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3. Adult Reconstruction (Hip & Knee) MCQs

Practice Set 155 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 3081

Topic: 3. Adult Reconstruction (Hip & Knee)

A 78-year-old female presents with thigh pain and inability to bear weight after a mechanical fall. Radiographs demonstrate a transverse periprosthetic femur fracture around a fully porous-coated femoral stem placed 10 years ago. The stem appears loose on radiographs, but there is adequate proximal bone stock.

What is the most appropriate treatment?

. Open reduction and internal fixation with cables alone
. Open reduction and internal fixation with a locking plate and cables
. Revision to a long, fully porous-coated diaphyseal-engaging stem
. Proximal femoral replacement
. Conservative management in a long leg cast

Correct Answer & Explanation

. Open reduction and internal fixation with cables alone

Explanation

This is a Vancouver B2 periprosthetic fracture (loose stem, good bone stock). The standard of care is revision arthroplasty using a long uncemented diaphyseal-engaging stem to bypass the fracture, often supplemented with cables.

Question 3082

Topic: Total Hip Arthroplasty (THA)

A 55-year-old male with a ceramic-on-ceramic total hip arthroplasty complains of a loud, high-pitched squeaking noise with ambulation. Which of the following factors is most strongly associated with this complication?

. High patient BMI
. Vertical acetabular cup placement (excessive inclination)
. Retroverted femoral stem
. Use of a short neck offset
. Elevated serum cobalt levels

Correct Answer & Explanation

. High patient BMI

Explanation

Squeaking in ceramic-on-ceramic THA is highly associated with edge loading. This most commonly results from component malposition, specifically increased acetabular cup inclination (a steep cup) or extremes of version.

Question 3083

Topic: 3. Adult Reconstruction (Hip & Knee)

A 45-year-old female presents with unexplained groin pain 5 years after receiving a metal-on-metal total hip arthroplasty. Her radiographs are unremarkable. What is the most appropriate initial diagnostic workup for the suspected pathology?

. C-reactive protein and Erythrocyte Sedimentation Rate
. Hip aspiration for cell count and culture
. Serum cobalt and chromium ion levels and MARS MRI
. Technetium-99m bone scan
. Diagnostic local anesthetic injection into the iliopsoas bursa

Correct Answer & Explanation

. C-reactive protein and Erythrocyte Sedimentation Rate

Explanation

Patients with metal-on-metal implants and unexplained pain should be evaluated for adverse local tissue reaction (ALTR) or pseudotumors. The initial workup involves checking serum cobalt and chromium ion levels and obtaining a metal artifact reduction sequence (MARS) MRI.

Question 3084

Topic: 3. Adult Reconstruction (Hip & Knee)

Following a primary total hip arthroplasty, a patient is noted to have a new-onset sciatic nerve palsy. Which of the following motor deficits is most likely to be present on physical examination?

. Inability to actively extend the knee
. Inability to actively flex the hip
. Weakness in ankle plantar flexion
. Weakness in ankle dorsiflexion and great toe extension
. Weakness in thigh adduction

Correct Answer & Explanation

. Inability to actively extend the knee

Explanation

The peroneal division of the sciatic nerve is most commonly injured during THA due to its lateral position and relative tethering at the fibular head. This injury classically results in foot drop (weakness in ankle dorsiflexion and extensor hallucis longus).

Question 3085

Topic: 3. Adult Reconstruction (Hip & Knee)

A 60-year-old female complains of anterior groin pain 1 year after an uncomplicated total hip arthroplasty. The pain is worst when she actively raises her leg to get into a car. Radiographs reveal the acetabular component has 10 degrees of anteversion and a prominent anterior rim. Conservative management has failed. What is the most appropriate surgical treatment?

. Revision of the femoral stem to increase offset
. Revision of the acetabular component to increase retroversion
. Endoscopic or open iliopsoas tenotomy
. Proximal hamstring release
. Trochanteric bursectomy and IT band release

Correct Answer & Explanation

. Revision of the femoral stem to increase offset

Explanation

Iliopsoas impingement classically presents as groin pain with active hip flexion (e.g., getting into a car) and is often caused by a prominent anterior acetabular rim. If prolonged conservative measures fail, an iliopsoas tenotomy is highly successful and less morbid than cup revision.

Question 3086

Topic: 3. Adult Reconstruction (Hip & Knee)
A 42-year-old male presents with progressively worsening hip pain. Radiographs demonstrate a crescent sign and early subchondral collapse of the femoral head, but the joint space is preserved (Ficat Stage III). What is the most reliable definitive treatment for this patient?
. Core decompression alone
. Core decompression with non-vascularized fibular grafting
. Free vascularized fibular graft
. Total hip arthroplasty
. Proximal femoral varus-producing osteotomy

Correct Answer & Explanation

. Total hip arthroplasty

Explanation

Ficat Stage III avascular necrosis involves subchondral collapse without significant acetabular involvement. Once mechanical collapse has occurred, head-preserving procedures have high failure rates, making total hip arthroplasty the most reliable option for pain relief and function.

Question 3087

Topic: 3. Adult Reconstruction (Hip & Knee)

During a standard posterior approach to the hip for arthroplasty, preserving the insertion of the quadratus femoris muscle or remaining proximal to it is recommended to protect which of the following vascular structures?

. Medial circumflex femoral artery
. Lateral circumflex femoral artery
. Obturator artery
. Inferior gluteal artery
. Superior gluteal artery

Correct Answer & Explanation

. Medial circumflex femoral artery

Explanation

The ascending branch of the medial circumflex femoral artery (MCFA) runs near the inferior border of the obturator externus and the superior border of the quadratus femoris. Protecting the quadratus femoris during a posterior approach helps prevent injury to the MCFA.

Question 3088

Topic: 3. Adult Reconstruction (Hip & Knee)

A surgeon utilizes a direct lateral (Hardinge) approach for a total hip arthroplasty. The gluteus medius is split longitudinally. Extending this split more than 5 cm proximal to the tip of the greater trochanter places which nerve at significant risk?

. Sciatic nerve
. Femoral nerve
. Superior gluteal nerve
. Inferior gluteal nerve
. Pudendal nerve

Correct Answer & Explanation

. Sciatic nerve

Explanation

The superior gluteal nerve innervates the gluteus medius, minimus, and tensor fasciae latae. It enters the deep surface of the gluteus medius approximately 3 to 5 cm proximal to the greater trochanter; splitting the muscle proximal to this point risks denervation and a severe Trendelenburg gait.

Question 3089

Topic: 3. Adult Reconstruction (Hip & Knee)

An 88-year-old female nursing home resident with severe dementia and minimal ambulatory capacity sustains a displaced femoral neck fracture. Which of the following is the most appropriate surgical intervention?

. In situ fixation with multiple cannulated screws
. Closed reduction and percutaneous pinning
. Cemented unipolar hemiarthroplasty
. Uncemented bipolar hemiarthroplasty
. Total hip arthroplasty

Correct Answer & Explanation

. In situ fixation with multiple cannulated screws

Explanation

For low-demand, elderly patients with displaced femoral neck fractures, a cemented unipolar hemiarthroplasty provides immediate stability for weight-bearing and reliable pain relief. Cementing the stem significantly reduces the risk of postoperative periprosthetic fractures compared to uncemented designs.

Question 3090

Topic: 3. Adult Reconstruction (Hip & Knee)

When evaluating a patient for a potential metal-on-metal total hip arthroplasty, which of the following medical conditions is widely considered an absolute contraindication to this bearing surface?

. Severe renal failure
. Previous history of deep vein thrombosis
. Rheumatoid arthritis
. Age greater than 60 years
. Body Mass Index (BMI) greater than 40

Correct Answer & Explanation

. Severe renal failure

Explanation

Metal ions (cobalt and chromium) generated by metal-on-metal articulations are renally excreted. Severe renal failure is an absolute contraindication due to the inability to clear these ions, leading to systemic accumulation and toxicity.

Question 3091

Topic: Total Hip Arthroplasty (THA)

When comparing total hip arthroplasty (THA) to hemiarthroplasty for the treatment of a displaced femoral neck fracture in an active, independent 72-year-old woman, which of the following statements is most accurate?

. Hemiarthroplasty is associated with a lower dislocation rate but a higher long-term reoperation rate than THA.
. THA is associated with a lower dislocation rate and a lower reoperation rate.
. Hemiarthroplasty provides superior long-term functional hip scores compared to THA.
. THA is associated with a significantly higher 1-year mortality rate.
. There is no difference in the reoperation rate between the two procedures at 10 years.

Correct Answer & Explanation

. Hemiarthroplasty is associated with a lower dislocation rate but a higher long-term reoperation rate than THA.

Explanation

In functionally active elderly patients, THA yields better functional outcomes and lower reoperation rates (mainly due to avoidance of acetabular wear). However, THA carries a historically higher risk of postoperative dislocation compared to hemiarthroplasty.

Question 3092

Topic: 3. Adult Reconstruction (Hip & Knee)

A 78-year-old man with a displaced femoral neck fracture undergoes a primary total hip arthroplasty. Compared to a patient undergoing total hip arthroplasty for elective primary osteoarthritis, this patient is at an increased risk for which of the following complications?

. Aseptic loosening of the femoral stem
. Postoperative dislocation
. Heterotopic ossification
. Deep vein thrombosis
. Leg length discrepancy

Correct Answer & Explanation

. Aseptic loosening of the femoral stem

Explanation

THA performed for acute femoral neck fractures has a significantly higher rate of postoperative dislocation (up to 5-10%) compared to THA performed for elective primary osteoarthritis (approx. 1%). Soft tissue laxity and lack of capsular contracture contribute to this risk.

Question 3093

Topic: 3. Adult Reconstruction (Hip & Knee)

A 75-year-old woman sustains a valgus-impacted femoral neck fracture. What is the primary rationale for recommending operative fixation with percutaneous cannulated screws over non-operative management?

. It decreases the risk of avascular necrosis.
. It prevents secondary fracture displacement.
. It stimulates osteoblastic bone healing.
. It allows for earlier return to driving.
. It eliminates the risk of deep vein thrombosis.

Correct Answer & Explanation

. It decreases the risk of avascular necrosis.

Explanation

Valgus-impacted femoral neck fractures (Garden I) treated non-operatively have a high rate of secondary displacement (up to 15-40%). Surgical fixation is performed primarily to prevent displacement, which would necessitate more extensive surgery like arthroplasty.

Question 3094

Topic: 3. Adult Reconstruction (Hip & Knee)

An 82-year-old woman is scheduled for a hemiarthroplasty for a displaced femoral neck fracture. When counseling the family on the choice between a cemented and an uncemented femoral stem, current evidence suggests that a cemented stem is associated with:

. A higher rate of intraoperative periprosthetic fractures
. A lower risk of postoperative periprosthetic fractures and less thigh pain
. A significantly higher 1-year mortality rate
. A higher dislocation rate
. A greater risk of long-term aseptic loosening

Correct Answer & Explanation

. A higher rate of intraoperative periprosthetic fractures

Explanation

Cemented stems in elderly patients with femoral neck fractures result in significantly fewer intraoperative and postoperative periprosthetic fractures and less thigh pain compared to uncemented stems, without a significant difference in 1-year mortality.

Question 3095

Topic: Total Hip Arthroplasty (THA)

An 81-year-old nursing home resident with severe Parkinson's disease sustains a displaced femoral neck fracture. Which of the following surgical options minimizes her risk of postoperative instability while addressing the fracture?

. Unipolar hemiarthroplasty via a posterior approach
. Standard total hip arthroplasty via a posterior approach
. Cemented hemiarthroplasty or THA with a dual mobility articulation
. In situ fixation with cannulated screws
. Sliding hip screw fixation

Correct Answer & Explanation

. Unipolar hemiarthroplasty via a posterior approach

Explanation

Patients with neuromuscular disorders such as Parkinson's disease are at an exceptionally high risk for postoperative dislocation. Utilizing a larger head size via hemiarthroplasty or a dual mobility THA component significantly mitigates this risk.

Question 3096

Topic: Total Hip Arthroplasty (THA)

A 65-year-old woman undergoes conversion of a failed ORIF of a femoral neck fracture to a total hip arthroplasty. Compared to primary THA for osteoarthritis, this conversion procedure is associated with:

. Similar operative times and clinical outcomes
. A higher risk of postoperative dislocation, infection, and periprosthetic fracture
. A lower risk of femoral stem loosening due to retained hardware tracks
. Decreased intraoperative blood loss
. A lower rate of heterotopic ossification

Correct Answer & Explanation

. Similar operative times and clinical outcomes

Explanation

Conversion THA following failed femoral neck fracture fixation is technically demanding and carries higher complication rates, including increased risks of dislocation, deep infection, intraoperative fracture, and increased blood loss, behaving more like a revision THA.

Question 3097

Topic: 3. Adult Reconstruction (Hip & Knee)

A 68-year-old active man presents with a displaced femoral neck fracture. Radiographs reveal the fracture along with severe, pre-existing osteoarthritis of the ipsilateral hip characterized by joint space narrowing and large osteophytes. The most appropriate surgical treatment is:

. Cemented bipolar hemiarthroplasty
. Uncemented unipolar hemiarthroplasty
. Total hip arthroplasty
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with a sliding hip screw

Correct Answer & Explanation

. Cemented bipolar hemiarthroplasty

Explanation

In a patient with a displaced femoral neck fracture and symptomatic, advanced pre-existing osteoarthritis of the same hip, a total hip arthroplasty (THA) is indicated to address both the fracture and the arthritic acetabulum. Hemiarthroplasty would result in persistent groin pain.

Question 3098

Topic: 3. Adult Reconstruction (Hip & Knee)

A 55-year-old woman sustains a displaced femoral neck fracture. She has a history of severe pelvic radiation for cervical cancer 15 years ago. Which of the following is the most appropriate surgical management?

. Closed reduction and percutaneous screw fixation
. Open reduction and internal fixation with a sliding hip screw
. Total hip arthroplasty with a cemented acetabular component
. Total hip arthroplasty with a highly porous uncemented acetabular component
. Unipolar hemiarthroplasty

Correct Answer & Explanation

. Closed reduction and percutaneous screw fixation

Explanation

Prior pelvic radiation causes radiation osteitis, severely impairing the biologic potential for bony ingrowth. If a THA is indicated, a cemented acetabular component is required, as uncemented cups have an extremely high failure rate in irradiated bone.

Question 3099

Topic: Total Hip Arthroplasty (THA)

A 77-year-old woman undergoes total hip arthroplasty for a displaced femoral neck fracture. Which of the following surgical approaches, if performed without meticulous soft-tissue repair, is associated with the highest risk of postoperative dislocation?

. Direct anterior approach
. Anterolateral approach (Watson-Jones)
. Direct lateral approach (Hardinge)
. Posterior approach (Moore)
. Trochanteric osteotomy approach

Correct Answer & Explanation

. Direct anterior approach

Explanation

The standard posterior approach, especially without a robust repair of the capsule and short external rotators, carries the highest historic risk of posterior dislocation, particularly in the femoral neck fracture population where soft tissues are lax.

Question 3100

Topic: 3. Adult Reconstruction (Hip & Knee)

An active, independent 74-year-old woman sustains a displaced femoral neck fracture. Compared to treatment with a bipolar hemiarthroplasty, treatment with a total hip arthroplasty (THA) is associated with which of the following?

. Higher risk of reoperation
. Lower risk of dislocation
. Increased long-term pain relief and functional scores
. Decreased operative time and blood loss
. Shorter length of hospital stay

Correct Answer & Explanation

. Higher risk of reoperation

Explanation

In healthy, active elderly patients with displaced femoral neck fractures, THA provides better functional outcomes and lower long-term pain compared to hemiarthroplasty. However, THA is associated with a higher risk of dislocation and increased operative time.

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