Hip and Knee
Reconstruction
OITE 2006
Large femoral heads, compared to small
femoral heads, produce what effect in
total hip arthroplasty?
1.
2.
3.
4.
Smaller wear surface
Decreased polyethylene modulus
Increased contact stress
Increased range of motion to
impingement
5. Increased joint constraint
2
Large femoral heads, compared to small
femoral heads, produce what effect in
total hip arthroplasty?
1.
2.
3.
4.
Smaller wear surface
Decreased polyethylene modulus
Increased contact stress
Increased range of motion to
impingement
5. Increased joint constraint
2
A 72-year-old woman with severe rheumatoid arthritis has had
three hip dislocations in 1 week. History reveals that she underwent
total hip arthroplasty 15 years ago. A radiograph obtained after
attempted closed reduction is shown in Figure 7. Management
should now consist of
1.
2.
3.
4.
5.
open reduction followed by bracing with a hip
orthosis for 6 weeks.
revision of the acetabular metal shell and liner.
revision of both the femoral and acetabular
components.
revision to a constrained liner, with metal shell
retention.
revision to a large diameter femoral head with
metal shell retention.
18
A 72-year-old woman with severe rheumatoid arthritis has had
three hip dislocations in 1 week. History reveals that she underwent
total hip arthroplasty 15 years ago. A radiograph obtained after
attempted closed reduction is shown in Figure 7. Management
should now consist of
1.
2.
3.
4.
5.
open reduction followed by bracing with a hip
orthosis for 6 weeks.
revision of the acetabular metal shell and liner.
revision of both the femoral and acetabular
components.
revision to a constrained liner, with metal shell
retention.
revision to a large diameter femoral head with
metal shell retention.
18
During normal knee flexion from 0° to 100°,
which of the following kinematic motions
occurs?
1. Both the lateral and medial femoral
condyles move posteriorly an equal
distance.
2. The lateral condyle moves posteriorly more
than the medial condyle.
3. The medial condyle moves posteriorly more
than the lateral condyle.
4. The lateral condyle moves anteriorly.
5. The medial condyle moves anteriorly.
32
During normal knee flexion from 0° to 100°,
which of the following kinematic motions
occurs?
1. Both the lateral and medial femoral
condyles move posteriorly an equal
distance.
2. The lateral condyle moves posteriorly more
than the medial condyle.
3. The medial condyle moves posteriorly more
than the lateral condyle.
4. The lateral condyle moves anteriorly.
5. The medial condyle moves anteriorly.
32
Stripe wear in ceramic-on-ceramic hip
arthroplasty indicates which of the following?
1.
2.
3.
4.
5.
Damage to the liner at the time of its insertion into
the shell
Damage to the femoral head because of lift-off
separation of the femoral head during gait
Wear of the acetabular liner because of third-body
wear
Wear of the Morse taper portion of the femoral
head because of corrosion
Backside wear of the acetabular liner
46
Stripe wear in ceramic-on-ceramic hip
arthroplasty indicates which of the following?
1.
2.
3.
4.
5.
Damage to the liner at the time of its insertion into
the shell
Damage to the femoral head because of lift-off
separation of the femoral head during gait
Wear of the acetabular liner because of third-body
wear
Wear of the Morse taper portion of the femoral
head because of corrosion
Backside wear of the acetabular liner
46
During cemented bipolar hemiarthroplasty for treatment
of a femoral neck fracture in an 80-year-old woman, the
patient suddenly becomes hypotensive and hypoxic.
What is the most likely reason for the change in the
patient’s status?
1.
2.
3.
4.
5.
Pulmonary emoblism caused by venous trauma
during hip reduction
Pulmonary embolism caused by preexisting deep
venous thrombosis
Intramedullary fat embolization
Inadequate intraoperative fluid replacement
Vasodilation caused by methacrylate monomer
62
During cemented bipolar hemiarthroplasty for treatment
of a femoral neck fracture in an 80-year-old woman, the
patient suddenly becomes hypotensive and hypoxic.
What is the most likely reason for the change in the
patient’s status?
1.
2.
3.
4.
5.
Pulmonary emoblism caused by venous trauma
during hip reduction
Pulmonary embolism caused by preexisting deep
venous thrombosis
Intramedullary fat embolization
Inadequate intraoperative fluid replacement
Vasodilation caused by methacrylate monomer
62
Compared with a standard incision for a total
hip arthroplasty, a minimally invasive approach
using a single incision that is less than 4 inches
in length is likely to result in
1.
2.
3.
4.
5.
a shorter length of stay in the hospital.
less postoperative pain.
cosmetic improvement only.
better Harris hip scores at 6 weeks.
fewer complications.
89
Compared with a standard incision for a total
hip arthroplasty, a minimally invasive approach
using a single incision that is less than 4 inches
in length is likely to result in
1.
2.
3.
4.
5.
a shorter length of stay in the hospital.
less postoperative pain.
cosmetic improvement only.
better Harris hip scores at 6 weeks.
fewer complications.
89
A 39-year-old laborer reports pain over the medial compartment of
his knee joint. History reveals that he underwent nonsurgical
management of a torn posterior cruciate ligament 20 years ago.
Radiographs are shown in Figures 31 and 31b. What surgical
option is most compatible with his occupation?
1.
2.
3.
4.
5.
99
Lateral closing wedge proximal tibial
osteotomy
Medial opening wedge proximal tibial
osteotomy
Unicompartmental knee arthroplasty
Total knee arthroplasty
Arthroscopic-assisted insertion of a
unispacer into the medial compartment
A 39-year-old laborer reports pain over the medial compartment of
his knee joint. History reveals that he underwent nonsurgical
management of a torn posterior cruciate ligament 20 years ago.
Radiographs are shown in Figures 31 and 31b. What surgical
option is most compatible with his occupation?
1.
2.
3.
4.
5.
99
Lateral closing wedge proximal tibial
osteotomy
Medial opening wedge proximal tibial
osteotomy
Unicompartmental knee arthroplasty
Total knee arthroplasty
Arthroscopic-assisted insertion of a
unispacer into the medial compartment
An obese 72-year-old woman with isolated medial knee
osteoarthritis and 100° of passive motion is
considering undergoing unicompartmental knee
arthroplasty. Which of the following is considered the
greatest advantage of unicompartmental knee
arthroplasty compared with a total (tricompartmental)
knee arthroplasty?
1.
2.
3.
4.
5.
Improved range of motion postoperatively
Greater prosthetic longevity
Greater relief of postoperative knee pain
Faster early rehabilitation
Better correction of preoperative deformity
107
An obese 72-year-old woman with isolated medial knee
osteoarthritis and 100° of passive motion is
considering undergoing unicompartmental knee
arthroplasty. Which of the following is considered the
greatest advantage of unicompartmental knee
arthroplasty compared with a total (tricompartmental)
knee arthroplasty?
1.
2.
3.
4.
5.
Improved range of motion postoperatively
Greater prosthetic longevity
Greater relief of postoperative knee pain
Faster early rehabilitation
Better correction of preoperative deformity
107
While performing a quadriceps-sparing minimally
invasive total knee arthroplasty, the patellar tendon
starts to peel off the tibial tubercle. Retraction is stopped
before the integrity of the tendon is compromised. What
is the best course of action?
1.
2.
3.
4.
5.
Insert transfixation pins into the tibial tubercle to
protect the patellar tendon.
Repair the peeled portion of the tendon using
suture anchors.
Augment the patellar tendon with a semitendinous
autograft.
Convert the quadriceps-sparing technique into a
mini-midvastus approach.
Convert the quadriceps-sparing technique into a
standard medial parapatellar arthrotomy.
118
While performing a quadriceps-sparing minimally
invasive total knee arthroplasty, the patellar tendon
starts to peel off the tibial tubercle. Retraction is stopped
before the integrity of the tendon is compromised. What
is the best course of action?
1.
2.
3.
4.
5.
Insert transfixation pins into the tibial tubercle to
protect the patellar tendon.
Repair the peeled portion of the tendon using
suture anchors.
Augment the patellar tendon with a semitendinous
autograft.
Convert the quadriceps-sparing technique into a
mini-midvastus approach.
Convert the quadriceps-sparing technique into a
standard medial parapatellar arthrotomy.
118
Figure 50a shows the preoperative AP pelvic radiograph of a 58-yearold woman with osteoarthritis who is scheduled to undergo total hip
arthroplasty. Six weeks after surgery, the patient reports that she has
difficulty walking because the left leg is longer than the right. Figures
50b and 50c show the AP pelvic radiographs at 6 weeks and 3 months
later. What is the cause of the patient’s early postoperative gait
impairment?
1.
2.
3.
4.
5.
Excessive length of the modular
femoral head
Excessive femoral offset
Lateralized acetabular component
Apparent limb-length discrepancy
Incomplete seating of
the femoral component
6 wks
3 mos
141
Figure 50a shows the preoperative AP pelvic radiograph of a 58-yearold woman with osteoarthritis who is scheduled to undergo total hip
arthroplasty. Six weeks after surgery, the patient reports that she has
difficulty walking because the left leg is longer than the right. Figures
50b and 50c show the AP pelvic radiographs at 6 weeks and 3 months
later. What is the cause of the patient’s early postoperative gait
impairment?
1.
2.
3.
4.
5.
Excessive length of the modular
femoral head
Excessive femoral offset
Lateralized acetabular component
Apparent limb-length discrepancy
Incomplete seating of
the femoral component
6 wks
3 mos
141
If the posterior condylar axis is used for determining the
rotation of the femoral component, which of the
following errors if expected when 3° of external
rotation are built into the jig that controls femoral
rotation?
1. Internal rotation of the femoral component if the
lateral femoral condyle is hypoplastic
2. Internal rotation of the femoral component in a
varus knee
3. Internal rotation of the femoral component when
there is wear of the posterior aspect of the medial
femoral condyle
4. External rotation of the femoral component if the
lateral femoral condyle is hypoplastic
5. Femoral component rotation parallel to the
epicondylar axis in all knees
162
If the posterior condylar axis is used for determining the
rotation of the femoral component, which of the
following errors if expected when 3° of external
rotation are built into the jig that controls femoral
rotation?
1. Internal rotation of the femoral component if the
lateral femoral condyle is hypoplastic
2. Internal rotation of the femoral component in a
varus knee
3. Internal rotation of the femoral component when
there is wear of the posterior aspect of the medial
femoral condyle
4. External rotation of the femoral component if the
lateral femoral condyle is hypoplastic
5. Femoral component rotation parallel to the
epicondylar axis in all knees
162
During revision total knee arthroplasty for flexion
instability, the tibial baseplate is retained. Compared to
the original femoral component, the revision femoral
component should be
1.
2.
3.
4.
5.
smaller.
larger.
more distal.
lateralized.
at the same position and size, with a thicker tibial
insert.
165
During revision total knee arthroplasty for flexion
instability, the tibial baseplate is retained. Compared to
the original femoral component, the revision femoral
component should be
1.
2.
3.
4.
5.
smaller.
larger.
more distal.
lateralized.
at the same position and size, with a thicker tibial
insert.
165
During revision total knee arthroplasty with the trial
components in place, the knee is stable in flexion but a
10-degree flexion contracture is present with the
thinnest polyethylene liner. Treatment should consist of
which of the following surgical techniques?
1.
2.
3.
4.
5.
Increase the tibial posterior slope
Use a larger femoral component
Use a smaller femoral component
Resection of additional distal femur
Posterior displacement of the femoral component
171
During revision total knee arthroplasty with the trial
components in place, the knee is stable in flexion but a
10-degree flexion contracture is present with the
thinnest polyethylene liner. Treatment should consist of
which of the following surgical techniques?
1.
2.
3.
4.
5.
Increase the tibial posterior slope
Use a larger femoral component
Use a smaller femoral component
Resection of additional distal femur
Posterior displacement of the femoral component
171
Figure 67a shows the radiograph of a 72-year-old man who has a
periprosthetic fracture nonunion that was treated with revision total
hip arthroplasty using segmental structural femoral and acetabular
allografts. A postoperative radiographs is shown in Figure 67b. Five
months after surgery, failure of the reconstruction occurred. A
current radiograph is shown in Figure 67c. What is the most likely
cause of the failure of the revision procedure?
1.
2.
3.
4.
5.
Allograft failure
Osteoporosis
Pelvic discontinuity
Infection
Inadequate allograft fixation
174
Figure 67a shows the radiograph of a 72-year-old man who has a
periprosthetic fracture nonunion that was treated with revision total
hip arthroplasty using segmental structural femoral and acetabular
allografts. A postoperative radiographs is shown in Figure 67b. Five
months after surgery, failure of the reconstruction occurred. A
current radiograph is shown in Figure 67c. What is the most likely
cause of the failure of the revision procedure?
1.
2.
3.
4.
5.
Allograft failure
Osteoporosis
Pelvic discontinuity
Infection
Inadequate allograft fixation
174
An 82-year-old man fell and sustained the fracture shown in
Figures 69a and 69b. History reveals that the patient had
undergone a hemiarthroplasty and reported postoperative groin
pain after activity. Treatment should now consist of
1.
2.
3.
4.
5.
allograft strut with cerclage
cables.
combined plate and allograft strut
with cerclage cables.
cemented bipolar revision.
cemented revision total hip
arthroplasty.
cementless revision total hip
arthroplasty.
180
An 82-year-old man fell and sustained the fracture shown in
Figures 69a and 69b. History reveals that the patient had
undergone a hemiarthroplasty and reported postoperative groin
pain after activity. Treatment should now consist of
1.
2.
3.
4.
5.
allograft strut with cerclage
cables.
combined plate and allograft strut
with cerclage cables.
cemented bipolar revision.
cemented revision total hip
arthroplasty.
cementless revision total hip
arthroplasty.
180
A 56-year-old man with diabetes mellitus reports the sudden onset of hip pain
with weight bearing for the past day. History reveals that he underwent an
uncomplicated total hip arthroplasty 4 years ago and underwent dental work 1
week ago. Laboratory studies show an erythrocyte sedimentation rate of 95
mm/h (normal up to 20 mm/h) and a C-reactive protein of 32 mg/ml (normal
value is <10). Hip aspiration revealed a cell count of 25 X 103, with a
differential of 70% polymorphonuclear leukocytes. Management should
consist of
1.
2.
3.
4.
5.
awaiting the results of 5-day cultures, followed by IV antibiotics if
cultures are positive.
awaiting the results of 5-day cultures, followed by irrigation and
debridement and 6 weeks of IV antibiotics if cultures are positive.
immediate one-stage exchange arthroplasty.
immediate two-stage exchange arthroplasty.
immediate irrigation, debridement, and femoral head and liner
exchange.
184
A 56-year-old man with diabetes mellitus reports the sudden onset of hip pain
with weight bearing for the past day. History reveals that he underwent an
uncomplicated total hip arthroplasty 4 years ago and underwent dental work 1
week ago. Laboratory studies show an erythrocyte sedimentation rate of 95
mm/h (normal up to 20 mm/h) and a C-reactive protein of 32 mg/ml (normal
value is <10). Hip aspiration revealed a cell count of 25 X 103, with a
differential of 70% polymorphonuclear leukocytes. Management should
consist of
1.
2.
3.
4.
5.
awaiting the results of 5-day cultures, followed by IV antibiotics if
cultures are positive.
awaiting the results of 5-day cultures, followed by irrigation and
debridement and 6 weeks of IV antibiotics if cultures are positive.
immediate one-stage exchange arthroplasty.
immediate two-stage exchange arthroplasty.
immediate irrigation, debridement, and femoral head and liner
exchange.
184
Figure 74 shows the radiograph of a 75-year-old man who is
undergoing a revision total hip arthroplasty. During surgery, it is
noted that the acetabular component is well fixed. After revising the
femur, the hip is noted to be unstable. Treatment should now
consist of
1.
2.
3.
4.
5.
removing the liner, roughening the metal
part of the shell, and cementing a
polyethylene liner into the socket.
removing the liner, roughening the metal
part of the shell, and cementing a
constrained liner.
revising the metal shell to a hemispherical
socket.
revising the acetabular metal shell to a
bipolar component.
trochanteric advancement.
195
Figure 74 shows the radiograph of a 75-year-old man who is
undergoing a revision total hip arthroplasty. During surgery, it is
noted that the acetabular component is well fixed. After revising the
femur, the hip is noted to be unstable. Treatment should now
consist of
1.
2.
3.
4.
5.
removing the liner, roughening the metal
part of the shell, and cementing a
polyethylene liner into the socket.
removing the liner, roughening the metal
part of the shell, and cementing a
constrained liner.
revising the metal shell to a hemispherical
socket.
revising the acetabular metal shell to a
bipolar component.
trochanteric advancement.
195
What is the treatment of choice for a chronic
rupture of the patellar tendon after a total knee
arthroplasty?
1. Arthrodesis
2. Amputation
3. Transposition of the medial and lateral
gastrocnemius muscles
4. Reconstruction of the patellar tendon using a
gracilis autograft
5. Reconstruction using an Achilles tendon
bone/tendon allograft
198
What is the treatment of choice for a chronic
rupture of the patellar tendon after a total knee
arthroplasty?
1. Arthrodesis
2. Amputation
3. Transposition of the medial and lateral
gastrocnemius muscles
4. Reconstruction of the patellar tendon using a
gracilis autograft
5. Reconstruction using an Achilles tendon
bone/tendon allograft
198
What complication occurs more frequently with
current resurfacing arthroplasty compared to
conventional total hip arthroplasty?
1.
2.
3.
4.
5.
Osteolysis
Infection
Sciatic nerve palsy
Periprosthetic fracture
Dislocation
204
What complication occurs more frequently with
current resurfacing arthroplasty compared to
conventional total hip arthroplasty?
1.
2.
3.
4.
5.
Osteolysis
Infection
Sciatic nerve palsy
Periprosthetic fracture
Dislocation
204
Which of the following features improved fluid film
lubrication in a metal-on-metal total hip arthroplasty?
1.
2.
3.
4.
5.
Smaller diameter femoral head, a completely congruent fit
between the socket and the head, and sufficient surface
roughness to allow for some microseparation between the head
and the socket
Smaller diameter femoral head, a slight clearance between the
socket and the head, and no surface roughness
Larger diameter femoral head, a completely congruent fit
between the socket and the head, and no surface roughness
Larger diameter femoral head, a slight clearance between the
socket and the head, and minimal surface roughness
Larger diameter femoral head, a slight clearance between the
socket and the head, and sufficient roughness to allow for some
microseparation between the head and the socket
210
Which of the following features improved fluid film
lubrication in a metal-on-metal total hip arthroplasty?
1.
2.
3.
4.
5.
Smaller diameter femoral head, a completely congruent fit
between the socket and the head, and sufficient surface
roughness to allow for some microseparation between the head
and the socket
Smaller diameter femoral head, a slight clearance between the
socket and the head, and no surface roughness
Larger diameter femoral head, a completely congruent fit
between the socket and the head, and no surface roughness
Larger diameter femoral head, a slight clearance between the
socket and the head, and minimal surface roughness
Larger diameter femoral head, a slight clearance between the
socket and the head, and sufficient roughness to allow for some
microseparation between the head and the socket
210
Figure 86 shows the appearance of the tibial component
at the time of revision total knee arthroplasty. The most
likely reason for this appearance is that the polyethylene
was sterilized using which of the following methods?
1.
2.
3.
4.
5.
Ethylene oxide
Gamma irradiation in an
inert atmosphere
Gamma irradiation in air
Gamma irradiation in a
vacuum
Gas plasma
215
Figure 86 shows the appearance of the tibial component
at the time of revision total knee arthroplasty. The most
likely reason for this appearance is that the polyethylene
was sterilized using which of the following methods?
1.
2.
3.
4.
5.
Ethylene oxide
Gamma irradiation in an
inert atmosphere
Gamma irradiation in air
Gamma irradiation in a
vacuum
Gas plasma
215
What design feature of cementless femoral
stems limits osteolysis of the distal femur when
used in total hip arthroplasty?
1.
2.
3.
4.
5.
Fills the diaphysis of the femur
Fills the metaphysis of the femur
Collared
Circumferentially coated
Distally fluted
220
What design feature of cementless femoral
stems limits osteolysis of the distal femur when
used in total hip arthroplasty?
1.
2.
3.
4.
5.
Fills the diaphysis of the femur
Fills the metaphysis of the femur
Collared
Circumferentially coated
Distally fluted
220
During a two-incision minimally invasive total hip arthroplasty, the socket is
inserted without any complications. While inserting the proximally coated
nonmodular femoral stem, a fracture is noted at the junction between the
proximal and middle thirds of the femur, roughly at the anticipated tip of the
stem. What is the best course of action?
1.
2.
3.
4.
5.
Extend the incision with the patient in the supine position, insert the femoral
stem, and use a cable-plate for internal fixation of the femur.
Insert a longer stem through the minimally invasive approach, and reduce
the fracture under radiographic control as the stem is being advanced.
Close both incisions prior to inserting the stem, reposition the patient into the
lateral position, extend the femoral incision into an extensile posterolateral
approach to expose the hip joint and the fracture, and insert a longer fully
porous-coated stem to bypass the fracture.
Close both incisions prior to inserting the stem, reposition the patient into the
lateral position, extend the femoral incision into an extensile posterolateral
approach to expose the hip joint and the fracture, reduce the fracture, insert
the proximally coated stem into the proximal femur, and use cerclage cables
to fix the fracture.
Continue the surgery with the patient in the supine position, insert the
femoral stem into the femur under radiographic control, and use a minimally
invasive locking plate technique to fix the fracture.
232
During a two-incision minimally invasive total hip arthroplasty, the socket is
inserted without any complications. While inserting the proximally coated
nonmodular femoral stem, a fracture is noted at the junction between the
proximal and middle thirds of the femur, roughly at the anticipated tip of the
stem. What is the best course of action?
1.
2.
3.
4.
5.
Extend the incision with the patient in the supine position, insert the femoral
stem, and use a cable-plate for internal fixation of the femur.
Insert a longer stem through the minimally invasive approach, and reduce the
fracture under radiographic control as the stem is being advanced.
Close both incisions prior to inserting the stem, reposition the patient into the
lateral position, extend the femoral incision into an extensile posterolateral
approach to expose the hip joint and the fracture, and insert a longer fully
porous-coated stem to bypass the fracture.
Close both incisions prior to inserting the stem, reposition the patient into the
lateral position, extend the femoral incision into an extensile posterolateral
approach to expose the hip joint and the fracture, reduce the fracture, insert
the proximally coated stem into the proximal femur, and use cerclage cables
to fix the fracture.
Continue the surgery with the patient in the supine position, insert the
femoral stem into the femur under radiographic control, and use a minimally
invasive locking plate technique to fix the fracture.
232
Hip and Knee
Reconstruction
OITE 2006