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5. OITE > Hip & Knee 2014 > Flashcards

Hip & Knee 2014 Flashcards

1
Q

Question 3.

During a total hip arthroplasty, the surgeon inadvertently injects bolus of bupivacaine into the femoral vein. The patient goes into asystole. Which agent is the treatment of choice to correct this situation?

  1. Propranolol
  2. Epinephrine
  3. 20% fat emulsion
  4. Norepinephrine bitartrate
  5. Phenylephrine hydrochloride
A
  1. 20% fat emulsion

RECOMMENDED READINGS

Rosenblatt MA, Abel M, Fischer GW, Itzkovich CJ, Eisenkraft JB. Successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest. Anesthesiology. 2006 Jul;105(1):217-8. PubMed PMID: 16810015.

Corman SL, Skledar SJ. Use of lipid emulsion to reverse local anesthetic-induced toxicity. Ann Pharmacother. 2007 Nov;41(11):1873-7. Epub 2007 Sep 25. Review. PubMed PMID: 17895327.

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2
Q

Question 20

While performing primary total knee arthroplasty using a cruciate-retaining knee implant, a surgeon notices an iatrogenic injury to the medial collateral ligament (MCL) following femoral component preparation. The injury is a saw cut at the level of the joint line with partial transection of the MCL, resulting in valgus laxity. What is the best next step?

  1. Convert to a posterior stabilized (PS) knee design.
  2. Convert to a hinged knee design.
  3. Repair the MCL using heavy sutures or suture anchors.
  4. Repair the MCL using heavy sutures or suture anchors and brace the patient postsurgically.
  5. Repair the MCL using heavy sutures or suture anchors and convert to a PS knee implant.
A
  1. Repair the MCL using heavy sutures or suture anchors and brace the patient postsurgically.

RECOMMENDED READINGS

Lee GC, Lotke PA. Management of intraoperative medial collateral ligament injury during TKA. Clin Orthop Relat Res. 2011 Jan;469(1):64-8. doi: 10.1007/s11999-010-1502-6. PubMed PMID: 20686933; PubMed Central PMCID: PMC3008909.

Leopold SS, McStay C, Klafeta K, Jacobs JJ, Berger RA, Rosenberg AG. Primary repair of intraoperative disruption of the medical collateral ligament during total knee arthroplasty. J Bone Joint Surg Am. 2001 Jan;83-A(1):86-91. PubMed PMID: 11205863.

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3
Q

Question 30

An otherwise healthy 60-year-old woman has intermittent severe knee pain and effusions 10 years after undergoing total knee arthroplasty. She denies recent infections. Radiographs show normal alignment and no osteolysis. Examination reveals a large effusion, and range of motion is 10 to 110 degrees. She has slight varus-valgus laxity. Her C-reactive protein level is 11 mg/L (reference range [rr], 0.08-3.1 mg/L) and her erythrocyte sedimentation rate is 40 mm/h (rr, 0-20 m/h). Aspiration of the knee reveals a white blood cell count of 8000 and 95% neutrophils. Cultures are negative. What is the best treatment option?

  1. Observation
  2. Open synovectomy
  3. Arthroscopic synovectomy
  4. Revision of all components
  5. Removal of all components
A
  1. Removal of all components

PREFERRED RESPONSE: 5

RECOMMENDED READINGS

Buller LT, Sabry FY, Easton RW, Klika AK, Barsoum WK. The preoperative prediction of success following irrigation and debridement with polyethylene exchange for hip and knee prosthetic joint infections. J Arthroplasty. 2012 Jun;27(6):857-64.e1-4. doi: 10.1016/j.arth.2012.01.003. Epub 2012 Mar 6. PubMed PMID: 22402229.

Aggarwal VK, Higuera C, Deirmengian G, Parvizi J, Austin MS. Swab cultures are not as effective as tissue cultures for diagnosis of periprosthetic joint infection. Clin Orthop Relat Res. 2013 Oct;471(10):3196-203. doi: 10.1007/s11999-013-2974-y. PubMed PMID: 23568679; PubMed Central PMCID: PMC3773152.

Della Valle C, Parvizi J, Bauer TW, DiCesare PE, Evans RP, Segreti J, Spangehl M, Watters WC 3rd, Keith M, Turkelson CM, Wies JL, Sluka P, Hitchcock K; American Academy of Orthopaedic Surgeons. American Academy of Orthopaedic Surgeons clinical practice guideline on: the diagnosis of periprosthetic joint infections of the hip and knee. J Bone Joint Surg Am. 2011 Jul 20;93(14):1355-7. doi: 10.2106/ JBJS.9314ebo. PubMed PMID: 21792503.

Huang R, Hu CC, Adeli B, Mortazavi J, Parvizi J. Culture-negative periprosthetic joint infection does not preclude infection control. Clin Orthop Relat Res. 2012 Oct;470(10):2717-23. doi: 10.1007/s11999-012- 2434-0. PubMed PMID: 22733184; PubMed Central PMCID: PMC3441976.

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4
Q

Question 44

When templating for total hip arthroplasty, which image demonstrates the best recreation of the proper biomechanics of the hip joint, assuming that the patient’s left leg is 8 mm longer than the right?

  1. Figure 44a
  2. Figure 44b
  3. Figure 44c
  4. Figure 44d
  5. Figure 44e
A
  1. Figure 44b

RECOMMENDED READINGS

Merle C, Waldstein W, Pegg E, Streit MR, Gotterbarm T, Aldinger PR, Murray DW, Gill HS. Femoral offset is underestimated on anteroposterior radiographs of the pelvis but accurately assessed on anteroposterior radiographs of the hip. J Bone Joint Surg Br. 2012 Apr;94(4):477-82. doi: 10.1302/0301-620X.94B4.28067. PubMed PMID: 22434462.

Della Valle AG, Padgett DE, Salvati EA. Preoperative planning for primary total hip arthroplasty. J Am Acad Orthop Surg. 2005 Nov;13(7):455-62. Review. PubMed PMID: 16272270.

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5
Q

Question 50

Figure 50 is the clinical photograph of a healthy and active 50-year-old man who underwent total knee arthroplasty 10 weeks ago. Wound drainage, which occurred for more than 1 week after the index procedure, was treated with oral antibiotics and local wound care. He is now in the emergency department and has had increasing pain and swelling around the knee for 3 days. What is the best next step?

  1. A 6-week course of intravenous antibiotics
  2. A 2-stage protocol
  3. A single-stage exchange
  4. Irrigation, debridement, and polyethylene exchange
  5. Chronic suppressive oral antibiotic therapy
A
  1. A 2-stage protocol

RECOMMENDED READINGS

Parvizi J, Ghanem E, Menashe S, Barrack RL, Bauer TW. Periprosthetic infection: what are the diagnostic challenges? J Bone Joint Surg Am. 2006 Dec;88 Suppl 4:138-47. PubMed PMID: 17142443.

Koyonos L, Zmistowski B, Della Valle CJ, Parvizi J. Infection control rate of irrigation and débridement for periprosthetic joint infection. Clin Orthop Relat Res. 2011 Nov;469(11):3043-8. doi: 10.1007/s11999- 011-1910-2. PubMed PMID: 21553171; PubMed Central PMCID: PMC3183205.

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6
Q

Question 59

A patient is undergoing the second stage of a 2-stage exchange for a previously infected total knee arthroplasty. The infection has resolved. Howeer, surgical exposure is difficult to achieve with patella baja, a scarred patellar tendon, and profuse cement in the proximal tibia. What is the best surgical option?

  1. Lateral release
  2. Full quadricep turndown
  3. Z lengthening of patellar tendon
  4. Extended tibial tubercle osteotomy
  5. Patella tendon detachment and subsequent reattachment with a toothed screw at the time

of closure

A
  1. Lateral release

RECOMMENDED READINGS

Mendes MW, Caldwell P, Jiranek WA. The results of tibial tubercle osteotomy for revision total kneearthroplasty. J Arthroplasty. 2004 Feb;19(2):167-74. PubMed PMID: 14973859.

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7
Q

Question 76

A patient has had several dislocations 12 months after undergoing a seemingly successful revision total hip arthroplasty. The arthroplasty was performed after the patient experienced a failed metal-on-metal bearing and abductor damage. What is the most appropriate course of action?

  1. Trochanteric advancement
  2. Surgical repair of the abductors
  3. Application of an abduction brace
  4. Revision with constrained polyethylene liner
  5. Revision with increased ball head size, length, and offset
A
  1. Revision with constrained polyethylene liner

RECOMMENDED READINGS

Sikes CV, Lai LP, Schreiber M, Mont MA, Jinnah RH, Seyler TM. Instability after total hip arthroplasty: treatment with large femoral heads vs constrained liners. J Arthroplasty. 2008 Oct;23(7 Suppl):59-63. doi: 10.1016/j.arth.2008.06.032. Review. PubMed PMID: 18922375.

Killampalli VV, Reading AD. Late instability of bilateral metal on metal hip resurfacings due to progressive local tissue effects. Hip Int. 2009 Jul-Sep;19(3):287-91. PubMed PMID: 19876887.

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8
Q

Question 98

Based on the acetabular defect seen in Figures 98a through 98c, what is the best treatment?

  1. Impaction grafting
  2. Modular head and polyethylene liner exchange
  3. Reconstruction with an acetabular reinforcement cage
  4. Cementless reconstruction with a porous hemispherical shell
  5. Cementless reconstruction with a porous cup and highly porous augment
A
  1. Cementless reconstruction with a porous hemispherical shell

RECOMMENDED READINGS

Sheth NP, Nelson CL, Springer BD, Fehring TK, Paprosky WG. Acetabular bone loss in revision total hip arthroplasty: evaluation and management. J Am Acad Orthop Surg. 2013 Mar;21(3):128-39. doi: 10.5435/ JAAOS-21-03-128. Review. PubMed PMID: 23457063.

Issack PS. Use of porous tantalum for acetabular reconstruction in revision hip arthroplasty. J Bone Joint Surg Am. 2013 Nov 6;95(21):1981-7. doi: 10.2106/JBJS.L.01313. Review. Erratum in: J Bone Joint Surg Am. 2013 Nov 6;95(21):1987. J Bone Joint Surg Am. 2013 Dec 18;95(24):e196. PubMed PMID: 24196469.

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9
Q

Question 108

Two years after undergoing right total hip arthroplasty with a large-head metal-on-metal bearing, a 57-year-old asymptomatic woman returns for follow-up. Radiographs reveal appropriate component position with no osteolysis. Her serum cobalt level is 12 ppb (reference range [rr], 4.0-10.0 ug/L) and her chromium level is 11 ppb (rr, 0.7-28.0 ug/L). What is the next step in evaluation?

  1. Revision
  2. MR image with metal subtraction
  3. CT scan
  4. Follow-up in 3 to 6 months
  5. No further follow up
A
  1. MR image with metal subtraction

RECOMMENDED READINGS

Lombardi AV Jr, Barrack RL, Berend KR, Cuckler JM, Jacobs JJ, Mont MA, Schmalzried TP. The Hip Society: algorithmic approach to diagnosis and management of metal-on-metal arthroplasty. J Bone Joint Surg Br. 2012 Nov;94(11 Suppl A):14-8. doi: 10.1302/0301-620X.94B11.30680. Review. PubMed PMID: 23118373.

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10
Q

Question 121

Figures 121a and 121b are the current radiographs of a 58-year-old man who has recurrent instability of his right total hip arthroplasty (THA). He underwent acetabular open reduction and internal fixation 20 years ago and required THA for posttraumatic arthritis 15 years ago. Shortly after his THA, he had 1 dislocation episode that necessitated closed reduction, but he did not have any additional dislocations until recently. During the last 2 years he has experienced 6 hip dislocations. What is the most likely reason for his hip instability?

  1. Polyethylene wear
  2. Femoral component retroversion
  3. Acetabular component retroversion
  4. Excessive femoral component offset
  5. Excessive acetabular component abduction
A
  1. Polyethylene wear

RECOMMENDED READINGS

Parvizi J, Wade FA, Rapuri V, Springer BD, Berry DJ, Hozack WJ. Revision hip arthroplasty for late instability secondary to polyethylene wear. Clin Orthop Relat Res. 2006 Jun;447:66-9. PubMed PMID: 16672896.

Berry DJ, von Knoch M, Schleck CD, Harmsen WS. The cumulative long-term risk of dislocation after primary Charnley total hip arthroplasty. J Bone Joint Surg Am. 2004 Jan;86-A(1):9-14. PubMed PMID: 14711939.

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11
Q

Question 136

A 68-year-old patient is seen 10 years after undergoing total hip arthroplasty; extensive wear of the polyethylene and osteolysis has occurred (Figure 136). The polyethylene used for this procedure has had an otherwise excellent track record. The femoral head is zirconia ceramic. What is the most likely cause of accelerated wear?

  1. Infection
  2. Third body debris from broken wires
  3. Monoclinic phase transformation of zirconia
  4. Loosening of the cemented stem with resultant cement debris
  5. Macrophage-mediated osteoclastic resorption
A
  1. Monoclinic phase transformation of zirconia

RECOMMENDED READINGS

Haraguchi K, Sugano N, Nishii T, Miki H, Oka K, Yoshikawa H. Phase transformation of a zirconia ceramic head after total hip arthroplasty. J Bone Joint Surg Br. 2001 Sep;83(7):996-1000. PubMed PMID: 11603539.

Cales B. Zirconia as a sliding material: histologic, laboratory, and clinical data. Clin Orthop Relat Res. 2000 Oct;(379):94-112. Review. PubMed PMID: 11039797.

Hernigou P, Bahrami T. Zirconia and alumina ceramics in comparison with stainless-steel heads. Polyethylene wear after a minimum ten-year follow-up. J Bone Joint Surg Br. 2003 May;85(4):504-9. PubMed PMID: 12793553.

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12
Q

Question 150

During primary total knee arthroplasty, an intraoperative fracture is an uncommon complication. What is the most common fracture location?

  1. Patella
  2. Lateral tibial plateau
  3. Medial tibial plateau
  4. Lateral femoral condyle
  5. Medial femoral condyle
A
  1. Medial femoral condyle

RECOMMENDED READINGS

Alden KJ, Duncan WH, Trousdale RT, Pagnano MW, Haidukewych GJ. Intraoperative fracture during primary total knee arthroplasty. Clin Orthop Relat Res. 2010 Jan;468(1):90-5. doi: 10.1007/s11999-009- 0876-9. Epub 2009 May 9. PubMed PMID: 19430855; PubMed Central PMCID: PMC2795828.

Sharkey PF, Hozack WJ, Booth RE Jr, Rothman RH. Intraoperative femoral fractures in cementless total hip arthroplasty. Orthop Rev. 1992 Mar;21(3):337-42. PubMed PMID: 1565523.

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13
Q

Question 154

Figures 154a through 154g are the radiographs and MR images of a 48-year-old healthy man who works in construction and has left knee pain. He is unable to climb stairs and has locking and buckling of his knee that is worse with twisting activities. Steroid injections, anti-inflammatory drugs physiotherapy and bracing have failed to provide pain relief. What is the best treatment recommendation for this patient?

  1. Tibial osteotomy
  2. Mensical transplant
  3. Knee arthroscopy
  4. Medial unicompartmental knee arthroplasty
  5. Total knee arthroplasty
A
  1. Medial unicompartmental knee arthroplasty

RECOMMENDED READINGS

Laprade RF, Spiridonov SI, Nystrom LM, Jansson KS. Prospective outcomes of young and middle-aged adults with medial compartment osteoarthritis treated with a proximal tibial opening wedge osteotomy. Arthroscopy. 2012 Mar;28(3):354-64. doi: 10.1016/j.arthro.2011.08.310. Epub 2011 Dec 14. PubMed PMID: 22169761.

Steadman JR, Briggs KK, Matheny LM, Ellis HB. Ten-year survivorship after knee arthroscopy in patients with Kellgren-Lawrence grade 3 and grade 4 osteoarthritis of the knee. Arthroscopy. 2013 Feb;29(2):220- 5. doi: 10.1016/j.arthro.2012.08.018. Epub 2012 Dec 27. PubMed PMID: 23273893.

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14
Q

Question 165

A 52-year-old woman underwent a cruciate-retaining total knee arthroplasty to address a valgus knee. Although she received adequate physical therapy during the immediate postsurgical period, she has only 70 degrees of knee flexion. Her C-reactive protein and erythrocyte sedimentation levels are within defined limits. What is the most appropriate next step?

  1. Bone scan
  2. Aspiration
  3. Manipulation under anesthesia
  4. Arthroscopic release of the posterior cruciate ligament
  5. Continuous passive motion and additional physical therapy
A
  1. Manipulation under anesthesia

RECOMMENDED READINGS

Issa K, Kapadia BH, Kester M, Khanuja HS, Delanois RE, Mont MA. Clinical, objective, and functional outcomes of manipulation under anesthesia to treat knee stiffness following total knee arthroplasty. J Arthroplasty. 2014 Mar;29(3):548-52. doi: 10.1016/j.arth.2013.07.046. Epub 2013 Sep 4. PubMed PMID: 24011781.

Maniar RN, Baviskar JV, Singhi T, Rathi SS. To use or not to use continuous passive motion post total knee arthroplasty presenting functional assessment results in early recovery. J Arthroplasty. 2012 Feb;27(2):193-200.e1. doi: 10.1016/j.arth.2011.04.009. Epub 2011 Jul 12. PubMed PMID: 21752575.

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15
Q

Question 177

What is the mechanism of action of tranexamic acid in decreasing blood loss during joint arthroplasty surgery?

  1. Activates factor V
  2. Activates factor XIII
  3. Inhibits fibrinogen
  4. Inhibits plasminogen
  5. Blocks conversion of factor X to Xa
A
  1. Inhibits plasminogen

RECOMMENDED READINGS

Watts CD, Pagnano MW. Minimising blood loss and transfusion in contemporary hip and knee arthroplasty. J Bone Joint Surg Br. 2012 Nov;94(11 Suppl A):8-10. doi: 10.1302/0301-620X.94B11.30618. Review. PubMed PMID: 23118371.

Gillette BP, DeSimone LJ, Trousdale RT, Pagnano MW, Sierra RJ. Low risk of thromboembolic complications with tranexamic acid after primary total hip and knee arthroplasty. Clin Orthop Relat Res. 2013 Jan;471(1):150-4. doi: 10.1007/s11999-012-2488-z. PubMed PMID: 22814857; PubMed Central PMCID: PMC3528901.

Imai N, Dohmae Y, Suda K, Miyasaka D, Ito T, Endo N. Tranexamic acid for reduction of blood loss during total hip arthroplasty. J Arthroplasty. 2012 Dec;27(10):1838-43. doi: 10.1016/j.arth.2012.04.024. Epub 2012 Jun 14. PubMed PMID: 22704229.

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16
Q

Question 184

While performing total hip arthroplasty, a surgeon places a retractor under the transverse acetabular ligament and encounters some brisk bleeding. Which artery most likely has been injured?

  1. Obturator
  2. External iliac
  3. Profunda femoris
  4. Lateral femoral circumflex
  5. Medial femoral circumflex
A
  1. Obturator

RECOMMENDED READINGS

Della Valle CJ, DiCesare PE. Bulletin of the NYU Hospital for Joint Disease;June, 2002. http://www. highbeam.com/publications/bulletin-of-the-nyu-hospital-for-joint-diseases-p136781/june-2002 Last accessed 9/8/14

Nachbur B, Meyer RP, Verkkala K, Zürcher R. The mechanisms of severe arterial injury in surgery of the hip joint. Clin Orthop Relat Res. 1979 Jun;(141):122-33. PubMed PMID: 477093.

Rue JP, Inoue N, Mont MA. Current overview of neurovascular structures in hip arthroplasty: anatomy, preoperative evaluation, approaches, and operative techniques to avoid complications. Orthopedics. 2004

Jan;27(1):73-81; quiz 82-3. Review. PubMed PMID: 14763537.

17
Q

Question 191

Figure 191 is the fracture radiograph of a 74-year-old woman who underwent uncomplicated primary left total hip arthroplasty 2 weeks ago. Shortly after surgery, she fell and sustained a periprosthetic femur fracture. What is the most appropriate next step?

  1. Open reduction and internal fixation using plates and screws
  2. Open reduction and internal fixation using plates, screws, and cables
  3. Revision of the femoral component using a cemented femoral component
  4. Revision of the femoral component using a distally fixing femoral component design
  5. Revision of the femoral component using a larger femoral component of the same design
A
  1. Revision of the femoral component using a distally fixing femoral component design

RECOMMENDED READINGS

Springer BD, Berry DJ, Lewallen DG. Treatment of periprosthetic femoral fractures following total hip arthroplasty with femoral component revision. J Bone Joint Surg Am. 2003 Nov;85- A(11):2156-62. PubMed PMID: 14630846.

Haidukewych GJ, Langford J, Liporace FA. Revision for periprosthetic fractures of the hip and knee. J Bone Joint Surg Am. 2013 Feb 20;95(4):368-76. Review. PubMed PMID: 23553235.

18
Q

Question 197

Figures 197a and 197b are the radiographs of a 90-year-old woman who had her hip replaced 2 years ago through an anterior lateral approach. She did well for 8 weeks after surgery and was able to walk with only a cane. Now she has progressive thigh pain. She is unable to climb stairs and feels that her hip is going to give way. She has a Trendelenburg gait and feels that one leg is shorter than the other. She has no pain with passive range of hip motion and no pain or weakness with hip abduction or flexion. An intra-articular injection provided temporary pain relief. Her C-reactive protein and erythrocyte sedimentation levels are within defined limites. Current radiographs reveal no changes since surgery. What is the most likely cause of her hip pain?

  1. Hip subluxation
  2. Gluteus avulsion
  3. Asceptic loosening
  4. Leg length descrepancy
  5. Illiopsoas impingement
A
  1. Asceptic loosening

RECOMMENDED READINGS

Lombardi AV Jr, Berend KR, Adams JB, Jefferson RC, Sneller MA. Smoking may be a harbinger of early failure with ultraporous metal acetabular reconstruction.Clin Orthop Relat Res. 2013 Feb;471(2):486-97. doi: 10.1007/s11999-012-2748-y. PubMed PMID: 23292885; PubMed Central PMCID: PMC3549182.

Lachiewicz PF, Kauk JR. Anterior iliopsoas impingement and tendinitis after total hip arthroplasty. J Am Acad Orthop Surg. 2009 Jun;17(6):337-44. Review.PubMed PMID: 19474443.Nov;471(11):3672-8. doi: 10.1007/s11999-013-3200-7. Epub 2013 Aug 1. PubMed PMID: 23904245; PubMed CentralPMCID: PMC3792275.

Portillo ME, Salvadó M, Alier A, Sorli L, Martínez S, Horcajada JP, Puig L. Prosthesis failure within 2 years of implantation is highly predictive of infection. Clin Orthop Relat Res. 2013 Nov;471(11):3672-8. doi: 10.1007/s11999-013-3200-7. Epub 2013 Aug 1. PubMed PMID: 23904245; PubMed CentralPMCID: PMC3792275.

19
Q

Question 206

Figures 206a through 206d are the radiographs and clinical photograph of a 90-year-old man who had knee arthroplasty 20 years ago. He cannot fully straighten his knee. His C-reactive protein level is 1 mg/L (reference range [rr], 0.08-3.1 mg/L) and his erythrocyte sedimentation rate is 10 mm/h (rr, 0-20 mm/h). Knee aspiration reveals 500 WBC/mm3 with 40% neutrophils. What is the most likely cause of his condition?

  1. Infection
  2. Instability
  3. Implant loosening
  4. Malalignment
  5. Patella maltracking
A
  1. Implant loosening

RECOMMENDED READINGS

Jacobs E, Feczko P, Emans P. Recurrent patella loosening and extra-articular migration after TKA. J Knee Surg. 2013 Dec;26 Suppl 1:S100-2. doi:10.1055/s-0032-1322601. Epub 2012 Jul 30. PubMed PMID: 23288755.

Pilling RW, Moulder E, Allgar V, Messner J, Sun Z, Mohsen A. Patellar resurfacing in primary total knee replacement: a meta-analysis. J Bone Joint SurgAm. 2012 Dec 19;94(24):2270-8. doi: 10.2106/ JBJS.K.01257. PubMed PMID: 23318618.

Schroer WC, Berend KR, Lombardi AV, Barnes CL, Bolognesi MP, Berend ME, Ritter MA, Nunley RM. Why are total knees failing today? Etiology of total knee revision in 2010 and 2011. J Arthroplasty. 2013 Sep;28(8 Suppl):116-9. doi: 10.1016/j.arth.2013.04.056. Epub 2013 Aug 15. PubMed PMID: 23954423.

20
Q

Question 238

A healthy 65-year-old woman fell while biking and sustained the fracture shown in Figures 238a and 238b. Her body mass index is 25. She does yoga daily and also enjoys hiking and swimming. What is the most appropriate surgery for this patient?

  1. Hemiarthroplasty
  2. Total hip arthroplasty
  3. Cepholomedullary nail
  4. Percutaneous pinning with open reduction
  5. Percutaneous pinning with closed reduction
A
  1. Total hip arthroplasty

RECOMMENDED READINGS

Macaulay W, Nellans KW, Garvin KL, Iorio R, Healy WL, Rosenwasser MP; other members of the DFACTO Consortium. Prospective randomized clinical trial comparing hemiarthroplasty to total hip arthroplasty in the treatment of displaced femoral neck fractures: winner of the Dorr Award. J Arthroplasty. 2008 Sep;23(6 Suppl1):2-8. doi: 10.1016/j.arth.2008.05.013. PubMed PMID: 18722297.

Abboud JA, Patel RV, Booth RE Jr, Nazarian DG. Outcomes of total hip arthroplasty are similar for patients with displaced femoral neck fractures and osteoarthritis. Clin Orthop Relat Res. 2004 Apr;(421):151-4. PubMed PMID: 15123940.

21
Q

Question 248

Figures 248a and 248b are the radiographs of an 80-year-old woman who had total knee arthroplasty 15 years ago. The procedure had been working well until 1 week ago when she heard a pop while standing from a chair. An initial examination reveals she cannot extend her knee. After aspirating 50 cc of bloody fluid and injecting the knee with lidocaine, she can extend the knee against gravity but not against resistance. There is no palpable gap in her quadriceps or patella tendon. What is the most appropriate treatment?

  1. Patellectomy
  2. Extensor mechanism allograft
  3. Primary repair of the tendon rupture
  4. Nonsurgical treatment with a knee immobilizer
  5. Physical therapy to improve quadriceps strength
A
  1. Nonsurgical treatment with a knee immobilizer

RECOMMENDED READINGS

Dobbs RE, Hanssen AD, Lewallen DG, Pagnano MW. Quadriceps tendon rupture after total knee arthroplasty. Prevalence, complications, and outcomes. J Bone Joint Surg Am. 2005 Jan;87(1):37-45. PubMed PMID: 15634812.

Kim TW, Kamath AF, Israelite CL. Suture anchor repair of quadriceps tendon rupture after total knee arthroplasty. J Arthroplasty. 2011 Aug;26(5):817-20.doi: 10.1016/j.arth.2011.01.006. Epub 2011 Mar 11. Review. PubMed PMID: 21397449.

22
Q

Question 255

A 52-year-old woman underwent postmedial unicompartmental arthroplasty for anteromedial osteoarthritis 8 years ago. For the last few months, she has had generalized pain in her knee that worsens with weight bearing and activity. What is the most likely reason for unicompartmental arthroplasty failure?

  1. Infection
  2. Malalignment
  3. Neuropathic pain
  4. Component loosening
  5. Osteoarthritis progression
A
  1. Osteoarthritis progression.

RECOMMENDED READINGS

Argenson JN, Blanc G, Aubaniac JM, Parratte S. Modern unicompartmental knee arthroplasty with cement: a concise follow-up, at a mean of twenty years, of a previous report. J Bone Joint Surg Am. 2013 May 15;95(10):905-9. doi: 10.2106/JBJS.L.00963. PubMed PMID: 23677357.

Price AJ, Svard U. A second decade lifetable survival analysis of the Oxford unicompartmental knee arthroplasty. Clin Orthop Relat Res. 2011 Jan;469(1):174-9. doi: 10.1007/s11999-010-1506-2. PubMed PMID: 20706811; PubMed Central PMCID: PMC3008876.

23
Q

Question 258

Which bearing couple is associated with the least volumetric wear?

  1. Metal on metal
  2. Metal on highly cross-linked polyethylene
  3. Metal on ceramic
  4. Ceramic on ceramic
  5. Ceramic on highly cross-linked polyethylene
A
  1. Ceramic on ceramic

RECOMMENDED READINGS

Garino JP. Modern ceramic-on-ceramic total hip systems in the United States: early results. Clin Orthop Relat Res. 2000 Oct;(379):41-7. PubMed PMID: 11039791.

Clarke IC, Donaldson T, Jobe C. Impact of wear debris on success of total hip replacements. In: Garino JP, Beredjiklian PK, eds. Core Knowledge in Orthopaedics: Adult Reconstruction and Arthroplasty. Mosby/ Elsevier;2007.

24
Q

Question 264

What is the best predictor of pain for patients with hip osteonecrosis?

  1. Ficat stage II disease
  2. Bone marrow edema
  3. Bilateral hip involvement
  4. Modified Kerboul angle less than 190 degrees
  5. Use of oral bisphosphonates
A
  1. Bone marrow edema

RECOMMENDED READINGS

Ito H, Matsuno T, Minami A. Relationship between bone marrow edema and development of symptoms in patients with osteonecrosis of the femoral head. AJR Am J Roentgenol. 2006 Jun;186(6):1761-70. PubMed PMID: 16714671.

25
Q

Question 275

A 61-year-old man with medial knee pain and a fixed varus deformity fails a comprehensive nonsurgical treatment program. His pain is exacerbated with weight bearing and his range of motion is 20 to 90 degrees of flexion. A radiograph reveals bone-on-bone anteromedial osteoarthritis. He is neurovascularly intact. Which technical steps will allow for the most successful arthroplasty outcome?

  1. Increase the slope of the tibial resection.
  2. Perform a medial unicompartmental arthroplasty.
  3. Downsize the femoral component 1 size (compared to the templated size).
  4. Resect 2 mm less bone from the distal femur during total knee arthroplasty.
  5. Resect an additional 4 mm of bone from the distal femur during total knee arthroplasty.
A
  1. Resect an additional 4 mm of bone from the distal femur during total knee arthroplasty.
26
Q
A

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