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Z MCQ Of OrthoBullets > Arthroplasty (2008-2019) > Flashcards

Arthroplasty (2008-2019) Flashcards

1
Q
  1. When standing on one leg, what is the hip joint reaction force?
  2. 2.5
  3. 4.5
  4. 6.5
  5. 8.5
A

ANSWER: A (previously has been debated A vs B)

2012, 2013

  • Journal of Biomechanics (2001) - Hip contact forces and gait patterns from routine activities
    • The average peak forces of the patients during normal walking at about 4km/h were between 211and 285% bodyweight.
    • Sagars, millers, orthobullets says 4 BW for single leg stance
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2
Q

2.When are you more likely to injure the superior gluteal nerve?

  1. Glut med split with Hardinge approach
  2. Retractor placement with Kocher Langenbach
  3. When doing a GT osteotomy
A

ANSWER: A

2012

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3
Q
  1. What is the most common nerve injury associated with the Hardinge approach for a THA?
    a. Sciatic
    b. Inferior gluteal
    c. Superior gluteal
    d. Femoral
A

ANSWER: C

2015

  • Picado CH (CORR 2007) Damage to the superior gluteal nerve after direct lateral approach to the hip
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4
Q
  1. The most common nerve injured during THA is:
  2. Sciatic (peroneal division)
  3. Obturator
  4. Superior Gluteal Nerve
  5. Femoral Nerve
A

ANSWER: A

2013

JAAOS 1999 - Nerve Injuries in THA

  • Abitbol JJ (J Arthroplasty 1990) Gluteal nerve damage following THA
  • Subclinical gluteal nerve injury documented in over 77% of patients
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5
Q
  1. Sciatic nerve in THA. All of the following except:
  2. Most completely recover
  3. 70% have subclinical EMG changes
  4. more common in females
  5. more common in revisions
A

ANSWER: A

2009

Farrell CM (JBJS 2005) Motor nerve palsy following primary THA

  • Risk factors for nerve palsy –> DDH, post-traumatic arthritis, posterior approach, lengthening of extremity, cementless fixation
  • Only 36% had complete recovery at 21 months
  • 7/18 patients with incomplete palsy fully recovered their strength

JAAOS 1999 - Nerve Injuries in THA

  • 70% of THA had subclinical sciatic nerve injury
  • Mentions women as potential risk
  • Isolated peroneal division did well, but very poor recovery if both tibial and peroneal divisions involved
  • More frequent in DDH and revision scenario
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6
Q
  1. When putting in screws into the acetabulum and going into the safe posterosuperior zone, what is at risk?
  2. Obturator NV bundle
  3. External iliac
  4. Superior gluteal
  5. Inferior gluteal
A

ANSWER: C

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7
Q
  1. In order to determine the acetabular safe zone for screw placement, a line is drawn from where to where?
  2. AIIS to center of acetabulum
  3. ASIS to center of acetabulum
  4. Ischial tuberosity to center of acetabulum
  5. Cannot remember the last option
A

ANSWER - B

2014

  • Wasielewski RC (JBJS 1990) Acetabular anatomy and the transacetabular fixation of screws in total hip arthroplasty.
    • The quadrants are formed by drawing a line from the anterior superior iliac spine through the center of the acetabulum to the posterior fovea, forming acetabular halves. A second line is then drawn perpendicular to the first at the mid-point of the acetabulum, forming four quadrants. The posterior superior and posterior inferior acetabular quadrants contain the best available bone stock and are relatively safe for the transacetabular placement of screws. The anterior superior and anterior inferior quadrants should be avoided whenever possible, because screws placed improperly in these quadrants may endanger the external iliac artery and vein, as well as the obturator nerve, artery, and vein. The acetabular-quadrant system provides the surgeon with a simple intraoperative guide to the safe transacetabular placement of screws during primary and revision acetabular arthroplasty.
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8
Q
  1. 3rd generation cement technique does not include which of the following
  2. Vacuum mixing PMMA
  3. Pressurized
  4. Use of a cement plug
  5. Retrograde filling
A

ANSWER: C/D

2013

  • Confusing – other version said pressurized mixing which is wrong
  • Cement plug and retrograde (cement gun) filling were introduced in the 2nd generation but still part of 3rd generation.
  •  AAOS Comprehensive Review States:
  • First-generation femoral cement techniques: cement mixed by hand in an open bowl; cement placed in canal by hand; no canal lavage or drying; pressure provided by surgeon’s thumb
  • Second-generation techniques: plug, injecting doughy cement, using a cement gun
  • Third-generation techniques: porosity reduction with vacuum, pressurization, pulsatile lavage

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3880950/#bib23 Bone Cement – J Clin Orthop Trauma 2013 – doi 10.1016/j.jcot.2013.11.005

Orthobullets: Technique

cementing techniques have evolved with time

1st generation

  • hand-mixed cement
  • finger packed cement
  • no canal preparation or cement restrictor

2nd generation

  • cement restrictor placement
  • cement gun
  • femoral canal preparation
  • brush and dry

3rd generation

  • vacuum-mixing to reduce cement porosity
  • cement pressurization
  • femoral canal preparation
  • pulsatile lavage

*** 4th generation is an even cement mantle using centralizers for the stem

The well cemented THA p 150-154 Heisel 2005

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9
Q
  1. When pre-op planning for a THA, the femoral mechanical axis is?
  2. A line drawn through the centre of the femoral head to 1.5 cm medial to center of knee
  3. A line drawn through the centre of the femoral head to 1.5 cm lateral to center of knee
  4. A line drawn through the centre of the femoral head and intersecting the anatomic axis at the intercondylar notch
  5. A line bisecting the medullary canal
A

ANSWER: C

2014

  • C correctly describes the mechanical axis of the femur, some argument for D in planning of a THA specifically
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10
Q
  1. What is a disadvantage of HXPE vs UHMWPE:
  2. Decreased fracture
  3. Decreased oxidization
  4. Increased cost
  5. Decreased wear
A

ANSWER: C

2015

  • Thomas GE (JBJS 2011) The seven-year wear of highly cross-linked polyethylene in total hip arthroplasty: a double-blind, randomized controlled trial using radiosterometric analysis
  • XHPE has significantly lower steady-state wear than conventional ultra-high molecular weight polyethylene
  • Sakellariou V (HSS J 2013) Highly cross-linked polyethylene may not have an advantage in TKA
  • We concluded that:
    • the material properties of XLPE reduce adhesive and abrasive wear, but not the risk of crack propagation, deformation, pitting, and delamination found in TKR
    • wear-induced osteolysis in TKR has not been found to be a major cause of failure at long-term follow-up
    • mid-term follow-up studies show no difference in any recorded outcome measure between conventional PE and XLPE
    • XLPE is two to four times the cost of conventional PE without an improvement in clinical or radiographic outcomes.
  • Bhandari - Evidence Based Orthopedics
    • Short duration follow up
    • Improvement in wear with HXPE
    • Mechanical properties of HCLPE are negatively affected by crosslinking
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11
Q
  1. Regarding the mechanical axis in the tibia, all are true except?
  2. Colinear and parallel in coronal plane
  3. Colinear and parallel in sagittal plane
  4. Mechanical and anatomical tibia axes are colinear
  5. LE axis passes 8 mm medial to tibial spines
A

ANSWER: D

2008

  • 8mm is way to medial – variable but wither centre or slight medial
  • Orthobullets: MAT (mech axis of tibia) is from central prox tibia to central talus, same as AAT (anatomic axis of tibia)
  • Cherian et al. 2014: The position of the mechanical axis causes it to usually pass just medial to the tibial spine, but this can vary widely based on the patient height and pelvic width (increased pelvic width as in females and decreased height results in increased axis deviation
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12
Q
  1. What can be expected following trochanteric advancement which creates relative neck lengthening?
  2. Abductor weakness
  3. Reduces trendelenberg gait
  4. Will cause a limp
  5. Increased joint reaction forces
A

ANSWER: B

2016

  • Usually aim to distalize and lateralize to improve abductor moment arm
  • Aim is to tension abductors, increase stability (in THA) or improve function/ decrease tredelenburg
  • Yes, it increases compressive forces (see millers pic) in general = increased instability
  • But technically increases offset (lateralize), increase abductor moment arm, abductor efficiency and decrease JRF
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13
Q
    1. Metal on poly total hip. What is the most common cause of wear?
  2. Mode 1
  3. Mode 2
  4. Mode 3
  5. Mode 4
A

ANSWER: A

2011

JBJS 1999 - Current Concepts Review: Wear in Total Hip and Knee Replacements

  • Mode 1 - motion between one primary bearing surface and another (head on liner)
  • Mode 2 - primary bearing surface articulates with non-bearing surface (Head on shell)
  • Mode 3 - entrapped abrasive particles between bearings
  • Mode 4 - motion at secondary surfaces (impingement/fretting/backside wear)
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14
Q
  1. Stability of THA reduced by?
  2. larger head
  3. smaller head
  4. troch bursitis secondary to altered soft tissue tension
  5. position of cup at 40 degrees inclination and 15 degrees anteversion
A

ANSWER: B

2011

  • decreased jump distance
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15
Q
  1. Which articulation has the least wear?
  2. large head metal on metal
  3. small head metal on metal
  4. head on crosslinked poly
  5. ceramic on ceramic
A

ANSWER: D

2011, 2012

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16
Q
  1. All of these are properties of PMMA except?
  2. exothermic to 75 degrees
  3. stronger in tension than compression
  4. does not have adhesive properties to implant
  5. Porosity reduction increases strength by 10-15%
A

ANSWER: B

2011

  • Miller’s Orthopedics:
  • Acts as a grout, not an adhesive
  • Poor tensile and shear strength, strongest in compression
  • Reducing porosity increases cement strength and decreases cracking
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17
Q
  1. What increases the incidence of cobalt chromium ions with MoM hips?
  2. Cup in 55o abduction
  3. Increase in head size

 

A

ANSWER: A

2013

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18
Q
  1. Regarding the benefits of tantalum in THA components. All are true except:
  2. More biocompatible than other metals
  3. More ingrowth in pores compared to other porous coated metals
  4. Greater friction at bone-metal interface
  5. Young’s modulus of tantalum more closely approximates bone than that of titanium
A

ANSWER: A

2008

All metal has excellent biocompatibility

JAAOS 2006 - Applications of Porous Tantalum in THA

  • High volumetric porosity (70-80%), low modulus of elasticity, high frictional characteristics
  • Excellent biocompatibility
  • Modulus of elasticity similar to that of subchondral bone, but ultimate and yield strength much stronger
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19
Q
  1. 6 causes for groin pain and decreased function in a THA (2012)
A

Duffy PJ (JBJS 2005) Evaluation of patients with pain following total hip replacement

  • Infection
  • Aseptic loosening of acetabular component/Pelvic osteolysis
  • Psoas tendonitis
  • Dislocation/instability
  • Synovitis secondary to wear debris
  • Periprosthetic fracture
  • Pseudotumor
  • Heterotopic ossification
  • Hernia
  • Stress fracture of pelvis
  • Lumbar spine disease
  • GU/Gyne/Abdo
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20
Q
  1. List 4 advantages of using a high offset femoral stem. (2013, 2015)
A

JBJS 2004 - The role of femoral offset restoration

  • Improved ROM
  • Increased stability
  • Decreased impingement of GT on pelvis
  • Improved joint reactive forces - decreased wear/loosening
  • Increased abductor strength/decreased limping
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21
Q
  1. What are 5 potential complications from a mal-positioned acetabular component? (2011, 2013, 2014)
A
  • JAAOS 2010 - Improving the Accuracy of Acetabular Component Orientation
  • Instability/Dislocation
  • Impingement
  • Aseptic Loosening
  • Bearing surface wear/pelvic osteolysis
  • Revision Surgery
  • Psoas Irritation
  • Leg Length Discrepancy
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22
Q
  1. X-ray of a hip with cystic changes and sclerosis (AVN). Give 3 common causes for this disease process. (2010, 2014)
A

AAOS Core Review:

  • Trauma
  • Steroids
  • Alcohol
  • SLE
  • Renal Failure
  • Organ Transplant
  • Irradiation
  • Hematologic Disorder (sickle cell, hypofibrinolysis, thrombophilia)
  • Cytotoxins
  • Dysbarism
  • Storage Diseases (Gaucher’s)
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23
Q
  1. X-ray with a Crowe 4 hip - The patient is ready to undergo a THA. List 4 things that you have to consider from a technical aspect with regards to the procedure. (2010)
A
  • Femoral Side:
    • Increased anteversion
    • Small diameter canal (ML smaller than AP)
    • Increased anterior bow of femur
    • Valgus neck shaft angle
    • Small head, posterior GT
  • Acetabulum:
    • Increased anteversion
    • Deficient anterosuperiorly
    • Difficulty identifying true acetabulum
    • Deficient bone stock
  • Soft Tissues:
    • Tensioning of sciatic nerve by leg lengthening (3cm or 10%*)
    • Contracted, deficient abductors
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24
Q
  1. List 4 relative contraindications to total joint arthroplasty. (2011)
A
  • Active or remote infection
  • Presence of well-functioning, painless arthrodesis
  • Neuromuscular disease causing potential instability
  • Medically unfit
  • Non-ambulatory patients/lack of active muscle power
  • Active Charcot Neuroarthropathy
  • Asymptomatic Arthritis
  • Insufficient soft tissues
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25
Q
  1. Patient with a 15 year old THA. Suffers peri-prosthetic fracture. List 3 factors that are important when deciding on treatment. (2010, 2014)
A

Vancouver Classification

  • Location of fractures
  • Implant Stability
  • Bone Stock
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26
Q
  1. 70 yr old with cemented 15 yr THA, 1 yr history of thigh pain and periprosthetic fracture. List 3 factors important in the surgical management. (2010)
A

Vancouver Classification:

  • Location of fracture
  • Stability of implant
  • Bone stock available

Other:

  • Pre-operative medical optimization/function
  • Rule out infection (ESR, CRP)
  • Abductor deficiency (constraint)
  • Acetabular component stability (dual revision)
  • Previous components
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27
Q
  1. All are risk factors for Osteonecrosis of femoral head except
  2. Corticosteroid use
  3. Caissons disease
  4. Trauma
  5. Hemophilia A
A

ANSWER: D

2013

JAAOS 2004/2014

  • Pathogenic Mechanisms for Osteonecrosis
  • Ischemia –> femoral neck fracture, dislocation, surgery
  • Vascular compression
  • Corticosteroids
  • Alcohol
  • Thrombosis/thrombophilias
  • Embolization with fat or air
  • Sickle cell occlusion
  • Cellular toxicity –> drugs, radiation, oxidative stress
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28
Q
  1. 70 yo with cemented (cup and stem) THA 15 years ago presents with worsening activity-related pain gradually over 2 year period. No constitutional symptoms, otherwise healthy. ESR and CRP are normal. X-ray shows loose acetabular component only. What further workup is indicated before proceeding to revision THR?
  2. Bone scan
  3. WBC Scan
  4. Aspiration and nuclear med
  5. Nothing
A

ANSWER: D

2012

Spangehl (JBJS 1999)

  • If both CRP and ESR are normal then negative predictive value for infection is 100%
  • Could argue bone scan to assess for loosening of femoral component, but I agree this question is likely getting at ruling out infection
  • Doesn’t matter because you are already doing a revision so you can test it which is more definitive
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29
Q
  1. What can be done to increase the primary arc of motion in a total hip arthroplasty?
  2. Use a larger head
  3. Placing a collar on the femoral neck
  4. Increasing the offset
  5. Increasing the acetabular anteversion
A

ANSWER: A

2014

Miller’s Review - pg 377 THA Joint Instability

  • Primary Arc Range is controlled by the head/neck ratio:
  • Best stability is achieved by maximizing head/neck ratio
  • Things that decrease arc range:
  • Neck skirt (femoral head collar)
  • Acetabular hood
  • Constrained cups
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30
Q
  1. Which situation is best for a constrained acetabular liner in a recurrently unstable THA?
  2. well-positioned cup with GT nonunion
  3. well-positioned cup with absent GT
  4. mal-positioned cup with absent GT
  5. mal-positioned cup with GT non-union
A

ANSWER - B

2014

JAAOS Dislocation after THA

“the ideal candidate for a constrained device is a low-demand patient who lacks inherent soft-tissue constraint and has either a well-fixed cup suitable for a constrained liner or adequate bone stock for maximal screw fixation of a constrained cup”

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31
Q
  1. What is true regarding modular neck in THA prosthesis:
  2. Decreased notching due to increased varus in the component
  3. Increased corrosion
  4. Increased osteolysis
  5. Increased soft tissue reaction
A

ANSWER: B

2015

JBJS 2014 - early corrosion-related failure of the rejuvenate modular total hip replacement

JAAOS 2016 - Corrosion of the Head-neck Junction after Total Hip Arthroplasty

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32
Q
  1. What is the most common reason for revision in THA?
  2. Instability
  3. Infection
  4. Pain
  5. LLD
A

ANSWER: A

2015, 2016

Aseptic Loosening MOST COMMON NOW

JBJS 2009 – The Epidemiology of revision total hip arthroplasty in the United States

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33
Q
  1. 56 yo male with THA complains of groin pain. Pain with circumduction and resisted flexion on exam. XRAY shows abducted cup - what do you do?
    a. Physio
    b. WBC scan
    c. Acetabular cup revision +/- psoas release
    d. Revision of acetabular and femoral components
A

ANSWER: C

2015

  • Dora C (JBJS Br 2007) Iliopsoas impingement after THA: The results of non-operative management, tenotomy or acetabular revision
  • Review of 30 hips with well-fixed but mal-positioned or over-sized cups and iliopsoas tendonitis
  • 86% of patients with surgery had improvement
  • Conservative management failed in all cases
  • No benefit between tenotomy and acetabular revision at 2 years, revision had higher initial complications
  • JAAOS 2009 - Anterior Iliopsoas Impingement and Tendinitis after THA
  • Non-surgical treatment successful in only 39% of cases in our literature review
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34
Q
  1. What is the most predictable treatment of a femoral head with AVN of femoral head that already shows collapse?
  2. arthroplasty
  3. core decompression
  4. fibular allograft
  5. bisphosphates
A

ANSWER: A

2011

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35
Q
  1. Chiari Osteotomy now needs a THA, what is the challenge of THA?
  2. Move GT distally
  3. Move GT laterally
  4. Acetabular exposure
  5. Over reaming of anterior and posterior walls
A

ANSWER: C

2008

Looked for a relevant paper and didn’t get anything

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36
Q
  1. Least likely to have HO after THA
  2. Pagets
  3. Females under 65
  4. Ankylosing Spondylitis
  5. Cementless Implants
A

ANSWER: B

2008

JAAOS HO After Total Hip and Knee Arthroplasty

  • Risk factors:
  • high risk
  • men with bilateral hypertrophic oA
  • history of HO in either hip
  • post-traumatic arthritis characterized by hypertrophic osteophytosis
  • moderate
  • ankylosing spondylitis
  • DISH
  • Paget’s
  • Unilateral hypertrophic OA
  • Men > women
  • Cementless femoral component
  • Approach: extended iliofemoral > Kocher > ilioinguinal
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37
Q
  1. HO and TKA, risk factors - all of the following except
  2. Femur Notching
  3. RA
  4. Manipulation post-op
  5. Female with hypertrophic osteoarthropathy
A

ANSWER: B

2008

JAAOS

Patients at high risk for developing HO after TKA include those with limited post-op knee flexion, increased lumbar BMD, hypertrophic arthrosis, excessive periosteal trauma, notching of the anterior femur, those who require forced manipulation after TKA

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38
Q
  1. THA and hemophilia, all of the following except:
  2. Replace factors to 100%
  3. Coxa valga
  4. Infection rate similar to non-hemophiliac patients
  5. HO rate is decreased
A

ANSWER: C

2008

JAAOS 2005 - Hemophiliac Arthropathy

  • Clotting Replacement
  • Two hours pre-op –> infusion to 100%
  • Maintain >60% throughout procedure and maintain until discharge
  • With juvenile onset of synovitis and secondary inhibition of abductor function, coxa valga is the usual pattern
  • “There appears to be no increased incidence of heterotopic ossification after hip replacement”
  • Incidence of late infection in prosthetic joints averages 10%
  • High prevalence of HIV
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39
Q
  1. THA and Sickle Cell anemia - all of the following except:
  2. Must cover for salmonella
  3. Increased dislocation rate
  4. Increased early revision
  5. Increased deep infection
A

ANSWER: A

2008

JAAOS 2005 - THA in Sickle Cell Anemia

  • Infection rate 16-20%
  • No cases of Salmonella infection of THA
  • Dislocation rates up to 25%
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40
Q
  1. List 4 radiographic findings in considering adult FAI? (2013, 2014, 2016)
A

Cam: (no good cut-off evidence)

  • Decreased head-neck offset (<0.18) or ratio <0.18
  • Alpha angle > 42° (group 55-60)
  • Pistol Grip Deformity

Pincer:

  • Acetabular Retroversion:
    • Cross-over sign
    • Ischial spine sign
    • Posterior wall sign
  • Acetabular protrusio
    • Extrusion index < 15%
  • Global Overcoverage:
    • Lateral CEA > 35°
    • Down-sloping sourcil
    • Acetabular Index (Tonnis) < 0°
41
Q
  1. What are 3 cause of impingement in the hip other than FAI? (2015)
A
  • Blankenbaker DG (Semin Musc Radiol 2013) Non-Femoral Acetabular Impingement

Ischiofemoral Impingement Syndrome

  • Narrowing between ischial tuberosity and LT –> QF gets pinched

Anterior Inferior Iliac Spine/Sub-spine Impingement Syndrome

  • Abnormal contact between AIIS and proximal femur

Iliopsoas Impingement Syndrome

  • Thickened or taut psoas at acetabular rim/anterior hip capsule

Pelvitrochanteric impingement

  • Perthes disease or SCFE, more prominent GT, pain during walking, limping, abductor weakness.

I SIP

42
Q
  1. Picture of a BHR with a femoral neck fracture. Name 4 risk factors for this complication. (2011, 2014)
A

JAAOS 2006 - Hip Resurfacing Arthroplasty

  • Patient Factors:
    • Obesity
    • Decreased BMD
    • Inflammatory arthritis
    • Female gender (2x)
  • Intra-operative (85% of fractures)
    • Femoral neck cysts
    • Excessive prosthesis varus (<130O)
    • Improper implant seating
    • Notching of femoral neck
43
Q
  1. What are 5 factors to consider preop that suggest poor prognosis when considering a pelvic osteotomy in adult developmental dysplasia of the hip?

2013, 2014, 2015, 2016 (slight variations)

A

“considerations, poor prognosticators or contra-indications” for PAO in adult patients

Radiographic poor prognosticators (Troelsen JBJS 2009)

Tonnis grade 2/3 OA

Pre-op CEA < 0o

Pre-op os acetabuli (calcified labrum)

Incongruent abduction IR view

Post-op medial clear space > 2cm

Post-op acetabular sclerotic zone width < 2.5cm

JAAOS 2002 - Surgical Treatment of DDH in Adults

  • Moderate to advanced degenerative disease
  • Loss of ROM
  • Asymptomatic dysplasia
  • Proximal migration of center of rotation of femoral head
  • Non-ambulatory patient
  • Incongruent joint
  • Advanced physiologic age (better candidate for THA)
  • Morbid obesity (relative)
44
Q
  1. All are cause of snapping hip EXCEPT:
  2. IT band
  3. Iliopsoas
  4. Hamstring
  5. Labrum
A

ANSWER: C

2012

  • Variants 2010, 2013 with rectus instead of hamstring
  • JAAOS 1995 - The Snapping Hip: Revisited
  • External Type:
  • IT Band over GT
  • Internal Type:
  • Iliopsoas over iliopectineal eminence
  • Intra-articular:
  • Loose body
  • Acetabular labrum
  • Usually posterosuperior labrum
45
Q
  1. Youngish patient has hip pain. What is NOT true:
  2. L1 radiculopathy
  3. Retroverted acetabulum causing Pincer impingement
  4. Shape of femoral head is normal in CAM impingement
  5. Impingement related hip pain typically occurs when seated for long periods or after activity.
A

ANSWER: C

2013

46
Q
  1. In a patient with acetabular dysplasia, which position will provoke anterior instability?
  2. Flexion and internal rotation
  3. Flexion and external rotation
  4. Extension and internal rotation
  5. Extension and external rotation
A

ANSWER: D

2014

  • Hip Instability. Smith and Sekiya. Sports Med Arthrosc Med 2010.
  • The iliofemoral ligament (Y-ligament of Bigelow) is the strongest hip capsule ligament. It lies anterior to the femoral head and helps to resist anterior translation during external rotation and extension.
  • For anterior dislocations, patients should refrain from hip hyperextension and external rotation for 6 weeks.
  • As anterior cap-sular ligaments become lax, the hip will externally rotate well beyond the resting position with minimal resistance, often asymmetric to the contralateral side. In addition, patients may develop a feeling of apprehension with hip hyperextension and external rotation.
47
Q
  1. 6 anatomical releases for balancing a varus knee (2012)
A

JAAOS 2009 - Soft tissue balancing during total knee arthroplasty in the varus knee

  • Removal of osteophytes
  • Medial capsule
  • Posterior oblique ligament
  • Deep MCL
  • Superficial MCL
  • Semimembranosus fibres
  • PCL
  • Pes anserine
  • Medial Gastrocnemius
48
Q
  1. List 4 soft tissue releases for a valgus knee in TKA (2016)
A

JAAOS 2002 - TKA in Valgus Knee

  • IT Band
  • Posterolateral Capsule
  • LCL
  • Popliteus Tendon
  • Lateral Head of Gastrocnemius
  • PCL
49
Q
  1. 6 types of failure of a TKA requiring a revision (2012)
A

JAAOS 2008 - Revision Total Knee Arthroplasty

  • Infection
  • Patello-femoral instability
  • Aseptic Loosening/Osteolysis
  • Extensor Mechanism Disruption
  • Peri-prosthetic Fracture
  • Instability (varus/valgus)
  • Arthrofribrosis/Stiffness
  • Metal Allergy
50
Q
  1. List 3 technique to determine rotation of the femoral component in TKA. (2011, 2014)
A
  • Trans-epicondylar axis
  • Perpendicular to Whiteside’s Line
  • 3o ER from posterior condylar axis
  • Parallel to cut surface of tibia (gap balancing)
  • Computer Navigation
51
Q
  1. 45yo male presents 8mos post TKA with ROM 0-70 (0-120 pre-op). What are 3 possible causes of his flexion deficiency? (2010, 2014, 2015)
A

JAAOS 2004 Stiffness after TKA

Technical Errors:

  • Gap imbalance
  • Malalignment
  • Patellofemoral overstuffing
  • Joint line elevation/patella baja
  • Posterior cement extra-vasation
  • Component Malrotation

Patient Factors:

  • Poor Pre-op ROM
  • Poor patient motivation/rehabilitation
  • Poor pain control
  • Heterotopic ossification
  • Aggressive anti-coagulation with hematoma
  • Infection
  • Factors that do NOT affect ROM:
  • Obesity, previous OR, Keloid scar, age, sex, mutiple joint involvement, bilateral TKA
52
Q
  1. List 3 soft tissue releases to improve your flexion gap in performing a TKA. (2014)
A
  • Posterior Capsule
  • Gastrocnemius
  • Medial and lateral posterior corners
  • popliteus
  • PCL
  • Not a soft tissue release but can also increase the posterior slope of the tibial cut
  •  
  • Jess’ answer:
  • Anterior half of superficial MCL
  • Pes anserinus
  • PCL
  • Campbells: In general, release of posterior structures affects extension gap more than flexion gap (ie. POL, posterior capsule, semimembranosus), and release of anterior structure affects flexion gap more (i.e. anterior half of superficial MCL and pes anserinus)
53
Q
  1. List three ways to prevent PF maltracking in TKA (2014)
A
  • External rotation of tibial and femoral components
  • Lateralization of tibial and femoral components
  • Medialization of patellar component
54
Q
  1. A patient is being chemoprophylaxed against DVT/PE after a TKA. You are worried about HIT. What is true?
  2. Because you used low molecular weight heparin, the patient is not at risk for thrombocytopenia.
  3. You need to start the HIT work up if platelets drop below 100,000.
  4. It can present 4 to 5 days after starting heparin
A

ANSWER: C

2013

Ahmen I (Postgrad Med J 2007) Heparin Induced thrombocytopenia: diagnosis and management update

0-3 points - HIT unlikely

4-5 - intermediate possibility

6-8 highly likely

55
Q
  1. What has the lowest level of evidence for prevention of DVT in TJA?
  2. LMWH
  3. Mechanical compression devices
  4. Rivoroxaban
  5. ASA
A

ANSWER: B

2015

CHEST Guidelines 2012

“In patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA), we recommend use of one of the following for a minimum of 10 to 14 days rather than no antithrombotic prophylaxis: low-molecular-weight heparin (LMWH), fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose unfractionated heparin (LDUH), adjusted-dose vitamin K antagonist (VKA), aspirin (all Grade 1B), or an intermittent pneumatic compression device (IPCD) (Grade 1C).

56
Q
  1. Why do you ER the femoral component in a TKA

Brendan likes boys

Make a rectangular flexion gap

Because Femur is 6 degrees and tibia 3 degrees

A

ANSWER: B

2012

Miller’s Orthopedics:

57
Q
  1. What is the best way to assess implant malrotation following TKA?
  2. Xray
  3. Physical exam
  4. Metal subtraction CT
  5. MRI
A

ANSWER: C

2016

JAAOS 2015 - Extensor Mechanism Disruption after TKA

  • Prior radiographs can aid in the evaluation of component position as well as assessment of component migration over time
  • CT can provide detailed information regarding rotational malalignment of the femoral or tibial component
  • Beurger Protocol
58
Q
  1. Bilateral TKA, what risk goes up? REPEAT
  2. DVT
  3. Bleeding
  4. CV events
  5. Periprosthetic infections
A

ANSWER: C

2009, 2010, 2012

B a possible answer if comparing unilateral to simultaneous

  • Restrepo C (JBJS 2007) Safety of Simultaneous Bilateral TKA: A Meta-analysis
  • 150 articles with 27,807 patients included
  • Simultaneous TKA:
  • Higher:
  • Higher PE (OR 1.8)
  • Cardiac complications (OR 2.49)
  • Mortality (OR 2.2)
  • Lower:
  • DVT (not significant though)
  • Complications after staged TKA similar to those in unilateral TKA
  • Fu D (J Arthroplasty 2013) Comparison of clinical outcome between simultaneous-bilateral and staged-bilateral TKA
  • Simultaneous TKA had higher mortality, PE, transfusion
  • Lower deep infection and revision
  • No difference in neurologic complication, DVT, cardiac complications, superficial infection
  • A whole bundle of studies that show almost anything really.
  • JBJS Current Concepts Review 2015:
  • Emphasizes high level of bias in the current evidence for this
59
Q
  1. When doing a PCL-sacrificing total knee arthroplasty which is true?
  2. can raise joint line 12mm
  3. resection of PCL increases flexion arc 3-5mm
  4. better ROM postop with PCL retaining
  5. better long term outcome with PCL- retaining
A

ANSWER: D, (poor Q)

Summary:

  • PCL retaining knees have better survival
  • Slightly better ROM with sacrificing –> but not clinically significant
  • All patients getting arthroplasty have slight elevation of joint line, but no difference between implant types
  • Resection PCL increases flexion gap around 2 mm, more at 120-140 degrees flex
  •  
  • Cochrane Review 2013 - Retention versus sacrifice of the posterior cruciate ligament in total knee replacement for the treatment of osteoarthritis
  • Review of 17 RCTs
  • Range of motion: PCL retaining have 2o less ROM than PCL sacrificing
  • Knee Society Score was 2.3 points higher in sacrificing group
  • No results were clinically significantly different
  •  
  • Abdel MP (JBJS 2011) Increased Long-term survival of PCL retaining vs PCL stabilizing TKA
  • Knees with pre-op deformity: 15 year survival was 90% for PCL retaining vs 77% for PCL stabilizing
  • Knees without deformity: 88% for PCL retaining, 78% for PCL stabilizing
  • After adjustment for age, sex, preoperative diagnosis and preoperative deformity, the risk of revision was significantly lower in knees with a posterior cruciate retaining total knee replacement
60
Q
  1. All have been shown to decrease infection in TKA EXCEPT?
  2. Antibiotic loaded cement
  3. Shorter operating time
  4. Lower BMI
  5. Irrigation
A

ANSWER - A

2014

JAAOS - Infection in total knee arthroplasty

  • Pre-operative risk factors nutritional deficiency, uncontrolled DM, obesity, male sex, longer surgical time, RA
  • Namba RS (JBJS 2013) Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees
  • A total of 56,216 total knee arthroplasties were identified; 63.0% were done in women, the average age of the patients was 67.4 years (standard deviation [SD] = 9.6), and the average body mass index (BMI) was 32 kg/m2 (SD = 6).
  • The incidence of deep surgical site infection was 0.72% (404/56,216).
  • Patient factors associated with deep surgical site infection included a BMI of ‡35 (hazard ratio [HR] = 1.47), diabetes mellitus (HR = 1.28), male sex (HR = 1.89), an American Society of Anesthesiologists (ASA) score of ‡3 (HR = 1.65), a diagnosis of osteonecrosis (HR = 3.65), and a diagnosis of posttraumatic arthritis (HR = 3.23).
  • Protective surgical factors included use of antibiotic irrigation (HR = 0.67), a bilateral procedure (HR = 0.51), and a lower annual hospital volume (HR = 0.33).
  • Surgical risk factors included quadriceps-release exposure (HR = 4.76) and the use of antibiotic-laden cement (HR = 1.53).
  • In a sub-analysis, operative time was a risk factor, with a 9% increased risk per fifteen-minute increment.  
  • Schiavone PA (KSSTA 2016) Antibiotic loaded bone cement reduces risk of infections in primary total knee arthroplasty
  • Systematic review
  • Six articles with 6318 arthroplasties
  • No difference between groups in either superficial or deep infections
  • Bohm E (CORR 2014) Does adding antibiotics to cement reduce the need for early revision in total knee arthroplasty?
  • Canadian registry data
  • No significant difference within 2 years
61
Q
  1. For post-traumatic or post-operative arthrofibrosis of the knee, which is true?
  2. Hoffa sign can help determine suprapatellar scarring
  3. Anterior arthrofibrosis prevents extension
  4. Manipulation under anesthesia should be performed within 12 weeks
  5. Flexion contracture of 5-10 degrees is usually well tolerated
A

ANSWER - C (actual version of Q from bank lists C as 16 weeks which too long out to do an MUA); B is also correct (this is same things as a cyclops lesion)

2014, 2015

Dragoo JL (Sports Med 2012)

  • The Hoffa test. Firm pressure is applied with the thumb inferior to the patella outside the margin of the patellar tendon with the knee in (a) 30–60° of flexion. (b) The knee is fully extended, and increased pain in the infrapatellar fat pad indicates a positive test. The test is repeated on both the medial and lateral side
  • One stem version refers to “Anterior interval fibrosis”.
  • Fibrosis of the posterior border of the IFP to the anterior surface of the tibia or transverse meniscal ligament, is termed ‘anterior interval scarring’, which effectively adheres the IFP to the anterior tibia.[7,8,56] If clinical presentation includes distal displacement of the patella (patellar infera), significant flexion contracture and decreased patellar mobility, the diagnosis of ‘infrapatellar contracture syndrome’ has been used
  • JAAOS - Stiffness after Total Knee Arthroplasty:
  • Patients with late-onset knee stiffness (>3 months after TKA and after adequate ROM had been achieved initially) are less likely to benefit from physical therapy
  • “Controversy continues regarding both the usefulness and timing of manipulation”
  • Issa K (JBJS 2014) The Effect of timing of manipulation under anesthesia to improve range of motion and functional outcomes following total knee arthroplasty
  • 144 MUA - comparison of <6 weeks, 6-12 weeks, 13-26 weeks, >26 weeks
  • Early manipulation gained more motion (36 vs 17o) and had higher final ROM
  • No difference between <6 weeks and < 12 weeks
62
Q
  1. A patient is 8 weeks postop from a TKA and has significant stiffness. Given an AP, skyline and lateral x-ray which are totally normal. What do you do?
  2. Manipulate under anesthesia
  3. Revise to stemmed components
  4. Arthroscopic lysis of adhesions
  5. Open lysis of adhesions
A

ANSWER: A

2016

JAAOS 2004 - Stiffness after TKA

Patients with early-onset stiffness (<90o of flexion or significant flexion contracture < 3 months after surgery) and had adequate preoperative and intra-operative Rom but are not progressing with physical therapy should be considered for manipulation

63
Q
  1. Most important predictor of post-op ROM of TKA
  2. Use of PS knee
  3. pre-op motion
  4. high flex knee
  5. participation in PT
A

ANSWER: B

2011

64
Q
  1. What is the only advantage to not resurfacing the patella in TKA?
    a. less complications
    b. decreased dislocation
    c. improved patellar tracking
    d. less anterior knee pain
A

ANSWER: A

2015

JAAOS 2000 - Patellar Resurfacing in TKA

  • “…complications included patellar fracture, patellar subluxation or dislocation, exten- sor mechanism disruption, and component wear, loosening, or dissociation. Many of these complications occurred only with, or were much more common with, resurfaced patellae.”
  • (CORR 2005) Failure to resurface the patella during total knee arthroplasty may result in more knee pain and secondary surgery
  • Meta-analysis
  • More anterior knee pain without patellar resurfacing
65
Q
  1. With regards to patellar resurfacing. All of the following except:
  2. Metal backed patella do better than all poly
  3. Rotation of 3-5deg of femoral component is better than neutral
  4. Subluxation is more common than dislocation
  5. Lateralizing femoral component helps
A

ANSWER: A

2009

Garcia RM (CORR 2008) Isolated all-poly patellar revision for metal-backed patella failure

66
Q
  1. A patient presents with worsening knee pain, swelling erythema over the last 2 weeks following dental extraction. TKA 10 years ago. Inflammatory markers elevated. What is the most appropriate NEXT step:
  2. Single stage revision
  3. Two stage revision
  4. I&D and liner exchange
  5. I&D
A

ANSWER: C

2016

Acute infection

  • 2016 J of Arthroplasty Is there still a role for irrigation and debridement with liner exchange in acute periprosthetic total knee infection?
  • They did liner exchange with extensive I+D in patients with acute infections (few than 3 weeks of symptoms and no immune compromise)
  • Found that for all commers, irradication rate was 68.66%. If pseudamonas (66.67% failure rate) and MRSA (80% failure rate) were removed, success of I+D with liner exchange was raised to 85.25%
67
Q
  1. When performing TKA for varus knee, medial side is tight. Release semimembranosus. What does this effect?
  2. It affects flexion gap more extension gap
  3. It affects both flexion and extension equally
  4. It affects extension gap more than flexion gap
  5. It affects the flexion gap only if the PCL is gap
A

ANSWER: C

2011

  • JAAOS - Soft Tissue Balancing in the Varus Knee
  • sMCL will improve flexion and extension gaps
  • POL affects mostly extension space
  • Semimembranosus tendon affects extension space more than flexion
  • Pes Tendons –> affect extension gap (surprising) - Campbells says that pes tendons affect flexion gap more
68
Q
  1. Surgeon wants to use extramedullary referencing for tibia cuts in a total knee arthroplasty. If he ignores the rotational mismatch between the ankle and the tibial tubercle, what will the result?
  2. No coronal malalignment  
  3. Varus malalignment on coronal
  4. Valgus malalignment on coronal
  5. Increase posterior slope cut into tibia
A

ANSWER: B

2010

The Effect of Ankle Rotation on Cutting of the Tibia in Total Knee Arthroplasty

69
Q
  1. What is true about mobile bearing TKR’s?
  2. Better flexion
  3. No benefit shown in literature
  4. Better wear properties
  5. Longevity
A

ANSWER: B

2009

  • AAOS Comprehensive review:
  • Mobile-bearing TKA
  • Allows motion at the interface between the undersurface of the tibial polyethylene and the top surface of the tibial base plate.
  • Advocates believe it allows for increased ROM, lower polyethylene stresses, and a more idealized kinematic knee function.
  • Increasing conformity of tibial liner implants reduces polyethylene stress but increases stress at the tibial fixation interfaces.
  • A theoretical advantage for mobile-bearing TKA is that the articular surface of the implant can be congruent over the entire ROM without increasing constraint.
  • This leads to lower contact stresses as a result of increasing contact area.
  • Some authors believe lower contact stresses will translate into a lower incidence of osteolysis.
  • Data do not exist to show whether these apparent advantages with regard to contact stresses actually translate into decreased wear and osteolysis in vivo.
70
Q
  1. Hemophiliac has a TKA. All of the following except:
  2. Need to keep factor levels at 60% x 2wks post
  3. Lots of problems w/ jt instability
  4. If you take away infection, revision rates = everyone else
  5. Post op hemarthrosis is most common at 4-7d post op
A

ANSWER: B

2009

Patients are stiff, not lax

Guidelines for management of hemophilia

40-60% for 1 week post op

30-50% for the next week after

71
Q
  1. 24 year old female. LCEA of 17 degrees. Concentrically reduced hip. Preserved joint space. Will be undergoing a PAO. All of the following are true about this procedure except
  2. She will be unable to return recreation sports
  3. Risk of conversion to THA is <5% (or possibly <15%) in the next 15 years
  4. This will not affect her ability to deliver vaginally
  5. 5% risk of permanent sciatic nerve injury
A

ANSWER: A

2019

debateable.

Can deliver vaginally

Risk of sciatic nerve injury ~2-5% however PERMANENT is much lower (<1%)

  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3392380/
  • JAAOS 2017 - Descriptive Epidemiology of Acetabular Dysplasia: The Academic Network of Conservational Hip Outcomes Research (ANCHOR) Periacetabular Osteotomy
  • In patients with acetabular dysplasia, timely surgical correction via a Bernese PAO may improve patients’ ability to engage in recreational and athletic activities and may prevent or delay the development of otherwise predictable degenerative hip joint disease
72
Q
  1. All of the following are associated with osteoarthritis except:
  2. Legg Calve Perthes Stulberg IV
  3. Alpha angle of 65 in the setting of CAM impingement
  4. LCEA of 22 with dysplasia
  5. Pincer deformity with LCEA of 40
A

ANSWER: D

2019

  • pincer deformity with LCEA of 40
  • LCP – Stulberg classification à correlates shape of head and development of radiographic OA (eliminates a)
  • Type 1: Normal hip joint
  • Type 2: Spherical head
  • Type 3: Non-spherical head – 60% develop OA within 40 years
  • Type IV: Flat head
  • Type V: Flat head with incongruent hip joint
  • Dysplasia – persistent dysplasia leads to premature OA (eliminates c)
  • CAM vs Pincer
  • These impingement abnormalities result in:
  • Labral degeneration and tears
  • Articular cartilage delamination
  • Secondary osteoarthritis
  • Cam + alpha 65 (>50 abnormal)
  • Pincer + LCEA 40 (normal 25-45) – less likely to cause OA
73
Q
  1. 65 yo with a previous well function total hip arthroplasty with no issues. Comes in with 2 week history of worsening pain in his hip, recent dental work procedure, and has a temperature of 38.0, CRP 193, WBC 14, and sterile aspirate was performed that showed purulence, what is the best NEXT step in management?
  2. Indium WBC scan
  3. Two stage exchange
  4. I+D and liner exchange change
  5. One stage exchange
A

ANSWER: C

2019

  • According to the Clinical Practice Guidelines by the Infectious Diseases Society of America, patients who have a well-fixed, functioning prosthesis without a sinus tract, infection occurring within 30 days of index arthroplasty or <3 weeks of onset of infectious symptoms, and having an organism susceptible to oral antimicrobial agents, should be candidates for debridement and implant retention (DAIR)
74
Q
  1. TKA pre-hab, which of the following is true?
  2. Improves quadriceps strength
  3. Improves hamstring strength
  4. Does not influence length of stay after surgery
  5. Improves mortality post-op
A

ANSWER: A

2019

  •  A significant group by time interaction was found for the number of sit-to-stand repetitions in 30 seconds (p = 0.03), time to ascend the first (p = 0.02) and second (p = 0.05) flight of stairs, and peak extension torque in the surgical leg (P = 0.01). These findings support the hypothesis that older adults with severe knee OA who engage in a resistance band and step exercise program before their TKA improve their knee flexion and extension strength and the ability to perform some of the functional tasks. A number of investigators have observed that individuals with knee OA present with significantly lower quadriceps strength compared to their nonaffected leg or with healthy age-matched controls (21,24). Mizner et al. (23) reported that this reduction in strength is because the inability to fully activate the quadriceps muscle group and this reduced strength appears to continue after the TKA. These same authors later reported preoperative quadriceps strength to be a significant positive predictor of the ability to perform functional tasks, including stair climbing and rising from a chair, up to 1 year after TKA (22-25). Their findings were consistent with other researchers who reported that preoperative functional ability was a significant predictor of postoperative functional ability among individuals after TKA (13). These studies indicate that the declines in leg strength and ability to perform functional tasks associated with knee OA are not resolved after the TKA.
75
Q
  1. Regional compared to General anaesthetic for total hip and total knee surgery, what is true? (options not completely remembered)
  2. No difference in mortality rates
  3. Decreased length of stay
  4. Decreased pulmonary complications
  5. Increased cardiovascular complications
A

ANSWER: B/C

2019

  • Patients who received neuraxial anesthesia had statistically significant lower rates of surgical site infection (0.68% versus 0.92%; P = 0.0003), blood transfusions (5.02% versus 6.07%; P = 0.0086), and overall complications (10.72% versus 12.34%; P = 0.0032) as well as shorter surgical times (96 versus 100 minutes; P , 0.0001) and length of stay (3.45 versus 3.77 days; P , 0.0001).
  • Comparing general anesthesia with neuraxial anesthesia in the TKA subgroup, they found that general anesthesia was associated with higher risks of pulmonary compromise (odds ratio [OR], 1.83; 95% confidence interval [CI], 1.43 to 2.35; P , 0.0001), pneumonia (OR, 1.27; 95% CI, 1.05 to 1.53; P = 0.0083), all infections (OR, 1.38; 95% CI, 1.26 to 1.52; P , 0.0001), acute renal failure (OR, 1.44; 95% CI, 1.24 to 1.67; P , 0.0001), and overall 30-day mortality (OR, 1.83; 95% CI, 1.08 to 3.1; P = 0.0211).
76
Q
  1. Tibial tubercle osteotomy is a reasonable option for improved exposure revision TKA, what is true with respect to TTO? 
  2. It should only be used in a revision TKA 
  3. It has low complication rates 
  4. It has low union rates 
  5. It requires good bone stock in the proximal tibia (at least 2.5 cm) 
A

ANSWER: B

2019

  • The extensile approach described by these authors consists in the osteotomy of a fragment containing the anterior tibial tuberosity and the patellar tendon, approximately 7 to 11 cm long and at least 2 cm thick
  • JBJS 2016 - Tibial tubercle osteotomy to aid exposure for revision total knee arthroplasty

o Reliable and safe exposure during revision total knee arthroplasty with a high union rate, low complication rate, and predictable outcomes

o Indications:

§ Difficult knee exposure during revision (or primary) total knee arthroplasty

§ There must be sufficient thickness of bone stock along the anterior aspect of the tibia (a minimum of 1.5 cm from the anterior tibial tubercle to the deepest part of the osteotomy) after taking into account the existing cement mantle and tibial keel or stem

77
Q
  1. You are doing a THA through a direct anterior approach. If you are to extend the approach distally to address a peri-prosthetic femur fracture with a cerclage wire,  
  2. MFCA injury 
  3. LFCN injury 
  4. Femoral nerve 
  5. Innervation to the antero-lateral quadriceps (vastus lateralis, lateral aspect of vastus intermedius) 
A

ANSWER: D

2019

  • https://oce-ovid-com.proxy1.lib.uwo.ca/article/00004623-201501210-00006/HTML
  • The distal extension of the anterior approach compromises the nerve supply to the anterolateral portions of the quadriceps. Introduction of a cerclage cable passer through the anterior access also jeopardizes nerve branches to the vastus lateralis, lateral parts of the vastus intermedius, and branches of the lateral femoral circumflex artery.
78
Q
  1. With respect to revision total hip arthroplasty, what decrease implant failure? 
  2. Surgeon experience 
  3. Keeping the cemented femoral stem leads to better outcomes 
  4. Young age 
  5. Metal head with a constrained liner 
A

ANSWER: A

2019

79
Q
  1. Releases for a valgus TKA, what would you release? 
  2. ITB in flexion 
  3. Popliteus in flexion 
  4. Complete release of the LCL 
  5. Medial capsular release 
A

ANSWER: B

2019

80
Q
  1. With respect to smoking and total knee arthroplasty, what is true? 
  2. Increased rates of wound complications and deep infection 
  3. Being a previous smoker normalizes your risk to that of a non-smoker 
  4. Odds ratio of getting a DVT is 3.5x risk 
  5. Some other option that legit could have been the right answer 
A

ANSWER: A

2019

81
Q
  1. Mechanical vs kinematic alignment tka questions. Which of the following is true? 
  2. In mechanical alignment you want to place the joint line perpendicular to the ANATOMIC axis of the limb 
  3. There is no evidence to show that placing the tibial component in greater than 3 degrees of varus increases failure 
  4. If you were to do a kinematically aligned knee, the tibial component is in several degrees of varus and the femoral component is in several degrees of valgus 
  5. Kinematic tka  has better short and long-term outcomes compared to mechanical tka 
A

ANSWER: C

2019

  • This step leads to femoral components that are aligned in 2_ to 4_ more valgus and tibial components that are positioned in 2_ to 4_ more varus, while maintaining similar hip-knee-ankle angles and anatomic angles of the knee compared to a mechanically aligned TKA.21 
82
Q

82.Stiffness post-TKA. Which is true? 

  1. You should do an MUA at 16 weeks if they have decreased ROM 
  2. Anterior interval scarring can lead to decreased extension 
  3. Hoffa test is for superior patellar scarring 
  4. 20 degrees of flexion contracture is well tolerated 
A

ANSWER: B

2019

83
Q

83.When performing a total knee arthroplasty, trialing of the components causes lateral patellar dislocation. What is the most common technical error that could lead to this?

  1. Medicalization of patella button
  2. Lateralization of the femoral component
  3. Internal rotation of the tibial component
  4. Lateralization of the tibia component
A

Answer: C (2017)

A – is a good thing

B – good thing

C- not good

D – good thing

84
Q
  1. The most significant barrier to obese people getting TKA’s
  2. Concerns about longevity of implants
  3. Anaesthetic concerns
  4. Orthopaedic Surgeon’s attitudes toward obese people
  5. Obtaining medical clearance for surgery
A

Answer: C

2017

(What the group thought – unless you’re TVas and a BMI 65 gets you in the back door)

A - yes

B – sort of

C - probably

D – not really

  • Multiple studies have shown worse implant survivorship in the obese TKA population.23,39 As previously discussed, Abdel et al23 reported that patients with a BMI >35 kg/m2 had a significantly increased risk of tibial loosening (P , 0.05). In addition, multiple studies have shown a statistically higher risk of revision for deep infection.
  • JAAOS 2014 Obesity, orthopedics and outcomes – summary
  • •Obesity is very prevalent
  • •Waist measurement may be more reliable predictor of health risks
  • •Medical comorbidities:
  • DM
  • Cardiovasc disease, pulmonary disease
  • OSA
  • Metabolic syndrome
  • OA
  • BMI > 30 = 8X risk of TKA
  • BMI >35 = 18X risk of TKA
  • •Periop considerations
  • Preop: preop eval with BW and glucose testing. ECG and an echo if any signs of CHF. Renal function testing.
  • Anaesthesia: positions that restrict the chest are not well tolerated (trendelenburg, lithotomy, prone). Tend to have decrease lung volumes and functional residual capacity. OSA often indicated need for awake intubation with fiberoptic bronchoscope. Blocks still work well.
  • Postop considerations: Obesity is independent risk factor for DVT/PE
  • •Total joints: Mixed literature regarding outcomes post THA TKA in obese. Generally these patients do worse and have higher complications, but they actually improve more with surgery (since their preop function is much lower
  • oSuggest BMI >40 – preop weight loss
  • •Doctors perception: “the biggest obstacle to optimal orthopedic care of obese patients is..the attitude of the physician”
  • o53% patients reported innapropriate comments made by the surgeon about their weight (Obviously underestimated in McCalden’s clinic)
85
Q
  1. With regards to MI and total joint arthroplasty, what is true?
  2. lowered risk with intraop cardiac monitoring
  3. 5% risk of MI in 30 days
  4. HTN, age > 80, previous cardiac disease are risk factors
  5. The majority are intraoperative MIs
A

Answer: C (2017)

86
Q
  1. 75F with TKA, presents with pain at 18 months and says never felt good. What is the most likely cause?
  2. Infection
  3. Instability
  4. Periprosthetic fracture
  5. Osteolysis
A

Answer: B

2017

  • Chronic failure for everything is aseptic loosening.
  • Acute for hips is instability, for knees it’s infection.
  • TKA failure/ reason for revision = infection < 2 yr (early), aseptic loosening > 2years (late)
  • Orthobullets, systematic reviews, registries
87
Q
  1. Previous femoral neck fracture, underwent ORIF. Has failed. Now undergoing THA. All of the following are true with regards to salvage THA except?
  2. Increased infection rate
  3. Increased dislocation
  4. Increased risk of periprosthetic fracture
  5. Primary THA functional outcomes are better than post-fracture
A

Answer: D (2017)

Functional outcomes are the same.

  • Bone Joint J. 2016 Apr;98-B(4):452-60. doi: 10.1302/0301-620X.98B4.36922.
  • Outcomes of total hip arthroplasty, as a salvage procedure, following failed internal fixation of intracapsular fractures of the femoral neck: a systematic review and meta-analysis.
  • Mahmoud SS1, Pearse EO2, Smith TO3, Hing CB2.
  • Our analyses revealed a significantly increased risk of complications including deep infection, early dislocation and peri-prosthetic fracture with salvage THA when compared with primary THA for an intracapsular fracture of the femoral neck (overall risk ratio of 3.15). Functional outcomes assessment using EuroQoL (EQ)-5D were not significantly different (p = 0.3).
88
Q
  1. Patient sustains foot drop post-TKA. What was their most likely preoperative deformity?
  2. Valgus and flexion contracture
  3. Varus and flexion contracture
  4. Varus and internal rotation contracture
  5. Valgus and extensor mechanism incompetence
A

Answer: A (2017)

89
Q
  1. What does not cause hip AVN?
  2. Hemophilia A
  3. Caisson
  4. Steroids
  5. Sickle cell anemia
A

Answer: A (2017)

ASEPTIC

A: alcohol

S: sickle cell disease / SLE

E: exogenous steroid

P: pancreatitis

T: trauma

I: infection

C: caisson disease

Caisson disease is an uncommon diving-related decompression illness that is an acute neurological emergency typically occurring in deep sea divers.

90
Q
  1. What is true about arthrofibrosis after TKA?
  2. MUA after 16 weeks if inadequate ROM
  3. Hoffa test is for suprapatellar impingement
  4. Flexion contracture of 20 degrees is well-tolerated
  5. Anterior interval fibrosis causes decreased extension
A

Answer – D (2017), 2019

  • A- False – less than 3 months show better results
  • B - False Hoffa fat pad is infrapatellar, Hoffa test is for impingement
  • C – False – that’s the upper limit.
  • D – True – this is a cyclops lesion!!
  • Manipulation appears to have notably better results when undertaken within the first 3 months after TKA.
91
Q
  1. What indicates anterior stability in residual dysplasia (it was honestly worded really fucked up like this, but this is a repeat)
  2. Extension and ER
  3. Extension and IR
  4. Flexion and ER
  5. Flexion and IR
A

ANSWER: A

2018

92
Q
  1. A patient has a THA. He comes to you for their 2-week follow up. Their first 6 days (?in hospital?) were unremarkable and there where no intra-op complications. He has a low-grade fever and a CRP that was somewhere in the 60-80 range. There has been increased wound drainage over the last three days and the incision is red. What should you do?
  2. Admit to hospital for IV antibiotics
  3. Admit to hospital to get an aspirate to rule out infection
  4. Admit to hospital for urgent I and D and exchange of poly
  5. ??Something else that was wrong…like send them home or sprinkle some fairy dust
A

ANSWER: C

2018

93
Q
  1. All of the following are risk factors for a metal hypersensitivity reaction in total joint arthroplasty EXCEPT?
  2. Males
  3. Pierced ears
  4. eczema
  5. Smoking
A

ANSWER: A

2018

94
Q
  1. When planning to do a take down of a hip fusion for conversion to THA, what is the most important thing that predicts outcome
  2. Abductor function
  3. Leg lengths
A

ANSWER: A

2018

95
Q
  1. What is true regarding polyethelene wear?
  2. It is not commonly assessed/evaluated on xrays
  3. It is commonly assessed/evaluated with CT scan
  4. _____ can determine the difference between creep and wear
  5. ?stereographic measurements are best
A

ANSWER: D

2018

96
Q
  1. The best way to assess for malrotation in a TKA is:
  2. Clinical exam
  3. Metal subtraction MRI
  4. Metal subtraction CT
  5. Skyline xray
A

ANSWER: C

2018

97
Q
  1. A patient gets a periprosthetic fracture above a TKA. You recommend a retrograde nail. Instead he gets a plate. Other than the type of components, as shown in the image (you are shown a post op image of a TKA with a lateral plate, a fracture below the anterior flange of the prosthesis, it looks like shit…it looks like there is bone loss distally and the distal fragment is fixed in extension. Also there are randomly 2 wires.) what else would you want to know from the original surgical notes?
  2. Whether there was anterior femoral notching
  3. What incision was used
  4. The type of femoral component box
A

ANSWER: C

2018

98
Q
  1. All of the following are true regarding mechanically assisted crevice corrosion aka trunionosis (MACC) EXCEPT?
  2. Retrieval studies show it to be as high as 40%
  3. It is commonly symptomatic
  4. Proposed revision is to a ceramic head with a titanium sleeve
  5. <5% will develop metalosis
A

ANSWER: B

2018

99
Q
  1. Adult DDH. Who gets early PAO?
  2. Lateral CE angle <25, BMI >35
  3. Lateral CE angle <5, high demand
  4. Lateral CE angle <5, BMI >35
  5. Lateral CE angle <25 degrees, active patient
A

Answer: B (2017)

  • BMI too high
  • Prob true
  • Fat
  • Not 100%, but these pple are worth watching
  • Patients with advanced osteoarthritis (Tönnis grade ≥ 2), physiologically older age, or low pre-operative functional scores experience less favorable results and, in general, are poor candidates for PAO [10]. Reduced hip joint range of motion (b90°) and obesity (BMI N 30 kg/m2 ) are relative contraindications for PAO.

Z MCQ Of OrthoBullets (27 decks)

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