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3. Adult Reconstruction (Hip & Knee) MCQs

Practice Set 292 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 5821

Topic: 3. Adult Reconstruction (Hip & Knee)

What is the typical long-term complication rate for infection following primary total elbow arthroplasty for osteoarthritis?

. Less than 0.5%
. 0.5% - 2%
. 2% - 5%
. 5% - 10%
. Greater than 10%

Correct Answer & Explanation

. 2% - 5%

Explanation

The reported infection rate following primary total elbow arthroplasty (TEA) for osteoarthritis or rheumatoid arthritis typically ranges from 2% to 5%. This rate is generally higher than that for total hip or total knee arthroplasty, primarily due to the superficial nature of the elbow joint, the relatively thin soft tissue envelope, and the presence of underlying systemic diseases (like RA) in some patient populations. Therefore, infection is a significant and serious complication that surgeons must counsel patients about.

Question 5822

Topic: 3. Adult Reconstruction (Hip & Knee)

A 52-year-old male with long-standing elbow osteoarthritis complains of severe pain and clicking during forearm pronation and supination. Radiographs show significant narrowing of the radiocapitellar joint space and capitellar wear. The ulnohumeral joint is relatively spared. Which surgical procedure is most indicated?

. Total elbow arthroplasty
. Ulnohumeral interposition arthroplasty
. Radial head arthroplasty (replacement)
. Olecranon osteophyte excision
. Distraction arthroplasty

Correct Answer & Explanation

. Radial head arthroplasty (replacement)

Explanation

The patient's symptoms of pain and clicking during pronation/supination, coupled with radiographic evidence of isolated radiocapitellar joint narrowing and capitellar wear, strongly indicate severe radiocapitellar osteoarthritis with sparing of the ulnohumeral joint. In such cases, radial head arthroplasty (replacement) is a highly effective treatment to restore normal joint mechanics, relieve pain, and improve forearm rotation while preserving the native elbow. Total elbow arthroplasty is overly aggressive for isolated radiocapitellar disease. Ulnohumeral interposition and olecranon osteophyte excision would not address the primary pathology. Distraction arthroplasty is a more complex salvage procedure.

Question 5823

Topic: 3. Adult Reconstruction (Hip & Knee)

What is the primary benefit of bone-grafting options for interposition arthroplasty in elbow OA?

. It provides immediate, rigid fixation for the joint.
. It promotes rapid regeneration of hyaline cartilage.
. It acts as a biological spacer, preserving motion and reducing pain while minimizing hardware complications.
. It completely eliminates the risk of infection.
. It is a permanent cure for all types of elbow arthritis.

Correct Answer & Explanation

. It acts as a biological spacer, preserving motion and reducing pain while minimizing hardware complications.

Explanation

Interposition arthroplasty, often using fascia lata autograft or other soft tissue grafts, or occasionally bone-grafting options, serves as a biological spacer. The primary benefit is to preserve motion and reduce pain by creating a smooth, gliding surface between the humeral and ulnar articular surfaces, without the need for prosthetic implants and their associated risks of loosening. It doesn't provide rigid fixation, promote hyaline cartilage regeneration, eliminate infection risk, or serve as a permanent cure for all types of arthritis. It is a viable option for younger, active patients not suitable for TEA who still desire motion preservation.

Question 5824

Topic: 3. Adult Reconstruction (Hip & Knee)

What is the MOST critical factor influencing functional outcomes after total elbow arthroplasty for osteoarthritis?

. Patient's age at the time of surgery
. Preoperative range of motion
. Presence of associated ulnar neuropathy
. Adherence to postoperative rehabilitation protocols and activity restrictions
. Type of implant (linked vs. unlinked)

Correct Answer & Explanation

. Adherence to postoperative rehabilitation protocols and activity restrictions

Explanation

While all listed factors can influence outcomes, adherence to postoperative rehabilitation protocols and activity restrictions (particularly weight-bearing limits) is arguably the most critical factor influencing the long-term functional success and longevity of a total elbow arthroplasty. Non-compliance can lead to early loosening, instability, or periprosthetic fracture. Preoperative range of motion and ulnar neuropathy influence the starting point and potential for improvement but are less critical for long-term implant survival and functional maintenance than patient adherence. Age influences demand, and implant type is chosen based on patient factors, but neither guarantees success without compliance.

Question 5825

Topic: Total Hip Arthroplasty (THA)

Which of the following is an advantage of anterior surgical approach over a posterior approach for direct spinal cord decompression of an anteriorly located extradural tumor?

. Less risk of cerebrospinal fluid (CSF) leak
. Better spinal stability post-op
. Ability to achieve direct decompression and reconstruction of the anterior column
. Easier access to multiple spinal levels
. Lower risk of iatrogenic neurological injury

Correct Answer & Explanation

. Ability to achieve direct decompression and reconstruction of the anterior column

Explanation

The primary advantage of an anterior approach for an anteriorly located extradural tumor is the ability to achieve direct decompression of the spinal cord by removing the pathology from the front, and simultaneously reconstructing the anterior column (e.g., with cages and plates). Posterior approaches primarily provide indirect decompression and are better for posterior element tumors or stabilization. While anterior approaches can be very effective, they often carry higher risks (e.g., visceral injury, complex access) and are not necessarily 'easier' or lower risk of neurological injury compared to posterior in all cases. CSF leak risk depends on dural integrity.

Question 5826

Topic: Total Hip Arthroplasty (THA)

Which surgical technique is most commonly used for repair of a distal biceps tendon rupture?

. Single incision anterior approach with suture anchors
. Double incision anterior and posterior approach with cortical button
. Posterior approach with tension band wiring
. Medial approach with tendon graft
. Lateral approach with interference screw

Correct Answer & Explanation

. Single incision anterior approach with suture anchors

Explanation

Both single-incision anterior approach and double-incision approaches are commonly used for distal biceps tendon repair. However, the single-incision anterior approach with cortical button or suture anchors has become increasingly popular due to its excellent cosmetic results and strong fixation. The double-incision approach traditionally used a transosseous tunnel but has fallen out of favor for some surgeons due to concerns about heterotopic ossification and cosmesis. Posterior, medial, or lateral approaches are not suitable for distal biceps repair.

Question 5827

Topic: 3. Adult Reconstruction (Hip & Knee)

A patient undergoes total elbow arthroplasty (TEA) for severe rheumatoid arthritis. What is a key contraindication for this procedure?

. Age greater than 70 years
. Active infection in the elbow joint
. Previous failed elbow arthroscopy
. High functional demands (e.g., heavy manual labor)
. Concomitant ipsilateral wrist arthritis

Correct Answer & Explanation

. Active infection in the elbow joint

Explanation

Active infection in the elbow joint is an absolute contraindication for total elbow arthroplasty due to the high risk of periprosthetic joint infection, which can be devastating. While high functional demands (heavy manual labor) are a relative contraindication due to the risk of implant loosening and failure, it's not an absolute contraindication like active infection. Age is generally not a contraindication in elderly, low-demand patients. Previous arthroscopy or ipsilateral wrist arthritis are not contraindications.

Question 5828

Topic: 3. Adult Reconstruction (Hip & Knee)

A 60-year-old male with long-standing rheumatoid arthritis presents with increasing elbow pain, stiffness, and instability. Radiographs show severe destruction of the ulnohumeral and radiocapitellar joints. What is the most appropriate surgical option to improve function and reduce pain?

. Elbow arthrodesis
. Excision arthroplasty
. Total elbow arthroplasty (TEA)
. Interposition arthroplasty
. Debridement arthroscopy

Correct Answer & Explanation

. Total elbow arthroplasty (TEA)

Explanation

For severe, destructive rheumatoid arthritis of the elbow with pain, stiffness, and instability, Total Elbow Arthroplasty (TEA) is the most appropriate surgical option. It reliably provides pain relief, improves motion, and restores stability in this patient population, who typically have lower functional demands and poorer bone quality that makes other reconstructive options less suitable. Elbow arthrodesis is rarely performed. Excision and interposition arthroplasty have less predictable pain relief and stability. Debridement arthroscopy is for less severe, early-stage arthritis.

Question 5829

Topic: 3. Adult Reconstruction (Hip & Knee)
An 84-year-old female's shoulder X-ray following a fall shows a single, minimally displaced fracture of the greater tuberosity (<5mm displacement). Which of the following is generally the most appropriate initial management based on this X-ray finding?
. Immediate surgical fixation
. Shoulder arthroplasty
. Immobilization with early range of motion
. Sling immobilization for 6 weeks followed by PT
. Diagnostic arthroscopy

Correct Answer & Explanation

. Sling immobilization for 6 weeks followed by PT

Explanation

Minimally displaced greater tuberosity fractures (<5mm for non-dominant, <3mm for dominant arm, or as per local protocol) are typically managed non-operatively with initial immobilization (e.g., sling) for comfort, followed by early gentle range of motion exercises to prevent stiffness and facilitate healing. Surgical fixation is generally reserved for significant displacement, often exceeding 5mm, or involvement of the articular surface. Arthroscopy or arthroplasty are not indicated for this simple injury.

Question 5830

Topic: 3. Adult Reconstruction (Hip & Knee)

An 84-year-old patient has a long-standing total shoulder arthroplasty. On a follow-up X-ray, you notice a large, localized area of bone resorption around the distal tip of the humeral stem, without obvious infection. This is most likely indicative of:

. Stress shielding
. Heterotopic ossification
. Aseptic loosening with osteolysis
. Periprosthetic fracture
. Component fatigue

Correct Answer & Explanation

. Aseptic loosening with osteolysis

Explanation

Localized bone resorption (osteolysis) around a prosthetic component, especially if progressive and without signs of infection, is a hallmark of aseptic loosening. It is often caused by particulate wear debris triggering an inflammatory response that leads to bone loss. Stress shielding refers to bone atrophy due to reduced load transfer, usually more diffuse. Heterotopic ossification is bone formation in soft tissues. Periprosthetic fracture is a distinct event. Component fatigue refers to material failure, not bone resorption.

Question 5831

Topic: 3. Adult Reconstruction (Hip & Knee)

An 84-year-old lady reports increasing pain and stiffness in her shoulder after an anatomical total shoulder arthroplasty performed 5 years ago. Her X-ray shows a stable humeral component, but there is significant widening of the acromiohumeral interval. This widening is most likely due to:

. Polyethylene wear of the glenoid component
. Rotator cuff tear
. Glenoid component loosening
. Subacromial impingement
. Periprosthetic infection

Correct Answer & Explanation

. Rotator cuff tear

Explanation

In an anatomic total shoulder arthroplasty, a widening of the acromiohumeral interval strongly suggests a rotator cuff tear. The rotator cuff is essential for centralizing the humeral head on the glenoid. If it tears post-arthroplasty, the deltoid's unopposed pull leads to superior migration of the humeral head, increasing the acromiohumeral distance. Polyethylene wear or glenoid loosening would affect joint space or implant stability, not directly widen the AHI to this extent. Subacromial impingement is often associated with a reduced AHI initially, then tears. Periprosthetic infection would typically show aggressive osteolysis.

Question 5832

Topic: 3. Adult Reconstruction (Hip & Knee)

An examiner asks about the indications for surgical intervention in a patient with osteolysis of the distal clavicle. Which of the following is the most common indication for surgery?

. Severe osteoporosis.
. Recurrent AC joint dislocation.
. Persistent pain despite extensive non-operative management.
. Associated rotator cuff tear.
. Bilateral symptoms.

Correct Answer & Explanation

. Persistent pain despite extensive non-operative management.

Explanation

Osteolysis of the distal clavicle (ODC) is often treated non-operatively with rest, NSAIDs, and activity modification. Surgical intervention, typically a distal clavicle excision (Mumford procedure), is indicated for persistent and disabling pain that has failed to respond to a comprehensive course of non-operative management (typically 6-12 months). The other options are either not direct indications or secondary considerations.

Question 5833

Topic: 3. Adult Reconstruction (Hip & Knee)

When discussing the post-operative management of a patient after a total shoulder arthroplasty, what is the most important consideration in the immediate post-operative period (first 24-48 hours)?

. Aggressive range of motion exercises to prevent stiffness.
. Early strengthening of the rotator cuff.
. Pain control and prevention of stiffness with gentle passive range of motion.
. Immediate full weight-bearing on the affected arm.
. Discontinuation of all pain medication.

Correct Answer & Explanation

. Pain control and prevention of stiffness with gentle passive range of motion.

Explanation

In the immediate post-operative period following total shoulder arthroplasty, pain control is paramount to allow for early, gentle passive range of motion. The goal is to prevent post-operative stiffness and promote healing without stressing the repaired soft tissues. Aggressive range of motion or strengthening is contraindicated, and full weight-bearing is not allowed. Discontinuation of pain medication would be inappropriate.

Question 5834

Topic: Total Hip Arthroplasty (THA)

Which of the following is a common early complication specific to the anterior approach for L5-S1 spondylolisthesis fusion?

. L5 nerve root palsy
. Retrograde ejaculation in males
. Superficial wound infection
. Deep vein thrombosis
. Pseudarthrosis

Correct Answer & Explanation

. Retrograde ejaculation in males

Explanation

Retrograde ejaculation is a well-known, albeit rare, complication specific to anterior lumbar approaches, particularly at L5-S1. It results from injury or disruption of the superior hypogastric plexus (autonomic nerves responsible for seminal vesicle and vas deferens contraction) during dissection anterior to the sacrum. Other listed complications are general surgical risks or specific to posterior approaches.

Question 5835

Topic: 3. Adult Reconstruction (Hip & Knee)

A 65-year-old man undergoes revision shoulder arthroplasty for presumed aseptic loosening. Intraoperative cultures subsequently grow Cutibacterium acnes (formerly Propionibacterium acnes). Which of the following best describes the microbiological profile of this organism?

. Gram-negative, aerobic, non-spore-forming bacillus
. Gram-positive, aerobic, spore-forming bacillus
. Gram-positive, anaerobic, non-spore-forming bacillus
. Gram-negative, anaerobic, spore-forming coccus
. Gram-positive, facultative anaerobic coccus

Correct Answer & Explanation

. Gram-positive, anaerobic, non-spore-forming bacillus

Explanation

Cutibacterium acnes is a Gram-positive, anaerobic (or microaerophilic), non-spore-forming pleomorphic bacillus. It is a slow-growing commensal organism commonly found in the sebaceous glands of the shoulder and is a leading cause of indolent periprosthetic joint infections following shoulder arthroplasty.

Question 5836

Topic: 3. Adult Reconstruction (Hip & Knee)

A 19-year-old male is brought to the trauma bay after a high-speed motor vehicle collision. He has dyspnea, dysphagia, and an obvious depression at the medial aspect of his right clavicle. A CT scan confirms a posterior sternoclavicular dislocation. What is the most appropriate next step in management?

. Immediate open reduction and internal fixation with a hook plate
. Closed reduction under procedural sedation in the emergency department
. Urgent closed reduction in the operating room with a cardiothoracic surgeon available
. Resection arthroplasty of the medial clavicle
. Observation and sling immobilization

Correct Answer & Explanation

. Urgent closed reduction in the operating room with a cardiothoracic surgeon available

Explanation

Posterior sternoclavicular dislocations are orthopedic emergencies due to the proximity of the great vessels, trachea, and esophagus. Up to 30% are associated with intrathoracic injury. The standard of care is urgent closed reduction under general anesthesia in the operating room, with a cardiothoracic surgeon present or on immediate standby in case of a catastrophic vascular injury during reduction.

Question 5837

Topic: 3. Adult Reconstruction (Hip & Knee)

In the design of a semi-constrained (linked) total elbow arthroplasty, the 'sloppy hinge' (a degree of toggle between the components) is incorporated primarily to accomplish which of the following?

. Increase the terminal range of motion in extension
. Transfer stress from the implant-cement interface to the articulation
. Prevent early triceps insufficiency
. Compensate for a deficient medial collateral ligament
. Allow for easier intraoperative assembly of the components

Correct Answer & Explanation

. Transfer stress from the implant-cement interface to the articulation

Explanation

Early rigid hinge elbow arthroplasties failed at high rates due to aseptic loosening caused by transmission of rotational and varus/valgus forces directly to the implant-cement-bone interface. Modern linked (semi-constrained) implants utilize a 'sloppy hinge' with several degrees of toggle. This design intentionally dissipates these forces at the articulation rather than at the stem interfaces, dramatically reducing the rate of aseptic loosening.

Question 5838

Topic: Total Hip Arthroplasty (THA)

When performing a 2-incision (modified Boyd-Anderson) approach for a distal biceps tendon rupture repair, which of the following complications occurs at a significantly higher rate compared to the single-incision anterior approach?

. Lateral antebrachial cutaneous nerve (LABCN) neuropraxia
. Radial nerve palsy
. Radioulnar synostosis
. Median nerve injury
. Brachial artery thrombosis

Correct Answer & Explanation

. Radioulnar synostosis

Explanation

The 2-incision technique for distal biceps repair was developed to avoid the radial/posterior interosseous nerve injuries associated with extensive anterior dissection. However, due to the dissection between the radius and ulna and the creation of a bone tunnel from a separate posterior approach, the rate of heterotopic ossification and resultant radioulnar synostosis is higher than in the single-incision anterior approach. LABCN injury is the most common complication of the single-incision approach.

Question 5839

Topic: 3. Adult Reconstruction (Hip & Knee)

In a patient undergoing total elbow arthroplasty (TEA) for rheumatoid arthritis, a triceps-sparing (triceps-on) approach is utilized. Compared to a triceps-reflecting approach, the triceps-sparing approach is primarily associated with a decreased risk of which complication?

. Ulnar neuropathy
. Aseptic loosening
. Triceps insufficiency
. Periprosthetic fracture
. Deep infection

Correct Answer & Explanation

. Triceps insufficiency

Explanation

Triceps-sparing approaches maintain the anatomic insertion of the triceps tendon on the olecranon. This significantly reduces the postoperative risk of triceps weakness or insufficiency compared to approaches that detach and repair the mechanism.

Question 5840

Topic: 3. Adult Reconstruction (Hip & Knee)
A 68-year-old female with severe rheumatoid arthritis undergoes a primary linked semi-constrained total elbow arthroplasty (TEA). At 7-year follow-up, she complains of gradually worsening elbow pain. Radiographs show radiolucent lines >2 mm around both the humeral and ulnar stems without signs of fracture. What is the most common long-term complication leading to revision in this procedure?
. Deep infection
. Aseptic loosening
. Ulnar component fracture
. Triceps avulsion
. Periprosthetic joint dislocation

Correct Answer & Explanation

. Aseptic loosening

Explanation

Aseptic loosening is the most common long-term complication and the leading cause of revision in total elbow arthroplasty, particularly in linked (semi-constrained) designs. These designs transmit significant stresses to the bone-cement interface.

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