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3. Adult Reconstruction (Hip & Knee) MCQs

Practice Set 232 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 4621

Topic: 3. Adult Reconstruction (Hip & Knee)

Regarding avascular necrosis (AVN) of the femoral head, which of the following is considered the earliest radiographic sign?

. Crescent sign
. Flattening of the femoral head
. Joint space narrowing
. Subchondral collapse
. Diffuse osteopenia

Correct Answer & Explanation

. Crescent sign

Explanation

The earliest radiographic sign of avascular necrosis (AVN) of the femoral head is the 'crescent sign,' which represents a subchondral fracture. This precedes gross flattening of the femoral head and eventual joint space narrowing. Subchondral collapse is a more advanced stage. Diffuse osteopenia is a non-specific finding. While MRI is more sensitive for early detection of AVN, the crescent sign is the earliest identifiable change on plain radiographs.

Question 4622

Topic: 3. Adult Reconstruction (Hip & Knee)

A patient with osteoarthritis of the knee is considering total knee arthroplasty. Which of the following factors is most predictive of poor functional outcomes after TKA?

. Patient age over 75 years
. History of prior knee arthroscopy
. Preoperative severe obesity (BMI > 40)
. High preoperative pain scores and functional limitation
. Depression and anxiety

Correct Answer & Explanation

. Depression and anxiety

Explanation

While factors like severe obesity can increase complication rates, psychological factors such as depression and anxiety are increasingly recognized as strong predictors of poor functional outcomes and patient satisfaction after total knee arthroplasty, even more so than age or severity of osteoarthritis. These conditions can influence pain perception, motivation for rehabilitation, and overall recovery. High preoperative pain and functional limitation are indications for surgery and often improve after TKA. Prior arthroscopy does not typically predict poor TKA outcomes.

Question 4623

Topic: Total Hip Arthroplasty (THA)

Which nerve is at greatest risk of injury during anterior surgical approaches to the hip (e.g., direct anterior approach for THA)?

. Sciatic nerve
. Femoral nerve
. Obturator nerve
. Lateral femoral cutaneous nerve
. Superior gluteal nerve

Correct Answer & Explanation

. Lateral femoral cutaneous nerve

Explanation

The lateral femoral cutaneous nerve (LFCN) is particularly vulnerable during direct anterior approaches to the hip, as it crosses the iliac crest and lies superficial within the surgical field. Injury can lead to meralgia paresthetica (numbness, tingling, or burning pain in the lateral thigh). The sciatic nerve is at risk with posterior approaches. The femoral, obturator, and superior gluteal nerves are deeper and less frequently injured during anterior approaches.

Question 4624

Topic: Total Hip Arthroplasty (THA)

Which surgical approach for total hip arthroplasty (THA) is most commonly associated with a higher risk of postoperative dislocation?

. Direct anterior approach
. Anterolateral approach
. Posterior approach
. Lateral approach (Hardinge)
. Minimally invasive approach (any type)

Correct Answer & Explanation

. Posterior approach

Explanation

The posterior approach for total hip arthroplasty (THA) has traditionally been associated with a higher risk of postoperative dislocation, primarily due to the necessary division of the short external rotator muscles and posterior capsule. While surgical techniques and repair of the capsule have reduced this risk, it remains a concern compared to anterior or lateral approaches. Direct anterior and lateral approaches are generally considered to have lower dislocation rates, although each approach has its own unique set of potential complications.

Question 4625

Topic: 3. Adult Reconstruction (Hip & Knee)

A 70-year-old active male presents with chronic insidious onset groin pain, worse with weight-bearing and internal rotation. Radiographs show joint space narrowing, subchondral sclerosis, and osteophytes in the hip. What is the most appropriate non-operative management strategy?

. Corticosteroid injections into the joint
. Oral NSAIDs and physical therapy
. Total hip arthroplasty
. Opioid pain medication
. Bed rest and immobilization

Correct Answer & Explanation

. Oral NSAIDs and physical therapy

Explanation

The patient's symptoms and radiographic findings are consistent with hip osteoarthritis. The most appropriate initial non-operative management typically involves a combination of oral NSAIDs for pain and inflammation, along with physical therapy to maintain range of motion, strengthen surrounding muscles, and improve function. Corticosteroid injections can provide temporary relief but are not a long-term solution. Total hip arthroplasty is a surgical option reserved for failed non-operative management. Opioids are generally avoided for chronic non-cancer pain, and bed rest is detrimental.

Question 4626

Topic: Total Hip Arthroplasty (THA)

Which of the following describes the anatomical landmark used to locate the neurovascular bundle during a posterior approach to the knee for meniscal repair or PCL reconstruction?

. Popliteal fossa
. Adductor tubercle
. Gerdy's tubercle
. Medial epicondyle
. Fibular head

Correct Answer & Explanation

. Popliteal fossa

Explanation

The popliteal fossa is the anatomical landmark containing the neurovascular bundle (popliteal artery, vein, and tibial nerve) that must be carefully protected during a posterior approach to the knee. These vital structures are located in the deep aspect of the fossa. The adductor tubercle and medial epicondyle are on the medial aspect of the femur. Gerdy's tubercle is on the lateral tibia. The fibular head is on the lateral aspect of the knee.

Question 4627

Topic: Total Knee Arthroplasty (TKA)

A 32-year-old competitive rugby player sustains a twisting injury to his right knee. MRI reveals a complex tear of the posterior horn of the medial meniscus, extending to the meniscocapsular junction, with displacement. He experiences persistent locking and effusions. Which of the following management strategies offers the best long-term outcome for return to high-level sport?

. Partial meniscectomy
. Non-operative management with physiotherapy
. Meniscal repair
. High tibial osteotomy
. Total meniscectomy

Correct Answer & Explanation

. Meniscal repair

Explanation

For a displaced, repairable meniscal tear in a young, active athlete, meniscal repair is the preferred treatment. Preserving meniscal tissue is crucial for long-term knee health, as it distributes load, provides shock absorption, and contributes to joint stability. Partial meniscectomy, while offering faster recovery, removes crucial meniscal tissue, predisposing to early osteoarthritis. Non-operative management is unlikely to succeed with a displaced tear causing mechanical symptoms. High tibial osteotomy is for malalignment with unicompartmental arthritis, not acute meniscal tears. Total meniscectomy is largely historical due to its devastating long-term consequences for joint health.

Question 4628

Topic: 3. Adult Reconstruction (Hip & Knee)

In total knee arthroplasty, the optimal mechanical alignment aims to achieve:

. Neutral alignment with the load-bearing axis passing through the center of the knee
. Slight varus alignment (3-5 degrees)
. Slight valgus alignment (3-5 degrees)
. Anatomic alignment based on individual patient anatomy
. Restoration of the pre-arthritic joint line angle

Correct Answer & Explanation

. Neutral alignment with the load-bearing axis passing through the center of the knee

Explanation

The primary goal of mechanical alignment in total knee arthroplasty (TKA) is to achieve a neutral mechanical axis, where the load-bearing axis passes through the center of the knee. This ensures even load distribution across the tibial polyethylene insert, minimizing wear and extending implant longevity. Deviations from neutral mechanical alignment are associated with increased polyethylene wear and potential early failure. While kinematic alignment aims to restore individual anatomy, mechanical alignment remains the most widely accepted and evidence-based approach for conventional TKA.

Question 4629

Topic: Total Hip Arthroplasty (THA)

Which of the following surgical approaches to the hip is most commonly associated with a higher risk of sciatic nerve injury?

. Direct anterior approach
. Anterolateral approach
. Posterior approach
. Transtrochanteric approach
. Hardinge approach

Correct Answer & Explanation

. Posterior approach

Explanation

The posterior approach to the hip is most commonly associated with a higher risk of sciatic nerve injury compared to other approaches. The sciatic nerve lies posterior to the short external rotators and is exposed during this approach, making it vulnerable during muscle release, retraction, or instrument placement. The direct anterior and anterolateral approaches generally have a lower risk of sciatic nerve injury but may pose risks to the lateral femoral cutaneous nerve (DAA) or superior gluteal nerve (Anterolateral). The Hardinge approach is an older term for a variation of the anterolateral approach. Transtrochanteric approaches are less common for primary THA but involve osteotomy of the greater trochanter.

Question 4630

Topic: Total Knee Arthroplasty (TKA)

Which of the following is considered a relative contraindication for unicompartmental knee arthroplasty (UKA)?

. Anterior cruciate ligament (ACL) insufficiency
. Moderate obesity (BMI 30-35)
. Inflammatory arthritis (e.g., rheumatoid arthritis)
. Fixed varus deformity >15 degrees
. Patellofemoral osteoarthritis

Correct Answer & Explanation

. Inflammatory arthritis (e.g., rheumatoid arthritis)

Explanation

Inflammatory arthritis (e.g., rheumatoid arthritis) is generally a contraindication for UKA. The disease process typically affects multiple compartments and can lead to diffuse synovial hypertrophy, bone loss, and progressive disease in the 'unaffected' compartments, leading to early failure of the UKA. While ACL insufficiency used to be an absolute contraindication, modern UKA designs and surgical techniques have made it a relative contraindication in some cases, provided the knee remains stable. Moderate obesity, fixed deformities, and patellofemoral osteoarthritis (if not symptomatic or severe) are relative contraindications or considerations, but inflammatory arthritis is a more definitive contraindication due to the systemic nature of the disease affecting all joint tissues.

Question 4631

Topic: 3. Adult Reconstruction (Hip & Knee)

Which of the following conditions is considered a major cause of recurrent dislocations in patients undergoing total hip arthroplasty?

. Component malpositioning
. Trochanteric nonunion
. Heterotopic ossification
. Aseptic loosening
. Periprosthetic fracture

Correct Answer & Explanation

. Component malpositioning

Explanation

Component malpositioning, particularly of the acetabular component (e.g., excessive anteversion or retroversion, or inclination), is one of the most significant and preventable causes of recurrent dislocations following total hip arthroplasty. Incorrect placement alters the hip's stability and impingement-free range of motion. While the other options are serious complications, they are less directly or frequently associated with recurrent dislocations. Trochanteric nonunion can cause abductor insufficiency but is not the primary cause of recurrent dislocation. Heterotopic ossification can restrict range of motion but doesn't typically lead to recurrent dislocation itself. Aseptic loosening and periprosthetic fractures are different modes of failure.

Question 4632

Topic: Total Knee Arthroplasty (TKA)

Which of the following conditions is most likely to be treated with a constrained total knee arthroplasty (TKA)?

. Isolated medial compartment osteoarthritis with intact ligaments.
. Severe valgus deformity with incompetent medial collateral ligament (MCL).
. Primary osteoarthritis with mild varus deformity and competent ligaments.
. Patellofemoral arthritis.
. Post-traumatic arthritis with a well-aligned knee.

Correct Answer & Explanation

. Severe valgus deformity with incompetent medial collateral ligament (MCL).

Explanation

Constrained total knee arthroplasties are used in cases of significant ligamentous instability, typically when both collateral ligaments are deficient or severely incompetent, or in revision cases where there is bone loss and severe instability. Severe valgus deformity with an incompetent MCL indicates significant instability requiring a more constrained implant to provide stability. Isolated medial compartment osteoarthritis, primary osteoarthritis with mild deformity, patellofemoral arthritis, and well-aligned post-traumatic arthritis would typically be treated with less constrained implants (e.g., cruciate-retaining, cruciate-substituting) or unicompartmental knees.

Question 4633

Topic: 3. Adult Reconstruction (Hip & Knee)

A 65-year-old male undergoes a revision total knee arthroplasty. Intraoperatively, he is found to have a severe deficiency of the medial collateral ligament (MCL) requiring significant constraint. Which of the following implant designs would be most appropriate in this scenario?

. Cruciate-retaining (CR) knee
. Posterior-stabilized (PS) knee
. Constrained condylar knee (CCK)
. Unicompartmental knee arthroplasty (UKA)
. Patellofemoral arthroplasty

Correct Answer & Explanation

. Constrained condylar knee (CCK)

Explanation

When there is a severe deficiency of a collateral ligament (like the MCL), a constrained condylar knee (CCK) implant is required. CCK designs have a larger post-and-cam mechanism and often thicker polyethylene posts to provide varus-valgus stability, substituting for deficient collateral ligaments. Cruciate-retaining and posterior-stabilized designs rely on intact or functional collateral ligaments. UKA is for unicompartmental disease with intact ligaments. Patellofemoral arthroplasty addresses isolated patellofemoral arthritis. Therefore, CCK is the most appropriate choice for severe MCL deficiency.

Question 4634

Topic: 3. Adult Reconstruction (Hip & Knee)

Which of the following statements regarding total hip arthroplasty (THA) in patients with osteonecrosis of the femoral head is most accurate?

. Cementless components are generally preferred in younger, active patients.
. The risk of dislocation is significantly higher compared to THA for osteoarthritis.
. Component sizing is typically more straightforward due to preserved bone stock.
. Heterotopic ossification is a rare complication.
. Younger patients with osteonecrosis should always be managed with core decompression instead of THA.

Correct Answer & Explanation

. Cementless components are generally preferred in younger, active patients.

Explanation

In younger, active patients undergoing THA for osteonecrosis, cementless components are generally preferred. This is due to the potential for longer implant survival with biologic fixation and to avoid the long-term complications associated with cement. The risk of dislocation in THA for osteonecrosis is comparable to that for osteoarthritis, not significantly higher. Bone stock can be compromised, especially in collapsed stages, making component sizing challenging. Heterotopic ossification is actuallymorecommon in THA for osteonecrosis than for osteoarthritis. Core decompression is indicated for early-stage (pre-collapse) osteonecrosis, not for advanced disease requiring THA.

Question 4635

Topic: 3. Adult Reconstruction (Hip & Knee)

Regarding the vascular supply of the femoral head in an adult, which artery is considered most critical in preventing avascular necrosis following a femoral neck fracture?

. Artery of the ligamentum teres (foveal artery)
. Medial circumflex femoral artery
. Lateral circumflex femoral artery
. Superior gluteal artery
. Inferior gluteal artery

Correct Answer & Explanation

. Medial circumflex femoral artery

Explanation

The medial circumflex femoral artery (MCFA), via its retinacular branches, is the primary blood supply to the femoral head in adults. Displaced femoral neck fractures often disrupt these critical posterolateral retinacular vessels, leading to a high risk of avascular necrosis (AVN). The artery of the ligamentum teres is insignificant in adults but plays a role in children. The lateral circumflex femoral artery mainly supplies the greater trochanter and vastus lateralis. The superior and inferior gluteal arteries supply the gluteal muscles.

Question 4636

Topic: 3. Adult Reconstruction (Hip & Knee)

Which of the following is considered the most common complication following total knee arthroplasty (TKA)?

. Infection
. Periprosthetic fracture
. Venous thromboembolism (VTE)
. Arthrofibrosis/stiffness
. Neurovascular injury

Correct Answer & Explanation

. Arthrofibrosis/stiffness

Explanation

Arthrofibrosis and persistent stiffness are reported as the most common complications after TKA, affecting a significant percentage of patients and often requiring manipulation under anesthesia or revision surgery. While infection, periprosthetic fracture, VTE, and neurovascular injury are serious complications, their incidence is generally lower than that of arthrofibrosis, which can significantly impact functional outcomes. Modern protocols have reduced VTE incidence, and neurovascular injuries are relatively rare.

Question 4637

Topic: 3. Adult Reconstruction (Hip & Knee)

Regarding avascular necrosis (AVN) of the femoral head, which of the following statements is true?

. Corticosteroid use is protective against AVN.
. The most sensitive imaging study for early diagnosis is plain radiography.
. Core decompression is primarily indicated for advanced, collapsed stages of AVN.
. Alcohol abuse is a recognized risk factor for AVN.
. Total hip arthroplasty is always contraindicated in AVN.

Correct Answer & Explanation

. Alcohol abuse is a recognized risk factor for AVN.

Explanation

Alcohol abuse is a well-established non-traumatic risk factor for avascular necrosis (AVN) of the femoral head, similar to corticosteroid use, sickle cell disease, and caisson disease. Corticosteroid use is arisk factor, not protective. The most sensitive imaging for early AVN is MRI, not plain radiography (which shows changes late). Core decompression is indicated for early stages (pre-collapse) to halt progression, not advanced stages. Total hip arthroplasty is a viable treatment option for advanced, collapsed AVN, especially in older patients, making the statement that it's always contraindicated incorrect.

Question 4638

Topic: 3. Adult Reconstruction (Hip & Knee)

A 72-year-old female presents with hip pain and progressive difficulty walking after a fall. Radiographs show a displaced femoral neck fracture. She has a history of Parkinson's disease, cognitive impairment, and is a poor surgical candidate for prolonged procedures. What is the most appropriate surgical management?

. Open reduction and internal fixation with cannulated screws
. Hemiarthroplasty (bipolar)
. Total hip arthroplasty (THA)
. Closed reduction and spica cast
. Non-operative management with pain control

Correct Answer & Explanation

. Hemiarthroplasty (bipolar)

Explanation

For a displaced femoral neck fracture in an elderly patient with significant comorbidities (Parkinson's, cognitive impairment) who is a poor candidate for extensive surgery, hemiarthroplasty (bipolar or unipolar) is generally the preferred treatment. It provides immediate stability and pain relief with a shorter operative time than THA, reducing the risks associated with prolonged anesthesia. THA is often considered the gold standard for healthy, active elderly patients, but less so for those with significant cognitive or medical burden. ORIF with screws has a higher risk of failure and AVN in displaced femoral neck fractures in the elderly. Non-operative management leads to poor outcomes.

Question 4639

Topic: 3. Adult Reconstruction (Hip & Knee)

A 6-year-old boy sustains a traumatic posterior hip dislocation while playing. What is the most critical modifiable factor in preventing the development of avascular necrosis (AVN) of the femoral head in this patient?

. The child's skeletal maturity
. The energy mechanism of the injury
. Time to concentric closed reduction
. Modality of post-reduction immobilization (Spica vs. brace)
. Surgical repair of concomitant labral tears

Correct Answer & Explanation

. Time to concentric closed reduction

Explanation

Avascular necrosis (AVN) of the femoral head is the most devastating complication of traumatic hip dislocations in pediatric patients. The single most important modifiable factor to reduce the incidence of AVN is the time to reduction. Reduction within 6 hours significantly lowers the risk of AVN. While age and energy mechanism affect risk, they are not modifiable. Immobilization modality does not directly alter AVN rates.

Question 4640

Topic: 3. Adult Reconstruction (Hip & Knee)

A 28-year-old male sustains a posterior hip dislocation following a motor vehicle collision. Closed reduction is successful. Post-reduction CT reveals a Pipkin Type I fracture (femoral head fracture inferior to the fovea capitis) with a 1 mm step-off, a concentrically reduced joint, and no intra-articular loose bodies. What is the most appropriate next step in management?

. Open reduction internal fixation via an anterior approach
. Open reduction internal fixation via a posterior approach
. Excision of the fracture fragment
. Conservative management with weight-bearing restrictions
. Total hip arthroplasty

Correct Answer & Explanation

. Conservative management with weight-bearing restrictions

Explanation

A Pipkin Type I involves the non-weight-bearing portion of the femoral head (below the fovea). If anatomically reduced (less than 1-2 mm step-off) and stable without loose bodies, conservative management yields excellent outcomes.

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