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3. Adult Reconstruction (Hip & Knee) MCQs

Practice Set 231 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 4601

Topic: 3. Adult Reconstruction (Hip & Knee)

A 68-year-old male undergoes a complex revision total hip arthroplasty. Postoperatively, he develops hypotension, oliguria, and increasing serum creatinine. Given the potential for significant blood loss and release of inflammatory mediators during such a procedure, which of the following is the most likely initial mechanism leading to acute renal failure in this orthopedic context, correlating with the provided general medical content?

. Glomerulonephritis due to immune complex deposition.
. Renal ischemia, often exacerbated by hypovolemia or vasopressor use.
. Acute tubular necrosis due to nephrotoxic antibiotics.
. Obstructive uropathy from bladder catheter malfunction.
. Interstitial nephritis from an allergic reaction to surgical materials.

Correct Answer & Explanation

. Renal ischemia, often exacerbated by hypovolemia or vasopressor use.

Explanation

In the context of major orthopedic surgery like revision arthroplasty, significant blood loss can lead to hypovolemia and subsequent renal hypoperfusion. This renal ischemia is a primary mechanism for acute kidney injury (AKI), as mentioned in the general medical content regarding 'renal ischemia' and 'ischemia-reperfusion injury' as causes of acute renal failure. While nephrotoxic antibiotics or obstructive uropathy can cause AKI, renal ischemia due to surgical stress and potential hypovolemia is often the initial and most common pathway in such a scenario. The other options are less likely primary mechanisms post-major orthopedic surgery in an otherwise healthy patient without specific risk factors.

Question 4602

Topic: 3. Adult Reconstruction (Hip & Knee)

A 70-year-old patient undergoes an elective total knee arthroplasty. During the postoperative period, she develops fever, severe abdominal pain, and significant jaundice. This constellation of symptoms, coupled with a history of gallstones, is highly suspicious for acute cholangitis. Based on the provided general medical definitions, which specific clinical syndrome involving additional features of shock and CNS depression would indicate a fulminant and life-threatening progression requiring urgent surgical intervention?

. Systemic Inflammatory Response Syndrome (SIRS).
. Multiple Organ Dysfunction Syndrome (MODS).
. Charcot's Triad.
. Reynold's Pentad.
. Krukenberg Tumor.

Correct Answer & Explanation

. Reynold's Pentad.

Explanation

The question describes a progression from Charcot's Triad (abdominal pain, fever, jaundice) to a more severe state with 'additional features of shock and CNS depression'. This specific clinical picture is defined as Reynold's Pentad, which is characteristic of acute obstructive suppurative cholangitis and signifies a severe, life-threatening infection requiring emergency decompression. The general medical content explicitly states: 'Charcot's Triad is abdominal pain, chills and high fever, jaundice, while Reynold's Pentad further adds shock and central nervous system depression. Seen in acute obstructive suppurative cholangitis.' SIRS and MODS are broader systemic responses, and Krukenberg tumor is unrelated.

Question 4603

Topic: 3. Adult Reconstruction (Hip & Knee)

A 70-year-old female with osteoporosis suffers a displaced femoral neck fracture. She has a history of atrial fibrillation on anticoagulation and mild dementia. Which of the following surgical options is generally preferred to minimize the risk of complications and optimize functional outcome in this patient?

. Cannulated screw fixation.
. Hemiarthroplasty.
. Total hip arthroplasty (THA).
. Dynamic hip screw (DHS) fixation.
. Conservative management with bed rest.

Correct Answer & Explanation

. Hemiarthroplasty.

Explanation

For elderly patients with displaced femoral neck fractures and cognitive impairment or significant comorbidities (like atrial fibrillation on anticoagulation), hemiarthroplasty is generally preferred. It offers a quicker recovery compared to THA, lower dislocation rates than THA in cognitively impaired patients, and avoids the high rates of failure, avascular necrosis, and nonunion associated with internal fixation (cannulated screws, DHS) in displaced fractures in osteoporotic bone. Conservative management is associated with high mortality and morbidity. THA is typically reserved for more active, cognitively intact patients.

Question 4604

Topic: 3. Adult Reconstruction (Hip & Knee)

A 75-year-old female with severe, disabling osteoarthritis of her bilateral knees is considering total knee arthroplasty (TKA). She expresses concern about postoperative pain and recovery. Which of the following is least likely to be a significant complication unique to TKA?

. Periprosthetic joint infection.
. Deep vein thrombosis (DVT) and pulmonary embolism (PE).
. Avascular necrosis of the femoral head.
. Stiffness and arthrofibrosis.
. Neurovascular injury (e.g., common peroneal nerve palsy).

Correct Answer & Explanation

. Avascular necrosis of the femoral head.

Explanation

Avascular necrosis (AVN) of the femoral head is a complication primarily associated with hip pathology (e.g., femoral neck fractures, hip dislocations, steroid use) and does not occur as a direct complication of total knee arthroplasty. All other options are well-known, significant complications associated with TKA. Periprosthetic joint infection, DVT/PE, stiffness/arthrofibrosis, and neurovascular injury (e.g., common peroneal nerve palsy from traction or direct injury) are all important risks to counsel patients about before TKA.

Question 4605

Topic: 3. Adult Reconstruction (Hip & Knee)

A 68-year-old female with severe genu varum undergoes total knee arthroplasty (TKA). Postoperatively, she complains of numbness and weakness in her foot, specifically difficulty with ankle dorsiflexion and eversion. What is the most likely iatrogenic nerve injury during TKA?

. Femoral nerve.
. Sciatic nerve.
. Tibial nerve.
. Common peroneal nerve.
. Saphenous nerve.

Correct Answer & Explanation

. Common peroneal nerve.

Explanation

The common peroneal nerve (a branch of the sciatic nerve) is the most frequently injured major nerve during total knee arthroplasty, especially in cases of significant preoperative genu varum deformity. Correction of the varus deformity during surgery can stretch the common peroneal nerve as it wraps around the fibular head, leading to neuropraxia or, rarely, neurapraxia. Its dysfunction manifests as foot drop (difficulty with ankle dorsiflexion) and impaired ankle eversion. The femoral and saphenous nerves are anterior and less commonly injured in TKA. The tibial nerve is posterior and less prone to stretch injury in varus correction.

Question 4606

Topic: 3. Adult Reconstruction (Hip & Knee)

A 70-year-old active male presents with chronic insidious left hip pain. Radiographs show superior migration of the femoral head, joint space narrowing, and osteophytes. He desires pain relief and improved function. Which of the following is the most appropriate definitive surgical intervention?

. Hip arthroscopy for debridement.
. Core decompression for avascular necrosis.
. Femoral osteotomy to realign the joint.
. Total hip arthroplasty (THA).
. Hip fusion (arthrodesis).

Correct Answer & Explanation

. Total hip arthroplasty (THA).

Explanation

The patient's symptoms (chronic insidious hip pain, active lifestyle) and radiographic findings (superior migration, joint space narrowing, osteophytes) are classic for advanced hip osteoarthritis. For an active 70-year-old with disabling symptoms and end-stage arthritis, Total Hip Arthroplasty (THA) is the gold standard definitive surgical intervention, offering excellent pain relief and restoration of function. Hip arthroscopy is generally for younger patients with FAI or early arthritis. Core decompression is for AVN. Osteotomy is for younger patients with specific deformities. Arthrodesis is a salvage procedure, typically not for active elderly patients.

Question 4607

Topic: 3. Adult Reconstruction (Hip & Knee)

A 55-year-old diabetic patient undergoes a total knee arthroplasty. Four months later, he develops fever, increasing knee pain, and swelling. Synovial fluid aspiration shows a WBC count of 80,000 cells/ยตL with 90% neutrophils, and Gram-positive cocci in clusters. Based on general principles, what is the most appropriate initial surgical management for this confirmed acute periprosthetic joint infection?

. Aspiration and long-term suppressive oral antibiotics.
. Irrigation and debridement (I&D) with component retention, followed by intravenous antibiotics.
. One-stage revision arthroplasty with new components.
. Two-stage revision arthroplasty (explant, antibiotic spacer, then reimplantation).
. Knee arthrodesis (fusion) as a salvage procedure.

Correct Answer & Explanation

. Irrigation and debridement (I&D) with component retention, followed by intravenous antibiotics.

Explanation

For an acute periprosthetic joint infection (PJI) (symptoms <3-4 weeks duration) in a well-fixed prosthesis and an otherwise healthy patient, Irrigation and Debridement (I&D) with component retention (DAIR - Debridement, Antibiotics, Implant Retention) is the preferred initial surgical approach. This is followed by prolonged intravenous antibiotics. One-stage revision is considered for select, less virulent organisms or chronic infections in favorable hosts. Two-stage revision is the gold standard for chronic PJI or acute PJI with highly virulent organisms or compromised hosts. Aspiration with oral antibiotics is generally insufficient for established PJI. Arthrodesis is a salvage procedure for failed revisions. Given the 'acute' nature, I&D with retention is the appropriate first surgical step.

Question 4608

Topic: 3. Adult Reconstruction (Hip & Knee)

A 60-year-old female undergoes revision total hip arthroplasty due to aseptic loosening of the acetabular component. Given her age and the complexity of the procedure, which of the following infection risk factors, aligned with general prophylactic antibiotic indications, is most relevant for administering prophylactic antibiotics?

. The duration of the surgical procedure is expected to be over 2 hours.
. The revision nature of the surgery necessitates a larger incision.
. Her age (60 years) increases her susceptibility to infection.
. The patient requires placement of an artificial implant (new acetabular component).
. The risk of intraoperative blood transfusion.

Correct Answer & Explanation

. The patient requires placement of an artificial implant (new acetabular component).

Explanation

The most directly relevant indication for prophylactic antibiotics here, from the provided general medical principles, is: '(3) Procedures involving artificial implants, such as joint, vascular, and heart valve replacements, and artificial material repair of abdominal wall hernias.' The placement of new artificial components in a revision arthroplasty is a prime indication. While long surgery duration and age can be contributing factors, the presence of the implant itself is a specific and strong indication for prophylaxis in orthopedic surgery. The size of incision or need for transfusion are less direct indications for prophylaxis compared to the implant itself.

Question 4609

Topic: 3. Adult Reconstruction (Hip & Knee)
A 70-year-old patient with multiple comorbidities is scheduled for an elective total hip arthroplasty. According to general prophylactic antibiotic guidelines, which of the following is an independent high-risk factor for surgical site infection that warrants careful preoperative optimization, beyond the standard indication of implant placement?
. Age greater than 70 years.
. History of deep vein thrombosis.
. Diabetes mellitus (even if well-controlled).
. History of prior hip surgery.
. Body Mass Index (BMI) of 28 kg/mยฒ.

Correct Answer & Explanation

. Diabetes mellitus (even if well-controlled).

Explanation

According to the general medical content, high-risk factors for infection include: 'Patients with high-risk factors for infection, such as advanced age, malnutrition, diabetes, granulocytopenia; or those undergoing steroid, immunosuppressant, or anticancer drug therapy, and those with immune dysfunction requiring surgery.' Diabetes mellitus, even if well-controlled, significantly increases the risk of surgical site infection and requires careful preoperative glucose optimization. While age >70 and history of prior surgery (especially if infected) are risk factors, diabetes is explicitly listed as a 'high-risk factor' relevant to systemic immunity. A BMI of 28 is overweight but not obese enough to be a high-risk factor by itself.

Question 4610

Topic: 3. Adult Reconstruction (Hip & Knee)

Which of the following is a contraindication to total knee arthroplasty (TKA)?

. Obesity (BMI > 35).
. Age greater than 80 years.
. Uncontrolled active infection in the knee.
. Previous knee surgery.
. Mild rheumatoid arthritis.

Correct Answer & Explanation

. Uncontrolled active infection in the knee.

Explanation

Uncontrolled active infection in the knee is an absolute contraindication to total knee arthroplasty because implanting a foreign body into an infected joint significantly increases the risk of periprosthetic joint infection, which is a devastating complication. Obesity, advanced age, previous knee surgery, and mild rheumatoid arthritis are relative contraindications or not contraindications at all, often managed with careful patient selection and optimization.

Question 4611

Topic: 3. Adult Reconstruction (Hip & Knee)

A 40-year-old female presents with persistent pain, stiffness, and catching in her right thumb MP joint. Radiographs show significant joint space narrowing and osteophytes. She has failed conservative management. What is the most appropriate surgical intervention?

. Flexor pollicis longus tenolysis.
. Carpometacarpal (CMC) joint arthroplasty.
. Metacarpophalangeal (MP) joint arthroplasty or fusion.
. De Quervain's release.
. Scaphoidectomy.

Correct Answer & Explanation

. Metacarpophalangeal (MP) joint arthroplasty or fusion.

Explanation

The patient's symptoms and radiographic findings are indicative of osteoarthritis of the thumb metacarpophalangeal (MP) joint. For symptomatic MP joint arthritis refractory to conservative care, surgical options include MP joint arthroplasty (replacement) or fusion, which can provide pain relief and stability. CMC joint arthroplasty is for basilar thumb arthritis. De Quervain's release is for stenosing tenosynovitis of the abductor pollicis longus and extensor pollicis brevis. Scaphoidectomy is not relevant here. Flexor pollicis longus tenolysis is for trigger thumb.

Question 4612

Topic: 3. Adult Reconstruction (Hip & Knee)

A 70-year-old male with long-standing bilateral knee osteoarthritis reports severe pain and functional limitation. He has undergone multiple intra-articular injections and physical therapy with minimal relief. Radiographs show tricompartmental severe degenerative changes. Which of the following is the most appropriate definitive treatment option?

. High tibial osteotomy.
. Arthroscopic debridement.
. Total knee arthroplasty.
. Patellectomy.
. Unicompartmental knee arthroplasty.

Correct Answer & Explanation

. Total knee arthroplasty.

Explanation

For severe tricompartmental knee osteoarthritis that has failed extensive conservative management, total knee arthroplasty (TKA) is the gold standard definitive treatment. High tibial osteotomy is typically for younger, active patients with isolated medial compartment osteoarthritis. Arthroscopic debridement has limited long-term efficacy for advanced osteoarthritis. Patellectomy is rarely performed. Unicompartmental knee arthroplasty is for isolated single-compartment disease.

Question 4613

Topic: 3. Adult Reconstruction (Hip & Knee)

Which surgical approach for total hip arthroplasty typically carries the lowest risk of dislocation?

. Posterior approach.
. Anterolateral approach.
. Direct anterior approach.
. Lateral approach.
. Transtrochanteric approach.

Correct Answer & Explanation

. Direct anterior approach.

Explanation

The direct anterior approach for total hip arthroplasty is generally associated with the lowest risk of postoperative dislocation compared to posterior or lateral approaches. This is because it spares the posterior soft tissue structures (posterior capsule, short external rotators) which are critical for hip stability. The posterior approach traditionally has the highest dislocation rate, while anterolateral and direct lateral approaches have intermediate rates.

Question 4614

Topic: 3. Adult Reconstruction (Hip & Knee)

A 75-year-old female with a known femoral hernia presents with vague right groin and medial thigh pain. She is otherwise asymptomatic from a gastrointestinal perspective. On physical exam, a small, firm, non-tender mass is felt in the femoral canal. What should be the orthopedic surgeon's primary consideration in managing this finding?

. Recommend watchful waiting as it's non-tender.
. Prescribe muscle relaxants for thigh pain.
. Refer to a general surgeon for elective hernia repair.
. Order an MRI of the hip to rule out avascular necrosis.
. Immediately escalate for urgent general surgery consultation due to Richter hernia risk.

Correct Answer & Explanation

. Immediately escalate for urgent general surgery consultation due to Richter hernia risk.

Explanation

Given the description of a small, firm, non-tender mass in the femoral canal in a patient with a known femoral hernia and groin/medial thigh pain, even without acute GI symptoms, a Richter hernia must be considered. Femoral hernias have a high rate of incarceration and strangulation, and Richter hernias can be subtle. The 'non-tender' aspect might be misleading in some cases, or it could be a newly incarcerated but not yet strangulated segment. The high risk of rapid progression warrants immediate general surgery consultation for evaluation and potential urgent repair, rather than elective repair, watchful waiting, or orthopedic-specific imaging. While hip pathologies are in the differential for groin pain, a palpable, irreducible mass strongly suggests hernia.

Question 4615

Topic: 3. Adult Reconstruction (Hip & Knee)

A patient is scheduled for an elective total hip arthroplasty. During the pre-operative evaluation, the patient mentions a 'small lump' in the groin that occasionally bothers them but is generally painless and reducible. What is the most prudent action for the orthopedic surgeon?

. Proceed with total hip arthroplasty, noting the hernia for post-operative observation.
. Refer to a general surgeon for an elective hernia repair prior to hip arthroplasty.
. Prescribe prophylactic antibiotics to prevent infection of the lump.
. Advise the patient to monitor the lump and inform the orthopedic surgeon if it becomes painful.
. Cancel the hip arthroplasty indefinitely.

Correct Answer & Explanation

. Refer to a general surgeon for an elective hernia repair prior to hip arthroplasty.

Explanation

The most prudent action is to refer to a general surgeon for an elective hernia repair prior to hip arthroplasty. While the hernia is currently reducible and painless, the stress of surgery, changes in activity, and post-operative straining can lead to incarceration or strangulation (including Richter-type) in the peri-operative period. An elective repair of the hernia before a major orthopedic procedure minimizes the risk of a combined or sequential surgical emergency, which would significantly complicate recovery and increase morbidity. Proceeding with hip arthroplasty without addressing a known hernia is risky.

Question 4616

Topic: 3. Adult Reconstruction (Hip & Knee)

Why might an orthopedic surgeon performing a total hip arthroplasty via an anterior approach be particularly vigilant for a femoral hernia, including a Richter variant?

. The anterior approach directly dissects through the femoral canal.
. The patient's supine position during surgery makes hernias more prominent.
. The surgical dissection field is adjacent to the femoral canal, making a femoral hernia a differential for groin pain and a potential site of complication.
. Increased intra-abdominal pressure during hip dislocation predisposes to new hernia formation.
. Hernias in this region always cause osteolysis around the implant.

Correct Answer & Explanation

. The surgical dissection field is adjacent to the femoral canal, making a femoral hernia a differential for groin pain and a potential site of complication.

Explanation

The surgical dissection field for an anterior approach total hip arthroplasty is adjacent to the femoral canal, making a femoral hernia a differential for groin pain and a potential site of complication. Surgeons need to be aware of anatomical variations and potential pathologies in the surgical field. While the dissection doesn't gothroughthe femoral canal in a standard approach, it's very close. A femoral hernia, particularly an incarcerated one, can mimic or complicate post-operative groin pain, or become incarcerated/strangulated due to the peri-operative stress or positioning. Therefore, being vigilant is important for accurate diagnosis and management.

Question 4617

Topic: Total Hip Arthroplasty (THA)

During a routine post-operative visit for a patient who had spinal fusion through an anterior approach, the patient complains of a new, subtle bulge and discomfort lateral to their surgical incision. No other GI symptoms are present. What type of hernia, potentially a Richter, is most likely in this context?

. Inguinal hernia
. Femoral hernia
. Obturator hernia
. Spigelian hernia
. Incisional hernia (at the anterior approach site)

Correct Answer & Explanation

. Incisional hernia (at the anterior approach site)

Explanation

An anterior approach spinal fusion involves an abdominal incision, often paramedian or transverse. An incisional hernia at this site is a direct complication of the surgical incision itself. Given the 'subtle bulge and discomfort lateral to their surgical incision' and lack of other GI symptoms, an incisional hernia, potentially with Richter incarceration, is the most likely type. Inguinal, femoral, obturator, and Spigelian hernias occur at distinct anatomical sites unrelated to the spinal fusion incision itself, though they might exist concomitantly. The prompt is specifically about anewbulgelateral to their surgical incision.

Question 4618

Topic: 3. Adult Reconstruction (Hip & Knee)

When preparing a patient for elective orthopedic surgery (e.g., total knee arthroplasty), what is a key question to ask regarding prior abdominal surgeries that might hint at a risk for Richter hernia?

. Have you ever had a vasectomy?
. Have you ever had a laparoscopic procedure, and if so, what size were the incisions?
. Do you have a history of gallstones?
. Have you ever had a colonoscopy?
. Do you have a family history of hernias?

Correct Answer & Explanation

. Have you ever had a laparoscopic procedure, and if so, what size were the incisions?

Explanation

Asking about prior laparoscopic procedures and, ideally, the size of the incisions is a key question. Larger trocar sites (typically >10-12mm) used in laparoscopic surgery carry a higher risk of developing incisional hernias, including Richter hernias, due to inadequate fascial closure. Identifying such a history allows for pre-operative assessment of any existing defects that might complicate the peri-operative period of the orthopedic surgery. While a family history of hernias is relevant, prior laparoscopic surgery creates a specific iatrogenic risk. Vasectomy, gallstones, or colonoscopy are not directly related to Richter hernia risk.

Question 4619

Topic: 3. Adult Reconstruction (Hip & Knee)

A 65-year-old male with a history of osteoporosis sustains a low-energy fall resulting in a subcapital femoral neck fracture. He is active and has no significant comorbidities. What is the most appropriate definitive surgical management?

. Cannulated screw fixation
. Hemiarthroplasty
. Total hip arthroplasty (THA)
. Dynamic hip screw (DHS)
. Intramedullary nailing

Correct Answer & Explanation

. Total hip arthroplasty (THA)

Explanation

For an active, otherwise healthy elderly patient with a displaced femoral neck fracture, Total Hip Arthroplasty (THA) is often preferred over hemiarthroplasty due to superior functional outcomes and lower reoperation rates, especially in those with pre-existing arthritis or significant activity demands. Cannulated screw fixation is typically reserved for non-displaced or minimally displaced fractures, given the high risk of nonunion and avascular necrosis in displaced fractures. Hemiarthroplasty is a reasonable option for less active elderly patients or those with significant comorbidities. DHS and intramedullary nailing are not indicated for femoral neck fractures.

Question 4620

Topic: 3. Adult Reconstruction (Hip & Knee)

Which of the following is considered a relative contraindication to total knee arthroplasty (TKA)?

. Active systemic infection
. Extensor mechanism dysfunction
. Charcot joint
. Recent myocardial infarction (within 3 months)
. Severe obesity (BMI > 40)

Correct Answer & Explanation

. Recent myocardial infarction (within 3 months)

Explanation

A recent myocardial infarction (within 3 months) is a relative contraindication to elective surgeries like TKA due to the increased risk of perioperative cardiac events. While not an absolute contraindication, it warrants careful cardiac evaluation and optimization. Active systemic infection and Charcot joint are absolute contraindications. Severe obesity (BMI > 40) and extensor mechanism dysfunction (e.g., patella alta, patella baja) are also relative contraindications or factors that increase surgical complexity and complication rates, but a recent MI carries significant immediate life-threatening risks.

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