Orthopedics Hyperguide Review | Dr Hutaif General Ortho -...

- Hemoglobin A1C

Given the size of the rotator cuff tear, it is likely to be repaired; therefore, the treatment of choice is a total shoulder replacement with rotator cuff repair. Severe rotator cuff insufficiency can lead to early glenoid failure because of superior instability, and glenoid resurfacing should be avoided in those instances.

Scientific References

: Boyd AD Jr, Thomas WH, Scott RD, Sledge CB, Thornhill TS: Total shoulder arthroplasty versus hemiarthroplasty: Indications for glenoid resurfacing. J Arthroplasty 1990;5:329-336.
Arntz CT, Jackins S, Matsen FA III: Prosthetic replacement of the shoulder for treatment of defects in the rotator cuff and surface of the glenohumeral joint. J Bone Joint Surg Am 1993;75:485-491.

- Figure 51e_

- Dedifferentiated chondrosarcoma_

The rate of malignant transformation in patients with multiple hereditary exostoses is variable and is generally reported between
0.5% to 25%.

Although the anterior tibial muscle is weak, the cavus is the predominant deformity of this condition, caused by weakness of the peroneus brevis. The peroneus longus is functioning and is responsible for the plantarflexion of the first metatarsal.

This patient appears to have sustained a lateral condyle fracture as a young adult. She was treated with surgical repair and now has posttraumatic arthritis. The best treatment, especially in the setting of mechanical symptoms, is debridement with capsular excision to regain motion and loose body removal. Radial head excision is not indicated because she has no pronation/supination loss or pain with forearm rotation. Elbow arthrodesis is severely limiting because of an associated inability to perform activities of daily living. Unconstrained TEA is more effectively used as a salvage for an older person who has failed debridement and has mid arc motion pain. Unconstrained elbow arthroplasty mandates near-normal elbow bony architecture and intact and normal collateral ligaments, both of which may be compromised in this case.
RECOMMENDED READINGS
48. [Papatheodorou LK, Baratz ME, Sotereanos DG. Elbow arthritis: current concepts. J Hand Surg Am. 2013 Mar;38(3):605-13. doi: 10.1016/j.jhsa.2012.12.037. Epub 2013 Feb 5. Review. PubMed PMID: 23391361. ](http://www.ncbi.nlm.nih.gov/pubmed/23391361)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23391361)
49. [Ring D. Instability after total elbow arthroplasty. Hand Clin. 2008 Feb;24(1):105-12. doi: 10.1016/j.hcl.2007.11.002. Review. PubMed PMID: 18299024. ](http://www.ncbi.nlm.nih.gov/pubmed/18299024)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18299024)

DISCUSSION: The late cocking phase of the overhand throw places a marked valgus moment across the medial elbow. This repetitive force reaches the tensile limits of the medial collateral ligament.
REFERENCES: Fleisig GS, Andrews JR, Dillman CJ, et al: Kinetics of baseball pitching with implications about injury mechanisms. Am J Sports Med 1995;23:233-239.
Lynch JR, Waitayawinyu T, Hanel DP, et al: Medial collateral ligament injury in the overhand-throwing athlete. J Hand Surg 2008;33:430-437.

Figure 5a Figure 5b

The accumulation of Co in the myocardium can induce cardiomyopathy, which was particularly evident after the 1996 episode of âbeer-drinkersâ cardiomyopathy, during which Co was used as a foam-stabilizing agent in beer

He has a kyphosis of 35°.
This degree of kyphosis increases the risk of pseudarthrosis with posterior fusion alone. The laminectomy increases the risk of pseudarthrosis.
Anterior fusion should be added when there is a history of pseudarthrosis.
A 9-year-old boy has a high risk of crankshift phenomenon with posterior fusion alone.

Elbow flexion is central to management of brachial plexus management because it serves the most important function of feeding.

Although this patient’s history includes a recent fall, the radiographs show evidence of a scaphoid nonunion with carpal collapse but no arthritis. Obtaining union of the scaphoid is important to prevent progressive carpal collapse and arthritic changes. ORIF with bone graft is most appropriate to obtain union and correct the collapse deformity. Screw fixation with volar wedge graft often is
performed to realign a scaphoid humpback deformity, although cancellous bone graft also is a reasonable option. Vascularized bone graft is considered for a nonunion of long duration, avascular necrosis of the proximal pole, and failed prior surgery. Cast immobilization will not lead to union of the scaphoid. Percutaneous screw fixation is not indicated for the treatment of a displaced nonunion. A proximal row carpectomy is a salvage procedure and is not indicated for this patient because there are no arthritic changes.
RECOMMENDED READINGS
33. Moon ES, Dy CJ, Derman P, Vance MC, Carlson MG. Management of nonunion following surgical management of scaphoid fractures: current concepts. J Am Acad Orthop Surg. 2013 Sep;21(9):548-57. doi: 10.5435/JAAOS-21-09-548. Review. PubMed PMID: 23996986. View Abstract at PubMed
34. Kawamura K, Chung KC. Treatment of scaphoid fractures and nonunions. J Hand Surg Am. 2008 Jul-Aug;33(6):988-97. doi: 10.1016/j.jhsa.2008.04.026. Review. PubMed PMID: 18656779.

Fretting corrosion occurs when micromotion exists between two metals in contact. One of the most common examples of fretting corrosion is micromotion between a modular femoral head and the tapered neck junction. Modular components, such as the S- ROM system (DePuy Orthopaedics Inc., Warsaw, Ind), are subject to fretting corrosion at each of the junctions.
Techniques to minimize fretting corrosion include:
Making sure the head-neck junctions are dry and clean
Eliminating micromotion but having an exact fit (ie, not mixing manufacturers)
The other responses refer to:
Galvanic corrosion: Impurities within a metal implant C revice corrosion: At a surface defect of an implant Galvanic corrosion: At sites of electrochemical gradients
Oxidative degradation: Irradiation of high-density polyethylene in an ambient environment
C orrect Answer: Relative micromotion under load

The posterior and superior acromioclavicular ligaments provide the most restraint to posterior translation of the acromioclavicular joint and must be preserved during a Mumford procedure. Anterior and superior acromioclavicular joint ligaments are the opposite of the
nd prevent anterior translation of the clavicle. Injuries to the conoid and trapezoid ligaments are more pronounced with grade III or higher acromioclavicular separations, with superior migration of the clavicle relative to the acromion.
Correct answer : B

Ninety percent of cases are noted on the right side. Ten percent of cases are bilateral and have been associated with bilateral cervical ribs. Only a few cases of left-sided pseudarthrosis have been described and have been associated with dextrocardia.
Only

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- A genetic defect in the type I collagen gene

This case starts as standard degenerative spondylolisthesis but develops into a sagittal imbalance problem necessitating a major spinal procedure including
a pedicle subtraction osteotomy and extended posterior spinal instrumentation. Initially the patient had an L3-L5 posterior spinal fusion with a laminectomy and interbody fusion for an L4-L5 stenosis and degenerative spondylolisthesis. Two years after this procedure she is having difficult ambulation that improves with sitting. These symptoms are typical for neurogenic claudication associated with spinal stenosis. Adjacent segment degeneration leading to spinal stenosis is a common late complication associated with lumbar instrumented fusions, particularly in older patients. Figure 40b shows the adjacent segment degeneration at L5-S1 with the development of a degenerative spondylolisthesis. Degenerative spondylolisthesis is a radiographic sign of substantial degeneration of a disk space and is often associated with spinal stenosis. The primary procedure typically planned to address a degenerative spondylolisthesis is a laminectomy. An adjacent-level degenerative spondylolisthesis is typically instrumented and fused to the previous fusion construct.
The degeneration of the adjacent disk is also associated with a loss of disk height. A concern in this patient is the development of kyphosis at the L5-S1 disk space. Kyphosis at the lumbosacral junction can lead to sagittal imbalance issues. Spinal surgeons need to be aware of spinopelvic measurements to help prevent sagittal imbalance and proximal junctional failures. Improving the lumbar lordosis in this patient would necessitate restoration of the disk height at L5-S1. This can be accomplished with an interbody strut device placed either anteriorly or posteriorly via a posterolateral interbody approach at the time of the laminectomy.
This patient has undergone a posterior extension of her previous fusion without the addition of an interbody strut device. She now has further sagittal imbalance issues and an inability to stand erect without flexing her knees. This is a typical compensation posture that patients with significant sagittal imbalance acquire when trying to stand upright. Patients with sagittal imbalance are at increased risk for proximal junctional kyphosis or a more acute complication of proximal junctional failure.
The sagittal vertical axis is a plumb line dropped from C7 and should fall behind the hip joints and within 4 to 5 cm of the posterior corner of S1 (an easily identifiable radiographic marker). Pelvic incidence is a constant that is unique to each patient's spinopelvic anatomy. Pelvic incidence typically is within 10 degrees of the lumbar lordosis in an upright adult. Pelvic tilt (PT), on the other hand, can vary based on a patient's stance. PT is an indicator of the amount of compensation a patient has developed by retroverting their pelvis to stand upright. In an upright patient who is not compensating for loss of spinal sagittal alignment, the PT should be less than 20 degrees. In this case, the patient has a high PT and a significant lumbar lordosis/pelvic incidence mismatch with a significant positive sagittal imbalance (sagittal vertical axis of +8 cm). These are all indicators that a major spinal alignment procedure will be required to rebalance the spine. The use of posterior
osteotomies, such as a pedicle subtraction osteotomy, will be required if spinal realignment is planned. Pedicle subtraction osteotomies are considered 3-column osteotomies that remove the entire lamina, the facets, the pedicles (the posterior column), the underlying posterior vertebral wall and posterior vertebral body (middle column), and the underlying anterior vertebral body (anterior column) in a wedge fashion. Three-column osteotomies are associated with increased risk for neurologic injury and substantial blood loss. A Smith-Petersen osteotomy is a single-column posterior osteotomy that can provide a lesser amount of sagittal plane correction than pedicle subtraction osteotomy. A single-level Smith-Petersen osteotomy likely will not provide enough correction in this case.
RECOMMENDED READINGS
Lafage V, Schwab F, Vira S, Patel A, Ungar B, Farcy JP. Spino-pelvic parameters after surgery can be predicted: a preliminary formula and validation of standing alignment. Spine (Phila Pa 1976). 2011 Jun;36(13):1037-45. doi: 10.1097/BRS.0b013e3181eb9469. PubMed PMID:
[21217459/. ](http://www.ncbi.nlm.nih.gov/pubmed/21217459)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21217459)
Schwab F, Patel A, Ungar B, Farcy JP, Lafage V. Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine (Phila Pa 1976). 2010 Dec 1;35(25):2224-
[31/. doi: 10.1097/BRS.0b013e3181ee6bd4. Review. PubMed PMID: 21102297. ](http://www.ncbi.nlm.nih.gov/pubmed/21102297)[View Abstract](http://www.ncbi.nlm.nih.gov/pubmed/21102297)[ ](http://www.ncbi.nlm.nih.gov/pubmed/21102297)[at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21102297)

of gap balancing techniques. They note that appropriate balance is key to obtaining excellent outcomes, and that augmentation or increased constraint is often needed in revision cases.
Ries et al. present a technique paper looking at balancing only in revision total knee arthroplasty. They make note of the need of full exposure to properly evaluate balancing and soft tissue restrictions to proper balance.
Incorrect Answers:

: Downsizing the tibial insert would increase both the flexion and extension gaps; the knee would be unstable in extension.
Answer 2: Placing augments on the posterior femur would make the flexion gap even tighter.
Answer 3: Resection of more distal femur would loosen the extension gap without changing flexion.
Answer 5: Tibial reduction osteotomy on the medial side would result in more laxity to valgus stress, but it would not symmetrically increase the flexion gap.

In order to determine the boundaries of the posterior-superior safe zone for acetabular screw placement during THA, a line is initially drawn through which of the following two anatomic landmarks, represented by dots on the illustration?
1) A and C

2) B and C

3) D and C

4) C and E

5) A and E

Acetabular quadrants are formed from a line extending from the ASIS (Marker A) through the center of the acetabulum (Marker C) to the posterior fovea, forming acetabular halves. The second line is drawn perpendicular to the first at the center of acetabulum, forming four quadrants (Illustration A).
In their initial cadaver study in 1990, Wasielewski et al studied the relationship of the at risk structures during transacetabular screw placement. The quadrants and structures most at risk are found in Illustration B.
In a later study by the same group in 2005, they investigated the intrapelvic structures at risk in a “high hip” center which was reamed superiorly to a distance ½ of the native acetabular diameter. They found that in the new “high hip” the anatomic anterosuperior and anteroinferior quadrants were positioned in the posterosuperior quadrant. Therefore the safest place for screw placement was the peripheral 1/2 of the posterosuperior quadrant.

A 68-year-old right handed male golfer presents with significant left knee pain which has not been amenable to conservative management. A radiograph is shown in Figure A. He is interested in pursuing total knee arthroplasty (TKA). What can this patient expect with regards to his golf game after undergoing this procedure?
1) A significant rise in his handicap

2) No change in his drive distance

3) Decreased pain compared to undergoing a right TKA

4) A significant chance of having severe pain during play

5) Patients are required to use a cart while golfing

Active golfers who undergo total knee arthroplasty (TKA) typically have a significant increase in their handicap when they return to the game.
Mallon et al studied 83 (80 of which were right handed) active golfers who underwent TKA and found that they invariably experienced a significant rise in their handicap (mean +4.6 strokes) and also a decrease in the length of their drives. Approximately 15% of the cohort experienced a mild ache while playing, and golfers with left TKA's had more difficulty with pain during and after play than did golfers with right TKA's. It also should be stated that statistically significant increased pain ratings occur in golfers with a TKA on the target-side knee. Finally, almost 90% of the patients in this study utilized a cart while playing post-operatively.
Mallon et al also evaluated the effect of total hip arthroplasty (THA) on the game of avid golfers. They found that hybrid and uncemented primary THA's had lower rates of radiographic loosening in active golfers when compared to
cemented THA's. However, symptoms of pain while playing or after playing did not differ among these groups.
Arbuthnot et al sent golfing habit questionnaires to 750 consecutive avid golfers who had undergone total hip arthroplasty. They found no significant change from their predisease state to their 1-year postoperative golf performance and level of participation.

A 73-year-old female undergoes a total hip arthroplasty (THA) using a cemented stem design shown in Figure A. She returns to clinic 3 years post-operatively with signifcant thigh pain. Current radiographs, shown in Figure B, demonstrate femoral subsidence. What affect does this have on the biomechanics of her THA?
1) Excursion distance is decreased

2) Primary arc range is increased

3) Abductor complex tension is decreased

4) Joint reactive forces are decreased

5) Femoral offset is increased

Femoral stem subsidence effectively decreases the neck length of the prosthesis resulting in a lax abductor complex which causes an increase in the joint reactive force. This decrease in leg length can also lead to increased hip instability.
Kim et al performed clinical, radiographic, and computed tomography
examinations on 1268 patients to determine the prevalence of and factors contributing to dislocation after using a primary cementless total hip arthroplasty system. The significant risk factors for dislocation (3.6% rate overall) were female sex, advanced age, high ASA score, fracture of the femoral neck, nonrepair of the posterior soft-tissue sleeve, low or high cup anteversion, low or high stem anteversion, and low height of hip rotation center.
Nishii et al evaluated component positioning in a series of THA patients who underwent the same surgical procedure to determine if there was a correlation with the occurrence of postoperative dislocation. They found that cup anteversion is one of the important factors for risk of dislocation, and that intentionally placing the cup at low anteversion to compensate for high femoral neck anteversion may predispose the hip to postoperative dislocation.
Illustration A shows a free body diagram of the hip joint. The magnitude of the joint reaction force depends critically on the ratio of (d1:d2). As d2 decreases due to less offset, such as in this question, and body weight remains the same, the joint reaction forces increase.
Incorrect Answers:
Answer 1: The excursion distance (the distance the femoral head must travel to dislocate) is unchanged.
Answer 2: The primary arc range (arc range before impingement) may be decreased due to early trochanteric impingement, but is not increased.
Answer 4: A more lax abductor complex results in an increased joint reactive force.
Answer 5: Femoral offset (distance from center of femoral head to long axis of femur) is unchanged as the radiographs show subsidence primarily in a caudal direction.

A 68-year-old woman underwent a right total knee arthroplasty 5 years ago and has increasing right knee pain over the past 2 months. Radiographs are seen in Figures A and B, respectively. Laboratory studies demonstrate a C-reactive protein of 10 mg/dL (normal
1) Irrigation and debridement with polyethylene spacer exchange

2) One-stage revision

3) Two-stage revision

4) One-stage revision with antibiotic impregnated cement

5) One-stage revision with direct antibiotic infusion into knee joint via hickman catheter

The patients history, labs, and imaging are consistent with an infected total joint prosthesis. Two-stage resection and replacement arthroplasty for hip and knee arthroplasty is the gold standard for treatment of infection beyond 4 weeks. Reimplantation within 2 weeks has a 35% success rate compared to success rates of 80% with delayed reimplantation (>6 weeks) and more extensive antimicrobial therapy.
Spangehl et al conducted a Level 2 study of patients being diagnosed with prosthetic hip infection. They found that combination of a normal erythrocyte sedimentation rate and C-reactive protein level has the highest negative predictive value for infection. They found the gram stain to be unreliable and intraoperative frozen sections useful only in equivocal cases.
Schinsky et al evaluated 55 total hip infections and 146 non-infected total hip patients to evaluate which markers are most reliable for diagnosis of prosthetic infection. They found that a synovial fluid cell count of >3000 white blood cells/mL was the most predictive perioperative testing modality when
combined with an elevated preoperative erythrocyte sedimentation rate and C-reactive protein level.
It should be noted that similar OITE questions in years past have cited a synovial fluid aspiration with WBC of >1100 cells/mm3 and PMN > 64% as suggestive of infection based on the article by Ghanem et al.

A 72-year-old man reports persistent, progressively worsening pain in his hip after undergoing a total hip arthroplasty 15 months ago. A current AP hip radiograph is shown in Figure A. What is the next most appropriate step in the care of this patient?
1) IV Antibiotics

2) Obtain serum metal ion values

3) Obtain ESR, CRP, and WBC

4) Obtain CT and MRI of the hip

5) Urgent debridement and component explantation

The key to this question is recognizing the radiographic findings of periprosthetic infection. Figure A shows new, lacey periosteal bone formation about the metadiaphyseal region of the femur with scalloping resorption. This is suggestive for a deep periprosthetic infection. Initial work-up starts with ESR, CRP and WBC. If these are elevated, joint aspiration to confirm periprosthetic infection is warranted.
Fitzgerald in this review article discusses 3 types of periprosthetic infection. Stage I is an acute postoperative infection that is radiographically silent. Stage II infections occur 6-24 months after the primary procedure and represent indolent infections that manifest radiographically with new bone formation as described above. Stage III infections occur more than 2 years after the primary procedure and are the result of hematogenous seeding of the joint via recent dental or surgical procedure.
Meehan et al in this review article discuss the use of Vancomycin for preoperative prophylaxis in total joint arthroplasty. At their institution, staph aureus and staph epidermidis were resistant to cefazolin in 50 and 70% of cases, respectively.
Incorrect Answers:
Answer 1: IV antibiotics should be withheld until a diagnosis is made, or a culture has been obtained.
Answer 2: The utility of serum metal ion levels in patients undergoing metal-on-metal hip arthroplasty is still unclear.
Answer 4: Advanced imaging may be helpful in diagnosing soft tissue reactions or subtle fractures, however, they are not the most appropriate next step in this situation.
Answer 5: Urgent debridement should only be considered after joint aspiration is performed to confirm the diagnosis of infection.

Failure to identify a hypoplastic lateral condyle in a valgus knee will result in which of the following errors if a posterior condylar referencing guide is used for total knee arthroplasty?

1) External rotation of the femoral component

2) External rotation of the tibial component

3) Internal rotation of the femoral component

4) Internal rotation of the tibial component

5) Internal rotation of the tibial and femoral components

Failure to identify a hypoplastic lateral condyle will lead to internal rotation of the femoral component if a posterior condylar referencing guide is used for total knee arthroplasty.
The posterior condylar axis of an average knee rests in 3 degrees of internal
rotation compared to the transepicondylar axis. Posterior referencing guides are set with 3 degrees of external rotation to compensate for this discrepancy. In the case of a hypoplastic lateral condyle, greater than 3 degrees of internal rotation will be present. If the surgeon does not identify this abnormality and uses a posterior referencing guide, then the cuts will be made with too much internal rotation.
Laskin et al. review techniques of total knee arthroplasty. Pertinent to this question, the posterior condylar axis may not be a suitable landmark to guide the posterior cut in patients with deformity. A hypoplastic lateral condyle will create a cut that is internally rotated if only 3 degrees of external rotation is applied.
Illustration A demonstrates that the line perpendicular to the AP axis (Whiteside's Line) is the neutral rotational axis (approximately equal to the transepicondylar axis). The femoral component should be placed in 3° of external rotation in relation to the posterior condylar axis to maintain symmetric flexion gap.

A 64-year-old male undergoes acetabular revision of his failed total hip arthroplasty using a large uncemented component. Postoperatively he is noted to have a foot drop and radicular pain in the operative extremity. A CT scan of the hip is obtained and reveals screw penetration into the sciatic notch. Where was this screw most likely inserted in the acetabulum?

1) Anterior superior quadrant

2) Through the medial wall

3) Anterior inferior quadrant

4) Posterior superior quadrant

5) Through the femoral nerve

Long screws placed into the posterior superior or posterior inferior quadrant may pass into sciatic notch and endanger the sciatic nerve and superior gluteal vessels. This is particularly a risk in revision surgery when the acetabular component may be placed in a high hip center position, as the sciatic nerve is at increased risk when placing transacetabular screws posteriorly.
Meldrum et al evaluated the quadrant system used to guide screw placement in primary cadaveric uncemented total hip surgery in the high hip center, jumbo component, and 3 designs of reinforcement rings. Of all the acetabular revision scenarios tested, the high hip center showed increase risk of neurovascular injury in the center and anterior portions of the posterior superior quadrant. All of the other implants met the standard, non-revision scenario quadrant recommendations.
Wasielewski et al performed an anatomical and radiographic study to determine the safest zones in the acetabulum for the transacetabular placement of screws during uncemented acetabular arthroplasty. They found that the posterior superior and posterior inferior acetabular quadrants are relatively safe for the transacetabular placement of screws. They also determined that the anterior superior and anterior inferior quandrants should be avoided whenever possible, because screws placed improperly in these quadrants may endanger the external iliac artery and vein, as well as the obturator nerve, artery, and vein.
Illustration A demonstrates the four quadrants of the acetabulum relevant to transacetabular screw placement.

During trialing for a cruciate-sacrificing total knee arthroplasty, the surgeon notes an imbalance between the flexion and extension gaps with significant flexion instability. The extension gap is well balanced. Which of the following options is the best intra-operative solution?

1) Downsize the femoral component

2) Downsize the tibial component

3) Upsize the femoral component and add posterior augments

4) Upsize the tibial component

5) Move the femoral component more anteriorly

Understanding flexion/extension gaps in total knee arthroplasty is paramount to patient success. Treatment for flexion instability consists of either increasing the size of the femoral component, shifting the femoral component posteriorly, or increasing the size of the polyethylene and then dealing with the tight extension gap.
As discussed by Ries et al, increasing the size of the femoral component will change the anterior/posterior size of the component without changing the
proximal/distal size of the component, thus changing only the flexion gap. With upsizing the femoral component, you will likely have to add augments as the bone cut will not match a larger component. Moving the femoral component more posterior will accomplish the same goal of decreasing only the flexion gap. Increasing the poly thickness will change both the flexion and extension gaps, and in this patient, the surgeon would then have to address the tight extension gap by resecting more distal femur and/or releasing the posterior capsule.

Patella baja is most likely to occur after which of the following procedures?

1) Arthroscopic ACL reconstruction with cadaver allograft

2) PCL reconstruction using tibial inlay technique

3) High tibial osteotomy

4) MPFL reconstruction with semitendinosus autograft

5) Total knee arthroplasty (TKA)

Patella baja is a well known complication of high tibial osteotomies, especially opening wedge osteotomies. This procedure raises the tibiofemoral joint line and can cause retropatellar scarring and tendon contracture, decreasing the distance of the patellar tendon from the inferior joint line.
Wright et al found that the patellar height after opening wedge medial tibial osteotomies decreased the patellar height in 100% of their patients. They explain that the decrease in distance between the patella and the tibiofemoral joint line following medial opening wedge proximal tibial osteotomy is a function of joint line elevation. Their results are important when considering possible future TKA in these patients, as patella baja may have deleterious effects on patellofemoral biomechanics for future procedures.
Kolb et al studied the short-term results of opening-wedge high tibial osteotomies with locked plate fixation for patients with medial compartment arthrosis. Their results suggestted that opening-wedge high tibial osteotomy for presurgical varus deformity allowed for good short-term results and correction of the deformity.
Illustration A shows an example of this complication.

A patient undergoes the procedure depicted in Figures A and B with standard components (non-gender specific). Which of the following outcomes most appropriately describes the difference in females compared to males for this procedure?
1) Greater implant survivorship

2) Decreased WOMAC scores

3) Increased rate of extensor mechanism rupture

4) Increased postoperative pain

5) Increased component osteoloysis

Females undergoing total knee arthroplasty with standard (non-gender specific) components show improved implant survivorship compared to males.
MacDonald et al performed a Level 2 study of 3817 patients who underwent 5279 primary total knee replacements (3100 female, 2179 male) with a minimum of 2 years followup. They found that women demonstrated greater implant survivorship, greater improvement in WOMAC scores, equal improvements in SF-12 scores, and less improvement in only the Knee Society function and total scores.
Greene discusses the role of gender-specific implant designs that are currently marketed and their benefit to patients. The article concludes that the amount of attention that implant manufacturers have focused on female specific components(e.g. narrower M/L dimensions, decreased thickness of the anterior flange, and increased trochlear groove angle) is of interest, considering that there is no evidence suggesting that females have inferior outcomes with standard components.

A 64-year-old female with rheumatoid arthritis is undergoing a left total knee arthroplasty. During the tibial cut, a ligament is transected by a reciprocating saw. The ligament is not able to be repaired. The surgeon is balancing the tibial and femoral cuts with sizing blocks and finds that the knee has valgus instability greater than 1cm in full extension. Which implant offers the most appropriate level of constraint while limiting the amount of implant-host interface stresses?

1) Unlinked constrained (varus-valgus constrained)

2) Fixed bearing PCL-substituting (posterior-stabilized)

3) Mobile bearing PCL-substituting (posterior-stabilized)

4) PCL-retaining (cruciate-retaining)

5) Rotating-hinge constrained

The history and intraoperative examination are consistent with an iatrogenic MCL injury that is irreparable. An unlinked constrained (varus-valgus constrained) prosthesis has a tall tibial post and a deep femoral box, which provide more inherent coronal plane stability than do standard cruciate retaining or cruciate-substituting prostheses. Because there is no axle connecting the tibial and femoral components, these implants are sometimes referred to as unlinked constrained implants.
Morgan et al discuss in their Level 5 review that the added degrees of implant stability confer disadvantages. As the amount of constraint increases, stress transmitted to the modular implant-host or prosthesis-host interface also increases. The heightened stress may result in increased backside polyethylene wear in modular tibial components or in early implant loosening, and ultimately to failure. Therefore, a rotating-hinge constrained knee would offer sufficient stability for a MCL deficiency but offers more constraint than is necessary and appropriate.
Gonzalez et al present a Level 5 reivew stating that the primary causes of failure of total knee arthroplasty include pain, postoperative stiffness, and instability. They state that medial-lateral instability can be a product of improper implant balancing or deficient medial or lateral collateral ligaments.
Illustration A shows a varus-valgus unlinked constraint knee implant and Illustration B shows a rotating hinge constraint knee implant. Illustration C and D show a cruciate-retaining implant on the left and a cruciate-substituting implant with femoral box and tibial polyethylene post on the right.
Illustration E depicts a cadaveric right knee with a MCL (sutured in picture) that has been transected during a tibial cut.

During trialing for a cruciate-retaining total knee arthroplasty, the surgeon is unable to fully extend the knee and is left with a 15 degree flexion contracture. The flexion gap is well balanced. Which of the following options will create a knee that is balanced in both flexion and extension?

1) Recess the PCL

2) Increase the tibial slope

3) Decrease the size of the femoral component

4) Resect more distal femur

5) Resect more proximal tibia

Flexion/extension gap balancing is crucial to the success in total knee arthroplasty. The inability to achieve full extension suggests extension tightness. This can be improved by either resecting more distal femur or releasing the posterior capsule from the femoral insertion. While resecting more proximal tibia will improve the extension gap, it will loosen the flexion gap and require either upsizing of the femoral component with placement of posterior augments or translation of the femoral component posteriorly.
Recessing the PCL and increasing the tibial slope would be appropriate for flexion not extension tightness.
In their review, Ries et al discuss flexion/extension balancing, focusing on revision total knee arthroplasty.

A 62-year-old female has persistent activity related anterior groin pain 10 months after total hip arthroplasty (THA). Infection workup is negative. New radiographs are unchanged compared to the intial films provided in Figures A and B. Pain is temporarily relieved following an injection of lidocaine and cortisone into the iliopsoas tendon sheath. What is the next appropriate treatment option?
1) Indefinite activity modification

2) Iliopsoas tendon release

3) Femoral component revision

4) Acetabular component revision

5) Femoral and acetabular component revision

After diagnosis of iliopsoas impingement, iliopsoas muscle tenotomy or resection is the treatment of choice if radiographs are within normal limits. In contrast, if imaging shows anterior acetabular overhang (as shown in Illustration A), then acetabular revision would be the next appropriate step in
management.
Lachiewicz et al provide a great review on iliopsoas impingement after THA. Anterior iliopsoas impingement can cause functional disability after total hip arthroplasty. The diagnosis may be confirmed by one or more imaging studies, including a cross-table lateral radiograph, computed tomography, magnetic resonance imaging, and ultrasonography, in combination with a confirmatory diagnostic injection into the iliopsoas sheath. Treatment, consisting of release or resection of the iliopsoas tendon, alone or in combination with acetabular revision for an anterior overhanging component, usually provides permanent pain relief.
Trousdale et al also reviewed cases of iliopsoas impingment after THA. They studied two cases of iliopsoas tendinitis following THA due to a malpositioned, uncemented, metal-backed acetabular component. In cases of anterior acetabular overhang, acetabular revision to reduce anterior impingement is the appropriate management.
Illustration A shows an example of anterior acetabular overhang which would require acetabular revision if symptomatic.

Figure A shows an AP hip radiograph of a 72-year-old woman who had had a right total hip arthroplasty fifteen years previously. CT imaging of the affected hip shows non-contained defects in both the anterior and posterior columns of the peri-acetabular region affecting greater than 50% of the weight bearing surface. Which of the
following revision procedures would restore the most acetabular bone stock and be most appropriate for this patient?
1) Morselized allograft and/or autograft bone, combined with a cemented acetabular component

2) Acetabular revision with use of a bilobed cementless component and morselized allograft

3) Morselized allograft and/or autograft bone, combined with a cementless acetabular component

4) Revision using an ilioischial reconstruction ring acetabular component and structural corticocancellous graft

5) Revision using a roof ring acetabular component and structural corticocancellous graft

In cases of minor, contained, acetabular defects, morcellized allograft and/or autograft bone, combined with a cemented or cementless acetabular component can lead to successful reconstruction. However, these constructs do not confer enough stability when the loss of bone stock is more extensive and encroaches on the acetabular columns, or compromises >50% of the weight-bearing surface. A bilobed implant is a viable option in these scenarios, however these components replace lost bone with artificial materials rather than restoring acetabular bone stock making revision very difficult. Roof ring
acetabular components have been largely replaced by cementless cups fixed with multiple screws, and do not offer the same degree of fixation stability found with reconstruction rings for large bone defects.
Goodman et al review the complications, management, and outcome of a consecutive series of 61 ilioischial reconstruction rings performed by 1 surgeon over a 15-year period. On the acetabular side, allograft failure was the most common complication.
Illustration A shows an example of an ilioischial reconstruction ring, and Illustration B shows this reconstruction ring in situ.

A 56-year-old man reports progressively worsening left knee pain after undergoing total knee arthroplasty 6 years ago. He was initially very happy with his progress, but 18 months after surgery he began to have knee pain. Radiographs are shown in Figures A and B. Laboratory values reveal a C-reactive protein of 0.1 mg/dL (normal 0.0-0.6 mg/dL) and an erythrocyte sedimentation rate of 3 mm/h (normal 0-15 mm/h). An aspiration of the knee reveals 157 leukocytes/ml with 18% polymorphonucleocytes. What is the most appropriate next step in management?
1) One-stage revision

2) Irrigation and debridement with polyethylene spacer exchange

3) Antibiotic impregnated cement spacer placement

4) Two-stage revision

5) Broad-spectrum, empiric oral antibiotics

The history, radiographs, and laboratory values are consistent with aseptic loosening. The lateral radiograph demonstrates a thin cement mantle that has separated from the prosthesis. The question stem details that infection is not likely given the normal serology and aspirate values. A one-stage revision of the arthroplasty components is the most appropriate next step in management among the options provided.
Brown and Bartel present a Level 5 review of the intrinsic and extrinsic factors that can effect wear behavior in arthroplasty bearing surfaces. They state that increased sliding distance, third body wear, and impingement can be sources for accelerated wear rates of bearings.
Gonzalex and Mekhail present a Level 5 review discussing the etiologies for a failed joint arthroplasty. Sources identified for continued pain were aseptic loosening, component failure, patellar dysfunction, infection, or complex regional pain syndrome.

A 50-year-old woman underwent cemented total knee arthroplasty 3 weeks ago. She reports that she has 1 week of drainage the size of a quarter on a gauze pad that she places over the incision three times daily. Her body mass index is 53 and her medical problems include hypertension and type 2 diabetes. Blood work shows a CRP of
1.1mg/L (normal 1-3mg/L). Knee aspiration yields WBC of 673 cells/mm(3) with 30% polymorphonucleocytes, and a negative gram stain. There is no surrounding erythema but there is a 1cm area at the inferior aspect of the wound that has a large amount of serous drainage able to be expressed. She has a painless range of motion is 0° to 117°. What would be the next most appropriate step in management?

1) Removal of all components with antibiotic spacer placement and staged revision

2) One-stage irrigation and debridement with removal of components to a cementless prosthesis

3) Empiric oral antibiotics for 4 weeks and steri-strips over the area of drainage

4) Surgical exploration with debridement and possible polyethylene exchange

5) Bone scan and repeat aspiration with empiric intravenous antibiotics for 4 weeks

Irrigation and débridement with possible polyethylene exchange is the most appropriate treatment for persistent drainage within a few weeks from total joint arthroplasty surgery.
Malinzak et al performed a Level 4 review of 8494 patients undergoing a total knee arthroplasty. They found that patients with a body mass index greater
than 50 had an increased odds ratio of infection of 21.3 (P 1 month) deep infections were successfully treated 75% with debridement, intravenous antibiotics, tobramycin-impregnated polymethylmethacrylate beads, and delayed exchange arthroplasty with mean interval of staged reimplantation being 8 weeks.

A 47-year-old man presents with 1 week of left leg pain. 6 months prior he underwent a vascularized free-fibula bone graft from his left leg to his right hip for avascular necrosis. The pain is located at the level of his donor site and is worse with weight-bearing and relieved by rest. Physical exam shows focal tenderness over his tibia. A lateral radiograph from the day of presentation is shown in Figure A. WBC, ESR, and CRP are all within normal limits. What is the next best step in management to confirm the diagnosis?
1) Compartment pressure measurements

2) CT scan

3) MRI scan

4) Ultrasound to rule out deep abscess

5) Bone biopsy

The clinical presentation is suspicious for a stress fracture of the tibia following free-fibula bone grafting. If plain radiographs are negative, more sensitive imaging such as a MRI or bone scan should be performed.
Tibial stress fractures are a known complication following free-fibula bone grafting. Radiographs may be normal (as is the case in figure A), or might show the "dreaded black line" and/or new periosteal bone formation. If a stress fracture is confirmed with imaging, appropriate management would then consist of protective weight bearing until symptoms subside.
Pacifico et al detail a case report of tibial stress fractures after vascularised free-fibula graft to the mandible. They report non-traumatic stress fracture to the tibia following a vascularised free-fibula graft is an uncommon but important complication.
Ivey et al detail a case report of a tibial stress fracture after vascularised free-fibula graft for repair of non-union of the humerus.
Emery et al report a case-series of 5 patients who sustained tibial stress fractures after a graft had been obtained from the ipsilateral fibula for use in anterior reconstruction of the spine. They theorize that the increased load the tibia bears as a result of the missing fibular graft may result in stress fractures.
Illustration A shows new periosteal bone formation on the lateral cortex of the tibia consistent with a stress fracture.
Incorrect Answer Choices:
1: While compartment syndrome is on the differential diagnosis, his signs and symptoms are not most consistent with that diagnosis.
2: While CT scan may show evidence of a stress fracture, MRI/bone scans have been shown to be superior methods for detection.
4: As infectious laboratories are normal, an ultrasound to rule out a deep abscess would likely be negative.
5: Bone biopsy is not appropriate without evidence of a lesion or concern for
osteomyelitis.

A 65-year-old female with a history of developmental dysplasia of the hip (DDH) undergoes a total hip arthroplasty (THA) utlizing a posterior approach. Following THA, she notices an inability to dorsiflex the ankle of her operative extremity. Her pre-operative and postoperative radiographs are seen in figues A and B. Which of the following intra-operative techniques could have avoided this complication in this patient?
1) Utilization of an anterior approach

2) Modular components

3) Use of a larger femoral head

4) Femoral shortening osteotomy

5) Acetabular osteotomy

Patients with DDH undergoing THA are at risk for post-operative sciatic nerve palsy due to intra-operative limb lengthening which increases tension on the sciatic nerve. Appropriate management after discovering a sciatic nerve palsy
after surgery should include immediate knee flexion and hip extension to decrease tension on the sciatic nerve. Sciatic nerve palsy following THA most commonly only affects the common peroneal nerve branch, and spares the tibial nerve and can present as an inability to dorsiflex and evert the ankle.
Farrell et al retrospectively looked at the risk factors for motor nerve palsy after THA. They found while motor nerve palsy is uncommon following primary THA, it can be a devastating complication. Some risk factors include: preoperative diagnosis of developmental dysplasia of the hip, posttraumatic arthritis, the use of a posterior approach, lengthening of the extremity, and use of an uncemented femoral implant. In their review, many of the motor nerve deficits did not fully resolve.
Barrack et al reviewed neurovascular complications following THA. They stated that sciatic nerve injury is the most common nerve injury following THA utilizing a posterior approach. In comparison, femoral nerve injury is much less common and is usually from an anterior approach.

A cane held in the contralateral hand reduces joint reactive forces through the affected hip approximately 50% by which of the following mechanisms?

1) Reducing hip abductor muscle pull

2) Increasing hip flexor muscle pull

3) Moving the center of rotation for the femoroacetabular joint

4) Increasing joint congruence at the femoroacetabular joint

5) Moving the center of gravity posterior to the second sacral vertebra

A cane held in the contralateral hand reduces joint reactive forces through the affected hip up to 50% by reducing abductor muscle pull.
A cane create an additional force that keeps the pelvis level in the face of gravity's tendency to adduct the hip during unilateral stance. The cane's force must substitute for the hip abductors of the affected hip and creates a moment arm that is relatively long and originates on the side opposite the hip whose abductor muscles are weak. Additionally, the person needs adequate strength in the muscles of the wrist, elbow, shoulder girdle, and trunk.
Brand and Crowninshield performed a 3-dimensional hip joint reactive force evaluation of 4 different groups of patients. The groups included normal
subjects, preoperative THA subjects walking without a cane, preoperative THA subjects walking with a cane, and subjects following total hip reconstruction. Each of the 3 groups evaluated without the cane had statistically similar hip joint reactive forces. The preoperative THA subjects walking with a cane and significantly lower joint reactive forces (approximately 60%).
The article by Blount was named by JBJS as a "Classics in JBJS" in 2003. It is a commentary encouraging the use of canes by describing how the biomechanics of the hip joint are altered while using a cane.
Illustration A shows some of the mathematics behind cane use.

Which of the following is an example of an antalgic gait pattern not typically seen in clinical practice?

1) Patient's knee is maintained in slight flexion throughout the stance period for ipsilateral knee arthritis

2) Patient's contralateral step length is shortened with ipsilateral ankle arthritis

3) Patient leans their trunk laterally over the painful leg during stance phase with ipsilateral hip arthritis

4) Patient ambulates on their toes with an ipsilateral calcaneal stress fracture

5) Patient ambulates predominately through the heel for ipsilateral knee arthritis

The term antalgic gait is non-specific and describes any gait abnormality resulting from pain. A patient with knee arthritis maintains slight flexion throughout the gait cycle. This compensatory knee flexion is exacerbated if the patient has a concomitant effusion in the knee as flexion reduces tension on
the knee joint capsule. Gait compensation for knee arthritis also involves toe walking on the affected side, reducing the stride length, and reducing time of weight bearing on the painful leg.
Gok et al performed a case-control gait analysis study of 13 patients with OA and 13 normal patients. They found that walking velocity, cadence and stride length were reduced in the OA group and that the overall stance phase was prolonged in the OA group. They concluded that computerized gait analysis can be used to reveal various mechanical abnormalities accompanying arthrosis of the knee joint at an early stage.
Cole and Harner present Level 5 evidence about knee arthritis in the active patient. They stress that weightbearing radiographs are important in the diagnosis of arthritis. They also discuss the importance of looking for medial or lateral thrusts during gait and dynamic gait changes such as quadriceps avoidance or out-toeing.
Incorrect Answers:
Answer 1: Maintaining slight flexion is an example of quadriceps avoidance as keeping the knee flexed will decrease patellofemoral movement.
Answer 2: Shortening the stride length allows less time on the painful extremity.
Answer 3: Leaning laterally decreased the moment arm of body weight and reduces the joint reaction force on an arthritic hip.
Answer 4: Toe walking is another example of both quad avoidance for knee arthritis or avoiding weight bearing through the ankle joint in ankle arthritis.

A 78-year-old male falls at home four months following a right total hip arthroplasty. Right leg deformity, pain, and inability to bear weight are present on physical exam. An injury radiograph is provided in Figure A, while radiographs taken immediately following the initial total hip arthroplasty are provided in Figures B and C. The patient denies any prodromal groin pain prior to his fall. Which of the following is the best treatment option?
1) Traction for 6 weeks followed by slow return to weight bearing

2) Open reduction and internal fixation

3) Revision to a long, cementless femoral stem

4) Revision to a long, cementless stem with strut allograft

5) Revision to a long, cemented stem

The clinical presentation and radiograph are consistent with a Vancouver B1 periprosthetic femur fracture. The stem appears stable within the femur, and there is no evidence of subsidence with comparison to the initial post-THA radiographs. This fracture pattern is best treated with internal fixation.
Illustrations A and B are radiographs of this patient following fixation. Illustrations C and D show bone healing at 2 years following the fracture.
Duwelius et al report on 33 periprosthetic femur fractures. All fractures that demonstrated a stable stem at the time of surgery were treated with internal fixation, while those that were unstable were treated with a long, cementless revision femoral stem. At 2.5 years complications were minimal and the patients had regained their pre-fracture level of function.
The review article by Kelley outlines the evaluation, classification, and treatment of periprosthetic femur fractures reinforcing the importance of stem stability within the femur. Periprosthetic fractures around a hemiarthroplasty should be treated with the same algorithm. However, if the patient had antecedent groin pain, then conversion to a total hip arthroplasty should be considered to prevent continued groin pain.

A 64-year-old male underwent the procedure shown in Figures A and B 7 weeks ago. He complains of difficulty with going down stairs. He reports no pain and denies constitutional symptoms. On examination the incision is well healed and no effusion is present. He is able to perform a straight leg raise with 5/5 strength. He lacks 2 degrees of terminal extension and has 80 degrees of active flexion. The knee is stable to varus and valgus stress testing at extension and mid flexion. His C-reactive protein and erythrocyte sedimentation rate are normal. What is the next most appropriate step in management?
1) Manipulation under anesthesia

2) Cortisone injection followed by physical therapy for quadriceps strengthening

3) Aspiration to evaluate for septic arthritis

4) Revise femoral component by downsizing A-P diameter

5) Revise tibial component and add 5 degrees of posterior tibial slope

The history, physical examination, laboratory studies, and imaging are consistent with a total knee arthroplasty patient with arthrofibrosis. The next most appropriate option includes a manipulation under anesthesia to increase the patient's flexion.
Maloney presents Level 4 evidence discussing TKA postoperative arthrofibrosis. They report that manipulation under anesthesia was successful in improving flexion from an average of 67 degrees premanipulation to 111 degrees
postmanipulation.
Keating et al report Level 4 evidence of 113 patients that underwent manipulation following TKA. They found that 90% of the patients achieved improvement of ultimate knee flexion following manipulation. The average improvement in flexion from the measurement made before manipulation to that recorded at the five-year follow-up was 35 degrees.

Which of the following total hip arthroplasty patients appropriately meets the criteria for a surgical debridement with isolated femoral head and polyethylene liner exchange?

1) Prosthesis infection of 4 months duration

2) Prosthesis infection 8 weeks following implantation

3) Prosthesis infection 3 days following a systemic infection

4) Acetabular component loosening due to osteolysis

5) Vancouver Type A periprosthetic fracture.

Femoral head and polyethylene liner exchange is an appropriate treatment for the acutely infected arthroplasty. Acute infection has been defined as 3-6 weeks following surgery or following a systemic infection depending on the literature source. Subacute and chronic infections must be treated with a complete explant and exchange of all components. (One-stage or two-stage is controversial).
Salvati et al review the management of total hip arthroplasty infection. Most importantly, the pathogen must be isolated to direct antibiotic treatment. The acuity of the infection must also be recognized to direct surgical management.

A 54-year-old woman is at physical therapy 3 months after a total knee arthroplasty when she feels a pop and develops increased pain in her knee. She continues therapy for another 3 months but reports weakness and frequent buckling. On exam, she has full passive extension but a 60 degree extensor lag. A lateral radiograph is shown in Figure A. What is the treatment of choice?
1) Reconstruction with a bone-tendon allograft

2) Repair augmented with hamstring autograft

3) Continued therapy and strengthening

4) Arthrodesis

5) Treatment with orthotics for support

The patient has a chronic patellar tendon rupture following a TKA with marked extensor lag and patella alta on radiograph. A study by Barrack et al concluded that allograft reconstruction for the chronically-disrupted extensor mechanism after TKA could restore active extension and improve ambulatory function. In chronic cases, primary repair with or without local tissue augmentation have had disappointing results. Extensor mechanism injuries after TKA was reviewed by Parker et al. Patellar tendon ruptures are rare complications after TKA with an incidence reported
When compared to the standard medial parapatellar approach for revision total knee arthroplasties, the oblique rectus snip approach
showed impairment in which of the following post-operative outcomes?

1) range-of-motion

2) patient satisfaction

3) pain

4) WOMAC function score

5) no difference in outcomes

Meek et al compared the rectus snip to a standard medial parapatellar approach for revision total knee arthroplasty. The WOMAC function, pain, stiffness and satisfaction scores demonstrated no statistical difference. They concluded that use of a rectus snip as an extensile procedure had no adverse effect on outcome.

What is the range of pore size of cementless porous implants to allow for optimal bony ingrowth?

1) Less than 1 micron

2) 50 to 400 microns

3) 1,000 to 5,000 microns

4) 10,000 to 50,000 microns

5) 100,000 to 500,000 microns

The range of 50 to 400 microns is the optimal pore size for cementless porous implants to allow for optimal bony ingrowth.
Bobyn et al looked at the optimum pore size for fixation of porous surfaced metallic implants. Four different pore sizes were examined and placed in canine femurs for 4, 8, and 12 weeks and tested to measure the shear strength based on pore sizes. A pore size of 50 to 400 microns provided the maximum fixation strength in the shortest time period (8 weeks), implying maximal bony ingrowth.
Pilliar et al discussed two independent canine studies which showed that initial implant movement relative to host bone can result in attachment by a nonmineralized fibrous connective tissue layer. They state that implant movement of greater than 150 microns leads to fibrous ingrowth.
Jasty et al implanted porous-coated implants in the distal femoral metaphyses of twenty dogs and subjected them to zero, twenty, forty, or 150 micrometers of oscillatory motion. They found that that the implants that had been subjected to 150 micrometers of motion were surrounded by dense fibrous tissue.

An active 73-year-old male presents with progressive pain and instability 15 years after undergoing a left total knee arthroplasty. He denies any recent trauma. A comprehensive workup for infection is negative. What is the most appropriate management of this patient?
1) Protected weight bearing for 6 weeks

2) Revision total knee arthroplasty

3) Bisphosphonate therapy

4) Routine follow-up in 1 year

5) Polyethylene liner exchange and bone grafting

This patient has evidence of periarticular osteolysis and component loosening around a previous total knee arthroplasty. He is symptomatic and would benefit from revision total knee arthroplasty (TKA).
Osteolysis is one of the leading causes for late reoperation in patients who undergo TKA. Osteolysis occurs as the result of a foreign body response to particulate wear debris from the prosthetic joint. These particles consist of polyethylene, polymethylmethacrylate cement, and metal, all of which have been shown to elicit a distinct inflammatory response. Once the particles are generated from and around the implant, they become phagocytosed by macrophages and giant cells in the synovial or periprosthetic tissue. These cells, in turn, become activated and can directly or indirectly cause osteolysis. The femur is prone to osteolysis in the region of the femoral condyles and near the attachments of the collateral ligaments of the femur. Osteolysis around the tibia tends to occur along the periphery of the component or along the access channels to the cancellous bone.
Maloney & Rosenberg reviewed the management and outcome of periprosthetic osteolysis around hip and knee implants. They recommended surgical intervention for periprosthetic osteolysis around a TKA with (1) first-time presentation of advanced osteolysis in the presence of an identifiable cause of wear particle production or in the presence of associated bone loss that places the structural integrity of the bone or fixation of the components at risk, (2) bearing surface wear in the presence of impending wear-through or related mechanical symptoms, (3) progressive osteolysis in an active individual, and (4) symptoms of wear debris-related synovitis that are refractory to conservative treatment.
Griffin et al. evaluated the results of isolated polyethylene exchange for wear and/or osteolysis in 68 press-fit condylar TKAs from four centers. At a minimum of 24 months after polyethylene exchange surgery, there were 11 failures (16.2%).
Gupta et al. discuss the etiology, diagnosis, contributing factors, and management of osteolysis as it relates to TKAs. They recommend that if the patient is asymptomatic with minimal osteolysis on plain radiographs, regular
follow-up at 6 months to 1 year with medical management including calcium and bisphosphonates would be adequate. If the patient becomes symptomatic or the osteolysis is progressive, then early liner exchange with or without tibial baseplate exchange is considered.
Figure A & B are AP and lateral radiographs of periarticular osteolysis and component loosening. Illustration A is an AP and lateral radiograph of the revision TKA.
Incorrect Answers:
Answer 1: Protecting this patient's weight bearing will not address the underlying cause of their pain, which is osteolysis and should be addressed with revision TKA.
Answer 3: Bisphosphonate therapy would not be appropriate in this case due to the extensive osteolysis and component loosening present.
Answer 4: Observation for 1 year is not advised because the amount of osteolysis is extensive.
Answer 5: The patient is symptomatic (i.e., pain and instability) and has evidence of osteolysis and component loosening on x-ray. Liner exchange and bone grafting would not adequately address this degree of osteolysis as the components are loose and failure rate would be unacceptably high.

Which of the following statements is true regarding the thirty-year follow-up data obtained from the Charnley "low-friction" total hip arthroplasty?

1) Acetabular component failure was the least common reason for revision surgery

2) The number of revisions required for periprosthetic fractures was higher than that for deep infections

3) Acetabular component failure was a more common reason for revision than deep infection

4) Femoral component failure was a more common reason for revision than acetabular component failure

5) Deep infection was the most common reason for revision

Failure of the acetabular component was the most common reason for revision at thirty-years for the Charnley "low-friction" total hip arthroplasty.
The Charnley low-friction torque arthroplasty was introduced in 1962. It consisted of a 22mm diameter metal head, a cemented femoral component, and a cemented ultra-high-molecular-weight polyethylene acetabular component. Overall, the results were very good at thirty years with only 11.8% requiring revision.
Charnley et al. in 1972 reported the 4-7 year results of 379 "low-friction" total hip arthroplasties. Overall, their short-term results were very good with only 2 loose acetabular components, 0 loose femoral components, and 1 late dislocation.
Wroblewski et al. in 2009 reported the 30 year follow-up of 110 patients who underwent the "low-friction" total hip arthroplasty. 13 hips (11.8%) had to be revised. Of these, 5 were for problems with the acetabular component, 4 were for loosening of both components, 2 were for deep infection, 1 was from a loose femoral component, and 1 was from a fractured femoral component.
Illustration A shows a radiograph after a Charnley low-friction total hip arthroplasty. Note the all poly-ethylene acetabular component. Illustration B shows the components used for the operation.
Incorrect Answers:
Answer 1: Acetabular component failure was the most common reason for revision.
Answer 2: Revision for deep infection was more common than for fracture. Answer 4: Acetabular component failure was more common than femoral component failure.
Answer 5: Acetabular component failure was the most common reason for revision.

A 71 year old gentleman underwent left total hip arthroplasty 10 years ago. Eighteen months ago he began having hip and thigh pain. Over the past 6 weeks, the pain has become excruciating and he has been unable to ambulate, even with the aid of a walker. He has mild pain with passive internal and external rotation of the hip. He is unable to ambulate in the office. Laboratory values are notable for a WBC of 10,300, CRP of 0.2, and ESR of 13. A radiograph is provided in figure A. Which of the following is the best treatment option?
1) Radionuclide bone scan and MRI

2) Open reduction internal fixation with a cable plate and allograft strut

3) Revision arthroplasty with a fully coated cementless stem, cable wiring, and bone graft

4) Revision arthroplasty with a modular, tapered stem and bone grafting of the diaphyseal fixation

5) Revision arthroplasty with a total femur prosthesis

The radiograph is consistent with a periprosthetic femur fracture, with a loose femoral stem, and a Paprosky IIIA femoral defect. This is best treated with a fully-coated cementless stem with metaphyseal onlay allograft.
Paprosky devised a classification for femoral bone loss following THA. The classification is as follows:
Type I: minimal metaphyseal bone loss and intact diaphyseal fixation Type II: extensive metaphyseal bone loss with intact diaphyseal fixation
Type IIIA: severe metaphyseal bone loss with greater than 4 cm of diaphyseal bone preservation for distal fixation.
Type IIIB: severe metaphyseal bone loss and less than 4 cm of diaphyseal
bone preservation for distal fixation
Type IV: extensive metaphyseal and diaphyseal bone loss.
Type IIIA may be treated with a fully coated stem. Type IIIB should consider a tapered, modular stem and/or bone grafting. Type IV likely needs a megaprosthesis. In this patient, given the preserved diaphyseal bone, revision arthroplasty with a fully coated femoral stem is the most appropriate treatment.
The Sporer article reviews a case series of patients undergoing revision hip arthroplasty for femoral bone loss. Type IIIB defects with a femoral canal less than 19 mm may be treated with a fully porous-coated stem. However, patients with Type IIIB defect and a cavernous canal greater than 19 mm or a Type IV defect may need a modular tapered stem or a bone grafting procedure.
The Paprosky article summarizes his classification of femoral bone loss in revision hip arthroplasty and provides an algorithm for treatment. Extensively porous-coated, diaphyseal filling femoral components showed excellent results in Paprosky IIIA defects.
Radiograph A shows a total hip arthroplasty with severe metaphyseal bone loss and a supportive diaphysis.
Incorrect Answers:
Answer 1: No additional work-up is required prior to revision arthroplasty if laboratory results are negative for infection.
Answer 2: Given the amount of bone loss and the loose femoral stem, fixation of the fracture/defect would not be advisable.
Answers 4,5: These would be reasonable options if extensive bone loss was seen in the diaphysis.

A 74-year-old man presents with start-up thigh pain following a total hip replacement 10 years ago. Immediate post-operative radiograph is shown in Figure A. A current radiograph is shown in Figure B. Aspiration of the hip yields 1,005 white blood cells/ml. ESR is 12 (normal
1) Revision of the femoral component to an uncemented, long, fully porous-coated stem

2) Revision of the femoral component to a cemented stem

3) Revision of the femoral component to an allograft prosthetic composite

4) Revision of the femoral component to a proximal femoral replacement

5) Removal of prosthesis with insertion of antibiotic spacer

The clinical presentation is consistent with symptomatic, aseptic femoral component loosening with no evidence of femoral bone defects. Appropriate management consists of revision of the femoral component to an uncemented, fully porous-coated stem.
Aseptic loosening remains one of the most common indications for revision total hip arthroplasty. After infection has been ruled-out, management is determined by gauging the patients symptoms, the rate of progression of the subsidence, and the amount of femoral bone loss. Uncemented revision femoral components have shown superior results to cemented revision femoral components in the long-term. In the setting of Paprosky Type I, II, and IIIA defects of the femur, revision to an uncemented, fully porous-coated stem is advised.
Moreland et al. review the results of 134 patients (137 hips) who underwent revision arthroplasty with an extensively porous-coated cobalt chrome femoral prosthesis. At a mean follow-up of 9.3 years, only 10 (7%) had to removed for any reason.
Sporer et al. review the results of fully porous-coated stems, impaction bone grafting, and modular tapered stems for Paprosky III and IV femoral defects. They found a high rate of failure with fully porous-coated stems when used in patients with Type IIIB defects >19mm and Type IV defects. They attribute these failures to instability and the inability to eliminate micromotion.
Figure A shows a cementless, metaphyseal engaging femoral component in good alignment. Figure B is a post-operative radiograph from 10 years later showing significant subsidence of the femoral component.
Incorrect Answers:
Answer 2: Uncemented femoral component revision stems have shown superior results to cemented femoral component revision stems.
Answer 3-4: Both of these options would be reasonable if there were high-grade femoral bone loss (Paprosky IIIB, IV) in the setting of a loose stem. Answer 5: Aspiration and laboratory values are not consistent with infection.

A 72-year old female who underwent an uncemented right total hip arthroplasty 2 years ago complains of right hip pain after a fall. Figure A shows her current radiograph. Which acetabular bone defect classification and treatment option best describes this scenario?
1) AAOS Type III - anti-protrusio cage with augmentation and a posterior column plate

2) AAOS Type IV - anti-protrusio cage with screw fixation and a posterior column plate

3) AAOS Type II - jumbo cup with augmentation and a posterior column plate

4) AAOS Type I - total acetabular allograft with a cemented cup

5) AAOS Type II - custom triflange acetabular component

Figure A shows pelvic discontinuity, which is consistent with a AAOS Type IV defect. Acetabular antiprotrusio cage with screw fixation and a posterior column plate is a reasonable treatment option for this condition.
Acetabular bone loss following total hip arthroplasty is a challenging problem with a wide variety of treatment options available. The two most widely accepted classification systems are the AAOS and Paprosky classifications.
AAOS type I defects are segmental, type II are cavitary, type III are combined cavitary and segmental, type IV is discontinuity, and type V is arthrodesis. All of the treatment options listed above are described for pelvic discontinuity,
with none being described as superior.
DeBoer et al. describe the results of 28 patients with pelvic discontinuity treated with a custom-made porous-coated triflange acetabular prosthesis. 20 of these patients were followed for 10 years. There were no re-operations, 5 hip dislocations, 1 sciatic nerve palsy, and an average improvement in the Harris hip score from 41 to 80.
Paprosky et al. retrospectively reviewed patients who had an acetabular revision using a trabecular metal acetabular component for a pelvic discontinuity and compared these patients with a cohort of patients who had a previous reconstruction for a pelvic discontinuity using an acetabular cage.
They found a decreased incidence of pain and need for walking aids in those patients who had revision with a trabecular metal acetabular component.
Figure A shows pelvic discontinuity, likely acute given the lack of associated bony defects and recent fall. Illustration A details the AAOS hip acetabular defect classification and Illustration B is the often cited Paprosky classification.
Incorrect Answers:
Answer 1: Type III defects are combined cavitary and segmental. Answer 3: Type II defects are cavitary.
Answer 4: Type I defects are segmental. Answer 5: Type II defects are cavitary.

Which of the following is indicative of type 1 collagen breakdown and can be utilized as a marker of bone turnover?

1) Increased urinary N-telopeptide

2) Increased urinary cAMP and phosphate

3) Increased urinary phosphoethanolamine

4) Increased urinary Bence Jones proteins

5) Increased serum bone sialoprotein

Urinary N-telopeptide is a marker of increased bone turnover and is a breakdown product of Type 1 collagen.
Increased serum alkaline phosphatase level and increased urinary markers of N-telopeptide, hydroxylproline, deoxypyridinoline indicate high bone turnover and can be seen in metabolic bone diseases such as Paget's disease.
von Schewelov et al. reviewed 160 patients that underwent total hip replacements and examined their urine specimens to see if N-telopeptide levels correlated to periprosthetic osteolysis. They found that n-telopeptide levels were 1/3 higher in the patients that had evidence of osteolysis. N-
telopeptide release and annual wear were both associated with increased prevalence of osteolysis in the study.
Illustration A shows a radiograph of Pagets disease of the femur, an example of a condition where there is an increased level of N-telopeptide in the urine. Illustration B is a radiograph showing periprosthetic osteolysis, another condition where there is an increased level of N-telopeptide in the urine.
Incorrect Answers:
Answer 2: Increased urinary cAMP is found in Type 2 pseudohypoparathyroidism.
Answer 3: Phosphoethanolamine is found in the urine in patients with hypophosphatasia.
Answer 4: Bence Jones proteins are found in the urine of patients with multiple myeloma.
Answer 5: Bone sialoprotein (BSP) is a component of mineralized tissues such as bone, dentin, cementum and calcified cartilage.

A 78-year-old female undergoes total hip arthroplasty through a minimally invasive surgical approach. During insertion of a metaphyseal fixation stem with a cementless press-fit technique, a crack in the calcar is identified. The stem is removed, two cable wires are passed around the calcar, and the same stem is reinserted. Which of the following statements is true?

1) The patient should be advised she is at greater risk of stem subsidence and early revision

2) Female sex is a risk factor for intraoperative calcar fracture

3) A better outcome would be expected if a long-stem diaphyseal fixation stem had been inserted after recognition of the calcar fracture

4) Cementless press-fit technique is not a risk factor for intraoperative fracture

5) Minimally invasive surgical approach is not a risk factor for intraoperative fracture

Of the statements listed, the only true statement is that female gender is a risk factor for intraoperative calcar fracture.
Calcar fractures are a documented complication of total hip arthroplasty. Studies have shown that successful outcomes can be achieved with stem removal, cable wiring of the calcar, and re-insertion of the primary stem.
Berend et al. reviewed a series of 58 total hip arthroplasties who sustained an intraoperative calcar fracture. All were treated with cable wiring of the calcar and stem insertion. The authors report no femoral component subsidence or failure otherwise at 16 year follow-up.
Graw et al. review a series of 46 revision THA's. Of the 46, fifteen underwent primary THA through a minimally invasive technique. The average length of time from primary THA to revision was 1.4 years for the minimally invasive group versus 14.7 years for the traditional exposure THA's. The authors conclude minimally invasive THA is a risk for early revision.
Davidson et al. review intraoperative periprosthetic hip fractures. "Risk factors for intraoperative periprosthetic fractures include the use of minimally invasive techniques; the use of press-fit cementless stems; revision operations, especially when a long cementless stem is used or when a short stem with impaction allografting is used; female sex; metabolic bone disease; bone diseases leading to altered morphology such as Paget disease; and technical errors at the time of the operation." The authors summarize techniques for treatment and postulate that long term outcome is unaffected when the intraoperative fracture is identified and treated appropriately.
Illustration A shows a nondisplaced calcar crack that was treated with a single Luque wire.
Incorrect Answers:
Answer 1. The patient is not at risk for further complications. See Berend reference.
Answer 3. The patient is not at risk for further complications. See Berend reference.
Answer 4. Intraoperative fractures occur more often with press-fit technique compared to cemented stems.
Answer 5. Minimally invasive surgical approaches are a risk factor for intraoperative fracture during THA.

Which of the following types of prosthetic designs, seen in figures A-E, has been shown to have a high rate of loosening secondary to overconstraint?
1) Figure A

2) Figure B

3) Figure C

4) Figure D

5) Figure E

Figure C shows an example of an Walldius hinge total knee prosthesis. This design had a higher rate of aseptic loosening (up to 20%) secondary to a high-degree of constraint.
Constraint is defined as the effect of the elements of knee implant design that provides the stability needed to counteract forces about the knee after arthroplasty in the presence of a deficient soft-tissue envelope. While increasing component constraint increases the stability of the knee, it also transmits forces to the fixation and implant interfaces, which may lead to premature aseptic loosening. First-generation total knee hinged prostheses were highly constrained devices that only allowed a single axis of rotation.
Lombardi et al. provide an Instructional Course Lecture on the different prosthetic designs in total knee arthroplasty. They argue that PCL sacrificing implants are more appropriate than cruciate-retaining implants in rheumatoid arthritis, previous patellectomy, previous high tibial osteotomy or distal femoral osteotomy, and in cases where the PCL is absent secondary to trauma.
Morgan et al. discuss constraint in primary total knee arthroplasty. They argue that a hinge total knee arthroplasty should be reserved for severe instability, elderly patients with comminuted distal femur fractures, patients with
extensor-mechanism disruption and unstable knees, and those with substantial bone loss not amenable to augmentation.
Figure C shows an example of a Walldius hinged prosthesis.
Illustration A shows an intra-operative example of a constrained-hinged knee prosthesis. Note the link between the tibial and femoral components, which differentiates it from a constrained, non-hinged prosthesis.
Incorrect Answers: The following responses are incorrect as they all have lower rates of aseptic loosening than than varus/valgus constrained prostheses or hinged designs.
Answer 1: Figure A shows a posterior-stabilized total knee arthroplasty. Answer 2: Figure B shows a patellofemoral arthroplasty.
Answer 4: Figure D shows an uncemented total knee replacement. Answer 5: Figure E shows a uni-compartmental total knee replacement.

A 28-year-old football player sustains a contact knee injury while being tackled. On physical exam, he has a 1A Lachman, and a normal McMurray test. His posterior drawer, dial, and varus stress tests are normal. He has pain and 5mm opening on valgus stress at 30 degrees of flexion. Which statement is true regarding the injured structure?

1) Resides between layers 1 and 2 on medial side of knee

2) Inserts onto Gerdy's tubercle

3) Originates slightly posterior and proximal to the medial epicondyle

4) Courses intraarticularly thru hiatus of lateral meniscus

5) Has an attachment between adductor tubercle and medial epicondyle at Schöttle's point

The clinical presentation is consistent with an injury to the superficial medial collateral ligament (MCL) of the knee, which originates slightly posterior and proximal to the medial epicondyle.
The superficial portion of the MCL is the primary stabilizer to valgus stress at all angles, contributing 57% and 78% of medial stability at 5 degrees and 25 degrees of knee flexion, respectively. Anatomic studies have shown that the superficial MCL originates approximately 3.2 mm proximal and 4.8 mm posterior from the medial femoral epicondyle and inserts into the periosteum of the proximal tibia (deep to pes anserinus). The superficial MCL lies in layer 2, just deep to gracilis and semitendinosus tendons.
Wijdicks et al. (2009) looked at radiographic identification of the primary medial knee structures including the superficial MCL. On the lateral radiograph, they found that the attachment of the superficial MCL was an average of 6.0 mm from the medial epicondyle.
Wijdicks et al. (2010) reviewed injuries to the MCL and associated medial structures of the knee. They state that physical examination is the initial method of choice for the diagnosis of medial knee injuries through the application of a valgus load both at full knee extension and between 20 degrees and 30 degrees of knee flexion. Treatment of isolated grade-III injuries to the MCL, or such injuries combined with an anterior cruciate ligament tear, should start with nonoperative treatment of the MCL due to high rates of success with nonoperative treatment. If operative treatment is required, an anatomic repair or reconstruction is recommended.
Illustration A shows the femoral and tibial attachments of the superficial MCL. Illustration B shows the osseous landmarks and attachments of medial knee structures (AT, adductor tubercle; GT, gastrocnemius tubercle; ME, medial epicondyle; AMT, adductor magnus tubercle; MGT, medial gastrocnemius tendon; sMCL, superficial MCL; MPFL, medial patellofemoral ligament; POL, posterior oblique ligament).
Incorrect Answers:
Answer 1: Superficial MCL resides in layer 2. Answer 2: Describes iliotibial band.
Answer 4: Describes the popliteus.
Answer 5: Describes the medial patellofemoral ligament.

Which of the following best describes normal tibio-femoral joint kinematics ?

1) The femur undergoes internal rotation with knee flexion

2) The lateral femoral condyle remains stationary on the lateral tibia plateau during knee flexion from 0 to 120 degrees

3) The tibia undergoes internal rotation with knee flexion

4) The medial femoral condyle moves posteriorly on the medial tibial plateau during knee flexion from 0 to 120 degrees

5) Beyond 120 degrees of flexion only the lateral femoral condyle participates in femoral rollback

Tibia is subjected to internal rotation with knee flexion and the tibia EXternally rotates on femur as the knee EXtends.
The axis of rotation shifts posterior on the lateral condyle with knee flexion. Flexion and extension at the knee occur about a constantly changing center of rotation (polycentric rotation).
Freeman et al. conducted a biomechanical experiment and found that the medial femoral condyle does not move much from 0 to 120 degrees of flexion. They also found that the lateral femoral condyle and the contact area between that condyle and the tibia move posteriorly and tibial internal rotation occurs with knee flexion. They found that from 120 degrees to full flexion both condyles participate in "roll back".
Illustration A shows why the screw-home mechanism occurs. The medial tibial plateau is longer than the lateral tibial plateau, leading to external rotation of the tibia during extension as the femoral condyle rotates about the tibia. Video V shows an example of external tibial rotation during extension.
Incorrect Answers:
Answer 1: Femur does not internally rotate with knee flexion.
Answer 2: Laterally the femoral condyle and the contact area moves posterior on the tibia during knee flexion from 0 to 120 degrees.
Answer 4: Medially the femoral condyle and the contact area remain relatively stationary during knee flexion from 0 to 120 degrees.
Answer 5: Beyond 120 degrees of flexion both condyles participate in femoral rollback.

Which of the following molecules is associated with macrophage induced osteolysis surrounding orthopaedic implants?

1) BMP-7

2) IL-10

3) SOX-9

4) Osteoprotegrin

5) IL-1

Of the options provided, IL-1 is most associated with macrophage induced osteolysis surrounding orthopaedic implants.
Macrophages initiate the inflammatory cascade associated with aseptic loosening of orthopaedic implants by secreting platelet-derived growth factor (PDGF), prostaglandin E2 (PGE2), TNF-alpha, IL-1, and IL-6.
Archibeck et al. state the primary cells involved in the process of periprosthetic loosening include the macrophage, osteoblast, fibroblast, and osteoclast. They report the chemical mediators that are responsible for the cellular interactions and effects on bone primarily include PGE2, TNF-alpha, IL-1, and IL-6.
Drees et al. discuss the molecular pathway of aseptic loosening of orthopedic implants. They describe the following steps: 1) Wear debris particles released at the cement–bone interface attract macrophages, which, in turn, are stimulated to produce proinflammatory mediators and proteolytic enzymes; 2) RANKL, TNF-alpha, IL-1, IL-6, IL-17, and M-CSF mediate the differentiation of myeloid precursor cells into multinucleated osteoclasts, which release cathepsin K and acid and cause resorption lacunae; 3) Mesenchymal cells (prosthesis-loosening fibroblasts) present at the bone surface contribute actively to bone resorption.
Illustration A shows the pathway described by Drees et al.
Incorrect Answers
Answer 1: BMP-2,4,6, and 7 all exhibit osteoinductive activity but BMP-3 does not.
Answer 2: IL-10 inhibits osteoclast formation along with calcitonin
Answer 3: SOX-9 is a key transcription factor involved in the differentiation of cells towards the cartilage lineage
Answer 4: Osteoprotegrin binds to RANKL on the osteoblast, preventing RANK activation and inhibiting osteoclast activity.

Which of the following templates, seen in Figures A-E, will increase the offset while keeping the leg lengths the same?
1) Figure A

2) Figure B

3) Figure C

4) Figure D

5) Figure E

If the total hip prosthesis is inserted according to the template in Figure E, the offset will be increased, while the leg lengths will remain unchanged.
Restoration of limb length is essential following total hip arthroplasty. The amount of limb-length change will be the vertical distance between the center of rotation of the femoral component and the center of rotation of the acetabular component. Thus, when the femoral center of rotation on templating is inferior to that of the acetabular component, the limb will be shortened. Restoring femoral offset is also important. If the center of rotation of the prosthetic head lies lateral to that of the cup on templating, the reconstruction will produce decreased offset.
Scheerlinck et al. present a stepwise approach to hip templating through four steps. Step 1 involves identifying landmarks, step 2 involves assessing the

A 91-year-old male with a history of chronic leukemia and dementia falls and sustains the hip fracture shown in Figure A. He undergoes a hemiarthroplasty through a posterior approach. A postoperative radiograph is shown in Figure B. Three weeks later he dislocates the hip arising from the toilet seat. A radiograph is shown in Figure C. The patient undergoes a closed reduction and is placed in a hip abduction brace. Post reduction radiograph is shown in Figure D. One month later he returns to clinic complaining of pain and inability to bear weight through the leg. A radiograph of the hip is included in Figure E. Which of the following factors has MOST likely contributed to the instability of the hip hemiarthroplasty?
1) Femoral stem subsidence

2) Increased offset

3) Inadequate femoral stem neck length

4) Patient's dementia status

5) Patient's gender

The most likely contributing factor to the instability include the patient's dementia.
Sultan et al use a basic science model to show liners with elevated rims placed in the posterior superior quadrant allow greater range of motion to dislocation than standard liners. They also show that 32 mm heads have greater range of motion to dislocation compared to 28 mm heads.
Morrey et al reviewed a series of 19,680 primary THA's for late dislocation (first dislocation greater than 5 years after surgery). 165 hips (0.8%) had a late dislocation. Factors associated with late dislocation include implant malposition, neurologic decline, trauma, and polyethylene wear.
Figure A shows a femoral neck fracture. Figures B and D show a hip hemiarthroplasty in appropriate position. Figure C and E show a dislocated hip hemiarthroplasty
This patient's instability was managed by converting the hip hemiarthroplasty to a total hip arthroplasty with a constrained liner as shown in illustration A. No further instability episodes occurred following the revision.
Incorrect Answers:
Answer 1: There is no evidence of femoral neck subsidence on any of these radiographs.
Answer 2: Increased offset would not lead to an increased risk of hip dislocation.
Answer 3: Post-operative radiographs suggest that the native femoral neck length has been re-established adequately.
Answer 5: Females have higher rates of dislocation than males.

What surgeon is credited for designing the prosthesis seen in Figure A?
1) John Charnley

2) San Baw

3) Sir Harry Platt

4) Austin T. Moore

5) Charles Frederick Thackray

Figure A shows an example of an Austin-Moore hemiarthroplasty.
Austin Moore developed the most popular long-stemmed prosthesis in the 1950s. The Austin-Moore prosthesis was a large, uncemented femoral stem that didn't use polyethylene. The Austin-Moore prosthesis had fenestrations for self-locking which later became the impetus for biological fixation. These implants were originally used to treat hip fractures and certain cases of degenerative arthritis. Later, in the 1960s, John Charnley introduced the idea of replacing the eroded acetabulum with a Teflon component.
Moore et al. describe the first metallic hip replacement surgery in 1940. The patient had a proximal femoral resection for a giant cell tumor. The original prosthesis he designed was a proximal femoral replacement, with a large fixed head, made of the Cobalt-Chrome alloy Vitallium.
Charnley et al. discuss the long-term results (up to 7 years) of the "low-friction" total hip arthroplasty. Infection rate was 3.8%, late mechanical failure was 1.3%, and most patients had excellent pain relief.
Figure A shows a radiograph of an Austin-Moore hemiarthroplasty. Illustration A shows an Austin-Moore prosthesis. Illustration B shows an example of Charnley's "low-friction" total hip arthroplasty, with a stainless steel head and
stem and a polyethylene acetabular component.
Incorrect Answers:
Answer 1: Charnley is credited with the invention of the "low-friction" total hip arthroplasty.
Answer 2: Dr. San Baw pioneered the use of ivory hip prostheses to replace ununited fractures of the neck of femur.
Answer 3: Sir Harry Platt was a mentor to John Charnley.
Answer 5: Charles F. Thackray Limited (now a subsidiary of DePuy Orthopaedics) was instrumental in the growth of Dr. Charnley's implants.

A 45-year-old man has had the gait disturbance shown in Video A ever since a total hip replacement two years ago. Since then he has undergone physical therapy and nerve exploration without any clinical improvement. Extensive AFO bracing was attempted but was not tolerated by the patient. A recent ankle radiograph is shown in Figure
A. The Silfverskiold test reveals dorsiflexion of 20 degrees with knee flexion, and 10 degrees with full knee extension. The results of muscle
testing using a Cybex dynamometer are shown in Figure B. What is the most appropriate next step in in treatment.
1) Ankle arthrodesis in 30 degrees of dorsiflexion

2) Posterior tibial tendon transfer to the lateral cuneiform through the interosseous membrane

3) Split anterior tibial tendon transfer to the cuboid

4) Peroneus longus transfer to the navicular and gastrocnemius recession

5) Flexor hallucis transfer to the navicular and tendo Achilles lengthening (TAL)

The clinical presentation is consistent with a sciatic neuropathy following THA in a patient that does not tolerate AFO bracing. Posterior tibialis tendon transfer is the next most appropriate step in treatment.
Sciatic neuropathy, especially involving the common peroneal branch, is a known complication of total hip arthroplasty. Typically a patient is adequately treated with an AFO. In some clinical situations an AFO is not tolerated, and a tendon transfer is required. The posterior tibial tendon is the most commonly used donor muscle. A tendon transfer is feasible only if the tendon possesses at least 4/5 power. There is a loss of 1 MRC grade of strength following transfer.
Rodriguez et al. retrospectively reviewed the results of the Bridle procedure 10 patients (11 feet) with a foot drop. The Bridle procedure consists of a posterior tibial tendon transfer through the interosseous membrane to the dorsum of the foot with a dual anastomosis to the tendon of the anterior tibial and a rerouted peroneus longus in front of the lateral malleolus. In their study all 11 feet were brace-free at final followup at 6.68 years.
Yeap et al. retrospectively reviewed 12 patients who were treated with tibialis posterior tendon transfer for footdrop. They found good/excellent patient satisfaction in 10/12 patients. Additionally they found favorable variables for a good outcome include common peroneal nerve palsy over sciatic nerve palsy, male gender less than 30 years of age.
Figure V is a Video that shows a right footdrop with high steppage gait. Figure A shows normal ankle radiographs. Figure B shows the results of dynamometer testing described above. Illustration A shows the Bridle procedure. The left panel shows how the tibialis posterior tendon (C) is tunneled through the interosseous membrane and through a slit in the tibialis anterior tendon (A) and inserted into the second cuneiform. The peroneus longus (B) is also transected and the distal stump is routed anterior the lateral malleolus and anastomosed to the tibialis anterior and tibialis posterior (at the slit where it passes through the tibialis anterior). The right panel shows retrieval of the tibialis posterior tendon above the ankle and passage through a window in the interosseous membrane.
Incorrect Answers:
Answer 1: There is no arthrosis of the ankle joint and several tendons possess sufficient strength to make a tendon transfer feasible. Tendon transfer should be attempted first.
Answer 3: The anterior tibial tendon attaches to the plantar-medial aspect of the medial cuneiform and 1st metatarsal base. This muscle is weak (0/5 power) and transfer of its tendon muscle will not correct footdrop.
Answer 4: The peroneus longus attaches to the medial cuneiform and 1st metatarsal (plantar-posterolateral aspect). This muscle is weak (2/5 power) and transfer of this tendon will not correct footdrop. Gastrocnemius recession will not increase the effectiveness of this transfer as there is no gastrocnemius contracture.
Answer 5: The flexor hallucis longus is a secondary plantar flexor of the ankle. Its power is not mentioned in the question stem. But it is a less desirable tendon transfer compared with the posterior tibialis tendon. TAL will not increase its effectiveness. TAL is not necessary as there is dorsiflexion to 10degrees past neutral with the knee extended.

Which of the following variables is associated with elevated serum metal ion levels following metal-on-metal hip resurfacing arthroplasty?

1) Smaller implant diameter

2) Smaller acetabular cup abduction angle

3) Higher postoperative functional scores

4) Severe preoperative osteoarthritis

5) Anteversion of acetabular cup between 10 and 20 degrees

Smaller femoral head diameter is associated with elevated serum metal ion levels with metal-on-metal hip resurfacing arthroplasty.
Metal-on-metal (MOM) hip resurfacing arthroplasty has the advantage of better wear properties (lower linear wear rate and volume of particles) than metal on polyethylene. However, elevated serum metal ion levels is one of the negatives which has received much attention recently. Studies have found smaller implant diameter and acetabular cup abduction angle >55 degrees are associated with elevated serum metal ion levels. Cup abduction angles of greater than 55 degrees lead to a more vertical cup and edge loading.
Desy et al. found that smaller implant diameter, larger cup inclination, and lower postoperative functional scores are associated with increased cobalt and chromium levels after metal-on-metal hip resurfacing. They found that severity of preoperative osteoarthritis, acetabular version, femoral stem-shaft and valgus angle, and anterior orientation of the femoral component had no effect on the circulating metal ion levels.
DeHaan et al. obtained serum ion levels in 214 MOM resurfacing patients at least 1 year following surgery. They found that cup abduction angles greater than 55 degrees combined with smaller component sizes led to edge loading and elevated ion levels.
Illustration A shows how a metal-on-metal prosthesis design allows you to have a larger femoral head as opposed to a metal on polyethylene design (example in THA). Illustrations B and C show a photo of a metal on metal resurfacing implant and radiographs of the implant.
Incorrect Answers:
2: Elevated cup abduction angle leads to elevated serum metal ions.
3: Higher postoperative functional scores have not been shown to increase serum metal ions.
4: Severity of pre-operative arthritis has not been associated with increased serum metal ions.
5: Anteversion of the acetabular cup between 10 and 20 degrees has not been shown to increase serum metal ions.

Which of the following intra-operative steps would put a patient at risk for lateral patellar maltracking during total knee arthroplasty (TKA)?

1) External rotation of the femoral component

2) Medial placement of the patellar component

3) Internal rotation of the tibial component

4) Lateral translation of the femoral component

5) Superior placement of the patellar component

Internal rotation of the tibial component increases the Q angle and causes an increased risk of lateral patellar maltracking.
During TKA, useful techniques that help prevent patellar maltracking include: external rotation of the femoral and tibial components, lateral translation of the femoral component, and medial placement of the patellar component.
In an instructional course lecture, McPherson looked at patellar tracking in primary TKA. He reviews the concept of patellofemoral maltracking, the importance of the Q angle, mechanical alignment, femoral component rotation, tibial component positioning, patellar component positioning, patellar height, and patellar resurfacing as factors related to patellofemoral tracking.
Bengs et al. studied the effect of patellar thickness on intra-operative knee flexion and patellar tracking during PCL retaining TKAs. Using 2mm increments (2-8 mm), passive knee flexion was recorded and gross mechanics of patellofemoral tracking were assessed. On average, passive knee flexion decreased 3 degrees for every 2-mm increment of patellar thickness, there was no gross effect on patellar subluxation or tilt.
Illustration A shows how internal rotation of the tibial component would increase the Q angle, and thus be more likely to have lateral patellar maltracking.
Incorrect answers:
Answer 1,2,4,5- Would all prevent lateral patellar maltracking.

A patient undergoes a primary total hip arthroplasty with a highly cross-linked ultra-high molecular weight (UHMW) polyethylene acetabular liner. In comparison to a 28mm femoral head, a 32mm femoral head will provide which of the following?

1) Increased risk of dislocation

2) Decreased range of motion

3) Decreased risk of osteolysis

4) Equivalent wear rate of the polyethylene acetabular liner

5) Increased risk of periprosthetic fracture

Wear rates of highly cross-linked UHMW polyethylene liners are independent of femoral head size between 22 and 46 mm in diameter.
While the wear rates of old polyethylene liners increased with increasing femoral head size, wear rates of the new highly cross-linked UHMW polyethylene liners have shown to be independent of head size. This is extremely advantageous, as increasing the femoral head size improves range of motion and increases jump distance, thereby decreasing dislocation rates.
Geller et al. report a prospective series of 42 patients that had a total hip arthroplasty with a highly cross-linked UHMW polyethylene liner and a femoral head >32 mm in diameter. After three years, there were no cases of osteolysis or failure due to aseptic loosening.
Muratoglu et al. studied the wear rates of several polyethylene liners with varying femoral head sizes. In the highly cross-linked UHMW polyethylene group, wear rates were independent of femoral head size.
Illustration A shows how increasing femoral head size increases the jump distance required for dislocation.
Incorrect Answers:
Answer 1: Increasing femoral head size decreases the risk of dislocation. Answer 2: Increasing femoral head size increases range of motion.
Answer 3: Increasing femoral head size has not been shown to affect rates of osteolysis.
Answer 5: Increasing femoral head size has not been shown to increase the rate of periprosthetic fracture.

A 56-year-old male undergoes an uncomplicated revision total knee arthroplasty. Post-operatively, he is noted to have a foot drop that has persisted despite conservative management including bracing and physical therapy. At two months, the patient undergoes external neurolysis with no improvement in function. At 18 months follow-up, he demonstrates passive ankle dorsiflexion 10 degrees past neutral, complete absence of active dorsiflexion, and 5/5 inversion strength. Which of the following is the most appropriate treatment at this time?

1) Continue Ankle-foot orthosis (AFO) and physical therapy

2) Repeat neurolysis with possible nerve repair

3) Peroneus tertius transfer

4) Peroneus tertius transfer with achilles tendon lengthening

5) Posterior tibial tendon transfer to dorsum of foot

A peroneal nerve palsy (with intact posterior tibial tendon strength) that has failed conservative management is best treated with a posterior tibial tendon transfer to the dorsum of the foot.
Peroneal nerve palsy following total knee arthroplasty or knee dislocation is a potentially devastating complication that may lead to lack of active dorsiflexion and a compensatory steppage gait pattern. Initial management consists of an ankle-foot orthosis (AFO) and physical therapy to maintain passive ankle dorsiflexion. If nerve function fails to return during the course of conservative management and the patient demonstrates intact posterior tibialis muscle strength, posterior tibial tendon transfer to the dorsum of the foot has been shown to improve functional outcomes and eliminate the need for continued bracing. The most common procedure for posterior tibial tendon transfer involves transferring the tendon through the interosseous membrane and inserting the tendon onto the lateral cuneiform.
Prahinski et al. review the results of 10 patients at 61 months' follow-up who underwent the Bridle transfer (posterior tibialis transfer through interosseous membrane and peroneus longus to front of lateral malleolus) for peroneal nerve palsies. They conclude the Bridle procedure is adequate for return to function in low-demand individuals, but may fail over time in those who return to vigorous physical activity.
Rodriguez et al. review the results of 10 patients who underwent the Bridle procedure for peroneal nerve palsy in an attempt to balance their foot and
provide dorsiflexion. All of their patients were brace free at an average followup of 6.8 years.
Video V shows the clinical results 10 weeks after transfer of the tibialis posterior tendon for a drop foot.
Incorrect Answers:
Answer 1: An AFO and physical therapy is appropriate for initial management while awaiting potential nerve recovery.
Answer 2: Repeat neurolysis is unlikely to achieve clinical improvement after initial failure.
Answer 3: The peroneus tertius is also located within the anterior compartment and is likely to be involved in her nerve injury pattern. Answer 4: The peroneus tertius is also located within the anterior compartment and is likely to be involved in her nerve injury pattern.

An 82-year-old male sustains a ground level fall and sustains the injury shown in Figure A. Which of the following treatment methods is most appropriate for treating this injury?
1) Closed reduction and functional bracing

2) Open reduction and fixation with a plate with screws and cerclage cables

3) Open reduction and fixation with a cortical allograft strut and cerclage cables

4) Revision hip arthroplasty with bridging of the fracture with a plate with screws and cerclage cables

5) Total femoral replacement

This fracture pattern is typically referred to as an interprosthetic fracture; this is increasing in incidence due to increasing numbers of patients with ipsilateral hip and knee arthroplasty.
The first reference by Ricci et al reviewed 50 Vancouver B1 fractures treated with a lateral plate without allograft. They reported 100% union rate at a mean of 12 weeks and only one deep infection. Nearly 75% of patients were able to return to their baseline ambulatory status.
The second reference by Ricci et al reviewed 59 patients with periprosthetic femur fractures (THA or TKA) treated with ORIF without bone grafting. They report 58/59 patients healed after the index procedure and 49/59 were able to
return to their baseline functional level.
The reference by Fulkerson et al reported on 24 patients who underwent LISS plate fixation of periprosthetic femur fractures around well-fixed THA or TKA. They reported union in 21/24 at a mean of 6.2 months, with only one failure of fixation. They note that percutaneous fixation is effective although technically demanding.
Figure A shows an interprosthetic femur fracture between well-fixed hip and knee arthroplasties.
Incorrect Answers:
Answer 1: Nonoperative management is not indicated for this fracture pattern in this patient.
Answer 3: Use of a cortical allograft strut without plate support is not indicated.
Answer 4: Revision of the femoral stem is not indicated in this case because the stem appears completely stable on the provided radiograph.
Answer 5: Total femoral replacement is not indicated as a primary procedure for this injury pattern.

A 62-year-old female undergoes an uncomplicated primary total knee replacement. Her knee range-of-motion pre-operatively was 0-135 degrees of flexion. Which of the following is true regarding the immediate post-operative use of a continuous passive motion machine in this patient?

1) Reduced risk of venous thromboembolism

2) No long-term difference in ROM compared to patients not using CPM

3) Increased passive knee flexion at 6 months

4) Increased length of hospitalization

5) Decreased risk of surgical site infection

The use of a continuous passive motion (CPM) machine following primary total knee arthroplasty has not shown any long-term benefits with regards to
range-of-motion.
The concept of CPM was created by Dr. Robert Salter in 1970 and is currently being used in select patients following total knee replacement, ACL
reconstruction, and a variety of other procedures about the knee. In theory, the CPM allows for movement of synovial fluid to allow for better diffusion of nutrients into damaged cartilage. Additionally, it has been thought to prevent fibrous scar tissue formation about the joint. While some studies have shown increased early active knee flexion at two weeks, these results were not significant at later follow-up. Controversy exists as to whether these small benefits offset the patient inconvenience and expense of the CPM.
Lotke et al. expolre the effects of tourniquets and CPM machines in 121 patients undergoing total knee arthroplasty. They found that immediate CPM combined with intraoperative release of the tourniquet increased blood loss. The patients with the least amount of blood loss had the tourniquet released after a compressive dressing was applied and in whom CPM was delayed for a few days.
Bourne et al. perform a meta-analysis on the effectiveness of CPM following total knee arthroplasty. They found the CPM plus physical therapy increased active knee flexion more than physical therapy alone 2 weeks after surgery with a decreased length of hospitalization. The benefits of increased active knee flexion were not maintained after 2 weeks.
Illustration A shows an example of a CPM machine. Incorrect Answers:
Answer 1: A current meta-analysis has shown there is not enough evidence
from available RCTs to conclude that CPM reduces the risk of venous thromboembolism following total knee arthroplasty.
Answer 3: There are no difference in passive range of motion at any time points following total knee arthroplasty.
Answer 4: Some studies have shown decreased length of hospitalization in those patients that use a CPM.
Answer 5: CPM has not shown to have any effect on rates of surgical site infections.

A 67-year-old female complains of anterior groin pain one year following a primary, uncemented total hip arthroplasty. The pain is exacerbated when she tries to climb stairs or get up from a seated position. She denies any recent fevers or chills. On physical exam, the pain is reproduced with resisted seated hip flexion. Laboratory analysis, including WBC, ESR, and CRP are within normal limits. Radiographs reveal that the components are appropriately positioned without evidence of loosening or fracture. Which of the following is the most appropriate at this time?

1) Revision of the acetabular component

2) Image-guided diagnostic injection of lidocaine into the iliopsoas tendon sheath

3) Hip aspiration

4) Bone scan

5) Conservative management including activity modifications, NSAIDs, and physical therapy

The patients history and physical exam are most consistent with iliopsoas impingement. This diagnosis is most reliably confirmed with a diagnostic/therapeutic injection of steroid or lidocaine into the iliopsoas tendon sheath.
Iliopsoas tendinitis following total hip arthroplasty is an uncommon but treatable cause of anterior groin pain following total hip arthroplasty. The true incidence is unknown, but some studies suggest it is the cause of a painful
total hip arthroplasty in up to 4.3% of cases. Potential causes include a malpositioned acetabular component, excessively long screws, limb length discrepancy, or retained cement. Diagnosis is confirmed by injecting the iliopsoas tendon sheath. Most cases are refractory to conservative management and often require surgical intervention. In the case of a malpositioned acetabular component, revision to a more agreeable position is advisable. In the absence of a defined etiology, iliopsoas tendon release offers adequate pain relief and return to function in a majority of patients.
Lachiewicz et al. review anterior iliopsoas impingement after total hip arthroplasty. They state that most patients with iliopsoas impingement often require surgical treatment, with options including iliopsoas tendon release or resection, removal of protruding cement or screws, and acetabular revision.
O' Sullivan et al. review 16 cases of iliopsoas impingement following primary total hip arthroplasty. Only 1 of the cases was secondary to a malpositioned acetabular component, with the other 15 cases being attributed to altered anatomy of the iliopsoas tendon as a result of the surgery. These 15 patients underwent iliopsoas tendon release, and all had improvement in pain and function following surgery.
Nunley et al. review 27 patients with a presumed diagnosis of iliopsoas impingement following total hip arthroplasty who were treated with fluoroscopically guided injections of the iliopsoas bursa. The average modified Harris hip score in the patients who underwent injection improved, however, 30% required an additional injection and 22% underwent surgical release for continued pain.
Illustration A shows a flouroscopic injection into the iliopsoas tendon sheath. Incorrect Answers:
Answer 1: Radiographs reveal well positioned components. In addition,
revision of the acetabular component without a confirmed diagnosis is not advisable.
Answer 3: Infectious laboratories are negative, and the patient denies constitutional symptoms.
Answer 4: Bone scan is unlikely to provide any additional information as her presentation is more consistent with iliopsoas impingement rather than aseptic loosening.
Answer 5: Conservative management could be entertained after confirming the diagnosis of iliopsoas impingement.

A 72-year-old female underwent an uncomplicated primary total hip replacement 18 years ago. Current radiographs reveal the abnormality shown in Figure A. Which of the following cell types (Figures B-F) is implicated in the process shown by the arrow?
1) Figure B

2) Figure C

3) Figure D

4) Figure E

5) Figure F

Figure F shows an example of a macrophage, which is a key mediator in the osteolytic process shown in Figure A.
Osteolysis is the end result of a biologic process that begins when the number of wear particles following a joint replacement overwhelms the body's capacity to clear them from circulation. The residual particles are phagocytosed by macrophages, which then release an array of cytokines and other inflammatory mediators that recruit osteoclasts to resorb bone.
Gupta et al. review osteolysis following total knee arthroplasty, including etiology, diagnosis, and management. Amongst other things, they highlight the importance of design changes to minimize osteolysis including highly cross-linked polyethylene and alternative bearing materials.
Ren et al. performed a study where they implanted a hollow titanium rod into the distal femur and pumped polyethylene particles into the femoral bone marrow cavity. They found that macrophage migration occurs at a systemic (rather than local) level, and that the recruitment of macrophages led to localized osteolysis.
Holt et al. review the biology behind aseptic osteolysis. Specifically, they highlight the importance of the RANK-RANKL-OPG pathway as the final
common pathway to osteoclastogenesis, and the possibility of eliminating osteolysis by blocking this pathway. AMG-162 is a human immunoglobulin monoclonal antibody with a high affinity for RANKL, and studies are currently being undertaken to determine its safety and efficacy.
Figure F shows an example of a macrophage, which may be identified by its irregular shape and phagocytic inclusions. Illustration A shows the pathway by which marcrophages induce osteolysis following a joint replacement surgery.
Incorrect Answers:
Answer 1: Figure B shows is an eosinophil, which may be seen in Eosinophilic Granulomatosis. It has a bilobed nucleus and granules that stain pink when eosin is used in the staining process.
Answer 2: Figure C shows a lymphocyte, with a round nucleus and a narrow rim of cytoplasm. Lymphocytes are seen in ALVAL, an adverse reaction to metal-on-metal hip prostheses.
Answer 3: Figure D shows a basophil with a multi-lobed nucleus and blue-stained granules.
Answer 4: Figure E shows the characteristic appearance of an erythrocyte.

A 45-year-old with a history of sickle cell anemia reports hip pain for the past 6 months. A radiograph of the affected hip is shown in Figure A. Which of the following interventions has been shown to have the best outcomes in this patient population?
1) Observation

2) Bisphosphonates

3) Hemi-arthroplasty

4) Uncemented metal on polyethylene total hip arthroplasty

5) Cemented metal on polyethylene total hip arthroplasty

Based on the radiographs and current literature, the best intervention is an uncemented metal on polyethylene total hip arthroplasty.
Avascular necrosis of the hip may be idiopathic in nature or associated with alcoholism, steroid use, or as in this case, sickle cell anemia. The Ficat staging system is used to classify avascular necrosis of the hip. Changes in treatment are driven by development of symptoms as well as the development of subchondral bone collapse (Ficat Stage 3). In those with with femoral head flattening (Ficat Stage 4) and acetabular degenerative changes (Ficat Stage 5), total hip replacement has good to excellent outcomes.
Mont et al. review surgical options for avascular necrosis of the hip. Head preserving procedures are generally reserved for those patients where the femoral head has not collapsed. Collapse and associated arthritis warrant utilization of arthroplasty procedures.
Mont et al. conducted a systematic review to better delineate the symptomatic progression of asymptomatic avascular necrosis of the hip. They found that patients with sickle cell disease have the highest rate of progression to
collapse. Medium sized, laterally located lesions were associated with a higher frequency of collapse and joint preserving procedures are recommended for these.
Figure A shows radiograph of a patient with avascular necrosis; note the femoral head flattening, narrowing of the joint space and acetabular sclerosis.
Incorrect Answers:
Answer 1: Conservative measures in this patient would not improve this patient’s outcome give the degree of the femoral head collapse and presence of acetabular degeneration.
Answer 2: Bisphosphonates can be used in patients with avascular necrosis of the hip prior to collapse. Current data is conflicting as to whether they prevent collapse or not.
Answer 3: Outcomes for patients undergoing hemiarthroplasty for avascular necrosis of the hip in the young patient are poor; and as a result, this has been largely abandoned.
Answer 5: Higher failure rates have been seen in patients undergoing cemented total hip arthroplasty in treatment of avascular necrosis of the hip.

The function of which of the following structures is to resist internal tibial rotation with the knee in full extension?

1) Anterior cruciate ligament

2) Iliotibial band

3) Popliteus tendon

4) Popliteofibular ligament

5) Posterior oblique ligament

The primary function of the posterior oblique ligament is to resist internal tibial rotation with the knee in full extension.
The posterior oblique ligament is a structure within the posteromedial corner of the knee, with attachments proximally to the adductor tubercle of the femur and distally to the tibia/posterior knee capsule. The posterior oblique ligament and posteromedial capsule play a significant role in the prevention of additional posterior tibial translation in the knee in the setting of posterior cruciate ligament injury. They also act to resist internal tibial rotation with the knee in full extension.
Griffith et al. reports that the posterior oblique ligament provides significant resistance to valgus and internal rotation forces with knee extension. They used a cadaver model and demonstrated that the superficial MCL resists valgus and external rotation forces more than the posterior oblique ligament, while the posterior oblique ligament is more involved in resisting internal rotation.
Tibor et al. reviews the anatomy of the posteromedial corner of the knee. They report that failing to recognize injury to these structures may cause failure of cruciate ligament reconstruction surgery, and that reconstruction or repair of the posteromedial corner may be indicated in the face of multiple ligament injuries.
Illustration A shows the posteromedial corner of the knee, including the posterior oblique ligament.
Incorrect answers:
1-4: These structures are not primary restraints to internal tibial rotation in full extension.

Increasing the porosity of a cement spacer for an infected total knee arthroplasty leads to which of the following?

1) Increased strength

2) Increased elution of antibiotics

3) Increased cement density

4) Improved cement-prosthesis bonding

5) Increased reinfection rate

Elution of an antibiotic is increased with increased porosity of a cement spacer. This porosity increase can be obtained with hand mixing and avoiding the use of a vacuum-type mixing device.
Joseph et al. reviews antibiotic-impregnated cement in hip arthroplasty. They note that use of this cement in one- or two-stage revisions has lowered reinfection rates, with the spacers acting to reduce dead space while stabilizing the joint.
Cui et al. reviews antibiotic impregnated cement for TKA and THA. They report that use of greater than 2 grams of antibiotic per 40 gram unit of cement weakens the cement and that use of two antibiotics in conjunction may potentially increase elution.
The reference by Stevens et al compared Simplex and Palacos bone cement in regards to elution in a TKA mold model. They found that initial as well as weekly (9 weeks total) elution rates were greater in the Palacos spacers than the Simplex models. They recommend use of the Palacos cement in TKA model to target antimicrobial delivery while limiting the potential for systemic antibiotic-related toxicity.
Illustrations A and B show an antibiotic spacer in a two-stage revision TKA. Illustration C shows a PROSTALAC in a two-stage revision THA.
Incorrect Answers:
Answer 1: Increasing the porosity acts to weaken the biomechanic characteristics of the cement.
Answer 3: Increasing the porosity acts to decrease the cement density. Answer 4: Increasing the porosity does not improve cement-prosthesis bonding.
Answer 5: Increasing the porosity has not been shown to alter reinfection rate.

A 65-year-old patient was treated with an open reduction/internal fixation for a left femoral neck fracture sustained 25 years ago. Five years ago he developed hip pain and was converted to a left hip hemiarthroplasty. He presents with complaints of groin pain for the past 6 weeks. A recent radiograph is shown in Figure A. The patient’s physical exam is limited secondary to pain. Serum laboratory values are WBC-8.0, ESR-20, CRP-0.5. A synovial fluid aspirate of the hip demonstrates
1) Acetabular protrusio

2) Infected hip hemiarthroplasty

3) Lumbar radiculopathy

4) Impingement of the hip hemiarthroplasty

5) Iliopsoas tendinitis

Based on the history, radiographs, and laboratory values, the patient has developed failure of his hip hemiarthroplasty. At this point in time he warrants a conversion to a total hip arthroplasty.
Avascular necrosis (AVN) of the femoral head after traumatic injury to the femoral neck occurs at an incidence of 10-45%. Although the risk increases with failure to anatomically reduce the fractue, it can still occur in non displaced settings. Treatment of avascular necrosis in older patients includes hip hemiarthroplasty or a total hip replacement. With the former, development of acetabular protrusio can contribute to groin symptoms. Functional outcomes have been reported to be higher in those receiving total hip replacement for AVN of the femoral head.
Lee et al. prospectively compared the use of bipolar hip hemiarthroplasty versus total hip arthroplasty for advanced stages of AVN of the femoral head (Ficat Stage 3). Total hip scores were most improved in the total hip arthroplasty group. Migration of the outer head in the hemiarthroplasty group was seen in 23% of patients. They recommend use of a total hip arthroplasty in patients with Ficat Stage 3 AVN of the femoral head
Ito et al. evaluated the outcomes of patients who underwent bipolar hemiarthroplasties for femoral head avascular necrosis. They found that proximal migration and acetabular degeneration were risk factors for groin symptoms. They also found that outcomes were inferior to patients who had undergone total hip arthroplasty for AVN of the femoral head. They recommend use of total hip arthroplasty in advanced osteonecrosis of the femoral head
Diwanji et al. evaluated outcomes of patients who underwent a conversion from a bipolar hip arthroplasty to total hip arthroplasty in 25 patients. Thirteen (52%) patients were revised to THA because of acetabular erosions. Follow up was completed for an average of 7.2 years. At final follow-up, they found improvement of the Harris Hip Scores and improvement of the pain portion of the WOMAC index. They recommend use of total hip replacement as an option to salvage failed bipolar hip hemiarthroplasty
Figure A shows the radiograph of a hip hemiarthroplasty where acetabular protrusion has developed.
Incorrect Answers
Answer 2: There is no evidence of infection based on laboratory results. Answer 3: There is no evidence of lumbar based pathology in this patient. Answer 4: While impingement could be a cause of pain, it is not as likely given the history, clinical findings and radiographs seen here.
Answer 5: While irritation of the iliopsoas could occur, it is not as likely given the radiograph seen here.

A 38-year-old female patient presents to your office three years after a hip resurfacing. She complains of worsening left hip discomfort for the last 6 months. Her ESR is 12 (normal 0-20) and CRP is 1.2 (0-5). A radiograph and axial and coronal MRI scans are shown in Figures A, B, and C. What is the most likely diagnosis?
1) Infection

2) Type I Hypersensitivity reaction

3) Femoral neck fracture

4) Prosthesis Loosening

5) Pseudotumor

The clinical presentation is consistent with a young woman who has developed a symptomatic pseudotumor following hip resurfacing. Her hip discomfort is related to a mass that has developed around the left hip.
Pseudotumors, also referred to as Aseptic Lymphocyte-Dominated Vascular-Associated Lesions (ALVAL), are sterile inflammatory lesions that most commonly occur from metal-on-metal articulations. They occur at an incidence of 0-39% with metal-on-metal resurfacing hip components. The exact mechanishm of formation is unclear, however excessive wear is considered the initiating process, leading to the release of microscopic metal particles. These are cytotoxic to macrophages once phagozytised, leading to necrosis within the lesions and the development of semi-solid or fluid-filled masses around the implant. Lymphocytes are thought to be responsible for the tissue reaction.
Patients often do not complain of pain, but present with a mass around the hip that causes discomfort.
Hart et al. performed a case-control study comparing patients with well-functioning metal-on-metal hip resurfacing to those who have painful prostheses. They found no significant difference between the painfree and painful groups with MRI diagnosed pseudtumors (61% vs. 57%). They concluded that the presence of a pseudotumor should not automatically necessitate revision surgery.
Daniel et al. reviewed the current concepts surrounding pseudotumor. Risk factors associated with pseudotumor formation and failure are female gender, age under 40, hip dysplasia, metal hypersensitivity, and small components.
Larger components have been found to decrease the risk of failure.
Figure A is an AP pelvis radiograph of a patient following a left hip resurfacing surgery. Figures B and C are axial and coronal MR images demonstrating a large pseudotumor around the left hip resurfacing. Illustrations A and B identify the large pseudotumor as outlined in red.
Incorrect Answers:
Answer 1: While infection should always be ruled out with symptomatic prosthetic joints, the radiograph and MRI clearly represent a pseudotumor from a metal-on-metal hip resurfacing.
Answer 2: Hypersensitivity reaction would be a rare presentation 2.5 years following a hip resurfacing.
Answer 3: Femoral neck fracture is a risk in the initial post-operative period (
After total hip arthroplasty (THA) for osteoarthritis a patient is unable to dorsiflex her ankle or extend her great toe. She is treated conservatively with an orthosis and after 3 months on physical therapy she ambulates with a "slapping gait." What is the most appropriate next treatment option?

1) MRI of her spine

2) Ankle Fusion

3) Continue Ankle-Foot Orthosis

4) Revision total hip arthroplasty

5) Sural nerve grafting

The patient has suffered from a peroneal nerve injury most likely from errant retractor placement during the hip replacement resulting in a foot drop. The most appropriate next treatment is an ankle-foot orthosis.
The ankle joint of an ankle-foot orthoses (AFOs) should restrict plantarflexion to prevent foot drop during the swing phase. In a patient who can not actively dorsiflex the foot the AFO keeps the foot in a neutral position during gait allowing for uninterrupted swing during ambulation.
Park et al reviewed common peroneal nerve injury after THA. Only one-half of the patients in the study who developed common peroneal nerve palsy following total hip arthroplasty recovered fully. The mean time to recovery was approximately one year for partial peroneal palsy and one and one-half years for complete palsy. Obesity adversely influenced the nerve recovery. Thus, at 3 months, the nerve should continue to be monitored and the use of an AFO would assist in ambulation.
Yokoyama et al. developed an AFO with an oil damper to adjust the plantarflexion resistive moment as excessive plantarflexion resistance will cause excessive knee flexion during the stance phase. They found the AFO with the oil damper achieved sufficient plantarflexion of the ankle and mild flexion of the knee by adjusting a proper plantarflexion resistive moment during initial stance phase, and provided a more comfortable gait than did the traditional AFOs.
Illustration A shows the location of the sciatic nerve relative to the short external rotators when performing a posterior approach to the hip.
Incorrect Answers:
Answer 1: Immediate foot drop following a total hip replacement is likely related to the procedure, not the spine.
Answer 2: Although an ankle fusion would eliminate the need for dorsiflexion while ambulating, it is more invasive than an AFO and does not consider the potential for nerve recovery over time.
Answer 4: Revising the hip would increase the risk of peroneal palsy.
Answer 5: It is too early to consider nerve grafting.

Which of the following statements is true about racial disparities in total joint arthroplasty?

1) The rate of surgical intervention for African American males is lower than white or Hispanic males

2) The rate of surgical intervention for Hispanics is higher than that for whites

3) The rate of surgical intervention for white males is lower than for African American males

4) There is no difference in the rate of surgical intervention between whites, Hispanics, or African Americans

5) The rate of surgical intervention is equal for Hispanic and white males

The rate of surgical intervention for African American males is lower than either white or Hispanic males.
Numerous studies have shown clear racial disparities in the utilization of total joint arthroplasty for the treatment of osteoarthritis. African American and Hispanic patients undergo total joint arthroplasty at a rate much lower than
white patients, even in areas where insurance coverage is more equitable. Currently, little is known about the reasons for such disparities.
Skinner et al. reviewed the Medicare claims between 1998 through 2000 to determine any racial or ethnic disparities amongst patients undergoing total knee arthroplasty. Amongst other things, they showed that the arthroplasty rates for black men were consistently lower than white men in nearly every region.
Nelson reviews health disparities in orthopaedic surgery. Amongst other things, they discuss how African American patients and white patients perceive the same pain and functional limitations for similar radiographic disease. Thus, ethnic differences in perception of symptoms cannot explan the racial disparities noted in total joint arthroplasty.
Incorrect Answers:
Answer 2: The rate of joint arthroplasty for whites is higher than Hispanics. Answer 3: The rate of joint arthroplasty for whites is higher than African Americans.
Answer 4: There are significant differences in the utilization of joint arthroplasty where comparing different races.
Answer 5: White males, on average, undergo total joint arthroplasty at a rate higher than Hispanic males.

A 65-year-old man presents with aseptic loosening 3 years after total knee arthroplasty. The surgeon reviews radiographs of his knee and takes him to the operating room for revision total knee arthroplasty. During surgery, the exposure technique shown in Figure A is used. Which of the following radiographs (Figures B-F) has the greatest likelihood of needing this exposure technique?
1) Figure B

2) Figure C

3) Figure D

4) Figure E

5) Figure F

Figure A shows a tibial tubercle osteotomy (TTO). Patella baja (Figure D) is an indication for a TTO.
In revision total knee arthroplasty (TKA), surgical exposure should be extensile. Different exposure techniques have been described (see below). Patella baja may indicate that there is patellar tendon contracture. In this instance, a TTO can be used to prevent inadvertent patellar tendon avulsion which is difficult to repair and may lead to loss of function. Further, proximal transfer of the osteotomized tibial tubercle may be used to correct patella baja, bearing in mind that excessive superior translation alters the mechanics of the knee by making the quadriceps less efficient.
Younger et al. reviewed surgical approaches in revision TKA. They include quadriceps snip, patellar turndown, TTO, femoral peel, medial epicondylar osteotomy and quadriceps myocutaneous approach.
Mendes et al. reviewed the results of TTO in revision TKA. They advocate TTO for cases where the patellar cannot be retracted laterally with knee in 90deg of flexion. Complications include nonunion, tubercle fragment fracture and displacement, and tibial metaphyseal fracture (at the level of the distal cut of the osteotomy).
Della Valle et al. reviewed surgical approaches for revision TKA. They advocate TTO because repair is stronger than patellar turndown, there is less tension on the tibial tubercle in flexion than on the quadriceps tendon, and where multiple operations are required (as multiple VY approaches lead to excessive scar, making the approach difficult) or where stemmed tibial components need to be removed.
Illustration A shows tibial tubercle osteotomy hinged on a lateral periosteal flap. Illustration B shows quadriceps snip. Illustration C shows patellar turndown. Illustration D shows medial epicondyle osteotomy.
Incorrect Answers
Answer 1: Figure B shows posterior dislocation. This is not an indication for a TTO. The knee can be approached through a standard medial parapatellar arthrotomy.
Answer 2: Figure C shows patellar tendon avulsion (with patella alta). There is no need for a TTO as patellar subluxation (or even eversion) is easy in this
situation.
Answer 4: Figure E shows rotating platform polyethylene spinout. This is not an indication for a TTO.
Answer 5: Figure F shows knee recurvatum in a cruciate-retaining implant because of attenuation of the PCL and posterior capsule. This is not an indication for a TTO.

Which of the following is the most common intraoperative complication in a patient with sickle cell disease undergoing a total hip arthroplasty?

1) Periprosthetic fracture distal to the implant

2) Iatrogenic fracture causing pelvic discontinuity

3) Perforation of the femoral canal

4) Cardiac arrest from fat embolization to lungs

5) Injury to the sciatic nerve

Perforation of the femoral canal during preparation of the femur is not an uncommon complication, with rates ranging from 4.9-18.2%.
While total hip arthroplasty is extremely effective for pain relief in patients with osteonecrosis of the hip secondary to sickle cell disease, the procedure carries a higher rate of complications compared with non-sickle cell disease patients. Particular attention should be given to the preparation of the femur as femoral medullary widening from chronic marrow hyperplasia adjacent to patchy areas of dense sclerosis can make preparation of the canal difficult.
Some surgeons prefer to ream over a guide-wire to avoid perforation.
Jeong et al. reviewed total hip arthroplasty in patients with sickle cell disease. Amongst other things, they discuss the difficulties associated with preparation of the femoral canal, quoting a perforation rate between 4.9-18.2%. They also state there are no prospective studies comparing cementless to cemented THA, but retrospective data has shown promising results with cementless components.
Hernigou et al. retrospectively reviewed 244 patients with sickle cell disease that underwent cemented total hip arthroplasty. They had a 3% infection rate, a relatively low rate of revision for aseptic loosening, and a 27% rate of medical complications. Overall, they viewed their results as favorable.
Illustration A shows a patient with bilateral AVN secondary to sickle cell disease. Note the areas of patchy dense sclerosis in the metaphyseal region of the proximal femur.
Incorrect Answers:
Answer 1: Periprosthetic fracture usually occurs at the area of perforation, not distal to the implant.
Answer 2: Acetabular fractures are more common in this patient population as well, but the rate of iatrogenic pelvic discontinuity is lower than that of femoral perforation.
Answer 4: The rate of cardiac arrest from fat embolization to the lungs is quite low.
Answer 5: While injury to the sciatic nerve is possibly, it has not been shown
to be more common in this patient population. The rate of post-operative hematoma causing sciatic nerve dysfunction may be higher in this patient population.

A 63-year-old patient presents with periprosthetic joint infection 3 years after primary total knee arthroplasty. A radiograph of her knee is seen in Figure A. She undergoes 2-stage revision total knee arthroplasty. Radiographs taken at the time of explantation are seen in Figure B. An articulating antibiotic spacer is placed. Two months later, she is deemed to be free of infection and is taken to the operating room for the second stage operation. Intraoperatively, it is noted that the collaterals are intact and the previous tibial tubercle osteotomy had healed. What is the most appropriate surgical strategy at this point?
1) Address epiphyseal defects with impaction particulate bone grafting

2) Address metaphyseal defects with structural allograft and uncemented, unstemmed implants

3) Address metaphyseal defects with uncemented, porous metaphyseal
sleeves and uncemented, stemmed implants

4) Address diaphyseal defects with porous metal cones and uncemented, stemmed implants

5) Address diaphyseal defects with cemented stemmed implants

This patient has massive metaphyseal defects following resection of primary TKA implants. Metaphyseal defects may be addressed with uncemented, porous metaphyseal sleeves and uncemented stemmed implants.
In revision settings, metaphyseal bone is often deficient. The Anderson Orthopaedic Research Institute classification (AORI) is most commonly used to classify defects. Stemmed implants are necessary to divert stress away from deficient metaphyseal defects to structurally sound cortical bone. These may be cemented or uncemented.
Haidukewych et al. reviewed metaphyseal fixation in revision TKA. For large defects, they advocate structural allograft, porous metal cones, and stepped metaphyseal sleeves.
Bush et al. reviewed managing bone loss in TKA. They cautioned that joint line elevation, distal femoral bone loss, and femoral prosthesis downsizing leads to flexion instability. They advocate cement filling for Type I defects, modular augments for Type 2, impaction grafting for Type 1 or 3, structural allograft for Types 2 and 3, metaphyseal filling or megaprosthesis for Type 3, including porous metal implants.
Figure A shows an infected primary TKA with a stemmed tibial component with medial augments. This suggests that the revision implant will require at least a stemmed, augmented component. Figure B shows massive metaphyseal defects (AORI Type 2) at the time of explantation. Illustration A comprises postop images of osseointegrated metaphyseal sleeves and stemmed implants. Illustration B depicts the AORI classification (see Review Topic for detailed description). Images courtesy of Haidukewych et al (Ref 1).
Incorrect Answers:
Answer 1: While there indeed is an epiphyseal defect, it is the metaphyseal defect that needs to be addressed for implant stability. Impaction bone grafting may be used for contained Type 1 defects.
Answer 2: Structural allografts are an option. Because there will be no ingrowth at the allograft-implant interface, cement is necessary. Stems are necessary to bypass large metaphyseal defects and transfer load to diaphyseal cortical bone.
Answer 4: Porous metal cones can be used to address metaphyseal defects. They are used together with stemmed components, which are cemented inside the cones. The cones, in turn, are press-fit into the metaphysis.
Answer 5: The defects addressed during TKA revision are predominantly metaphyseal. Stemmed implants may be cemented or uncemented.

During templating for a total hip arthroplasty, placing the femoral head center of rotation directly superior to the center of rotation of the acetabular component will have which of the following effects?

1) Increase offset

2) Decrease limb length

3) Decrease offset

4) Increase limb length

5) No change in length or offset

Placing the femoral head center of rotation directly superior (above) the acetabular center of rotation will lengthen the limb without changing offset.
When templating the femoral component for a total hip arthroplasty, it is imperative to restore limb length and offset. To change limb length, the femoral component center of rotation (COR) can be adjusted in a superior or inferior direction. If the femoral component COR is superior to the acetabular component COR, the limb will be lengthened (as in the example above).
Conversely, if the femoral component COR is inferior to the acetabular component COR, the hip will be shortened. A change in offset will be determined by the medial/lateral relationship between the acetabular and femoral components. In the example above, the COR of the femoral component is directly above the COR of the acetabular component. In this situation, there is no change in offset.
Merle et al. performed a retrospective cohort study to identify differences in femoral offset as measured on an AP pelvis radiograph, AP hip radiograph, and a CT scan. They found that femoral offset is significantly underestimated on AP radiographs of the pelvis. In contrast, AP radiographs of the hip are much more accurate in representing true offset.
Della Valle et al. review the importance of preoperative planning prior to total hip arthroplasty. While they mention that templating can be very accurate, determination of stem and cup size should also be determined by tactile feedback during broaching and reaming.
Illustration A shows the femoral head COR inferior to the acetabular COR. This will result in a decreased limb length.
Incorrect Answers:
Answer 1: To increase offset, the femoral head COR should be placed medial to the acetabular COR.
Answer 2: To decrease limb length, the femoral head COR should be placed inferior to the acetabular COR (see Illustration A).
Answer 3: To decrease offset, the femoral head COR should be placed lateral to the acetabular COR.
Answer 5: In order to keep limb length and offset the same, the acetabular and femoral offsets must overlap.

Which of the following intra-operative errors most commonly leads to patellar maltracking during a total knee arthroplasty?

1) Using the gap balancing technique instead of measured resection technique

2) Internal rotation of the femoral component

3) External rotation of the tibial component

4) Lateralization of the femoral prosthesis

5) Overresection of the patella

Internal rotation of the femoral component increases the Q-angle and will increase the likelihood of patellar maltracking.
Patellar maltracking is one of the most common complications following a total knee arthroplasty. Any alteration that results in increased lateral retinaculum tension or an increased Q-angle may lead to patellofemoral instability.
Common causes include internal rotation of the femoral or tibial components, medialization of the femoral component, and placement of the patellar prosthesis on the lateral border of the patella. If a patient presents with postoperative maltracking and component rotation is thought to be the cause, a CT scan is the diagnostic study of choice.
Rhoads et al. analyze 7 cadaveric specimens to define the kinematics of the intact knee and to evaluate the effects of prosthetic replacement on those kinematics. Amongst other things, they showed that lateralization of the femoral component improved patellar tracking and prevented dislocation.
Malo et al. review patellar maltracking following a total knee replacement. They discuss the importance of externally rotating the femoral component on the femur relative to the posterior articular condyles to establish a rectangular and balanced flexion gap and to accommodate central patellar tracking.
Illustration A shows how an internally rotated femoral component displaces the patella medially. The blue line is a straight line upwards from the tibial tubercle, and the green line represents a line from the tibial tubercle to the center of the patella. The difference between the blue and green lines in the internally rotated prosthesis is the amount the patella has displaced medially. If you deviate the patella medially, this increases the Q-angle and could lead to patellar maltracking in a total knee replacement.
Incorrect Answers:
Answer 1: This has not shown to impact the incidence of patellar maltracking. Answer 3: External rotation of the tibial component decreases the Q-angle.
Answer 4: Lateralization of the femoral prosthesis decreases the Q-angle. Answer 5: Underresection of the patella, not overresection, overstuffs the patellofemoral joint and tightens the lateral retinaculum, which may lead to maltracking.

When performing a total knee arthroplasty on a 60-year-old female patient, a surgeon chooses not to resurface the patella. Instead, he performs a patelloplasty by excising the marginal osteophytes and reshaping the patella. All of the following statements comparing the results of patelloplasty to patella resurfacing are true EXCEPT:

1) There is no difference in relative risk of anterior knee pain.

2) There is no difference in relative risk for revision surgery involving the tibial and femoral components.

3) There is an increased risk that she will need secondary resurfacing.

4) No difference in rates of patellar avascular necrosis or patellar tendon injury.

5) Total knee arthroplasty improved function regardless of whether the patella was resurfaced.

In TKA with an unresurfaced patella, there is an increased risk of anterior knee pain and secondary resurfacing.
Surgeons can choose to resurface or not resurface all patellae, or selectively resurface patellae. In unresurfaced patellae, they may perform a patelloplasty (excise marginal osteophytes and reshape the patella). Unresurfaced patellae have increased risk of anterior knee pain requiring secondary resurfacing.
Indications for resurfacing include inflammatory arthritis, patella maltracking, patellofemoral osteoarthritis as the main indication for TKA.
Meneghini et al. reviewed the literature on patellar resurfacing. Prospective, randomized studies show conflicting results with regards to satisfaction rates between groups. Meta-analyses show increased risk of re-operation and anterior knee pain in the unresurfaced group.
Parvizi et al. performed meta-analysis on 1519 knees. They found there was
(1) lower relative risk of re-operation (resurfaced group), (2) lower relative risk of anterior knee pain (resurfaced group), (3) increased rate of secondary resurfacing (unresurfaced group), (4) no difference in patient satisfaction, (5) TKA improved function regardless of whether the patella was resurfaced, (6) no difference in complications.
Incorrect Answers:
Answers 2,3: There is no difference in the rate of revision surgery involving the tibial and femoral components. But in the unresurfaced group, there is an increased likelihood that secondary patellar resurfacing will be required (8.7% incidence).
Answer 4: Meta-analysis studies show that there is no difference in the rate of patellar fractures, avascular necrosis and patellar tendon injury. In more recent publications, there is a decreased risk of complications related to the extensor mechanism for both groups because surgeons are more aware of possible complications and because surgical techniques have improved.
Answer 5: This statement is true.

A 55-year-old patient returns for followup 2 years after a left ceramic-on-ceramic total hip arthroplasty. He has no pain or symptoms of instability. The video in Figure V shows him ascending stairs. All of the following factors may contribute to this phenomenon EXCEPT

1) Impingement

2) Edge-loading

3) Loss of fluid film lubrication.

4) Third-body particles

5) Subclinical infection

The clinical presentation is consistent for prosthesis squeaking following a THA. Squeaking is multifactorial and may include impingement, edge-loading, loss of fluid film lubrication, and third-body particles. Subclinical infection does not play a role in squeaking.
Squeaking is defined as a high-pitched, audible sound occurring during movement of the hip. In ceramic-on-ceramic (COC) hips, the incidence is 0.5-10%. The incidence of revision because of squeaking is 0.5%. Squeaking is less common in metal-on-metal bearing surfaces (4-5%).
Chevilotte et al. reviewed COC bearing surfaces. They found that without lubrication, squeaking occurred with normal gait, high load, stripe wear, material transfer, edge wear and microfractures. In contrast, with lubrication, squeaking only occurred with material transfer.
Finkbone et al. reviewed COC total hip arthroplasty in patients
Figure A shows the image of a 72-year-old male who sustained a fall from standing. Past medical history is significant for hypertension. He was a community ambulator without the use of a cane or walker prior to the fall. During the operation, he is noted to have a well-fixed acetabular component without significant wear of his polyethylene liner, but his femoral component is easily extractable. Which of the following correctly pairs his Vancouver classification and appropriate surgical intervention?
1) Vancouver A, Revision of femoral component to cemented stem with fixation of the fracture

2) Vancouver B1, Revision of femoral component to cemented stem with fixation of the fracture

3) Vanvouver B1, Revision of femoral component to a long, porous-coated, cementless stem with fixation of the fracture

4) Vancouver B2, Fixation of the fracture with a plate and cerclage wires

5) Vancouver B2, Revision of femoral component to a long, porous-coated, cementless stem with fixation of the fracture

Figure A shows a Vancouver B fracture around the femoral prosthesis. Because the prosthesis is noted to be loose during the operation, it is classified as a Vancouver B2 fracture. The most appropriate operation would be revision of the femoral component to a long, porous-coated, cementless stem in addition to fixation of fracture with a plate and cerclage wires.
According to the Vancouver classification, a type B2 fracture occurs around or just distal to a loose femoral stem with adequate proximal bone. Revision of the femoral component is necessary, with uncemented stems showing superior clinical results to cemented stems in most studies. The revision prosthesis should bypass the distal fracture by 2 cortical widths.
Corten et al. reviewed thirty-one patients with Vancouver B2 fractures that
were treated with a long cemented stem with additional allograft or plate fixation. At 46 months, none of the implants had to be revised, but it should be noted that 43% of the patients died within the first year.
Mulay et al. reviewed 24 patients with Vancouver B2 and B3 fractures managed with a cementless, tapered, fluted, and distally fixed stem. 91% of fractures united uneventfully. Complications included dislocations (5), nonunions (2), and infection (1).
Springer et al. review 116 patients with Vanvouver B fractures treated with revision of the femoral component. The uncemented, extensively porous-coated implants had the highest likelihood of stable fixation and were not associated with any nonunions.
Illustration A reviews the Vancouver classification for periprosthetic femur fractures. Illustration B shows a post-operative radiograph following a Vancouver B2 fracture. In this case, a trochanteric plate with cerclage wires was used to fix the fracture. A long-stemmed, porous-coated, cementless femoral prosthesis was used for the revision.
Incorrect Answers:
Answer 1: Vancouver A fractures involve the trochanteric region. Answer 2: Vancouver B1 fractures have a well-fixed femoral prosthesis. Answer 3: Vancouver B1 fractures have a well-fixed femoral prosthesis.
Answer 4: Because the femoral prosthesis was loose, it needs to be revised.

A 56-year-old male undergoes revision of his right hip arthroplasty for acute pain and radiographs suggestive of ceramic femoral head fracture. At the time of the revision, multiple fragments of the ceramic femoral head were seen in the joint and soft tissues. The components were noted to be in good position. He was copiously irrigated and the ceramic head was exchanged with a metallic femoral head. 12 months later, the patient presents with insidious onset right groin pain. Radiographs show no gross abnormalities without signs of loosening. Which of the following is the most likely cause of the patient's pain?

1) Periprosthetic infection

2) Massive third body wear

3) Pseudotumor formation

4) Soft tissue metallosis

5) Iliopsoas tendonitis

The most likely cause of the patient's pain is massive third body wear caused by retained ceramic fragments.
Cermamic femoral head fractures create many fragments that are difficult to extract at the time of revision surgery. During the revision surgery, it is imperative to remove all fragments that can be visualized. Despite a thorough debridement, microscopic fragments will still remain. These particles may cause pain through the creation of an inflammatory response in the tissues.
Exchange of the femoral head should be performed with another ceramic head, as opposed to a metal head. If a metal head is used, abrasive wear will ensue as the microscopic fragments will scratch the femoral head due to differences in hardness.
Traina et al. describe their experiences with revision of ceramic components. Most commonly, fractures of ceramic components occur as a result of trauma, dislocation, or errors in operative technique. These include head-neck taper mismatch, impacting the ceramic head with too much force, debris, and intraoperative damage to the metal neck taper.
Hannouche et al. review ceramics in total hip replacement. They state that if the ceramic is properly manufactured, it can be a highly effective, low-wear solution for the young patient in need of a total hip replacement.
Illustration A shows the typical ceramic femoral head used for a total hip arthroplasty. Illustration B shows a fractured ceramic head in many pieces.
Incorrect Answers:
Answer 1: The patients history & presentation are not consistent with infection Answer 3: Pseudotumor formation is most commonly associated with metal on metal prostheses.
Answer 4: This presentation is not consistent with soft tissue metallosis; additionally that would be seen in metal on metal prostheses.
Answer 5: While iliopsoas tendonitis is in the differential diagnosis for groin pain after a total hip replacement, the clinical situation is more consistent with third body wear as a result of retained ceramic fragments.

Figure A and B are radiographs of a 77-year-old patient presenting with right hip and upper thigh pain for the past 3 months. He is an avid golfer and plans to travel south for 6 months on a golf tour. He denies fever, chills or weight loss. His past medical history includes hypertension and a right total hip replacement 15 years ago. Physical examination reveals minimal pain with range of motion. ESR=10 (normal range 0-20) and CRP=4 (normal range 0-10). He does not want any further surgery. The patient is at the highest risk of which complication with non-operative care?
1) Infection

2) Pseudotumour formation

3) Periprosthetic femoral fracture

4) Periprosthetic acetabular fracture

5) Dislocation

This patient has presented with significant osteolysis and aseptic loosening of his femoral THA component. If untreated, he is at an increased risk of a periprosthetic femur fracture.
Indications for surgery for periprosthetic osteolysis include: pathological fracture, impending pathological fracture, symptomatic THA with evidence of osteolysis, and extensive osteolysis that would compromise revision surgery in the future. The goal of surgery is to remove the loose component, repair/bypass/replace bone deficiency, and obtain stable component fixation.
Robbins et al. reviewed the causes of pain in THA. They report that hip pain can originate from the implant, soft tissue, or bone. The use of laboratory tests (e.g. ESR/CRP), radiographic and fluoroscopic imaging, hip aspirate, contrast arthrography and local anesthetic injections can help to determine the origin of pain.
Ollivere et al. report that the most frequent cause of failure after total hip replacement in all reported arthroplasty registries is periprosthetic osteolysis. Osteolysis occurs with the activation of macrophages and a complex biological cascade that results in bone loss.
Hirakawa et al. analyzed the circumstances around retrieved failed THA components. They showed that cement mantle defects, noncircumferential porous coatings, and screw holes are risk factors for osteolysis. They conclude by saying that the formation of a granulomatous tissue that ultimately invades the bone-implant interface is the final step in the pathogenesis of aseptic loosening.
Figure A and B show AP and lateral views of a right THA. The femoral stem shows gross loosening in all zones. Subsidence is obvious with a high-riding greater trochanter. The lateral cement mantle is fractured. There is endosteal erosion distally with the tip of the stem showing radiographic toggle.
Incorrect Answers:
Answer 1: Infection should always be ruled-out in cases of osteolysis. In this case, however, there are no infectious symptoms and laboratory analysis is within normal ranges.
Answer 2: Pseudotumour formation largely occurs with metal-on-metal components.
Answer 4: Periprosthetic acetabular fracture is less likely. The cup has some
osteolysis, but it remains well fixed. Acetabular fractures are less likely when there is minimal osteolysis.
Answer 5: Hip dislocation can occur secondary to massive osteolysis. The long standing history from the index procedure make hip dislocation less likely. He has no other risk factors for dislocation.

A 60-year-old woman undergoes a total knee arthroplasty for end-stage osteoarthritis. Preoperative knee range of motion is 5 to 100 degrees. Postoperatively, she experiences reduced range of motion. She is scheduled to undergo manipulation under anesthesia. In which of the following scenarios is this procedure best indicated?

1) Knee range of motion 0 to 60 degrees at 2 months postoperatively

2) Knee range of motion 0 to 60 degrees at 8 months postoperatively

3) Knee range of motion 30 to 120 degrees at 2 months postoperatively

4) Knee range of motion 30 to 120 degrees at 8 months postoperatively

5) Knee range of motion 30 to 120 degrees at 2 weeks postoperatively

Manipulation under anesthesia (MUA) can achieve the greatest gains in flexion when performed for patients with less than 90 degrees of flexion within the first three months.
There are many risk factors for postoperative stiffness, the most important being preoperative stiffness. MUA is indicated when flexion is less than 90 degrees. Flexion gains are generally greater when applied early (6-12 weeks postoperatively) rather than late (>12 weeks). In cases with late-presenting stiffness (>12wks), MUA may still be attempted. Failed MUA is addressed with arthroscopic or open adhesiolysis +/- MUA, quadricepsplasty, or component revision.
Namba et al. compared the results of early (90 days) MUA. They found that: (1) knee flexion improved a mean of 32 deg and 20 deg after early and late MUA respectively, (2) extension improved in the early MUA group, but not the late MUA group, and (3) pain improved after early but not late MUA. Despite early MUA being more desirable, the authors state that patients with limited flexion at 6-12 months may still benefit from late MUA.
Keating et al. assessed the outcomes of MUA in 113 knees at a mean of 10 weeks after surgery. They found that (1) 90% of patients achieved
improvement in knee flexion of 35 degrees at 5 year followup, (2) there was no difference in flexion gains between early (12 weeks) MUA and (3) patients treated with MUA had better pain control than those without MUA. They concluded that manipulation can result in significant and lasting improvement in knee flexion.
Incorrect Answers
Answer 2: Late MUA (>3 months) is less effective than early MUA.
Answers 3-5: Loss of flexion is better treated with MUA than loss of extension.

A 62-year-old man is scheduled for a total knee arthroplasty. In his pre-operative office visit, he asks questions about different tibial components. You tell him that compared with the tibial component shown in Figure A, the tibial component shown in Figure B:
1) Is less expensive

2) Has greater durability

3) Has greater instability because of its monobloc nature

4) Provides improved short-term functional status, but no difference in long term functional status

5) Is associated with fewer adverse events because of easier implantation

Figure B shows an all-polyethylene tibia (APT) component, which is $470 to
$1650 less expensive than metal-backed tibia (MBT) designs.
It was traditionally thought that modular MBT may have lower survivorship (compared to APT) because of locking mechanism dysfunction, breakage,
backside wear, and osteolysis. However, many studies now show the two to be comparable, with the only difference being that APT are less expensive.
Voight et al. performed a systematic review comparing APT and MBT. They found that the former was cheaper. There was no difference in adverse events, durability (need for revision or radiographic failure) at 2, 10, and 15 years, and functional status at 2, 8, and 10 years.
Toman et al. compared APT and MBT retrospectively. They found that APT implants perform as well as MBT implants in patients with BMI 40.
Dalury et al. examined APT performance in obese patients (125 knees) after a minimum of 7 years. There were no implant failures. There were 5 nonprogressive tibial radiolucencies and 1 case of nonprogressive osteolysis.
Figure A shows a cemented metal-backed tibia component. Figure B shows a cemented all-polyethylene tibia component.
Incorrect Answers:
Answer 2: There is no difference in durability at up to 15 years.
Answer 3: Instability (>0.2 mm migration) was reduced by 48% with an APT (compared with MBT) but this was not significant (p = 0.05, Voight study).
Answer 4: There is no difference in functional status at short-, medium- and long-term followup.
Answer 5: There is no difference in adverse events.

Figures A and B show pre- and post-operative radiographs of a sedentary 75-year-old female who underwent surgery on her left hip. Based on the radiographic findings, what was the most likely indication for revision surgery?
1) Left acetabular fracture

2) Left acetabular cup osteolysis

3) Left femoral stem osteolysis

4) Left hip instability

5) Left femoral stem valgus malalignment

Figure A shows a left total hip arthroplasty with eccentric polyethylene wear. Figure B shows that her left hip was revised to a constrained acetabular liner, most likely a result of recurrent instability.
Revision strategies for hip instability are typically directed at correcting the underlying cause of instability. For example, instability most commonly occurs as a result of poor implant design, positioning or loosening, or the loss of soft-tissue function or tensioning. Operative strategies are designed to correct these etiologies by repositioning or exchanging components, integrating modular designs and improving soft tissue tensioning, etc. Constrained acetabular liners are often used in conjunction with these modalities to address the problem of recurrent instability relating to soft tissue deficiency and dysfunction in the affected hip.
Alberton et al. retrospectively reviewed 1548 revision arthroplasties for the incidence of dislocation. They found the overall dislocation rate to be 7.8%. Factors contributing to increased dislocations were found to be trochanteric non-unions, femoral heads 28mm and re-establishing abductor tensioning.
Paterno et al. retrospectively reviewed 438 primary and 181 revision total hip arthroplasties for patient factors contributing to dislocation. They found an overall dislocation rate of 6%. 23% of patients with a history of excessive intake of alcoholic beverages (more than six ounces a day) had at least one dislocation. There was no relationship between the variables of age, gender, obesity, or preoperative diagnosis and the incidence of dislocation.
Figure A shows bilateral primary cementless, nonconstrained total hip replacements. The left hip shows eccentric femoral head placement within the acetabulum indicative of eccentric polyethylene wear. Figure B shows the conversion to a constrained, dual-mobility, polyethylene liner. The overall metal component position appears satisfactory.
Incorrect Answers:
Answer 1: There is no radigraphic finding of fracture. In addition, acetabular fractures would not be treated with conversion to a constrained liner.
Answer 2,3: The presence of osteolysis in the femoral and acetabular components is not significant based on these radiographic images.
Answer 5: There is no valgus malalignment of the left femoral implant.

A 62-year-old woman is brought to the emergency room after falling down a flight of stairs. Prior to her fall, she had no knee pain and was a community ambulator without assistance. Intraoperatively,
it is determined that the implants are well-fixed. What is the best next treatment step to optimize her quality of life?
1) Closed reduction and long leg casting at 20 degrees of flexion for 6 weeks, followed by hinged-knee brace for 6 weeks.

2) Open reduction and internal fixation with a distal femoral locking plate

3) Open reduction and internal fixation with a condylar buttress plate

4) Distal femoral replacement arthroplasty

5) Closed reduction and fixation with an antegrade intramedullary nail

This patient has a displaced far-distal supracondylar fracture around a stable TKA femoral component. Locked plating is the best option for management of this fracture.
Surgical fixation of periprosthetic fractures around a stable femoral component is challenging. Locked plating allows for multiple angle-stable fixation points around stems and lugs and does not depend on TKA design or quality of distal bone stock for fixation. Su Type I fractures may be treated with retrograde or antegrade intramedullary nailing. Type II fractures require retrograde intramedullary nailing or fixed-angle plating. Type III fractures require fixation with a fixed-angle device or revision arthroplasty when bone stock is poor.
Ricci et al. evaluated indirect reduction and locked lateral plating of Vancouver B1 THA fractures without allograft struts. They found that all fractures healed with satisfactory alignment and without implant loosening at an average of 12 weeks. They recommend this technique for stable Vancouver B1 fractures.
Streubel et al. examined the outcomes of locked plating in treatment of extreme distal periprosthetic supracondylar fractures located proximal to the flange (Su Types I and II) compared with fractures distal to the flange (Su Type III, see Illustration B). They found no difference in delayed union, nonunion, infection and failure rates between the 2 groups.
Figure A shows a Su Type III periprosthetic fracture around a TKA femoral component. Illustration A shows fixation of the same fracture with a distal femur locking plate. Illustration B shows the Su classification of fractures around the femoral component (Type I, proximal to the femoral component; Type II, starting at the anterior flange and extending proximally; Type III, fracture line distal to the anterior flange).
Incorrect Answers
Answer 1: High rates of malunion and nonunion are associated with nonoperative treatment
Answer 3: The complication rate after non-locked plating is high and nonunion rates of up to 50% have been observed.
Answer 4: Distal femoral replacement arthroplasty is a good choice if bone stock is poor and the component is loose.
Answer 5: There is insufficient distal bone stock for interlocking screw purchase for antegrade intramedullary nailing. Retrograde nailing might be possible with this CR implant using far distal fixed-angle interlocking screws that lie distal to the anterior flange of the prosthesis.

Which of the following fractures would most likely require revision arthroplasty with a long-stemmed, uncemented prosthesis?
1) Figure A

2) Figure B

3) Figure C

4) Figure D

5) Figure E

Figure B shows a Vancouver B2 periprosthetic femur fracture with an unstable femoral stem that requires revision arthroplasty with a long-stemmed prosthesis.
The Vancouver classification for periprosthetic femur fractures can help guide treatment of these challenging problems. Vancouver A fractures involve the greater and lesser trochanter and can be initially managed with non-operative measures. Vancouver B fractures occur around the stem and are broken down into B1 (stable prosthesis), B2 (unstable prosthesis) and B3 (poor proximal bone quality) fractures. B1 fractures may be treated with internal fixation, B2 fractures require a revision arthroplasty, and B3 fractures often require more advanced reconstruction with a proximal femoral replacement versus revision with a distally fixed prosthesis. Vancouver C fractures occur distal to the stem and require internal fixation.
Springer et al. reviewed 118 patients who underwent revision arthroplasty for Vancouver B2 periprosthetic fractures. They had a 90% survival rate at 5-years and a 79.2% survival rate at 10-years. The most common reasons for revision were loosening, infection, and non-union.
Illustration A shows the Vancouver classification of periprosthetic fractures about the femur.
Incorrect Answers:
Answer 1: Figure A shows an interprosthetic fracture with stable components best treated with internal fixation.
Answer 3: Figure C shows a Vancouver A fracture best treated with either nonoperative management or internal fixation.
Answer 4: Figure D shows another interprosthetic fracture with stable components best treated with internal fixation.
Answer 5: Figure E shows a Vancouver B1 fracture with a stable component best treated with internal fixation.

A 65-year-old female sustains a periprosthetic supracondylar femur fracture proximal to a well-fixed implant. She undergoes direct reduction and locked plating with a titanium distal femoral locking plate via an extensile lateral approach. At 9 months post-operatively, weightbearing is at 50% and is painful. Examination reveals mild swelling and warmth around the distal incision. Erythrocyte sedimentation rate and C-reactive protein are normal. Radiographs taken 9 months post-operatively are shown in Figure A. Which of the following may have increased the risk of this complication?
1) Neglecting to add topical rhBMP-2 on a carrier-scaffold

2) Neglecting to use lag screws and cerclage cables

3) Locked plating instead of locked antegrade nailing

4) Use of a titanium plate instead of a stainless steel plate

5) Use of an extensile lateral approach instead of a submuscular approach

A submuscular approach has been shown to have less risk of nonunion than an extensile lateral approach. There is less disruption of soft tissue attachments and devitalization of fracture fragments with the submuscular approach.
The risks for periprosthetic fractures include notching, knee stiffness, osteoporosis, poor mobility and falls. The risk is higher in females and after revision surgery. The treatment of periprosthetic supracondylar fractures depends on the location of the fracture, fixation of the implant, and bone stock.
Hoffman et al. retrospectively reviewed 36 periprosthetic supracondylar femur fractures treated with locked plating. They found that submuscular plating had reduced nonunion risk compared to an extensive lateral approach. They recommend indirect reduction and submuscular plating to reduce the incidence of nonunion.
Hou et al. retrospectively reviewed 53 fractures fixed with retrograde nailing
(18) and locked plating (34). They found no difference in blood loss, time to union, operating time and hospital stay. They believe locked plating can
provide the same favorable results as retrograde nailing and recommend this technique for most patients and prosthetic designs.
Figure A shows nonunion and surrounding osteopenia after locked plating of a periprosthetic supracondylar fracture. Illustration A shows management of these fractures according to the Su classification.
Incorrect Answers
Answer 1: rhBMP-2 is not FDA approved for femoral fractures. It is only approved for acute, open tibial shaft fractures stabilized with intramedullary nail fixation, or spine fusion at L4-S1 for degenerative disc disease via an anterior approach.
Answer 2: Lag screws and cerclage cables do not decrease the risk of nonunion. Placement is difficult with short oblique fractures at the metaphysis. Answer 3: There is insufficient distal locking screw purchase for antegrade nailing.
Answer 4: The metallurgy of locked plates has not been shown to affect nonunion rates.

Immediately following a total hip arthroplasty (THA), a healthy 55-year-old patient is unable to dorsiflex her ankle or extend her great toe. After 4 weeks she continues to ambulate with a "slapping gait." Examination reveals passive ankle joint dorsiflexion to 10 degrees. What is the most appropriate next treatment option?
1) MRI of her spine and pelvis

2) Revision total hip arthroplasty

3) Ankle-foot orthosis

4) Posterior tibial tendon transfer to navicular bone

5) Neurology consult

This patient is presenting with foot drop after a THA for hip dysplasia (Crowe 4). The most appropriate treatment at this stage would be providing her with an ankle foot orthosis (AFO) for mobility.
Sciatic nerve injury after THA is an uncommon and difficult situation to manage. Patients with DDH that have undergone a large limb-lengthening procedure are at a greater risk due to the significant stretch of the sciatic nerve. Intra-operative procedures that have been shown to prevent this outcome include good pre-operative planning, limb lengthening
A 60-year-old male with history of renal transplantation and previous intravenous drug abuse undergoes total knee arthroplasty. Two years later, he begins to have mild knee pain and low-grade swelling that persists for 10 months before he finally comes to the emergency room. Examination reveals no fever. Range of motion is 5 to 70 degrees. Erythrocyte sedimentation rate is 22mm/h, and C-reactive protein is 0.8mg/L. Knee aspiration reveals 12,000/mm3 nucleated cells with 76% neutrophils. Gram stain is negative and aerobic and anaerobic cultures are negative after 4 days in culture. His symptoms do not resolve after 5 days of empiric intravenous antibiotics and he is taken to the operating room for arthroscopic irrigation and debridement. Operative synovial tissue cultures are shown in Figure A. What is the best next step?
1) Cessation of immunosuppressant medication, lifelong antimycobacterial suppression

2) Open irrigation and debridement, implant retention and lifelong antifungal suppression

3) Open irrigation and debridement, resection arthroplasty, antimycobacterial drugs for 6 to 12 months

4) Open irrigation and debridement, single-stage exchange, antifungal drugs for 6 to 12 months

5) Open irrigation and debridement, two-stage exchange, antifungal drugs for 6 to 12 months

This patient has a fungal prosthetic joint infection (PJI) with Candida albicans. Optimal treatment involves resection arthroplasty, delayed reimplantation
arthroplasty, and antifungal drugs for 6-12 months.
Fungal PJI are uncommon. Risk factors include immune suppression and systemic illness e.g. diabetes and chronic renal failure. Candida species is usually the causative organism. The infection is usually indolent and systemic symptoms (e.g. fever) may be absent. ESR and CRP may be only minimally elevated. Two-stage exchange arthroplasty is standard of care.
Phelan et al. described delayed reimplantation in 10 patients with fungal PJI. They found that the median time from resection to reimplantation arthroplasty was 9 and 2 months for total hip and total knee arthroplasty respectively. Two patients had recurrence of infection. They recommend antifungal therapy and delayed reimplantation arthroplasty after confirmation of an infection-free period as the best chance for cure.
Azzam et al. retrospectively reviewed arthroplasty database data to identify 31 fungal PJIs in 6 centers. Delayed implantation was performed in 19 of 29 patients who underwent resection arthroplasty at an average of 7 months.
They recommend two-stage exchange arthroplasty as the treatment of choice, addition of antibacterial drugs to the cement spacer to prevent superinfection, antifungal drugs for 6-12 months, repeat joint aspirations prior to reimplantation, and optimization of host nutritional status prior to reimplantation.
Figure A is a high-powered micrograph showing synovial tissue covered by fibrinopurulent exudates containing fungal colonies of Candida albicans.
Incorrect Answers:
Answer 1: Drug therapy alone will only suppress symptoms at the expense of potential toxic side effects, and is unlikely to eradicate the infection. Cessation of immunosuppression and lifelong antifungal treatment will be detrimental to the transplanted kidney.
Answer 2: Debridement alone, with implant retention, is unlikely to control the infection as most infections are chronic infections in immunocompromised hosts, both of which are recognized causes of failure of debridement alone.
Answer 3: While resection arthroplasty (without secondary reimplantation) is acceptable therapy, his infection is fungal in nature and should be treated with antifungals.
Answer 4: Single-stage exchange for fungal PJI has rarely been successful and is ill-advised because of the high recurrence rate. Recurrence rates of 20-25% after two-stage exchange has been reported.

Which of the following non-operative treatments for osteoarthritis has the best evidence to support its use?

1) Combination of supervised and home exercise programs

2) Hyaluronic acid injections

3) Lateral heel wedge

4) Acetaminophen

5) Glucosamine

Of the options listed, a combination of home and supervised exercise has the best supporting evidence for the treatment of osteoarthritis.
The AAOS has recently developed guidelines for the treatment of osteoarthritis. Therapies that are recommended by the AAOS include weight loss, home and supervised exercise programs, and NSAIDs/tramadol.
Therapies that remain inconclusive (lack of supporting evidence) include electrotherapeutic modalities, manual therapy, bracing, acetaminophen/opiods, steroid injections and PRP. Glucosamine, lateral heel wedges and hyaluronic acid injections are not recommended, as current literature has shown them to be ineffective. Keep in mind that these guidelines are subject to change as new literature is published.
Zhang et al. present a systematic review of the literature on arthritis management in the three years following the original OA Research Society International (OARSI) guidelines published in 2006. While weight loss showed an increase in effectiveness with the addition of new studies, electromagnetic therapy, glucosamine, chondroitin sulfate, and hyaluronic acid injections showed a decrease in effectiveness.
Incorrect Answers:
Answer 2: Current AAOS guidelines recommend against hyaluronic acid injections as they are not supported by evidence.
Answer 3: AAOS guidelines recommend against the use of lateral heel wedges. Answer 4: AAOS guidelines show inconclusive evidence for the use of acetaminophen.
Answer 5: AAOS guidelines state that the use of glucosamine is not supported by current evidence.

Figure A shows the 2 bundles of the ACL dissected from a cadaveric knee off their bony attachments. They are labeled Bundle A and Bundle B, respectively. Which of the following is true?
1) The tibial attachment of Bundle A is anterior to Bundle B. In extension, Bundle B is loose and Bundle A is tight.

2) The tibial attachment of Bundle A is anterior to Bundle B. In flexion, Bundle B is loose and Bundle A is tight.

3) The tibial attachment of Bundle B is anterior to Bundle A. In flexion, Bundle B is loose and Bundle A is tight.

4) The tibial attachment of Bundle B is anterior to Bundle A. In flexion, Bundle A is loose and Bundle B is tight.

5) The tibial attachment of Bundle B is anterior to Bundle A. In extension, Bundle A is loose and Bundle B is tight.

Bundle A is the anteromedial (AM) bundle, which is longer, and is tight in flexion. Bundle B is the posterolateral (PL) bundle, which is shorter, and is loose in flexion. The AM bundle is attached anterior to the PL bundle on the tibia.
The ACL is comprised of 2 bundles. The AM bundle is longer than the PL bundle. Their names reflect their relative anatomic positions on the tibial insertion site. On the femur, the AM bundle begins at the proximal-anterior aspect of the femoral insertion site, while the PL bundle begins at the posterior-inferior part. In flexion, the AM bundle is tight and the PL bundle is loose. In extension, the AM bundle is loose and the PL bundle is tight.
Bicer et al. reviewed the anatomy of the ACL. They found that the AM bundle was longer (32mm) compared with the PL bundle (18mm). PL bundle carries greater force near full extension, and the AM bundle carries greater force after 15-45° of flexion. Under combined rotatory loads (valgus and internal tibial torque at knee flexion >30°), the AM bundle bore more force than the PL bundle.
Figure A shows the 2 bundles of the ACL. The AM bundle is longer than the PL bundle. The oft referred to length of ACL refers mainly to the length of the AM bundle. Illustrations A and B show the spatial relationships of the AM and PL bundles in a cadaveric knee. Illustration C shows the relative positions of the attachments of each bundle.
Incorrect Answers:
Answer 1: In extension, Bundle B (PL) is tight, and Bundle A (AM) is loose. Answers 3 to 5: The tibial attachment of Bundle A (AM) is anterior to Bundle B (PL).

An 83-year-old man, who had a total hip arthroplasty performed 13 years ago, is referred to your office for evaluation. He reports worsening groin pain over the past year, which has been increasing in frequency. Prior to this past year, he had no other complaints. His current radiograph is shown in Figure A. If he continues to ambulate with this implant, he is at greatest risk for which of the following?
1) Infection

2) Acetabular component loosening

3) Femoral component loosening

4) Dislocation

5) Periprosthetic fracture

The patient has eccentric polyethylene wear secondary to component malpositioning. He is at highest risk for dislocation.
Late dislocation following total hip arthroplasty(THA) can occur and has a high recurrence rate, thereafter. Risk factors include eccentric polyethylene, THA at an early age, neurologic decline or associated neurologic conditions (i.e.
Parkinson's disease), or associated trauma.
Parvizi et al. noted in this instructional course lecture that eccentric, excessive polyethylene wear is one of the most common reasons for late, recurrent dislocation. Revision is recommended.
Pulido et al. in this review, reiterated that polyethylene wear can lead to increased inflammation, capsular distention, and instability, increasing risk for dislocation.
von Knoch et al. reviewing over 500 dislocated hips, also noted that eccentric wear was one of major causes linked to late dislocation.
Figure A. exhibits a left total hip arthroplasty with eccentric wear. Incorrect answers:
Answer 1. This patient is not at increased risk for infection.
Answers 2 and 3. While this patient is at increased risk for loosening, the risk of dislocation due to eccentric wear.
Answer 5. This patient is not at increased risk for fracture.

Figure A shows a radiograph of a 62-year-old female that underwent a left total hip arthroplasty 5 years ago. She presents to your office with insidious onset of left groin and buttock pain. She denies trauma, fever or chills. On physical examination, her left hip has mild pain with range of motion. She has a normal gait cycle, normal power across the hip and her vitals signs are stable. A left hip aspirate was performed and results are shown in Figure B. What is the most likely cause of her hip pain?
1) Periprosthetic bacterial hip infection

2) Periprosthetic hip fracture

3) Large-particle wear debris disease

4) Pseudotumor hypersensitivity response

5) Abductor tendon tear

This patient is presenting with a metal induced system hypersensitivity response in the setting of a metal-on-metal total hip arthroplasty.
A hip aspiration of a painful THR is a very useful investigation for the work up of infection, having a sensitivity of 75-85% and specificity of 85-100% for
infection. Metal-on-metal THA may mimic infection as aspirate results will often show increased inflammatory infiltrate, with synovial WBC counts in the thousands. However, infected THA are more likely to produce higher percentages of PMNs (>70%) in comparison to hypersensitivity reactions/ adverse reaction to metal debris, which are more likely to produce a higher percentage of lymphocytes (>40%).
Campbell et al. looked at the histological features of pseudotumor-like tissues from metal-on-metal hips. They found that the patients with hip pain and suspected metal sensitivity had fewer metal particles but more aseptic lymphocytic vasculitis-associated lesions compared to patients with evidence of metallic wear. They concluded that pseudotumors occur more because of a hypersensitivity reaction than particle wear.
Kwon et al. examined a small cohort of patients with metal-on-metal hip arthroplasties to investigate the incidence and level of metal-induced systemic hypersensitivity. They found that lymphocyte reactivity to Co, Cr, and Ni did not significantly differ in patients with pseudotumors compared to those patients without pseudotumors. This suggests that systemic hypersensitivity type IV reactions may not be the dominant biological reaction involved in the occurrence of the soft tissue pseudotumors.
Figure A shows a patient with bilateral metal-on-metal total hip arthroplasties. There are no identifiable fractures. The position of the left acetabular cup is slightly vertical, which can increase edge loading and particle wear. Figure B shows the results from the hip aspirate.
Incorrect Answers:
Answer 1: Although WBCs > 3000, the low differential of PMNs and high lymphocytes are not consistent with a bacterial joint infection. Infected THA are more likely to produce higher percentages of PMNs (>70%).
Answer 2: Radiographs and physical exam do not suggest fracture, although CT scan or bone scan may be useful to detect subtle periprosthetic hip fractures.
Answer 3: Large-particle wear debris disease most commonly occurs with polyethylene wear. This is a metal-on-metal hip replacement. Metal surfaces are thought to give off smaller particles of debris.
Answer 5: Abductor tendon tear would present with an abnormal gait and some element of decreased abductor strength. The aspirate would also be negative.

A 72-year-old patient is scheduled to undergo revision total hip arthroplasty. A 3D-model of the patient's hemipelvis is constructed for pre-operative planning and is shown in Figure A. A custom-designed implant shown in Figure B is created. Which of the following is TRUE of the planned reconstruction?
1) The implant is a bilobed cup.

2) The most common complication is dislocation.

3) The acetabular defect can be classified as AAOS Type V.

4) Radiation-compromised bone stock is a contraindication.

5) The winged profile of the implant facilitates insertion through both anterior and anterolateral approaches.

The patient has pelvic discontinuity that will be reconstructed with a custom triflange acetabular component. Dislocation is the most common complication.
Custom triflange acetabular components are indicated for severe acetabular bone loss and pelvic discontinuity that are not amenable to treatment with off-the-shelf implants such as reconstruction plates, jumbo cups and antiprotrusio cages. Dislocation is common and possible etiologies include extensive dissection, less reliable soft tissue repair, deficient abductors/trochanteric nonunion, superior gluteal nerve stretch neuropraxia, and surgeon reluctance to use constrained liners in the face of poor bone stock.
Christie et al. reviewed reconstruction with the triflange cup in 78 hips with AAOS Type III (combined deficiency) or Type IV (pelvic discontinuity) defects. They found improvement in Harris hip scores, limp, need for walking aids.
Dislocation was the most common complication (15.6%, 12 patients), and half of these patients (6/12) needed re-operation for recurrent dislocation. They recommend the triflange cup for difficult reconstructions involving severe bone loss.
Taunton et al. reviewed 57 patients with pelvic discontinuity treated with a custom triflange component. They found that 21% developed instability (10 required revision, and 2 treated nonoperatively). Of note, 51% had preop trochanteric escape (nonunion of the greater trochanter to the femoral component or femur with >1cm of displacement. They recommend the custom triflange implant for discontinuity as it provides predictable midterm fixation and consistent healing.
Figure A is a 3D hemipelvis model generated by stereolithography from a patient’s CT scan. It shows massive bone loss and pelvic discontinuity. Figure B is a custom hydroxyapatite (HA)-coated porous triflange acetabular prosthesis with ilial and ischial screw holes. Illustration A shows a bilobed cup and its appearance on an AP radiograph.
Incorrect Answers:
Answer 1: This is a custom triflange implant.
Answer 3: The acetabular defect is AAOS Type IV (pelvic discontinuity). AAOS Type V is an arthrodesed hip.
Answer 4: The implant is especially indicated for radiation-compromised bone stock.
Answer 5: An anterior and anterolateral approach may allow for screw fixation of the pubic wing, but will make screw fixation of the ischial and ilial wings impossible without detachment of the abductors.

All of the following are risk factors for wear-related failure in total knee arthroplasty when using a polyethylene liner that underwent sterilization via gamma irradiation in air EXCEPT?

1) Increasing shelf age of polyethylene liner

2) Younger age of patient

3) Male gender

4) Posterior cruciate retaining knee design

5) Use of a rough tibial baseplate

Increasing shelf age, younger age, male gender, and a rough tibial baseplate are all risk factors for wear-related failure in total knee arthroplasty when using a polyethylene liner. Posterior cruciate retaining knee design is not a documented risk factor.
Fehring et al reviewed 2091 TKA using the Press fit condylar system and noted that the 13-year survivorship for all patients was 82.6% with a 8.3% prevalence of wear-related failure. Cox hazards analysis revealed five variables that were correlated with wear-related failure: patient age, patient gender, polyethylene sheet vendor, polyethylene finishing method, and polyethylene shelf age. They were unable to identify one factor as the defining reason for these wear-related failures. They cautioned that these findings may only be specific to inserts that underwent sterilization via gamma irradiation in air.
Collier et al followed 365 TKA (PCL-retaining) for 5-10 yrs and noted that
factors related to polyethylene insert osteolysis included advanced shelf age, sterilization method, and the material from which it was machined. Osteolysis was identified in 34% with an insert that had been gamma-irradiated in air and affixed to a rough baseplate surface, but only 9% when the insert had been gamma-irradiated in an inert gas or not irradiated at all and joined to a polished surface.

A 65-year-old healthy patient fell 18 years after a total hip arthroplasty and sustained the fracture shown in Figure A. Which of the following would be the most appropriate treatment?
1) Percutaneous locked plating

2) Open reduction internal fixation with a cable plate and allograft strut

3) Revision to a long femoral stem with allograft bone

4) Revision to a cemented revision femoral stem that bypasses the fracture site by 5 cm

5) Three months of non-weight bearing

The Vancouver classification of periprosthetic femur fractures is based on the fracture site, implant stability, and remaining bone stock. The patient in the question has a type B3 fracture. The cemented stem is loose and there is very poor remaining bone stock. He should be treated with a long, cementless
revision stem with biplanar strut grafts. A tumor prosthesis or allograft-prosthesis composite would be alternate possibilities. Illustrations A and B are a diagram and table of the Vancouver classification of periprosthetic hip fractures.
Springer, et al. looked at the results and complications of revision total hip arthroplasty for the treatment of acute Vancouver type-B periprosthetic femoral fracture. In their series they treated these fractures in multiple ways, including cemented stems, uncemented stems, allograft-prosthetic composite, or tumor prosthesis. They concluded that the best results were with an uncemented, porous coated femoral stem, and the most common cause of revision was loosening.
Parvizi, et al. concluded that due to the poor bone quality and delayed healing of older patients & their periprosthetic fractures that it is imperative that a strong mechanical construct be achieved in the treatment of these fractures. They “advocate the use of numerous screws with purchase of at least ten cortices and reinforcement of fixation with biplanar strut allografts whenever possible. When a revision stem is used, we ensure that adequate diaphyseal fixation is obtained and the fracture is traversed by at least 5 to 8 cm.”

A 85-year-old man who underwent hemiarthroplasty 5 years ago now complains of thigh pain for the past four months. Laboratory studies show a normal white blood cell count (WBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). An aspiration of the hip is performed and is negative for infection. A radiograph is shown in Figure A. Which of the following is the best management option for the femoral implant?
1) Bone scan to look for loosening

2) Touch down weight bearing and physical therapy

3) Revision with a tumor prosthesis

4) Revision of femoral component with metaphyseal cement fixation of the stem

5) Revision to a cementless femoral component with diaphyseal press-fit fixation of the stem

The radiograph shows lucency around the femoral stem cement mantle consistent with loosening. There is bone loss in the proximal femur. Diaphyseal fixation is the best option from the choices available. Revision to a cementless femoral stem is the most appropriate management.
Paprosky et al. described their results of revision to cementless femoral components and report 95% survivorship with a minimum of 10 years follow
up.
Haydon et al showed that despite historical literature discouraging the use of cemented femurs for revision, in their experience cemented femoral revision had 91% survivorship when the cause was aseptic loosening. They found early generation cementing techniques, poor cement mantle, poor bone quality, age of less than 60, and male gender to be risk factors for failure in cemented revisions.

Figure A is a diagram showing the medial side of the knee. During a total knee arthroplasty, proximal tibia resection results in the transection of the ligament in Figure A along the red line. Intraoperative examination reveals coronal plane instability. What are the best next steps?
1) Use of the implant shown in Figure B, and use of a hinged knee brace postoperatively

2) Suture repair of the torn ligament, use of the implant shown in Figure C

3) Use of the implant shown in Figure D, and use of a knee immobilizer postoperatively

4) Suture repair of the torn ligament, use of the implant shown in Figure D, and use of a hinged knee brace postoperatively

5) Use of the implant shown in Figure C alone

This patient has intraoperative midsubstance transection of the MCL. MCL repair, use of either a CR or PS implant, and postoperative knee bracing for 6 weeks is recommended. A possible alternative is the use of an unlinked constrained implant.
The MCL is likely to be compromised by medially placed retractors or during medial subperiosteal elevation (tibial avulsion) or injured by oscillating saw-blade during the tibial or posterior femoral condyle cut. There is no consensus for the treatment of intraoperative rupture. Acceptable salvage options include
(1) direct repair (heavy sutures for midsubstance rupture, and suture anchors for tibial sleeve avusions) and postop knee bracing for 6 weeks with either CR or PS implants, or (2) use of unlinked constrained implants with or without repair.
Lee and Lotke reviewed 37 patients with intraoperative MCL injury out of 1478 patients. They attempted repair in 14 patients, and increased constraint in 30
patients. They found higher failure rates (regardless of MCL repair technique) for cruciate retaining components. They recommend use of an unlinked constrained prosthesis (with or without ligament repair), especially for midsubstance injuries.
Leopold et al. reviewed 16 MCL injuries in 600 knees. They performed suture or suture anchor repair and used a hinged knee brace for 6 weeks postoperatively. All limbs were stable and did not require bracing beyond 6 weeks, demonstrated acceptable alignment, and did not require revision at 45 months. They recommend the use of primary MCL repair or reattachment and postoperative bracing instead of implants with increased constraint.
Figure A shows MCL transection in its midsubstance. Figure B shows a cruciate retaining implant. Figure C shows a hinged knee prosthesis (linked constrained implant). Figure D shows a posterior stabilized implant. Illustration A shows an unlinked constrained implant.
Incorrect Answers:
Answer 1: A cruciate retaining implant can be used (together with postoperative knee bracing) provided MCL repair/reattachment is performed. On its own, a CR implant cannot control coronal instability from a ruptured MCL.
Answers 2 and 5: A hinged knee is not indicated for simple ruptures of collateral ligaments. A hinged knee prosthesis is indicated for moderate to severe instability, ligament deficiency (eg, absence of 1 or both collateral ligaments), severe bone loss, or varus, valgus, or flexion deformities.
Answer 3: A posterior stabilized implant can be used (together with postoperative knee bracing) provided MCL repair/reattachment is performed. On its own, a PS implant cannot control coronal instability from a ruptured MCL.

A 65-year-old woman complains of intermittent knee pain 12 years after a total knee arthroplasty. She has no history of fever or recent infections. Radiographs are shown in Figures A and B. Examination reveals minimal warmth and a moderate knee effusion. Range of motion is 5 to 100 degrees bilaterally. The C-reactive protein level is 15 mg/L (normal, 0.0-0.8mg/L), and erythrocyte sedimentation rate is 45mm/h (normal, 0-10mm/h). Arthrocentesis reveals 7500 white blood cells and 90% neutrophils. Gram stain is negative. Cultures are negative at 3 days. What is the next best step?
1) MRI with metal subtraction protocol

2) Arthroscopic debridement

3) Open debridement and polyethylene liner exchange

4) Single-stage revision total knee arthroplasty (TKA)

5) Explantation of components with two-stage revision TKA

By the updated 2018 Musculoskeletal Infection Society (MSIS) criteria, this presentation is consistent with a diagnosis of periprosthetic joint infection (PJI). The patient has an elevated CRP (2), ESR (1), synovial WBC >3,000 (3), and >80% PMNs (2), for a total of 8 points. Given the chronicity of the infection, the patietn would be a candidate for two-stage revision.
This patient has clinical signs of PJI such as elevated laboratory values and radiographs suggestive of implant loosening. Even in the absence of positive cultures, the next most supported step in management if two-stage revision with explantation of the prosthesis and insertion of an antibiotic spacer.
Intraoperative cultures should be taken to guide post-operative antibiotic treatment.
Parvizi et al. recently released the updated 2018 MSI crtieria for diagnosis of PJI. The updated criteria (Illustration A) included new diagnostic tests and studies from the seven-year period since the previous criteria were established. Alpha defensin was a new addition. The two major criteria remained, each individually diagnostic of PJI. However the minor crtieria were broken down into pre-operative and intra-operative. The authors showed that a total of 6 points or more had a 97.7% SN and 99.5% SP for PJI.
Huang et al. retrospectively reported the infection control rates in 2-stage exchanges in 55 patients, and compared culture-negative cases with 295 culture-positive cases. They found that infection control in culture-negative cases was 73% at 1-year. Infection control rates were similar in culture-negative and culture-positive cases, and that infection-free survival is highest after 2-stage exchange with postoperative vancomycin. They recommend 2-stage exchange with postoperative vancomycin.
Buller et al. retrospectively assessed traits that would predict the success of debridement and liner exchange for 62 hips and 247 knees. They found that 149 (48.2%) cases failed to eradicate infection. Risks for recurrent infection include longer symptom, higher ESR, previous PJI or infection in the same joint, and an infection by a group 1 (MRSA, VRE, and methicillin-resistant S. epidermidis) or group 2 (MSSA or methicillin-sensitive coagulase-negative Staphylococcus) organism.
Della Valle et al. discuss the AAOS recommendations on diagnosis of periprosthetic hip and knee infections. They recommend repeat hip and knee aspirations when there is discrepancy between probability of PJI and initial aspiration culture result.
Aggarwal et al. prospectively compared the yield of intraoperative tissue and swab cultures in 74 hip, 43 knee, 30 septic and 87 aseptic cases. They found that tissue cultures had higher sensitivity, specificity, positive and negative predictive values for identifying PJI. Swab cultures had higher false positive and negative values. They recommend not using swab cultures, and only using tissue cultures.
Figures A and B are AP and lateral radiographs showing areas of bony erosion suggestive of loosening of the femoral and tibial components.
Illustration A is the 2018 MSIS criteria with point values.
Incorrect Answers:
Answer 1: MRI is not a recommended imaging modality if infection is suspected. Nuclear imaging (labeled WBC, bone scan, FDG-PET, gallium scan) is recommended instead.
Answer 2: Arthroscopic debridement is only indicated in the absence of infection e.g. adhesiolysis, patellar clunk.
Answer 3: Debridement and liner exchange is appropriate for acute PJI but will also not address prosthetic loosening.
Answer 4: Single-stage revision is not the accepted standard and is not as successful with clearance of pathogens as double-stage revision.

What are the affects on limb-length and offset according to the total hip arthroplasty template shown in Figure A?
1) Limb-length will stay the same, offset will be increased

2) Limb-length will be decreased, offset will be increased

3) Limb-length will stay the same, offset will be decreased

4) Limb-length will be increased, offset will be increased

5) No change in either limb-length or offset

In Figure A, the center of rotation of the femoral component lies medial to the center of rotation of the acetabular component. If these components are implanted as shown, the offset will be increased and the leg-lengths will remain equal.
Offset and leg-length changes during templating and insertion of a total hip replacement are determined by the changes in the center of rotation (COR) of the femur relative to the acetabulum. If changes are made in the horizontal plane (x-axis), a change in offset will occur. If changes are made in the vertical plane (y-axis), changes in leg-lengths will occur. If the femoral COR is templated superior to the acetabular COR, the leg will be lengthened. In
contrast, if the femoral COR is templated inferior to the acetabular COR, the leg will be shortened. For offset, the same principles apply. If the femoral COR is templated medial to the acetabular COR, offset will be increased. In contrast, if the femoral COR is templated lateral to the acetabular COR, offset will be decreased. One should aim to restore native offset and leg-lengths in uncomplicated primary total hip arthroplasty.
Merle et al. retrospectively reviewed 152 patients to evaluate femoral offset on an AP pelvis and AP hip radiograph compared to a CT scan of the affected hip. They found that AP pelvis radiograph underestimated femoral offset by 13% when compared to a CT scan. In contrast, the AP hip radiograph showed no difference when compared to the CT scan. They recommend obtaining AP of the hip prior to templating for accurate assessment of femoral offset.
Della Valle et al. review preoperative planning for total hip arthroplasty. While they state that templating has a high predictive value in achieving the desired plan, the surgeon should always be prepared to make intraoperative adjustments based on tactile feedback.
Illustration A shows an example where leg-length will be shortened (femoral COR is inferior to acetabular COR) and offset will stay the same (femoral COR and acetabular COR are in the same horizontal plane). Illustration B is a table which summarizes the points we have discussed.
Incorrect Answers:
Answer 2: This would be true if the femoral COR was templated medial to the acetabular COR, and if the femoral COR was templated inferior to the acetabular COR.
Answer 3: This would be true if the femoral COR was templated lateral to the acetabular COR.
Answer 4: This would be true if femoral COR was templated superior/medial to the acetabular COR.
Answer 5: This would be true if femoral and acetabular COR were templated at the same levels in both the horizontal and vertical planes.

A 65-year-old patient is diagnosed with a periprosthetic joint infection 6 years after total knee arthroplasty. He recalls a history of knee realignment surgery many years prior. Examination reveals lateral patellar tracking and passive flexion to 65 degrees. A recent radiograph is shown in Figure A. During the exposure for explantation, a standard medial parapatellar approach is performed through the previous incision. It is found that adequate knee flexion to allow exposure of the prosthesis cannot be achieved even after release of the lateral gutters and excision of the scar. Which surgical exposure technique (depicted in Figures B through F) would provide the best
surgical exposure for the procedure and preserve the blood supply to the patella?
1) Fig B

2) Fig C

3) Fig D

4) Fig E

5) Fig F

A tibial tubercle osteotomy (TTO) would provide the best surgical exposure without compromising patellar blood supply. This patient has patella baja arising from previous high tibial osteotomy, with a scarred, contracted patellar tendon leading to knee stiffness.
A TTO is able to provide good exposure while protecting the extensor mechanism and preventing inadvertent avulsion of a contracted patellar tendon. Further, proximal transfer of the osteotomized tibial tubercle may be used to correct patella baja, bearing in mind that excessive superior translation alters the mechanics of the knee by making the quadriceps less efficient.
Mendes et al. used TTO for surgical exposure in 67 knees undergoing revision TKA. There were good-excellent knee scores at 30 months in 87%. There were no patellofemoral complications, no component malalignments, and no avulsions of the patellar tendon occurred. They advocate TTO for cases where the patellar cannot be retracted laterally with knee in 90deg of flexion.
Whiteside described a series of TTO in 136 TKA. At 2 years, mean range of motion was 94deg. There were 2 tibial tubercle avulsion fractures and 3 tibial fractures (2 in a patient with Charcot arthropathy, and 1 following manipulation after open adhesiolysis. He advises using stemmed tibial components in patients with insensate knees and in cases where manipulation is expected.
Figure A is a lateral radiograph showing severe patella baja. Figure D shows a TTO. See below for Figures B, C, E and F. Illustration A shows the surgical technique for TTO. The distal saw cut angles out of the anterior cortex at a gentle angle to reduce the stress riser effect and risk of postoperative tibial stress fracture.
Incorrect Answers:
Answer 1: Figure B shows a quadriceps snip and lateral retinacular release. This technique provides good exposure for most revisions and will allow patella flip, but it does not provide as much exposure as a TTO, and may compromise the lateral genicular artery supply to the patella.
Answer 2: Figure C shows a patellar turndown (or VY turndown). The incision transects the rectus tendon, the vastus lateralis tendon, and the lateral retinaculum. This exposure provides excellent exposure but may compromise patellar blood supply.
Answer 4: Figure E shows a quadriceps snip. This technique provides increased exposure over a standard medial parapatellar approach but is unlikely to be
sufficient in the presence of severe patellar baja and patellar tendon contracture.
Answer 5: Figure F shows a modified V-Y quadricepsplasty. The incision curves along the edge of the vastus lateralis tendon, avoiding the lateral superior genicular artery. While this technique aims to preserve patellar blood supply, superior and medial branches are divided in the process. It will also not provide as much exposure as a TTO.

Figure A show pre- and post-operative radiographs, from left to right respectively, of a 79-year-old male that underwent revision total hip arthroplasty 2 years ago. He presents today for consultation after 4 episodes of right hip dislocation within the past 6 months. Physical examination reveals a trendelenburg gait with no clinical or radiographic limb length discrepancy. An Infection work-up is negative. Results from a CT scan are shown in Figure B. What would be the best treatment option?
1) Physiotherapy and application of abductor brace

2) Revision arthroplasty to medialize the cementless cup and surgical repair of the abductor tendon

3) Revision arthroplasty to a constrained polyethylene liner

4) Revision arthroplasty to a femoral component with extended offset

5) Revision arthroplasty to a large ceramic femoral head and offset polyethylene cup

On the left, Figure A shows a metal-on-metal (MOM) bearing hip resurfacing. On the right, Figure A shows a large head, uncemented metal-on-polyethylene (MOP) total hip replacement. In this setting, the most appropriate treatment option would be revision arthroplasty with constrained polyethylene liner.
Constrained liners should be reserved for patients demonstrating recurrent instability despite treatment with a large femoral head. Other indications include elderly patients who do not require implant longevity or have a low functional demand, as well as patients with deficient or non-repairable abductor mechanisms.
Sikes et al. report on the results of a series of 41 patients (52 hips) with recurrent dislocations. They recommend that large femoral heads (LFH) be used as a first-line treatment in high-risk patients (patients of any age with dementia, neuromuscular disability, and inability to comply with precautions). Constrained liners should be reserved for patients demonstrating recurrent
instability despite treatment with an LFH.
Kilampali et al. reviewed late instability of bilateral metal on metal hip resurfacings. They suggest that late instability of hip resurfacing should raise concerns relating to possible local tissue reaction and muscle damage.
Concerning features include steeply-inclined acetabular components a large abduction angle of more than 55 degrees along with a combination of small size component.
Figure A shows an image of a revised socket which was performed to convert the MOM THA to a MOP THA. Figure B shows normal parameters of THA components. The recommendation for acetabular position is anteversion 20° ± 10° and abduction 45° ± 10°. For the femur, recommendations are 10°- 15° of anteversion and 41mm - 45mm of offset.
Incorrect Answers:
Answer 1: Conservative treatment would be indicated in patients not suitable for operative intervention.
Answer 2: Medializing the cup would likely increase the potential for dislocation.
Answer 4: Revision arthroplasty to a femoral component with extended offset would help to decrease joint reaction forces. However, this patient has deficient abductors, which is likely related to local tissue reaction and muscle damage from the metal on metal implant.
Answer 5: A large ceramic femoral head and offset polyethylene cup would not help to restore stability.

Which of the following has been shown to increase the rate of failure of cemented femoral components in total hip arthroplasty?

1) Stems that are precoated with polymethylmethacrylate

2) Calcar contact of the collar

3) Smoother implant corners

4) Cement mantle of 2 millimeters

5) Stem material with a Young's modulus higher than 115 GPa

Precoating a stem with PMMA adds an additional inferface at risk of failure.
Stiffer stem materials (higher Young's modulus) improve performance. Titanium has a Young's modulus of 115 GPa with alloy and stainless steel
having a higher Young's modulus than titanium. Calcar collar contact adds minimal strength to the construct, but does not lead to premature failure. Smoother corners decrease the rate of failure since they decrease stress risers. The ideal cement mantle is ~2mm. Obtaining less than this would decrease the strength of the construct.

An 80-year-old male sustains a fall down the stairs and presents with knee swelling. He is a community ambulator who does not use walking aids. Injury radiographs are shown in Figures A and B. What is the next best step?
1) Intramedullary nailing

2) Locked plating

3) Long leg casting

4) External fixation

5) Revision total knee arthroplasty

This patient sustained a periprosthetic femoral fracture around the femoral component which is now loose. Revision of the femoral component is necessary.
Various classifications exist for periprosthetic fractures around TKA. In general, for the femoral component, treatment depends on fracture displacement, fracture location, bone stock, and whether the component is loose. For loose femoral components, revision TKA using distal femoral replacement prosthesis is an option.
Kim et al. proposed a new classification for periprosthetic fractures. Type IA fractures (good bone stock, well fixed, nondisplaced or easily reducible) are managed conservatively. Type IB fractures (good bone stock, well fixed, irreducible closed) are managed with reduction and fixation. Type II fractures (good bone stock, reducible, loose or malpositioned components) are managed with revision. Type III fractures (poor bone stock, loose or malpositioned components) are treated with distal femoral replacement.
Johnston et al. reviewed the options for treating periprosthetic fractures about the knee. They advocate revision of the femoral component when the prosthesis is loose, where there is poor bone stock, or insufficient bone to gain purchase for locked plates or distal locking screws of intramedullary nails.
Nauth et al. review the current concepts in treatment of periprosthetic fractures. They prefer minimally invasive locked plating unless the fracture is significantly proximal to the anterior flange and amenable to retrograde intramedullary nailing. Then they choose nails with options for distal interlocking screws and locking condylar bolts. In extreme osteopenia, they use intramedullary fibular strut allografts (with locked plating). For loose prostheses or poor bone stock, they perform alloprosthetic composite in younger patients and a distal femoral replacement in elderly patients.
Figures A and B are AP and lateral radiographs showing periprosthetic femoral fracture around a loose femoral component. Illustrations A and B are postoperative radiographs showing revision to a hinged prosthesis with long-stemmed components. Illustration C shows Kim' proposed classification of
periprosthetic fractures around the femoral component of a TKA.
Incorrect Answers:
Answers 1, 2, 3, 4: A loose femoral component requires revision.

Utility of the implant seen in Figure A would be best considered in which of the following revision total hip arthroplasty scenarios?
1) Minimal acetabular deformity, intact rim

2) Superior acetabular bone lysis with intact superior rim

3) Localized acetabular destruction of medial wall

4) Absent superior acetabular rim, superolateral migration

5) Significant acetabular bone loss, pelvic discontinuity

Paprosky Type 3B acetabular bone defects describes significant acetabular bone loss, with pelvic discontinuity. Type 3 defects often require reconstruction cages (as seen in Figure A) or acetabular distraction techniques
to treat severe bone loss with an associated pelvic discontinuity.
Deficient acetabular bone stock poses a technical challenge in hip arthroplasty surgery. Paprosky classification for acetabular bone loss to helps guide treatment for revision total hip arthroplasty. The classification is as follows:
Type 1: Minimal deformity, intact rim
Type 2A: Superior bone lysis with intact superior rim Type 2B: Absent superior rim, superolateral migration Type 2C: Localized destruction of medial wall
Type 3A: Significant bone loss, superolateral cup migration Type 3B: Significant bone loss, pelvic discontinuity
Sheth et al. reviewed acetabular bone loss in revision total hip arthroplasty. They state that Paprosky Type 1 and 2 defects can usually be managed with porous-coated hemisphere cup secured with screws. Type 3 defects require reconstruction cages to protect with cups and structural augments or custom triflange implants.
Taunton et al. investigated clinical outcomes and cost-effectiveness of using a custom triflange acetabular component to treat pelvic discontinuity in revision THA. They found satisfactory clinical outcomes (81% had a stable triflange component with healed pelvic discontinuity) and cost equivalence with Trabecular Metal cup-cage constructs.
Figure A shows a lateral image of the pelvis with a reconstruction cage and cup construct. Illustration A shows an illustration of the Paprosky classification. Illustration B shows a table of the Saleh/Gross classification. Illustration C shows a table of the AAOS classification.
Incorrect Answers:
Answer 1: Minimal deformity, intact rim = Paprosky Type 1 defects. These can be treated with porous-coated hemisphere cup secured with screws.
Answer 2: Superior bone lysis with intact superior rim = Paprosky Type 2A defect. This can be treated with porous-coated hemisphere cup secured with screws.
Answer 3: Localized acetabular destruction of medial wall = Paprosky Type 2C defect. This can be treated with porous-coated hemisphere cup secured with screws +/- bone grafting.
Answer 4: Absent superior acetabular rim, superolateral migration = Paprosky Type 2B defect. This can be treated with porous-coated hemisphere cup secured with screws, jumbo cups +/- metal augments +/- bone grafting.

A 65-year-old male who had a total knee arthroplasty 8 years ago comes into the office with worsening knee pain. The orthopaedic surgeon is concerned about infection and aspirates the knee. Which of the following are the lowest laboratory values from a synovial aspirate suggestive of infection?

1) WBC of 500 cells/ml and PMN 25%

2) WBC of 1,000 cells/ml and PMN 25%

3) WBC of 1,500 cells/ml and PMN 70%

4) WBC of 5,000 cells/ml and PMN 70%

5) WBC of 25,000 cells/ml and PMN 70%

WBC of 1,500 cells/ml and PMN 70% indicates the lowest synovial aspirate suggestive of infection.
Mason et al in 2003 reviewed 440 revision TKA's of which 86 had preoperative aspirations. The aspirations yield 55 aseptic failures and 31 septic failures. The mean WBC of the aseptic group was 645 cells/mm(3) compared to 25,951 cells/mm(3) for the septic group (P=1100 cells/mm3 and PMN > 64% are suggestive of infection. When both tests yielded results below their cutoff values, the negative predictive value was 98.2% (95% confidence interval, 95.5% to 99.5%), whereas when both tests yielded results greater, infection was confirmed in 98.6% (95% confidence interval, 94.9% to 99.8%) of the cases. Thus, according to the most recent literature, WBC >1100 and PMN > 64% should be considered suggestive of infection in a TKA.

A 50-year-old man with a past medical history significant for diabetes and end-stage renal disease presents with a chief complaint of instability 6-months following a total knee arthroplasty. Preoperative radiographs are shown in Figures A-C. Physical exam at that time was notable for a large effusion, maltracking patella, extensor lag of 15 degrees, medial instability, and gross laxity to anterior and posterior forces. The procedure was uncomplicated, and was completed using a posterior-stabilized prosthesis with tibial augements and uncemented intramedullary rods in both the femur and tibia. Which of the following surgical techniques should have been implemented to avoid this complication?
1) Cementing the intramedullary rods in the tibia and femur

2) Explant with placement of an antibiotic spacer

3) Taking 5mm of extra bone from the distal femur to elevate the joint line

4) Use of a hinged total knee arthroplasty

5) Taking 5mm of extra bone from the tibia to distalize the joint line

The patient has a neuropathic joint with ligamentous instability and a maltracking patella. The appropriate procedure would have included use of a hinged total knee arthroplasty.
Choosing the appropriate constraint during a total knee arthroplasty ensures the best possible outcome. Hinged total knee arthroplasty prostheses are indicated in the setting of global instability, massive bone loss in a neuropathic joint, oncologic procedures, and hyperextension instability. In a hinged prosthesis, the tibial and femoral components are linked with an axle that restricts varus/valgus and translational stresses. While hinged prostheses are useful in the setting of major revision surgery, they are at increased risk for aseptic loosening due to the high degree of constraint inherent to the device.
Petrou et al. review the results of 100 primary cemented rotating-hinge total knee arthroplasty at 7- to 15-years. At 15 years, survival was 96.1%.
Complications included DVT (n=3), skin necrosis (n=2), subcutaneous hematoma (n=5), intra-operative fracture of either the femur or tibia (n=4), and early infection (n=2).
Figures A-C show a neuropathic joint with considerable lateral bone loss and a frankly dislocated patella. Illustration A shows an example of a hinged total knee arthroplasty. Note how the tibial and femoral components are linked using an axle.
Incorrect Answers:
Answer 1: Cementing the intramedullary rods would not have increased the amount of device constraint.
Answer 2: There were no concerns for infection based on the information given in the question stem, and instability is unlikely to be the primary complaint in an infected prosthesis.
Answer 3: Elevating the joint line would not have improved the sensation of post-operative instability.
Answer 5: Distalizing the joint line would not have improved the sensation of post-operative instability.

A 63-year-old man returns for follow-up 4 years after metal-on-metal left total hip arthroplasty complaining of mild chronic hip pain with ambulation. He is afebrile and ESR and CRP are within normal limits. Radiograph of the left hip is shown in Figure A. What is the best next step?
1) Anti-inflammatory medication

2) Serum cobalt and chromium levels

3) MRI with metal subtraction

4) Physical therapy

5) Revision hip arthroplasty

Metal-on-metal total hip arthroplasties (THA) have been associated with complications presumably due to metal debris and toxicity. Serum cobalt and chromium levels are recommended as part of follow-up evaluation for patients with metal-on-metal hips, even when asymptomatic.
Many patients with metal-on-metal hips have been found to have elevated serum cobalt and chromium levels, for which MR with metal subtraction is recommended to look for pseudotumors and other pathologies. These solid or cystic masses are thought to be related to metal debris and macrophage infiltration and may be associated with pain in some patients.
Lombardi et al summarize and present on behalf of The Hip Society an algorithmic approach to evaluating and treating patients with metal-on-metal THA in follow-up. They state the goals of care as determining the etiology of any pain, managing any intrinsic problems with the arthroplasty, and reassuring/observing when appropriate. They organize the types of patients seen in followup and components of the evaluation.
Chang et al evaluate the correlation between symptoms and MRI findings and report that symptomatic patients tend to have bone marrow edema and tendon tearing on MRI. They report a 69% prevalence of pseudotumors on MRI after metal-on-metal hip arthroplasty, but did not find a correlation between pseudotumor presence and pain.
Hayter et al focus on MRI findings in symptomatic (painful) patients with metal-on-metal THA in a review including 31 hip resurfacing and 29 THA. In the THA group, they report 86% rate of synovitis, 10% extracapsular disease, and 24% osteolysis, with no statistically significant difference in rates between resurfacing and THA.
Figure A is an AP view radiograph of a left hip after metal-on-metal total hip arthroplasty with components well positioned and no osteolysis.
Illustrations A and B from Lombardi et al depict a recommended algorithm for the workup and management of symptomatic and asymptomatic patients, respectively, with metal-on-metal THA.
Incorrect Answers:
Answer 1: Anti-inflammatory medication can be a treatment for pain but the best next step is to continue the diagnostic workup.
Answer 3: MRI with metal subtraction should be ordered for patients with elevated serum metal levels or to work up persistent pain after metal levels are checked.
Answer 4: Physical therapy can be a reasonable treatment option after a full diagnostic workup is complete.
Answer 5: Workup with metal levels should be completed before considering any revision or invasive treatment.

A 72-year-old woman sustains a fall onto her knee three years after an uncomplicated total knee replacement. The fracture pattern is seen in Figure A. The operative note reveals that a cemented patellar component was used. On exam, she has a large effusion and an
inability to straight leg raise. If the patellar component is well fixed, what is the best treatment option?
1) Patellectomy

2) Extensor mechanism allograft

3) Revision of the patellar component with cement and bone grafting of any residual defect

4) Open reduction and internal fixation of the patella fracture

5) Non-operative treatment in a knee brace locked in extension for 6 weeks

Displaced, periprosthetic patella fractures with a deficient extensor mechanism and adequate bone stock are best treated with open reduction and suture or implant fixation.
Periprosthetic patella fractures are a rare, but potentially devastating complication associated with total knee arthroplasty. When evaluating patella fractures, it is important to consider 1) is the extensor mechanism intact, 2) is the patellar component well fixed or loose, and 3) is there sufficient bone stock remaining. Stable implants with an intact extensor mechanism should almost exclusively be treated non-operatively in a brace. In contrast, a deficient
extensor mechanism is an absolute indication for surgical management.
Adigweme et al. review the epidemiology, diagnosis, and treatment of periprosthetic patella fractures. When analyzing patella fractures, they suggest treatment should be based on fracture severity, remaining bone stock, patellar component stability, as well as extensor mechanism function.
Sarmah et al. review periprosthetic fracture around total knee arthroplasty. They provide an algorithm for treatment of periprosthetic patella fractures based on displacement, viability of remaining bone stock, and fracture type.
Figure A is a preoperative lateral radiograph showing a periprosthetic patellar fracture. The distal fragment is comminuted and separated from the proximal fragment by approximately 15 mm. The patellar component appears to be well fixed. Illustration A is intraoperative photograph showing the threads of the suture anchors in the proximal fragment passing through the tunnels in the distal fragment and exiting at the inferior pole of the patella. Illustration B demonstrates anatomical reduction after the knots were tied at the inferior pole of the patella. Illustration C is a lateral x-ray 1 year postoperatively showing fracture union.
Incorrect Answers:
Answer 1: Patellectomy is reserved for cases where patellar bone stock is insufficient.
Answer 2: Extensor mechanism allograft has similar indications to a patellectomy. Indications include a deficient extensor mechanism and poor patellar bone stock.
Answer 3: In this situation, the patellar component is not loose. Therefore, it does not need to be revised.
Answer 5: Non-operative treatment should only be considered if the extensor mechanism is intact.

Knee pain and osteoarthritis are associated with "metabolic syndrome." All of the following are included in the collection of risk factors known as "metabolic syndrome" EXCEPT:

1) Peripheral vascular disease

2) Dyslipidemia

3) Hypertension

4) Impaired glucose tolerance

5) Central obesity

Peripheral vascular disease (PVD) may develop in patients with metabolic syndrome. However, no direct relationship between metabolic syndrome and PVD is known, and it is not a part of metabolic syndrome itself. Metabolic syndrome has been shown to be associated with knee pain and development of knee osteoarthritis (OA).
Metabolic syndrome is a collection of medical comorbidities that are known to
be risk factors for developing cardiovascular disease. Metabolic syndrome includes central (abdominal) obesity, dyslipidemia (high triglycerides and low-density lipoproteins), high blood pressure, and elevated fasting glucose levels. There is an increased prevalence of knee pain (and OA) among patients with metabolic syndrome. It is felt that the most important contributing factor to knee pain and OA in metabolic syndrome is obesity. Patients presenting with knee pain or OA and the risk factors included in metabolic syndrome should be counseled on the need to control those risk factors.
Inoue et al. present a study comparing metabolic syndrome and knee OA in a Japanese population. They found that knee OA and metabolic syndrome were highly correlated in females, but not in males.
Engström et al. present a study comparing metabolic syndrome with hip and knee OA. They found no relationship to hip OA, but did find a strong correlation between patients with metabolic syndrome and risk of developing knee arthritis. Patient BMI was the most predictive factor. They also compared prevalence of knee OA to CRP levels, but found no significant relationship.
Incorrect answers:
Answers 2, 3, 4, and 5: These represent the collection of risk factors known as "metabolic syndrome."

A 75-year-old male presents with recurrent dislocations of this left hip. He underwent bilateral total hip arthroplasties 12 and 8 years ago. There were no early post-operative complications with either hip. Despite a total of 5 dislocations in 6 months, he does not have pain or weakness across the left hip. On examination, there is a healthy appearing left lateral scar, equal limb lengths, normal gait and full abductor strength. Radiographs of the pelvis are shown in Figure A. His laboratory results show an erythrocyte sedimentation rate of 8 mm/h (reference range, 0-20 mm/h), and C-reactive protein of 3 mg/L (reference range, 0-5.0 mg/L). A hip aspirate culture is negative. What is the next best management option for this patient?
1) Magnetic resonance imaging of left hip to exclude an abductor muscle tear

2) Re-aspiration of left hip to exclude a subclinical infection

3) Continued observation for trochanteric bursitis

4) Supervised physiotherapy and gait training for abductor strengthening

5) Left revision total hip arthroplasty for polyethylene wear

This patient presents with recurrent late hip instability with radiographic evidence of eccentric polyethylene wear. The best treatment option for this patient would be revision total hip arthroplasty (THA).
The etiology of late instability includes polyethylene wear, component malpositioning or loosening, trauma, infection or deterioration in neurological status of the patient. Identifying the cause of late instability will require a thorough work up. A good history, examination and scrutiny of radiographs can identify most causes. Advanced imaging may be requires when bone or soft-tissue pathology is suspected or radiographic evidence of osteolysis or malpositioning needs further assessment. Blood work to assess for an acute inflammatory response (ESR and CRP) should be ordered routinely as elevated markers may indicate an underlying infection.
Parvizi et al. evaluated the outcome of revision arthroplasty for polyethylene wear presenting as late dislocation. They found that revision surgery restored stability to eighteen of the twenty-two patients. Surgical treatment options may include liner-only exchange (contained or unconstrained) +/- soft-tissue repair, or revision of one or all components.
Berry et al. evaluated the long-term risk of dislocation in 6,623 consecutive primary total hip arthroplasties with a Charnley prosthesis. They found a 7% incidence of late dislocation at 25 years compared to 1% after 5 years.
Patients at highest risk were females, patients with osteonecrosis of the femoral head or an acute fracture, and nonunion of the proximal part of the femur.
Figure A shows an AP pelvis with bilateral, uncemented, total hip arthroplasties. There is eccentric wear of the left acetabular component. No fracture or loosening of the components can be identified. The components appear well-positioned.
Incorrect Answers:
Answers 1: Magnetic resonance imaging is effective for the assessment of the periprosthetic soft tissues in patients who have had a total hip arthroplasty.
This patient has no pain or weakness in the affected hip. Therefore, soft tissues can be evaluated intra-operatively during the revision THA procedure. Answer 2: A hip aspirate would not be warranted. There are no risk factors for infection in this patient (for example, no pain, no early wound complications or antibiotics, etc). Additionally, his inflammatory markers are normal.
Answer 3: Continued observation can be considered, but recurrent dislocations in the setting of polyethylene wear would be considered an indication for surgery.
Answer 4: Supervised physiotherapy would be considered in a patient with clinical evidence of weakness in the setting of an initial dislocation.

A 58-year-old woman undergoes a total knee arthroplasty with a posterior stabilized design. Two years later, she returns with recurrent sterile joint effusions, a sensation of instability without giving way and difficulty with ascending and descending stairs. Examination reveals diffuse tenderness around the pes anserinus and peripatellar region, and increased anterior tibial translation most notable at 90° of flexion. Radiographs demonstrate well cemented implants with 5° of posterior tibial slope. Figure A represents a femoral cutting block with lines 1 through 5 corresponding to femoral bone cuts. The most likely cause of her symptoms is over-resection at:
1) Resection line 1

2) Resection line 2

3) Resection line 3

4) Resection line 4

5) Resection line 5

Over-resection of the posterior femoral condyles (resection line 2) in posterior-stabilized (PS) TKA leads to flexion instability without frank dislocation.
There are 7 bone cuts in a total knee replacement. The posterior condylar cut determines the flexion gap. Flexion instability in PS knees arises because of an enlarged flexion gap (excessive posterior condylar resection, or increased tibial slope), allowing anterior tibial translation, which is pathognomonic. There will not be posterior subluxation because of the cam-post design. Symptoms include sensation of instability without giving way, especially with stair climbing, recurrent knee effusions, and diffuse knee pain. Signs include anterior tibial translation at 90° flexion, tenderness at multiple sites (including pes anserinus, peripatellar, posterior hamstrings), and effusion. Revision surgery is indicated for symptomatic patients.
Clarke et al. reviewed flexion instability after primary TKA. They caution that most cases arise from failure to create symmetric balanced flexion and extension spaces. Treatment is usually revision TKA using the same principles. If this is not possible, increased constraint is required (constrained condylar prosthesis or hinged prosthesis).
Schwab et al. reviewed flexion instability without dislocation in PS knees in 10 patients. Revision surgery focused on flexion-extension gap balancing and filling the enlarged flexion gaps and successfully relieved pain, and improved stability to anterior tibial translation. Flexion space reconstruction includes using a larger femoral component or posterior augments. Isolated polyethylene exchange is not recommended.
Figure A shows a 5-in-1 cutting block with anterior femoral cut (line 1), posterior femoral cut (line 2), posterior chamfer cut (line 3), anterior chamfer cut (line 4), and distal femoral cut (line 5). Of note, most TKA systems have a 4-in-1 cutting block and the distal femoral cut is made separately. Illustration A shows restoration of the posterior condylar offset (line A) with the femoral component (line B).
Incorrect Answers
Answer 1: The anterior femoral cut does not affect the flexion gap. Underresection leads to oversizing of the femoral component and patellofemoral stuffing (leading to patellar maltracking and reduced flexion). Over-resection leads to notching. A good cut looks like a grand piano.
Answer 3: The posterior chamfer cut does not affect the flexion gap. The posterior and anterior chamfer cut are essential for the prosthesis to fit over the distal femur.
Answer 4: The anterior chamfer cut does not affect the flexion gap.
Answer 5: The distal femoral cut does not affect the flexion gap. The amount of bone resected should be equal to the thickness of the femoral component. This cut sets the extension gap. Additional bone may be resected to correct a flexion contracture.

Which of the following is true regarding intra-operative fractures during total knee arthroplasty?

1) They occur more commonly in cruciate-retaining total knee replacements

2) Fractures of the medial femoral condyle are the most common fracture type

3) Fractures of the patella are the most common fracture type

4) Most can be treated without additional fixation at the time of surgery

5) Tibial fractures are more common than femoral fractures

Fractures of the medial femoral condyle are the most common type of intraoperative fracture during a total knee arthroplasty.
Intra-operative fractures during total knee replacement are rare, but usually requiring alterations in surgical technique once they occur. The most common time for fractures to occur is during exposure and bone preparation, with fracture during trialing being the next most common. Fractures occur more commonly in posterior cruciate substituting designs, likely due the box cut.
Osteoporosis, female gender, chronic steroid use, advanced age, rheumatoid arthritis, and neurologic disorders are risk factors for post-operative fracture, but are also thought to be risk factors for intra-operative fractures.
Alden et al. reviewed 17,389 primary TKAs and found an intra-operative fracture rate of 0.39%. Of the 67 fractures, 49 were femur fractures, 18 were tibia fractures, and none were patella fractures. They recommend careful surgical technique in patients at high risk for fracture to avoid such a complication.
Sharkey et al. reviewed 10 intra-operative femoral fractures during primary, cementless total hip arthroplasty. They matched these with 20 patients who did not have this complication. At follow-up, there were no differences found between the two groups.
Incorrect Answers:
Answer 1: Fractures occur more commonly in cruciate-substituting total knee replacements due to the box cut.
Answer 3: Intra-operative fractures of the patella are quite rare. In the series reported above they had no instances of patella fracture.
Answer 4: Most fractures require treatment consisting of a wires, screws, and/or plates.
Answer 5: Femoral fractures are more common than tibial fractures during total knee arthroplasty.

A 68-year-old male complains of increasing medial sided knee pain and buckling. The pain is exacerbated by sharp turns while
running. He undergoes knee arthroscopy. Recent radiographs and an arthroscopic photograph of the medial compartment are shown in Figure A. His pain has worsened since the arthroscopy. Which of the following images (Figures B through F) represents the best treatment recommendation for this patient?
1) Figure B

2) Figure C

3) Figure D

4) Figure E

5) Figure F

This patient has isolated medial compartment osteoarthritis with Outerbridge IV medial compartment cartilage wear on arthroscopy. The best surgical option is a medial unicompartmental knee arthroplasty (UKA).
Indications for UKA include range of motion >100deg with 30), and ACL deficiency in medial UKA. Asymptomatic patellofemoral chondromalacia is not a contraindication. In general, a UKA is preferred for older, less active patients with minimal varus, more severe arthritis, and no/little knee instability. A HTO is preferred for younger, active patients, with milder arthritis, more malalignment, and AP instability.
Steadman et al. retrospectively examined outcomes of TKA after arthroscopic treatment of OA in 73 patients. They found that mean survival time (conversion to TKA) after arthroscopy was 6.8 years (5.7 years in patients with Kellgren-Lawrence grade 4, and 7.5 years in those with grade 3). They conclude that in patients who want to avoid TKA, arthroscopy may help postpone TKA.
LaPrade et al. examined the results of proximal tibial opening wedge
osteotomies in 47 patients
A 58-year-old female, with a BMI of 34 kg/m2, underwent a total knee arthroplasty for osteoarthritis 6 weeks ago. She has been participating in supervised rehabilitation since the procedure. Her preoperative, intra-operative and 6 week post-operative knee flexion are shown in Figure A. Current radiographs are shown in Figure B. What is the best step in management?
1) Convert to a resurfaced patella

2) Downsize the polyethylene liner

3) Arthroscopic lysis of adhesions and release of posterior capsule

4) Continuous passive motion at home for two weeks

5) Manipulation under anesthesia

This patient has early post-operative stiffness after total knee arthroplasty (TKA). The next best step would be manipulation under anesthesia.
Management of stiffness following TKA can be challenging. The standard initial treatment option for post-operative knee stiffness is physical therapy. When this fails to achieve knee range of motion (ROM) greater than or equal to 90°, alternative treatment modalities should be considered, such as knee manipulation under anesthesia (MUA). MUA is a non-invasive treatment shown to achieve dramatic improvement in knee flexion during the early postoperative period (usually considered less than three months). Periprosthetic fracture during manipulation is rare, with an overall incidence less than 1%.
Issa et al. examined a cohort of patients that underwent MUA after TKA. At a mean follow-up of 51 months (range, 24 to 85 months), the mean gain in flexion in the MUA cohort was 33° (range, 5° to 65°). There was one periprosthetic fracture in 134 patients. The authors noted a significant improvement in ROM from pre-manipulation values.
Manrique et al. reviewed stiffness after total knee arthroplasty. MUA may be considered within the first three months after the index TKA if physical therapy fails to improve the ROM. Beyond this point, consideration should be given to surgical intervention such as lysis of adhesions, either arthroscopic or open.
Maniar et al. looked at the effectiveness of continuous passive motion immediately after TKA. A total of 84 patients were allocated to no CPM; 1 day CPM; or 3 day CPM. They found that continuous passive motion immediately after TKA did not improve short or mid-term knee ROM.
Figure B shows a cruciate sacrificing total knee arthroplasty with implants in a good position.
Incorrect Answers:
Answer 1: Indications for patellar resurfacing include inflammatory arthritis, patellar mal-tracking and patellofemoral arthritis (as the main generator of pain). Knee stiffness is not an indication for patellar resurfacing.
Answer 2: Downsizing the polyethylene spacer would not be indicated at this stage. Downsizing the polyethylene liner would increase the flexion and extension gaps. Because the patient had excellent motion intraoperatively, this outcome is unlikely to be related to the spacer size.
Answer 3: Arthroscopic lysis of adhesions and release of the posterior capsule would be considered after three months if there was persistent knee stiffness after MUA.
Answer 4: There is currently no high level evidence to suggest CPM as an effective treatment for arthrofibrosis post TKA.

Which of the following fracture patterns (Figures A-E) would require revision of the femoral component to a long-stemmed, cementless prosthesis?
1) Figure A

2) Figure B

3) Figure C

4) Figure D

5) Figure E

Figure C depicts a Vancouver B2 periprosthetic fracture, which is optimally treated with a long-stem, fully porous-coated, revision femoral prosthesis.
The Vancouver classification for total hip periprosthetic femoral fractures takes into account the three most important factors in management of these injuries: the site of the fracture, the stability of the femoral component, and the quality of the surrounding femoral bone stock. Type A fractures include those involving the lesser trochanter or the greater trochanter. Type B fractures occur around the stem or just below it. More specifically, B1 fractures have a well fixed stem, B2 fractures have a loose stem but good proximal bone stock and B3 fractures have a loose stem with proximal bone that is of poor quality or severely comminuted. Type C fractures are well below the tip of the femoral stem.
O'Shea et al. assessed the outcome of patients with Vancouver type B2 and B3 periprosthetic fractures treated with femoral revision using an uncemented extensively porous-coated implant. Union of the fracture was successfully achieved in 20 of the 22 patients. Overall, they found good early survival rates and a low incidence of nonunion using this implant.
Figure A depicts a radiograph of a Vancouver type C periprosthetic femur fracture, occurring distal to the stem of the total hip arthroplasty. Figure B demonstrates a Vancouver type A periprosthetic fracture of the greater trochanter. Figure C is an x-ray of a Vancouver type B2 periprosthetic fracture adjacent to the stem with an unstable implant, but adequate bone stock.
Figure D depicts a radiograph of a Vancouver type C periprosthetic femur fracture, occurring distal to the stem of the total hip arthroplasty. Figure E is a Vancouver type B1 periprosthetic fracture at the level of the stem that is well fixed. Illustration A shows a table summarizing the Vancouver classification of periprosthetic femur fractures and the corresponding management options.
Incorrect Answers:
Answer 1: Vancouver type C fractures are best treated with ORIF using a plate.
Answer 2: Vancouver type A (GT) fractures are typically managed using cerclage wiring or trochanteric claw plating, if displaced
Answer 4: Vancouver type C fractures are best treated with ORIF using a plate.
Answer 5: Vancouver type B1 fractures, are managed by ORIF using cerclage cables and locking plates.

Which of the following maneuvers places the obturator artery at greatest risk during a total hip arthroplasty?

1) Placement of a posterior retractor along the posterior wall

2) Placement of an acetabular screw in the posterior-superior quadrant

3) Placement of an inferior retractor under the transverse acetabular ligament

4) Placement of an acetabular screw in the anterior-superior quadrant

5) Placement of an anterior retractor along the anterior wall

Damage to the obturator artery most commonly occurs from placement of an inferior retractor inferior to the transverse acetabular ligament (into the obtrator foramen), and/or placement of an acetabular screw in the anterior-inferior quadrant.
Vascular injury during total hip arthroplasty is a rare but devastating complication with a reported incidence of 0.1%-0.2%. The obturator artery travels along the quadrilateral surface of the acetabulum and exits the pelvis at the superolateral corner of the obturator foramen. If the vessel is severely
damaged and bleeding cannot be controlled, ligation of the internal iliac artery has been reported.
Nachbur et al. report on 15 cases of severe arterial injury during hip reconstructive surgery over a period of 8 years. The most common injury was injury to the external iliac artery, the common femoral artery, or main branches of the lateral and medial circumflex femoral artery. These were thought to be caused by the tip of a narrow-pointed Hohmann retractor used for exposure of the hip joint.
Rue et al. review neurovascular injuries during total hip arthroplasty. Among other things, they recommend against placement of screws in the anterior-superior quadrant, prudent retractor placement, and avoiding excessive tension on the sciatic nerve.
Della Valle and Di Cesare review complications resulting from total hip replacement. They state that injury to the obturator artery can occur with acetabular screw fixation in the antero-inferior quadrant or from retractors placed underneath the transverse acetabular ligament.
Illustration A shows the obturator artery as it exits the pelvis at the superolateral corner of the obturator foramen. Illustration B reviews acetabular screw placement and the structures at risk in each quadrant.
Incorrect Answers:
Answer 1: This retractor places the sciatic nerve at risk.
Answer 2: This screw places the sciatic nerve and superior gluteal artery at risk. Although injury to these structures is possible, this zone is considered "safe."
Answer 4: This screw places the external iliac artery and vein at risk, and is considered the "danger" zone.
Answer 5: Anterior retractor placement with sharp retractors place the external iliac and femoral arteries at risk.

A 65-year-old male sustains a fall onto his left hip 3 years after a total hip arthroplasty. A radiograph taken at the emergency room is shown in Figure A. What is the next best step?
1) Open reduction and internal fixation with locked plates and cables through an extensile approach

2) Revision with a proximally porous-coated stem

3) Revision with an extensively porous-coated stem

4) Nonoperative management

5) Minimally invasive plate osteosynthesis

The patient has a Vancouver B2 periprosthetic fracture. There is a loose stem that should be treated with revision to an extensively coated stem that bypasses the fracture site.
Revision of the femoral component is recommended for Vancouver B2 and B3 periprosthetic fractures. Type B1 fractures are treated with ORIF and stem retention, and proximally deficient B3 fractures may be treated with alloprosthetic composites or tumor prostheses.
Springer et al. retrospectively reviewed 118 hips with Vancouver B fractures. Seventy-seven percent of 30 extensively coated stems, 60% of 42 cemented stems, 36% of 28 proximally coated stems, and 61% of 18 tumor prosthesis/allo-prosthetic composite stems were well fixed and demonstrated
fracture union. Nonunion and loosening were the most common complications. They recommend extensively porous-coated stems for better results.
Haidukewych et al. review revision of periprosthetic fractures. They found that most acetabular components are well fixed. When the distal fragment has parallel endosteal cortices with >=5 cm of tubular diaphysis (usually with a diameter of

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Patients who are older than age 45 years and have initial dislocations are at greater risk for tearing the rotator cuff. Patients who are unable to lift the upper extremity or who have continued pain should undergo further evaluation for potential rotator cuff tears; early diagnosis is preferred. Physical therapy or continued use of a sling will be of little benefit. A corticosteroid injection might delay the diagnosis and compromise subsequent rotator cuff repair. Repairing the labrum generally is not necessary in a patient of this age who has an initial dislocation.
REFERENCES: Hawkins RJ, Bell RH, Hawkins RH, Koppert GJ: Anterior dislocation of the shoulder in the older patient. Clin Orthop 1986;206:192-195.
Matsen FA III, Thomas SC, Rockwood CA: Anterior glenohumeral instability, in Rockwood CA, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 526-622.

In a parallel design trial, participants are randomized to 2 or more groups, each of which receives a different treatment or intervention. For example, Group A receives the drug and Group B receives the placebo. This type of
design allows for comparison between groups. In a crossover design clinical trial, both groups receive both interventions over a defined time period. For example, Groups A and B both receive the drug as well as the placebo. This allows for within-participant comparisons. In a cohort study, patient groups are followed over time on the basis of having or not having received an exposure. Cohort studies are not randomized. In a case series, patients often receive a particular treatment and the outcomes are then examined.
726. An otherwise healthy 50-year-old man who is a smoker undergoes a posterior spine fusion with instrumentation for spondylolisthesis. What can the patient do to minimize his risk for pseudarthrosis?
1. Increase calcium and vitamin D intake
2. Avoid all nonsteroidal anti-inflammatory drugs (NSAIDs)
3. Maintain smoking cessation
4. Engage in early physical therapy to strengthen the trunk musculature
**CORRECT answer: 3**
Smoking is the biggest risk factor for nonunion and should be strictly avoided. NSAIDs interfere with bone healing, but not as strongly as smoking. Early mobilization would potentially stress the construct, inducing movement that leads to nonunion. Without history of calcium and vitamin D deficiency, increasing intake would not decrease the risk of nonunion.
727. When making a comparison to autograft incorporation, the inflammatory process in allograft tissue anterior cruciate ligament (ACL) reconstruction
1. occurs earlier.
2. occurs later.
3. is prolonged.
4. is shortened.
**CORRECT answer: 3**
Compared to similar autograft, allograft tissue demonstrates a prolonged inflammatory response, slower rate of biological incorporation and remodeling, and a higher proportion of large-diameter collagen fibrils. Native ACL inserts
into bone through a transition of 4 distinct zones: tendon, unmineralized fibrocartilage, mineralized fibrocartilage, and bone. This transition is not reproduced with tendon grafts, which instead heal with interposed fibrovascular scar at the graft-tunnel interface. The scar rapidly remodels to form perpendicular fibers resembling Sharpey fibers and, eventually, mature bone growth into the outer portion of the graft. The intra- articular portion of allograft undergoes an initial phase of necrosis followed by repopulation by host synovial cells into the acellular collagen scaffold.
Revascularization and maturation complete the ligamentization of graft tissue.
728. A researcher decides she wants to look at the current total number of patients who have methicillin-resistant** _Staphylococcus aureus_**(MRSA) infections in a hospital on 1 particular day. What is the researcher measuring?
1. Correlation coefficient of MRSA
2. Prevalence of MRSA
3. Incidence of MRSA
4. Relative risk of MRSA
**CORRECT answer: 2**
The prevalence of a disease is a measure of the number of cases of a disease at or during a specific time point or time period. In this case, the researcher wants to know the prevalence of disease on a given day. Incidence measures new cases of a disease or event per unit of time. Correlation coefficient is a measure of how 2 things correlate with one another, while relative risk is a statistical outcome that is often used in case-control or cohort studies to provide a measure of the risk of a particular disease occurring when a certain exposure has already occurred.
729. A 48-year-old man who is scheduled to undergo total knee replacement has an X-linked clotting disorder that leads to abnormal bleeding and recurrent, spontaneous hemarthrosis. Before undergoing surgery, he should have replacement therapy of
1. protein C and S.
2. vitamin K.
3. von Willebrand factor.
4. factor VIII.
**CORRECT answer: 4**
Hemophilia A is an X-linked recessive deficiency of factor VIII that can lead to significant bleeding problems including recurrent spontaneous hemarthroses that can lead to synovitis and joint destruction. von Willebrand disease is a lack of von Willebrand factor that leads to decreased platelet aggregation; more commonly patients have mucosal bleeding and not hemarthroses. Vitamin K deficiency is not hereditary; it is typically attributable to inadequate dietary intake, malabsorption, and loss of storage sites from hepatocellular disease. Protein C and S deficiencies are autosomal-dominant diseases that lead to thrombosis, not bleeding, as protein C and S shut off thrombin formation.
730. What is the recommended optimal timing of presurgical antibiotic administration to prevent infection in patients undergoing total joint replacement surgery?
1. Within 1 hour before incision
2. Within 2 hours before incision
3. Immediately after incision
4. Within 1 hour after incision
**CORRECT answer: 1**
The current recommendation for antibiotic prophylaxis for major orthopaedic surgical procedures is to administer intravenous antibiotics within 1 hour of surgical incision. Redosing of antibiotics should occur 3 to 4 hours after the initial dose for procedures that extend beyond 3 to 4 hours. Little evidence supports postsurgical antibiotic use beyond 24 hours. As you move beyond 1 hour from time of administration of antibiotics, risk for infection increases and rates of bacterial cell death decline. It is not acceptable to
administer presurgical antibiotics after incision.
731. **Bacterial resistance to antibiotics in biofilm is an example of**
1. avoidance.
2. decreased susceptibility.
3. inactivation.
4. mutation. **CORRECT answer: 1**
Three basic mechanisms of antibiotic resistance have been identified: avoidance, decreased susceptibility, and inactivation. Biofilm formation is a classic example of avoidance, whereby the biofilm creates a physical barrier to the antibiotic. Bacteria can decrease their susceptibility to antibiotics by mutating the antibiotic target or generating a mechanism to inactivate the antibiotic. Biofilm formation develops when a sufficient mass of bacteria forms on a surface. The cell-to-cell signaling becomes sufficient to activate transcription of genes needed for biofilm formation in a process known as quorum sensing. Once the bacteria produce a mature biofilm, they enter a greatly reduced or stationary phase of growth. Lastly, high-shear
environments seem to stimulate biofilm production.
732. A patient with Paget disease who is intolerant of bisphosphonates is given calcitonin. What is the mechanism of action of calcitonin?
1. Promotes reabsorption of phosphate in the renal tubules
2. Interferes with osteoclast maturation
3. Interferes with intestinal absorption of calcium
4. Upregulates osteoblast formation
**CORRECT answer: 2**
Calcitonin is a hormone that reduces serum calcium concentration by directly interfering with osteoclast maturation via receptors. Calcitonin inhibits phosphate reabsorption and decreases calcium reabsorption in the kidneys. By attenuating cartilage breakdown and stimulating cartilage formation via inhibitory pathways of matrix metalloproteinases, calcitonin also has a
chondro-protective effect on articular cartilage. Calcitonin has no major effects on intestinal absorption of calcium, but may aid in small-bowel secretion of sodium, potassium, chloride, and water. Calcitonin also has no receptor effect on osteoblasts.
733. **A cartilage water content increase is the hallmark of which**
**osteoarthritis stage?**
1. Prearthritis
2. Early
3. Late
4. Terminal
**CORRECT answer: 2**
The first stage of osteoarthritis is marked by an increase in water content secondary to disruption of the matrix framework. This is followed by an increase in chondrocyte anabolic and catabolic activity in response to tissue damage. Wnt-induced signal protein 1 increases chondrocyte protease expression. Failure to restore tissue balance ultimately leads to continued destruction and osteoarthritis. One hallmark of osteoarthritic cartilage is a reduced repair mechanism attributable to decreased chondrocyte response to growth factor stimulation (transforming growth factor-alpha and insulin-like growth factor-1).
Mitochondrial dysfunction and increased production of reactive oxygen species may promote cell senescence, a progressive slowing of cellular activity. Microscopic evidence of cartilage degeneration begins with fibrillation of the superficial and transition zones, followed by disruption of the tidemark by subchondral blood vessels and eventual subchondral bone remodeling. This process ultimately leads to cartilage degradation with decreased water content in the late and terminal phases of osteoarthritis.
734. **What is the plasma half-life of warfarin?**
1. 1 to 2 hours
2. 4 to 6 hours
3. 12 to 18 hours
4. 36 to 42 hours
**CORRECT answer: 4**
Warfarin, which is dosed daily, can take 72 to 96 hours to reach therapeutic levels. It has a plasma half-life of 36 to 42 hours. Low-molecular heparins have a plasma half-life of 4 to 5 hours, and fondaparinux has a half-life of 17 to 21 hours. Warfarin will not affect the International Normalized Ratio (INR) until 2 to 3 days after it is given. Patients on chronic warfarin therapy should
have treatment stopped 3 to 5 days before elective surgery to allow the INR to normalize.
735. A 70-year-old woman with a body mass index (BMI) of 34 and a history of hypercholesterolemia has elected to undergo total hip arthroplasty. Her son recently learned he has Factor V Leiden following an episode of pulmonary embolism. What are this patient's risk factors for thromboembolic disease?
1. Type of surgery, age, and BMI
2. Type of surgery, hypercholesterolemia, and age
3. Age, BMI, and hypercholesterolemia
4. BMI, type of surgery, and hypercholesterolemia
**CORRECT answer: 1**
Risk stratification is one of the most critical clinical evaluations before undergoing total joint arthroplasty. Many factors have been identified to increase risk for venous thromboembolism (VTE). The major factors include previous VTE, obesity, type of surgery (such as total joint arthroplasty), hypercoagulable states, myocardial infarction, congestive heart failure, family history of VTE, and hormonal replacement therapy.
Hypercholesterolemia is not a risk factor for thromboembolic disease.
736. **DNA replication occurs during which phase of the cell cycle?**
1. M
2. S
3. R
4. G1
5. G2
**CORRECT answer: 2**
The cell cycle consists of four distinct phases: initial growth (G1), DNA replication/synthesis (S), a gap (G2), and mitosis (M) (see illustration).
The G1 and G2 phases of the cell cycle represent the “gaps” or growth phases in the cell cycle that occur between DNA synthesis and mitosis. G0 cells are in a stable state and have not entered the cell cycle. During the S phase, the DNA is synthesized and replicated. During the M phase or mitosis, all genetic material divides into two daughter cells.
The cells are diploid (2N) in the G0 and G1 phases. The cells become tetraploid (4N) at the end of S and for the entire G2 phases. There is no R phase in the cell cycle.

737. **What antithrombotic agent is a selective factor I0a inhibitor?**
1. Warfarin
2. Low-molecular-weight heparin
3. Rivaroxaban
4. Aspirin
**CORRECT answer: 3**
Rivaroxaban is a selective factor I0a inhibitor. Aspirin is a cyclooxygenase inhibitor. Low-molecular-weight heparin is a nonspecific anticoagulant. Warfarin is a vitamin K antagonist and reduces production of clotting factors II, VII, IX, and X.
738. A 68-year-old woman had advanced right knee arthritis and total knee replacement was planned. She learned she had primary biliary cirrhosis at age 41 and now has advancing liver failure. Preoperative coagulation tests show a baseline International Normalized Ratio (INR) of 1.36. Appropriate methods to prevent thromboembolic
**disease as recommended by the 2011 AAOS Clinical Practice Guideline,**_Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee_
**_Arthroplasty_****, include**
1. use of mechanical prophylaxis (eg, pneumatic calf compressors) while in the hospital.
2. oral warfarin with a goal INR between 2.0 and 3.0.
3. low-dose warfarin for 3 weeks postsurgically beginning 48 hours after surgery.
4. no prophylaxis because this patient already is partially anticoagulated secondary to her liver disease.
**CORRECT answer: 1**
The 2011 AAOS Clinical Practice Guideline, _Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty_ , recommends the use of mechanical prophylaxis for patients at increased risk
for bleeding (including those with liver disease or hemophilia). This recommendation is the consensus of the workgroup that established these guidelines because there was insufficient evidence to justify a stronger recommendation in this clinical scenario. The other responses use no prophylaxis or pharmacological prophylaxis. Pharmacological prophylaxis is not recommended in patients who are at increased risk for bleeding.
739. The pharmacokinetics of which deep venous thrombosis (DVT) prophylactic agent are affected by liver function and dietary intake?
1. Dalteparin
2. Warfarin
3. Fondaparinux
4. Enoxaparin
**CORRECT answer: 2**
Warfarin is an oral vitamin K antagonist that is rapidly absorbed from the gastrointestinal tract. It accumulates in the liver, where it is metabolized and excreted. The pharmacokinetics of warfarin can be affected by certain drugs or disease states that influence liver function. Fondaparinux is a synthetic factor Xa inhibitor that is eliminated through the kidneys. Both Dalteparin and Enoxaparin are low-molecular-weight heparins that activate antithrombin and inhibit factors Xa and IIa. Like Fondaparinux, they are eliminated through the kidneys and should be used with caution in patients with kidney disease.
740. What infection-control measure has been shown to have the most notable impact in reducing surgical-site infections?
1. Intravenous antibiotic administration within 1 hour of surgical incision
2. Screening and decolonization of patients colonized with methicillin-resistant
Staphylococcus aureus
3. Horizontal laminar flow
4. Use of enclosed body exhaust suits
**CORRECT answer: 1**
Timely administration of prophylactic antibiotics is the most important factor shown to decrease surgical-site infections. The use of horizontal laminar flow and body exhaust suits has not been shown to significantly affect infection rates.
741. The resistance to pullout of a screw in osteoporotic bone is increased by all of the following EXCEPT?
1. Placement parallel to the trabecular pattern
2. Purchase in cortical bone
3. Use of a fixed angle (locking screw construct)
4. Tapping prior to screw placement
5. Augmentation with polymethylmethacrylate
**CORRECT answer: 4**
Of the options listed, tapping prior to screw placement is the only variable that does not increase the pullout strength of a screw in osteoporotic bone.
Cornell reviews internal fixation in osteoporotic bone. According to this article, the quality of the bone is the primary determinant of the holding power of an individual screw. Other factors that increase the pullout strength include fixation in cortical bone (cortical bone has greater mineral density and, therefore, greater resistance to screw pullout than trabecular bone), screws placed parallel to the trabecular pattern, and screw fixation augmented with PMMA. The addition of a locking plate will also increase the resistance to failure by creating a fixed angle construct. Tapping prior to placement of the screw has not been shown to increase resistance to pullout, on the contrary studies have shown
this decreases resistance to pullout.
Turner et al examined the holding strength of small and large diameter screws in healthy bovine and diseased human bone. They found the screw diameter, trabecular orientation of the bone, and mineral content of the bone all affect the holding strength. A larger diameter screw, parallel placement to the trabecular pattern, and purchase in bone with a higher density all increase the holding strength.
742. Gigantism affects which region of the growth plate labeled in Figure A?

1. A
2. B
3. C
4. D
5. E
**CORRECT answer: 3**
Gigantism, like achondroplasia, affects the proliferative zone (Region C of Figure A) of the growth plate. In Figure A, Region A is the epiphysis, Region B is the resting zone, Region D is the hypertrophic zone, and Region E is the metaphysis. Illustration A is another depiction of the physis which is labeled. Gigantism is typically caused by a pituitary adenoma which over secretes growth hormone. Its effect on the proliferative zone results in bone overgrowth and excessive height and limb length. Acromegaly may also be
caused by a pituitary adenoma that over secretes growth hormone, but has its effect once the physis has closed.

743. Plain radiographs do not provide an accurate assessment of bone mineral density (BMD) until what percentage of mineral has been lost?
1/. 5%
2/. 20%
3/. 40%
4/. 90%
**CORRECT answer: 3**
Radiographic evidence of BMD loss is not apparent until 40% reduction. Osteopenia should not be ruled out based on an apparently normal mineralized bone.
744. Figure 85 is the radiograph of a 3-year-old boy whose chief issue is knocked knees. His mother notes that she has a similar condition and required multiple surgeries as a child. She states that her son walks with an unsteady gait and is small for his age. He does not currently take any medications and is not under medical care for any disorders. What is the most appropriate next treatment step?

1. Recommend bilateral valgus-producing proximal femoral osteotomies to CORRECT coxa vara
2. Recommend bilateral medial distal femoral and proximal tibial hemiepiphyseal arrests to CORRECT genu valgum using guided growth
3. Obtain serum calcium, phosphorus, alkaline phosphatase, and vitamin D
studies and refer the patient to an endocrinologist for evaluation
4. Refer the patient to a geneticist to evaluate him for skeletal dysplasia
**CORRECT answer: 3**
The radiograph shows a patient with osteopenia; marked limb deformity, including bilateral coxa vara and bilateral genu valgum; and extreme physeal widening, which is pathonomonic for rickets. Although surgery to CORRECT the limb deformities may be appropriate, a definitive diagnosis first needs to be established, and, if possible, the patient needs to be treated medically. In cases in which limb realignment surgery has been performed without proper medial correction of the metabolic bone disease, the recurrence rate is high. Serum calcium, phosphorus, alkaline phosphatase, and vitamin D are appropriate screening studies for diagnosis of metabolic bone disease, and treatment is most commonly performed by an endocrinologist. A geneticist may play a role in establishing the cause of the disease, especially if there is a hereditary component, but this step should not delay the consultation with endocrinology.
745. A 45-year-old man is placed on indomethacin for heterotopic ossification prophylaxis following surgery for an acetabular fracture. What is the most likely side effect of this medication?
1. Renal failure
2. Hepatitis
3. Peripheral neuropathy
4. Deep vein thrombosis
5. Gastrointestinal ulceration
**CORRECT answer: 5**
Indomethacin, commonly used to prevent heterotopic ossification, is associated with a high rate of gastrointestinal toxicity.
Berger, in a case-based review of nonsteroidal anti-inflammatory use in Orthopaedics, notes that NSAIDs block the protective effect of prostaglandins on the gastrointestinal mucosa, in addition to causing variable rates of platelet dysfunction. Elderly patients using NSAIDS are estimated to have a 4 to 5 times increased relative risk of death due to gastrointestinal hemorrhage compared with matched cohorts. Indomethacin, in particular, has a high rate
of gastrointestinal complications when compared with other NSAIDs.
746. **What region of the physis does collagen type X play a prominent role?**
1. resting zone
2. proliferative zone
3. zone of hypertrophy
4. metaphysis
5. diaphysis
**CORRECT answer: 3**
Type X collagen is important for bone mineralization and is produced by hypertrophic chondrocytes in the zone of hypertrophy.
There are 4 zones of the physis. The first is the RESTING ZONE, which is characterized by widely dispersed chondrocytes, abundant matrix, and is relatively inactive in cell or matrix turnover. The second zone is the PROLIFERATIVE ZONE. It characterized by longitudinal columns of flattened cells, significant endoplasmic reticulum, high ionized calcium. The third zone is the HYPERTROPHIC zone. It is characterized by enlargement of cells,
persistent metabolic activity, accumulate and calcium, synthesize alkaline phosphatase and type X collagen, aiding in mineralization. The final zone, in the METAPHYSIS, comprises the primary and secondary spongiosa layers. These layers are characterized by vascular invasion and bone remodeling, respectively.
Illustration A shows a histological view of the phyeal zones. Zone C is the proliferative zone, Zone D is the hypertrophic zone, and Zone E is the metaphysis.
InCORRECT Answers:
Answers 1,2,3,5: collagen type X play the greatest role in the zone of hypertrophy.

747. Which of the following modalities has been shown to have a positive effect when treating early stages of complex regional pain syndrome?
1. Casting of the involved extremity
2. Plyometric exercises
3. Ultrasound therapy
4. Acupuncture
5. Gentle physiotherapy
**CORRECT answer: 5**
Complex regional pain syndrome type I (reflex sympathetic dystrophy) is defined as a disease that develops after an initial noxious or painful event which causes the development of pain and dysfunction out of proportion to the event. It sometimes cannot be linked to a specific physiologic process. Hyperesthesias, edema, and/or blood flow changes are prevalent. Type II (synonym for causalgia) has a known identifiable nerve injury. Hypotheses include increased sympathetic tone causes feedback loop, activation of nociceptors to neurons in spinal cord, continued ischemia, re-activation of pain receptors, and possibly unregulated sensitivity of alpha adrenergic receptors.
For treatment, early gentle physiotherapy is recommended for this condition. Aggressive passive range of motion is contraindicated in the early phases because it will provoke pain and inflammation. The primary goal of therapy is to decrease pain and prevent stiffness. Contrast baths can help desensitize
and improve blood flow, and TENS (transcutaneous electrical nerve stimulator) has been shown to have a positive outcome on CRPS type II only (those with identifiable nerve lesions). Illustration A shows the basic pathology of this
condition.

748. **The force generated by a muscle is most highly dependent on its**
1. cross-sectional area.
2. fiber type.
3. length.
4. morphology.
5. level of conditioning.
**CORRECT answer: 1**
The cross-sectional area of a muscle determines to a great extent the force generated by the muscle. The force of a muscle contraction is controlled by the amount of myofibrils that contract; the greater the amount of contracting myofibrils, the greater the force of contraction. Fiber types have less to do
with the force of contraction and more to do with the duration and speed of contraction. Muscle length affects contraction force through the Blix curve. The morphology of a muscle can affect the cross-sectional area by varying the angle of the fibers in relation to the force vector. Conditioning mostly affects duration and fatigability.
749. Arachidonic acid is directly metabolized by which of the following substances?
1. Carbonic anhydrase
2. HMG-CoA reductase
3. 1-lipoxygenase
4. Cyclooxygenase
5. Thromboxane synthetase
**CORRECT answer: 4**
Arachidonic acid is the common substrate that is directly metabolized by cyclooxygenase into the prostanoids including prostaglandins, prostacyclin and thromboxane.
Cyclooxygenase 1 enzyme, or COX-1, results in prostaglandins responsible for maintenance and protection of the GI tract. Cyclooxygenase-II enzyme, or COX-2, results in prostaglandins responsible for inflammation and pain. Leukotrienes are synthesized from arachidonic acid by 5-Lipoxygenase, not 1-Lipoxygenase. Mevalonate is involved in the HMG-CoA reductase pathway – the metabolic pathway that produces cholesterol (site of action of the statins). A diagram of arachidonic acid metabolism is provided in Illustration A.

750. A 50-year-old male sustains a closed head injury and closed femur fracture after falling off of a ladder. His GCS is currently 15, and he only speaks Spanish; he has several family members in the waiting room of the hospital. Which of the following is true regarding informed consent for fixation of his femur fracture?
1. Patient must be able to read the consent form
2. Patient must be able to sign the consent form
3. Patient does not need to be able to communicate in any manner to give his or her own informed consent
4. Patient must not be on any antidepressant medication prior to verbal or written informed consent
5. Patient should give verbal informed consent prior to narcotic administration
**CORRECT answer: 5**
The patient should give verbal informed consent by understanding the important risks and benefits (not necessarily every potential complication that could possibly occur), as well as the indications for and alternatives to a procedure. This should be performed prior to administration of narcotic medication. However, narcotic administration should not be delayed for patients in pain secondary to lack of availability of a written consent form, if the verbal conversation has occurred, as documentation of the consent process can still be performed prior to surgical intervention.
Wenger et al developed a survey of 102 orthopaedic surgeons who correctly answered a mean of nineteen (73%) of the 26 questions. The respondents appropriately handled questions involving economic aspects, truth-telling, confidentiality, and an incompetent colleague. However, there was less understanding of proper ethical conduct with regard to informed consent
(58%), the physician-patient relationship (72%), and end-of-life decision- making (78%). There was also an analysis of the inCORRECT responses by the surgeons in the survey: Nineteen percent of the 102 respondents thought that a patient must be able to read the consent form, 39% thought that the patient must understand all of the risks of the procedure, 12% did not think that the patient needed to be able to communicate in some fashion to give their own consent, and 29% indicated that the patient must not be taking any
medication with psychoactive effects.
The CORRECT answers include; discussing the important (not necessarily all) risks and benefits as well as the indications for and alternatives to a procedure, ability to communicate with a patient that will give their own
consent, and the use of antidepressant medications are not a preclusion to the informed consent process.
751. Which of the following factors is most critical to the success of a meniscal allograft transplantation?
1. Accurate graft size
2. Donor cell viability
3. Reestablishment of the central meniscal blood supply
4. Suppression of the immune response
5. Cryopreservation of the donor graft
**CORRECT answer: 1**
Success of a meniscal allograft transplantation is strongly dependent on accurate graft sizing, typically within 5% of the native meniscus. Previous studies have established that donor cell viability is not mandatory for the survival of these grafts since they are replaced by the recipient’s cells (at least peripherally) within several weeks. Thus, cryopreservation of the graft to ensure cell viability is not necessary. There is a limited immune response to musculoskeletal allografts; therefore, immunosuppression, as is required for visceral organ transplantation, is not indicated.
752. A 21-year-old collegiate scholarship football player has an episode of transient quadriplegia. An MRI scan of the cervical spine reveals cord edema and severe congenital spinal stenosis. The athlete has aspirations of playing on a professional level and demands that he
be allowed to play. The team physician should give what recommendation to the college?
1. Do not allow the athlete to return to football.
2. Allow the athlete to participate.
3. Allow the athlete to play only if he signs a waiver.
4. Suggest that the college and atahlete enter binding arbitration.
5. Allow the athlete to play with special equipment.
**CORRECT answer: 1**
Federal courts have ruled that a student-athlete does not have a constitutional right to participate in athletics against medical advice. As long as the student retains his scholarship, the college is under no legal or ethical obligation to allow the student to participate in sports. A waiver would not hold up in court and would not indemnify the college or the team physician against suit. No equipment has been shown to be effective
in preventing transient quadriplegia.
753. **All of the following substances inhibit osteoclast activity, EXCEPT?**
1. Tumor necrosis factor-alpha (TNF-a)
2. Osteoprotegerin
3. Calcitonin
4. Bisphosphonates
5. Denosumab
**CORRECT answer: 1**
Osteoclasts have been identified as a key cellular target in the treatment of many diseases including osteoporosis, particle-induced osteolysis in total joint arthroplasty, and tumor-induced osteolysis. As such, anti-osteoclastic agents are a hot topic of orthopaedic research.
Calcitonin and Osteoprotegerin are naturally occuring cytokines which act either on cell surface receptors (calcitonin receptor) or bind soluable mediators
(RANK-L) to inhibit osteoclasts. While two forms of bisphosphonates exist, both function to induce osteoclast apoptosis (programmed cell death). Denosumab is a monoclonal antibody to RANK-L which when given subcutaneously, binds and sequesters RANK-L, preventing it from stimulating RANK, a pro-osteoclastic receptor.
Schoppet et al wrote a comprehensive review of osteoprotegerin or OPG, a cytokine produced by many cells including osteoblasts and marrow stromal cells. It is a vital component in regulating bone resorption as it inhibits both osteoclast activation and differentiation by acting as a decoy receptor for RANK-L. The mechanism of RANK-L is seen in Illustration A.

754. A player on a professional football team sustains a knee injury and is diagnosed with an anterior cruciate ligament rupture. When employed as the team physician, your ethical obligation is to inform
1. the player but not the team.
2. the team but not the player.
3. neither the team nor the player.
4. both the team and the player.
5. the team, the player, and the media
**CORRECT answer: 4**
When you are employed as a team physician, you are obligated to inform the players and the team organization of all athletically relevant medical issues. This differs significantly from the normal rule of patient confidentiality. If the player came to see you and you were not the team physician, you may not inform the team unless the player so desires. As the team physician, you are not obligated to inform the media.
755. Protamine functions to reverse the pharmacologic effects of which of the following anti-coagulants?
1. Aspirin
2. Clopidogrel (e.g. plavix)
3. Low molecular weight heparin
4. Warfarin
5. Hirudin
**CORRECT answer: 3**
Protamine functions to partially reverse the pharmacologic effects of low molecular weight heparin (LMWH). Protamine may help to stop bleeding related to LWMH, although anti- factor Xa activity is not fully normalized by protamine. Vitamin K reverses the pharmacologic effect of warfarin. As aspirin
and clopidogrel function directly at the level of the platelet, there is no medical method to "reverse" these effects. Hirudin is a naturally occuring enzyme with anti-coagulant property in the salivary glands of leeches.
756. Storage of musculoskeletal allografts by cryopreservation is achieved by
1. replacing water in the tissue with alcohol to a moisture level of 5% and then using a vacuum process to remove the alcohol from the tissue.
2. maintaining maximum cellular viability of fresh tissue without long-term storage.
3. using chemicals to remove cellular water and controlled rate freezing to prevent
ice crystal formation.
4. freezing the graft twice and packaging the tissue without solution at minus 80 degrees C.
5. freezing the graft in water without an antibiotic solution soak during quarantine, with final storage in liquid nitrogen.
**CORRECT answer: 3**
Cryopreservation uses chemicals to remove cellular water and controlled rate freezing to prevent ice crystal formation. The tissue is procured, cooled to wet ice temperature for quarantine, and then stored in a container with cryoprotectant solution of dimethyl sulfoxide or glycerol which displaces the cellular water. The controlled rate freezing is then done to prevent ice crystal formation. Fresh allografts are not frozen in order to maintain maximum cellular viability, and this process limits the shelf life of osteochondral allografts. Freeze-drying involves replacement of water in the tissue with
alcohol to a moisture level of 5% and then uses a vacuum process to remove the alcohol from the tissue. Preparation of fresh frozen grafts involves freezing the graft twice and packaging the tissue without solution at minus 80 degrees C.
757. A new scientific study is completed investigating the use of a new technique for lumbar decompression. The prospective cohort study enrolled 400 total patients into two groups (laminectomy versus interspinous spacer) based on 80% power and beta value of 0.2. Patients were not randomized in the study. Results showed a greater improvement in pre to post operative Oswestry Disability Index (ODI) in the interspinous spacer group (38.4) versus laminectomy group (34.1). ODI scores can range from 0 (no disability) to 100 (maximum disability). P value was 0.002.
**Interpretation of these results suggests which of the following?**
1. The number needed to treat (NNT) is high
2. The study was underpowered due to use of a high beta value
3. Due to lack of randomization, the study is subject to the Hawthorne effect
4. The difference in the primary outcome was stastically significant but likely did not reach the minimum clinically important difference
5. The control group was improperly selected given their improvement in ODI scores
**CORRECT answer: 4**
While most outcome measures do not have a well-established minimal clinically important difference (MCID), a 4.3 point difference in ODI is well below any reported MCID. The results suggest that the difference in primary endpoint was statistically significant but likely did not reach the MCID.
Interpretation of clinical studies requires a basic understanding of statistical and clinical principles. While the traditionally reported p values can comment on the statistical significance of a comparison in a data set, it does not give any information regarding the clinical relevance of the result. The MCID for several clinical outcomes has been studied, but consensus does not exist on this value for most outcome measurements.
Nevertheless, the clinical relevance of a study finding is much stronger when it reaches
MCID and is statistically significant.
Vaccaro et al. prospectively investigated the management of type II dens fracture in geriatric patients. They found improved outcomes in patients
undergoing surgical management of these injuries based on the Neck Disability Index (NDI).
Young et al. evaluated the reliability and validity of the NDI in a prospective randomized study. They found an MCID of 7.5 and a minimum detectable change (MDC) of 10.2. Their findings suggest that 10 points should be used as MCID for the NDI.
Gatchel et al. comment on both the importance and difficulty of establishing MCID for outcome measures. They stress the importance of interpreting statistically significant results in the context of MCID.
InCORRECT Answers:
Answer 1: NNT is a measure used in studies assessing relative risk of certain disease states. It does not apply to this study.
Answer 2: The beta value and power used in this study are standard for most studies. Answer 3: Lack of randomization can lead to confounding. The Hawthorne effect refers to change in patient behavior when they know they are part of a study.
Answer 5: The study was comparing one surgical intervention to another. The control group was appropriately selected.
758. Which of the following is most likely to decrease surgical mortality and inpatient morbidity while simultaneously increasing surgical team adherence to life-saving steps in operating room crisis situations?
1. An intra-operative surgical team leader
2. A surgical checklist
3. The presence of a senior surgeon
4. Magnet certification of nursing staff
5. Exclusion of surgical residents from the operating room team
**CORRECT answer: 2**
The utilization of a surgical safety checklist has demonstrated substantial reductions in surgical morbidity and mortality. Checklist use has also demonstrated efficacy in increasing team adherence to life-saving care plans in operating room crises.
The World Health Organization concept of a surgical safety checklist concept was validated in 2009 as a way of improving surgical outcomes. Successful implementation of a surgical checklist relies upon surgeon leadership to educate staff on its rationale and the practical components of implementation in the operating room.
Haynes et al. evaluated a 19-item surgical safety checklist and evaluated its ability to reduce complications and deaths associated with surgery in a global population. Across 8 diverse hospitals in 8 cities around the world, their study demonstrated that implementation of a pre-surgical checklist resulted in a
50% reduction in mortality (1.5% to 0.8%) and a 37% reduction in inpatient complications (11% to 7%). The patients in the study were over the age of 16 and undergoing non- cardiac surgery.
Conley et al. evaluated the effectiveness of implementation of surgical safety checklists in five hospitals using a series of interviews conducted with surgeons. Analysis of the survey results demonstrated that effective implementation relied upon surgeon leadership to explain the necessity of the checklist and how to effectively implement its use. When surgeon leadership failed in these functions, hospital staff failed to comprehend the utility of the checklist and were not able to appropriately use it. These failures eventually led to institutional abandonment of the safety checklist.
Arriaga et al. evaluated the utility of checklists to guide the surgical team through intraoperative crisis situations (e.g., massive hemorrhage, cardiac arrest). Their study of 17 surgical teams undergoing 106 simulated surgical- crises demonstrated that use of a crisis checklist led to greater adherence to life-saving steps of a care plan. 97% of participants agreed that they desired a checklist to be present if a crisis were to occur while they themselves were undergoing surgery.
InCORRECT answers:
Answers 1, 3-5: None of these have consistently demonstrated substantive improvement in surgical morbidity and mortality.
759. Which of the following is true regarding the sequence of motor unit recruitment during muscle contracture?
1. The sequence is: slow twitch, fatigue-resistant units (1st); fast-twitch, easily fatigable units (2nd); fast-twitch, fatigue-resistant units (3rd)
2. The sequence is: slow twitch, fatigue-resistant units (1st); fast-twitch, fatigue-resistant units (2nd); fast-twitch, easily fatigable units (3rd)
3. The sequence is: slow twitch, fatigue-resistant units (1st); slow-twitch, easily fatigable units (2nd); fast-twitch, easily fatigable units (3rd)
4. The sequence is: fast-twitch, fatigue-resistant units (1st); fast-twitch, easily fatigable units (2nd); slow twitch, fatigue-resistant units (1st);
5. The sequence is: fast-twitch, easily fatigable units (1st); fast-twitch, fatigue- resistant units (2nd); slow twitch, fatigue-resistant units (1st);
**CORRECT answer: 2**
The order of muscle recruitment starts with Type I fibers (slow twitch, fatigue- resistant units), followed by Type II units that first includes Type IIa (fast- twitch, fatigue-resistant) and ends with Type IIb (fast-twitch, easily fatigable)
Motor units are recruited in order of size, starting with small sized units that generate low
force, progressing to larger units with increasing strength of muscle contraction. Type I slow oxidative motor units have a lower threshold for activation, activate under lower force requirements, and generate less force. Type II units have a higher threshold and activate during activities that require significant force. Type IIa fibers are fast oxidative/glycolytic and Type IIb fibers are fast glycolytic. The terms "slow" and "fast" refer to the speed that myosin ATPases split ATP. The easy fatigability of type IIb fibers occurs because (1) they rely on anaerobic glycolysis to produce ATP, resulting in accumulation of lactic acid, which brings about muscular fatigue and (2) their low capillary density.
Staron reviewed human muscle fiber types. They state that children (2-5y) have a higher percentage of type I fibers than newborns and adults. Aging causes loss of function from sarcopenia (loss of muscle mass, loss of motor units, particularly type II) and reduced maximum oxygen consumption begining at 25y. Regarding sex differences, females have muscles 40% smaller than men because of smaller fibers and fewer total numbers of fibers diameter cross-sectional area.
Illustration A shows the distribution of muscle fiber types. Illustrations B and C show the progression in muscle fiber activation.
InCORRECT Answers:
Answer 1: Type IIb units (fast-twitch, easily fatigable) are the last to be activated. Answer 3: There are no slow twitch, easily fatigable units (only slow twitch, fatigue- resistant units).
Answers 4 and 5: Fast-twitch units (Type II) are not activated initially. Untrained individuals cannot voluntarily activate all higher threshold type II motor units

760. Which of the following conditions exhibit the inheritance pattern shown in Figure A, assuming no new mutations?

1. Duchenne muscular dystrophy
2. Hunter's syndrome
3. Hemophilia
4. Spondyloepiphyseal dysplasia (SED) tarda
5. Diastrophic dysplasia
**CORRECT answer: 5**
The pedigree chart (males are squares and females are circles) shown in Figure A demonstrates an autosomal recessive trait.
Diastrophic dysplasia is the only autosomal recessive condition with all of the other options being X-linked recessive disorders. Along with Becker's MD these are the main orthopaedic X-linked recessive disorders.
There are many more autosomal recessive orthopaedic disorders. Autosomal recessive pedigrees often appear in both sexes with equal frequency, tend to skip generations, and affected offspring are usually born to unaffected parents. When both parents are heterozygote, approximately 1/4 of the progeny will be affected.
X-linked and autosomal dominant disorders will not skip generations.
X-linked recessive disorders will always have affected sons if the mother has the disease (this does not occur in the 3rd cross of Figure A on the far right).
761. Which of the following is NOT a component of the WHO surgical safety checklist?
1. Whether team members have introduced themselves
2. Whether antibiotics have been given within the last 60 minutes
3. Whether essential imaging is displayed
4. Whether the CORRECT implants are in the room and if the product representative needs to be present
5. Whether there is a risk of blood loss
**CORRECT answer: 4**
The WHO surgical safety checklist concerns all surgical specialties. Whether CORRECT implants are in the room and if the representative needs to be present is not a component of this checklist.
The WHO checklist has 3 phases: the sign in (before induction), the time out (before skin incision), and the sign out (before the patient leaves the room). According to the WHO checklist, the steps that must occur prior to induction of anesthesia include checking the patient’s identity, procedure, consent, and signed surgical site are confirmed; an anesthesia safety check that includes evaluation for a difficult airway and aspiration risk is performed; and determination of risk for excessive blood loss is completed. Other features of this checklist are found in Illustration A.
Haynes et al. reviewed outcomes at 8 hospitals in 8 cities before and after introduction of the WHO surgical safety checklist. They found that the death rates were 1.5% and 0.8% and complication rates were 11.0% and 7.0% before and after introduction, respectively (p<0.05 for both).
Illustration A shows the WHO surgical safety checklist InCORRECT Answers:
Answers 1,2,3,5: These are all components of the WHO surgical safety checklist.
See Illustration A.

762. A 25-year-old female falls off her bike around 10:30 PM and sustains the closed injury seen in figures A and B. On exam, she is neurovascularly intact, but reports severe pain with finger flexion or extension. The chief resident calls the attending who reports he is at a benefit event and has had a few drinks, but feels fine and can operate on the patient in 1 hour and demands that the case be scheduled. When the attending arrives, he seems more jovial than normal. After the time out is complete, he reports he is feeling tired and is going to take a nap in the lounge, but he is confident the chief resident can complete the case. What should the resident do next?

1. Start the case and wake the surgeon up if any problems arise
2. Perform a closed reduction, apply a sugar tong splint, and schedule the case electively
3. Complete the case if she is confident she can do it
4. Express concern to the attending about his impairment
5. Wait for the surgeon to regain sobriety
**CORRECT answer: 4**
The surgeon in this case is likely impaired. It is the duty of the resident to confront the attending regarding his potential impairment, and if the surgeon insists on proceeding, to report the attending to another attending or department chief before the patient is put in a more dangerous situation.
The AAOS Code of Ethics and Professionalism for Orthopaedic Surgeons states surgeons "should be attuned to evolving mental or physical impairment, both in themselves and in their colleagues, and take or encourage necessary measures to ensure patient safety." The AMA code of medical ethics reports that physicians have an obligation to intervene to prevent their impaired colleagues from harming a patient. By reporting the impaired physician one might be saving him/her from medicolegal troubles down the road.
Oreskovich et al. conducted a nationwide survey of physicians across all medical specialties (26.7% response rate) and found that 12.9% of male physicians and 21.4% of female physicians met criteria for alcohol abuse/dependence. Younger physicians and depressed physicians were more likely to abuse alcohol. Dermatologists and orthopaedic surgeons were the medical specialties most likely to abuse alcohol while pediatrics and neurology were the least likely.
Dyrbye et al. conducted a cross-sectional survey of medical students (35% response rate) to assess how burnout and depression may affect students' willingness to report impaired colleagues. They determined that students with evidence of burnout or depression were significantly less likely to feel they should report colleagues impaired by mental health issues or substance abuse. The authors concluded that not only is more explicit training regarding professional responsibilities needed, but maintaining wellness is critical in the individual's willingness to fulfill their professional roles.
Figures A and B show displaced radius and ulna shaft fractures. InCORRECT Answers:
Answer 1 & 3: Even if the chief resident is capable of completing the case independently, it is inappropriate for a resident to operate without adequate supervision.
Answer 2: Closed reduction, splinting, and elective management would be inappropriate in this patient as she may have an evolving compartment syndrome Answer 5: It is inappropriate to keep a patient under anesthesia for a prolonged time due to physician impairment. Additionally, the patient may have an evolving compartment syndrome that should be addressed emergently
763. What is the first class of antibody to appear in serum after exposure to a foreign antigen?
1. IgA
2. IgD
3. IgE
4. IgG
5. IgM
**CORRECT answer: 5**
IgM is the first class of antibody to appear in our serum after exposure to an antigen. IgG is the most abundant immunoglobulin in our body. IgA is the major class of antibody in external secretions such as intestinal mucus, bronchial mucus, saliva, and tears. IgE is important in conferring protection against parasites and is also increased in allergic reactions. The role of IgD is not known.
764. A 67-year-old female falls off of a step ladder while changing a lightbulb in her kitchen and sustains the injury shown in Figures A and B. During fixation, the surgeon elects to use an osteoconductive bone graft substitute. Which of the following has been shown to have highest early compressive strength?

1. Coralline hydroxyapatite
2. Collagen-based matrices
3. Calcium phosphate
4. Calcium sulfate
5. Tricalcium phosphate
**CORRECT answer: 3**
Of the above bone graft substitutes, calcium phosphate demonstrates the highest early compressive strength.
Calcium phosphate is an injectable compound comprised of inorganic calcium and phosphate that hardens in situ and cures by a crystallization reaction to form dahllite, a carbonated apatite similar to that found in the mineral phase of bone. Reduction and placement of internal fixation must be performed prior to application of the calcium phosphate. Compared to cancellous bone grafts and other bone graft substitutes, calcium phosphate, when hardened, has a much higher compressive strength (4 to 10 times greater than cancellous
bone) and may be useful in preventing subsequent displacement or depression of reduced articular fragments.
Russell et al. prospectively compared autologous bone graft to calcium phosphate cement in a randomized controlled trial of 119 patients. The baseline demographics including the height, weight, age, sex, and injury pattern were comparable. The authors found a significantly higher rate of articular subsidence in the three to twelve month
post-operative period with the bone graft group. They concluded that calcium phosphate was associated with greater compressive strength and less subsidence.
Welch et al. directly compared calcium phosphate and autologous bone graft used to fill subchondral defects created in an animal model. The authors found that the prevalence and degree of fracture subsidence was significantly reduced at all time-points, from 24 hours to 18 months, in the defects treated with calcium phosphate cement compared with those filled with autograft (p <
0.05).
Figures A and B are AP and lateral radiographs of a right knee demonstrating a Schatzker II split-depression tibial plateau fracture.
Illustrations A shows, on the left, a photomicrograph of a subchondral defect treated with calcium phosphate demonstrating no subsidence and, on the right, a specimen treated with autologous bone graft showing subsidence.
InCORRECT Answers:
Answer 1: The compressive strength of coralline hydroxyapatite is only slightly greater than cancellous bone, but less than that of calcium phosphate.
Answer 2: Collagen-based matrices have compressive strength less than cancellous bone.
Answer 4: The compressive strength of calcium sulfate is similar to cancellous bone, but less than that of calcium phosphate.
Answer 5: The compressive strength of tricalcium phosphate is equal to or slightly less than cancellous bone.

765. In which of the following clinical scenarios would an urgent ophthalmology consultation be warranted to mitigate potential irreversible complications of the primary pathology?
1. A 4-year old male with proportionate dwarfism secondary to an autosomal recessive mutation resulting in L-alpha iduronidase deficiency.
2. A 5-year old male with proportionate dwarfism secondary to an X-linked recessive
mutation resulting in sulpho-iduronate-sulphatase deficiency
3. A 6-year old female with 2 months of persistent left knee swelling and associated stiffness, intermittent fever, and elevated ESR.
4. A 7-year old male with developmental delay, dolichostenomelia, and positive urine nitroprusside test secondary to a cystathionine b-synthase deficiency.
5. A 10-year old developmentally normal male with dolichostenomelia, generalized ligamentous laxity, and pecrus carinatum.
**CORRECT answer: 3**
Urgent ophthalmology consultation for slit lamp examination is warranted for the 6-year- old patient with juvenile idiopathic arthritis (JIA) in order to rule
out anterior uveitis. Ocular involvement in the disease process may lead to rapid and irreversible vision loss if not caught and appropriately treated early.
JIA is characterized by persistent arthritis in any individual joint for ≥6 weeks. The diagnosis of JIA is one of exclusion and requires onset of symptoms by age 16. The most common subtype of JIA is oligoarticular JIA, which typically
presents in females between 1-3 years of age, most often as morning stiffness and a relatively painless limp. The knee is most often affected. Uveitis is a common systemic manifestation of the disease process, and is most often asymptomatic, with up to 30% of patients experiencing loss of vision. This can be mitigated by early detection via slit lamp examination and subsequent ophthalmologic intervention.
Punaro reviews the presentation and orthoapedic manifestations of JIA. The authors note that while the diagnosis may be difficult due to the nonspecific presentation, early ophthalmologic evaluation is important for detection and treatment of ocular manifestations of the disease.
The Sherry article provides an overview of new treatment methods including intraarticular joint injections of methotrexate and etanercept, which have produced giant leaps in the treatment of the associated joint inflammation and resultant destruction.
InCORRECT answers:
Answer 1: This patient presents with Hurler syndrome, and while corneal clouding is characteristic, the process is due to glycosaminoglycan infiltration of the cornea and cannot be mitigated by ophthalmologic intervention.
Answer 2: This patient presents with Hunter syndrome, which may sometimes present with mild corneal clouding similar to Hurler syndrome, but is more often associated with clear corneas.
Answer 4: This patient presents with homocysteinuria. Although inferior lens dislocation is common, this is not an urgent diagnosis and does not result in irreversible blindness. Ophthalmologic intervention cannot prevent but is required to treat this complication.
Answer 5: This patient presents with Marfan's syndrome. Superior lens dislocation is common with this pathology, but similar to homocysteinuria, this is not an urgent diagnosis and cannot be prevented by early ophthalmologic evaluation.
766. A 42-year-old healthy woman presents to the emergency department with the injury shown in figures A and B. She undergoes the procedure shown in figures C and D. Which of the following is true regarding this procedure?

1. Fracture fragments must be cleaned and aligned anatomically
2. It relies on endochondral bone formation through chondrocyte proliferation and hypertrophy
3. It relies on endochondral bone formation through development of cutting cones
4. It relies on intramembranous bone formation through chondrycyte proliferation and hypertrophy
5. It relies on intramembranous bone formation though development of cutting cones
**CORRECT answer: 2**
The patient presents with an extra-articular distal tibia fracture and undergoes bridge plating. This method of fixation relies on endochondral bone formation through chondrocyte activity (secondary bone healing).
Fracture healing relies on complex interplay of biochemical and mechanical factors and can occur through intramembranous (primary bone healing)and endochondral bone formation (secondary bone healing). Primary bone healing relies on anatomic reduction, compression, and very little strain at the fracture site to allow for Haversian remodeling (development of cutting cones).
Absolute stability constructs lead to primary bone healing. Alternatively, secondary bone healing occurs in the periosteum and soft tissues in slightly higher strain environments. Relative stability constructs, such as intramedullary nails, external fixators, and bridge plates are examples of fixation that rely on secondary bone healing.
Perren reviews the biological and mechanical properties of bone remodeling and the complex interplay of patient, injury and surgical factors that influence healing. The use of relative stability fixation techniques allows bone to overcome the initial excess strain at a
fracture site and build a scaffold that brings the strain to more reasonable levels. The author stresses the importance of understanding bone biology to select optimal implant and methods of surgical fixation.
Figures A and B are AP and lateral radiographs, respectively, showing a comminuted distal tibia fracture. Figures C and D are post-operative radiographs after use of a bridge plating technique.
InCORRECT Answers:
Answer 1: This is usually required for primary bone healing
Answer 3: Cutting cones are seen in Haversian remodeling during primary bone healing
Answer 4, 5: Intramembranous bone formation occurs during primary bone healing and would not be present in this case.
767. A 61-year-old female smoker has a dual-energy x-ray absorptiometry scan at the femoral neck with a T-score of -1.5. She has a seizure disorder and takes phenytoin. According to the World Health Organization Fracture Risk Assessment Tool (FRAX), she has a ten year probability of sustaining a hip fracture of 4.8% and a ten- year probablity of sustaining a major osteoporotic fracture of 8%. In addition to a smoking cessation program, what is the most appropriate next step in treatment?
1. Initiate 1200 mg of calcium and repeat scan in 6 months
2. Initiate 800 units of Vitamin D and repeat scan in 6 months
3. Initiate 1200 mg of calcium, 800 units of Vitamin D, and repeat scan in 1 year
4. Initiate 1200 mg of calcium, 800 units of Vitamin D, begin bisphosphonate therapy, refer to neurologist to replace/discontinue phenytoin, and repeat scan in 1 year
5. Initiate 1200 mg of calcium, 800 units of Vitamin D, refer to neurologist to replace/discontinue phenytoin, and repeat scan in 1 year
**CORRECT answer: 4**
This patient has osteopenia and the FRAX assessment shows a ten-year probability of sustaining a hip fracture of >3%, which necessitates pharmacologic treatment and repeat scan in 1 year.
Osteoporosis is a systemic skeletal disorder that is characterized by the loss of bone tissue, disruption of bone architecture, and bone fragility, leading to an increased risk of fractures. Bone loss and low bone mass are asymptomatic until fractures occur.
Osteopenia is defined as a T score of -1 to -2.5 and osteoporosis is defined by a T score of < -2.5. Risk factors for osteoporosis are found in illustration A.
Unnanuntana et al. report that due to the limitations to DEXA, the FRAX was developed. The aim of FRAX is to provide an assessment tool for the prediction of fractures in men and women with use of clinical risk factors with or without femoral neck bone mineral
density. When reviewing the FRAX results, they recommend initiating treatment when there is a ten-year risk of hip fracture
>3% or a ten-year risk of a major osteoporosis-related fracture >20%.
Cosman et al. review the the 2008 National Osteoporosis Foundation
guidelines and report that pharmacologic treatment for osteoporosis should be considered if patients are postmenopausal women or men > 50 AND meet one of the following criteria: have a prior hip or vertebral fracture, a T score -2.5
or less at the femoral neck or spine, a T score between -1.0 and -2.5 at the femoral neck or spine AND a 10-year risk of hip fracture greater than 3% or
10-year risk of major osteoporosis-related fracture greater than 20%. DEXA scans should be repeated every 1-2 years if patients are on pharmacologic treatment.
Illustration A is a table listing the risk factors for osteoporosis. InCORRECT Answers:
Answers 1, 2, 3, and 5 do not include the CORRECT treatment which is 1200 mg
of calcium, 800 units of Vitamin D, bisphosphonate therapy, addressing the phenytoin side effects, and repeat scan in 1 year.

768. Which of the following statements about Familial Hypophosphatemic Rickets (Vitamin D resistant Rickets) is TRUE?
1. It is the second most common form of heritable rickets behind Type I Hereditary Vitamin D-Dependent Rickets
2. It is caused by inability of renal tubules to absorb phosphate
3. Leads to decreased vertical physeal width
4. There is a associated hyperphosphatemia
5. Early treatment with calcitriol results in completely normal bone mineralization
**CORRECT answer: 2**
Familial Hypophosphatemic Rickets results from a genetic defect of the PHEX gene that ultimately leads to renal phosphate wasting due to the inability of the renal tubules to absorb phosphate.
Familial Hypophosphatemic Rickets, also known as X-linked hypophosphatemic rickets, has been linked to mutations in the phosphate-regulating endopeptidase homolog X-linked (PHEX) gene that result in increased
fibroblast growth factor 23 (FGF-23) levels and, in turn, renal phosphate wasting. Laboratory analysis will demonstrate hypophosphatemia and a slightly elevated alkaline phosphatase with otherwise normal vitamin D and
calcium levels. Patients usually present with genu varum, medial tibial torsion, and short stature. The mainstay of treatment involves vitamin D supplementation with surgical treatment indicated for patients with
progressive bone deformities despite adequate medical therapy.
Hunziker et al. performed a histological analysis quantifying chondrocyte growth of the proximal tibial physis in rats. The authors found that chondrocytes remained in a fixed location at the physis and in the late hypertrophic zone increased in cellular height by four- fold and cellular volume by ten-fold. During the vascular invasion of the primary spongiosa, they showed that approximately one chondrocyte was eliminated every three hours. The authors concluded that quantifying normal growth plate anatomy can help understand pathologies affecting the physis.
Sharkey et al. reviewed the medical and surgical management of X-linked hypophosphatemic rickets. Per the literature included, the authors recommended medical treatment consisting of calcitriol 20 to 30 ng/kg split into two to three doses per day as well as 20 to 40 mg/kg of elemental phosphorus split between three to five doses per day, to ensure a steady serum level. They recommended that treatment be followed with serial radiographs of the knee, height measurements, and serum labs to ensure an appropriate response to therapy and avoidance of treatment complications. The authors concluded that the mainstay of treatment is calcitriol and phosphate replacement, with surgery indicated for patients with progressive bone deformities.
Illustration A depicts an AP bilateral knee radiograph of a patient with X-linked Hypophosphatemic rickets demonstrating increased physeal vertical width. Illustration B is a table depicting serum marker findings in X-linked
Hypophosphatemic Rickets compared to other bone metabolic disorders.
InCORRECT Answers:
Answer 1: Familial Hypophosphatemic Rickets (Vitamin D resistant Rickets) is the most common form of heritable rickets.
Answer 3: Radiographs of patients with X-linked Hypophosphatemic Rickets will demonstrate increased physeal vertical width due to disrupted mineralization within the zone of provisional calcification as well as vascular invasion of the primary spongiosa. Answer 4: X-linked Hypophosphatemic Rickets patients will have hypophosphatemia and elevated alkaline phosphatase with normal calcium and vitamin D levels.
Answer 5: Treatment with calcitriol supplementation improves outcomes, reduces the risk of deformity recurrence following surgery, and improves height. However, there is still abnormal bone mineralization even with adequate calcitriol supplementation.
769. All of the following have been associated with increased postoperative bleeding due to their direct effect on platelet function EXCEPT:
1. St John’s Wort
2. Aged Garlic Extracts
3. Aspirin
4. Ginseng
5. Ginkgo biloba
**CORRECT answer: 1**
All of the following listed have been associated with increased postoperative bleeding due to their direct effect on platelet function EXCEPT St John’s wort, which exerts its effects on the CNS by inhibiting serotonin, norepinephrine, and dopamine reuptake by neurons.
Ginkgo biloba, ginseng, and garlic are all herbal remedies that have been associated with increased postoperative bleeding and related complications. All three are known to act directly on platelet function. Physicians should be
aware not only of prescribed medications but also alternative nutraceuticals, herbal medications, and dietary supplements that are used by the patient.
Ang-Lee et al. review common herbal medications and their physiologic effects. They emphasize during the preoperative evaluation, physicians should
explicitly elicit and document a history of herbal medication use. Physicians should be familiar with the potential perioperative effects of the commonly used herbal medications to prevent, recognize, and treat potentially serious problems associated with their use and discontinuation.
Bebbington et al. reported on persistent postoperative bleeding after total hip arthroplasty secondary to ginkgo biloba usage. They found the postoperative bleeding stopped 6 weeks after the ginkgo biloba usage was discontinued.
Illustration A shows the mechanism of aspirin, which targets cyclooxygenase
1, and thus inhibits the conversion of Arachiodonic acid to Prostaglandin. This leads to a decrease in platelet activation and aggregation.
InCORRECT Answers:
Answer 2: Aged garlic extracts inhibits platelet aggregation by increasing cyclic nucleotides and inhibiting fibrinogen binding and platelet shape change.
Answer 3: ASA inhibits coagulation by inhibiting the production of prostaglandins and thromboxanes through irreversible inactivation of the cyclooxygenase enzyme.
Answer 4: Ginseng works through antiplatelet activity of panaxynol, a constituent of ginseng.
Answer 5: Ginkgo biloba is a popular nutraceutical for patients who have early dementia, intermittent claudication secondary to peripheral vascular disease, vertigo, and tinnitus. It
is reported to improve mental alertness and cognitive deficiency. It has antiplatelet properties as a result of one of its components, ginkgolide B, which displaces platelet- activating factor from its receptor binding sight.

770. As a diaphyseal fracture heals, peripheral callus forms about the shaft axis, creating a structure with a substantially larger diameter than the original diaphyseal shaft. What biomechanical properties does this callus impart to the healing fracture site?
1. Callus decreases torsional stability and stiffness at the fracture site
2. Callus formation is random and unstructured and does not affect the local biomechanical properties
3. The callus decreases peak torque to failure with time
4. The callus increases the moment of inertia, resulting in less strain at the fracture site
5. The callus decreases the moment of inertia, increasing stress at the fracture site
**CORRECT answer: 4**
Callus formation is biomechanically beneficial because it increases the outer diameter of the bone, leading to an increase in stiffness, torsional strength, moment of inertia, and decreases resultant interfragmentary strain at the fracture site.
The biomechanical role of the peripheral callus is to provide initial stability to the fracture and to act as a scaffold for gradual mineralization. Because the bending stiffness of a structure is proportional to the 4th power of the diameter, a peripherally located callus provides substantial stability to the
fracture, despite the relatively low stiffness and strength of callus. For example, doubling the diameter of the callus increases the resistance to bending by a factor of 16. As mineralization progresses, the bending stiffness and strength of the healed fracture eventually may be substantially greater than that of the original, intact bone.
Augat et al. review the mechanical and biological aspects of fracture healing. They report that increased diameter of periosteal callus formation benefits healing by enlarging the cross-sectional area of area of the bridging tissue and reducing interfragmentary motion. Patients with osteoporosis are known to have decreased callus mineralization and biomechanical properties.
Illustration A demonstrates how diaphyseal fracture callus expands its diameter to increase stiffness, increase the moment of inertia, and decrease strain at the fracture site.
InCORRECT Answers:
Answer 1: Callus will increase torsional stability and stiffness, not decrease Answer 2: While callus formation may be randomly arranged initially, it quickly becomes orderly as the fracture heals and remodels according to Wolff's law. As stated above, callus formation influences the local biomechanical
properties.
Answer 3: Callus formation increases peak torque to failure
Answer 5: Callus will actually increase the moment of inertia and distribute stress at the fracture site.

771. A 55-year-old male has severe knee pain and swelling for 2 days. He denies nausea, vomiting, fevers, or chills. On exam, the patient has an erythematous knee with a large effusion. He has pain with
attempted range of motion. Radiographs are unremarkable. WBC, CRP, and ESR are within normal limits. The knee was aspirated and the
**WBC count was 20,000. A specimen from the aspirate is seen in Figure**
1. **What is the next best step in treatment?**

1. Begin empiric antibiotics
2. Begin oral NSAIDs
3. Begin treatment with allopurinol
4. Emergent irrigation and debridement of the knee
5. Obtain serum uric acid level
**CORRECT answer: 2**
This patient has an acute gouty attack. The best treatment at this time is the initiation of an oral NSAID such as indomethacin.
It is clinically difficult to differentiate gout from an acute septic joint. Arthrocentesis and joint fluid analysis are used to diagnose both conditions. Crystals found in the fluid are suggestive of gout, though they may also cause an elevation of the synovial WBC count. Patients with an acute gouty flare may not have elevated serum uric acid levels. The treatment of acute gout is generally with indomethacin or colchicine for those who cannot tolerate NSAIDs. Chronic gout is treated usually with allopurinol. A similar scenario
may be encountered with pseudogout. The treatment approach is similar with the addition of a corticosteroid injection acutely.
Shah et al. performed a retrospective study to determine the incidence of septic arthritis in the presence of joint crystals. They report that the presence of crystals cannot exclude septic arthritis with certainty. They found that only
1.5% of patients had synovial fluid samples with crystal disease and concomitant bacterial growth. They conclude that the incidence increases to
11% if the synovial WBC count is > 50,000 and 22% if the synovial WBC count is > 100,000.
Choi et al. performed a review to determine the links between dietary and other factors and the incidence of gout. They report that red meats, seafood, beer, and liquor increase the risk of gout while total protein, wine, and purine rich vegetables did not. They also note that dairy products may be protective. They conclude that adiposity, weight gain, hypertension, and diuretics were all independent risk factors for gout while weight loss is protective.
Figure A demonstrates monosodium urate crystals that are negatively birefringent crystals seen in gout.
InCORRECT Answers:
Answer 1: There is no indication to begin antibiotic therapy as all inflammatory markers are within normal limits and the synovial WBC is below 50,000. Answer 3: Allopurinol would be the long-term treatment for gout and is not indicated in an acute attack.
Answer 4: There is no indication for irrigation and debridement of a joint with an acute gouty attack.
Answer 5: Serum uric acid levels may be normal in those with an acute gouty attack. The diagnosis was made with aspiration.
772. In 2012, the American College of Chest Physicians (ACCP) brought forth changes to their guidelines on postoperative pharmacologic venous thromboembolism prophylaxis (VTEP) after total joint arthroplasty in order to converge with the American Academy of Orthopaedic Surgeons (AAOS).
Which of the following describes the change in surgeon practice patterns following the convergence of these guidelines?
1. An increase in the prescribing of ASA (aspirin) monotherapy
2. An increase in the prescribing of coumadin at INR goals of 2-3
3. An increase in the prescribing of low-molecular-weight heparin monotherapy
4. An increase in the use of elastic compressive stockings as monotherapy
5. An increase in the prescribing of fish oil as monotherapy
**CORRECT answer: 1**
In 2012, the ACCP supported ASA monotherapy compared with no prophylaxis. This brought about a convergence of ACCP and AAOS recommendations and led to a subsequent increase in the prescribing of ASA
monotherapy among orthopedic surgeons following total knee arthroplasty.
Following elective total hip or knee arthroplasty, post-operative VTE prophylaxis has been shown to significantly lower the risk of deep venous thrombosis compared to rates of 60% without chemoprophylaxis. The 2012
ACCP guidelines on VTE prophylaxis include ASA, low molecular weight heparin (LMWH), fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose unfractionated heparin (LDUH), or adjusted-dose vitamin K antagonist (VKA) for a minimum of 10-14 days following elective joint arthroplasty surgery. The guidelines also recommend dual therapy of mechanical and chemoprophylaxis while inpatient.
Shah et al. looked at venous thromboembolism prophylaxis (VTEP) practice patterns before and after the ACCP guidelines in 2012 regarding the use of ASA monotherapy. They found a roughly 40% increase in the prescribing of ASA monotherapy on POD#1 and at discharge. They concluded that ASA was readily and rapidly incorporated into clinical practice and highlights how guidelines affect practice patterns.
Freedman et al. in a 2000 meta-analysis of randomized, controlled trials looked at postoperative VTE prophylaxis in patients following elective total hip arthroplasty. They found warfarin had the lowest risk of proximal deep vein thrombosis and no significant differences among agents with regard to the risk of fatal pulmonary embolism or of mortality with any cause. They concluded that the best prophylactic agent in terms of both efficacy and safety was warfarin.
InCORRECT Answers:
Answers 2, 3, 4, and 5: Following the ACCP and AAOS convergence regarding ASA monotherapy, prescribing patterns in ASA were found to increase.
773. SOX-9 is a key transcription factor involved in the differentiation of which of the following cell lineages?
1. Osteoclasts
2. Osteoblasts
3. Chondrocytes
4. Fibroblasts
5. SOX-9 is not a transcription factor, it is a transmembrane tyrosine kinase receptor
**CORRECT answer: 3**
SOX-9 is considered a “master switch” for the differentiation of cells of chondrocytic lineage.
As described in the review by Hoffman et al, SOX-9 binds to a critical consensus sequence in the collagen 2 (Col2) promoter to activate its transcription. Formation of the cartilage template involves a multi-step process in which prechondrogenic mesenchymal cells form condensations prior to differentiating into matrix-producing chondroblasts.
Retinoids, particularly retinoic acid, are among the numerous signaling molecules that have been implicated in this process. Efforts aimed at understanding the mechanisms by which expression of retinoic acid receptor attenuates chondroblast differentiation led to the discovery of the transcriptional activity of SOX-9.
774. Which of the following is NOT included in the best management of a elderly female newly diagnosed with a fragility fracture?
1. Hip and spine densitometry
2. Laboratory analysis for secondary causes of osteoporosis
3. Administration of calcium 1,500 mg/day
4. Administration of Vitamin D 400 to 800 IU/day
5. Low protein diet
**CORRECT answer: 5**
The management of fragility fractures includes both treatment of the diagnosed fracture and optimization of patient health to help prevent future fractures. Appropriate management includes densitometry, laboratory analysis for secondary causes of osteoporosis, and metabolic optimization to heal the current fracture with appropriate calcium, vitamin D, and a protein enriched diet. The referenced manuscript suggests bone mineral density testing to all women age 65 and older and men age 70 and older as well as appropriate levels of calcium and vitamin D to allow for fracture healing.
775. Which of the following chromosomal translocations is associated with osteosarcoma?
1. SYT-SSX1
2. CHOP-TLS
3. EWS-FLI1
4. FKHR-PAX3
5. no translocation associated
**CORRECT answer: 5**
Osteosarcoma has no associated chromosomal translocation, but often has a mutation in Rb gene (retinoblastoma gene).
Answer 1: Synovial cell sarcoma is characterized by translocation t(X;18) (p11;q11) in more than 90% of cases which causes the fusion gene is called the SYT-SSX1, SYT- SSX2, or SYT-SSX4. Answer 2: The consistent cytogenetic abnormality in myxoid liposarcoma is translocation t(12;16)(q13;p11.2). This involves fusion of the transcription factor gene CHOP, which is essential for adipocytic differentiation, to the translocated in liposarcoma (TLS) gene on chromosome 16. Answer 3: Translocation t(11;22) is one of a series of related translocations occurs in more than 95% of the Ewing sarcoma family of tumors. This translocation joins the Ewing sarcoma gene EWS on chromosome
22 to a gene of the ETS family, friend leukemia insertion (FLI1) on chromosome 11, creating an aberrant activating transcriptional factor. Answer
4: The alveolar subtype of rhabdomyosarcoma accounts for 31% of rhabdo cases and involves a unique translocation occurs between the FKHR gene on chromosome 13 and either the PAX3 gene on chromosome 2 (70%) or the PAX7 gene on chromosome 1 (30%).
776. Which of the following terms best describes failure to exercise the degree of diligence and care that a reasonable and prudent person would exercise under similar conditions?
1. Intent
2. Causation
3. Standard of care
4. Breach of duty
5. Damages
**CORRECT answer: 4**
Malpractice is defined as negligence by a healthcare provider that results in injury to a patient. Medical negligence comprises four elements: duty, breach of duty, causation, and damages.
The duty of the physician is to provide care equal to the same standard of care ordinarily executed by surgeons in the same medical specialty. Breach of duty occurs when action or failure to act deviates from the standard of care.
InCORRECT answers:
1: Intent is something that is intended; an aim or purpose.
2: Causation is present when it is demonstrated that failure to meet the standard of care was the direct cause of the patient’s injuries.
3: Standard of care is the level and type of treatment that would be expected in similar situations by treating physicians.
5: Damages are monies awarded as compensation for injuries sustained as the result of medical negligence.
777. Which of the following laboratory values would be consistent with nutritional rickets?
1. increased calcium level
2. increased phosphate level
3. decreased alkaline phosphatase level
4. increased vitamin D level
5. increased parathyroid hormone level
**CORRECT answer: 5**
With decreased vitamin D intake, intestinal calcium and phosphate absorption are reduced leading to hypocalcemia. Decreased serum calcium stimulates increased PTH (secondary hyperparathyroidism) that leads to bone resorption resulting in low to normal levels of serum calcium. Overall laboratory studies show low to normal calcium, low phosphate (excreted because of effect of PTH), increased PTH, low levels of vitamin D and increased alkaline phosphatase levels.
778. Ligaments are viscoelastic, meaning that their tensile strength is affected by:
1. Torsion and tension only
2. Orientation of applied strain
3. Rate of applied load
4. Compression only
5. Tension only
**CORRECT answer: 3**
Ligaments are viscoelastic material which means their stress-strain curve patterns are time/rate dependent (as a result of the internal friction).
The inital portion of the stress-strain curve, called the toe region, exhibits a high deformation/low force characteristic due to the uncrimping of collagen fibers and the elasticity of elastin. Next is the linear region where slippage within and then between collagen fibrils occurs. In this stage, ligaments gets stiffer (increased tensile strength) at higher strain rates.
Illustration A shows the different regions of the stress-strain curve.

779. Which of the following groups correctly identifies serologic tests that are required by the American Association of Tissue Banks (AATB) for musculoskeletal tissue allografts?
1. Cytomegalovirus, Hepatitis A, Hepatitis B, Hepatitis C, HIV, Syphillis
2. Cytomegalovirus, Hepatitis A, Hepatitis B, Hepatitis C, HIV
3. Hepatitis A, Hepatitis B, Hepatitis C, HIV, Syphillis
4. Hepatitis B, Hepatitis C, HIV, Syphillis
5. Hepatitis B, Hepatitis C, HIV
**CORRECT answer: 4**
The American Association of Tissue Banks performs screening testing on all allografts in addition to screening patients medical history. Specific tests include: HIV, HBV, HCV,
HTLV-I/II, and Syphilis (see [_www.aatb.or_ g for more](http://www.aatb.org/) info on screening process). Neither Cytomegalovirus (CMV) nor Hepatitis A is routinely tested for in the American Association of Tissue Banks for musculoskeletal tissue.
780. Which of the following is most often implicated as an etiology for a hypertrophic nonunion?
1. Malreduction with open plating
2. Smoking
3. Inadequate mechanical stability
4. Open injury with significant soft tissue stripping
5. Infection
**CORRECT answer: 3**
Hypertrophic nonunions are caused by inadequate stability, with callus formation by an appropriate biological response. Lack of biology leads to an atrophic nonunion.
Hypertrophic nonunions should be treated with a fixation construct that lends appropriate stability without creating a poor biological environment.
781. **Ca10(P04)6(OH)2 is the chemical formula of**
1. Calcium hydroxyapatite
2. Osteocalcium phosphate
3. Calcium pyrophosphate
4. Osteocalcin
5. Polymethylmethacrylate
**CORRECT answer: 1**
The chemical structure of hydroxyapatite is Ca10(PO4)6(OH)2. Hydroxyapatite is a naturally occurring mineral form of calcium apatite with the formula Ca5(PO4)3(OH), but is usually written Ca10(PO4)6(OH)2 to denote that the crystal unit cell comprises two entities. Up to 50% of bone by weight is made up of a modified form of hydroxyapatite. It is one of few materials that will support bone ingrowth and osseointegration when used in orthopaedic, dental and maxillofacial applications.
782. Which of the following best describes the benefits of implementing diversity and cultural competency in orthopaedic training programs?
1. Incorporating foreign languages in the residency curriculum to improve communication with members of diverse backgrounds.
2. Teaching the social stereotypes of diverse cultures to improve the delivery of healthcare.
3. Establishing racial and gender enrolment quotas in residency programs to better serve all members of the community.
4. Enhancing trainees knowledge of diverse cultures to improve patient- physician relationships, optimize patient access to orthopaedic care, and enhance the quality and delivery of care.
5. Promoting orthopaedic trainees to travel to other countries to obtain surgical experience in different cultures.
**CORRECT answer: 4**
The goals of diversity and cultural competency in orthopaedic training is to enhance the knowledge of patient-physician relationships in diverse cultural groups so to improve access and quality of orthopaedic care.
There is increasing cultural diversity within our populations. The ability to better serve a heterogenous population relies on the ability to enhance the knowledge of patient- physican relationships so that people of all backgrounds can better access and benefit from the healthcare system.
White et al. examined the need for diversity in orthopaedics. For example, African- Americans have higher infant mortality rates, shorter life expectancies, fewer joint replacements, and more amputations than caucasians. It was concluded that cultural competency in orthopaedics is good for patients and for the country.
Illustration A shows a 2008 NSF census of the USA population. InCORRECT Answers:
Answer 1: Incorporating languages into an orthopaedic curriculum would only benefit a small sub-population of patients and isolate many others.
Answer 2: Teaching social stereotypes of diverse cultures can be viewed as discriminatory towards those groups.
Answer 3: While healthcare facilities with diverse staff are more likely to influence and successfully treat a nations diverse population, quotas of racial and gender backgrounds in orthopaedic residency will not entirely address the complete cultural competency that is required of every orthopaedic surgeon.
Answer 5: Traveling to isolated countries will not give residents a complete understanding of cultural diversity.

783. A clinical study for lateral epicondylitis allocates 1 group to receive physical therapy for 4 weeks and another group a new oral medication for 4 weeks. Then the 2 groups immediately switch therapies with one another for the next 4 weeks. The half-life of the medication used in the study is 2 weeks. Which of the following best describes the bias that is present in this study design?
1. Recall bias
2. Verification bias
3. Washout period bias
4. Detection bias
5. Incorporation bias
**CORRECT answer: 3**
In a crossover study design, the washout period is the time between therapies, receiving no therapy, so that the effect of the first therapy is allowed to wear off. In this scenario, the medication's long half-life may continue to have effects after the first group (receiving the medication) has switched to the physical therapy treatment.
Verification bias occurs when results of a diagnostic test influence whether patients are assigned to a
treatment group. Incorporation bias occurs when someone studies a diagnostic test that includes features of the target outcome. Recall bias occurs when
patients who experience an adverse outcome have a different likelihood of recalling an exposure than others that don't have an adverse outcome. Detection bias occurs when one looks more carefully for an outcome in one specific group more than the other group(s). The review article by Kocher et al describes the basics of biostatistics for clinicians.
784. A 62-year-old man undergoes an uncomplicated total shoulder replacement 9 months ago. What is an appropriate choice of prophylactic antibiotics to be taken prior to dental work if he has no allergies?
1. Daptomycin 600 milligrams intravenous 2 hours prior to procedure
2. Cephalexin 2 grams oral 1 hour prior to procedure
3. Levaquin 500 milligrams oral 1 hour prior to procedure
4. Trimethoprim-sulfamethoxazole 2 tablets double-strength oral 1 hour prior to procedure
5. No antibiotics are necessary
**CORRECT answer: 5**
Antibiotics are not necessary for this uncomplicated shoulder arthroplasty situation.
785. Disruption of which of the following interrupts the major source of nutrients to the growth plate?
1. Diaphyseal artery
2. Metaphyseal artery
3. Perichondrial artery
4. Synovial fluid
5. Synovial blood vessels
**CORRECT answer: 3**
Blood supply to the growth plate is supplied both via the perichondrial artery, which is the main source of nutrients, and the epiphyseal artery, which supplies the proliferative zone of the growth plate.

Early radiographic findings of avascular necrosis (AVN) of the hip include sclerosis and a subchondral lucency. A common presentation of Legg-Calve-Perthes disease (idiopathic pediatric hip AVN) is intermittent pain in the thigh, groin, or knee with an examination localizing to the hip; a Trendelenburg gait or sign; and painful, restricted passive hip range of motion. AVN also may be observed in association with a slipped capital femoral epiphysis (SCFE). AVN risk is highest in the setting of an unstable SCFE (10%-60%); risk is 0% to 1.4% when the SCFE is stable. A multicenter review of the modified Dunn procedure for treatment of unstable SCFE noted an AVN rate of 26%.
The most common deformity associated with SCFE is proximal femoral varus, flexion, and external rotation leading to an abnormal femoral head-neck junction offset. This causes a loss of passive hip flexion and internal rotation and the phenomenon of obligate external
rotation with flexion. The residual deformity frequently results in femoroacetabular impingement. Labral tears also are associated with cam impingement secondary to underlying osseous abnormalities including abnormal femoral head-neck junction offset.
Endocrinopathies potentially are associated with SCFE because of hormone-related physeal changes and subsequent mechanical insufficiency of the proximal femoral physis. With renal osteodystrophy, the physeal widening results from secondary hyperparathyroidism and progressive proximal femoral deformity may develop. Optimal medical management of hyperparathyroidism is essential. Surgical stabilization via in situ fixation of the proximal femur is indicated when SCFE is diagnosed.
The proximal femoral epiphysis secondary ossification center commonly appears between the ages of 4 and 7 months. In the setting of developmental hip dislocation, the appearance of the secondary ossification center is commonly delayed. After closed or open reduction of developmental dysplasia of the hip, failure of the femoral head ossific nucleus to appear within 12 months following the reduction is a sign of proximal femoral growth disturbance and AVN.

Figure 46a

Figure 46b

Figure 46c

Figure 46d

Idiopathic scoliosis in skeletally immature patients should be braced if it is greater than 30° and significant growth remains (estimated by a Risser sign of 0, 1, or 2). Studies have shown that patients with idiopathic scoliosis without atypical findings do not need magnetic resonance imaging. Physical therapy and electrical stimulation have been shown not to have any effect on the progression of idiopathic scoliosis.

This patient has multiple criteria for necrotizing soft-tissue infection (NSTI, also known as necrotizing fasciitis) including rapidly progressive infection, black bulla, hypotension and hypoxia, and a history of immune compromise. Aggressive emergent debridement including the removal of all necrotic tissue and IV antibiotics can decrease morbidity and mortality. Not all patients will have such obvious NSTI findings. In less clear cases, a scoring system using laboratory values (the Laboratory Risk Indicator for Necrotizing Fasciitis) can help clarify the diagnosis. IV antibiotics are key to treatment as well, but any delay in surgical treatment can increase morbidity and mortality. The black bulla and necrotic-appearing thumb indicate that this infection is not confined to the flexor sheath, therefore irrigation of the tendon sheath alone would be insufficient treatment. Although the thumb is dysvascular, this is because of an _infection, and revascularization is not indicated._

- Posteriorly_

Squamous cell carcinoma of the fingertip/nail region is uncommon but remains the most common malignancy in the hand. A high degree of suspicion is needed to diagnose this condition. Biopsy and radiographs are necessary initially. The subsequent treatment depends on the extent of the lesion at the time of presentation. Treatment can vary from Mohs micrographic surgery (MMS) to digital amputation. Amputation is recommended when bone involvement is present. In this patient, because the distal phalanx tip is involved and no further bone involvement proximally was observed, an amputation at the IP joint level is recommended. More proximal involvement would require a more proximal amputation level. Curettage and bone graft is not appropriate for this malignant lesion. External beam radiation therapy is not a first-line treatment option for this condition. Metastatic spread is uncommon. MMS is inappropriate when bone invasion has occurred.

Injury to the latissimus dorsi tendon recently has been reported as a cause of pain in the thrower’s shoulder. The etiology of this injury is felt to be eccentric overload during the follow-through of the throwing motion. Recommended management for this unusual injury consists of a short period of rest, followed by physical therapy to restore shoulder motion and strength. Throwing is allowed when the athlete demonstrates full, pain-free motion and good strength and balance of the rotator cuff and scapular rotator muscles. Currently there are no defined indications for surgical repair.
REFERENCES: Schickendantz MS, Ho CP, Keppler L, et al: MR imaging of the thrower’s shoulder: Internal impingement, latissimus dorsi/subscapularis strains and related injuries.
Magn Reson Imaging Clin N Am 1999;7:39-49.
Livesey JP, Brownson P, Wallace WA: Traumatic latissimus dorsi: Tendon rupture. J Shoulder Elbow Surg 2002;11:642-644.

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In patients with painful AC joint osteoarthritis undergoing surgery for concomitant rotator cuff tear, several well-designed studies and meta- analyses have shown that distal clavicle excision does not improve pain, function, shoulder range of motion or decrease need for revision surgery compared with rotator cuff repair alone.

Nearly all approaches to shoulder arthroplasty require detachment of the subscapularis tendon from the humerus and subsequent repair. Healing of this tenotomy is one of the limiting factors in postoperative recovery. Failure of the tenotomy repair must be recognized and treated early with repeat repair or pectoralis muscle transfer for optimal results. Failure of the subscapularis is diagnosed clinically as excessive external rotation and weakness, especially in the lift-off or belly press position. Muscle testing can be difficult in the postoperative period and may not be possible to assess in those positions. Although MRI might be useful to confirm the diagnosis, studies may be limited by artifact. CT or electromyography would not be diagnostic.
REFERENCES: Wirth MA, Rockwood CA Jr: Complications of total shoulder-replacement arthroplasty. J Bone Joint Surg Am 1996;78:603-616.
Miuer SL, Hazrati Y, Klepps S, et al: Loss of subscapularis function after shoulder replacement: A seldom recognized problem. J Shoulder Elbow Surg 2003;12:29-34.
76. A 52-year-old man has shoulder pain and stiffness after undergoing a “mini-lateral” rotator cuff repair 6 months ago. Examination reveals that he is afebrile with normal vital signs. There is slight erythema but no drainage from the incision. Range of motion is limited in all planes, and there is weakness with resisted external rotation and abduction. Radiographs show a well-positioned metal implant within the greater tuberosity. Laboratory studies reveal a WBC count of 8,400/ mm3 (normal 3,500 to 10,500/ mm3) and an erythrocyte sedimentation rate of 63 mm/h (normal up to 20 mm/h). What is the next most appropriate step in management?
1- Subacromial corticosteroid injection
2- Aspiration of the subacromial and glenohumeral joint spaces
3- Nonsteroidal anti-inflammatory drugs
4- Extensive surgical debridement
5- Diagnostic arthroscopy
PREFERRED RESPONSE: 2
DISCUSSION: Deep sepsis of the shoulder following rotator cuff repair is an uncommon problem. Patients with infections of this type typically report persistent pain and are not systemically ill. They may have signs of local wound problems such as erythema, drainage, and dehiscence. Laboratory studies can be helpful in making an accurate diagnosis. Most patients will not show a significant elevation of the WBC count; however, an elevated erythrocyte sedimentation rate is nearly always present and should alert the clinician to the presence of infection. Aspiration of both subacromial and glenohumeral joint spaces is necessary to confirm the diagnosis. The most effective treatment for deep shoulder sepsis following rotator cuff repair involves extensive surgical debridement, removing all suspicious soft tissue as well as implants. Administration of appropriate antibiotic therapy is needed for complete control of the infection.
REFERENCES: Mirzayan R, Itamura JM, Vangsness CT, et al: Management of chronic deep infection following rotator cuff repair. J Bone Joint Surg Am 2000;82:1115-1121.
Settecerri JJ, Pitnu MA, Rock MG, et al: Infection after rotator cuff repair. J Shoulder Elbow Surg 1994;8:105.
Herrera MF, Bauer G, Reynolds F, et al: Infection after mini-open rotator cuff repair. J Shoulder Elbow Surg 2002;11:605-608.

The most common deformity after antegrade nailing of a subtrochanteric femur fracture is varus and procurvatum (or flexion). This is caused by the hip abductors and iliopsoas pulling the proximal fragment into abduction and flexion, while the distal fragment is pulled into adduction from the adductors.
The reference by French et al is a review on 45 patients with subtrochanteric fractures treated with cephalomedullary interlocked nailing. Based on femoral neck-shaft angle, 61% of the fractures were reduced in at least 5º varus. The authors attributed this malalignment to failure to counteract muscle forces acting on the proximal fragment, combined with the adducted position of the distal femur during portal creation.
The reference by Ricci et al is a report of 403 femoral shaft fractures treated with intramedullary nailing. Patients with proximal femoral shaft fractures were found to have the highest incidence of malalignment. The most common deformity in this group was varus, followed by procurvatum (or flexion).

Despite concerns regarding fracture, osteonecrosis, and patellar clunk, the routine retention of the native patella during primary total knee replacement is associated with a 20% to 30% increased revision risk in
large joint registries. In addition, the retention of the native patella results in a 5.7% revision surgery rate
in patients with anterior knee pain.

Anteversion of the humeral component may result in anterior instability of the component. Posterior instability after total shoulder arthroplasty is usually the result of some combination of the following factors: untreated anterior soft-tissue contractures, excessive posterior capsular laxity, and excessive retroversion of the humeral and/or glenoid components.
REFERENCES: Cofield RH, Edgerton BC: Total shoulder arthroplasty: Complications and revision surgery. Instr Course Lect 1990;39:449-462.
Wirth MA, Rockwood CA Jr: Complications of total shoulder replacement arthroplasty. J Bone Joint Surg Am 1996;78:603-616.
69. A 70-year-old man seen in the emergency department has had left shoulder pain and a fever of 101.5 degrees F (38.6 degrees C) for the past 3 days. He denies any history of trauma. Examination reveals tenderness anterosuperiorly and at the posterior glenohumeral joint line. He has very limited range of motion (passive and active). Laboratory studies show a WBC count of 12,000/mm3 and an erythrocyte sedimentation rate of 48 mm/h. Initial management should consist of
1- an oral cephalosporin antibiotic and discharge home.
2- IV oxacillin and gentamicin.
3- arthroscopic drainage of the glenohumeral joint.
4- open irrigation and drainage of the glenohumeral joint.
5- aspiration of the glenohumeral joint and subacromial space with Gram stain and culture of the fluid.
PREFERRED RESPONSE: 5
DISCUSSION: It appears that the patient has septic arthritis of the glenohumeral joint; therefore, initial management should consist of aspiration of the glenohumeral joint and subacromial space separately, followed by Gram stain and culture of the fluid. Based on the findings, broad-spectrum IV antibiotics should be started. If the diagnosis of septic arthritis is confirmed, then arthroscopic or open surgical drainage usually is indicated.
REFERENCES: Sawyer JR, Esterhai JL Jr: Shoulder infections, in Warner JJ, Iannotti JP, Gerber C (eds): Complex and Revision Problems in Shoulder Surgery. Philadelphia, PA, Lippincott-Raven, 1997.
Leslie BM, Harris JM, Driscoll D: Septic arthritis of the shoulder in adults. J Bone Joint Surg Am 1989;71:1516-1522.

The patient has painful lateral and plantar keratoses with metatarsus quintus valgus deformity. This combination of problems is best addressed with an oblique mid-diaphyseal osteotomy that allows the distal metatarsal to be displaced medially and dorsally. Lateral eminence resection alone will not address the painful plantar keratosis. A distal chevron osteotomy has a more limited ability to address the plantar keratosis (if translated medially and slight dorsally). Proximal diaphyseal osteotomies of the fifth metatarsal are associated with an increased risk of delayed union or nonunion secondary to the relative hypovascularity in the proximal diaphysis. Excision of the fifth metatarsal head can result in a floppy fifth toe and transfer metatarsalgia.
REFERENCES: Coughlin MJ: Treatment of bunionette deformity with longitudinal diaphyseal osteotomy with distal soft tissue repair. Foot Ankle 1991;11:195-203.
Moran MM, Claridge RJ: Chevron osteotomy for bunionette. Foot Ankle Int 1994;15:684-688.

Thousands of ankle sprains occur in the United States every day. Most affected patients do not have serious sequelae associated with their injury. In this case, a young athlete sprained her ankle. Her only area of tenderness is isolated to the anterior talofibular ligament. She also has associated weakness. The radiograph shows an os subfibulare; this is an entity that she likely was born with. There is no indication of bony pain, and it is too soon to test for instability; consequently, no further imaging is required. Considering the nature of the sprain and her weakness, physical therapy with proprioceptive training and peroneal strengthening would be most beneficial.
RECOMMENDED READINGS
[Lephart SM, Pincivero DM, Giraldo JL, Fu FH. The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med. 1997 Jan-Feb;25(1):130-7. PubMed PMID: 9006708. ](http://www.ncbi.nlm.nih.gov/pubmed/9006708)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/9006708)
[McGuine TA, Keene JS. The effect of a balance training program on the risk of ankle sprains in high school athletes. Am J Sports Med. 2006 Jul;34(7):1103-11. Epub 2006 Feb 13. PubMed PMID: 16476915. ](http://www.ncbi.nlm.nih.gov/pubmed/16476915)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16476915)
[Chun TH, Park YS, Sung KS. The effect of ossicle resection in the lateral ligament repair for treatment of chronic lateral ankle instability. Foot Ankle Int. 2013 Aug;34(8):1128-33. doi: 10.1177/1071100713481457. Epub 2013 Mar 7. PubMed PMID: 23471672.](http://www.ncbi.nlm.nih.gov/pubmed/23471672)[View Abstract at](http://www.ncbi.nlm.nih.gov/pubmed/23471672)[ ](http://www.ncbi.nlm.nih.gov/pubmed/23471672)[PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23471672)
CLINICAL SITUATION FOR QUESTIONS 29 THROUGH 33
Figures 29a and 29b are the weight-bearing radiographs of a 49-year-old woman who has had several months of increasing pain and deformity in her left foot. She points to her plantar medial arch as her area of greatest pain; however, she also has pain just distal to the tip of the distal fibula. Her pain worsens with walking or navigating stairs. Upon examination she has a flexible unilateral pes planus deformity with increased heel valgus and forefoot abduction. She is unable to perform a single heel raise.

29A

B

Based on the history and clinical presentation, the most likely diagnosis is intimate partner violence.
Domestic violence or intimate partner violence can be in the form of mental or physical abuse, neglect or abandonment. Close to 25% of women will experience domestic violence. Risk factors include young age (19-29 years of age), females, pregnancy and lower socioeconomic status. Affected patients will have repeated visits to the emergency room, find reasons to stay in a treatment facility for an extended period of time and constantly seek approval
of their partner.
Shields et al. reviewed factors influence outcome in treatment of patients affected by domestic violence. They found that positive outcomes were associated with interdisciplinary approaches to management. This included better history assessment, providing written documentation regarding intervention and better access to information on community resources.
Illustration A is a chart documenting the frequency of female domestic violence throughout the world as of 2012.
Incorrect Answers
Answers 1, 2, 3, 5: These conditions are not consistent with this patient’s history.

Figure C and Illustration A (below) demonstrate the radiographic "double-arc" finding.
McKee et al described a unique "shear fracture of the distal articular surface of the humerus" which involved coronal fractures of the capitellum and a portion of the trochlea. He described the characteristic radiographic finding as the "double-arc sign" which represents the subchondral bone of the displaced capitellum and lateral trochlea ridge.
Incorrect Answers:
Figure A shows a radial head fracture. Figure B shows an elbow dislocation.
Figure D shows a pediatric lateral condyle fracture.
Figure E shows a pediatric medial epicondyle apophyseal avulsion fracture.

The use of 6- and 8-strand repair techniques allow the flexor tendon repair to withstand the force applied by early active motion protocols. The addition of epitendinous tendon repair also strengthens the repair.

DISCUSSION: Disseminated intravascular coagulation is a syndrome that spans a spectrum from relatively asymptomatic to life-threatening. In its fulminant form, patients undergo widespread microvascular thrombosis leading to overconsumption of coagulation factors and platelets, and then subsequent hemorrhage. End-organ failure frequently results. The condition is therefore a “thrombohemorrhagic” disorder. The exact pathophysiology remains poorly understood, but can be seen in conjunction with a variety of medical conditions, including massive transfusions, sepsis, bums, crush injuries, liver disease, autoimmune disorders, hemolysis, obstetrical emergencies, and malignancy. Laboratory abnormalities frequently include depressed levels of fibrinogen and platelets, increased levels of fibrinogen degradation products and D-Dimer, and an elevation in the PT and aPTT. In fulminant DIC, treatment is controversial and frequently unsuccessful, leading to death in affected patients. Heparin, although commonly used, has not been shown to have beneficial effects in controlled trials. Low-grade DIC will frequently improve with correction of the underlying medical disorder.

REFERENCE: Townsend CM, Beauchamp RD, Evers BM, et al (eds): Sabiston Textbook of Surgery: The Biologic Basis of Modern Surgical Practice, ed 18. Philadelphia, PA, Saunders Elsevier, 2008, pp 122123.

Figure 94

DISCUSSION: Nonsurgical management of OCD of the talus in skeletally immature individuals frequently results in a fairly rapid decrease in symptoms, but radiographic abnormalities can frequently be found even 6 months after treatment. Spontaneous resolution of this condition is rare. Hyperbaric oxygen treatment has not been shown to be beneficial for this condition. Progression of the condition to the point of requiring ankle fusion is rare.
REFERENCES: Perumal V, Wall E, Babekir N: Juvenile osteochondritis dissecans of the talus. J Pediat Orthop 2007;27:821-825.
Letts M, Davidson D, Ahmer A: Osteochondritis dissecans of the talus in children. J Pediatr Orthop 2003;23:617-625.

After closed treatment, residual displacement of the greater tuberosity (GT) of
>5 mm will most likely result in altered rotator cuff biomechanics.
The GT is draped by the confluence of the postero-superior rotator cuff tendons, with the anterior half of the GT insertion composed of supraspinatus (SS) fibers and the posterior half composed of overlapping SS and
infraspinatus (IS) fibers. Greater tuberosity fractures with residual displacement less than 5 mm after closed treatment tend to yield great outcomes with nonoperative management. When displacement is >5 mm (or
>3 mm in active patients), surgical treatment is warranted as the resultant malunion of the rotator cuff attachment site can cause limitation in active abduction and external rotation.
Bissell et al. investigated the epidemiology and risk factors of humerus among skiers and snowboarders. They reported that the incidence of humerus fractures among snowboarders was significantly higher (50%) than that of skiers, and that GT displacement >5 mm predicted the need for operative fixation.
George reviewed GT fractures. They reported that nondisplaced and minimally displaced fractures may be successfully treated nonoperatively, with surgical fixation recommended for fractures with >5 mm of displacement in the general population or >3 mm of displacement in active patients. They recommended close follow-up and supervised rehabilitation to optimize outcomes after both nonoperative and operative management.
Incorrect Answers:
Answer 1 and 2: While a disrupted medial hinge would increase the likelihood of osteonecrosis of the humeral head, it would not directly alter rotator cuff biomechanics.
Answer 2: While an intact calcar length of 6 mm (<8 mm) would increase the likelihood of osteonecrosis of the humeral head, it would not directly alter rotator cuff biomechanics.
Answer 4: Anatomical neck displacement >10 mm would be considered a part in the Neer classification. Displacement of <10 mm has not been correlated with altered rotator cuff biomechanics.
Answer 5: Surgical neck displacement >10 mm would each be considered a part in the Neer classification. Displacement of <10 mm has not been correlated with altered rotator cuff biomechanics.

End-to-end repair of a chronic rupture of the Achilles tendon may not be considered if the gap is greater than 2 cm. Equinus positioning is never acceptable. Although each of the other alternatives above may be considered, each has its proponents and potential disadvantages.

DISCUSSION: Because UKA does not require cruciate sacrifice, patellofemoral resurfacing, or rotational changes to the femur or tibia, it reliably recreates normal knee kinematics. UKAs have generally demonstrated higher reoperation rates than TKAs at intermediate and long-term follow-up, due in part to progression of arthritis in the nonresurfaced compartments. Mobile bearings have been clinically successful in both UKA and TKA.

REFERENCES: Patil S, Colwell CW Jr, Ezzet KA, et al: Can normal knee kinematics be restored with unicompartmental knee replacement? J Bone Joint Surg Am 2005;87:332-338.
Gioe TJ, Killeen KK, Hoeffel DP, et al: Analysis of unicompartmental knee arthroplasty in a community- based implant registry. Clin Orthop Relat Res 2003;416:111-119.

Knee dislocations are known to have a high risk for vascular injury. Although the specific treatment of various combinations of ligamentous injuries is controversial, the need for emergent revascularization is not. In this particular patient, after vascular repair, the most important initial concern is protection of the vascular repair. A spanning external fixator, especially in this patient with gross instability, will allow for easier assessment of vascular status, evaluation of fasciotomy wounds,
and temporary stability of the knee. A cylinder cast can stabilize the knee but will not allow wound assessment or room for inevitable post-injury/postoperative swelling. Diagnostic knee arthroscopy is not necessary, and ligamentous repair/reconstruction should be delayed until the vascular repair is stable. PREFERRED RESPONSE: 1

Figure A is an axial CT scan slice of an intra-articular distal tibia fracture. The bands of the posterior tibiofibular ligament pass obliquely from the fibula to the posterolateral aspect of the distal tibia. The ligaments of the ankle often remain intact after a pilon fracture producing the major fracture segments consisting of posterolateral or Volkmann's fragment (labeled D), the anterolateral or Chaput fragment (labeled B), and the medial fragment (labeled C). The fibula is labeled A. Any surgical approach taken to treat this injuries should respect these attachments.
Michelson reviews the important role of ankle ligamentous anatomy in his study on rotational ankle fractures.
Hermans et al review the anatomy of the ankle syndesmosis and state that stress on the posterior inferior tibiofibular ligament results more often in a posterior malleolus avulsion fracture than in a rupture of the ligament. They go on to state that with direct reduction of the posterior malleolus avulsion fracture, the syndesmosis can often be stabilized.
Illustration A shows the posterior inferior tibiofibular ligament highlighted in red on MRI imaging in a LEFT ankle (the CT image in the question is of a RIGHT ankle).

The history and laboratory studies indicate that this is not an infection. A lesion in this location and in this age group is likely a Ewing’s sarcoma. The presentation is usually a painful mass. About 20% of patients have a fever. The radiograph shows a typical mottled, permeative lesion with periosteal reaction. An MRI scan should be obtained to further evaluate the soft-tissue mass. Staging of the lesion should take place before biopsy, which should be done by the surgeon who would be performing the next stage of surgical treatment, ideally an orthopaedic oncologist.
REFERENCES: Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.
Meyer JS, Nadel HR, Marina N, et al: Imaging guidelines for children with Ewing sarcoma and osteosarcoma: A report from the Children’s Oncology Group Bone Tumor Committee. Pediatr Blood Cancer 2008;51:163-170.
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_AL-Madena Copy_

The radiograph reveals bony overgrowth of the microfracture site on the lateral femoral condyle. This occurs from violation of the subchondral plate during aggressive removal of the calcified cartilage layer during the microfracture. It is important during a microfracture to attempt to have a contained lesion and remove the calcified cartilage layer down to the subchondral plate, but avoid aggressively penetrating the _plate._

The patient has a fixed deformity of the hindfoot and an Achilles tendon contracture; therefore, the treatment of choice is triple arthrodesis with Achilles tendon lengthening. Further bracing will not be helpful. Amputation is not indicated, and ankle arthrodesis will not address the hindfoot deformity. Palliative management would be more appropriate if the knee was unstable or the quadriceps were weak, because the equinus balances the ground reaction force across the knee.
REFERENCES: Perry J, Fontaine JD, Mulroy S: Findings in post-poliomyelitis syndrome: Weakness of muscles of the calf as a source of late pain and fatigue of muscles of the thigh after poliomyelitis. J Bone Joint Surg Am 1995;77:1148-1153.
Dehne R: Congenital and acquired neurologic disorders, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 1, pp 552-553.

Patients may present with severe knee pain after a mild traumatiCevent. Patients may have the inability to extend the knee or walk. Laxity in flexion (flexion instability) can result in dislocation of the femorotibial articulation. The cam of the femoral component rides up and over the top of the post of the tibial polyethylene insert. The dislocation is usually the result of a traumatiCepisode.
Flexion instability occurs in about 1% to 2% of knee replacements when the knee is not properly balanced following a replacement. The extension and flexion gap must be equal. When balancing a knee, especially one that is tight in extension, the surgeon may choose to place a smaller tibial polyethylene component to achieve full extension with resulting instability of the knee in flexion because the knee flexion gap is larger than the polyethylene insert.
Treatment of flexion instability in posterior stabilized knee replacements can be nonoperative with casting or bracing initially. Two- thirds of patients can be managed successfully nonoperatively. If symptoms persist, revision to a larger polyethylene component can be very effective. If the knee remains unstable, revision to a more constrained prosthesis may be necessary

Myerson and associates studied the outcomes of 19 patients with tarsometatarsal joint injuries during athletic activity. Injuries were classified as first- or second-degree sprains of the tarsometatarsal joint or a third-degree sprain with diastasis between the metatarsals or cuneiforms. Poor functional results were seen in those with a delay in diagnosis and with inadequate treatment. For patients with third-degree sprains, poor results were obtained with nonsurgical management. These patients required open reduction and internal fixation for optimal return to function. The anatomic reduction is critical to the outcome; therefore, open reduction is preferred.
REFERENCES: Baxter DE: The Foot and Ankle in Sport, ed 1. St Louis, MO, Mosby, 1995,
pp 107-123.
Curtis MJ, Myerson M, Szura B: Tarsometatarsal joint injuries in the athlete. Am J Sports Med 1993;21:497-502.
Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82:1609-1618.
Thompson MC, Mormino MA: Injury to the tarsometatarsal joint complex. J Am Acad Orthop Surg 2003;11:260-267.