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3. Adult Reconstruction (Hip & Knee) MCQs

Practice Set 115 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 2281

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 39 shows the AP radiograph of a 62-year-old man with degenerative osteoarthritis secondary to trauma. History reveals that he underwent total elbow arthroplasty 3 years ago. He continues to report instability and constant pain. A complete work-up, including aspiration and cultures, is negative. Treatment should consist of removal of the components and

Shoulder 2002 Practice Questions: Set 3 (Solved) - Figure 19

. distraction interpositional arthroplasty.
. elbow arthrodesis.
. conversion to a resection arthroplasty.
. conversion to semiconstrained elbow arthroplasty.
. revision to unconstrained total elbow arthroplasty.

Correct Answer & Explanation

. conversion to semiconstrained elbow arthroplasty.

Explanation

An unconstrained prosthesis dislocation is a disconcerting problem that is not easily resolved; however, revision to a semiconstrained prosthesis would best achieve both pain relief and stability. Removal of the components and distraction arthroplasty or conversion to a resection arthroplasty are options, but the results would be unpredictable with regards to pain relief, postoperative motion, or elbow stability. Arthrodesis is poorly tolerated. With revision to another unconstrained prosthesis, there is the risk of continued redislocation because of chronic ligamentous insufficiency. Linscheid RL: Resurfacing elbow replacement arthroplasty: Rationale, technique and results, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 602-610.

Question 2282

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 22 shows the radiograph of a 67-year-old woman who has an infected left total hip arthroplasty. The most efficient means to remove the distal cement mantle includes the use of

Hip Board Review 2004: High-Yield MCQs (Set 4) - Figure 3

. controlled perforation.
. cortical bone window.
. fluoroscopically guided instrumentation.
. extended trochanteric osteotomy.
. transtrochanteric osteotomy.

Correct Answer & Explanation

. extended trochanteric osteotomy.

Explanation

An extended trochanteric osteotomy has been shown to be very efficient in removing a well-fixed distal implant and cement with minimal complications. Direct lateral, posterior, and transtrochanteric osteotomy exposures do not provide exposure of the midfemur.

Question 2283

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 13 shows the radiographs of a 56-year-old woman who has pain and varus knee deformity after undergoing total knee arthroplasty 8 years ago. Aspiration and studies for infection are negative. During revision surgery, management of the tibial bone loss is best achieved by

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

. a custom tibial implant.
. a hinged prosthesis.
. reconstruction with structural allograft.
. reconstruction with iliac crest bone graft.
. filling the defect with cement.

Correct Answer & Explanation

. reconstruction with structural allograft.

Explanation

Massive bone loss encountered in revision total knee arthroplasty remains a significant challenge. Recent reports have shown high success rates using structural allograft to reconstruct massive bone defects. Custom and hinged prostheses in this setting are no longer favored. The defect shown is segmental and is too large to be filled with cement or iliac crest bone graft. Mow CS, Wiedel JD: Structural allografting in revision total knee arthroplasty. J Arthroplasty 1996;11:235-241. Engh GA, Herzwurm PJ, Parks NL: Treatment of major defects of bone with bulk allografts and stemmed components during total knee arthroplasty. J Bone Joint Surg Am 1997;79:1030-1039.

Question 2284

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 17 shows the radiograph of an 80-year-old woman who has left groin pain. She underwent a total hip arthroplasty 15 years ago and has no history of hip dislocation; however, she now reports that the pain results in functional impairment. Preoperative findings reveal that the component used has been discontinued, the locking mechanism is poor, and there is no replacement polyethylene available from the company. During surgery, the acetabular component is found to be well fixed, it is in satisfactory position, and adequate access can be obtained through the screw holes in the component to debride the osteolytic cavities. What is the best course of action for revision?

Hip 2004 Practice Questions: Set 3 (Solved) - Figure 5

. Remove the component and replace it with a "jumbo" cup with bone graft or substitute.
. Remove the component and replace it with a bipolar component with bone graft or substitute.
. Remove the component and replace it with a support ring with graft or graft substitute and cement a cup into the support ring.
. Score the component for improved cement interdigitation and cement a cup into the retained socket with bone graft or substitute.
. Use a structural acetabular graft to reconstruct the acetabulum and cement a cup into the structural graft.

Correct Answer & Explanation

. Score the component for improved cement interdigitation and cement a cup into the retained socket with bone graft or substitute.

Explanation

The clinical result in this patient has been good, with no dislocations, suggesting that the components are in reasonably good position. The radiograph and examination at the time of surgery suggest that the acetabular component is well fixed. The surrounding bone of the acetabulum is osteopenic and there would most likely be considerable bone loss if the acetabular component is removed. Access to the osteolytic lesions is possible. Cementing an acetabular component into the retained socket will cause the least amount of bone loss, shorten the procedure, and most likely result in a functional hip. Maloney WJ: Socket retention: Staying in place. Orthopedics 2000;23:965-966.

Question 2285

Topic: 3. Adult Reconstruction (Hip & Knee)

A 58-year-old man reports a 2-month onset of groin pain with no history of trauma. Examination reveals that range of motion of the hip is mildly restricted, and he has pain with both weight bearing and at rest. An MRI scan is shown in Figure 20. Treatment should consist of

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 2) - Figure 8

. protected weight bearing and anti-inflammatory drugs.
. core decompression of the femoral head.
. vascularized free fibular grafting to the femoral head.
. bipolar hemiarthroplasty of the hip.
. total hip arthroplasty.

Correct Answer & Explanation

. protected weight bearing and anti-inflammatory drugs.

Explanation

The MRI findings show highly increased signal through the entire femoral head and neck on STIR imaging, diagnostic of transient osteoporosis of the femoral head. This disease entity can be seen in middle-aged men, and should be treated nonsurgically. The natural history is that of self-resolution. Guerra JJ, Steinberg ME: Distinguishing transient osteoporosis from avascular necrosis of the hip. J Bone Joint Surg Am 1995;77:616-624.

Question 2286

Topic: 3. Adult Reconstruction (Hip & Knee)

A 58-year-old man has anterior knee pain after undergoing total knee arthroplasty for osteoarthritis 2 years ago. He denies any history of trauma. A Merchant view is shown in Figure 20. What is the most likely cause of his pain?

Hip 2004 Practice Questions: Set 3 (Solved) - Figure 9

. External rotation of the femoral component
. Overstuffing of the patellofemoral joint
. Less than 12 mm of bony patella remaining after resection
. Lateral retinacular release
. Use of a cemented patellar component

Correct Answer & Explanation

. Less than 12 mm of bony patella remaining after resection

Explanation

The patient has a patellar stress fracture after resurfacing in a total knee arthroplasty. Several studies have shown that over-resection of the patella to less than 12 to 15 mm increases anterior patellar surface strains to a point where the risk of fracture is increased. Increasing the patellar thickness, positioning of the femoral component, lateral releases, and component types have not been clearly associated with increased fracture risk. Reuben JD, McDonald CL, Woodard PL, Hennington LJ: Effect of patella thickness on patella strain following total knee arthroplasty. J Arthroplasty 1991;6:251-258. Hsu HC, Luo ZP, Rand JA, An KN: Influence of patellar thickness on patellar tracking and patellofemoral contact characteristics after total knee arthroplasty. J Arthroplasty 1996;11:69-80.

Question 2287

Topic: 3. Adult Reconstruction (Hip & Knee)

A 38-year-old woman with diabetes mellitus reports a 6-week history of fever and pain localized to the right sternoclavicular joint. Local signs on examination include swelling about the joint, erythema, and increased warmth. Initial aspiration of the joint reveals Staphylococcus aureus. Radiographs reveal medial clavicular osteolysis. What is the most effective treatment at this time?

. Broad-spectrum parenteral antibiotics
. Repeat aspirations
. Irrigation and debridement
. Hyperbaric oxygen
. Resection of the sternoclavicular joint

Correct Answer & Explanation

. Resection of the sternoclavicular joint

Explanation

Based on the findings, the treatment of choice is resection of the sternoclavicular joint. Antibiotic therapy, repeat aspirations, hyperbaric oxygen, and simple irrigation and debridement are generally ineffective and associated with a high rate of recurrence.

Question 2288

Topic: 3. Adult Reconstruction (Hip & Knee)

A patient who underwent a total knee arthroplasty for osteoarthritis 18 months ago now reports the sudden development of pain in the ipsilateral knee. Radiographs and examination of the knee are unremarkable. Aspiration of the synovial fluid 3 days later reveals a WBC count of 1,500/mm3. The cells consist of 30% neutrophils and 70% monocytes. Culture results will not be available for several days. The patient has not been on antibiotics prior to this point. Based on these findings, what is the most appropriate management?

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 2) - Figure 11

. Arthrotomy, debridement, and polyethylene exchange
. One-stage exchange arthroplasty
. Two-stage exchange arthroplasty
. Parenteral antibiotics
. Nonsurgical management without antibiotics

Correct Answer & Explanation

. Parenteral antibiotics

Explanation

Synovial fluid analysis is a very sensitive tool for detecting infection in total knee arthroplasties. Several studies have demonstrated that an absolute leukocyte count in the synovial fluid of less than 1,700 to 2,500/mm3 is an accurate predictor of absence of infection. Similarly, a differential cell count of the WBCs demonstrating less than 50% to 60% neutrophils is an accurate predictor of absence of infection. If both parameters are normal, it is unlikely that the patient has an infection. The three surgical options are contraindicated based on the normal examination findings and laboratory parameters. Similarly, antibiotics should be avoided. The work-up should include tests to evaluate noninfectious sources of knee pain and sources of referred knee pain. Trampuz A, Hanssen AD, Osmon DR, et al: Synovial fluid leukocyte count and differential for the diagnosis of prosthetic knee infection. Am J Med 2004;117:556-562. Mason JB, Fehring TK, Odum SM, et al: The value of white blood cell counts before revision total knee arthroplasty. J Arthroplasty 2003;18:1038-1043.

Question 2289

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. Patellar clunk syndrome is a distinct syndrome associated with the patella and has been reported in posterior stabilized knees. In addition to crepitation with range of motion, the patella literally snaps or jumps as the knee is taken from flexion to extension. Beight JL, Yao B, Hozack WJ, et al: The patellar "clunk" syndrome after posterior stabilized total knee arthroplasty. Clin Orthop 1994;299:139-142. Barnes CL, Scott RD: Popliteus tendon dysfunction following total knee arthroplasty. J Arthroplasty 1995;10:543-545.

Question 2290

Topic: 3. Adult Reconstruction (Hip & Knee)

A 70-year-old man underwent primary total knee arthroplasty 3 months ago. Figures 7a and 7b show the radiograph and clinical photograph following incision and drainage of the wound 1 week ago. Aspiration of the joint reveals methicillin-sensitive Staphylococcus aureus. What is the next most appropriate step in management?

. Repeat debridement, followed by 6 weeks of IV antibiotics
. Repeat debridement, followed by direct exchange arthroplasty
. Delayed exchange reimplantation
. Immediate knee arthrodesis
. Amputation

Correct Answer & Explanation

. Delayed exchange reimplantation

Explanation

The overriding factor determining treatment in this case is the appearance of the surgical wound. Based on MacPhearson's work, this "C" wound is best managed with two-stage exchange. The functional outcome is markedly diminished following a knee arthrodesis compared to revision knee arthroplasty. Harwin SF: The diagnosis and management of infected total knee replacement. Seminars Arthroplasty 2002;13:9-22. Goldmann RT, Scuderi GR, Insall JN: 2-stage reimplantation for infected total knee replacement. Clin Orthop 1996;331:118-124.

Question 2291

Topic: 3. Adult Reconstruction (Hip & Knee)

An otherwise healthy 57-year-old man has persistent, severe hip pain after undergoing total hip arthroplasty 3 months ago. What is the next most appropriate step in management?

Hip 2004 Practice Questions: Set 1 (Solved) - Figure 13

. Serial radiographs to assess progressive radiolucency from osteolysis or mechanical loosening
. Assessment of C-reactive protein, erythroctye sedimentation rate, and CBC, followed by aspiration
. Technetium and/or indium-labeled leukocyte scintigraphy
. A trial of broad-spectrum cefalosporin antibiotics to assess for a change in pain intensity
. Injection with lidocaine and methylprednisolone acetate

Correct Answer & Explanation

. Assessment of C-reactive protein, erythroctye sedimentation rate, and CBC, followed by aspiration

Explanation

Any patient who is severely symptomatic this quickly after surgery must be evaluated for infection. Loosening is also a possible cause, but infection must be ruled-out. Bone scans are not helpful at this early postoperative stage. Normal laboratory values argue strongly against infection, but when abnormal, need to be supplemented with a hip aspiration. Aspiration remains the most selective and sensitive measure, especially when linked to a WBC count of the synovial tissues in the joint. There is no indication for an antiobiotic trial because it may make future culture sensitivity more difficult. 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 2292

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 48a shows the full-leg standing radiograph of a patient with a prior femoral fracture. Figure 48b shows the lateral view of the same joint. The patient is scheduled to undergo total knee arthroplasty. Because the mechanical axis of the lower extremity in patients with a prior femoral fracture may be disrupted, which of the following should be used during surgery to restore the mechanical axis of the lower extremity in this patient?

. Customized components
. Specialized intramedullary jigs
. Hinged prosthesis
. Extra-articular osteotomy
. Routine knee prosthesis

Correct Answer & Explanation

. Routine knee prosthesis

Explanation

The radiograph shows hardware that was used for fixation of a prior femoral fracture. The mechanical axis of the lower extremity in this patient is nearly normal (3 degrees valgus), and the deformity at the healed fracture site (14 degrees) does not appear to affect the joint alignment and is acceptable. Use of a routine knee prosthesis will be possible in this patient. To avoid hardware removal, extramedullary jigs and/or computerized navigation may be used to measure and restore the long axis of the femur. The use of a hinged prosthesis does not influence the mechanical axis directly. Extra-articular osteotomy is occasionally needed to reverse severe deformities. Papadopoulos EC, Parvizi J, Lai CH, et al: Total knee arthroplasty following distal femoral fractures. Knee 2002;9:267-274.

Question 2293

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 10 shows the AP radiograph of an ambulatory 76-year-old patient. What is the most appropriate surgical treatment option for this patient?

Hip & Knee Reconstruction 2007 Practice Questions: Set 1 (Solved) - Figure 20

. Revision arthroplasty using a cemented femoral component
. Impaction allografting of the femoral component
. Proximal femoral replacement arthroplasty
. Resection arthroplasty
. Hip arthrodesis

Correct Answer & Explanation

. Proximal femoral replacement arthroplasty

Explanation

The patient has a periprosthetic fracture around a loose cemented femoral component. The proximal bone stock is poor; therefore, this fracture may be categorized as Vancouver 3-B. Hip arthrodesis and resection arthroplasty provide suboptimal results, particularly for ambulatory patients. Although impaction allografting may be an option to restore the bone stock in a younger patient, the latter procedure will be very difficult to perform when the proximal bone is poor in quality and fractured. Cementing another component into this wide femur is not an option. The best option for revision of the femoral component in this elderly patient is proximal femoral replacement arthroplasty. Malkani AL, Settecerri JJ, Sim FH, et al: Long-term results of proximal femoral replacement for non-neoplastic disorders. J Bone Joint Surg Br 1995;77:351-356.

Question 2294

Topic: 3. Adult Reconstruction (Hip & Knee)
Figures 3a through 3c show the radiographs and bone scan of a patient who reports increasing pain associated with activity for the past several months. Laboratory studies show an erythrocyte sedimentation rate of 14 mm/h and a C-reactive protein level of 0.4. Aspiration is negative for infection. Management should consist of
. antibiotics for 6 weeks.
. use of an unlocked brace.
. revision arthroplasty.
. resection of the implants.
. two-stage reimplantation.

Correct Answer & Explanation

. revision arthroplasty.

Explanation

The radiographs show polyethylene wear, but exchange of this will not necessarily provide pain relief. The presence of pain suggests the possibility of occult loosening, and the surgeon must be prepared for this option intraoperatively. There is little evidence of infection. Rand JA, Peterson LF, Bryan RS, Ilstrup DM: Revision total knee arthroplasty, in Anderson LD (ed): Instructional Course Lectures XXXV. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1986, pp 305-318.

Question 2295

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 16 shows the radiograph of a 75-year-old man who has progressive groin pain and a limp following total hip replacement. At revision surgery, the anterior and posterior columns of the acetabulum are noted to be intact. The optimal surgical technique for acetabular component reconstruction is a

Hip Board Review 2001: High-Yield MCQs (Set 2) - Figure 13

. threaded (screw-in) cup with a hydroxyapatite coating.
. protrusio cage reconstruction with a cemented cup.
. large cementless cup with bone grafting of defects.
. small cup with a high and lateral hip center.
. bulk allograft reconstruction of the defect with a cemented cup.

Correct Answer & Explanation

. large cementless cup with bone grafting of defects.

Explanation

Large cementless acetabular components have been shown to perform well in revision acetabular reconstruction. The use of such components is predicated on the presence of adequate anterior and posterior column bone. If a good press-fit can be achieved between the anterior and posterior columns, typically, the remaining defects can be filled with morcellized bone graft. Protrusio cages are typically used in situations where it is not possible to obtain adequate fixation with a large acetabular component. The use of a high hip center with small sockets is more typical of primary arthroplasty in patients with developmental dysplasia of the hip. Bulk acetabular allografts for large segmental defects might be necessary in certain situations, although the use of bulk allografts has resulted in a high failure rate after 5 years. Early results of the use of protrusio cages and bone grafting for large segmental defects have been favorable. Petrera P, Rubash HE: Revision total hip arthroplasty: The acetabular component. J Am Acad Orthop Surg 1995;3:15-21.

Question 2296

Topic: 3. Adult Reconstruction (Hip & Knee)

A 61-year-old man reports right hip pain and limited motion after undergoing total hip arthroplasty for posttraumatic arthritis 1 year ago. Figure 6 shows an AP radiograph of the pelvis. To improve motion and relieve pain, management should consist of

Hip 2004 Practice Questions: Set 1 (Solved) - Figure 14

. surgical excision of heterotopic ossification and ethyl hydroxydiphosphonate at a dose of 20 mg/kg of body weight for 3 months.
. surgical excision of heterotopic ossification and irradiation of the right hip in a single dose of 400 Gy postoperatively.
. surgical excision of heterotopic ossification and irradiation of the right hip in a single dose of 700 Gy postoperatively.
. ethyl hydroxydiphosphonate at a dose of 20 mg/kg of body weight for 3 months.
. 25 mg of oral indomethacin administered three times a day for 10 days.

Correct Answer & Explanation

. surgical excision of heterotopic ossification and irradiation of the right hip in a single dose of 700 Gy postoperatively.

Explanation

The patient has symptomatic grade IV Brooker heterotopic ossification. Once the bone has matured, it can be excised. Surgical excision should be combined with postoperative irradiation to avoid recurrence. Pharmacologic and irradiation intervention are not successful beyond the perioperative period unless they are combined with surgical excision of mature heterotopic ossification. Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 417-451.

Question 2297

Topic: 3. Adult Reconstruction (Hip & Knee)

Cementation technique has a definite influence on the long-term survival of cemented femoral components. Both clinical and autopsy studies support the use of a cement mantle with a thickness of how many millimeters?

Hip Board Review 2001: High-Yield MCQs (Set 2) - Figure 10

. 0.5
. 1
. 2
. 3
. 4

Correct Answer & Explanation

. 2

Explanation

Long-term radiographic analysis of cemented total hips supports the creation of a 2- to 5-mm cement mantle in the proximal medial region. Autopsy studies have shown that the incidence of crack formation was greatest when the cement mantle was less than 2 mm. Ebramzadeh E, Sarmiento A, McKellop HA, Llinas A, Gogan W: The cement mantle in total hip arthroplasty: Analysis of long-term radiographic results. J Bone Joint Surg Am 1994;76:77-87. Jasty M, Maloney WJ, Bragdon CR, O'Connor DO, Haire T, Harris WH: The initiation of failure in cemented femoral components of hip arthroplasty. J Bone Joint Surg Br 1991;73:551-558.

Question 2298

Topic: 3. Adult Reconstruction (Hip & Knee)

After trial placement of components in a primary total knee arthroplasty, the knee is unable to come to full extension, but the flexion gap is appropriately balanced. After adequate soft-tissue releases have been performed, what is the next most appropriate action to balance the reconstruction?

. Use a larger femoral component
. Use a thinner polyethylene insert
. Add posterior femoral augments
. Resect more proximal tibia
. Resect additional distal femur

Correct Answer & Explanation

. Resect additional distal femur

Explanation

The reconstruction requires additional resection of the distal femur to allow increased extension while maintaining the current flexion gap tension. Resecting more proximal tibia or decreasing the tibial polyethylene thickness will decrease flexion tension as well as extension tension. Adding posterior femoral augments and using a larger femoral component will increase flexion tension. Ayers DC, Dennis DA, Johanson NA, et al: Common complications of total knee arthroplasty. J Bone Joint Surg Am 1997;79:278-311.

Question 2299

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 28 shows the postoperative radiograph of a 36-year-old patient. The cerclage cable was placed for a minimal medial calcar fracture seen during femoral preparation. In the immediate postoperative period, what is the highest level of activity that would be safely permitted?

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 2) - Figure 25

. Immediate full weight bearing
. Protected weight bearing
. Toe touch weight bearing
. Non-weight-bearing
. 50% weight bearing

Correct Answer & Explanation

. Immediate full weight bearing

Explanation

The incidence of femoral fracture in primary cementless total hip arthroplasty ranges from 1.5% to 27.8%. It is imperative that the implant and fracture are stable both intraoperatively and postoperatively. Cerclage wiring or cerclage cabling is the current recommended treatment for nondisplaced calcar fractures and minimally displaced proximal fractures. Berend and associates reviewed the results of 58 total hips in 55 patients with intraoperative calcar fracture managed with single or multiple cerclage wires or cables and immediate full weight bearing. Follow-up averaged 7.5 years, and there were no revisions of the femoral component. No patients had severe thigh pain. Berend KR, Lombardi AV Jr, Mallory TH, et al: Cerclage wires or cables for the management of intraoperative fracture associated with a cementless, tapered femoral prosthesis: Results at 2 to 16 years. J Arthroplasty 2004;19:17-21. Schmidt AH, Kyle RF: Periprosthetic fractures of the femur. Orthop Clin North Am 2002;33:143-152.

Question 2300

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 35 shows the AP radiograph of a patient who underwent a previous upper tibial osteotomy (UTO). The patient may be at risk for which of the following during total knee arthroplasty (TKA)?

Hip & Knee Reconstruction 2007 Practice Questions: Set 3 (Solved) - Figure 8

. Bone loss
. Patella alta
. Myositis ossificans
. Fracture
. Instability

Correct Answer & Explanation

. Instability

Explanation

The results of TKA for patients with a prior UTO are reported to be slightly suboptimal. The major problems are patella baja, difficulty in exposure, and instability. Most of the patients exhibit some degree of instability prior to TKA, and ligamentous balancing may be difficult. Ligamentous structures are at risk of rupture during the difficult exposure. The problem of ligamentous balancing is exacerbated by the change in the joint slope that can occur after UTO. Parvizi J, Hanssen AD, Spangehl MJ: Total knee arthroplasty following proximal tibial osteotomy: Risk factors for failure. J Bone Joint Surg Am 2004;86:474-479.

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