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3. Adult Reconstruction (Hip & Knee) MCQs

Practice Set 190 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 3781

Topic: Total Hip Arthroplasty (THA)

A 68-year-old woman complains that her operative leg feels "too long" 6 weeks after a right total hip arthroplasty. On physical examination with her pelvis leveled, her right medial malleolus is 2 cm distal to the left medial malleolus. On the standard postoperative AP pelvis radiograph, the vertical distance from the inter-teardrop line to the right lesser trochanter is 35 mm, and the distance to the left lesser trochanter is 35 mm. What is the most likely cause of her perceived leg length discrepancy?

. Over-lengthening of the femoral stem relative to the neck cut
. Excessive femoral stem offset
. Acetabular component placed too inferiorly
. Pelvic obliquity secondary to abductor muscle contracture
. Use of a modular femoral head with a longer neck length

Correct Answer & Explanation

. Pelvic obliquity secondary to abductor muscle contracture

Explanation

Radiographically, the patient's leg lengths are symmetric because the distance from the bilateral teardrops (a fixed pelvic landmark) to the lesser trochanters (a fixed femoral landmark) is equal at 35 mm. The patient is experiencing an apparent (functional) leg length discrepancy. This is most commonly caused by pelvic obliquity due to abductor spasm, contracture, or concurrent lumbar spine pathology in the early postoperative period. True limb lengthening (options A, C, E) would result in a greater teardrop-to-lesser trochanter distance on the operative side.

Question 3782

Topic: 3. Adult Reconstruction (Hip & Knee)

A 45-year-old woman with a history of developmental dysplasia of the hip presents with worsening bilateral hip pain.

Radiographs demonstrate a Crowe type IV high hip dislocation on the right side. She is scheduled for a right total hip arthroplasty. Placing the acetabular component in the true anatomical acetabulum will most likely require which of the following adjunctive procedures to safely reduce the hip and prevent permanent neurologic injury?

. Greater trochanteric advancement
. Adductor tenotomy alone
. Femoral neck lengthening osteotomy
. Subtrochanteric femoral shortening osteotomy
. Proximal femoral replacement

Correct Answer & Explanation

. Subtrochanteric femoral shortening osteotomy

Explanation

Crowe type IV developmental dysplasia of the hip represents a high dislocation with >100% subluxation. When performing a THA, placing the cup in the true anatomical acetabulum (which provides the best bone stock and biomechanics) requires pulling the femur distally a significant distance. Stretching the limb more than 3-4 cm acutely places the sciatic nerve at an unacceptably high risk for stretch palsy. Therefore, a subtrochanteric femoral shortening osteotomy is frequently required to achieve reduction into the true acetabulum without placing excessive tension on the neurovascular structures.

Question 3783

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 1 shows the radiograph of a 62-year-old man who presents with persistent groin pain 6 years after an uncomplicated metal-on-polyethylene total hip arthroplasty utilizing a large-diameter (36 mm) modular cobalt-chromium femoral head on a titanium stem. Serologic testing reveals elevated serum cobalt and chromium levels. Aspiration of the hip yields clear fluid with a normal white blood cell count and negative cultures. MRI with metal artifact reduction sequence (MARS) demonstrates a solid cystic mass in the periprosthetic soft tissues. Which of the following is the most likely etiology of his condition?

. Accelerated polyethylene wear secondary to impingement
. Mechanically assisted crevice corrosion (trunnionosis)
. Aseptic loosening of the acetabular component
. Chronic indolent periprosthetic joint infection
. Iliopsoas tendon impingement against the acetabular shell

Correct Answer & Explanation

. Mechanically assisted crevice corrosion (trunnionosis)

Explanation

The clinical scenario describes trunnionosis, or mechanically assisted crevice corrosion, occurring at the modular head-neck junction of a total hip arthroplasty. Even in metal-on-polyethylene bearings, the use of large-diameter cobalt-chromium heads on titanium stems increases the torque and fretting at the trunnion. This fretting corrosion releases metal ions (cobalt and chromium), leading to an adverse local tissue reaction (ALTR) or aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL). This typically presents with groin pain, elevated metal ions, and pseudotumor formation on MRI, in the absence of infection.

Question 3784

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 3 shows the radiograph of an 82-year-old woman who sustained a low-energy fall 4 years after a cemented total hip arthroplasty. Imaging demonstrates a fracture extending around the tip of the femoral stem. Radiographic evaluation indicates that the femoral component has subsided 5 mm since her last follow-up, but the surrounding proximal femoral bone stock remains adequate. Based on the Vancouver classification, what is the most appropriate definitive management?

. Open reduction and internal fixation with a laterally applied locking plate and cables
. Revision of the femoral component to a standard-length fully porous-coated stem
. Revision of the femoral component to a long fluted tapered cementless stem bypassing the fracture
. Application of dual cortical strut allografts alone
. Closed reduction and application of a hip spica cast

Correct Answer & Explanation

. Revision of the femoral component to a long fluted tapered cementless stem bypassing the fracture

Explanation

This is a Vancouver B2 periprosthetic femur fracture, characterized by a fracture around or just below the stem tip with a loose implant (evidenced by subsidence) but adequate remaining bone stock. The standard of care for a Vancouver B2 fracture is revision of the loose femoral component to a long extensively porous-coated or fluted tapered cementless stem that bypasses the fracture site by at least two cortical diameters, typically supplemented with cables. Plate fixation alone (Option 0) is reserved for Vancouver B1 fractures (stable implant).

Question 3785

Topic: 3. Adult Reconstruction (Hip & Knee)

Figure 5 demonstrates the radiograph of a 68-year-old man who presents to the emergency department with his third posterior dislocation of a total hip arthroplasty performed 8 months ago. He is compliant with hip precautions. Radiographic analysis reveals the acetabular component is placed in 5 degrees of retroversion and 40 degrees of abduction. The femoral component has normal anteversion and stable fixation. Following closed reduction, what is the most appropriate definitive management to prevent further dislocations?

. Prescribe a customized hip abduction orthosis for 3 months
. Retain the acetabular shell and exchange the modular head to a larger diameter
. Revise the acetabular component to increase anteversion
. Convert the construct to a bipolar hemiarthroplasty
. Revise the femoral stem to a high-offset component

Correct Answer & Explanation

. Revise the acetabular component to increase anteversion

Explanation

The patient is experiencing recurrent posterior instability due to a malpositioned acetabular component (retroversion). The "safe zone" for acetabular cup placement is typically described as 15 +/- 10 degrees of anteversion and 40 +/- 10 degrees of abduction. A retroverted cup predisposes the hip to posterior dislocation, particularly during flexion and internal rotation. The most definitive and appropriate treatment for recurrent instability directly caused by component malposition is revision of the malpositioned component (in this case, increasing the anteversion of the acetabular cup).

Question 3786

Topic: 3. Adult Reconstruction (Hip & Knee)

A 51-year-old active man who underwent a cementless primary total hip arthroplasty with a ceramic-on-ceramic bearing surface 3 years ago presents with an audible "squeaking" sound originating from his hip during ambulation. He denies significant pain, and inflammatory markers are within normal limits. Which of the following factors is most strongly associated with the development of this acoustic phenomenon?

. High body mass index
. Subsidence of the femoral stem
. Acetabular component malposition leading to edge-loading
. Occult fracture of the ceramic femoral head
. Hypersensitivity to the titanium acetabular shell

Correct Answer & Explanation

. Acetabular component malposition leading to edge-loading

Explanation

Squeaking is a known complication specific to ceramic-on-ceramic bearing surfaces in total hip arthroplasty, occurring in up to 1-10% of cases. The most widely accepted etiology is a loss of fluid film lubrication leading to "stripe wear" and edge-loading. This is most strongly associated with malposition of the acetabular component (particularly steep cup inclination or excessive retroversion/anteversion), which alters the biomechanics and leads to edge-loading of the ceramic bearing.

Question 3787

Topic: 3. Adult Reconstruction (Hip & Knee)
A 35-year-old man presents with severe right hip pain that worsens with weight-bearing. He sustained a displaced femoral neck fracture 3 years ago, which was treated with closed reduction and percutaneous pinning. Current radiographs reveal a radiolucent subchondral line (crescent sign) with mild flattening of the superior femoral head, but the joint space is well preserved. According to the Ficat and Arlet classification, which of the following is the most appropriate surgical treatment?
. Core decompression with injection of bone marrow aspirate concentrate
. Free vascularized fibular grafting
. Total hip arthroplasty
. Valgus intertrochanteric osteotomy
. Arthroscopic labral repair and cam resection

Correct Answer & Explanation

. Total hip arthroplasty

Explanation

The patient has post-traumatic avascular necrosis (AVN) of the femoral head. A "crescent sign" with mild flattening indicates subchondral collapse, which corresponds to Ficat Stage III AVN. Once the femoral head has collapsed (Stage III or IV), joint-preserving procedures such as core decompression or vascularized fibular grafting have an unacceptably high failure rate. Total hip arthroplasty (THA) is the gold standard and most appropriate treatment for Ficat Stage III/IV AVN, providing reliable pain relief and functional improvement.

Question 3788

Topic: 3. Adult Reconstruction (Hip & Knee)

A 68-year-old man is scheduled for a left total hip arthroplasty. His medical history is significant for Brooker Class IV heterotopic ossification following a contralateral right total hip arthroplasty, which required surgical excision. Which of the following prophylactic regimens is most appropriate to prevent recurrence in his upcoming surgery?

. Extended-duration low molecular weight heparin for 35 days
. Single-fraction external beam radiation therapy (700-800 cGy) administered postoperatively
. High-dose oral corticosteroids for 2 weeks
. Prolonged antibiotic prophylaxis until surgical drains are removed
. Aggressive continuous passive motion (CPM) beginning on postoperative day zero

Correct Answer & Explanation

. Single-fraction external beam radiation therapy (700-800 cGy) administered postoperatively

Explanation

The patient is at high risk for heterotopic ossification (HO) given his history of Brooker Class IV HO in the contralateral hip. The most effective prophylactic modalities for HO are nonsteroidal anti-inflammatory drugs (e.g., indomethacin for 3-6 weeks) or localized external beam radiation therapy. A single fraction of 700-800 cGy radiation administered either within 24 hours preoperatively or within 48-72 hours postoperatively is highly effective and circumvents the gastrointestinal and bleeding risks associated with prolonged indomethacin use.

Question 3789

Topic: 3. Adult Reconstruction (Hip & Knee)
A 65-year-old man presents with chronic right hip pain 4 years after a primary total hip arthroplasty. His ESR is 45 mm/hr and CRP is 25 mg/L. Aspiration yields cloudy fluid with a synovial white blood cell (WBC) count of 4,500 cells/μL and 85% polymorphonuclear leukocytes (PMNs). A synovial alpha-defensin test is positive. According to the 2018 ICM / MSIS criteria for periprosthetic joint infection (PJI), what is the most appropriate diagnostic conclusion?
. The criteria are inconclusive; wait for 14-day culture results before diagnosing PJI.
. The patient has aseptic loosening, as the WBC count is below the threshold of 10,000 cells/μL.
. The diagnosis of PJI is definitively established based on the scoring criteria.
. A second aspiration is required to confirm the alpha-defensin result before diagnosing PJI.
. The patient requires an open biopsy for definitive histological diagnosis.

Correct Answer & Explanation

. The diagnosis of PJI is definitively established based on the scoring criteria.

Explanation

According to the 2018 International Consensus Meeting (ICM) criteria for PJI, a score of ≥6 indicates an infection. In this scenario, the elevated CRP (>10 mg/L) provides 2 points, elevated synovial WBC count (>3000 cells/μL) provides 3 points, elevated PMN% (>80%) provides 2 points, and a positive alpha-defensin test provides 3 points. The cumulative score is 10, which overwhelmingly establishes a definitive diagnosis of PJI even before culture results are finalized.

Question 3790

Topic: Total Hip Arthroplasty (THA)

A 62-year-old female presents with recurrent anterior dislocations of her total hip arthroplasty (THA). The original surgery was performed via a posterior approach. Which of the following combinations of component positioning is most classically associated with an anterior dislocation mechanism?

. Excessive acetabular anteversion and excessive femoral anteversion
. Excessive acetabular retroversion and excessive femoral anteversion
. Inadequate acetabular abduction and femoral retroversion
. Excessive acetabular retroversion and femoral retroversion
. Excessive acetabular abduction and neutral femoral version

Correct Answer & Explanation

. Excessive acetabular anteversion and excessive femoral anteversion

Explanation

Anterior dislocations in THA are most commonly caused by excessive combined anteversion (excessive acetabular anteversion and excessive femoral anteversion) or a mechanism of extension and external rotation. Conversely, posterior dislocations are associated with component retroversion (acetabular retroversion and/or femoral retroversion) and typically occur with hip flexion, adduction, and internal rotation.

Question 3791

Topic: 3. Adult Reconstruction (Hip & Knee)
A 72-year-old woman is undergoing revision total hip arthroplasty for severe aseptic loosening. Intraoperatively, there is independent movement between the superior and inferior halves of the hemipelvis, confirming pelvic discontinuity. However, there is adequate remaining host bone with >50% host-bone contact anticipated. Which of the following is considered the most reliable modern reconstruction method for this defect?
. Impaction bone grafting with a cemented polyethylene cup
. A standard hemispherical titanium cup without supplementary screws
. A highly porous multi-hole acetabular component with spanning iliac and ischial screws
. Resection arthroplasty (Girdlestone procedure)
. An anti-protrusio cage alone with allograft

Correct Answer & Explanation

. A highly porous multi-hole acetabular component with spanning iliac and ischial screws

Explanation

In the setting of pelvic discontinuity where there is still potential for biologic fixation (host bone contact >50%), achieving stable fixation that spans the discontinuity is crucial. The modern gold standard is a highly porous (e.g., trabecular metal) multi-hole hemispherical cup (often described as the 'cup distraction technique') utilizing multiple screws into both the intact ilium superiorly and the ischium inferiorly. This acts as an internal plate to stabilize the discontinuity while allowing for biologic ingrowth into the highly porous metal. Anti-protrusio cages alone have a high mechanical failure rate long-term because they do not achieve biologic fixation.

Question 3792

Topic: 3. Adult Reconstruction (Hip & Knee)

A 58-year-old man with a metal-on-metal total hip arthroplasty placed 10 years ago presents with worsening groin pain. Serum cobalt and chromium levels are significantly elevated. A metal artifact reduction sequence (MARS) MRI reveals a large, thick-walled fluid collection communicating with the joint space. What is the predominant histological feature expected in the periprosthetic tissue surrounding this lesion?

. Dense sheets of polymorphonuclear leukocytes
. Aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL)
. Birefringent monosodium urate crystals under polarized light
. Massive sheets of histiocytes containing polyethylene particles
. Caseating granulomas with Langhans giant cells

Correct Answer & Explanation

. Aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL)

Explanation

The patient is presenting with an adverse local tissue reaction (ALTR) secondary to a metal-on-metal articulation, specifically forming a pseudotumor. The hallmark histological finding in tissues affected by ALTR/metallosis from metal-on-metal implants is an Aseptic Lymphocyte-Dominated Vasculitis-Associated Lesion (ALVAL), representing a delayed type IV hypersensitivity reaction to metal ions (primarily cobalt). Dense PMNs suggest acute infection. Histiocytes with polyethylene debris are characteristic of osteolysis in metal-on-polyethylene bearings.

Question 3793

Topic: 3. Adult Reconstruction (Hip & Knee)

A 40-year-old active man presents 3 years after a primary total hip arthroplasty using a ceramic-on-ceramic bearing. He complains of an audible 'squeaking' sound coming from the hip with every step, which is embarrassing but entirely painless. Radiographs demonstrate well-fixed components with no subsidence or osteolysis. Which of the following factors is most strongly associated with the etiology of this phenomenon?

. Use of a femoral head < 28 mm in diameter
. Patient body mass index (BMI) < 25 kg/m2
. Malpositioning of the acetabular component leading to edge loading
. Galvanic corrosion at the modular head-neck junction
. Unrecognized low-grade periprosthetic joint infection

Correct Answer & Explanation

. Malpositioning of the acetabular component leading to edge loading

Explanation

Squeaking is a well-documented phenomenon specific to ceramic-on-ceramic (CoC) bearings, occurring in up to 10% of patients. The most significant predictive factor for squeaking is component malposition—specifically, excessive cup anteversion, vertical cup placement (high abduction angle), or loss of fluid lubrication, which leads to 'edge loading' and subsequent stripe wear on the ceramic head. Squeaking is less common with smaller heads and is instead associated with larger heads, younger/active patients, and higher BMI. Galvanic corrosion occurs at trunnions (trunnionosis) but does not cause squeaking.

Question 3794

Topic: 3. Adult Reconstruction (Hip & Knee)

A 65-year-old man presents with progressive groin pain and swelling 8 years after a metal-on-metal total hip arthroplasty (THA). Laboratory evaluation reveals elevated serum cobalt and chromium levels. MRI demonstrates a thick-walled, fluid-filled periprosthetic collection. Aspiration is negative for infection. If a biopsy of the periarticular tissue is obtained, which of the following is the most likely predominant histologic finding?

. Extensive acute neutrophilic infiltrate
. Extensive perivascular lymphocytic infiltrate
. Abundant polyethylene wear debris with foreign-body giant cells
. Negatively birefringent needle-shaped crystals
. Caseating granulomas with multinucleated giant cells

Correct Answer & Explanation

. Extensive perivascular lymphocytic infiltrate

Explanation

The clinical scenario describes an adverse local tissue reaction (ALTR), also known as aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL), which is a known complication of metal-on-metal bearing surfaces. It is characterized histologically by a hypersensitivity reaction featuring extensive perivascular lymphocytic infiltration, tissue necrosis, and fibrin deposition, rather than the pure macrophage response seen with polyethylene wear.

Question 3795

Topic: Total Hip Arthroplasty (THA)

A 72-year-old woman presents with recurrent posterior dislocations following a primary total hip arthroplasty performed via a posterior approach. Radiographic evaluation demonstrates the acetabular component is positioned in 35 degrees of abduction and 5 degrees of retroversion. The femoral stem has 15 degrees of anteversion. What is the most appropriate surgical management?

. Revision of the femoral stem to increase anteversion
. Revision of the acetabular component to increase anteversion
. Revision to a constrained acetabular liner
. Application of a hip abduction brace for 12 weeks
. Trochanteric advancement

Correct Answer & Explanation

. Revision of the acetabular component to increase anteversion

Explanation

Recurrent posterior instability in the setting of a retroverted acetabular cup (normal target is typically 15-20 degrees of anteversion and 40 degrees of abduction) is best managed by revising the malpositioned component. While constrained liners can treat instability due to abductor deficiency, they should not be used as a primary solution for severe component malposition, as this leads to early failure of the constrained mechanism.

Question 3796

Topic: 3. Adult Reconstruction (Hip & Knee)

A 68-year-old man has experienced gradually worsening, constant pain in his right total hip arthroplasty for the past 6 months. His index surgery was 2 years ago. Inflammatory markers reveal an ESR of 55 mm/hr and a CRP of 3.2 mg/dL. Joint aspiration yields synovial fluid with 4,200 WBC/uL and 82% polymorphonuclear leukocytes. Alpha-defensin is positive. Which of the following is the most appropriate next step in management?

. Single-stage revision arthroplasty
. Two-stage revision arthroplasty
. Chronic suppressive oral antibiotics
. Debridement, antibiotics, and implant retention (DAIR) with polyethylene exchange
. Intravenous antibiotics for 6 weeks followed by serial aspirations

Correct Answer & Explanation

. Two-stage revision arthroplasty

Explanation

The patient presents with a chronic late periprosthetic joint infection (PJI). The diagnostic criteria are met via elevated inflammatory markers, positive alpha-defensin, and a synovial WBC count >3,000 cells/uL with >80% PMNs. For chronic PJI (>4 weeks post-operatively), Debridement, Antibiotics, and Implant Retention (DAIR) is contraindicated. In North America, the gold standard for late chronic PJI remains two-stage revision arthroplasty.

Question 3797

Topic: 3. Adult Reconstruction (Hip & Knee)

A 55-year-old woman who underwent an uncomplicated total hip arthroplasty 3 years ago now complains of a painless 'squeaking' noise when she bends over or walks quickly. Radiographs are shown in Figure 4.

There is no evidence of loosening. What bearing surface was most likely utilized, and what is a primary biomechanical risk factor for this phenomenon?

. Ceramic-on-ceramic; edge loading due to component malposition
. Metal-on-metal; severe trunnionosis
. Ceramic-on-polyethylene; third body wear debris
. Metal-on-polyethylene; head-neck taper fretting
. Oxinium-on-polyethylene; highly cross-linked polyethylene wear

Correct Answer & Explanation

. Ceramic-on-ceramic; edge loading due to component malposition

Explanation

Squeaking is a highly specific complication of ceramic-on-ceramic bearing surfaces, occurring in roughly 1-10% of patients. It is strongly associated with edge loading, microseparation, and component malposition (e.g., excessively steep or anteverted/retroverted acetabular cups). In the absence of pain or functional limitation, reassurance is usually indicated.

Question 3798

Topic: 3. Adult Reconstruction (Hip & Knee)

A 45-year-old man presents for evaluation of hip arthroplasty options due to severe primary osteoarthritis. He works as a construction worker and expresses a strong interest in hip resurfacing arthroplasty. Which of the following represents an absolute contraindication to modern metal-on-metal hip resurfacing?

. Male sex
. Large femoral head size (>50 mm)
. Chronic kidney disease with GFR < 30 mL/min
. Body mass index > 35
. Primary osteoarthritis

Correct Answer & Explanation

. Chronic kidney disease with GFR < 30 mL/min

Explanation

Modern hip resurfacing utilizes a metal-on-metal (MoM) bearing surface. The generated cobalt and chromium ions are excreted primarily via the kidneys. Therefore, significant renal impairment (GFR < 30 mL/min) is an absolute contraindication to MoM hip resurfacing due to the risk of heavy metal toxicity. Males with large femoral head sizes and primary OA are actually ideal candidates.

Question 3799

Topic: 3. Adult Reconstruction (Hip & Knee)

During a primary cementless total hip arthroplasty, the surgeon opts to use a proximally coated, tapered flat wedge titanium stem. Which of the following best describes the primary fixation philosophy of this stem design and its most characteristic early mechanical complication if undersized?

. Metaphyseal fit; proximal thigh pain
. Diaphyseal fit; severe stress shielding
. Metaphyseal fit; early subsidence
. Proximal and distal coating; late distal osteolysis
. Distal fixation; early periprosthetic fracture

Correct Answer & Explanation

. Metaphyseal fit; early subsidence

Explanation

Tapered flat wedge stems achieve primary stability via a tight mediolateral fit in the proximal metaphysis. Because they are narrow in the anteroposterior dimension, they do not fill the metaphysis fully in the sagittal plane. If adequate cortical contact is not achieved during broaching, these stems are specifically prone to early subsidence.

Question 3800

Topic: 3. Adult Reconstruction (Hip & Knee)

A 79-year-old man sustains a fall and presents with severe thigh pain. Figure 11

demonstrates a periprosthetic femur fracture surrounding a cemented polished taper slip stem. Radiographs show the fracture extends just distal to the tip of the stem, the cement mantle is fractured, and the stem has subsided, but the surrounding cortical bone stock remains robust. According to the Vancouver classification, what is the injury and appropriate treatment?

. Vancouver A; nonoperative management with touch-down weight bearing
. Vancouver B1; open reduction and internal fixation with a locking plate and cables
. Vancouver B2; revision arthroplasty using a long-stem prosthesis
. Vancouver B3; revision arthroplasty using a proximal femoral replacement
. Vancouver C; open reduction and internal fixation alone

Correct Answer & Explanation

. Vancouver B2; revision arthroplasty using a long-stem prosthesis

Explanation

This is a Vancouver B2 fracture: the fracture occurs around or just below the stem tip (Type B), the implant is loose (Type 2), and the bone stock is adequate. The standard of care for a loose stem with good bone stock is revision arthroplasty, typically using a long cementless diaphyseal-engaging stem that bypasses the most distal fracture line by at least two cortical diameters. Type B1 (stable stem) is treated with ORIF, and Type B3 (poor bone stock) often requires a proximal femoral replacement.

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