Knee and hip orthopaedics

Question 1

what 2 joints make up the knee

Answer 1

tibiofemoral

patellofemoral

Question 2

lateral and medial menisci are important for what

Answer 2

joint congruence and shock absorption

Question 3

function of ACL

Answer 3

prevents anterior tibial subluxation and internal rotation during extension

Question 4

function of MCL

Answer 4

resists valgus force

Question 5

function of LCL

Answer 5

resists varus force and external rotation

Question 6

function of PCL

Answer 6

prevents hyperextension and posterior tibial translation or anterior femur translation

Question 7

consequence of TKR on a young patient?

Answer 7

may need revision surgery, deemed inferior to primary TKR

Question 8

when is TKR indicated

Answer 8

pain and disability where conservative management ineffective

Question 9

how does a meniscal tear classically occur and which meniscus is it

Answer 9

twisting force on a loaded knee or die to ACL rupture

usually medial

Question 10

what is true knee locking

Answer 10

15 degree spongy block to extension due to bucket handle meniscal tear

Question 11

what is knee pseudolocking

Answer 11

non-meniscal knee injury - temporary difficulty in straightening joint

Question 12

how do degenerate meniscus tears occur

Answer 12

older age, thought to be the first stage of OA

Question 13

what types of meniscal tears should be considered for repair

Answer 13

tears in a younger patient in the outer 1/3

Question 14

when is a partial menisectomy considered

Answer 14

if pain and inflammation from meniscal injury does not settle following injury

Question 15

who is indicated for ACL repair

Answer 15

professional athletes or those whos knees give way on sedentary activity despite physio

Question 16

what causes ACL rupture

Answer 16

high rotational force

Question 17

what causes PCL rupture

Answer 17

direct blow to anterior knee or hyperextension

Question 18

indication for isolated PCL rupture repair

Answer 18

ligament laxity, recurrent hyperextension with instability or unstable descending stairs

Question 19

what causes LCL injury, how is it managed, what type of instability do patients have

Answer 19

varus injury
reconstruction
instability on rotation due to excessive external rotation

Question 20

what causes MCL injury, how is it managed

Answer 20

valgus stress injury

usually well healing, only requires knee brace with little to no instability

Question 21

what happens to see complete knee dislocation

Answer 21

all 4 ligaments would have to rupture

compromised popliteal artery and common fibular artery

Question 22

what must you check following knee dislocation

Answer 22

distal pulses

Question 23

what extensor mechanism tendon is usually ruptured iun <20

Answer 23

patellar tendon

Question 24

what extensor mechanism tendon is usually ruptured in >40

Answer 24

quadriceps tendon

Question 25

risk factors for ruptured extensor mechanism

Answer 25

``` steriods ciprofloxacin chronic renal failure tendinitis diabetes rheumatoid arthritis ```

Question 26

clinical features of patellofemoral dysfunction

Answer 26

``` adolescents pain going downhill grinding/clicking at front of knee anterior knee pain stiffness/pseudolocking in flexed position ```

Question 27

true/false - patellar dislocations are almost always medial

Answer 27

false - theyre almost always lateral

Question 28

risk factors for patellar dislocation

Answer 28

``` ligament laxity females valgus deformity shallow trochlear groove high riding patella femoral neck anteversion ```

Question 29

rule of thirds in ACL rupture?

Answer 29

1/3 compensate 1/3 avoid instability by avoiding activity 1/3 do not compensate with frequent instability

Question 30

what is osteochondritis dissecans

Answer 30

area of surface of joint loses blood supply and piece of bone/cartilage fragments

Question 31

what is bone marrow oedema

Answer 31

impact to articular surface leads to microscopic fracture of trabecular bone with bleeding/inflammation can take months to repair

Question 32

why may a loose body in the knee become a problem and how can it be fixed

Answer 32

may cause painful locking/catching or mobile lump iwth occasional pain may be managed arthroscopically

Question 33

conservative management of knee pain

Answer 33

``` explanation support analgesia short term NSAIDS for flare up support physiotherapy steroid injection for acute referral ```

Question 34

conservative management of hip pain

Answer 34

``` education weight reduction home adaptation stick analgesia NSAIDS physiotherapy complementary medicine mobility allowance, disability badge ```

Question 35

when to refer for hip pain?

Answer 35

``` Pain, and pain at night lost function physical/mental fitness support at home patient expectation age of patient uncertain diagnosis ```

Question 36

3 patterns of hip pain?

Answer 36

pain in groin pain in buttock referred knee pain

Question 37

signs of hip pathology on examination

Answer 37

lost internal rotation leg shortening abductor weakness by +ve trendelenberg exacerbated pain on rotation

Question 38

what are other differentials for groin pain beside hip pathology

Answer 38

hernia tendonitis high lumbar disc prolapse pubic symphysis dysfunction

Question 39

how long does a THA/THR last

Answer 39

cup last 15 years and ball 20

Question 40

what determines whether someone needs THR

Answer 40

levels of pain and disability failing conservative management

Question 41

conservative measures for hip pain/disability

Answer 41

``` analgesia physiotherapy use of stick weight reduction activity modification ```

Question 42

early local THR complications

Answer 42

infection dislocation leg length discrepancy nerve injury

Question 43

early general THR complications

Answer 43

``` chest infection MI Hypovolaemia/blood loss Cardiac arrest DVT/PE UTI ```

Question 44

late local THR complications

Answer 44

dislocation late infection early loosening

Question 45

why are hip revision surgeries more difficulty

Answer 45

higher blood loss more complicated poorer outcome dont last as long

Question 46

why should you delay a young person getting a THR

Answer 46

theyll need a revision surgery

Question 47

risk factors/epidemiology for AVN

Answer 47

``` males 35-50 alcohol abuse steroids thrombophilia hyperlipidaemia decompression sickness ```

Question 48

how is AVN managed if detected early?

Answer 48

drill holes up femoral neck and head to relieve pressure and to promote healing and prevent collapse

Question 49

what can you do with the hip once avascular necrosis has occurred

Answer 49

replace it with THR

Question 50

how does AVN appear on X ray

Answer 50

patchy sclerosis of weight bearing femoral head with a lytic zone beneath "hanging rope sign"

Question 51

what is gluteal cuff syndrome/trochanteric bursitis

Answer 51

tendinous insertion of gluteal muscles in greater trochanter is subject to tendonitis trochanteric bursa may become inflamed

Question 52

what primary and secondary factors may lead to knee osteoarthritis

Answer 52

``` obesity older age genetics work/hobbies meniscal tear trauma ACL rupture malalignment heavy workload ```

Question 53

when would TKR be considered in a patient

Answer 53

in pain or disability refractory to conservative management constant pain and limited walking sleep disturbance frequent flare up

Question 54

true/false - 10% of patients who have a TKR have unexplained pain and these patients are usually older

Answer 54

false - 20% do and patients are usually younger, obese, chronic pain syndrome, mild OA in original joint, psychological distress

Question 55

what is the satisfaction rate of a TR and how long would you expect it to last in an ideal patient

Answer 55

expected to last 15-20 years | 75-80% satisfaction

Question 56

true/false - sport and heavy work may cause TKR to loosen and fial sooner than expected

Answer 56

true

Question 57

true/false - revision is a more complex surgery but works just as well as TKR

Answer 57

no, it is way more complicated and doesnt work nearly as well

Question 58

what are surgical options in a failed TKR revision

Answer 58

fusion | amputation

Question 59

in patients with chronic pain following TKR, would redoing the TKR be expected to work?

Answer 59

no

Question 60

alternatives to TKR

Answer 60

unicompartmental knee replacement for heavily affected and localised OA of the knee, reop rate is high osteotomy for younger patients who would trash a TKR, unfavoured

Question 61

when would you offer a clean out surgery for the knee

Answer 61

never, ever

Question 62

presentation of avascular necrosis

Answer 62

insidious onset groin pain exacerbated by stairs/impact normal examination

Question 63

conservative management of avascular necrosis

Answer 63

bisphosphonates with core decompression

Question 64

who is trochanteric bursitis more common in

Answer 64

runners | women

Question 65

presentation of trochanteric bursitis?

Answer 65

pain on lateral aspect of hip and greater trochanter

Question 66

management of trochanteric bursitis

Answer 66

analgesia NSAIDs physiotherapy steroid injection

Question 67

causes of OA of the hip

Answer 67

``` DDH SUFE Septic arthritis FAI Trauma AVN primary ```

Question 68

presentation of OA of hip

Answer 68

``` groin pain worse on activity pain at night stiff ROM start up pain ```

Question 69

what is CAM femoroacetabular impingement syndrome, who is is more common in

Answer 69

femoral deformity with asymmetric head and decreased head/neck ratio usually young and athletic males and may be related to previous SUFE

Question 70

what is pincer femoroacetabular impingement syndrome and who is it more common in

Answer 70

acetabular deformity with overhang | more common in females

Question 71

what actions cause pain in femoroacetabular impingement syndrome

Answer 71

flexion, adduction, internal rotation

Question 72

presentation of FA impingement syndrome

Answer 72

activity related pain in groin difficulty sitting C sign positive FADIR provocation positive

Question 73

management of FA impingement syndrome

Answer 73

observe if incidental manage conservatively arthroscopic/open removal of CAM or debride labral tears/osteotomy arthroplasty in older patients