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3. Adult Reconstruction (Hip & Knee) MCQs

Practice Set 114 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 2261

Topic: 3. Adult Reconstruction (Hip & Knee)

During total hip arthroplasty, profuse bleeding is noted following predrilling for placement of an acetabular component screw. The drill most likely penetrated too deep in the

Anatomy Board Review 2005: High-Yield MCQs (Set 2) - Figure 22

. anterior-superior acetabular quadrant.
. posterior-superior acetabular quadrant.
. posterior-inferior acetabular quadrant.
. medial acetabular wall.
. ischial body.

Correct Answer & Explanation

. anterior-superior acetabular quadrant.

Explanation

The acetabular quadrants are defined by two lines: one drawn from the anterosuperior iliac spine to the posterior fovea, forming acetabular halves, and a second drawn perpendicular to the first at the midpoint of the acetabulum, forming four quadrants. The anterior quadrants should be avoided because improper screw placement may injure the external iliac artery and vein, as well as the obturator nerve, artery, and vein. These structures lie close to the pelvic bone, with little protective interposition of soft tissue. Wasielewski RC, Cooperstein LA, Kruger MP, et al: Acetabular anatomy and the transacetabular fixation of screws in total hip arthroplasty. J Bone Joint Surg Am 1990;72:501-508.

Question 2262

Topic: 3. Adult Reconstruction (Hip & Knee)

A 68-year-old woman who underwent a right total hip arthroplasty 1 year ago has dislocated her hip five times since surgery. Radiographs show a retroverted acetabular component. What is the best treatment for this patient?

. Use a constrained acetabular liner
. Revise the femoral component to provide greater femoral offset
. Revise the femoral head from a 28-mm head size to a 36-mm head size
. Revise the acetabular component to 15 degrees of anteversion and 45 degrees of abduction
. Perform a greater trochanteric osteotomy to improve soft-tissue tension

Correct Answer & Explanation

. Revise the acetabular component to 15 degrees of anteversion and 45 degrees of abduction

Explanation

The most common cause of recurrent dislocation following total hip arthroplasty continues to be component malposition. Component malposition should be addressed prior to any other treatment options, such as increasing soft-tissue tension with increased femoral offset or greater trochanteric advancement. A larger femoral head size may help, but correcting the component malposition should give more predictable results. A retroverted acetabular component should be revised to 15 degrees to 20 degrees of anteversion, matching the patient's anatomy with an abduction angle close to 45 degrees. Daly PJ, Morrey BF: Operative correction of an unstable total hip arthroplasty. J Bone Joint Surg Am 1992;74:1334-1343. Jolles BM, Zangger P, Leyvraz PF: Factors predisposing to dislocation after primary total hip arthroplasty: A multivariate analysis. J Arthroplasty 2002;17-282-288.

Question 2263

Topic: 3. Adult Reconstruction (Hip & Knee)

An otherwise healthy 57-year-old woman has limited range of motion and moderate effusion after undergoing total knee arthroplasty 6 months ago. One of two cultures of joint aspirate reveals methicillin-resistant Staphylococcus epidermidis. Management should now consist of

. repeat aspiration to rule out culture contamination.
. IV administration of kanamycin for 6 weeks, followed by suppressive oral antibiotics.
. removal of the implant and 6 weeks of antibiotics, followed by reimplantation.
. removal of the implant, followed by knee fusion.
. open irrigation of the implant and intraoperative cultures, followed by 6 weeks of antibiotics.

Correct Answer & Explanation

. removal of the implant and 6 weeks of antibiotics, followed by reimplantation.

Explanation

The rapidly increasing prevalence of infection from Staphylococcus epidermidis has made this the most frequently cultured organism. In most patients, the infection occurred intraoperatively, thereby resulting in a chronic infection if not detected within the first 6 weeks after surgery. Irrigation of the joint may be successful during this time in 60% of patients, but the most successful treatment is extirpation for 6 weeks, followed by delayed reimplantation. This approach may result in a salvage rate of as high as 90% in some patients. Drancourt M, Stein A, Argenson JN, et al: Oral rifampin plus ofloxacin for treatment of staphylococcus-infected orthopedic implants. Antimicrob Agents Chemother 1993;37:1214-1218. Duncan CP, Beauchamp C: A temporary antibiotic-loaded joint replacement system for the management of complex infections involving the hip. Orthop Clin North Am 1993;24:751-759.

Question 2264

Topic: 3. Adult Reconstruction (Hip & Knee)

At the time of the revision surgery shown in Figure 14, the acetabular component was found to be stable. Polyethylene exchange with a standard ultra-high molecular weight polyethylene liner and grafting was performed. The patient is at significantly increased risk for

Hip & Knee Reconstruction 2007 Practice Questions: Set 1 (Solved) - Figure 30

. loosening of the femoral component.
. loosening of the acetabular component.
. prosthetic hip dislocation.
. rapid wear of the polyethylene.
. continued expansion of the lytic defects.

Correct Answer & Explanation

. prosthetic hip dislocation.

Explanation

Maloney and associates reported a 35% increased risk of pelvic osteolysis after total hip arthroplasty with a porous-coated acetabular component without cement. All components were stable at the time of revision. Only liners were exchanged and debridement of the granuloma with or without bone graft was performed. No defects progressed and one third of the lesions were no longer visible on radiographs, regardless of bone grafting. Unfortunately, despite the technical ease of many of these types of revisions, the dislocation rate for these cases is significant. Precautions should be taken postoperatively, and patients should be educated about this risk preoperatively. Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 411-424. Boucher HR, Lynch C, Young AM, et al: Dislocation after polyethylene liner exchange in total hip arthroplasty. J Arthroplasty 2003;18:654-657.

Question 2265

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 15 shows the radiograph of an active 60-year-old woman. Which of the following variables is considered the strongest contraindication to a unicompartmental knee arthroplasty in this patient?

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

. Obesity
. Fixed varus deformity of more than 15 degrees
. Five degree flexion contracture
. Contralateral knee osteoarthritis
. Joint subluxation of 5 mm

Correct Answer & Explanation

. Fixed varus deformity of more than 15 degrees

Explanation

Unicompartmental arthroplasty of the knee for single compartment arthrosis has recently become more popular. Contraindications to unicompartmental knee arthroplasty include fixed varus or valgus deformity of more than 5 degrees, restricted range of motion, fixed flexion contracture, joint subluxation of 5 mm or greater, and arthrosis of the opposite and/or patellofemoral compartment. Cossey AJ, Spriggins AJ: The use of computer-assisted surgical navigation to prevent malalignment in unicompartmental knee arthroplasty. J Arthroplasty 2005;20:29-34. Iorio R, Healy WL: Unicompartmental arthritis of the knee. J Bone Joint Surg Am 2003;85:1351-1364.

Question 2266

Topic: 3. Adult Reconstruction (Hip & Knee)

A patient who underwent total knee arthroplasty now reports a loss of sensation in the area circled in Figure 38. This area is innervated by which of the following nerves?

Anatomy 2002 Practice Questions: Set 3 (Solved) - Figure 20

. Infrapateller branch of the saphenous
. Ascending branch of the peroneal
. Anterior branch of the femoral
. Posterior cutaneous of the thigh
. Lateral cutaneous of the thigh

Correct Answer & Explanation

. Infrapateller branch of the saphenous

Explanation

The saphenous nerve follows the saphenous vein, giving off the infrapatellar branch that crosses the knee anteriorly to supply the peripatellar skin. A longitudinal incision can interrupt the nerve, leaving the terminal distribution without sensation.

Question 2267

Topic: 3. Adult Reconstruction (Hip & Knee)

A 48-year-old woman has knee pain that is worse with weight bearing. She reports no night pain or pain at rest. History reveals that she underwent total knee arthroplasty with cementless components 2 years ago. Examination reveals tenderness along the medial joint line. Figures 12a through 12c show radiographs and a bone scan. What is the most likely cause of the patient's pain?

. Deep infection
. Malalignment
. Fibrous ingrowth of the femoral component
. Fibrous ingrowth of the tibial component
. Patellar component loosening

Correct Answer & Explanation

. Fibrous ingrowth of the tibial component

Explanation

The radiographs show a halo-like sclerotic margin around the tibial stem and lucency under the baseplate. The bone scan shows markedly increased uptake under the tibial component, particularly on the medial side (not diffusely through the knee as seen with infection). These studies indicate lack of bone ingrowth fixation of the cementless porous-coated tibial component. The recent report of Fehring and associates has identified failure of ingrowth of a porous-coated implant as a dominant mode of early failure of total knee arthroplasties. Fehring TK, Odum S, Griffin WL, Mason B, Nadaud M: Early failures of total knee arthroplasty. Clin Orthop 2001;392:315-318.

Question 2268

Topic: 3. Adult Reconstruction (Hip & Knee)

A patient who underwent primary total hip arthroplasty 7 years ago that resulted in excellent pain relief and a normal gait now reports pain and a limp. Postoperative and current AP radiographs are shown in Figures 2a and 2b. What is the most likely cause of the pathology seen?

. Infection
. Injury of the superior gluteal nerve
. Loosening of the acetabular component
. Loosening of the femoral component
. Osteolysis

Correct Answer & Explanation

. Osteolysis

Explanation

Osteolysis in the trochanteric bed can result in weakening of the bone and fracture. Nonsurgical management will provide reasonable clinical and radiographic results in patients with limited fracture displacement. Claus MC, Hopper RH, Engh CA: Fractures of the greater trochanter induced by osteolysis with the anatomic medullary locking prosthesis. J Arthroplasty 2002;17:706-712.

Question 2269

Topic: 3. Adult Reconstruction (Hip & Knee)

A 55-year-old woman who underwent a left total hip arthroplasty 8 months ago using a modified Hardinger approach reports a persistent painless limp. Examination reveals that when she is not using a cane, she lurches to the left during weight bearing on the left lower extremity. An AP radiograph is shown in Figure 29. Which of the following hip muscle groups should be strengthened to improve the gait abnormality?

Anatomy 2002 Practice Questions: Set 3 (Solved) - Figure 6

. External rotators
. Extensors
. Abductors
. Flexors
. Adductors

Correct Answer & Explanation

. Abductors

Explanation

The modified Hardinger approach includes a partial anterior trochanteric osteotomy creating a trochanteric wafer (as seen on the radiograph) that is displaced anterior and medial in continuity with the gluteus medius and vastus lateralis. Failure of abductor reattachment, migration of the trochanter, nonunion of the osteotomy site, and excessive splitting of the gluteus medius muscle causing injury to the inferior branch of the superior gluteal nerve can result in weakness of the abductor mechanism. Abductor strength should be evaluated with the patient lying on the opposite side and elevating the affected limb. Although slight weakness may manifest itself as a limp only after prolonged muscular activity, significant weakness results in a constant limp without associated discomfort. Morrey BF (ed): Joint Replacement Arthroplasty. New York, NY, Churchill Livingstone, 1991, pp 512-526.

Question 2270

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 21 shows the radiograph of a 32-year-old patient with right hip pain that has failed to respond to nonsurgical management. What is the most appropriate surgical treatment at this time?

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 2) - Figure 9

. Femoral derotational osteotomy
. Total hip arthroplasty
. Arthrodesis
. Surgical dislocation of the hip
. Periacetabular osteotomy

Correct Answer & Explanation

. Periacetabular osteotomy

Explanation

The radiograph reveals developmental dysplasia of both hips. The patient has classic anterolateral undercoverage of the femoral head on the right side as demonstrated by a high acetabular index (measured at 27 degrees). Anterior undercoverage can be determined by drawing the marking for the anterior wall that fails to overlap the femoral head in this patient. Currently in North America, the most accepted surgical management for symptomatic dysplasia of the hip with good joint space is a Bernese (Ganz) periacetabular osteotomy. Surgical dislocation of the hip and femoroacetabular osteoplasty may be considered for patients with symptomatic femoroacetabular impingement of the hip. Ganz R, Klaue K, Vinh TS, et al: A new periacetabular osteotomy for the treatment of hip dysplasias: Technique and preliminary results. Clin Orthop 1988;232:26-36.

Question 2271

Topic: 3. Adult Reconstruction (Hip & Knee)

An 82-year-old woman reports activity-related knee pain. History reveals that she underwent total knee arthroplasty 16 years ago. AP and lateral radiographs and a bone scan are shown in Figures 38a through 38c. What is the most likely diagnosis?

. Particle-mediated osteolysis
. Metastatic carcinoma
. Stress shielding
. Septic joint
. Osteosarcoma

Correct Answer & Explanation

. Particle-mediated osteolysis

Explanation

The radiographs reveal a large femoral metaphyseal lytic lesion with well-defined borders. Joint space narrowing medially is consistent with polyethylene wear. The most likely diagnosis is particle-mediated osteolysis. Metastatic tumors and primary sarcomas adjacent to an arthroplasty are extremely rare. In addition, malignant tumors and infection would more likely reveal a destructive lesion with poorly defined borders and increased uptake on a bone scan. Stress shielding with massive bone loss has not been described in knee arthroplasty literature, although this entity has been observed in fully porous-coated femoral implants in total hip arthroplasty. Robinson EJ, Mulliken BD, Bourne RB, et al: Catastrophic osteolysis in total knee replacement: A report of 17 cases. Clin Orthop Relat Res 1995;321:98-105. Archibeck MJ, Jacobs JJ, Roebuck KA, et al: The basic science of periprosthetic osteolysis. Instr Course Lect 2001;50:185-195.

Question 2272

Topic: 3. Adult Reconstruction (Hip & Knee)
A 62-year-old man who underwent total knee arthroplasty 6 months ago now reports pain after falling on the anterior portion of the knee. Examination reveals weakness of knee extension but no extensor lag. Flexion that had once measured 115 degrees is now limited to 70 degrees because of pain. A radiograph is shown in Figure 25. Management should now consist of:
. immediate repair of the ruptured patellar tendon insertion.
. knee joint aspiration and injection of a local anesthetic to facilitate examination.
. joint aspiration for culture, broad-spectrum antibiotics, and immobilization.
. immobilization until comfortable, followed by protected range of motion and strengthening.
. immediate fracture repair.

Correct Answer & Explanation

. immobilization until comfortable, followed by protected range of motion and strengthening.

Explanation

The patient has a type IIIB patellar fracture (inferior pole fracture with an intact patellar tendon). Nonsurgical management is the treatment of choice if there is little displacement and the extensor mechanism is intact.

Question 2273

Topic: Total Knee Arthroplasty (TKA)

A 17-year-old high school gymnast who has peripatellar knee pain has been unable to practice on a consistent basis for the past 3 years. She denies any specific injury events. Physical therapy for modalities, quadriceps strengthening, and hamstring stretching provide temporary relief. A trial of patellar taping significantly reduces her pain. Examination reveals an 15-degree Q angle, moderate lateral facet tenderness, negative patellar apprehension, and the inability to evert the patella. Radiographs show a moderate lateral patellar tilt. Treatment should now consist of

. a lateral patellar restraining brace for practice and competition.
. arthroscopic lateral retinacular release.
. open medial retinacular plication.
. medial tibial tubercle transfer.
. Maquet tibial tubercle elevation.

Correct Answer & Explanation

. arthroscopic lateral retinacular release.

Explanation

The patient has patellofemoral stress and a tight lateral retinaculum that has failed to respond to nonsurgical management; therefore, the most appropriate treatment includes an arthroscopic lateral retinacular release. A patellar restraining brace may aggravate the peripatellar pain by increasing pressure on the lateral facet. There is no evidence of patellar instability or significant malalignment; therefore, medial retinacular repair or a tibial tubercle transfer is not indicated. A modified Maquet tibial tubercle elevation would be considered only for significant patellofemoral arthrosis. Gambardella RA: Techical pitfalls of patellofemoral surgery. Clin Sports Med 1999;18:897-903.

Question 2274

Topic: 3. Adult Reconstruction (Hip & Knee)

A 75-year-old woman undergoes hybrid total hip arthroplasty for osteoarthritis. A postoperative radiograph obtained in the recovery room is shown in Figure 18. Treatment should now consist of

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 2) - Figure 6

. open reduction and internal fixation with strut graft and cerclage wire.
. open reduction and internal fixation with a plate, screws, and bone graft.
. exchange of the femoral components with insertion of a long stem cementless implant.
. cast immobilization.
. minimal weight bearing and observation.

Correct Answer & Explanation

. minimal weight bearing and observation.

Explanation

Intraoperative femoral fractures can often be avoided by careful preoperative planning to optimize implant design and size. Most fractures occur during implantation of a cementless implant; many can be avoided by careful femoral preparation and component implantation, with particular caution in osteopenic bone. Intraoperative femoral fractures are managed according to fracture severity. Minor cracks that do not affect stability or femoral integrity can often be managed intraoperatively with cerclage fixation, limited weight bearing, and observation. Femoral fractures that compromise implant stability or femoral integrity require fracture fixation with cerclage wires, strut grafts, or plates and may require conversion to a long stem implant. This patient's fracture is nondisplaced and the implant is well seated; therefore, limited weight bearing is considered appropriate management. Lee SR, Bostrom MP: Periprosthetic fractures of the femur after total hip arthroplasty. Instr Course Lect 2004;53:111-118. Kelley SS: Periprosthetic femoral fractures. J Am Acad Orthop Surg 1994;2:164-172.

Question 2275

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 10 shows the radiograph of an active 75-year-old woman who reports severe leg pain after a fall. Management should consist of

Hip 2001 Practice Questions: Set 1 (Solved) - Figure 22

. a total hip arthroplasty with a long-stem prosthesis.
. a resection arthroplasty with skeletal traction.
. hemiarthroplasty with a long-stem prosthesis.
. retention of the prosthesis and open reduction and internal fixation.
. closed treatment with skeletal traction.

Correct Answer & Explanation

. a total hip arthroplasty with a long-stem prosthesis.

Explanation

The patient has a comminuted fracture of the proximal femur and joint space narrowing of the acetabulum. Therefore, the prosthesis should be converted to a total hip arthroplasty. Because there is extensive comminution, the revision stem should bypass the area of bone loss by two bone diameters. A hemiarthroplasty is not indicated because the patient has no acetabular cartilage. Open reduction and internal fixation may not stabilize the prosthesis. A resection arthroplasty or treatment in traction will not leave the patient with adequate function. Garbuz DS, Masri BA, Duncan CP: Periprosthetic fractures of the femur: Principles of prevention and management, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 237-242.

Question 2276

Topic: 3. Adult Reconstruction (Hip & Knee)

During total knee arthroplasty using a posterior cruciate-retaining design, excessive tightness in flexion is noted, while the extension gap is felt to be balanced. Which of the following actions will effectively balance the knee?

Hip 2004 Practice Questions: Set 1 (Solved) - Figure 18

. Resect more distal femur.
. Resect more anterior tibia.
. Use a larger femoral component.
. Use a smaller polyethylene insert.
. Recess the posterior cruciate ligament.

Correct Answer & Explanation

. Use a smaller polyethylene insert.

Explanation

Excessive flexion gap tightness can be addressed with a variety of techniques; including: (a) recess and release the posterior cruciate ligament; (b) resect a posterior slope in the tibia; (c) avoid an oversized femoral component that moves the posterior condyles more distally; (d) resect more posterior femoral condyle and use a smaller femoral component placed more anteriorly; and (e) release the tight posterior capsule and balance the collateral ligaments.

Question 2277

Topic: 3. Adult Reconstruction (Hip & Knee)

A 32-year-old man has posttraumatic arthritis after undergoing open reduction and internal fixation of a left acetabular fracture. A total hip arthroplasty is performed, and the radiograph is shown in Figure 18. What is the most common mode of failure leading to revision in this group of patients?

Hip 2004 Practice Questions: Set 3 (Solved) - Figure 6

. Infection
. Heterotopic ossification
. Dislocation
. Periprosthetic fracture
. Acetabular component loosening

Correct Answer & Explanation

. Acetabular component loosening

Explanation

Acetabular component loosening has been reported as the most common mode of failure following total hip arthroplasty in patients with a previous acetabular fracture. Following acetabular fracture and subsequent open reduction and internal fixation, the bone quality and vascularity are compromised, thus reducing the success rate of acetabular component cementless fixation. Jimenez ML, Tile M, Schenk RS: Total hip replacement after acetabular fracture. Orthop Clin 1997;28:435-446.

Question 2278

Topic: 3. Adult Reconstruction (Hip & Knee)

An 82-year-old man has had episodic right thigh pain after undergoing a total hip arthroplasty 10 years ago. Initial postoperative radiographs are shown in Figures 26a and 26b, and current radiographs are shown in Figures 26c and 26d. What is the most likely cause of his pain?

. Acetabular osteolysis
. Femoral osteolysis
. Acetabular loosening
. Femoral loosening
. Femoral and acetabular loosening

Correct Answer & Explanation

. Femoral loosening

Explanation

These radiographs are dominated by the subsidence of the femoral component. There is also evidence of polyethylene wear and femoral osteolysis in the region of the greater trochanter. There is no evidence of proximal (calcar) stress shielding, and there is a thick distal pedestal. Engh and associates defined two major signs of osseointegration - the absence of radiolucent lines around the porous-surfaced portion of the implant and new bone bridging the gap between the endosteal surface and the porous portion of the implant. Implant migration indicates failure of ingrowth. Osteolysis is a periprosthetic loss of bone secondary to particulate debris and it is often clinically silent unless it is accompanied by pathologic fracture. It is often globular. Acetabular loosening is based on radiolucent lines and implant migration. The current radiographs demonstrate subsidence of the stem with pedestal formation. Engh CA, Massin P, Suthers KE: Roentgenographic assessment of biologic fixation of porous-surface femoral components. Clin Orthop Relat Res 1990;257:107-128.

Question 2279

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 27 shows the AP radiograph of a patient who has late instability. The problem most likely occurred as a result of

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 2) - Figure 24

. greater trochanter detachment.
. femoral stem loosening.
. wear.
. osteolysis.
. infection.

Correct Answer & Explanation

. wear.

Explanation

Although dislocation can occur anytime after hip arthroplasty, the highest incidence is observed within the first few months. Dislocation occurring many years after arthroplasty has also been described. In contrast to early dislocation, it appears that late dislocation frequently requires surgical intervention. Recent studies suggest that the incidence of late dislocation may be greater than initially appreciated and that the cumulative rate of dislocation rises with increasing follow-up. The presumed etiologic factors for late instability include long-standing problems with the prosthesis (such as malpositioning of the components) with late manifestation, trauma, deterioration in the neurologic status of the patient, and polyethylene wear. The eccentric position of the femoral head in this patient confirms polyethylene wear. The femoral stem is well-fixed, and the greater trochanter osteotomy has united well. The minor osteolysis observed around the proximal femur is also the consequence of wear and is not the cause of instability. Infection, without component loosening and massive soft-tissue destruction, is not otherwise known to result in late instability. Berry DJ, von Knoch M, Schleck CD, et al: The cumulative long-term risk of dislocation after primary Charnley total hip arthroplasty. J Bone Joint Surg Am 2004;86:9-14.

Question 2280

Topic: 3. Adult Reconstruction (Hip & Knee)
A 58-year-old woman is seen in the emergency department after falling at home. History reveals that she underwent right total knee arthroplasty 2 years ago. Radiographs are shown in Figures 56a and 56b. What is the most appropriate treatment?
. Closed reduction and casting
. Bed rest and skeletal traction
. Open reduction and internal fixation
. Retrograde intramedullary nailing
. Revision of the femoral component with a stemmed component

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

The radiographs show an oblique periprosthetic distal femoral fracture. Of the options listed, open reduction and internal fixation is the most appropriate surgical option because a well-fixed, posterior stabilized closed box femoral component is present. Nonsurgical methods are not favored because of the highly displaced, unstable fracture pattern and prolonged immobility. Revision with a stemmed component is an option but would sacrifice more bone stock in this younger patient.

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