AAOS 2001 Reconstructive Hip and Knee

AAOS Hip 2001 MCQ

1. Figure 1 shows the radiograph of a 68-year-old man who underwent revision hip arthroplasty with impaction grafting of the femur and cementing of a tapered component into the graft 2 years ago. The patient remains symptom-free. Which of the following best describes the most likely histologic appearance of the proximal femur if a biopsy was performed? 12345C o m p l resto rati n o f th e co rtex,w i i terd i i o n o f cem en t i to th e p ati t n ati b o n e ete o th n g tati n en s ve Fibrous membrane encapsulating the stem, surrounded by a cement mantle and dead allograft Healing by mixed endochondral ossification, similar to fracture healing, surrounding the cement mantle Allograft resorption, with some cortical restoration because of osteoinduction Viable trabecular bone resulting from incorporation and remodeling of allograft

PREFERRED RESPONSE: 5 DISCUSSION: The radiograph shows three zones: an outer regenerated cortical layer, an interface zone consisting of viable trabecular bone and occasional particles of bone cement, and an inner layer of necrotic bone embedded in cement. No fibrous membrane is noted, and there is no direct contact of cement with native bone. Based on these findings, it is believed that the middle layer is the result of incorporation of the allograft with further remodeling. 2. Compared with cobalt-chromium, the biomechanical properties of titanium on polyethylene articulation in total hip replacement result in 12345an increased rate of volumetric wear. increased stability. decreased frictional force. a decreased rate of acetabular loosening. a decreased rate of femoral stem loosening.

PREFERRED RESPONSE: 1 DISCUSSION: The surface hardness of titanium is low compared with that of cobalt-chromium alloys. Titanium articulations are easily scratched, resulting in a significantly increased rate of wear and debris production. The wear and resulting lysis can also result in an increased rate of loosening. 3. What is the most common reason for reoperation in total knee arthroplasty? 12345Polyethylene insert failure Malalignment of the knee Ligamentous instability Perioperative infection Patellar-related complications

PREFERRED RESPONSE: 5

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Which of the following factors is most commonly associated with mechanical failure of a cemented total hip arthroplasty? 12345Increased stem offset Varus position of the stem Osteoporotic bone Patient weight of greater than 154 lb Gender

4.

PREFERRED RESPONSE: 2 5. Figure 2 shows the radiograph of a 72-year-old woman who reports pain after a fall. History includes several years of increasing thigh pain and limb shortening. Management consisting of an extensive work-up for infection reveals normal laboratory studies, a positive bone scan, and a negative hip aspiration. What is the most likely etiology of this complication? 12345Loosening of the prosthesis Modulus mismatch Chronic infection Osteoporosis Metastatic tumor

PREFERRED RESPONSE: 1 DISCUSSION: The patient has a midstem periprosthetic fracture, which commonly results in loosening of the prosthesis. Patients who have a large amount of bone loss may require an allograft with the surgical reconstruction. Although the patient reported a fall, her history is also consistent with preexisting loosening of th e p ro sth esi C h ro n i i fecti n h as b een sh o w n i u p to 1 6 % o f th ese fractu res;h o w ever,th e p ati t w o rk s. c n o n en s up revealed no infection. 6. Figures 3a through 3c show the radiographs and bone scan of a patient who reports increasing pain associated with activity for the past several months. Laboratory studies show an erythrocyte sedimentation rate of 14 mm/h and a C-reactive protein level of 0.4. Aspiration is negative for infection. Management should consist of 12345antibiotics for 6 weeks. use of an unlocked brace. revision arthroplasty. resection of the implants. two-stage reimplantation.

PREFERRED RESPONSE: 3 DISCUSSION: The radiographs show polyethylene wear, but exchange of this will not necessarily provide pain relief. The presence of pain suggests the possibility of occult loosening, and the surgeon must be prepared for this option intraoperatively. There is little evidence of infection. 7. Which of the following studies has the highest sensitivity and specificity in diagnosis of osteonecrosis of the femoral head? 1Intraosseous pressures 2AP and frog-lateral radiographs 3Technetium Tc 99m bone scan 4MRI scan 5CT scan

PREFERRED RESPONSE: 4

AAOS 2001 Reconstructive Hip and Knee

8.

Figure 4 shows the AP radiograph of a 28-year-old woman who has had moderate pain in the left hip for the past year. Nonsurgical management has failed to provide relief. She denies any history of hip pain, pathology, or trauma. Management should consist of 12345observation. a Pemberton osteotomy. a periacetabular osteotomy. a Chiari osteotomy. total hip arthroplasty.

PREFERRED RESPONSE: 3 DISCUSSION: The radiograph shows developmental dysplasia of the hip with the hip reduced and congruent. The treatment of choice is a periacetabular osteotomy because it can improve hip biomechanics and prolong the function of the hip joint. This procedure should be performed prior to the development of severe deg en erati ch an g es. O b servati n w iln o t al th e p ati t n atu ralh i ry o r th e b i m ech an i o f th e h i . ve o l ter en s sto o cs p A total hip arthroplasty should be delayed until severe degenerative changes are present. A Chiari osteotomy is a salvage osteotomy used for a noncongruent subluxated hip. A Pemberton osteotomy requires an open triradiate cartilage; therefore, it is not an option in an adult. 9. What complication is most likely to develop after right total hip arthroplasty in the patient shown in Figure 5? 12345Infection Dislocation Heterotopic bone formation Early mechanical loosening Excessive bleeding

PREFERRED RESPONSE: 3

10.

In revision total hip arthroplasty, an acetabular reconstruction cage is best indicated for which of the following patterns of bone loss? 12345Enlarged acetabular rim Cavitary central defect Superior migration of 2 cm Deficient anterior wall Pelvic discontinuity

PREFERRED RESPONSE: 5 DISCUSSION: Acetabular cage reconstruction is indicated in severe disruption of acetabular bone stock when a cementless acetabular component cannot be stabilized in intimate contact with a sufficient bed of structurally sound and viable host bone, with or without a structural graft. Cages are used in pelvic discontinuity where they provide a bridge between the ilium and the ischium, while supporting a cemented cup. All of the other scenarios are amenable to achieving an adequate rim fit for a cementless component, using a jumbo cup if necessary.

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Mechanical reduction of the pain associated with the condition shown in Figure 6 can be accomplished through the use of a cane on the contralateral side. Similarly, if this patient must carry any type of load in his or her arms, it should be carried 12345on the ipsilateral side. on the contralateral side. in a backpack. directly in front with both arms. with a broad, padded strap on both shoulders.

11.

PREFERRED RESPONSE: 1 12. Figure 7 shows the AP radiograph of a 60-year-old man who has had pain in the thigh for past 6 months. History reveals that he underwent hip replacement 1 year ago. The radiographic changes are most likely the result of what process? 12345Microtrauma Mechanical loosening Septic loosening Neoplasia Congenital anomaly

PREFERRED RESPONSE: 3 DISCUSSION: The arrows in the radiograph point to circumferential radiolucencies that strongly support the diagnosis of septic loosening. Radiolucent lines that occur in such a short time are also typical of an infection. 13. Figure 8 shows the radiograph of a 72-year-old man who has had severe pain in the left hip for the past 3 weeks. History reveals alcohol abuse. The next most appropriate step should consist of 12345hip aspiration. Doppler ultrasound. AP tomograms. a CT scan. a technetium Tc 99m bone scan.

PREFERRED RESPONSE: 1 DISCUSSION: The radiograph reveals destruction of the femoral head with loss of the articular cartilage. These findings are consistent with an infected hip, and aspiration will confirm the diagnosis. Although the patient could have advanced osteonecrosis, typically the cartilage interval is maintained and such destruction is rarely associated with osteonecrosis. 14. Which of the following articulation couplings shows the lowest coefficient of friction as tested in the laboratory? 12345Cobalt-on-polyethylene Cobalt-on-cobalt Titanium-on-polyethylene Stainless steel-on-polyethylene Ceramic-on-ceramic

PREFERRED RESPONSE: 5

AAOS 2001 Reconstructive Hip and Knee

15. Which of the following is considered the best cementless acetabular reconstruction method when planning for total hip arthroplasty in a patient with developmental dysplasia of the hip (DDH)? 12345-

Cemented reconstruction with the cup in an anatomic position and cement filling the defect Medialized component positioning with no femoral head graft, leaving up to 20% of the shell uncovered High and lateral positioning of the acetabular component with a femoral head graft Anatomic positioning of a small shell with a 28-mm liner and 4 mm of polyethylene Anatomic positioning of the cup and a femoral head graft covering 70% of the cup

PREFERRED RESPONSE: 2

16.

Which of the following mechanisms is considered the most common cause of failure of osteoarticular allografts used for articular reconstruction? 12345Osteocyte surface antigens that trigger an immune rejection Chondrocyte surface antigens that trigger an immune rejection Graft collapse during revascularization Mechanical loosening at the bone-bone junction Infection via graft contamination

PREFERRED RESPONSE: 3 DISCUSSION: Mechanical loosening and infection can occur as complications after surgery, but the most common cause of osteoarticular allograft failure is graft collapse during revascularization. Clinical rejection because of an immune response is an unusual means of failure. 17. When compared with a patient who has a subluxated hip, a patient with a dislocated hip who is undergoing acetabular reconstruction for developmental dysplasia of the hip will most likely have 12345an increased need for revision. a greater limb-length discrepancy. a decreased rate of postoperative instability. a decreased rate of wear. a decreased rate of peroneal nerve palsy.

PREFERRED RESPONSE: 1 DISCUSSION: The rate of revision has been found to be significantly increased in patients with a dislocated hip preoperatively compared with patients with a subluxated hip. This may be the result of compromised acetabular bone stock. The rate of nerve palsy may be increased because of the greater degree of lengthening required to reduce the reconstructed hip. 18. The anticoagulant effect of the low-molecular-weight heparins (LMWH) is mediated by the binding affinity of antithrombin III to which of the following coagulation factors? 12345III V IX Xa XII

PREFERRED RESPONSE: 4

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The primary purpose of obtaining the radiograph shown in Figure 9 is to assess 12345the anterior column of the acetabulum. the acetabular rim. the os acetabulae. anterior coverage of the femoral head. femoral anteversion.

19.

PREFERRED RESPONSE: 4 DISCUSSION: The radiograph shows a faux profil view of the hip. The primary purpose of this view is to evaluate anterior coverage of the femoral head. REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 455-492. Ganz R, Klaue K, Vinh TS, Mast JW: A new periacetabular osteotomy for the treatment of hip dysplasias: Technique and preliminary results. Clin Orthop 1988;232:26-36. Leq u esn e M ,d eSez S:Le fau x p ro fi d u b assi :N o u vele i ci en ce rad i g rap h i u e p o u r letu d e d e l h an ce. l n l n d o q a Son utilite dans les dysplasies et les differentes coxopathies. Rev Rhum Mal Osteoartic 1961;28:643. 20. Figure 10 shows the radiograph of an active 75-year-old woman who reports severe leg pain after a fall. Management should consist of 12345a total hip arthroplasty with a long-stem prosthesis. a resection arthroplasty with skeletal traction. hemiarthroplasty with a long-stem prosthesis. retention of the prosthesis and open reduction and internal fixation. closed treatment with skeletal traction.

PREFERRED RESPONSE: 1 DISCUSSION: The patient has a comminuted fracture of the proximal femur and joint space narrowing of the acetabulum. Therefore, the prosthesis should be converted to a total hip arthroplasty. Because there is extensive comminution, the revision stem should bypass the area of bone loss by two bone diameters. A hemiarthroplasty is not indicated because the patient has no acetabular cartilage. Open reduction and internal fixation may not stabilize the prosthesis. A resection arthroplasty or treatment in traction will not leave the patient with adequate function. 21. Which of the following procedures is considered most appropriate in patients with rheumatoid arthritis?

1Hip arthrodesis 2Osteotomy of the hip 3Core decompression of the hip 4Synovectomy of the knee 5Unicondylar knee arthroplasty PREFERRED RESPONSE: 4 DISCUSSION: Synovectomy of the knee prior to loss of articular cartilage has been shown to consistently relieve pain in patients with rheumatoid arthritis. Partial knee replacement will not arrest the process of joint destruction. Osteotomy of the hip has not been found to be a successful procedure in patients with rheumatoid arthritis. Hip arthrodesis should not be considered because of the multiarticular involvement in patients with rheumatoid arthritis. Core decompression of the hip has not been shown to save the femoral head because the necrosis appears to occur simultaneously with the inflammatory joint process.

AAOS 2001 Reconstructive Hip and Knee

22.

In a patient who has rheumatoid arthritis with acetabular protrusion, what is the best biomechanical position for the cup with respect to the preoperative center of rotation? 12345Medial and superior Medial Lateral and superior Anterior and inferior Posterior and lateral

PREFERRED RESPONSE: 4 DISCUSSION: Acetabular protrusion in patients with rheumatoid arthritis moves the center of hip rotation medially and posteriorly. Positioning of the acetabular component in a patient with protrusion is best accomplished in the normal (anterior and inferior) position and not in a protruded position. This has been shown both clinically and in a finite-element analysis. Any medial positioning will produce impingement of the prosthesis neck on the rim, and superior placement produces improper hip mechanics. 23. Figures 11a and 11b show the radiographs of a 50-year-old man who was struck by a car. Treatment should consist of 12345cemented bipolar hemiarthroplasty. cementless bipolar hemiarthroplasty. hybrid total hip arthroplasty. cementless total hip arthroplasty. open reduction and internal fixation.

PREFERRED RESPONSE: 5 DISCUSSION: The patient has a displaced femoral neck fracture. Although the treatment remains controversial, most clinicians advocate either a closed or open reduction in younger active patients. Achieving an anatomic reduction is necessary to avoid loss of reduction, nonunion, or osteonecrosis. An acceptable reduction may have up to 15 of valgus angulation and 10 of posterior angulation. Parallel multiple screws or pins are the most common method of internal fixation. Prosthetic replacement is generally reserved for older and less active individuals. 24. One advantage of using onlay strut allograft in femoral revision surgery is that it can 12345provide some structural support to host bone. provide better osteoconductive properties than cancellous graft. completely incorporate into the host femur to restore bone stock. be used for cavitary defects of the femur. be used as a primary structural support for the femoral component.

PREFERRED RESPONSE: 1 DISCUSSION: Onlay grafts can provide more structural support than morcellized grafts. They are more easily incorporated into the host femur than bulk segmental total femur allografts; however, the incorporation is never complete. The use of onlay grafts is principally directed at addressing segmental defects of the femur; their use can be applied with either cementless or cement fixation of the femoral stem.

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Which of the following methodologies has been proven to be effective in reducing the use of homologous blood transfusion following total hip arthroplasty (THA)?

25.

1Type of postoperative anticoagulation 2Preoperative autologous blood donation 3General anesthesia 4Cementless fixation of the components 5The use of wound drains PREFERRED RESPONSE: 2 DISCUSSION: A variety of methodologies have been used to decrease the need for homologous blood transfusions following THA. Some of the effective strategies include preoperative donation of autologous units, intraoperative salvage and recycling, preoperative injection of erythropoietin, and regional anesthesia. Cementless fixation and use of wound drains have been shown to increase the blood loss with THA. 26. A 67-year-old man is requesting revision surgery because of continued pain in the knee after undergoing a total knee replacement 2 years ago. Examination reveals that the knee is not warm, the incision is well-healed, and the skin has normal coloration and hair formation. No varus or valgus instability is noted, and knee range of motion is 5 to 100. Laboratory studies show an erythrocyte sedimentation rate of 15 mm/h and a WBC of 5,000/mm3. Aspiration of the knee reveals clear fluid that shows no growth on culture. Radiographs reveal an appropriately positioned cruciate-retaining cemented total knee arthroplasty that is well-fi . W h at i th e p ro b ab ii th at th e p ati t p ai w ilb e xed s lty en s n l improved with revision surgery?

15% 210% 340% 460% 590% PREFERRED RESPONSE: 3 DISCUSSION: The patient has a well-fixed and aligned painful total knee replacement. The success rate of revision knee replacement for pain when no mechanical problem can be identified is approximately 40%. The critical step is to rule out the presence of infection with appropriate laboratory studies and aspiration. If no infection is detected, revision should be avoided. 27. For patients undergoing a surgical procedure where the risk of requiring a transfusion is less than 10%, the International Committee of Effective Blood Usage suggests

11 unit of autologous blood. 22 units of autologous blood. 31 unit of direct donated blood. 4use of cell saver intraoperatively. 5no donation is necessary. PREFERRED RESPONSE: 5 DISCUSSION: Recent studies have shown a high rate of waste of autologous blood. Therefore, the Committee does not recommend autologous blood donation for procedures that carry a transfusion risk of 10% or less. 28. Figure 12 shows the radiograph of a 55-year-old man who has severe, painful osteoarthritis of the left hip and is scheduled to undergo a left total hip arthroplasty. History reveals that he underwent a right total hip arthroplasty 5 years ago that remains pain-free. Based on the preoperative radiograph, the patient is at greatest risk for what complication?

1Intraoperative fracture 2Deep vein thrombosis 3Limb-length discrepancy 4Sciatic nerve palsy 5Thigh pain PREFERRED RESPONSE: 3

AAOS 2001 Reconstructive Hip and Knee

29.

Figures 13a and 13b show the preoperative radiographs of a 60-year-old woman who is scheduled to undergo total knee arthroplasty under epidural anesthesia. Postoperatively she reports a burning sensation on the dorsum of her foot despite the administration of IV analgesics through a patientcontrolled analgesia (PCA) pump. Management should now include 12345increasing the dose released by the PCA. administering a different narcotic with the PCA pump. elevating the leg. releasing the dressings and knee flexion. immediately returning to the operating room for revision.

PREFERRED RESPONSE: 4 DISCUSSION: The patient has a significant flexion contracture and valgus deformity; therefore, the risk of peroneal nerve injury is increased. Idusuyi and Morrey noted that epidural anesthesia also increases the risk of peroneal nerve injury. The initial symptom can be a burning sensation on the foot, followed by pain and then motor weakness. Initial management should consist of release of the dressings and knee flexion. 30. Figures 14a and 14b show the plain radiographs of an 85-year-old woman who has had severe pain in the right knee for the past 4 months. Management should consist of 12345a hinged knee brace. arthroscopic debridement. high tibial osteotomy. total knee arthroplasty. osteochondral grafts.

PREFERRED RESPONSE: 4 DISCUSSION: The patient has osteonecrosis of the lateral femoral condyle with collapse of the articular surface. Because there is already collapse of the articular surface, a total knee arthroplasty is the treatment of choice. The results of total knee arthroplasty in these patients are usually excellent. However, knee replacement is only a resurfacing procedure, and some patients with global osteonecrosis of the distal femur may have residual pain after knee replacement. High tibial osteotomy may be indicated in younger patients who have a varus deformity and localized osteonecrosis. Arthroscopic surgery would provide minimal relief for this patient because there is already collapse of the articular surface. A hinged knee brace will not adequately unload the joint. An osteochondral allograft should be considered only for younger patients with localized osteonecrosis. 31. The failure of the acetabular component shown in Figure 15 is most likely the result of the use of a 32mm head and

1the material properties of the polyethylene. 2the initial alignment of the component. 3overuse of the component by the patient. 4failure to stabilize the cup with screws. 5increased femoral head offset. PREFERRED RESPONSE: 1 32. The use of elevated rim acetabular liners and long femoral necks may result in 12345increased abductor tension. an increased likelihood of impingement. an increased likelihood of osteolysis. restricted hip range of motion. dissociation of polyethylene from the acetabular cup.

PREFERRED RESPONSE: 2

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33. Cementation technique has a definite influence on the long-term survival of cemented femoral components. Both clinical and autopsy studies support the use of a cement mantle with a thickness of how many millimeters? 123450.5 1 2 3 4

PREFERRED RESPONSE: 3 34. A 73-year-old man is scheduled to have mature heterotopic bone resected from around his left total hip arthroplasty. The optimal management for prophylaxis against the return of heterotopic bone postoperatively is radiation therapy that consists of 12345400 cGy in one dose. 700 cGy in one dose. 1,000 cGy in five doses. 2,000 cGy in 10 doses. 3,000 cGy in 10 doses.

PREFERRED RESPONSE: 2 35. Which of the following is considered a potential advantage in prophylaxis for the prevention of deep venous thrombosis associated with the use of low-molecular weight heparin (LMWH) as compared with fixed-dose unfractionated heparin? 12345Reduction in free fibrinogen radicals Reduction in bleeding complications Increased venous flow Improved bioavailability Inhibition of factors V, VI, and IX

PREFERRED RESPONSE: 4 36. Figure 16 shows the radiograph of a 75-year-old man who has progressive groin pain and a limp following total hip replacement. At revision surgery, the anterior and posterior columns of the acetabulum are noted to be intact. The optimal surgical technique for acetabular component reconstruction is a 12345threaded (screw-in) cup with a hydroxyapatite coating. protrusio cage reconstruction with a cemented cup. large cementless cup with bone grafting of defects. small cup with a high and lateral hip center. bulk allograft reconstruction of the defect with a cemented cup.

PREFERRED RESPONSE: 3 DISCUSSION: Large cementless acetabular components have been shown to perform well in revision acetabular reconstruction. The use of such components is predicated on the presence of adequate anterior and posterior column bone. If a good press-fit can be achieved between the anterior and posterior columns, typically, the remaining defects can be filled with morcellized bone graft. Protrusio cages are typically used in situations where it is not possible to obtain adequate fixation with a large acetabular component. The use of a high hip center with small sockets is more typical of primary arthroplasty in patients with developmental dysplasia of the hip. Bulk acetabular allografts for large segmental defects might be necessary in certain situations, although the use of bulk allografts has resulted in a high failure rate after 5 years. Early results of the use of protrusio cages and bone grafting for large segmental defects have been favorable.

AAOS 2001 Reconstructive Hip and Knee

37. Which of the following is a recognized consequence of hip fusion? 12345Low back pain Contralateral knee laxity Difficulty delivering children Meralgia paresthetica Contralateral abductor weakness

11

PREFERRED RESPONSE: 1 DISCUSSION: Low back pain is an expected long-term complication of fusion; ipsilateral knee laxity is frequently encountered, as is degeneration of the contralateral hip. Hip fusion is equally valuable for both men and women, with both genders reporting satisfactory sexual function. Female patients often deliver by elective Cesarean section, although vaginal deliveries are reported. 38. Treatment of a cruciate-retaining total knee that is unstable in flexion is best accomplished by

1revising the implant to a posterior stabilized device. 2revising the implant with a thinner polyethylene insert. 3revising the implant with a larger femoral component. 4limiting flexion to only 90. 5using quadriceps conditioning exercises and a derotation brace. PREFERRED RESPONSE: 1 39. The stiffness of a 16-mm femoral stem is mostly influenced by the

1elastic modulus of the material. 2surface coating or treatment. 3diameter of the femoral stem. 4length of the femoral stem. 5ultimate tensile strength. PREFERRED RESPONSE: 3 DISCUSSION: The stiffness is most influenced by the geometry, in particular the diameter of the stem. The bending rigidity increases to the fourth power of the radius. The elastic modulus of the material increases as a direct linear relationship. The surface coating does not affect the bending rigidity greatly unless it increases the diameter significantly. 40. Figures 17a and 17b show the AP and lateral radiographs of a 75-year-old woman who reports giving way and shifting of the knee, particularly when she is descending stairs or ambulating on level surfaces. History reveals a total knee replacement 5 years ago. Treatment should consist of

1extra-articular ligament repair. 2resection arthroplasty with a cement spacer. 3revision of the tibial tray. 4revision of the patella to an all-polyethylene component. 5revision to a posterior cruciate-substituting implant. PREFERRED RESPONSE: 5 DISCUSSION: The radiographs show well-fixed components of a posterior cruciate-retaining total knee replacement. The relative position of the femoral component is anteriorly subluxated relative to the tibial component. The AP radiograph shows that the articular space is markedly asymmetric, indicating either failure or fracture of the p o l yeth yl e o r su b l xati n o f th e fem u r rel ve to th e ti i Th e p ati t sym p to m s su g g est en u o ati b a. en s a failure of the posterior cruciate ligament that is consistent with the radiographic findings; therefore, the treatment of choice is revision to a posterior cruciate-substituting implant.

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41. Factors contributing to an increased risk of hip fracture include reduced bone mineral density of the femoral neck, cognitive status of the individual, and 1increased trunk muscle activity. 2increased muscle activity about the hip. 3increased muscle activity about the shoulder. 4a flexed hip configuration during impact. 5falling forward on an outstretched hand. PREFERRED RESPONSE: 1 42. A healthy 70-year-old man has a swollen knee after undergoing a knee replacement 10 years ago. Aspiration of the knee reveals cloudy, viscous synovial fluid. Laboratory studies show an erythrocyte sedimentation rate of 10 mm/h and a C-reactive protein level of less than 0.5. What is the most likely diagnosis?

1Infected total knee arthroplasty 2Polyethylene wear-related synovitis 3Rheumatoid arthritis synovitis 4Gout 5Tibial component loosening PREFERRED RESPONSE: 2 43. The insurance carrier of a patient who underwent total knee arthroplasty 4 days ago is now demanding that the patient be discharged from the hospital. However, examination reveals that the patient has a range of motion of only 10 to 55, and the patient is concerned whether she will ever move her knee normally. The insurance company representative should be advised that 1-

discharge at this time may result in loss of motion and the necessity of manipulation under anesthesia. 2the insurance company has no right to make such demands on the surgeon or the patient. 3if the patient is discharged and fails to regain full motion, she will most likely file a suit against the insurance company. 4the patient will require a follow-up examination in 6 weeks to evaluate her progress. 5the patient will be given an extra set of exercises to perform at home. PREFERRED RESPONSE: 1 44. Figure 18 shows the radiograph of a patient with a total hip arthroplasty dislocation. During revision, increasing the diameter of the femoral head while maintaining the ratio of head-to-neck diameter constant has the effect of

1- increasing the force to dislocation of the femoral head. 2- increasing the range of motion until impingement of the neck on the liner. 3- decreasing the resisting moment to dislocation of the femoral head. 4- decreasing the range of motion until dislocation of the femoral head. 5- decreasing the range of motion until impingement of the neck on the liner. PREFERRED RESPONSE: 2 DISCUSSION: Although there is strong clinical and laboratory evidence that suggests smaller head size is linked with lower rates of polyethylene wear, moving to the use of 22-mm heads from larger sizes would tend to increase the dislocation rate. The key premise to this argument is that the absolute size of the femoral neck remains unchanged. While neck diameters were appropriate for the early monoblock femoral components, the use of modular femoral stems allows the surgeon to place 22-mm heads onto the same neck and trunion as used by larger heads. This has the effect of lessening the head-to-neck diameter ratio, which then accentuates the rate of impingement and dislocation. Reducing the neck diameter in proportion to the head diameter would eliminate the range-of-motion penalty accompanying head size reduction.

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45.

13

During primary total knee arthroplasty with trial implants in place, the surgeon notes technically satisfactory patellar resurfacing and restoration of a physiologic mechanical axis but excessively lateral patellar tracking. Treatment should now include 12345a lateral retinacular release. a tubercle transfer to reduce the Q angle. a repeat of the tibial and femoral cuts to introduce 5 of varus. release of the popliteus. medial vastus advancement.

PREFERRED RESPONSE: 1 DISCUSSION: The most common causes of patellar instability after total knee arthroplasty are valgus malalignment, internal rotation of the femoral or tibial component, medialization of the femoral component, errors in patellar preparation and resurfacing, and failure to perform a lateral release. These factors should be addressed before considering capsular closure. Distal extensor mechanism realignment should be avoided because of the complication rate. The proximal extensor mechanism would not adequately compensate for implant malrotation. 46. Figure 19 shows the current radiograph of a 48-year-old man who reports hip pain and marked difficulty walking after undergoing revision of a failed total hip replacement 2 years ago. What is the mechanism of failure? 12345Fatigue Crevice corrosion Galvanic corrosion Loosening Wear

PREFERRED RESPONSE: 1 DISCUSSION: Fatigue from repetitive loading of the stem with the distal aspect well-fixed resulted in stem failure. If the stem had loosened, it would not have broken. Crevice corrosion occurs at a taper interface; galvanic corrosion occurs at the junction of two metals of differing electrochemical potentials, not along a uniform portion of the implant. 47. Torsional moments about the longitudinal axis of a total hip arthroplasty show what change during stair climbing compared with walking? 12345Increase by a factor of 50% during stair climbing Increase by a factor of 100% during stair climbing Increase only during the first 6 to 8 weeks following implantation, then revert to normal Decrease by a factor of 50% during stair descent Decrease by a factor of 100% during stair descent

PREFERRED RESPONSE: 2 DISCUSSION: The magnitudes of out-of-plane loads on a total hip replacement during activities of daily living can be substantial. Bergmann and associates studied these forces about two instrumented hip prostheses. They noted that the torsional moment about the hip during stair climbing is twice as high as during slow walking and that similar moments are generated during slow jogging. Higher loads were noted when the patients stumbled without falling. They also noted that the torsional moments observed in vivo were close to or even exceeded the experimentally determined limits of the torsional strength of implant fixations.

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When converting the knee shown in Figure 20 to a total knee arthroplasty, satisfactory outcome can be expected in what percent of patients? 12345Less than 5% Less than 50% 60% 80% 90%

48.

PREFERRED RESPONSE: 2 49. The specificity of intraoperative frozen sections obtained for the evaluation of infected total hip arthroplasty may be improved by 12345setting the threshold for diagnosis to 10 polymorphonuclear leukocytes per high-powered field. setting the threshold for diagnosis to 15 polymorphonuclear leukocytes per high-powered field. ensuring that each sample is obtained and submitted in a truly random fashion. ensuring that polymorphonuclear leukocyte counts are obtained in a truly random fashion. correlating the frozen section results with those of the intraoperative Gram stain.

PREFERRED RESPONSE: 1 50. Figures 21a through 21c show the radiographs of a 70-year-old woman who has persistent pain with activity after undergoing hip revision 6 months ago. Treatment should now consist of 12345shortening of the femoral neck. exchange of the acetabular liner. revision of the femoral component. revision of both components. revision of the acetabular component.

PREFERRED RESPONSE: 5 DISCUSSION: The radiographs show disruption of the posterior column of the acetabulum with radiolucencies about the component. Because the patient requires a stable construct to allow the bone to heal, the treatment of choice is an antiprotrusio cage and a graft. 51. A patient who underwent a high tibial osteotomy (HTO) is now scheduled to undergo total knee arthroplasty (TKA). When compared with a patient undergoing primary TKA without a prior HTO, the patient should be advised to expect a higher incidence of 12345limited range of motion. patella complications. infection. loosening. tibia fracture.

PREFERRED RESPONSE: 2 DISCUSSION: Conversion TKA following a previous HTO can be successful; however, it is associated with poorer clinical results when compared with other primary TKAs. There is an increased likelihood of poor range of motion that is partially affected by patella infera created from the osteotomy. Patella infera also results in difficulty with surgical exposure. There has been no reported increase in the rate of infection, fracture, or loosening.

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15

52. Figures 22a and 22b show the radiographs of a patient who reports stiffness of the hip and associated pain. Management should consist of 12345use of a cane for ambulation. diphosphonate therapy. physical therapy and indomethacin. surgical excision and radiation therapy. revision arthroplasty.

PREFERRED RESPONSE: 4 DISCUSSION: The patient has grade IV heterotopic ossification with the limb in an abnormal nonfunctional position. Treatment should consist of excision of the bone to restore hip motion and prophylaxis to prevent recurrent formation. The best time to excise the bone is controversial, with no conclusive evidence supporting early or late excision. 53. Figure 23 shows the radiograph of a 55-year-old man who underwent a total hip arthroplasty 5 years ago. Management should now consist of 12345an Ogden-type plate with screws and cerclage bands or cables. allograft bone plates fixed with cerclage cables and wires. skeletal traction for 8 weeks. revision of the femoral stem. resection arthroplasty.

PREFERRED RESPONSE: 4 DISCUSSION: Because the radiograph shows that the femoral stem is loose within the femoral canal and there is a fracture in the distal cement mantle, the stem should be revised. The Ogden-type plate and the allograft bone plates will reconstruct the femur but will not restore stability to the stem. Similarly, traction may allow the femur to heal but will not restore stability to the femoral stem within the femur. Resection arthroplasty is considered a salvage option following failure of the other procedures. 54. Compared with wear rates of metal-on-standard polyethylene bearings (75 to 250 m/y), the wear rate of metal-on-metal bearings for hip arthroplasty is approximately how many micrometers per year? 12345Less than 0.5 2 to 5 5 to 20 20 to 50 50 to 150

PREFERRED RESPONSE: 2 DISCUSSION: Studies on older systems, as well as newer designs, have confirmed that metal-on-metal bearing surfaces undergo linear wear of 2 to 5 m per year. Ceramic bearing surfaces produced with recent technology perform even better, with a wear rate of 0.5 to 2.5 m per year. Clinical wear rates of metal-oncrosslinked polyethylene have not yet been determined.

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AAOS 2001 Reconstructive Hip and Knee

A follow-up examination of a patient 6 weeks after knee surgery reveals a range of motion from 5 to 55 of flexion. Which of the following statements best summarizes the role of manipulation under anesthesia for this patient? 12345Manipulation under anesthesia offers the best chance of improving and maintaining the p ati t ran g e o f m o tion. en s The gains from manipulation under anesthesia are only temporary and rarely last more than 6 months. Increasing the frequency and intensity of physical therapy over the next 2 months will have the same effect as manipulation under anesthesia. The risks of fracture are so great from manipulating a knee that the patient should be advised to live with a limited range of motion. Th e p ati t fi alresu l w ilb e p o o r w i o r w i o u t m an i u l o n . en s n t l th th p ati

55.

PREFERRED RESPONSE: 1 56. The most compelling clinical reason to convert a hip arthrodesis to a total hip arthroplasty is that the latter 12345improves hip range of motion. relieves pain associated with arthritis of the lumbar spine. relieves pain associated with arthritis of the knee. relieves pain in the contralateral hip. corrects a limb-length discrepancy.

PREFERRED RESPONSE: 2 DISCUSSION: Studies show that degenerative arthritis of the spine associated with a hip arthrodesis can be decreased with conversion to a total hip arthroplasty. The pain associated with degenerative arthritis of the knee usually persists after arthrodesis take-down procedures and often requires total knee arthroplasty. Pain in the contralateral hip is not resolved by converting the arthrodesis. Improving range of motion of the hip and correcting a limb-length discrepancy are not good indications for take-down procedures. 57. A 60-year-old woman reports a painful hip arthroplasty after undergoing surgery 18 months ago. Radiographs show stable cementless implants without signs of ingrowth. Laboratory studies show an erythrocyte sedimentation rate of 50 mm/h. Management should now consist of 12345a technetium Tc 99m scan. an indium scan. an ultrasound examination. aspiration. revision.

PREFERRED RESPONSE: 4 58. Femoral osteotomy for dysplasia of the hip will most likely result in 12345improved range of motion. improved abduction strength. pain relief. equal limb lengths. a normal gait.

PREFERRED RESPONSE: 3 DISCUSSION: Patients should expect pain relief after femoral osteotomy for hip dysplasia. Patients should not expect improved motion or abduction strength and should be counseled about a postoperative limp and unequal limb lengths.

AAOS 2001 Reconstructive Hip and Knee

59.

17

Figure 24 shows the radiograph of an otherwise healthy 56-year-old patient who reports hip pain after undergoing a primary cementless hip replacement 4 months ago. The next most appropriate step should consist of

1indomethacin for 3 months. 2C-reactive protein and a sed rate. 3MRI scan. 4bone scan. 5follow-up radiograph in 3 months. PREFERRED RESPONSE: 2 60. Which of the following is considered a physiologic effect of anemia? 1Decreased heart rate 2Decreased coronary artery flow requirement 3Increased cardiac output 4Increased peripheral resistance 5Increased blood viscosity

PREFERRED RESPONSE: 3 61. A patient with severe rheumatoid arthritis reports progressive hip pain. Serial hip radiographs will most likely show which of the following findings? 1Asymmetric joint space narrowing 2Sacroiliac joint ankylosis 3Progressive superior and lateral migration of the femoral head 4Periarticular osteopenia 5Hip synovitis

PREFERRED RESPONSE: 4 DISCUSSION: Radiographic findings in patients with rheumatoid arthritis include symmetric joint space narrowing, periacetabular and femoral head erosions, and diffuse periarticular osteopenia. In advanced stages, protrusio acetabuli is a common finding. Ranawat and associates have shown a rate of superior femoral head migration of 4.5 mm per year and medial (axial) migration of 2.5 mm per year. Asymmetric joint space narrowing is a classic radiographic finding of degenerative arthrosis. Sacroiliac joint ankylosis commonly occurs in ankylosing spondylitis. Hip synovitis is a pathologic diagnosis, not a radiographic finding. 62. A 70-year-old woman reports anterior knee pain after undergoing an uncomplicated total knee arthroplasty 6 months ago. Examination reveals prepatellar tenderness, with no extensor lag. The radiographs shown in Figures 25a through 25c reveal a well-fixed patellar component. Management should consist of 1closed treatment with early motion. 2a cylindrical cast and restricted weight bearing. 3open reduction and internal fixation. 4patellar revision. 5patellectomy. PREFERRED RESPONSE: 1 DISCUSSION: Patellar fractures that occur after a total knee arthroplasty are usually stress fractures. Integrity of the extensor mechanism precludes the need for surgical repair or internal fixation, while stability and fixation of the patellar component determine whether revision is indicated. A cylindrical cast and full weight bearing for 6 weeks is recommended for transverse fractures with an intact extensor mechanism and a stable component. A similar fracture, if vertical, may be treated with earlier motion.

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AAOS 2001 Reconstructive Hip and Knee

Figure 26 shows the MRI scan of a 60-year-old man who has had groin pain for the past 2 months. The patient reports pain with ambulation, and examination reveals an antalgic gait. He denies any history of steroid or alcohol abuse. Plain radiographs are normal. Management should include 12345core decompression. a vascularized fibula graft. intraosseous steroid injection. total hip replacement. protected weight bearing.

63.

PREFERRED RESPONSE: 5 DISCUSSION: The patient has transient osteoporosis of the hip. Transient osteoporosis is usually a self-limited condition that is most frequently seen in women in the third trimester of pregnancy and in men in the sixth decade of life. Transient osteoporosis is best treated with protected weight bearing.
EFR C: urJ,tebrM: i gihgnnsoo s mvsurersf ei .BnJi tuAm99;7 1-2. EENE eJ i e E s ui tr s t tep rif aa lncio hJo en r 1 5 : 6 4 G rSn g D sn a i o or ca o th p o Sg a n t e o 76 6

64.

Which of the following is considered the most common complication of the impaction grafting technique for femoral revision surgery? 12345Loss of fixation Osteolysis Bone graft resorption Early stem subsidence Infection

PREFERRED RESPONSE: 4 65. What is the most likely late complication associated with cementless total knee replacement? 12345Loss of motion Patellofemoral pain Osteolysis Heterotopic ossification Patellar clunk

PREFERRED RESPONSE: 3 DISCUSSION: In cementless total knee replacement, the risk of osteolysis is 30% if both components are placed without cement and screws are used for tibial fixation. The risk is 10% when a cemented tibial component is used, and the risk is 0% when both components are cemented. Loss of motion, patellofemoral pain, heterotopic bone formation, and patellar clunk are complications that can occur after cemented or cementless components are placed.
EFR C: ety (e) ro ad nwd e p a6 smnA eaAcdmo r o adSren99 p 98. EENE aJ d t peiK o l gUdte. e o t, mr n ae yf t p ei u o s 9, 55- 2 B H: h c e O Ro , i L I c Oh c g , p 5 1

66.

Figure 27 shows the radiograph of a 68-year-old woman with a history of rheumatoid arthritis who was injured in a fall. History reveals that she has been asymptomatic since undergoing a left total knee arthroplasty 9 years ago. Management should consist of 12345skeletal traction. immediate application of a cast brace. a retrograde supracondylar nail. revision total knee replacement. resection arthrodesis.

PREFERRED RESPONSE: 3

AAOS 2001 Reconstructive Hip and Knee

67. Design factors that enhance the long-term survival of proximally coated cementless hip implants include both initial stability and 12345circumferential porous coating. a titanium porous coating. a fluted stem. a distal centralizer. modular fixation pads.

19

PREFERRED RESPONSE: 1 68. A 45-year-old man with a painful varus knee is being considered for an upper tibial osteotomy. Which of the following factors is considered the most compelling argument against this procedure? 12345Flexion contracture of 5 Subchondral cyst in the medial tibial condyle Lateral meniscal degeneration seen in an MRI scan Rheumatoid arthropathy Previous medial meniscectomy

PREFERRED RESPONSE: 4 DISCUSSION: Proximal tibial osteotomy is appropriate for the younger and/or athletic patient who has mild to moderate medial compartment osteoarthritis. Relative contraindications include limited range of motion (eg, flexion contracture of 15), anatomic varus of greater than 10, advanced patellofemoral arthritis, and tibial subluxation. Inflammatory arthritides involve all the compartments and are a contraindication to osteotomies around the knee. 69. An obese patient undergoing total knee arthroplasty is at increased risk for which of the following complications? 12345Wound complication Infection Lower knee score Aseptic loosening Patellar subluxation

PREFERRED RESPONSE: 1 DISCUSSION: The rate of wound complications is significantly increased after total knee arthroplasty in obese patients. Knee scores and the rate of aseptic loosening or patellar subluxation do not appear to be significantly altered. 70. Figures 28a and 28b show the radiographs of a 79-year-old man who has constant knee pain. Prior to performing elective knee replacement surgery, management should include 12345reduction of the serum alkaline phosphatase level by 50%. preoperative radiation therapy of 600 cGy to the surgical site. aspiration of the knee joint with cell count. insertion of a vena caval filter. administration of 25 mg of indomethacin three times a day.

PREFERRED RESPONSE: 1

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AAOS 2001 Reconstructive Hip and Knee

71. What is the most common complication of using structural bulk allograft to reconstruct segmental defects of the acetabulum? 12345Infection Early loss of cup fixation Graft resorption and collapse Limb-length discrepancy Dislocation

PREFERRED RESPONSE: 3 72. Radiographs of a 12-year-old boy who has knee pain show a 2-cm osteochondral lesion of the lateral aspect of the medial femoral condyle. The fragments are not detached from the femur. Initial management should consist of 12345casting in flexion. observation. arthroscopic drilling and pinning of the lesion. removal and reattachment of the osteochondral lesion. allograft transplantation for the lesion.

PREFERRED RESPONSE: 1 DISCUSSION: For a pediatric patient without mechanical symptoms, initial management of an osteochondral defect lesion that is not detached should consist of casting in flexion. Failure to respond to several weeks or months of nonsurgical management may warrant surgical treatment. 73. Which of the following drawbacks is associated with the Ganz periacetabular osteotomy? 12345The tendency to anterior displacement of the hip joint The need for two incisions Limited potential for acetabular reorientation Posterior column disruption Devascularization of the acetabulum

PREFERRED RESPONSE: 1 74. Which of the following lesions is best suited for autologous chondrocyte implantation? 12345Patellofemoral arthritis Lateral femoral condylar arthritis Medial femoral condylar arthritis Medial femoral chondral defect Medial femoral and tibial articular chondral matching defects

PREFERRED RESPONSE: 4 DISCUSSION: Articular chondrocyte implantation is best performed for focal chondral defects of one area of the joint. It is not indicated for osteoarthritis.

AAOS 2001 Reconstructive Hip and Knee

75.

21

The additional risk of complications in organ transplant patients receiving a total joint arthroplasty is attributed to 12345infection. dislocation. deep venous thrombosis. periprosthetic fracture. myocardial infection.

PREFERRED RESPONSE: 1 76. Figure 29 shows the radiograph of a 55-year-old patient who has recurrent total hip dislocation. Dislocation is most likely to occur in this patient when the hip is in which of the following positions? 12345Neutral rotation External rotation Internal rotation Hyperflexion Midstance phase of gait

PREFERRED RESPONSE: 2 77. Back pain and ipsilateral knee pain are common long-term sequelae of hip arthrodesis. To limit these problems, what position should be avoided during fusion of the hip? 12345Flexion Abduction Adduction External rotation Internal rotation

PREFERRED RESPONSE: 2 DISCUSSION: The recommended position for a hip fusion is flexion of 20 to 30, slight adduction (5) or neutral, and 10 of external rotation. In long-term follow-up, patients who underwent fusion in abduction had more ipsilateral knee and low back pain than patients who were positioned in adduction. Internal rotation should be avoided to prevent interference with the opposite foot during gait. External rotation facilitates the application of shoe wear. 78. Which of the following methods most reliably detects mechanical loosening of the hip? 12345Serial planar radiographs Joint aspiration Aspiration and arthrogram Technetium Tc 99m scan CT scan

PREFERRED RESPONSE: 1

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AAOS 2001 Reconstructive Hip and Knee

A 55-year-old man underwent cementless total hip arthroplasty for advanced painful osteoarthritis of the hip 2 years ago. The follow-up radiograph shown in Figure 30 shows 12345spot welds and calcar atrophy. subsidence. distal cortical hypertrophy. distal pedestal formation. complete lucent line around the stem.

79.

PREFERRED RESPONSE: 1 80. A 52-year-old woman has bicompartmental osteoarthritis following patellectomy. Treatment should consist of 12345high tibial osteotomy. arthroscopic debridement. patella arthroplasty. total knee arthroplasty. knee arthrodesis.

PREFERRED RESPONSE: 4 DISCUSSION: The patient has extensive degenerative changes in both the medial and lateral compartments within the knee; therefore, arthroscopic debridement or an osteotomy will not be helpful. A patellar arthroplasty will not address the medial and lateral compartments. Because the extensor mechanism provides a significant amount of anteroposterior stability, a posterior cruciate-substituting total knee arthroplasty is the treatment of choice for this patient. 81. In hybrid arthroplasty, the use of a polymethylmethacrylate (PMMA) precoated femoral component has been shown to result in 12345increased survivorship compared with nonprecoated stems. increased bonding of the stem to the cement mantle. a reduced rate of wear compared with nonprecoated stems. a reduced rate of revision compared with nonprecoated stems. a reduced rate of postoperative infection.

PREFERRED RESPONSE: 2 DISCUSSION: Precoating of the femoral stem with PMMA results in increased bonding of the stem to the cement mantle. However, this has not been shown to result in superior survivorship compared with nonprecoated stems of similar design. In one series, the rate of revision of precoated stems was greater than that of nonprecoated cohorts. The wear and infection rates have not been shown to differ between precoated and nonprecoated stems. 82. A 72-year-old woman has had progressively increasing pain in the right knee for the past 6 months. She denies any trauma and has no pain in any other joints, but she notes occasional swelling in the knee and a catching sensation. Figures 31a and 31b show the plain radiographs and Figure 31c shows the MRI scan. Treatment should consist of 12345arthroscopy and subtotal meniscectomy. arthroscopy and shaving chondroplasty. osteochondral bone graft. high tibial valgus osteotomy. total knee replacement.

PREFERRED RESPONSE: 5

AAOS 2001 Reconstructive Hip and Knee

83.

23

Which of the following is considered the most appropriate indication for conversion of a hip fusion to total hip arthroplasty? 12345Moderate arthritis of the ipsilateral knee Progressive arthritis of the contralateral hip Severe disabling back pain Limb-length discrepancy Increased hip motion

PREFERRED RESPONSE: 3 DISCUSSION: Hip fusion provides successful long-term results (20 to 30 years). The usual mode of failure is symptomatic arthrosis of the lower back, contralateral hip, or the ipsilateral knee. Disabling low back pain is the best indication for conversion and responds well to the procedure. Degenerative changes in the other joints do not respond as well and frequently require replacement arthroplasty. Restoration of limb length is not predictable after conversion to hip replacement. 84. Which of the following methods is effective in correcting recurrent dislocation following total hip arthroplasty?

1Lateralization of the greater trochanter without advancement 2Use of a shorter neck length 3Use of a constrained acetabular component 4Use of a small diameter head 5High cup abduction angle PREFERRED RESPONSE: 3 85. A 58-year-old woman who underwent a successful total hip replacement for degenerative arthritis 8 years ago reports groin pain for the past 6 months. A radiograph of the hip is shown in Figure 32. At revision, severe deficiency of the posterior column is noted. What reconstructive option would be most appropriate for the acetabulum?

1Cementless cup without graft 2Cemented cup without graft 3Cemented cup with structural bone graft 4Bone graft, reconstruction cage, and cemented cup 5Bilobed cementless acetabular component PREFERRED RESPONSE: 4 86. A patient with a previously pain-free knee replacement now reports a sudden inability to ambulate. Radiographs of the knee are shown in Figures 33a and 33b. Management should consist of 12345bracing and physical therapy. insertion of a thicker polyethylene insert. revision with a cementless modular prosthesis. revision with a cemented semiconstrained prosthesis. reconstruction of the extensor mechanism.

PREFERRED RESPONSE: 5 DISCUSSION: The radiographs show a patellar tendon rupture following a total knee replacement. This infrequent, but serious, complication is reported to occur in 0.17% to 1.4% of patients after total knee arthroplasty. Although the radiographs show concerning features such as incomplete tibial and femoral periprosthetic lucencies, it is most important for the surgeon to recognize extensor mechanism disruption.

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AAOS 2001 Reconstructive Hip and Knee

Which of the following factors will adversely affect bone ingrowth in a revision porous-coated stem? 12345Pore size of 400 m Interface instability of 25 m of micromotion Use of a nonmodular implant Noncircumferential metaphyseal patch coating Failure of ingrowth in the previous stem

87.

PREFERRED RESPONSE: 4 DISCUSSION: The optimal conditions for bony ingrowth include a pore size of 100 to 400 m, interface micromotion of 50 m or less, intimate contact between the bone and the implant, circumferential porous coating of the implant, and use of a biocompatible material. Stem designs with patch coatings have a poor record of bony ingrowth, especially in the revision setting. Failure of ingrowth in the previous stem would be the result of its own mechanical milieu and would not necessarily predict results for the new stem. 88. In the preoperative planning of revision acetabular reconstruction, the surgeon should identify significant posterior column deficiency by noting which of the following radiographic features? 12345Excessive vertical position of the acetabular component Medial displacement of the hip center to the ilioischial line Visible wear of the polyethylene articulation Osteolysis in the ischium Superior migration of 1 cm

PREFERRED RESPONSE: 4 DISCUSSION: Proximal and medial migration of the femoral head usually indicates deficiencies of the dome or anterior column. Wear of the polyethylene may result in osteolysis and impingement, which are not indicative of any major bone deficiency. A significant osteolytic lesion in the ischium may represent a major posterior column deficiency that can create a technical challenge during the reconstruction. 89. An 82-year-old woman reports right buttock pain after a car trip. Laboratory studies show an erythrocyte sedimentation rate of 30 mm/h and WBC of 4,600/mm3. Figure 34a shows a plain AP radiograph of the pelvis, and Figure 34b shows a delayed technetium Tc 99m bone scan. Management should consist of 12345bed rest and pain medication. revision of the right acetabular component. revision of the right femoral component. revision of the right total hip replacement. resection arthroplasty.

PREFERRED RESPONSE: 1 DISCUSSION: The radiograph shows bilateral cemented total hip arthroplasties. The acetabular components are loose bilaterally, but there has been no acute change. Therefore, it is unlikely that the acetabular loosening i co n tri u ti g to th e p ati t p ai . Th e b o n e scan i co n si s b n en s n s sten t w i a sacral i su ffi en cy fractu re. Th i i b est th n ci s s treated with bed rest and pain medication. Activity can be increased as the pain allows. Revision will not address the pain.

AAOS 2001 Reconstructive Hip and Knee

90.

25

Figures 35a and 35b show the radiographs of a patient who underwent debridement of a chronically infected, fully constrained knee prosthesis and now reports pain and instability despite bracing. History reveals that the patient has had no drainage since undergoing the last debridement 6 months ago. A C-reactive protein level and aspiration are negative for infection. Treatment should now consist of 12345knee arthrodesis. insertion of a semiconstrained prosthesis. insertion of an antibiotic-impregnated polymethylmethacrylate (PMMA) spacer. reconstruction of the extensor mechanism. amputation.

PREFERRED RESPONSE: 1 91. Which of the following is considered an advantage of metal femoral heads compared with ceramic heads? 12345Superior lubrication properties Smoother surface Less susceptible to third body wear More inert material Greater neck-length options

PREFERRED RESPONSE: 5 DISCUSSION: Ceramic-on-ceramic bearing surfaces have superior tribological properties and show lower linear wear than metal-on-metal implants. However, because of their lower strength and vulnerability to fracture, design considerations constrain the neck-length options available to ensure optimal taper fit. 92. What is the most common result if the acetabulum is rotated too far anteriorly during a periacetabular osteotomy? 12345Posterior dislocation Limited hip flexion Heterotopic ossification Femoral nerve injury Fracture of the posterior column

PREFERRED RESPONSE: 2 DISCUSSION: In patients with hip dysplasia who undergo a periacetabular osteotomy, the authors note that the freed acetabular segment can be overcorrected for the deformity. If it is placed too anteriorly, then hip flexion is limited. Posterior dislocation is a rare complication. The other complications should not occur as a result of this procedure. 93. Which of the following radiographic views best assesses anterior coverage of the dysplastic hip? 12345AP of the hip Obturator oblique Lauenstein lateral Faux profil Pelvic inlet

PREFERRED RESPONSE: 4

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AAOS 2001 Reconstructive Hip and Knee

Figure 36a shows the current radiograph of a 65-year-old woman who slipped and fell. History reveals that prior to the fall she was actively functioning without pain. Figure 36b shows a radiograph obtained 1 year ago. Based on the fracture pattern, the failure is most likely related to 12345repetitive loading and fatigue failure. incomplete bone ingrowth with focal osteolysis. rotational bone axial loading. a fixed component with a modulus mismatch. use of titanium instead of cobalt-chromium.

94.

PREFERRED RESPONSE: 4 95. A 70-year-old man has worn through his metal-backed patellar component and sustained damage to the femoral component. Following removal of the components and debridement of the metal-stained synovium, the surgeon finds that the thickness of the remaining patella is 10 mm. Treatment should now include 12345insertion of a thicker cement mantle and a thicker patellar insert to achieve a total patellar thickness of 24 mm. a lateral release after inserting a standard patella. a distal femoral augmentation to maximize the moment-arm on a standard patellar insert. leaving the patella alone and performing a lateral release, if necessary, for proper patellar tracking. an oversized femoral component to improve the moment-arm on a standard patellar insert.

PREFERRED RESPONSE: 4 96. A 65-year-old man has a painful and often audible crepitus after undergoing a total knee arthroplasty 8 months ago. His symptoms are reproduced with active extension of about 30. Examination reveals no effusion or localized tenderness, a stable knee, and a range of motion of 5 to 120. Radiographs are shown in Figures 37a and 37b. Management should consist of 12345revision of all components to ensure patellar tracking. athroscopic debridement. arthrotomy and keloid excision. intra-articular corticosteroid injections. patellar component revision.

PREFERRED RESPONSE: 2 DISCUSSION: This is a typical presentation of the patellar clunk syndrome. The syndrome usually follows implantation of a posterior stabilized prosthesis. It is thought to be the result of femoral component design and altered extensor mechanics. The condition usually resolves with arthroscopic debridement of the suprapatellar fibrous nodule. Arthrotomy or revision is seldom warranted. 97. What clinical parameter will most likely decrease the need for blood transfusion after total joint arthroplasty? 12345Bilateral total joint replacement Rheumatoid arthritis Preoperative donation of autologous blood Age greater than 65 years Hemoglobin level of greater than 15 g/dL

PREFERRED RESPONSE: 5

AAOS 2001 Reconstructive Hip and Knee

98.

27

Figure 38 shows the radiograph of a 40-year-old woman who reports severe groin pain and lack of motion of the right hip. History reveals that the patient underwent a femoral osteotomy for hip dysplasia approximately 30 years ago. Treatment should include 12345femoral osteotomy. periacetabular osteotomy. arthroscopic debridement. total hip arthroplasty. hip arthrodesis.

PREFERRED RESPONSE: 4 DISCUSSION: Although the patient is young, a total hip arthroplasty will provide pain relief and improve her range of motion. The arthritis is too advanced for the patient to benefit from an osteotomy. In addition, periacetabular osteotomy and hip arthrodesis do not improve range of motion of the hip. It has not been established that patients with severe osteoarthritis will benefit from arthroscopic debridement of the hip. 99. What is the primary concern for arthrodesis of a failed infected total knee arthroplasty using internal fixation? 12345Recurrent infection Lack of stability Lack of soft-tissue coverage Stress shielding Stress risers

PREFERRED RESPONSE: 1 DISCUSSION: Arthrodesis of the failed infected total knee arthroplasty may be accomplished by external fixation, intramedullary rod fixation, and dual plates and screws. External fixation runs the risk of pin tract infection, although after its removal, there are no metal surfaces left in place. Intramedullary rods have been used successfully in the treatment of infected total knees, although they also leave metal within the region of the infection. The dual plate technique of knee fusion is useful in patients with rheumatoid arthritis who require fusion in the absence of infection because it provides good initial stability and avoids the use of external pins. However, in the face of infection, the large surface area of the screws and plates may serve as a site for bacteria to hide within a glycocalyx and make eradication of the infection almost impossible. 100. Oxidation of polyethylene after sterilization occurs most rapidly when the implant undergoes 12345gamma radiation in air. gamma radiation in nitrogen. gamma radiation in argon. gas plasma exposure. ethylene oxide exposure.

PREFERRED RESPONSE: 1 DISCUSSION: The use of gamma radiation to sterilize polyethylene will result in the formation of free radicals in the material that increase the susceptibility of the material to oxidation and wear. The packaging can also have an impact. If the polyethylene is packaged in air, the oxygen in the packaging can significantly oxidize the material on the shelf prior to clinical use. Gas plasma and ethylene oxide sterilization do not appear to increase oxidation of polyethylene.