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3. Adult Reconstruction (Hip & Knee) MCQs

Practice Set 25 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 481

Topic: 3. Adult Reconstruction (Hip & Knee)

A 60-year-old male is undergoing a medial unicompartmental knee replacement (UKR) using a robotic-assisted system. The pre-operative CT scan has been used to create a 3D bone model, and the surgical plan for bone resections and component positioning has been meticulously developed. Intra-operatively, the robot guides the surgeon's resections. Which of the following is the MOST well-established advantage of using robotic-assisted systems in UKR?

. Significantly lower rates of deep periprosthetic joint infection compared to conventional techniques.
. Elimination of the need for pre-operative radiographic planning and templating.
. Higher accuracy and precision in component positioning and limb alignment.
. Guaranteed superior long-term patient-reported outcomes and implant survival rates.
. Complete automation of the surgical procedure, reducing surgeon involvement.

Correct Answer & Explanation

. Higher accuracy and precision in component positioning and limb alignment.

Explanation

Correct Answer: CThe case states under 'Robotic-Assisted UKR' -> 'Accuracy': 'Multiple studies have demonstrated that robotic-assisted UKR achieves higher accuracy and precision in component positioning and limb alignment compared to conventional manual techniques, reducing outliers.' This is the primary and most consistently demonstrated advantage of robotic assistance.Option A (Significantly lower rates of deep periprosthetic joint infection):While robotic assistance may reduce surgical trauma, there is no strong evidence presented in the text or widely accepted in the literature that it significantly lowers infection rates compared to conventional techniques. Infection rates are more influenced by sterile technique, patient factors, and perioperative antibiotics.Option B (Elimination of the need for pre-operative radiographic planning and templating):This is incorrect. The text explicitly states, 'These systems utilize pre-operative CT scans to create 3D bone models, allowing for precise planning of bone resections and component positioning.' This is a form of advanced pre-operative planning, not an elimination of it.Option D (Guaranteed superior long-term patient-reported outcomes and implant survival rates):The text states, 'While improved accuracy is clear, evidence for superior long-term clinical outcomes (e.g., survival, patient-reported outcomes) directly attributable to robotics is still evolving. Early studies suggest comparable or potentially improved short-to-mid-term outcomes and satisfaction.' It does not guarantee superior long-term outcomes.Option E (Complete automation of the surgical procedure, reducing surgeon involvement):This is incorrect. Robotic-assisted systems are 'guided' by the surgeon; they do not completely automate the procedure. The surgeon remains in control and performs the resections with robotic guidance.

Question 482

Topic: 3. Adult Reconstruction (Hip & Knee)

A 78-year-old female with severe rheumatoid arthritis sustains a highly comminuted, intra-articular distal humerus fracture (AO/OTA 13-C3). Considering her bone quality and comorbidities, which of the following elbow arthroplasty designs is most appropriate, and what is its primary biomechanical advantage in this specific trauma setting?

. Unlinked total elbow arthroplasty; preserves native collateral ligaments for proprioception.
. Linked semiconstrained total elbow arthroplasty; compensates for severe bone loss and ligamentous insufficiency.
. Unlinked total elbow arthroplasty; allows greater range of motion without the risk of aseptic loosening.
. Distal humeral hemiarthroplasty; completely avoids ulnar bone loss and triceps weakness.
. Linked fully constrained total elbow arthroplasty; strictly prevents any varus-valgus stress.

Correct Answer & Explanation

. Linked semiconstrained total elbow arthroplasty; compensates for severe bone loss and ligamentous insufficiency.

Explanation

Linked semiconstrained TEA is the treatment of choice for elderly patients with comminuted distal humerus fractures and poor bone quality or ligamentous insufficiency. The semiconstrained design allows a few degrees of toggle, decreasing stresses at the implant-cement-bone interface to minimize aseptic loosening.

Question 483

Topic: 3. Adult Reconstruction (Hip & Knee)

A 72-year-old female undergoes a total knee arthroplasty (TKA) via a standard medial parapatellar approach. During the procedure, a lateral retinacular release is deemed necessary to improve patellar tracking. Which artery provides the primary blood supply to the patella and is at greatest risk of transection during this release?

. Superior medial genicular artery
. Superior lateral genicular artery
. Inferior medial genicular artery
. Inferior lateral genicular artery
. Descending genicular artery

Correct Answer & Explanation

. Superior lateral genicular artery

Explanation

The superior lateral genicular artery provides the primary blood supply to the patella. It is at significant risk of injury during lateral retinacular release, potentially leading to patellar avascular necrosis if other collaterals are compromised.

Question 484

Topic: 3. Adult Reconstruction (Hip & Knee)

A 75-year-old female with severe rheumatoid arthritis and a comminuted intra-articular distal humerus fracture undergoes a Total Elbow Arthroplasty (TEA). To ensure longevity of the implant and prevent aseptic loosening, what is the standard lifelong lifting restriction typically advised for this patient?

. Limit of 1 to 2 pounds for a single lifting event
. Limit of 10 pounds for a single lifting event
. Limit of 20 pounds for a single lifting event
. Limit of 30 pounds for a single lifting event
. No lifting restriction is required once the triceps has fully healed

Correct Answer & Explanation

. Limit of 10 pounds for a single lifting event

Explanation

Standard post-operative guidelines for total elbow arthroplasty recommend a lifelong lifting restriction of 1 to 2 pounds for continuous/repetitive lifting and a strict maximum of 5 to 10 pounds for any single event to prevent aseptic loosening.

Question 485

Topic: 3. Adult Reconstruction (Hip & Knee)

A 68-year-old female presents with a painful catching and popping sensation in her anterior knee when extending from a flexed position, one year after a posterior-stabilized total knee arthroplasty (TKA). What is the most likely etiology of her symptoms?

. Patella baja
. Patellar clunk syndrome
. Aseptic loosening of the tibial tray
. Popliteus impingement syndrome
. Arthrofibrosis of the medial gutter

Correct Answer & Explanation

. Patellar clunk syndrome

Explanation

Patellar clunk syndrome occurs primarily in posterior-stabilized TKAs when a fibrosynovial nodule forms at the superior pole of the patella. This nodule painfully catches in the intercondylar box of the femoral component during knee extension.

Question 486

Topic: 3. Adult Reconstruction (Hip & Knee)

A surgeon is performing a primary total knee arthroplasty using a midvastus approach. To avoid denervation of the medial vastus muscle, the split in the vastus medialis obliquus (VMO) should not extend proximally from the superior pole of the patella beyond what distance?

. 2.5 cm
. 4.5 cm
. 6.5 cm
. 8.5 cm
. 10.5 cm

Correct Answer & Explanation

. 4.5 cm

Explanation

During a midvastus approach, extending the VMO split more than 4.5 cm proximal to the superior pole of the patella risks denervating the muscle. This is due to the transection of the traversing motor branches from the femoral nerve.

Question 487

Topic: 3. Adult Reconstruction (Hip & Knee)

A 82-year-old frail female with severe dementia and a non-displaced femoral neck fracture is admitted. She is non-ambulatory at baseline and experiences minimal pain with passive range of motion. Her medical history includes severe cardiac disease (ASA V), making her an extremely high anesthetic risk. Her family is primarily concerned with her comfort. Based on the provided case, what is the most appropriate management strategy for this patient?

. A. Urgent hemiarthroplasty to allow for immediate weight-bearing.
. B. Open reduction and internal fixation with cannulated screws.
. C. Non-operative management with analgesia and comfort care.
. D. Delayed surgical intervention after medical optimization for 72 hours.
. E. Total hip arthroplasty to ensure long-term stability.

Correct Answer & Explanation

. C. Non-operative management with analgesia and comfort care.

Explanation

Correct Answer: CThe case provides specific non-operative indications for proximal femur fractures: 'Non-ambulatory patient with severe dementia and minimal pain; Unacceptable anesthetic risk (ASA V).' This patient perfectly fits these criteria. Given her severe dementia, non-ambulatory status, minimal pain, and unacceptable anesthetic risk (ASA V), the primary goal shifts from restoring ambulation to ensuring comfort and avoiding the significant physiological burden of surgery. Non-operative management with analgesia and comfort care is the most appropriate strategy.Option A (Urgent hemiarthroplasty to allow for immediate weight-bearing)andOption E (Total hip arthroplasty to ensure long-term stability)are typically the gold standard for displaced femoral neck fractures in physiologically active osteoporotic patients to allow immediate weight-bearing and prevent avascular necrosis. However, for this specific patient, the anesthetic risk and baseline functional status contraindicate major surgery.Option B (Open reduction and internal fixation with cannulated screws)is generally reserved for non-displaced or minimally displaced femoral neck fractures in younger, physiologically active patients, or as a temporizing measure. It carries a high risk of failure and avascular necrosis in osteoporotic bone and is not suitable for this patient given her comorbidities and functional status.Option D (Delayed surgical intervention after medical optimization for 72 hours)is generally discouraged for hip fractures. The case states that current guidelines strongly advocate for surgical intervention within 24 to 48 hours of admission, as delays beyond this window are independently associated with increased mortality. While medical optimization is crucial, delaying surgery for 72 hours in a patient who is already ASA V and likely to remain so, with the intent to operate, would be inappropriate and potentially harmful.

Question 488

Topic: Total Hip Arthroplasty (THA)

A 62-year-old patient considering total ankle replacement (TAR) asks about the long-term prognosis.

Based on the information provided in the case, what is the approximate 10-year survival rate for total ankle replacements, and how does this compare to hip and knee replacements?

. Approximately 95%, with more extensive data available than for hip and knee replacements.
. Approaching 85%, but with fewer data available than for hip and knee replacements.
. Around 70%, with comparable data to hip and knee replacements.
. Approximately 60%, with significantly better data than for hip and knee replacements.
. Over 90%, but only for fixed-bearing designs.

Correct Answer & Explanation

. Approaching 85%, but with fewer data available than for hip and knee replacements.

Explanation

Correct Answer: BThe candidate's response to the question about TAR longevity is: 'The 10-year survival is approaching 85% but there are fewer data available than for knee and hip replacements. Many series are small.' This directly matches option B.Options A, C, D, and E provide incorrect survival rates or make inaccurate comparisons regarding the availability of data for ankle replacements versus hip and knee replacements.

Question 489

Topic: 3. Adult Reconstruction (Hip & Knee)

During total knee arthroplasty for a valgus knee, the surgeon notes significant deficiency of the lateral femoral condyle. This anatomical variation can lead to a specific rotational malalignment if standard referencing techniques are used. To prevent this malalignment, which of the following intraoperative techniques is most appropriate for determining femoral component rotation?

. Option A: Referencing 3 degrees of external rotation relative to the posterior femoral condylar axis.
. Option B: Utilizing the transepicondylar axis as the primary rotational reference.
. Option C: Employing the anteroposterior (AP) axis (Whiteside line) for rotational alignment.
. Option D: Aligning the femoral component parallel to the tibial cut.
. Option E: Relying solely on the measured resection technique from the posterior condyles.

Correct Answer & Explanation

. Option C: Employing the anteroposterior (AP) axis (Whiteside line) for rotational alignment.

Explanation

Correct Answer: CThe case states: 'Due to the posterior femoral condyle deficiency, the standard 3 posterior condylar referencing can result in internal rotation of the component. In this situation, AP axis (Whiteside line) is used to prevent malrotation in the form of internal rotation.' The Whiteside line (AP axis) is a reliable anatomical landmark that is less affected by condylar wear, making it crucial for accurate femoral rotation in valgus knees with condylar deficiency.Option A is incorrectbecause while 3 degrees of external rotation relative to the posterior condylar axis is a common goal, the posterior condylar deficiency in valgus knees makes this reference unreliable and prone to internal rotation malalignment.Option B (Transepicondylar axis) is incorrectas it is a valid reference but the case specifically highlights the AP axis (Whiteside line) as the preferred method to address the posterior condylar deficiency issue in valgus knees.Option D (Aligning the femoral component parallel to the tibial cut) is incorrectas this does not directly address femoral rotation relative to the femur's anatomical axes and could lead to malrotation if the tibial cut is not perfectly aligned or if there are significant soft tissue imbalances.Option E (Relying solely on the measured resection technique from the posterior condyles) is incorrectbecause, as stated in the case, posterior condylar deficiency makes this method unreliable and can lead to internal rotation of the component.

Question 490

Topic: Total Knee Arthroplasty (TKA)

A 72-year-old female, similar to the patient in the case, undergoes TKR for a valgus knee. Intraoperatively, after femoral and tibial cuts, the surgeon observes persistent lateral subluxation of the patella despite appropriate component rotation and a mild distal femoral valgus cut. What is the most appropriate next step to address this issue?

. Option A: Increase the distal femoral valgus cut to 9 degrees.
. Option B: Perform a medial retinacular release.
. Option C: Perform a lateral retinacular release.
. Option D: Downsize the femoral component.
. Option E: Use a thicker polyethylene insert.

Correct Answer & Explanation

. Option C: Perform a lateral retinacular release.

Explanation

Correct Answer: CThe case states: 'Patients with severe valgus deformity usually require lateral retinacular release to achieve proper patella tracking.' The scenario describes persistent lateral subluxation, indicating the need to release the tight lateral structures that are pulling the patella laterally.Option A is incorrectbecause while a distal femoral cut of 7 degrees can help in mild valgus, increasing it further is not the primary solution for persistent patellar subluxation after initial cuts and may lead to other issues like over-resection or instability. The case mentions 7 degrees formildvalgus toavoidrelease, implying that for persistent issues, a release is needed.Option B (Medial retinacular release) is incorrectas this would worsen lateral patellar subluxation by releasing the medial restraints.Option D (Downsizing the femoral component) is incorrectas this would primarily affect flexion gap and overall knee size, not directly address patellar tracking issues caused by tight lateral retinaculum.Option E (Use a thicker polyethylene insert) is incorrectas this primarily addresses flexion-extension gap balancing and joint line elevation, not patellar tracking.

Question 491

Topic: Total Knee Arthroplasty (TKA)

A 65-year-old patient with a mild valgus deformity (8 degrees) is undergoing TKR. The surgeon is focused on optimizing patellar tracking and avoiding unnecessary lateral retinacular release. According to the case, what specific distal femoral cut angle can be utilized to improve patellar tracking in this scenario?

. Option A: A distal femoral cut of 3 degrees of valgus.
. Option B: A distal femoral cut of 5 degrees of valgus.
. Option C: A distal femoral cut of 7 degrees of valgus.
. Option D: A distal femoral cut of 9 degrees of valgus.
. Option E: A distal femoral cut of 0 degrees (neutral) valgus.

Correct Answer & Explanation

. Option C: A distal femoral cut of 7 degrees of valgus.

Explanation

Correct Answer: CThe case specifically mentions: 'In mild valgus deformity (7–10) a distal femoral cut of 7 can improve patella tracking and avoid the need for lateral retinacular release.' This directly provides the recommended angle for mild valgus deformities to aid patellar tracking.Option A (3 degrees) is incorrectas this is a common valgus angle for a varus knee or a neutral knee, but not specifically highlighted for improving patellar tracking in mild valgus.Option B (5 degrees) is incorrectas the case specifies 7 degrees for this particular purpose.Option D (9 degrees) is incorrectas while it falls within the 7-10 degree range of mild valgus, the specific recommendation for the cut is 7 degrees to improve tracking and avoid release.Option E (0 degrees) is incorrectas a neutral cut would not address the valgus deformity or specifically aid patellar tracking in a valgus knee.

Question 492

Topic: 3. Adult Reconstruction (Hip & Knee)

During a primary posterior-stabilized total knee arthroplasty (TKA), after the trial components are placed, the surgeon notes that the knee is symmetric and well-balanced in 90 degrees of flexion, but it is tight medially and laterally in full extension. Which of the following is the most appropriate intraoperative maneuver to correct this mismatch?

. Decrease the anteroposterior (AP) size of the femoral component
. Resect additional posterior femoral condyle
. Release the posterior cruciate ligament
. Resect additional distal femur
. Increase the thickness of the polyethylene tibial insert

Correct Answer & Explanation

. Resect additional distal femur

Explanation

Resecting additional distal femur increases the extension gap without affecting the flexion gap. Decreasing the AP femoral size or resecting more posterior condyle would alter the flexion gap, which is already well-balanced in this scenario.

Question 493

Topic: 3. Adult Reconstruction (Hip & Knee)

A 68-year-old female presents 14 months after a primary posterior-stabilized (PS) total knee arthroplasty complaining of a painful "catching" sensation when she extends her knee from 40 degrees to 30 degrees of flexion. Examination reveals a palpable pop at the superior pole of the patella. What is the most likely diagnosis?

. Aseptic loosening of the tibial baseplate
. Patellar clunk syndrome
. Polyethylene wear
. Popliteus tendon impingement
. Periprosthetic joint infection

Correct Answer & Explanation

. Patellar clunk syndrome

Explanation

Patellar clunk syndrome is caused by a fibrosynovial nodule forming on the superior pole of the patella, which becomes entrapped in the intercondylar box of a posterior-stabilized femoral component during knee extension. It typically presents as a painful pop or catch at 30 to 40 degrees of flexion.

Question 494

Topic: 3. Adult Reconstruction (Hip & Knee)

A 55-year-old male with isolated medial compartment knee osteoarthritis is being considered for a medial unicompartmental knee arthroplasty (UKA). Which of the following is considered an accepted contraindication to this procedure?

. Intact anterior cruciate ligament
. Flexion arc of 110 degrees
. Varus deformity of 5 degrees that is passively correctable
. Deficient anterior cruciate ligament
. Body mass index of 28

Correct Answer & Explanation

. Deficient anterior cruciate ligament

Explanation

A deficient anterior cruciate ligament (ACL) is traditionally viewed as a contraindication for mobile-bearing medial UKA due to altered knee kinematics and risk of early failure. The other options represent ideal criteria for a UKA.

Question 495

Topic: 3. Adult Reconstruction (Hip & Knee)

A 65-year-old man presents with medial knee pain and is being evaluated for a unicompartmental knee arthroplasty (UKA). Which of the following physical examination findings is traditionally considered a strict contraindication to performing a UKA?

. A body mass index (BMI) of 29 kg/m2
. An intact anterior cruciate ligament (ACL)
. A fixed varus deformity of 5 degrees
. A fixed flexion contracture greater than 15 degrees
. Passive knee flexion up to 120 degrees

Correct Answer & Explanation

. A fixed flexion contracture greater than 15 degrees

Explanation

A fixed flexion contracture greater than 15 degrees is a classic contraindication for unicompartmental knee arthroplasty, as it is difficult to correct without performing extensive releases that are typically reserved for total knee arthroplasty. Other contraindications include ACL deficiency, inflammatory arthritis, and fixed varus deformity greater than 10 degrees.

Question 496

Topic: 3. Adult Reconstruction (Hip & Knee)

A 52-year-old active male presents with isolated medial compartment knee osteoarthritis. He is being evaluated for a medial unicompartmental knee arthroplasty (UKA). Which of the following preoperative findings is an established contraindication to proceeding with a medial UKA?

. Intact anterior cruciate ligament
. Flexion contracture of 10 degrees
. Weight-bearing varus deformity of 15 degrees that is not passively correctable
. Body Mass Index of 28
. Age of 52 years

Correct Answer & Explanation

. Weight-bearing varus deformity of 15 degrees that is not passively correctable

Explanation

Contraindications for unicompartmental knee arthroplasty include inflammatory arthritis, ACL deficiency, fixed varus deformity greater than 10 degrees, and flexion contracture greater than 15 degrees. A non-correctable varus deformity of 15 degrees makes him a poor candidate for UKA and better suited for a TKA.

Question 497

Topic: 3. Adult Reconstruction (Hip & Knee)




A 65-year-old female presents with severe, bilateral knee pain limiting her ambulation to a single block. She has failed extensive conservative measures. Assuming the radiograph demonstrates advanced tricompartmental osteoarthritis with bone-on-bone changes, what is the most appropriate definitive management?

. Bilateral medial opening wedge high tibial osteotomies
. Bilateral unicompartmental knee arthroplasties
. Arthroscopic debridement, lysis of adhesions, and lavage
. Total knee arthroplasty
. Patellofemoral arthroplasty

Correct Answer & Explanation

. Total knee arthroplasty

Explanation

Total knee arthroplasty is the definitive management of choice for advanced tricompartmental knee osteoarthritis in older patients who have exhausted conservative therapies. Osteotomies and unicompartmental replacements are strictly contraindicated in the setting of widespread tricompartmental disease.

Question 498

Topic: 3. Adult Reconstruction (Hip & Knee)

During an anterior approach for a total ankle arthroplasty (TAA), the surgeon develops the interval between the extensor hallucis longus (EHL) and extensor digitorum longus (EDL). Which of the following neurovascular structures is at the greatest risk of iatrogenic injury deep to the extensor retinaculum in this interval?

. Superficial peroneal nerve
. Deep peroneal nerve and anterior tibial artery
. Sural nerve and lesser saphenous vein
. Saphenous nerve and great saphenous vein
. Tibial nerve and posterior tibial artery

Correct Answer & Explanation

. Deep peroneal nerve and anterior tibial artery

Explanation

The standard anterior approach to the ankle utilizes the internervous interval between the EHL and EDL. The deep peroneal nerve and the anterior tibial artery lie directly beneath the extensor retinaculum in this space and are at high risk during exposure and retractor placement.

Question 499

Topic: 3. Adult Reconstruction (Hip & Knee)

A 45-year-old female presents with severe anterior knee pain and crepitus. Radiographs demonstrate isolated, end-stage patellofemoral osteoarthritis with no tibiofemoral involvement. She is being considered for an isolated patellofemoral arthroplasty. Which of the following is considered a primary contraindication to this specific procedure?

. Age less than 50 years
. Previous arthroscopic chondroplasty of the patella
. Uncorrected patellar maltracking or malalignment
. Intact anterior cruciate ligament
. Body Mass Index of 25

Correct Answer & Explanation

. Uncorrected patellar maltracking or malalignment

Explanation

Uncorrected patellar maltracking, instability, or significant malalignment are contraindications to isolated patellofemoral arthroplasty due to the high risk of early implant failure. The underlying biomechanical tracking issues must be addressed concurrently, or a total knee arthroplasty should be considered if the malalignment is uncorrectable.

Question 500

Topic: 3. Adult Reconstruction (Hip & Knee)

During a posterior (Kocher-Langenbeck) approach to the hip for a total hip arthroplasty, the surgeon releases the short external rotators near their femoral insertion. Brisk, pulsatile bleeding is suddenly encountered deep to the quadratus femoris. Which vessel is most likely the source of this bleeding?

. Superior gluteal artery
. Inferior gluteal artery
. Ascending branch of the medial femoral circumflex artery
. Transverse branch of the lateral femoral circumflex artery
. First perforating branch of the profunda femoris

Correct Answer & Explanation

. Ascending branch of the medial femoral circumflex artery

Explanation

The ascending branch of the medial femoral circumflex artery runs between the quadratus femoris and obturator externus. It is at high risk of injury during the release of the short external rotators in a posterior approach to the hip.

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