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3. Adult Reconstruction (Hip & Knee) MCQs

Practice Set 210 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 4181

Topic: 3. Adult Reconstruction (Hip & Knee)

A 59-year-old male presents with worsening groin pain and a palpable anterior thigh mass 6 years after undergoing a metal-on-metal total hip arthroplasty. Serum cobalt and chromium levels are significantly elevated. A metal-artifact reduction sequence (MARS) MRI reveals a large cystic mass communicating with the hip joint. If a biopsy of the periprosthetic tissue were performed, which of the following histological findings would be most characteristic of this patient's pathology?

. Abundant polymorphonuclear leukocytes with intracellular bacteria.
. Dense perivascular infiltrate of T-lymphocytes and macrophages with tissue necrosis.
. Multinucleated giant cells containing birefringent particles under polarized light.
. Sheets of monoclonal plasma cells with kappa light chain restriction.
. Non-caseating granulomas with asteroid bodies.

Correct Answer & Explanation

. Dense perivascular infiltrate of T-lymphocytes and macrophages with tissue necrosis.

Explanation

Correct Answer: Dense perivascular infiltrate of T-lymphocytes and macrophages with tissue necrosis.This patient is presenting with an adverse local tissue reaction (ALTR) or aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL), commonly referred to as a pseudotumor, which is a known complication of metal-on-metal hip arthroplasty. The histological hallmark of ALVAL is a dense, perivascular infiltrate of T-lymphocytes, macrophages, and plasma cells, often accompanied by extensive tissue necrosis and fibrin exudation. This represents a delayed-type (Type IV) hypersensitivity reaction to metal ions (cobalt and chromium). Polymorphonuclear leukocytes indicate acute infection. Multinucleated giant cells with birefringent particles are characteristic of polyethylene wear-induced osteolysis. Monoclonal plasma cells suggest multiple myeloma. Non-caseating granulomas are seen in sarcoidosis.

Question 4182

Topic: 3. Adult Reconstruction (Hip & Knee)

A 72-year-old female presents with insidious onset of right hip pain 3 years after a primary total hip arthroplasty. She denies fevers or chills. Radiographs show a well-fixed prosthesis with no signs of loosening. Laboratory studies reveal an erythrocyte sedimentation rate (ESR) of 55 mm/hr and a C-reactive protein (CRP) of 3.2 mg/dL. Hip aspiration yields synovial fluid with a white blood cell count of 5,200 cells/ยตL and 88% neutrophils. Which of the following is the most appropriate definitive management?

. Debridement, antibiotics, and implant retention (DAIR) with polyethylene exchange.
. Two-stage revision arthroplasty.
. Intravenous antibiotics for 6 weeks followed by lifelong oral suppression.
. Single-stage revision arthroplasty with retention of the well-fixed femoral stem.
. Observation and repeat aspiration in 3 months.

Correct Answer & Explanation

. Two-stage revision arthroplasty.

Explanation

Correct Answer: Two-stage revision arthroplasty.This patient meets the Musculoskeletal Infection Society (MSIS) criteria for a chronic periprosthetic joint infection (PJI) of the hip. She has elevated inflammatory markers (ESR >30, CRP >1.0) and an elevated synovial WBC count (>3,000 cells/ยตL) with a high neutrophil percentage (>80%). Because the infection is chronic (occurring 3 years postoperatively with an insidious onset), a DAIR procedure is contraindicated, as the mature biofilm cannot be eradicated without removing the implants. The gold standard treatment for chronic PJI in North America is a two-stage revision arthroplasty, which involves complete removal of all components and cement, placement of an antibiotic-loaded spacer, a course of IV antibiotics, and subsequent reimplantation once the infection is cleared.

Question 4183

Topic: 3. Adult Reconstruction (Hip & Knee)

An 81-year-old female sustains a fall and presents with severe left thigh pain. She underwent a left total hip arthroplasty 12 years ago. Radiographs reveal a spiral fracture of the femoral diaphysis extending just distal to the tip of the femoral stem. Comparison with previous radiographs demonstrates 4 mm of stem subsidence and a new varus alignment of the femoral component. The acetabular component is well-fixed. What is the most appropriate surgical management?

. Open reduction and internal fixation with a lateral locking plate and cerclage cables.
. Open reduction and internal fixation with cortical strut allografts and cerclage cables.
. Revision of the femoral component to a fully porous-coated or fluted tapered stem bypassing the fracture.
. Revision of the femoral component using a standard-length cemented stem.
. Closed reduction and application of a hip spica cast.

Correct Answer & Explanation

. Revision of the femoral component to a fully porous-coated or fluted tapered stem bypassing the fracture.

Explanation

Correct Answer: Revision of the femoral component to a fully porous-coated or fluted tapered stem bypassing the fracture.This patient has a Vancouver B2 periprosthetic femur fracture. The Vancouver classification is based on fracture location, implant stability, and bone stock. Type B fractures occur around or just distal to the stem. B1 indicates a well-fixed stem, B2 indicates a loose stem with adequate bone stock, and B3 indicates a loose stem with poor bone stock. The radiographic findings of subsidence and varus shift confirm the stem is loose (B2). The standard of care for a Vancouver B2 fracture is revision of the femoral component using a long, uncemented, extensively porous-coated or fluted tapered stem that bypasses the most distal aspect of the fracture by at least two cortical diameters. ORIF alone (Options 1 and 2) is reserved for B1 fractures. A standard-length cemented stem would not provide adequate distal fixation.

Question 4184

Topic: 3. Adult Reconstruction (Hip & Knee)

A 66-year-old male presents with his third posterior dislocation of his right total hip arthroplasty, which was performed 6 months ago via a posterior approach. Radiographic evaluation reveals the acetabular component is positioned at 40 degrees of inclination and 0 degrees of anteversion. The femoral stem is well-fixed with 15 degrees of anteversion. Which of the following is the most likely primary cause of his recurrent instability?

. Impingement of the femoral neck against the posterior acetabular rim during hip flexion and internal rotation.
. Impingement of the femoral neck against the anterior acetabular rim during hip flexion and internal rotation.
. Excessive combined anteversion of the components.
. Insufficient acetabular inclination leading to lateral uncoverage.
. Abductor deficiency secondary to the surgical approach.

Correct Answer & Explanation

. Impingement of the femoral neck against the anterior acetabular rim during hip flexion and internal rotation.

Explanation

Correct Answer: Impingement of the femoral neck against the anterior acetabular rim during hip flexion and internal rotation.Posterior dislocation of a total hip arthroplasty typically occurs with the hip in flexion, adduction, and internal rotation. The "safe zone" for acetabular component positioning is generally considered to be 40 ยฑ 10 degrees of inclination and 15 ยฑ 10 degrees of anteversion. In this patient, the cup has 0 degrees of anteversion (it is relatively retroverted). When the cup lacks adequate anteversion, the anterior rim of the acetabular component is prominent. During hip flexion and internal rotation, the anterior aspect of the femoral neck impinges against this prominent anterior rim, which acts as a fulcrum to lever the femoral head out of the socket posteriorly. Therefore, anterior impingement leads to posterior dislocation.

Question 4185

Topic: 3. Adult Reconstruction (Hip & Knee)
A 38-year-old male with a history of systemic lupus erythematosus managed with chronic corticosteroids presents with progressive right hip pain. Radiographs of the right hip demonstrate a subchondral radiolucent line (crescent sign) with mild flattening of the femoral head, but preservation of the joint space and a normal-appearing acetabulum. According to the Ficat and Arlet classification, what is the stage of his disease, and what is the most reliable surgical treatment to relieve pain and restore function?
. Stage II; Core decompression with or without bone grafting.
. Stage III; Core decompression with vascularized fibular graft.
. Stage III; Total hip arthroplasty.
. Stage IV; Total hip arthroplasty.
. Stage IV; Proximal femoral osteotomy.

Correct Answer & Explanation

. Stage III; Total hip arthroplasty.

Explanation

The patient has osteonecrosis (avascular necrosis) of the femoral head. The Ficat and Arlet classification is based on radiographic findings: Stage I has normal x-rays (MRI positive); Stage II shows cystic/sclerotic changes but a spherical head; Stage III is characterized by subchondral collapse (the "crescent sign") and flattening of the femoral head, with a preserved joint space; Stage IV involves secondary osteoarthritis with joint space narrowing and acetabular changes. This patient has a crescent sign and mild flattening with preserved joint space, making it Stage III. Once subchondral collapse has occurred (Stage III or IV), joint-preserving procedures like core decompression are highly prone to failure. Total hip arthroplasty is the most reliable and successful treatment for Stage III and IV osteonecrosis to relieve pain and restore function.

Question 4186

Topic: Total Hip Arthroplasty (THA)

A 65-year-old man undergoes a right total hip arthroplasty. During preoperative templating, the surgeon plans to use a high-offset femoral stem to increase the femoral offset by 8 mm without changing the vertical height or leg length. What is the primary biomechanical effect of this modification?

. Increased overall joint reaction force.
. Decreased abductor muscle tension required for pelvic stability.
. Decreased bending moment on the femoral stem.
. Decreased impingement-free range of motion.
. Medialization of the hip center of rotation.

Correct Answer & Explanation

. Decreased abductor muscle tension required for pelvic stability.

Explanation

Correct Answer: Decreased abductor muscle tension required for pelvic stability.Increasing the femoral offset increases the lever arm of the abductor musculature. According to the biomechanics of the hip, the joint reaction force is a balance between the body weight (and its lever arm) and the abductor force (and its lever arm). By increasing the abductor lever arm (offset), less abductor force is required to counteract the body weight and maintain a level pelvis. Consequently, this decreases the overall joint reaction force across the hip. Increasing offset also increases the impingement-free range of motion and soft tissue tension, reducing the risk of dislocation. However, a negative consequence of increasing femoral offset is that it increases the bending moment (stress) on the femoral stem, potentially increasing the risk of stem fatigue failure or loosening if extreme.

Question 4187

Topic: 3. Adult Reconstruction (Hip & Knee)

A 45-year-old highly active woman undergoes a cementless total hip arthroplasty utilizing a ceramic-on-ceramic bearing surface. Which of the following is a unique complication most specifically associated with this bearing couple compared to standard metal-on-polyethylene?

. Trunnionosis
. Squeaking
. Osteolysis from submicron particulate debris
. Elevated serum cobalt and chromium levels
. Aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL)

Correct Answer & Explanation

. Squeaking

Explanation

Correct Answer: SqueakingCeramic-on-ceramic (CoC) bearings offer the lowest wear rates of all bearing couples, making them an attractive option for young, active patients. However, a unique complication associated with CoC bearings is "squeaking," which has been reported in up to 10% of patients. Squeaking is often associated with component malposition (specifically edge loading), loss of fluid film lubrication, or third-body wear. Trunnionosis (corrosion at the head-neck junction) is typically seen with large metal heads on titanium stems. Osteolysis is most classically associated with polyethylene wear debris. Elevated metal ions and ALVAL are characteristic of metal-on-metal bearing surfaces.

Question 4188

Topic: 3. Adult Reconstruction (Hip & Knee)

A 72-year-old woman presents to the emergency department after a mechanical fall. She underwent a cementless total hip arthroplasty 5 years ago. Radiographs reveal a spiral fracture around the distal tip of the femoral stem. The stem is radiographically loose with 1 cm of subsidence. The fracture extends 2 cm distal to the stem tip. Her proximal femoral bone stock is adequate. According to the Vancouver classification, what is the most appropriate surgical management?

. Open reduction and internal fixation with a lateral locking plate and cerclage wires.
. Revision to a long fully porous-coated cementless stem.
. Revision to a standard length cemented stem.
. Proximal femoral replacement.
. Nonoperative management with a hip spica cast.

Correct Answer & Explanation

. Revision to a long fully porous-coated cementless stem.

Explanation

Correct Answer: Revision to a long fully porous-coated cementless stem.This patient has a Vancouver B2 periprosthetic femur fracture. The Vancouver classification is based on fracture location, implant stability, and bone stock. Type A fractures are in the trochanteric region. Type B fractures are around or just distal to the stem. Type C fractures are well below the stem. Type B is subdivided into B1 (well-fixed stem), B2 (loose stem, adequate bone stock), and B3 (loose stem, poor bone stock). Because this stem is loose (subsidence) but bone stock is adequate, it is a B2 fracture. The standard of care for a Vancouver B2 fracture is revision to a long cementless stem that bypasses the most distal aspect of the fracture by at least two cortical diameters. ORIF alone (Option A) is reserved for B1 or C fractures. Proximal femoral replacement (Option D) is indicated for B3 fractures.

Question 4189

Topic: 3. Adult Reconstruction (Hip & Knee)

A 55-year-old man presents with progressive groin pain and a palpable anterior mass 6 years after a metal-on-metal total hip arthroplasty. Aspiration of the hip yields a sterile, cloudy fluid. MRI with metal artifact reduction sequence (MARS) demonstrates a large cystic mass communicating with the joint. Histologic analysis of the periprosthetic tissue is most likely to demonstrate which of the following?

. Abundant polymorphonuclear leukocytes.
. Sheets of macrophages containing birefringent particles.
. Perivascular lymphocytic infiltrate.
. Granulomas with caseating necrosis.
. Malignant spindle cells with high mitotic figures.

Correct Answer & Explanation

. Perivascular lymphocytic infiltrate.

Explanation

Correct Answer: Perivascular lymphocytic infiltrate.The patient is presenting with an adverse local tissue reaction (ALTR), specifically an aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL), which is a known complication of metal-on-metal hip arthroplasty. ALVAL is a Type IV delayed hypersensitivity reaction to metal ions (cobalt and chromium). Histologically, it is characterized by a dense perivascular lymphocytic infiltrate. Polymorphonuclear leukocytes (Option A) would indicate an acute bacterial infection. Sheets of macrophages with birefringent particles (Option B) are characteristic of polyethylene wear-induced osteolysis. Caseating granulomas (Option D) are seen in tuberculosis.

Question 4190

Topic: Total Hip Arthroplasty (THA)

During a posterior approach to the hip for a hemiarthroplasty, the surgeon identifies and protects the main blood supply to the adult femoral head. Which of the following arteries provides the predominant blood supply to the weight-bearing dome of the adult femoral head?

. Artery of the ligamentum teres (foveal artery)
. Ascending branch of the lateral circumflex femoral artery
. Lateral epiphyseal branch of the medial circumflex femoral artery
. Inferior gluteal artery
. First perforating artery of the profunda femoris

Correct Answer & Explanation

. Lateral epiphyseal branch of the medial circumflex femoral artery

Explanation

Correct Answer: Lateral epiphyseal branch of the medial circumflex femoral arteryThe predominant blood supply to the adult femoral head is the medial circumflex femoral artery (MCFA). Specifically, the lateral epiphyseal branches of the MCFA supply the critical weight-bearing superior and lateral portions of the femoral head. The lateral circumflex femoral artery supplies the anterior and inferior portions of the head and neck but is less critical. The artery of the ligamentum teres (a branch of the obturator artery) provides a negligible amount of blood supply in the adult, though it is more significant in the pediatric population.

Question 4191

Topic: 3. Adult Reconstruction (Hip & Knee)

A 68-year-old man is evaluated 3 years after an uncomplicated total hip arthroplasty using an extensively porous-coated, diaphyseal-fitting cylindrical femoral stem. Radiographs show proximal femoral osteopenia with calcar resorption, but no radiolucent lines around the distal stem. He is completely asymptomatic. What is the primary biomechanical principle responsible for these radiographic findings?

. Galvanic corrosion
. Stress shielding
. Particulate disease (osteolysis)
. Micromotion
. Impingement

Correct Answer & Explanation

. Stress shielding

Explanation

Correct Answer: Stress shieldingThe radiographic findings describe stress shielding, which is a manifestation of Wolff's Law. Wolff's Law states that bone remodels in response to the mechanical stresses placed upon it. When a stiff, extensively porous-coated diaphyseal-fitting stem is used, the implant achieves rigid distal fixation and assumes the majority of the mechanical load, bypassing the proximal femur. Because the proximal femur is "shielded" from normal physiological stress, it undergoes disuse osteopenia and calcar resorption. This is typically asymptomatic and rarely leads to clinical failure, but it is a distinct radiographic phenomenon compared to osteolysis (which is driven by a macrophage response to particulate wear debris).

Question 4192

Topic: 3. Adult Reconstruction (Hip & Knee)

A 70-year-old woman sustains a posterior dislocation of her total hip arthroplasty 4 weeks postoperatively while bending over to tie her shoes. Closed reduction is successful. Radiographs demonstrate the acetabular component is positioned in 45 degrees of abduction and 0 degrees of anteversion. Which of the following is the most likely cause of her dislocation?

. Excessive acetabular anteversion
. Insufficient acetabular anteversion
. Excessive acetabular abduction
. Insufficient femoral offset
. Abductor deficiency

Correct Answer & Explanation

. Insufficient acetabular anteversion

Explanation

Correct Answer: Insufficient acetabular anteversionThe "safe zone" for acetabular component positioning, as classically described by Lewinnek, is 40 +/- 10 degrees of abduction (inclination) and 15 +/- 10 degrees of anteversion. This patient's cup is in 0 degrees of anteversion, meaning it is retroverted relative to the safe zone. Insufficient anteversion (or retroversion) of the acetabular component strongly predisposes the hip to posterior dislocation, especially during activities involving hip flexion, adduction, and internal rotation (like bending over to tie a shoe). Her abduction angle (45 degrees) is within the acceptable range.

Question 4193

Topic: Total Hip Arthroplasty (THA)

During a posterior approach to the hip (Kocher-Langenbeck), the surgeon releases the short external rotators. While releasing the quadratus femoris from its femoral insertion, brisk arterial bleeding is encountered. Which of the following vessels is most likely injured?

. Ascending branch of the medial circumflex femoral artery
. Descending branch of the lateral circumflex femoral artery
. Inferior gluteal artery
. First perforating artery
. Superior gluteal artery

Correct Answer & Explanation

. Ascending branch of the medial circumflex femoral artery

Explanation

Correct Answer: Ascending branch of the medial circumflex femoral arteryDuring the posterior approach to the hip, the short external rotators are detached from the femur. The ascending branch of the medial circumflex femoral artery (MCFA) consistently runs near the superior border of the quadratus femoris. If the quadratus femoris is released too far medially or without prior identification and coagulation of this vessel, brisk bleeding can occur. To avoid this, many surgeons leave the quadratus femoris intact or only partially release its superior edge while carefully cauterizing the ascending branch of the MCFA.

Question 4194

Topic: 3. Adult Reconstruction (Hip & Knee)
A 72-year-old female requires revision THA for aseptic loosening. Preoperative radiographs demonstrate superior migration of the acetabular component greater than 3 cm, medial migration past the Kohler line, and severe ischial osteolysis. Intraoperatively, there is less than 30% remaining host bone contact for a new cup. Which of the following is the most appropriate acetabular reconstruction strategy?
. Jumbo uncemented hemispherical cup
. Uncemented cup with superior metal augments
. Cup-cage construct or custom triflange component
. Impaction bone grafting with a cemented polyethylene cup
. Bipolar hemiarthroplasty

Correct Answer & Explanation

. Cup-cage construct or custom triflange component

Explanation

Paprosky IIIB defects are characterized by severe superior/medial migration and less than 30% host bone contact, often with pelvic discontinuity. A cup-cage construct or custom triflange is required to bridge the defect and achieve adequate stability when host bone cannot support a standard hemispherical cup.

Question 4195

Topic: Total Hip Arthroplasty (THA)

A 68-year-old male sustains an anterior dislocation of his primary THA 3 years postoperatively. Fluoroscopic evaluation during reduction reveals the dislocation consistently occurs with hip extension and external rotation. Radiographs demonstrate well-fixed components with optimal femoral offset. Which of the following is the most likely etiology of this specific pattern of instability?

. Excessive acetabular and femoral combined anteversion
. Inadequate femoral offset
. Excessive acetabular retroversion
. Impingement secondary to anterior retained osteophytes
. Abductor muscle deficiency

Correct Answer & Explanation

. Excessive acetabular and femoral combined anteversion

Explanation

Anterior dislocation typically occurs when the hip is subjected to extension and external rotation. This is most frequently caused by excessive combined anteversion of the acetabular and femoral components, causing posterior impingement that levers the head anteriorly.

Question 4196

Topic: 3. Adult Reconstruction (Hip & Knee)

A 62-year-old male underwent a primary cemented THA 3 weeks ago. He now presents with increasing hip pain, erythema, and a draining sinus tract from the surgical incision. Joint aspiration yields 45,000 WBC/uL (92% neutrophils). Radiographs show well-fixed components. What is the most appropriate management?

. Intravenous antibiotics for 6 weeks followed by a drug holiday
. Single-stage exchange arthroplasty
. Two-stage exchange arthroplasty with an antibiotic spacer
. Debridement, antibiotics, and implant retention (DAIR) with modular exchange
. Suppressive oral antibiotics indefinitely

Correct Answer & Explanation

. Debridement, antibiotics, and implant retention (DAIR) with modular exchange

Explanation

The patient has an acute early periprosthetic joint infection (less than 4 weeks post-op) with well-fixed components. The standard of care is Debridement, Antibiotics, and Implant Retention (DAIR), which strictly includes thorough irrigation and exchange of the modular head and polyethylene liner.

Question 4197

Topic: Total Hip Arthroplasty (THA)

A surgeon is performing a primary THA utilizing a direct lateral (Hardinge) approach. To gain adequate exposure, the splitting of the gluteus medius is extended proximally. To minimize the risk of denervating the anterior portion of the gluteus medius and the tensor fascia lata, the proximal split should not extend beyond what distance from the tip of the greater trochanter?

. 1 cm
. 3 cm
. 5 cm
. 8 cm
. 10 cm

Correct Answer & Explanation

. 5 cm

Explanation

The superior gluteal nerve courses approximately 5 cm proximal to the tip of the greater trochanter. Extending the split of the gluteus medius beyond 5 cm during a direct lateral approach risks transecting the nerve, leading to abductor weakness and a Trendelenburg gait.

Question 4198

Topic: Total Hip Arthroplasty (THA)
A 72-year-old male presents with severe thigh pain 12 years after a primary total hip arthroplasty. Radiographs reveal a loose femoral stem with substantial metaphyseal and diaphyseal bone loss. The bone defect extends to the diaphyseal isthmus, and there is less than 3 cm of diaphyseal scratch fit available. According to the Paprosky classification (Type IIIB), which of the following femoral components is the most appropriate choice for revision?
. Cemented standard length stem
. Fully porous-coated cylindrical uncemented stem
. Impaction bone grafting with a short cemented stem
. Modular fluted tapered uncemented stem
. Proximal femoral replacement

Correct Answer & Explanation

. Modular fluted tapered uncemented stem

Explanation

Paprosky IIIB femoral defects are characterized by extensive metaphyseal and diaphyseal bone loss with less than 4 cm of diaphyseal scratch fit available. A modular fluted tapered stem provides rigid distal fixation in the remaining healthy diaphyseal bone, whereas fully porous stems require at least 4 cm of intact isthmus.

Question 4199

Topic: 3. Adult Reconstruction (Hip & Knee)

A 68-year-old female with a history of a multi-level lumbar fusion (L2 to the pelvis) is undergoing a primary total hip arthroplasty. Preoperative standing and sitting lateral spinopelvic radiographs demonstrate a completely stiff spinopelvic junction with no change in pelvic tilt between positions. What is the most significant biomechanical consequence of this stiffness during the transition from standing to sitting?

. Decreased risk of anterior impingement
. Increased risk of posterior dislocation
. Increased pelvic retroversion (rollback)
. Decreased required acetabular anteversion
. Increased joint reaction forces during normal gait

Correct Answer & Explanation

. Increased risk of posterior dislocation

Explanation

In patients with a fused or stiff spinopelvic junction, the pelvis fails to retrovert (rollback) when transitioning from standing to sitting. This lack of mobility causes anterior osseous or component impingement, significantly increasing the risk of posterior dislocation.

Question 4200

Topic: 3. Adult Reconstruction (Hip & Knee)

An 80-year-old female sustains a fall and presents with thigh pain. Radiographs demonstrate a fracture around her cemented femoral stem, which was placed 15 years ago. The fracture is localized around the stem, the stem is obviously loose, and the proximal femur exhibits severe osteolysis with extremely poor bone stock. Based on the Vancouver classification, which of the following is the most definitive surgical management?

. Open reduction and internal fixation with cerclage cables only
. Open reduction and internal fixation with a laterally applied locking plate
. Revision to a standard length cemented stem
. Proximal femoral replacement prosthesis
. Revision to a fully porous-coated cylindrical stem without structural allograft

Correct Answer & Explanation

. Proximal femoral replacement prosthesis

Explanation

A Vancouver B3 fracture involves a loose implant with severely compromised proximal bone stock. Proximal femoral replacement (or a long revision stem with bulk structural allograft) is the most reliable treatment to allow early mobilization in the elderly.

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