Hip & Knee 2013 Flashcards
- The ability of bacteria to adhere to orthopaedic impalants and elude antimicrobial therapies through the use of biofilm is attributable to their ability to produce
- pyrrolidonyl arylamidase.
- virulence factor exotoxin A.
- Panton-Valentine leukocidin.
- exopolysaccharide glycocalyx.
- glyceraldehyde-3-phosphate dehydrogenase.
- exopolysaccharide glycocalyx.
- Figures 20a and 20b are the radiograph and MRI scan of a 58-year-old man who had total hip arthroplasty 3 years ago. His hip has been increasingly painful for 6 months. Laboratory studies show an erythrocyte sedimentation rate of 24 mm/h (reference range [rr], 0-20 mm/h) and a C-reactive protein level of 0.3 mg/L (rr, 0.08-3.1 mg/L). In Figure 20b, which abnormality is indicated by the arrows?
- Infection
- Malignancy
- Pseudotumor
- Polyethylene debris
- Heterotopic ossification
- Pseudotumor
RECOMMENDED READINGS
Daniel J, Holland J, Quigley L, Sprague S, Bhandari M. Pseudotumors associated with total hip arthroplasty. J Bone Joint Surg Am. 2012 Jan 4;94(1):86-93. Review. PubMed PMID: 22218386.
Hart AJ, Satchithananda K, Liddle AD, Sabah SA, McRobbie D, Henckel J, Cobb JP, Skinner JA, Mitchell AW. Pseudotumors in association with well-functioning metal-on-metal hip prostheses: a case-control study using three-dimensional computed tomography and magnetic resonance imaging. J Bone Joint Surg Am. 2012 Feb 15;94(4):317-25. PubMed PMID: 22336970.
- Which population is least likely to receive total joint arthroplasty?
- Black men
- Black women
- White men
- White women
- Hispanic men
- Black men
- A 70-year-old healthy man had total knee arthroplasty 18 years ago, and it now is painful. Radiographs reveal aseptic loosening and the range of motion before surgery is 15 to 85 degrees. The strongest indication for performing a tibial tubercle osteotomy to aid in exposure in his knee would be
- patella baja.
- nonresurfaced patella.
- isolated femoral revision.
- noncemented tibial component.
- previous use of the quadriceps turn-down technique.
- patella baja.
RECOMMENDED READINGS
\Younger AS, Duncan CP, Masri BA. Surgical exposures in revision total knee arthroplasty. J Am Acad Orthop Surg. 1998 Jan-Feb;6(1):55-64. Review. PubMed PMID: 9692941.
Mendes MW, Caldwell P, Jiranek WA. The results of tibial tubercle osteotomy for revision total knee arthroplasty. J Arthroplasty. 2004 Feb;19(2):167-74. PubMed PMID: 14973859.
- Figure 50 is the radiograph of a 45-year-old man who has avascular necrosis of the hip attributable to his sickle cell anemia. He is scheduled for total hip arthroplasty. To prevent the most likely intrasurgical technical complication, particular attention should be directed toward
- dislocating the hip.
- preparing the femur.
- reaming the acetabulum.
- inserting the acetabular screws.
- cutting the short external rotators
- preparing the femur.
RECOMMENDED READINGS
Jeong GK, Ruchelsman DE, Jazrawi LM, Jaffe WL. Total hip arthroplasty in sickle cell hemoglobinopathies. J Am Acad Orthop Surg. 2005 May-Jun;13(3):208-17. Review. PubMed PMID: 15938609.
Hernigou P, Zilber S, Filippini P, Mathieu G, Poignard A, Galacteros F. Total THA in adult osteonecrosis related to sickle cell disease. Clin Orthop Relat Res. 2008 Feb;466(2):300-8. Epub 2008 Jan 10. PubMed PMID: 18196410.
- A 63-year-old woman with rheumatoid arthritis is undergoing a knee arthroplasty. Her rheumatoid arthritis has been well controlled with methotrexate, etanercept, and naproxen. Which medication-related instructions should be followed 7 days before surgery?
- Continue all medications
- Discontinue naproxen
- Discontinue naproxen and etanercept
- Discontinue naproxen and methotrexate
- Discontinue naproxen, etanercept, and methotrexate
- Discontinue naproxen and etanercept
RECOMMENDED READINGS
Howe CR, Gardner GC, Kadel NJ. Perioperative medication management for the patient with rheumatoid arthritis. J Am Acad Orthop Surg. 2006 Sep;14(9):544-51. Review. PubMed PMID: 16959892.
- Figures 76a through 76c are the anteroposterior and lateral radiographs and bone scan of a 66-year-old
man with type I diabetes mellitus who had revision right total knee arthroplasty for aseptic loosening 3 years ago. He has pain over the proximal tibia with startup at the end of the day. He has difficutly walking on level ground. Laboratory studies reveal an erythrocyte sedimentation rate of 5 mm/h (reference range [rr], 0-20 mm/h) and C-reactive protein of <3.0 mg/L (rr 0.08-3.1 mg/L). Synovial fluid has 389 nucleated cells with 11% neutrophils and cultures are negative. What is the most likely failure mechanism for this revision total knee arthroplasty?
- Unrecognized fungal infection
- Improper component alignment
- Posterior cruciate ligament insufficiency
- Aseptic loosening beacause of inadequate diaphyseal fixation
- Aseptic loosening because of inadequate meaphyseal fixation
- Aseptic loosening because of inadequate meaphyseal fixation
RECOMMENDED READINGS
Bush JL, Wilson JB, Vail TP. Management of bone loss in revision total knee arthroplasty. Clin Orthop Relat Res. 2006 Nov;452:186-92. Review. PubMed PMID: 16906109.
- When templating total hip arthroplasty, which figure reveals the best recreation of the proper biomechanics of the hip joint, assuming that the right leg is 5 mm shorter than the left?
- Figure 98a
- Figure 98b
- Figure 98c
- Figure 98d
- Figure 98e
- Figure 98c
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. 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.
- Internal rotation of the femoral component can cause patella maltracking by
- increasing the Q angle.
- increasing the medial-directed force vector on the patella.
- producing valgus malalignment.
- tightening of the lateral retinaculum.
- overstuffing the patellofemoral compartment
- increasing the Q angle.
- A 70-year-old man with osteoarthrosis is scheduled to undergo total knee arthroplasty. He inquires about patellar resurfacing. He should be told that a potential advantage of having the patella resurfaced as opposed to leaving the patella unresurfaced is
- increased extensor strength.
- lower risk for patellar fracture.
- lower risk for requiring reoperation.
- lower risk for patellar subluxation.
- higher chance of achieving desirable range of motion.
- lower risk for requiring reoperation.
RECOMMENDED READINGS
Meneghini RM. Should the patella be resurfaced in primary total knee arthroplasty? An evidence-based analysis. J Arthroplasty. 2008 Oct;23(7 Suppl):11-4. Epub 2008 Aug 12. Review. PubMed PMID: 18701250.
Parvizi J, Rapuri VR, Saleh KJ, Kuskowski MA, Sharkey PF, Mont MA. Failure to resurface the patella during total knee arthroplasty may result in more knee pain and secondary surgery. Clin Orthop Relat Res. 2005 Sep;438:191-6. PubMed PMID: 16131890
- Figures 121a and 121b are the current radiographs of a 39-year-old woman who had left total hip arthroplasty 1 year ago. She is experiencing squeaking from the left hip while ambulating. Which factor most likely contributes to her symptoms?
- Activity level
- Surgical approach
- Component design
- Component loosening
- Component positioning
- Component positioning
RECOMMENDED READINGS
Finkbone PR, Severson EP, Cabanela ME, Trousdale RT. Ceramic-on-ceramic total hip arthroplasty in patients younger than 20 years. J Arthroplasty. 2012 Feb;27(2):213-9. Epub 2011 Aug 9. PubMed PMID: 21831576.
- What is the optimal treatment for a Vancouver type B2 fracture in a healthy patient?
- Retain the stem and fracture fixation with cortical strut graft and cables
- Revision to a proximal femoral-replacing stem
- Revision to a long porous-coated stem and cable fixation
- Revision to a long cemented stem bypassing the fracture site
- Revision to a proximally coated stem and open reduction and internal fixation of the fracture
- Revision to a long porous-coated stem and cable fixation
RECOMMENDED READINGS
Corten K, Macdonald SJ, McCalden RW, Bourne RB, Naudie DD. Results of cemented femoral revisions for periprosthetic femoral fractures in the elderly. J Arthroplasty. 2012 Feb;27(2):220-5. Epub 2011 Jul 12.PubMed PMID: 21752585.
- The failure of total hip arthroplasty using a zirconium-ceramic femoral head as seen in Figures 153a and
153b is most likely the result of
- infection.
- aseptic loosening.
- bony impingement.
- material properties.
- component alignment.
- material properties.
RECOMMENDED READINGS
Traina F, Tassinari E, De Fine M, Bordini B, Toni A. Revision of ceramic hip replacements for fracture of a ceramic component: AAOS exhibit selection. J Bone Joint Surg Am. 2011 Dec 21;93(24):e147. Review. PubMed PMID: 22258782.
Hannouche D, Hamadouche M, Nizard R, Bizot P, Meunier A, Sedel L. Ceramics in total hip replacement. Clin Orthop Relat Res. 2005 Jan;(430):62-71. Review. PubMed PMID: 15662305.
- Which figure best shows femoral component loosening
- Figure 164a
- Figure 164b
- Figure 164c
- Figure 164d
- Figure 164e
- Figure 164a
- A 57-year-old woman had right total knee arthroplasty for varus gonarthrosis. Before surgery, her range of motion was 5 to 110 degrees. At skin closure, her range of motion was 0 to 120 degrees. Her range of motion at 10 weeks after surgery is 0 to 70 degrees. What is the best next treatment step?
- Observation
- Dynamic bracing
- Manipulation under anesthesia
- Revision with open adhesiolysis
- Physical therapy with aggressive range of motion
- Manipulation under anesthesia
RECOMMENDED READINGS
Namba Rs, Inacio M. Early and later manipulation improve flexion after total knee arthroplasty. J Arthroplasty. 2007 Sep;22(6 Suppl 2):58-61. Epub 2007 Jul 26. PubMed PMID: 17823017.
Keating EM, Ritter MA, Harty LD, Haas G, Meding JB, Faris PM, Berend ME. Manipulation after total knee arthroplasty. J Bone Joint Surg Am. 2007 Feb;89(2):282-6. PubMed PMID: 17272441.
- Figure 197 is the radiograph of a 62-year-old woman who is seen in the emergency department with a dislocated left total hip arthroplasty. This is her seventh dislocation during the last 3 months and she most recently had a liner revision. What is the best next treatment step?
- Skeletal traction
- Open reduction
- Closed reduction
- Component revision
- Hip abduction orthosis
- Component revision
RECOMMENDED READINGS
Alberton GM, High WA, Morrey BF. Dislocation after revision total hip arthroplasty: an analysis of risk factors and treatment options. J Bone Joint Surg Am. 2002 Oct;84-A(10):1788-92. PubMed PMID: 12377909.
- Figure 214 is the current radiograph of a 74-year-old man who had right total hip arthroplasty 3 weeks ago. He stumbled and has increasing pain with weight-bearing activity. What is the best next treatment
step?
- Revision
- Resection arthroplasty
- Routine follow-up at 3 months
- Open reduction and internal fixation
- Nonweight bearing activity for 6 weeks
- Revision
RECOMMENDED READINGS
Duncan CP, Masri BA. Fractures of the femur after hip replacement. Instr Course Lect. 1995;44:293-304. Review. PubMed PMID: 7797866.
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.
234.
Figure 234a is the clinical photograph of an 82-year-old man who had left total knee arthroplasty 1 year ago. He has difficulty with pain and stiffness and recently noted swelling on the medial side. He had aspiration of the knee 1 month ago with a cell count of 22,000/mm3 nucleated cells. Aerobic and anerobic culture and gram stain findings are negative. Laboratory studies reveal the erythrocyte sedimatation rate and C-reactive protein are within defined limits. He is able to perform a straight-leg raise. Range of motion is 15 to 80 degrees. Anteroposterior and lateral radiographs are shown in Figures 234b and 234c. What is the best next step?
- An MRI scan to evaluate for possible vastus medialis oblique disruption
- Physical therapy with biofeedback focusing on gentle range of motion
- Reaspirate and send for aerobic, anaerobic, fungal, and acid fast bacilli cultures
- Resection arthroplasty and placement of vancomycin and gentamicin cement spacer
- Revision total knee arthroplasty, elevation of joint line for flexion contracure, repair of the extensor mechanism disruption
- Reaspirate and send for aerobic, anaerobic, fungal, and acid fast bacilli cultures
RECOMMENDED READINGS
Phelan DM, Osmon DR, Keating MR, Hanssen AD. Delayed reimplantation arthroplasty for candidal prosthetic joint infection: a report of 4 cases and review of the literature. Clin Infect Dis. 2002 Apr 1;34(7):930-8. Epub 2002 Feb 26. Review. PubMed PMID: 11880958.
Azzam K, Parvizi J, Jungkind D, Hanssen A, Fehring T, Springer B, Bozic K, Della Valle C, Pulido L, Barrack R. Microbiological, clinical, and surgical features of fungal prosthetic joint infections: a multiinstitutional experience. J Bone Joint Surg Am. 2009 Nov;91 Suppl 6:142-9. PubMed PMID: 19884422.
- Figure 253 shows the fracture sustained by an otherwise healthy 61-year-old man who was knocked down by an automobile door that was suddenly opened as he was riding his bicycle. Which treatment will most likely provide him with the best long-term function?
- Hemiarthroplasty
- Total hip arthroplasty
- Open reduction and internal fixation with a blade plate
- Open reduction and internal fixation with a dynamic hip screw
- Closed reduction and percutaneous cannulated screw fixation
- Total hip arthroplasty
RECOMMENDED READINGS
Lee BP, Berry DJ, Harmsen WS, Sim FH. Total hip arthroplasty for the treatment of an acute fracture of the femoral neck: long-term results. J Bone Joint Surg Am. 1998 Jan;80(1):70-5. PubMed PMID: 9469311.
Ricci WM, Langer JS, Leduc S, Streubel PN, Borrelli JJ. Total hip arthroplasty for acute displaced femoral neck fractures via the posterior approach: a protocol to minimize hip dislocation risk. Hip Int. 2011 Jun 8;21(3):344-350. doi: 10.5301/HIP.2011.8401. PubMed PMID: 21698586.
- Figure 259 is the radiograph of an 85-year-old man who had hip arthroplasty 15 years ago. He is now living in a nursing home, ambulating with a walker, and has dementia. During the past 3 months, his hip, which had been previously stable, has dislocated 3 times. What is the most likely cause of the recurrent
dislocations?
- Polyethylene wear
- Small-diameter femoral head
- Damage to the locking mechanism of the liner
- Insufficient anteversion of the acetabular cup
- Failure to comply with hip dislocation precautions
- Polyethylene wear
RECOMMENDED READINGS
Parvizi J, Picinic E, Sharkey PF. Revision total hip arthroplasty for instability: surgical techniques and principles. J Bone Joint Surg Am. 2008 May;90(5):1134-42. Review. PubMed PMID: 18451408.
Pulido L, Restrepo C, Parvizi J. Total hip arthroplasty for instability. Clin Med Res. 2007 Jun;5(2):139-42. PMID 17607050.
von Knoch M, Berry DJ, Harmsn WS, Morrey BF. Late dislocation after total hip arthroplasty. J Bone Joint Surg Am 2002 Nov;84-A(11):1949-53. PubMed PMID: 12429754.
- Figures 272a through 272c are the current radiographs and CT reconstruction scan of a 58-year-old woman who has increasing pain with household ambulation. An intrasurgical video is shown in Figure 272e. After undergoing treatment as seen in Figure 272d, what is the most likely complication?
- Infection
- Instability
- Nonunion
- Aseptic loosening
- Periprosthetic fracture
- Instability
RECOMMENDED READINGS
Taunton MJ, Fehring TK, Edwards P, Bernasek T, Holt GE, Christie MJ. Pelvic discontinuity treated with custom triflange component: a reliable option. Clin Orthop Relat Res. 2012 Feb;470(2):428-34. PubMed PMID: 21997785.
Christie MJ, Barrington SA, Brinson MF, Ruhling ME, DeBoer DK. Bridging massive acetabular defects 27. with the triflange clup: 2- to 9-year results. Clin Orthop Relat Res. 2001 Dec; (393):216- PubMed PMID: 11764351.
