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3. Adult Reconstruction (Hip & Knee) MCQs

Practice Set 22 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 421

Topic: 3. Adult Reconstruction (Hip & Knee)

A 72-year-old male with a history of atrial fibrillation is chronically managed with apixaban. He is scheduled to undergo an elective total hip arthroplasty. Assuming normal renal function, when should his apixaban be discontinued prior to surgery?

. It should not be discontinued
. 12 hours preoperatively
. 48 to 72 hours preoperatively
. 7 days preoperatively
. 14 days preoperatively

Correct Answer & Explanation

. 48 to 72 hours preoperatively

Explanation

For elective major orthopedic surgery like THA, direct oral anticoagulants (DOACs) such as apixaban are typically held for 48 to 72 hours preoperatively in patients with normal renal function to minimize surgical bleeding.

Question 422

Topic: 3. Adult Reconstruction (Hip & Knee)

A 55-year-old female with a heavily fused lumbar spine extending to the sacrum (L2-Pelvis) presents for a total hip arthroplasty due to severe osteoarthritis. Due to her lumbopelvic stiffness, she is at a significantly increased risk for which of the following postoperative complications?

. Aseptic loosening of the femoral stem
. Posterior dislocation of the THA
. Anterior dislocation of the THA
. Heterotopic ossification
. Periprosthetic joint infection

Correct Answer & Explanation

. Posterior dislocation of the THA

Explanation

Patients with a fused or stiff lumbopelvic segment fail to increase pelvic retroversion when transitioning from standing to sitting. This lack of dynamic acetabular anteversion leads to anterior bony impingement and subsequent posterior dislocation.

Question 423

Topic: 3. Adult Reconstruction (Hip & Knee)

A patient with severe hemophilia A requires an elective total hip arthroplasty. Due to the exceptionally high risk of perioperative bleeding, pharmacologic VTE prophylaxis is contraindicated. What is the standard of care for VTE prophylaxis in this specific scenario?

. Aspirin 81 mg daily
. Subcutaneous unfractionated heparin
. Pneumatic compression devices alone
. Preoperative IVC filter insertion
. Routine postoperative duplex ultrasounds without prophylaxis

Correct Answer & Explanation

. Pneumatic compression devices alone

Explanation

In patients where pharmacologic VTE prophylaxis is strictly contraindicated due to a high risk of active bleeding or severe bleeding disorders, mechanical prophylaxis with pneumatic compression devices alone is the standard recommendation.

Question 424

Topic: 3. Adult Reconstruction (Hip & Knee)

According to the American College of Chest Physicians (ACCP) guidelines, for a patient undergoing total hip arthroplasty, what is the recommended optimal duration of extended pharmacologic VTE prophylaxis?

. 7 to 10 days
. 10 to 14 days
. 14 to 21 days
. 28 to 35 days
. 90 days

Correct Answer & Explanation

. 28 to 35 days

Explanation

ACCP guidelines recommend that patients undergoing major orthopedic surgery such as THA receive extended pharmacologic VTE prophylaxis for up to 35 days postoperatively, as the risk for VTE remains elevated during this period.

Question 425

Topic: 3. Adult Reconstruction (Hip & Knee)
A patient presents with a malunited Denis Zone III sacral fracture that occurred 10 years ago, resulting in significant, fixed pelvic obliquity. He now requires a total hip arthroplasty (THA) for severe secondary osteoarthritis. How does this fixed pelvic deformity most critically impact THA surgical technique?
. It mandates the use of a constrained acetabular liner.
. It requires a fully porous-coated femoral stem.
. It alters the functional orientation of the acetabular component.
. It prevents the safe use of regional anesthesia.
. It necessitates the use of a dual-mobility bearing surface.

Correct Answer & Explanation

. It alters the functional orientation of the acetabular component.

Explanation

Fixed pelvic obliquity from a prior sacral or pelvic malunion significantly alters the functional anteversion and inclination of the pelvis. The surgeon must adjust acetabular cup placement to account for this to prevent postoperative impingement and dislocation.

Question 426

Topic: 3. Adult Reconstruction (Hip & Knee)

According to recent ACCP and AAOS guidelines, which of the following regimens is deemed acceptable and non-inferior for VTE prophylaxis in a standard-risk patient undergoing an elective primary total hip arthroplasty (THA)?

. Aspirin 81 mg twice daily
. Unfractionated heparin infusion
. Warfarin with a target INR of 3.5
. Clopidogrel 75 mg daily
. Intravenous tranexamic acid

Correct Answer & Explanation

. Aspirin 81 mg twice daily

Explanation

Aspirin is recommended as a safe and effective option for VTE prophylaxis in standard-risk patients undergoing elective THA, demonstrating non-inferiority to low-molecular-weight heparin with a lower bleeding profile.

Question 427

Topic: 3. Adult Reconstruction (Hip & Knee)

A 65-year-old male undergoes a routine, uncomplicated total hip arthroplasty. According to the American College of Chest Physicians (ACCP), what is the recommended minimum duration for pharmacologic venous thromboembolism (VTE) prophylaxis?

. 3 to 5 days
. 10 to 14 days
. 21 to 28 days
. 35 to 40 days
. 60 to 90 days

Correct Answer & Explanation

. 10 to 14 days

Explanation

ACCP guidelines recommend VTE prophylaxis for a minimum of 10 to 14 days following total hip and knee arthroplasty, with an extension up to 35 days suggested for high-risk patients.

Question 428

Topic: 3. Adult Reconstruction (Hip & Knee)

A 72-year-old female undergoes a primary THA and is discharged on Apixaban for VTE prophylaxis. Two weeks later, she presents with severe hip pain, swelling, and persistent wound drainage. Aseptic loosening is ruled out. What is the most likely complication driving her current presentation?

. Deep vein thrombosis
. Post-operative periprosthetic joint infection secondary to hematoma formation
. Sciatic nerve palsy
. Avascular necrosis of the greater trochanter
. Heterotopic ossification

Correct Answer & Explanation

. Post-operative periprosthetic joint infection secondary to hematoma formation

Explanation

Aggressive anticoagulation (like DOACs) can lead to postoperative hematoma formation, which is a major risk factor for delayed wound healing and subsequent periprosthetic joint infection (PJI) following THA.

Question 429

Topic: 3. Adult Reconstruction (Hip & Knee)

A 65-year-old male with a history of cemented total hip arthroplasty presents with a periprosthetic femoral fracture. The fracture is located at the distal tip of the stem, similar to the case described. Which of the following biomechanical factors is most directly responsible for concentrating stress at this specific location, predisposing to fracture?

. Increased endosteal blood supply leading to localized osteolysis
. Stress shielding causing proximal femoral osteopenia
. The viscoelastic properties of the native bone compared to the rigid metallic stem
. Excessive periosteal stripping during the primary arthroplasty
. Increased bone density at the stem tip due to load transfer

Correct Answer & Explanation

. The viscoelastic properties of the native bone compared to the rigid metallic stem

Explanation

Correct Answer: The viscoelastic properties of the native bone compared to the rigid metallic stemThe case highlights that the transition zone between the rigid prosthetic stem and the more elastic native diaphyseal bone acts as a massive stress riser. This mismatch in the modulus of elasticity concentrates torsional and bending forces exactly at the tip of the prosthesis, making it a common site for periprosthetic fractures, especially with torsional injuries.Increased endosteal blood supply leading to localized osteolysis:The endosteal blood supply is typically compromised or obliterated by the stem and cement, not increased. Localized osteolysis can occur but is not the primary biomechanical factor for stress concentration at the tip.Stress shielding causing proximal femoral osteopenia:Stress shielding does lead to proximal osteopenia, weakening the bone in that region. While this is a general biomechanical alteration, the specific concentration of stress at thedistal tipis due to the modulus mismatch, not directly the proximal osteopenia.Excessive periosteal stripping during the primary arthroplasty:While excessive periosteal stripping can compromise fracture healing by devascularizing the bone, it is not a direct biomechanical factor that concentrates stress at the stem tip to cause the initial fracture.Increased bone density at the stem tip due to load transfer:Load transfer occurs, but the effect at the tip is a stress concentration due to the material mismatch, not an increase in bone density that would prevent fracture. In fact, the opposite is true; the stress concentration makes it vulnerable.

Question 430

Topic: 3. Adult Reconstruction (Hip & Knee)

The American Academy of Orthopaedic Surgeons (AAOS) guidelines emphasize an interdisciplinary approach for managing periprosthetic fractures, particularly in elderly patients. What is the primary benefit of the orthogeriatric co-management model, as highlighted in the case?

. It primarily focuses on reducing surgical time and blood loss during the procedure.
. It has been definitively shown to reduce time to surgery, decrease length of hospital stay, and lower the one-year mortality rate.
. It ensures that all patients receive revision arthroplasty regardless of fracture type.
. It eliminates the need for advanced imaging like CT scans.
. It exclusively manages the patient's psychological well-being post-injury.

Correct Answer & Explanation

. It has been definitively shown to reduce time to surgery, decrease length of hospital stay, and lower the one-year mortality rate.

Explanation

Correct Answer: It has been definitively shown to reduce time to surgery, decrease length of hospital stay, and lower the one-year mortality rate.The case explicitly states: 'The orthogeriatric co-management modelโ€”where orthopedic surgeons and geriatricians collaboratively manage the patient from admission through dischargeโ€”has been definitively shown to reduce time to surgery, decrease length of hospital stay, and lower the one-year mortality rate in elderly patients with periprosthetic fractures.' This highlights the significant, evidence-based benefits of a comprehensive, multidisciplinary approach to these complex patients.It primarily focuses on reducing surgical time and blood loss during the procedure:While optimizing patient health can indirectly affect surgical parameters, the primary focus of orthogeriatric co-management is broader patient outcomes, not just intraoperative metrics.It ensures that all patients receive revision arthroplasty regardless of fracture type:This is incorrect. The management strategy (fixation vs. revision) is dictated by the Vancouver classification and implant stability, not by the co-management model.It eliminates the need for advanced imaging like CT scans:Advanced imaging remains crucial for accurate diagnosis and surgical planning, regardless of the co-management model.It exclusively manages the patient's psychological well-being post-injury:While psychological well-being is part of holistic care, orthogeriatric co-management encompasses a much broader range of medical, functional, and rehabilitative aspects, not exclusively psychological care.

Question 431

Topic: 3. Adult Reconstruction (Hip & Knee)

A 75-year-old female presents with a periprosthetic femur fracture sustained after a mechanical fall. Radiographs demonstrate a fracture around the femoral stem with obvious subsidence of the implant. Intraoperative assessment confirms the stem is grossly loose, but the proximal femoral bone stock remains adequate to support a porous-coated implant. According to the Vancouver classification, what is the most appropriate definitive management?

. Open reduction and internal fixation with a locking plate and cerclage cables
. Revision arthroplasty using a fully porous-coated, diaphyseal-engaging long stem
. Revision arthroplasty with a proximal femoral replacement (tumor prosthesis)
. Open reduction and internal fixation utilizing cortical strut allografts
. Nonoperative management in a long leg cast

Correct Answer & Explanation

. Revision arthroplasty using a fully porous-coated, diaphyseal-engaging long stem

Explanation

This is a Vancouver B2 periprosthetic fracture, characterized by a fracture around a loose stem with adequate proximal bone stock. The standard of care is revision arthroplasty utilizing a diaphyseal-engaging long stem that bypasses the fracture by at least two cortical diameters. Cortical strut allografts or proximal femoral replacements are reserved for Vancouver B3 fractures where bone stock is critically compromised.

Question 432

Topic: 3. Adult Reconstruction (Hip & Knee)
A 71-year-old male with a well-functioning cemented total knee arthroplasty (TKA) sustains a low-energy supracondylar femur fracture. Radiographs confirm a displaced fracture above the anterior flange of the femoral component. The femoral component shows no signs of loosening. According to the Rorabeck classification, this is a Type II fracture. Which of the following factors makes retrograde intramedullary nailing contraindicated in this specific scenario?
. The presence of an open-box posterior stabilized (PS) femoral component
. A distal fracture fragment that is too short to accept two locking screws
. The presence of a closed-box cruciate-retaining (CR) femoral component
. A history of previous deep vein thrombosis in the contralateral leg
. An intramedullary canal diameter of 14 mm

Correct Answer & Explanation

. The presence of a closed-box cruciate-retaining (CR) femoral component

Explanation

Retrograde intramedullary nailing of a periprosthetic supracondylar femur fracture requires access through the intercondylar notch. A closed-box cruciate-retaining (CR) femoral component, or a PS component without a sufficiently wide box, blocks passage of the nail, making this technique contraindicated and necessitating locked plating instead.

Question 433

Topic: Total Hip Arthroplasty (THA)

A patient with a Vancouver Type C periprosthetic femur fracture (fracture well distal to a solidly fixed femoral stem) undergoes open reduction and internal fixation with a lateral locking plate. To minimize the risk of a subsequent stress riser and peri-implant failure, what is the minimum recommended plate overlap of the existing femoral stem?

. The plate must span entirely to the greater trochanter
. The plate should stop exactly at the tip of the stem
. The plate must overlap the stem by at least two cortical diameters
. The plate must overlap the stem by at least six cortical diameters
. Overlap is unnecessary if bicortical screws are used distal to the stem

Correct Answer & Explanation

. The plate must overlap the stem by at least two cortical diameters

Explanation

When treating a Vancouver C periprosthetic fracture with a plate, the hardware must overlap the existing intramedullary stem by at least two cortical diameters (or approximately 2 to 3 bone widths). Stopping the plate at or near the tip of the stem creates a severe stress riser, significantly increasing the risk of subsequent fracture.

Question 434

Topic: 3. Adult Reconstruction (Hip & Knee)

A 78-year-old female with profound osteoporosis and a well-fixed total knee arthroplasty presents with a highly comminuted, osteopenic supracondylar femur fracture (Rorabeck II). If locking plate osteosynthesis is chosen, which technical principle is paramount to preventing construct failure in this osteoporotic bone?

. Using a short plate with all screw holes filled to increase stiffness
. Using a long spanning plate with a low screw density (wide screw spread) to increase the working length
. Applying dynamic compression across the comminuted metaphyseal segment
. Routinely adding an intramedullary fibular strut allograft to the distal segment
. Utilizing exclusively non-locking cortical screws to allow micro-motion

Correct Answer & Explanation

. Using a long spanning plate with a low screw density (wide screw spread) to increase the working length

Explanation

In comminuted fractures with osteoporotic bone, bridge plating principles should be utilized. A long plate with a low screw density (leaving empty holes over the fracture site) increases the 'working length' of the plate, distributing strain over a wider area and reducing the risk of plate fatigue or screw pull-out.

Question 435

Topic: 3. Adult Reconstruction (Hip & Knee)

A 72-year-old female sustains a periprosthetic femur fracture around a cementless total hip arthroplasty.

Radiographs demonstrate a fracture around the stem with visible subsidence of the implant, but adequate proximal bone stock is noted. According to the Vancouver Classification, what is the most appropriate treatment?

. Open reduction and internal fixation with a lateral locking plate
. Revision to a fully porous-coated long cementless stem
. Revision to a proximal femoral replacement
. Skeletal traction for 6 weeks followed by bracing
. Cortical strut allografting alone

Correct Answer & Explanation

. Revision to a fully porous-coated long cementless stem

Explanation

This is a Vancouver B2 periprosthetic fracture, characterized by a fracture around the stem, a loose implant, and adequate bone stock. The standard of care is revision arthroplasty using a long, fully porous-coated or fluted tapered cementless stem that bypasses the fracture.

Question 436

Topic: 3. Adult Reconstruction (Hip & Knee)

An 82-year-old female presents with a periprosthetic femur fracture around a loose cemented THA stem. Radiographs reveal severe comminution and extensively poor bone stock of the proximal femur extending into the diaphysis. What is the most appropriate surgical treatment for this patient?

. ORIF with a lateral locking plate and cerclage wires
. Revision with a standard length proximally coated cementless stem
. Proximal femoral replacement
. Impaction bone grafting and a cemented stem
. Strut allografting and retention of the stem

Correct Answer & Explanation

. Proximal femoral replacement

Explanation

This describes a Vancouver B3 fracture (loose stem, poor bone stock). In an elderly, lower-demand patient, a proximal femoral replacement (tumor prosthesis) provides immediate stability and allows early weight-bearing, avoiding the high failure rates of complex osteosynthesis or impaction grafting.

Question 437

Topic: 3. Adult Reconstruction (Hip & Knee)

During the insertion of a cementless, proximally porous-coated femoral stem for a primary total hip arthroplasty, a non-displaced longitudinal fracture is noted in the proximal calcar region. The stem is fully seated and demonstrates excellent rotational stability. What is the most appropriate intraoperative management?

. Remove the stem and bypass the fracture with a fully porous-coated diaphyseal fitting stem
. Place a cerclage wire or cable around the proximal femur and retain the stem
. Remove the stem and convert to a cemented construct
. Apply a lateral locking plate with unicortical screws
. Observe without fixation and enforce non-weight bearing for 6 weeks

Correct Answer & Explanation

. Place a cerclage wire or cable around the proximal femur and retain the stem

Explanation

Intraoperative non-displaced calcar fractures occurring during cementless stem impaction (Vancouver Type A) should be treated with immediate prophylactic cerclage wiring to prevent propagation. If the stem remains rotationally stable, it does not need to be revised.

Question 438

Topic: 3. Adult Reconstruction (Hip & Knee)

A 68-year-old female, 5 years post-total hip arthroplasty, presents with thigh pain after a mechanical fall. Radiographs demonstrate a spiral periprosthetic fracture around the femoral stem. The stem has subsided 6 mm compared to prior radiographs, but the proximal bone stock remains robust. What is the most appropriate definitive management for this Vancouver B2 fracture?

. Open reduction and internal fixation with a lateral locking plate and cables
. Open reduction and internal fixation with cortical strut allografts
. Revision to a fully porous-coated or modular fluted tapered long stem
. Proximal femoral replacement
. Revision to a standard-length cemented stem

Correct Answer & Explanation

. Revision to a fully porous-coated or modular fluted tapered long stem

Explanation

Vancouver B2 fractures involve a loose stem with adequate bone stock. The standard of care is revision arthroplasty using a cementless long stem (fully porous or modular fluted) that bypasses the fracture by at least two cortical diameters.

Question 439

Topic: 3. Adult Reconstruction (Hip & Knee)

A 70-year-old female with a prior posterior-stabilized total knee arthroplasty presents with a displaced Rorabeck type II periprosthetic supracondylar femur fracture. The surgeon plans to fix the fracture using a retrograde intramedullary nail. Which specific characteristic of her existing femoral component is an absolute contraindication to this technique?

. Open box intercondylar design
. Closed box intercondylar design
. Highly cross-linked polyethylene insert
. Cementless fixation of the femoral component
. Anterior flange with a 5-degree valgus cut

Correct Answer & Explanation

. Closed box intercondylar design

Explanation

A closed box design in a posterior-stabilized (PS) or constrained condylar knee (CCK) prevents access to the intercondylar notch. This makes establishing a starting point for a retrograde intramedullary nail impossible without destroying the implant.

Question 440

Topic: 3. Adult Reconstruction (Hip & Knee)

An 82-year-old community-ambulating female sustains a Vancouver B3 periprosthetic femur fracture. Radiographs exhibit a loose cemented stem with severe proximal osteolysis and paper-thin cortices extending down to the diaphyseal isthmus. What is the most appropriate surgical management?

. Open reduction internal fixation with a lateral locking plate and cerclage cables
. Revision to a fully porous-coated standard length stem
. Impaction bone grafting with a new cemented stem
. Proximal femoral replacement (tumor prosthesis)
. Cortical strut allograft combined with a constrained acetabular liner

Correct Answer & Explanation

. Proximal femoral replacement (tumor prosthesis)

Explanation

Vancouver B3 fractures involve a loose stem with severely deficient proximal bone stock. In an elderly, lower-demand patient, a proximal femoral replacement allows for immediate weight-bearing and avoids the high failure rates associated with complex bone-reconstruction techniques.

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