to definitive fixation. Younger AS, Dunwoody I, Duncan CP: Periprosthetic hip and knee fractures: The scope of the problem. Inst Course Lect 1998;47:251-256.

Question 2238

Topic: 3. Adult Reconstruction (Hip & Knee)

A 55-year-old man underwent cementless total hip arthroplasty for advanced painful osteoarthritis of the hip 2 years ago. The follow-up radiograph shown in Figure 30 shows

Hip Board Review 2001: High-Yield MCQs (Set 4) - Figure 2

. spot welds and calcar atrophy.
. subsidence.
. distal cortical hypertrophy.
. distal pedestal formation.
. complete lucent line around the stem.

Correct Answer & Explanation

. spot welds and calcar atrophy.

Explanation

The radiograph shows a well-osseointegrated tapered stem with a metaphyseal porous coating, spot welds in the porous region, and calcar rounding. Trochanteric stress shielding and distal cortical hypertrophy are also signs of ingrown stems but are seen more frequently in association with extensively porous-coated stems exhibiting diaphyseal ingrowth. There is no evidence of lucent lines or a pedestal, signs that suggest instability. Femoral stem subsidence can be determined only by a review of sequential radiographs. Engh CA, Massin P, Suthers KE: Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components. Clin Orthop 1990;257:107-128.

Question 2239

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 3 shows the AP radiograph of a patient with diabetes mellitus who has knee pain. A semiconstrained knee prosthesis was used in this patient to prevent which of the following complications?

Hip & Knee Reconstruction 2007 Practice Questions: Set 1 (Solved) - Figure 8

. Infection
. Instability
. Stiffness
. Bone loss
. Malalignment

Correct Answer & Explanation

. Instability

Explanation

The radiographic appearance of the joint is highly suspicious for neuropathic joint (Charcot's joint). Evidence of bone loss on both the tibial and the femoral sides may necessitate the use of metal and/or bone augments. Patients with a neuropathic joint often have excellent range of motion, and postoperative stiffness is not a problem. The main problem with these patients is instability that occurs secondary to ligamentous laxity. Use of a semiconstrained prosthesis prevents the latter complication. Parvizi J, Marrs J, Morrey BF: Total knee arthroplasty for neuropathic (Charcot) joints. Clin Orthop 2003;416:145-150.

Question 2240

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 1 shows the radiograph of a patient who underwent a total knee revision with a posterior stabilized mobile-bearing prosthesis and now has recurrent knee dislocations. What is the most likely cause?

Hip & Knee Reconstruction 2007 Practice Questions: Set 1 (Solved) - Figure 2

. Loose extension gap
. Loose flexion gap
. Malrotation of the tibial component
. Malrotation of the femoral component
. Poor prosthetic design

Correct Answer & Explanation

. Loose flexion gap

Explanation

The patient has a posterior stabilized total knee revision, and the femoral component has dislocated over the tibial polyethylene cam/post. This usually indicates a loose flexion gap, or "flexion instability." A loose flexion gap can occur due to undersizing of the femoral component, anteriorization of the femoral component, excessive distal augmentation of the distal femur, or collateral ligament insufficiency, especially if combined with posterior capsular insufficiency. Isolated laxity of the extension gap (with a well-balanced flexion gap) causes varus/valgus instability, but it rarely causes the femoral component to "jump" the tibial cam of a posterior stabilized tibial insert. Malrotation of the components may cause patellar instability or a rotational instability of the tibiofemoral joint but should not cause a frank posterior dislocation of the tibia, unless combined with other errors of balancing. Although a mobile-bearing total knee arthroplasty may be more sensitive to errors in balancing than a fixed-bearing total knee arthroplasty, this complication does not reflect a faulty prosthetic design. Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 339-365. Lotke PA, Garino JP: Revision Total Knee Arthroplasty. New York, NY, Lippincott-Raven, 1999, pp 173-186, 227-249.

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