TKR 2007

1.
A patient is scheduled to undergo total knee arthroplasty (TKA) following failure of

nonsurgical management. History reveals that she underwent a patellectomy as a
teenager as the result of a motor vehicle accident. Examination reveals normal
ligamentous stability. For the most predictable outcome, which of the following implants
should be used?
1- Mobile-bearing knee
2- Posterior cruciate ligament-sparing knee
3- Posterior cruciate ligament-substituting knee
4- Semiconstrained-style knee
5- Triaxial hinged knee
PREFERRED RESPONSE: 3
DISCUSSION: Paletta and Laskins performed a retrospective study of the results of TKA with
cement in 22 patients who had a previous patellectomy. Nine of the patients had insertion of a
posterior cruciate ligament-substituting implant. Thirteen patients had insertion of a posterior
cruciate ligament-sparing implant. The 5-year postoperative knee scores were 89 for the
posterior cruciate ligament-substituting knee versus 67 for the posterior cruciate
ligament-sparing knee (P < 0.01). The patella functions to increase the lever arm of the extensor
mechanism and to position the quadriceps tendon and the patellar ligament roughly parallel to
the anterior cruciate ligament and posterior cruciate ligament, respectively. The patellar
ligament thereby provides a strong reinforcing structure that functions to prevent excessive
anterior translation of the femur during flexion of the knee. The absence of the patella results in
the patellar ligament and the quadriceps tendon being relatively in line with one another. After a
patellectomy, the resultant quadriceps force is no longer parallel to the posterior cruciate
ligament. This results in loss of the reinforcing function of the patellar ligament. The authors
believe this loss of reinforcing function may place increased stresses on the posterior cruciate
ligament and posterior aspect of the capsule, which may result in stretching of these structures
over time. They found a high rate of anteroposterior instability, a high prevalence of recurvatum,
and a high rate of loss of full active extension compared with passive extension in the posterior
cruciate ligament-sparing group, which supports their theory.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American

Academy of Orthopaedic Surgeons, 1999, pp 559-582.
Paletta GA Jr, Laskins RS: Total knee arthroplasty after a previous patellectomy. J Bone Joint
Surg Am 1995;77:1708-1712.
2. Figure 1 shows the radiograph of a patient who underwent a total knee revision with a
posterior stabilized mobile-bearing prosthesis and now has recurrent knee dislocations.
What is the most likely cause?
1- Loose extension gap

2- Loose flexion gap
3- Malrotation of the tibial component
4- Malrotation of the femoral component
5- Poor prosthetic design
DISCUSSION: The patient has a posterior stabilized total knee revision, and the femoral
component has dislocated over the tibial polyethylene cam/post. This usually indicates a loose
flexion gap, or “flexion instability.” A loose flexion gap can occur due to undersizing of the
femoral component, anteriorization of the femoral component, excessive distal augmentation of
the distal femur, or collateral ligament insufficiency, especially if combined with posterior
capsular insufficiency. Isolated laxity of the extension gap (with a well-balanced flexion gap)
causes varus/valgus instability, but it rarely causes the femoral component to “jump” the tibial
cam of a posterior stabilized tibial insert. Malrotation of the components may cause patellar
instability or a rotational instability of the tibiofemoral joint but should not cause a frank
posterior dislocation of the tibia, unless combined with other errors of balancing. Although a
mobile-bearing total knee arthroplasty may be more sensitive to errors in balancing than a
fixed-bearing total knee arthroplasty, this complication does not reflect a faulty prosthetic design.
REFERENCES: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip
and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000,
pp 339-365.
Lotke PA, Garino JP: Revision Total Knee Arthroplasty. New York, NY, Lippincott-Raven,
1999, pp 173-186, 227-249.
Clarke HD, Scuderi GR: Flexion instability in primary total knee replacement. J Knee Surg
2003;16:123-128.
3. A metal-on-metal bearing used for total hip arthroplasty shows which of the
following properties?
1- Baseline serum ion levels increase with increasing activity levels.

2- The risk of cancer is substantially increased.
3- Linear ion production increases over time.
4- Ions produced are excreted primarily through the kidney.
5- Nickel is the most prevalent ion released into circulation.
DISCUSSION: Activity levels do not affect cobalt and chromium ion levels, which are the bulk
of serum ion levels. The majority of ions are produced in the run-in period in the first several
years. A gradual reduction in ion levels occurs thereafter. The kidneys are responsible for the
bulk of clearance from the serum, and to date there is no relationship of cancer to ion levels in
the serum.
REFERENCE: Heisel C, Silva M, Skipor AK, et al: The relationship between activity and ions in
patients with metal-on-metal bearing hip prostheses. J Bone Joint Surg Am 2005;87:781-787.
4. Which of the following treatment regimens for thromboembolic prophylaxis meets the
American College of Chest Physicians Guidelines for 10-day treatment after total hip
arthroplasty and total knee arthroplasty?
1- Low-molecular-weight heparin
2- Adjusted dose unfractionated heparin
3- Aspirin
4- Warfarin, INR 1.5 to 2.0
5- Elastic compressive stockings
DISCUSSION: Only three thromboembolic treatment protocols have reached Grade 1A status
for the American College of Chest Physicians Guidelines for thromboembolic prophylaxis after
total hip arthroplasty and total knee arthroplasty. Grade 1A evidence shows a clear benefit/risk
improvement with supportive data from randomized clinical trials, which are strongly applicable
in most clinical circumstances. Warfarin is recommended but at an INR level of 2 to 3.
Low-molecular-weight heparin and fondaparinox are also acceptable treatment options. Aspirin,
adjusted dose unfractionated heparin, and elastic compressive stockings are not recommended as
stand-alone options.
REFERENCES: Colwell C: Evidence based guidelines for prevention of venous

thromboembolism: Symposia. Proceedings of the 2005 AAOS Annual Meeting. Rosemont, IL,
American Academy of Orthopaedic Surgeons, 2005, pp 15-18.
Freedman KB, Brookenthal KR, Fitzgerald RH, et al: A meta-analysis of thromboembolic
prophylaxis following elective total hip arthroplasty. J Bone Joint Surg Am 2000;82:929-938.
5. Figures 2a and 2b show the radiographs of a 72-year-old man with aseptic loosening of
the tibial component of his total knee arthroplasty. Optimal management should include
1- tibial revision only, without stems or augmentations.

2- tibial revision only, with stems and augmentations.
3- revision of the tibial and femoral components, without stems or augmentations.
4- revision of the tibial and femoral components, with stems and augmentations.
5- primary arthrodesis.
DISCUSSION: The radiographs show massive subsidence of the lateral side of the tibia with
severe tibial bone loss and a fractured proximal fibula. Reconstruction should consist of a large
metal or bony lateral tibial augmentation, and a stem long enough to bypass the defect is
required. The femoral and tibial components are articulating without any remaining
polyethylene medially; therefore, the femoral component is damaged and needs revision.
The insertions of the lateral ligaments are absent, thereby rendering the lateral side of the knee
predictably unstable. Also, the large valgus deformity compromises the medial collateral
ligament. The posterior cruciate ligament is also likely to be deficient with this much tibial bone
destruction. The patient requires a posterior stabilized femoral component at the minimum, and
possibly a constrained femoral component. Retention of the femoral component, even though it
may be well-fixed, jeopardizes the outcome.
REFERENCES: Lotke PA, Garino JP: Revision Total Knee Arthroplasty. New York, NY,
Lippincott-Raven, 1999, pp 137-250.
Insall JN, Windsor RE, Scott WN, et al: (eds): Surgery of the Knee, ed 2. New York, NY,
Churchill Livingstone, 1993, pp 935-957.
Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee
Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000,
pp 339-365.
6. Which of the following factors is responsible for causing the distal femur to pivot about a
medial axis as the knee moves from full extension into early flexion?
1- Differential forces generated from the vastus lateralis and vastus medialis
2- Differential tension within the bundles of the posterior cruciate ligament
3- Differential radius of curvature between the medial and lateral femoral condyles
4- Asymmetry of the tibial tubercle on the anterior surface of the tibia
5- Asymmetric forces generated from the uneven patellar facets
DISCUSSION: The radius of curvature of the distal femur is greater over the distal aspect of the
lateral femoral condyle than the distal aspect of the medial femoral condyle. As the femur rolls
posteriorly during early knee flexion, both condyles undergo similar angular changes equal to the
amount of flexion. With a similar amount of angular rotation, the sphere with the larger radius
experiences greater net rollback, producing a pivoting motion. Although the anterior cruciate
ligament plays a role in producing tibial rotations, the posterior cruciate ligament does not play a
significant role in producing such rotations. Similarly, the tibial tubercle does not play a
significant role in producing normal rotations of the femur relative to the tibia. The popliteus
may also play a role in producing rotational pivots, as might differential laxity of the medial and
lateral collateral ligaments in early knee flexion.
REFERENCES: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update:
Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons,
2000, pp 239-240.
Insall JN, Windsor RE, Scott WN, et al (eds): Surgery of the Knee, ed 2. New York, Churchill
Livingstone, 1993, pp 1-13.
7. Figure 3 shows the AP radiograph of a patient with diabetes mellitus who has knee pain.
A semiconstrained knee prosthesis was used in this patient to prevent which of the
following complications?
1- Infection
2- Instability
3- Stiffness
4- Bone loss
5- Malalignment
DISCUSSION: The radiographic appearance of the joint is highly suspicious for neuropathic
joint (Charcot’s joint). Evidence of bone loss on both the tibial and the femoral sides may
necessitate the use of metal and/or bone augments. Patients with a neuropathic joint often have
excellent range of motion, and postoperative stiffness is not a problem. The main problem with
these patients is instability that occurs secondary to ligamentous laxity. Use of a
semiconstrained prosthesis prevents the latter complication.
REFERENCES: Parvizi J, Marrs J, Morrey BF: Total knee arthroplasty for neuropathic
(Charcot) joints. Clin Orthop 2003;416:145-150.
Kim YH, Kim JS, Oh SW: Total knee arthroplasty in neuropathic arthropathy. J Bone Joint
Surg Br 2002;84:216-219.
8. Based on the radiograph shown in Figure 4, the innervation of what muscle is most at risk
with total hip arthroplasty?
1- Quadriceps
2- Extensor hallucis longus
3- Lateral gastrocnemius
4- Adductor magnus
5- Semitendinosus
DISCUSSION: The radiograph reveals a Crowe IV deformity in a patient with developmental

dysplasia of the hip. If hip arthroplasty is performed, then some degree of limb lengthening is
anticipated. Excessive limb lengthening can result in sciatic nerve palsy in these patients. The
peroneal branch of the sciatic nerve is most often affected. Of the muscles listed, only the
extensor hallucis longus is innervated by the peroneal branch of the sciatic nerve.
REFERENCES: Eggli S, Hankemayer S, Muller ME: Nerve palsy after leg lengthening in total
replacement arthroplasty for developmental dysplasia of the hip. J Bone Joint Surg Br
1999;81:843-845.
Schmalzried TP, Amstutz HC, Dorey FJ: Nerve palsy associated with total hip replacement:
Risk factors and prognosis. J Bone Joint Surg Am 1991;73:1074-1080.
9. A 75-year-old woman who fell on her right knee now reports pain and is unable to bear
weight. History reveals that she underwent total knee arthroplasty on the right knee
6 years ago. Radiographs are shown in Figure 5. Management should now consist of
1- closed reduction and casting for 6 weeks.

2- open reduction and internal fixation, using a locked intramedullary rod.
3- open reduction and internal fixation, using two cancellous screws.
4- open reduction and internal fixation, using a locked plate and screws.
5- open reduction and internal fixation and revision of the femoral component.
DISCUSSION: The radiographs show a loose femoral component with an associated medial
condyle distal femoral fracture. The treatment of choice is open reduction and internal fixation
with revision of the femoral component because of the femoral component loosening.
REFERENCES: Moran MC, Brick GW, Sledge CB, et al: Supracondylar femoral fracture
following total knee arthroplasty. Clin Orthop 1996;324:196-209.
McLaren AC, DuPont JA, Schroeber DC: Open reduction internal fixation of supracondylar
fractures above total knee arthroplasties using the intramedullary supracondylar rod. Clin
Orthop 1994;302:194-198.
Figgie MP, Goldberg VM, Figgie HE III, et al: The results of treatment of supracondylar fracture
above total knee arthroplasty. J Arthroplasty 1990;5:267-276.
10. Which of the following nutraceuticals has been associated with perioperative bleeding?
1- Glucosamine
2- Chondroitin sulfate
3- Ginseng
4- Nitric oxide
5- Ginkgo biloba
DISCUSSION: Ginkgo biloba is a popular nutraceutical for patients who have early dementia,
intermittent claudication secondary to peripheral vascular disease, vertigo, and tinnitus. It is
reported to improve mental alertness and cognitive deficiency. It has antiplatelet properties as a
result of one of its components, ginkgolide B, which displaces platelet-activating factor from its
receptor binding sight. Rowin and Lewis reported on spontaneous bilateral subdural hematomas
associated with chronic ginkgo biloba ingestion. Vale also reported on subarachnoid
hemorrhage associated with ginkgo biloba. Bebbington and associates reported on persistent
postoperative bleeding after total hip arthroplasty secondary to ginkgo biloba usage.
Furthermore, the use of ginkgo biloba with aspirin or other antiplatelet agents or anticoagulants
represents a relative contraindication. Physicians should be aware not only of prescribed
medications but also alternative nutraceuticals that are used by the patient.
REFERENCES: Rowin J, Lewis SL: Spontaneous bilateral subdural hematomas associated with
chronic ginkgo biloba ingestion. Neurology 1996;46:1775-1776.
Vale S: Subarachnoid hemorrhage associated with ginkgo biloba. Lancet 1998;352:36.
Bebbington A, Kulkarni R, Roberts P: Ginkgo biloba: Persistent bleeding after total hip
arthroplasty caused by herbal self-medication. J Arthroplasty 2005;20:125-126.
11. A 64-year-old man undergoes a primary total knee arthroplasty. Three months after
surgery he reports persistent pain, weakness, and difficulty ambulating. Postoperative
radiographs are shown in Figures 6a through 6c. What is the best course of action at
this time?
1- Hinged knee brace

2- Patellar component revision with a tantalum implant and lateralization of the
patella
3- Revision knee arthroplasty with greater internal rotation of the tibial component
4- Revision total knee arthroplasty with a lateral release and external rotation of the
femoral component
5- Revision total knee arthroplasty with a lateral release and internal rotation of the
femoral component
DISCUSSION: The Merchant view reveals subluxation of the patellar component. The etiology
of maltracking of the patella includes internal rotation of the femoral component, internal
rotation of the tibial component, excessive patellar height, and lateralization of the patella
component. The treatment of choice in this patient is revision total knee arthroplasty with
external rotation of the femoral component. Preoperatively the patient also may require a lateral
release, revision of the tibial component if it is internally rotated, and possibly a soft-tissue
realignment. Component malalignment needs to be addressed first.
REFERENCES: Kelly MA: Extensor mechanism complications in total knee arthroplasty.

Instr Course Lect 2004;53:193-199.
Malkani AL, Karandikar N: Complications following total knee arthroplasty. Sem Arthroplasty
2003;14:203-214.
Norman AJ, Scott S, David GN (eds): Master Techniques in Knee Arthroplasty, ed 2.
Philadelphia, PA, Lippincott Williams & Wilkins, 2003.
12. Compared to metal-on-polyethylene total hip bearing surfaces, the debris particles
generated by metal-on-metal articulations are
1- larger and less numerous.

2- larger and more numerous.
3- smaller and less numerous.
4- smaller and more numerous.
5- not detectable.
DISCUSSION: Retrieval studies have shown that the debris particles produced by
metal-on-metal articulations in total hip arthroplasty are several orders of magnitude smaller
and may be up to 100 times more numerous than those found with metal-on-polyethylene
articulations.
REFERENCES: Davies AP, Willert HG, Campbell PA, et al: An unusual lymphocytic
perivascular infiltration in tissues around contemporary metal-on-metal joint replacements.
J Bone Joint Surg Am 2005;87:18-27.
Firkins PJ, Tipper JL, Saadatzadeh MR, et al: Quantitative analysis of wear and wear debris from
metal-on-metal hip prostheses tested in a physiological hip joint simulator. Biomed Mater Eng
2001;11:143-157.
13. A 60-year-old patient had the procedure shown in Figure 7 performed 5 years ago. When
converting this patient to a total knee arthroplasty (TKA), what patellar problem is
commonly encountered intraoperatively?
1- Fracture
2- Patella baja
3- Patella alta
4- Osteonecrosis
5- Maltracking
DISCUSSION: Patella baja is commonly encountered when converting a high tibial osteotomy
(HTO) to a TKA. Patella baja most likely occurs because of scarring. Meding and associates’
study did not show an increased rate of lateral release when converting a knee that had
undergone a previous HTO.
REFERENCES: Yoshino N, Shinro T: Total knee arthroplasty after failed high tibial osteotomy,
in Callaghan JJ, Rosenberg AG, Rubash HE, et al (eds): The Adult Knee. Philadelphia, PA,
JB Lippincott, 2003, vol 2, pp 1265-1271.
Meding JB, Keating EM, Ritter MA, et al: Total knee arthroplasty after high tibial osteotomy:
A comparison study in patients who had bilateral total knee replacement. J Bone Joint Surg Am
2000;82:1252-1259.
14. Antibiotic-loaded bone cement prostheses, such as that shown in Figure 8, are best
created by using which of the following methods?
1- Using commercially available antibiotic-loaded bone cement

2- Adding 0.5 g vancomycin to commercially available antibiotic-loaded bone
cement
3- Adding 0.5 g tobramycin and 0.5 g vancomycin/unit of standard bone cement
4- Adding either 1.0 g vancomycin or 1.2 g tobramycin per 40 g of standard bone
cement
5- Adding a minimum of 3.6 g tobramycin and 1.0 g vancomycin per 40 g of bone
cement
DISCUSSION: In a review of the practical applications of antibiotic-loaded bone cement for the
treatment of the infected total joint arthroplasties, Hanssen and Spangehl described commercially
available antibiotic-loaded bone cement as low-dose antibiotic cements. These cements
generally contained 0.5 g of either tobramycin or gentamicin per 40 g of cement. They are
indicated for use in prophylaxis and not for treatment of infected total joint arthroplasties.
High-dose antibiotic-loaded bone cements are described as those containing greater than 1.0 g of
antibiotic per 40 g of cement. Effective elution levels have been documented with 3.6 g
tobramycin and 1.0 g vancomycin per 40 g of bone cement. This was documented by Penner
and associates. Furthermore, it was shown that the combination of the two antibiotics in the
bone cement improved the elution of both antibiotics.
REFERENCES: Hanssen AD, Spangehl MJ: Practical applications of antibiotic-loaded bone

cement for treatment of infected joint replacements. Clin Orthop 2004;427:79-85.
Penner MJ, Masri BA, Duncan CP: Elution characteristics of vancomycin and tobramycin
combined in acrylic bone-cement. J Arthroplasty 1996;11:939-944.
15. Figures 9a and 9b show the radiographs of a 75-year-old man who underwent a revision
total knee arthroplasty with a long-stemmed tibial component. In rehabilitation, he
reports fullness and tenderness in the proximal medial leg (at the knee). The strategy that
would best limit this postoperative problem is use of
1- a base plate with an offset tibial stem attachment.

2- a bone ingrowth surface on the augment.
3- a nonstemmed tibial base plate.
4- allograft bone instead of metal augments.
5- bone cement to smooth the outline of the proximal medial tibia.
DISCUSSION: The problem with this reconstruction is the medial protrusion of the base plate.
The use of a base plate with an offset stem can prevent the protrusion and thus the impingement
and pain. Allograft bone or smoothing the outline with cement would be just as prominent and
likely to cause pain. An ingrowth surface may improve soft-tissue attachment but would still
leave the implant protruding medially and likely to cause pain. A nonstemmed tibial base plate
would lead to less medial protrusion but at the expense of a smaller area for load carriage on the
proximal tibia.
REFERENCE: Gustke K: Cemented tibial stems are not requisite in revision. Orthopedics
2004;27:991-992.
16. Figure 10 shows the AP radiograph of an ambulatory 76-year-old patient. What is the
most appropriate surgical treatment option for this patient?
1- Revision arthroplasty using a cemented femoral component

2- Impaction allografting of the femoral component
3- Proximal femoral replacement arthroplasty
4- Resection arthroplasty
5- Hip arthrodesis
DISCUSSION: The patient has a periprosthetic fracture around a loose cemented femoral
component. The proximal bone stock is poor; therefore, this fracture may be categorized as
Vancouver 3-B. Hip arthrodesis and resection arthroplasty provide suboptimal results,
particularly for ambulatory patients. Although impaction allografting may be an option to
restore the bone stock in a younger patient, the latter procedure will be very difficult to perform
when the proximal bone is poor in quality and fractured. Cementing another component into this
wide femur is not an option. The best option for revision of the femoral component in this
elderly patient is proximal femoral replacement arthroplasty.
REFERENCES: Malkani AL, Settecerri JJ, Sim FH, et al: Long-term results of proximal femoral
replacement for non-neoplastic disorders. J Bone Joint Surg Br 1995;77:351-356.
Parvizi J, Sim FH: Proximal femoral replacements with megaprostheses. Clin Orthop
2004;420:169-175.
17. A 74-year-old woman has had acute medial right knee pain for the past 3 months. She
denies any history of trauma or previous problems. Coronal and sagittal MRI scans are
shown in Figures 11a and 11b. What is the most likely diagnosis?
1- Osteoarthritis
2- Rheumatoid arthritis
3- Medial meniscal tear
4- Osteonecrosis
5- Transient osteoporosis
DISCUSSION: Spontaneous osteonecrosis of the medial femoral condyle is seen in the MRI
scans, and is most common in women older than age 60 years. Although usually present in the
weight-bearing portion of the medial femoral condyle, spontaneous osteonecrosis has also been
described involving the lateral femoral condyle and patella. Most patients are seen postcollapse,
and the treatment of choice is arthroplasty. Optimal treatment in precollapse stages is
controversial.
REFERENCES: Kidwai AS, Hemphill SD, Griffiths HJ: Spontaneous osteonecrosis of the knee
reclassified as insufficiency fracture. Orthopedics 2005;28:236,333-336.
Soucacos PN, Xenakis TH, Beris AE, et al: Idiopathic osteonecrosis of the medial femoral
condyle: Classification and treatment. Clin Orthop 1997;341:82-89.
Yamamoto T, Bullough PG: Spontaneous osteonecrosis of the knee: The result of subchondral
insufficiency fracture. J Bone Joint Surg Am 2000;82:858-866.
18. Patients with patellar clunk syndrome are best managed by which of the
following methods?
1- Rest and nonsteroidal anti-inflammatory drugs

2- Surgical debridement
3- Patellectomy
4- Patellar revision
5- Lateral release/patellar realignment
DISCUSSION: Patellar clunk syndrome is usually the result of a fibrous nodule that forms on
the undersurface of the distal quadriceps tendon. It may get entrapped in the intercondylar notch
of the femoral component during flexion, and lead to a sudden snap as the nodule is pulled out of
the notch during active extension. Nonsurgical management is rarely successful. Surgical
debridement is usually curative, with only rare recurrence. More aggressive procedures such as
realignment, revision, or patellectomy are usually not necessary, and are reserved for cases
resistant to soft-tissue debridement.
REFERENCES: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update:
2000, p 329.
Diduch DR, Scuderi GR, Scott WN, et al: The efficacy of arthroscopy following total knee
replacement. Arthroscopy 1997;13:166-171.
Lucas TS, DeLuca PF, Nazarian DG, et al: Arthroscopic treatment of patellar clunk. Clin Orthop
1999;367:226-229.
19. Increasing articular conformity of the tibial polyethylene insert of a fixed-bearing
total knee arthroplasty (TKA) prosthesis will have which of the following
biomechanical effects?
1- Decreased contact stress within the polyethylene

2- Decreased risk of patellofemoral instability
3- Decreased risk of mechanical loosening
4- Increased risk of subsurface polyethylene cracking
5- Increased tibial rollback during flexion
DISCUSSION: Increasing articular conformity increases the surface area for contact between the
polyethylene and the femoral component. Advantages of this include lower peak contact stress
within the polyethylene and less risk of polyethylene fatigue failure. Patellofemoral tracking is
unchanged by increasing conformity unless gross component apposition is present. A potential
disadvantage of increasing conformity includes some restriction in tibial rollback. Modest
changes in conformity have not been shown to alter the rate of mechanical loosening. If
conformity was increased to the extent of significant constraint, a potential increased risk of
loosening would be expected, not a decrease. Design of modern TKAs includes a compromise in
achieving enough constraint to lower polyethylene stress, without providing so much constraint
as to limit kinematics and stress the fixation interfaces.
REFERENCES: D’Lima DD, Chen PC, Colwell CW Jr: Polyethylene contact stresses, articular
congruity, and knee alignment. Clin Orthop 2001;392:232-238.
Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee
pp 265-274.
20. A 63-year-old woman reports giving way of the knee and pain after undergoing primary
total knee arthroplasty (TKA) 1 year ago. Examination reveals that the knee is stable in
full extension but has gross anteroposterior instability at 90 degrees of flexion. The
patient can fully extend her knee with normal quadriceps strength. Studies for infection
are negative. AP and lateral radiographs are shown in Figures 12a and 12b, respectively.
What is the appropriate management?
1- Anti-inflammatory drugs
2- Knee brace
3- Physical therapy for quadriceps strengthening
4- Revision to a thicker polyethylene insert
5- Revision to a larger, posterior stabilized implant
DISCUSSION: The radiographs show posterior flexion instability that is the result of a
flexion-extension gap imbalance and posterior cruciate ligament incompetence after a posterior
cruciate ligament-retaining TKA. The femur is anteriorly displaced on the tibia, with lift-off of
the femoral component from the tibial polyethylene. Revision to a larger femoral component
will address the larger flexion gap relative to the extension gap, and a posterior stabilized implant
will address the posterior cruciate ligament insufficiency. Pagnano and associates, reporting on a
series of painful TKAs previously diagnosed as pain of unknown etiology, showed that the pain
was secondary to flexion instability. Pain relief was achieved by revision to a posterior
stabilized implant.
REFERENCES: Pagnano MW, Hanssen AD, Lewallen DG, et al: Flexion instability after
primary posterior cruciate retaining total knee arthroplasty. Clin Orthop 1998;356:39-46.
Fehring TK, Valadie AL: Knee instability after total knee arthroplasty. Clin Orthop
1994;299:157-162.
Fehring TK, Odum S, Griffin WL, et al: Early failures in total knee arthroplasty. Clin Orthop
2001;392:315-318.
21. A 72-year-old woman who underwent right total hip arthroplasty 7 years ago now
reports right hip pain and limb shortening. Studies for infection are negative. AP
and lateral radiographs are shown in Figures 13a and 13b. What is the most
appropriate management?
1- Observation only
2- Nonsteroidal anti-inflammatory drugs and protected weight bearing
3- Revision of the acetabular component with a jumbo cup with screws
4- Revision of the acetabular component with a reinforcement cage and bone
grafting
DISCUSSION: Current literature supports the use of reinforcement cages for the reconstruction
of failed, loosened acetabular components associated with major bone loss as seen in this patient.
Although results of revision using the so-called jumbo cup with screws generally have been
good, the amount of bone loss and medial wall penetration shown here and the likelihood of
pelvic discontinuity precludes the use of that technique. With either technique, bone grafting of
remaining defects is recommended.
REFERENCES: Sporer SM, O’Rourke M, Paprosky WG: The treatment of pelvic discontinuity
during acetablular revision. J Arthroplasty 2005;20:79-84.
Paprosky WG, O’Rourke M, Sporer SM: The treatment of acetabular bone defects with an
associated pelvic discontinuity. Clin Orthop 2005;441:216-220.
22. What is the most prevalent adverse event associated with allogeneic blood transfusion?
1- Clerical error leading to transfusion reaction

2- Anaphylactic reaction
3- HIV transmission
4- Hepatitis C transmission
5- Bacterial contamination leading to sepsis/shock
DISCUSSION: Clerical error leading to acute hemolysis and even death occurs in 1:12,000 to
1:50,000 transfusions. Bacterial contamination leading to sepsis/shock occurs in 1:1 million
transfusions. HIV transmission is approximately 1:500,000 transfusions and hepatitis C is
1:103,000 transfusions. Anaphylactic reactions occur in 1:150,000 transfusions.
REFERENCES: Aubuchon JP, Birkmeyer JD, Busch MP: Safety of the blood supply in the
United States: Opportunities and controversies. Ann Intern Med 1997;127:904-909.
Popovsky MA, Whitaker B, Arnold NL: Severe outcomes of allogeneic and autologous blood
donation: Frequency and characterization. Transfusion 1995;35:734-737.
23. At the time of the revision surgery shown in Figure 14, the acetabular component was
found to be stable. Polyethylene exchange with a standard ultra-high molecular weight
polyethylene liner and grafting was performed. The patient is at significantly increased
risk for
1- loosening of the femoral component.

2- loosening of the acetabular component.
3- prosthetic hip dislocation.
4- rapid wear of the polyethylene.
5- continued expansion of the lytic defects.
DISCUSSION: Maloney and associates reported a 35% increased risk of pelvic osteolysis after
total hip arthroplasty with a porous-coated acetabular component without cement. All
components were stable at the time of revision. Only liners were exchanged and debridement of
the granuloma with or without bone graft was performed. No defects progressed and one third of
the lesions were no longer visible on radiographs, regardless of bone grafting. Unfortunately,
despite the technical ease of many of these types of revisions, the dislocation rate for these cases
is significant. Precautions should be taken postoperatively, and patients should be educated
about this risk preoperatively.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American

Boucher HR, Lynch C, Young AM, et al: Dislocation after polyethylene liner exchange in total
hip arthroplasty. J Arthroplasty 2003;18:654-657.
Maloney WJ, Herzwurm P, Paprosky W, et al: Treatment of pelvic osteolysis associated with a
stable acetabular component inserted without cement as part of a total hip replacement. J Bone
Joint Surg Am 1997;79:1628-1634.
24. What is the most frequent complication of both lateral closing wedge high tibial
osteotomy and medial opening wedge osteotomy?
1- Patella baja
2- Fracture
3- Peroneal nerve palsy
4- Compartment syndrome
5- Infection
DISCUSSION: Scuderi and associates reported on patellar height after a high tibial osteotomy.
Eighty-nine percent of the patellae, as measured by the Insall-Salvati index, and 76.3 percent, as
measured by the Blackburne-Peel index, were observed to be lowered. More recently, Wright
and associates reported a 64% incidence of patella baja in patients undergoing a medial opening
wedge osteotomy. The incidence of intra-articular fracture during medial opening wedge
osteotomy has been reported to be as high as 11% by Hernigou and associates, whereas the
incidence of intra-articular fracture during lateral closing wedge high tibial osteotomy has been
reported to be 10% to 20% by Matthews and associates. The incidence of peroneal nerve palsy
with a lateral closing wedge high tibial osteotomy ranges from 0% to 20%, according to Marti
and associates, whereas the incidence of peroneal palsy following a medial opening wedge
osteotomy has been reported to be 15.7% by Flierl and associates. The exact incidence of
compartment syndrome after a high tibial osteotomy is not known; however, it does not reach the
level of patella baja. The incidence of deep infection after a lateral closing wedge high tibial
osteotomy ranges from 0% to 4% according to Billings and associates.
REFERENCES: Scuderi GR, Windsor RE, Insall JN: Observations on patellar height after
proximal tibial osteotomy. J Bone Joint Surg Am 1989;71:245-248.
Wright JM, Crockett HC, Slawski DP, et al: High tibial osteotomy. J Am Acad Orthop Surg
2005;13:279-289.
Hernigou P, Medevielle D, Debeyre J, et al: Proximal tibial osteotomy for osteoarthritis
with varus deformity: A ten to thirteen-year follow-up study. J Bone Joint Surg Am
1987;69:332-354.
Matthews LS, Goldstein SA, Malvitz TA, et al: Proximal tibial osteotomy: Factors that influence
the duration of satisfactory function. Clin Orthop 1988;229:193-200.
Marti CB, Gautier E, Wachtl SW, et al: Accuracy of frontal and sagittal plane correction in open-
wedge high tibial osteotomy. Arthroscopy 2004;20:366-372.
Marti RK, Verhigan RA, Kerkhoffs GM, et al: Proximal tibial varus osteotomy: Indications,
technique, and five to twenty-one-year results. J Bone Joint Surg Am 2001;83:164-170.
Flierl S, Sabo D, Hornig K, et al: Open wedge high tibial osteotomy using fractioned drill
osteotomy: A surgical modification that lowers the complication rate. Knee Surg Sports
Traumatol Arthrosc 1996;4:149-153.
Billings A, Scott DF, Camargo MP, et al: High tibial osteotomy with a calibrated osteotomy
guide, rigid internal fixation, and early motion: Long-term follow-up. J Bone Joint Surg Am
2000;82:70-79.
25. Stiffness can occur following total knee arthroplasty. What is the most appropriate
management for a patient who has deteriorating arc of motion after undergoing a revision
knee arthroplasty 9 months ago?
1- Aggressive physical therapy

2- Manipulation under anesthesia
3- Investigation for periprosthetic infection
4- Revision knee arthroplasty
DISCUSSION: Stiffness following total knee arthroplasty can be a disabling condition. There
are many reasons for loss of knee motion following total knee arthroplasty. Technical errors,
such as overstuffing of the patella, malpositioning of the components, and ligamentous
imbalance, are all known to result in stiffness following total knee arthroplasty. In some patients
with a possible genetic predisposition, aggressive arthrofibrosis may develop and result in loss of
knee motion. In any patient who has deteriorating knee motion, particularly after revision
arthroplasty, deep infection should be ruled out. Although on occasion surgical intervention may
be required to address knee stiffness, the outcome of revision surgery is poor if no reason for
stiffness can be determined.
REFERENCES: Kim J, Nelson CL, Lotke PA: Stiffness after total knee arthroplasty: Prevalence
of the complication and outcomes of revision. J Bone Joint Surg Am 2004;86:1479-1484.
Gonzalez MH, Mekhail AO: The failed total knee arthroplasty: Evaluation and etiology. J Am
Acad Orthop Surg 2004;12:436-446.
26. A 59-year-old woman who underwent a total hip arthroplasty 5 years ago now has
recurrent dislocation following bariatric surgery and a weight loss of 200 lb. An attempt
at converting to a larger head size and trochanteric advancement has failed. Her
components are well aligned. What is the best course of action?
2- Hip abduction brace
3- Constrained acetabular liner
4- Thermal ablation of the posterior capsule
5- Conversion to a bipolar prosthesis
DISCUSSION: When a patient has well-aligned components and soft-tissue tensioning with a
larger femoral head and trochanteric advancement has failed, options are limited. The use of a
constrained acetabular liner is the best option in this situation. Goetz and associates and Shrader
and associates have demonstrated good results with these implants. Shrader used this device on
109 patients with recurrent instability with a successful outcome in all but 2 patients. Resection
arthroplasty is a salvage situation and is not the best option at the present time. A hip abduction
brace does not address the soft-tissue laxity. Conversion to a bipolar arthroplasty, although
possibly minimizing the incidence of dislocation, will lead to groin pain and migration of the
component with diminished functional results.
REFERENCES: Goetz DD, Capello WN, Callaghan JJ, et al: Salvage of recurrently
dislocating hip prosthesis with use of a constrained acetabular component: A retrospective
analysis of fifty-six cases. J Bone Joint Surg Am 1998;80:502-509.
Shrader MW, Parvizi J, Lewallen DG: The use of constrained acetabular component to treat
instability after total hip arthroplasty. J Bone Joint Surg Am 2003;85:2179-2183.
Hamilton WG, McAuley JP: Evaluation of the unstable total hip arthroplasty. Inst Course Lect
2004;53:87-92.
27. Figure 15 shows the radiograph of an active 60-year-old woman. Which of the following
variables is considered the strongest contraindication to a unicompartmental knee
arthroplasty in this patient?
1- Obesity
2- Fixed varus deformity of more than 15 degrees
3- Five degree flexion contracture
4- Contralateral knee osteoarthritis
5- Joint subluxation of 5 mm
DISCUSSION: Unicompartmental arthroplasty of the knee for single compartment arthrosis has
recently become more popular. Contraindications to unicompartmental knee arthroplasty include
fixed varus or valgus deformity of more than 5 degrees, restricted range of motion, fixed flexion
contracture, joint subluxation of 5 mm or greater, and arthrosis of the opposite and/or
patellofemoral compartment.
REFERENCES: Cossey AJ, Spriggins AJ: The use of computer-assisted surgical navigation to
prevent malalignment in unicompartmental knee arthroplasty. J Arthroplasty 2005;20:29-34.
Iorio R, Healy WL: Unicompartmental arthritis of the knee. J Bone Joint Surg Am
2003;85:1351-1364.
Argenson JN, Chevrol-Benkeddache Y, Aubaniac JM: Modern unicompartmental knee
arthroplasty with cement: A three to ten-year follow-up study. J Bone Joint Surg Am
2002;84:2235-2239.
28. Figure 16 shows the radiograph of an otherwise healthy 62-year-old woman who fell.
Management should consist of
1- revision total hip arthroplasty with a cemented femoral component and adjuvant
fracture fixation.
2- revision total hip arthroplasty with a cementless femoral component and adjuvant
fracture fixation.
3- open reduction and internal fixation of the fracture and retention of the original
components.
4- removal of the components, open reduction and internal fixation of the fracture,
and delayed replantation of the components when the fracture is healed.
5- resection arthroplasty and internal fixation of the fracture.
DISCUSSION: The radiograph reveals that the femoral component is grossly loose as evidenced
by disruption of the cement column; therefore, retention of the original components will not
yield a successful outcome. A cementless revision is the procedure of choice. A strut graft
and/or plate may be added at the surgeon’s discretion. A resection arthroplasty would only be
considered in a nonambulatory patient. Cemented fixation of the revision component would be
problematic given the numerous fracture fragments and the inability to contain the cement.
REFERENCES: Springer BD, Berry DJ, Lewallen DG: Treatment of periprosthetic fractures
following total hip arthroplasty with femoral component revision. J Bone Joint Surg Am
2003;85:2156-2162.
Duwelius PJ, Schmidt AH, Kyle RF, et al: A prospective, modernized treatment protocol for
periprosthetic femur fractures. Orthop Clin North Am 2004;35:485-492.
29. Which of the following is the strongest contraindication to unicompartmental knee
arthroplasty (UKA)?
1- Patient age of younger than 60 years

2- Patient age of older than 80 years
3- Anterior cruciate ligament (ACL) deficiency
4- Varus deformity of 5 degrees
5- Outerbridge grade II chondromalacia of the patella
DISCUSSION: UKA prostheses cannot substitute for an absent ACL, and if arthroplasty is
indicated, these patients should receive a total knee arthroplasty rather than a UKA. Age is not
an absolute contraindication, and the procedure has been advocated for young patients as well as
older patients if they meet the appropriate indications for an arthroplasty. Varus deformities of
the mechanical axis of up to 10 degrees generally are not a contraindication to unicompartmental
arthroplasty, as long as the knee can be properly balanced at the time of surgery. Modest
chondromalacia of the patellofemoral joint, especially if asymptomatic, is not a contraindication
to UKA.
REFERENCES: Lotke PA (ed): Knee Arthroplasty: Master Techniques in Orthopaedic Surgery.

New York, NY, Raven Press, 1995, pp 275-293.
Insall JN, Windsor RE, Scott WN, et al (eds): Surgery of the Knee, ed 2. New York, NY,
Churchill Livingstone, 1993, pp 805-814.
Tabor OB Jr, Tabor OB: Unicompartmental arthroplasty: A long-term follow-up study.
J Arthroplasty 1998;13:373-379.
30. Figure 17 shows the AP radiograph of a 75-year-old man with right hip pain. The
femoral component is loose. The mechanism of loosening is most likely secondary to
1- osteolysis.
2- fatigue failure of the implant.
3- failure of bone ingrowth.
4- wear debris from cerclage wire.
5- trochanteric impingement.
DISCUSSION: The femoral construct shown in the radiograph has failed to produce ingrowth of
the stem. The stem has subsided and rotated. Impingement of the trochanter did not occur until
after the stem subsided. There is no evidence of osteolysis or third-body wear debris from the
cerclage wire. A larger femoral stem needs to be implanted to achieve rigid fixation.
REFERENCES: Pelicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update:
2000, pp 217-238.
Peter CL, Rivero DP, Kull LR, et al: Revision total hip arthroplasty without cement: Subsidence
of proximally porous-coated femoral components. J Bone Joint Surg Am 1995;77:1217-1226.
31. A 75-year-old woman undergoes hybrid total hip arthroplasty for osteoarthritis. A
postoperative radiograph obtained in the recovery room is shown in Figure 18.
Treatment should now consist of
1- open reduction and internal fixation with strut graft and cerclage wire.
2- open reduction and internal fixation with a plate, screws, and bone graft.
3- exchange of the femoral components with insertion of a long stem cementless
implant.
4- cast immobilization.
5- minimal weight bearing and observation.
DISCUSSION: Intraoperative femoral fractures can often be avoided by careful preoperative

planning to optimize implant design and size. Most fractures occur during implantation of a
cementless implant; many can be avoided by careful femoral preparation and component
implantation, with particular caution in osteopenic bone. Intraoperative femoral fractures are
managed according to fracture severity. Minor cracks that do not affect stability or femoral
integrity can often be managed intraoperatively with cerclage fixation, limited weight bearing,
and observation. Femoral fractures that compromise implant stability or femoral integrity
require fracture fixation with cerclage wires, strut grafts, or plates and may require conversion to
a long stem implant. This patient’s fracture is nondisplaced and the implant is well seated;
therefore, limited weight bearing is considered appropriate management.
REFERENCES: Lee SR, Bostrom MP: Periprosthetic fractures of the femur after total hip
arthroplasty. Instr Course Lect 2004;53:111-118.
Kelley SS: Periprosthetic femoral fractures. J Am Acad Orthop Surg 1994;2:164-172.
Berry DJ: Management of periprosthetic fractures: The hip. J Arthroplasty 2002;17:11-13.
32. A 42-year-old man undergoes right total hip arthroplasty for hip dysplasia.
Postoperatively, he has a significant limb-length increase with a foot drop. A
preoperative radiograph is shown in Figure 19. Which of the following should have been
considered preoperatively to avoid this complication?
1- Medialization of the acetabular component

2- Use of a modular femoral implant
3- Anterolateral approach to the hip
4- Femoral shortening
5- Electromyography
DISCUSSION: In a patient with bilateral hip dysplasia, there are significant technical challenges
that need to be addressed to ensure a successful total hip arthroplasty. Restoring the center of the
hip may cause significant lengthening and require femoral shortening. Lengthening of greater
than 4 cm can lead to sciatic nerve palsy that will present clinically as a foot drop. A high hip
center can be used when there is inadequate bone stock in the acetabulum to achieve adequate
host bone coverage. A modular femoral implant may be used for a dysplastic hip with
significant rotational deformity. Although an anterolateral approach to the hip may decrease the
incidence of sciatic nerve palsy during the exposure, it will not be helpful when there is more
than 4 cm of limb lengthening.
REFERENCES: Schmalzried TP, Amstutz HC, Dorey FJ: Nerve palsy associated with total hip
replacement: Risk factors and prognosis. J Bone Joint Surg Am 1991;73:1074-1080.
Papagelopoulos PJ, Trousdale RT, Lewallen DG: Total hip arthroplasty with femoral osteotomy
for proximal femoral deformity. Clin Orthop 1996;332:151-162.
Huo MH, Zatorski LE, Keggi KJ: Oblique femoral osteotomy in cementless total hip
arthroplasty: Prospective consecutive series with a 3-year minimum follow-up period.
33. A 58-year-old man reports a 2-month onset of groin pain with no history of trauma.
Examination reveals that range of motion of the hip is mildly restricted, and he has pain
with both weight bearing and at rest. An MRI scan is shown in Figure 20. Treatment
should consist of
1- protected weight bearing and anti-inflammatory drugs.

2- core decompression of the femoral head.
3- vascularized free fibular grafting to the femoral head.
4- bipolar hemiarthroplasty of the hip.
5- total hip arthroplasty.
DISCUSSION: The MRI findings show highly increased signal through the entire femoral head
and neck on STIR imaging, diagnostic of transient osteoporosis of the femoral head. This
disease entity can be seen in middle-aged men, and should be treated nonsurgically. The natural
history is that of self-resolution.
REFERENCES: Guerra JJ, Steinberg ME: Distinguishing transient osteoporosis from avascular
necrosis of the hip. J Bone Joint Surg Am 1995;77:616-624.
Urbanski SR, de Lange EE, Eschenroeder HC Jr: Magnetic resonance imaging of transient
osteoporosis of the hip: A case report. J Bone Joint Surg Am 1991;73:451-455.
34. Figure 21 shows the radiograph of a 32-year-old patient with right hip pain that has failed
to respond to nonsurgical management. What is the most appropriate surgical treatment
at this time?
1- Femoral derotational osteotomy

2- Total hip arthroplasty
3- Arthrodesis
4- Surgical dislocation of the hip
5- Periacetabular osteotomy
DISCUSSION: The radiograph reveals developmental dysplasia of both hips. The patient has
classic anterolateral undercoverage of the femoral head on the right side as demonstrated by a
high acetabular index (measured at 27 degrees). Anterior undercoverage can be determined by
drawing the marking for the anterior wall that fails to overlap the femoral head in this patient.
Currently in North America, the most accepted surgical management for symptomatic dysplasia
of the hip with good joint space is a Bernese (Ganz) periacetabular osteotomy. Surgical
dislocation of the hip and femoroacetabular osteoplasty may be considered for patients with
symptomatic femoroacetabular impingement of the hip.
REFERENCES: Ganz R, Klaue K, Vinh TS, et al: A new periacetabular osteotomy for the
treatment of hip dysplasias: Technique and preliminary results. Clin Orthop 1988;232:26-36.
Trousdale RT, Ekkernkamp A, Ganz R, et al: Periacetabular and intertrochanteric osteotomy for
the treatment of osteoarthrosis in dysplastic hips. J Bone Joint Surg Am 1995;77:73-85.
35. A patient reports pain in the hip with functional positioning. With the patient supine,
pain in which of the following positions would be typical for femoral acetabular
impingement?
1- Hip is internally rotated, passively flexed to 90 degrees, and adducted

2- Hip is internally rotated, passively flexed to 90 degrees, and abducted
3- Hip is externally rotated, maximally flexed to 90 degrees, and adducted
4- Hip is externally rotated, passively flexed to 90 degrees, and abducted
5- Hip is externally rotated, maximally flexed, and abducted
DISCUSSION: Patients with dysplasia often have a hypertrophic labrum. Abnormal contact
between the femoral neck and the acetabular rim leads to labral injury, especially in the anterior-
superior acetabular zone. Typically, young patients with the condition report pain with activity
or long periods of sitting or driving. The hips often have limited motion, in particular in internal
rotation and flexion. Forceful adduction with the maneuver causes pain.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American

Beck M, Leunig M, Parvizi J, et al: Anterior femoroacetabular impingement: Part II. Midterm
results of surgical treatment. Clin Orthop 2004;418:67-73.
McCarthy JC, Noble PC, Schuck MR, et al: The role of labral lesions to development of early
degenerative hip disease. Clin Orthop 2001;393:25-37.
36. A patient who underwent a total knee arthroplasty for osteoarthritis 18 months ago now
reports the sudden development of pain in the ipsilateral knee. Radiographs and
examination of the knee are unremarkable. Aspiration of the synovial fluid 3 days later
reveals a WBC count of 1,500/mm3. The cells consist of 30% neutrophils and 70%
monocytes. Culture results will not be available for several days. The patient has not
been on antibiotics prior to this point. Based on these findings, what is the most
appropriate management?
1- Arthrotomy, debridement, and polyethylene exchange

2- One-stage exchange arthroplasty
3- Two-stage exchange arthroplasty
4- Parenteral antibiotics
5- Nonsurgical management without antibiotics
DISCUSSION: Synovial fluid analysis is a very sensitive tool for detecting infection in total
knee arthroplasties. Several studies have demonstrated that an absolute leukocyte count in the
synovial fluid of less than 1,700 to 2,500/mm 3 is an accurate predictor of absence of infection.
Similarly, a differential cell count of the WBCs demonstrating less than 50% to 60% neutrophils
is an accurate predictor of absence of infection. If both parameters are normal, it is unlikely that
the patient has an infection. The three surgical options are contraindicated based on the normal
examination findings and laboratory parameters. Similarly, antibiotics should be avoided. The
work-up should include tests to evaluate noninfectious sources of knee pain and sources of
referred knee pain.
REFERENCES: Trampuz A, Hanssen AD, Osmon DR, et al: Synovial fluid leukocyte count and
differential for the diagnosis of prosthetic knee infection. Am J Med 2004;117:556-562.
Mason JB, Fehring TK, Odum SM, et al: The value of white blood cell counts before revision
total knee arthroplasty. J Arthroplasty 2003;18:1038-1043.
Kersey R, Benjamin J, Mason B: White blood cell counts and differential in synovial fluid of
aseptically failed total knee arthroplasty. J Arthroplasty 2000;15:301-304.
37. A 38-year-old man who is an avid tennis player has had persistent pain over the medial
aspect of his knee for the past 6 years. He notes that the pain occurs on a daily basis with
any significant activity. Nonsteroidal anti-inflammatory drugs have failed to provide
relief. Radiographs are shown in Figures 22a and 22b. What is the best course of action?
1- Total knee arthroplasty

2- Unicompartmental arthroplasty
3- Insertion of a unispacer
4- Tibial osteotomy
5- Knee arthroscopy
DISCUSSION: In a relatively young patient who is an avid tennis player, the treatment of choice
is a joint preserving procedure. The radiographs reveal varus alignment with loading of the
medial compartment. After all nonsurgical management options have been used, the best
treatment option is a medial opening wedge osteotomy. A lateral closing wedge osteotomy of
the proximal tibia is also a reasonable option, but it is not one of the choices. A
unicompartmental arthroplasty or a total knee arthroplasty would place significant restrictions in
this patient. A unispacer may be a temporizing procedure but is controversial and without
substantial data in the literature. The knee arthroscopy will not address the medial compartment
osteoarthritis.
REFERENCES: Nagel A, Insall JN, Scuderi GR: Proximal tibial osteotomy: A subjective
outcome study. J Bone Joint Surg Am 1996;78:1353-1358.
Rinonapoli E, Mancini GB, Corvaglia A, et al: Tibial osteotomy for varus gonarthrosis: A 10- to
21-year followup study. Clin Orthop 1998;353:185-193.
Manifold SG, Kelly MA, Richardson L, et al: Osteotomies about the knee, in Fitzgerald RH,
Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 947-961.
38. Which of the following statements best describes the outcome of the routine use of
continuous passive motion (CPM) machines after total knee arthroplasty (TKA)?
1- CPM is likely to improve early range of motion and final range of motion.
2- CPM may improve early range of motion but is unlikely to improve final range of
motion.
3- CPM is likely to decrease postoperative pain.
4- CPM is likely to improve extension but not flexion.
5- CPM is likely to restore quicker ambulatory ability.
DISCUSSION: Although CPM machines are used widely in the United States for patients
undergoing TKA, the benefit seems to be marginal, if any. Numerous randomized trials have
shown that final outcomes after total knee arthroplasty are unaffected by the use of CPM
machines postoperatively. Some studies have suggested that use of CPM may improve flexion
in the first few weeks, but any short-term benefit from the machine was lost by intermediate-term
follow-up. Aside from potential improvement in flexion within the first few postoperative
weeks, there does not appear to be any benefit from the machines. There is no improvement in
pain, ambulation, or extension. The cost-effectiveness of these machines has been questioned by
many authors.
REFERENCES: Pellicci PM, Tria AJ, Garvin KL (eds): Orthopaedic Knowledge Update: Hip
pp 287-293.
McInnes J, Larson MG, Daltroy LH, et al: A controlled evaluation of continuous passive motion
in patients undergoing total knee arthroplasty. JAMA 1992;268:1423-1428.
Kumar PJ, McPherson EJ, Dorr LD, et al: Rehabilitation after total knee arthroplasty: A
comparison of 2 rehabilitation techniques. Clin Orthop 1996;331:93-101.
39. When performing knee arthroplasty, which of the following procedures provides the most
consistent fixation for the tibial component?
1- Cementless fixation of the tibial component

2- Augmenting cementless fixation of the tibial component with pegs or screws
3- Cementing the metaphyseal portion and press fitting the keel of the tibial
component
4- Cementing the metaphyseal and keel portions of the tibial component
5- Cemented fixation of the tibial component with screws
DISCUSSION: All of the options, except cementing the metaphyseal portion and press fitting the
keel of the tibial component, have been shown to create strong and long-lasting constructs;
however, cementing of both the platform and the keel offers the most predictable solution.
Cementing the platform and not the keel has been shown to have a higher loosening rate than the
more traditional methods of fully cementing or using screws to augment fixation.
REFERENCE: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American

40. Sterilization of ultra-high molecular weight polyethylene by gamma irradiation in air will
degrade its wear performance because of
1- oxidation.
2- melting.
3- cross-linking.
4- corrosion.
5- creep.
DISCUSSION: Gamma irradiation has long been used as a sterilization method for polyethylene.
Exposure to gamma irradiation causes breakage of the chemical bonds in the polyethylene, and
oxidation will occur if the material is subsequently exposed to air. The amount of oxidation and
decrease in wear performance is also related to the length of time that the gamma-irradiated
polyethylene is exposed to oxygen.
REFERENCES: Collier JP, Sutula LC, Currier BH, et al: Overview of polyethylene as a bearing
material: Comparison of sterilization methods. Clin Orthop 1996;333:76-86.
McKellop H, Shen FW, Lu B, et al: Effect of sterilization method and other modifications on the
wear resistance of acetabular cups made of ultra-high molecular weight polyethylene: A hip-
simulator study. J Bone Joint Surg Am 2000;82:1708-1725.
Sychterz CJ, Young AM, Orishimo K, et al: The relationship between shelf life and in vivo wear
for polyethylene acetabular liners. J Arthroplasty 2005;20:168-173.
41. Figure 23 shows failure of the femoral stem in a patient. What is the most likely reason
for the failure?
1- Torsional loading
2- Cantilever bending
3- Pistoning
4- Subsidence
5- Torque
DISCUSSION: A two-dimensional stress analysis has been used to study the effects of some of
the factors leading to early fatigue failure of the femoral stem in total hip arthroplasty. It has
been demonstrated that loss of proximal stem support at the level of the calcar femorale and
subsequent stem stress can lead to fatigue failure. In addition, the role of body weight and range
of cyclic stress fluctuation play an important role in fatigue life under conditions where the stem
has lost proximal support. These results indicate that stem design could be improved by
incorporating some means of adequate support at the calcar femorale where maximum tensile
stresses are found to occur. Femoral component fracture is a rare but well-documented
complication after total hip arthroplasty. Historically, most stem fractures occur at the middle
third of the implant where proximal stem loosening and solid distal stem fixation result in
cantilever bending and eventual fatigue failure. The component shown is a modular fluted
cementless stem that occasionally fractures at the modular junction in patients with poor
proximal bone support.
REFERENCES: Andriacchi TP, Galante JO, Belytschko TB, et al: A stress analysis of the
femoral stem in total hip prostheses. J Bone Joint Surg Am 1976;58:618-624.
Gruen TA, McNeice GM, Amstutz HC: “Modes of failure” of cemented stem-type femoral
components: A radiographic analysis of loosening. Clin Orthop 1979;141:17-27.
42. What property of titanium alloys accounts for their high corrosion resistance in vivo?
1- Self-passivation
2- Ductility
3- Hardness
4- Modulus of elasticity
5- Conductivity
DISCUSSION: In both room temperature air and physiologic fluids, titanium alloys self-
passivate or spontaneously form a layer of titanium oxide very rapidly. This layer makes
titanium alloys resistant to surface breakdown.
REFERENCES: Callaghan JJ, Rosenberg AG, Rubash HE, et al (eds): The Adult Knee.
Philadelphia, PA, Lippincott, 2003, vol 1, pp 269-278.
Lemons JE: Metallic alloys, in Morrey BF (ed): Joint Replacement Arthroplasty, ed 3.
Philadelphia, PA, Churchill-Livingstone, 2003, pp 19-27.
43. Which of the following aids in correction of patellar tracking after total knee arthroplasty
(TKA)?
1- Internal rotation of the femoral component

2- Internal rotation of the tibial component
3- Increasing size of the tibial component
4- Medialization of the patellar component
5- Joint line elevation
DISCUSSION: Correct patellofemoral tracking has proven to be a crucial aspect in TKA

because a large percent of problems after TKA are related to the patellofemoral articulation.
External rotation of the femoral and tibial components has been shown to aid in tracking.
Likewise, medialization of the patellar button aids in patellar tracking and prevention of lateral
subluxations and dislocations. Attention to the distal femoral cut is critical in maintaining the
joint line and preventing patella baja or alta. Tibial sizing, however, is not directly related to
patellar tracking after TKA.
REFERENCES: Callaghan JJ, Rosenberg AG, Rubash HE, et al (eds): The Adult Knee.
Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 1245-1258.
Merkow RL, Soudry M, Insall JN: Patellar dislocation following total knee replacement. J Bone
Joint Surg Am 1985;67:1321-1327.
44. Figure 24 shows the radiograph of a 36-year-old volleyball player with right hip pain.
What is the cause of the pain?
1- Osteonecrosis
2- Rheumatoid arthritis
3- Developmental dysplasia of the acetabulum
4- Femoral neck fracture
5- Femoral acetabular impingement
DISCUSSION: Femoral acetabular impingement usually presents in active young adults with the
slow onset of groin pain that often starts after a minor trauma. Physical examination reveals
limitation of motion with a positive impingement test which consists of forceful internal rotation
with flexion and adduction. Femoral acetabular impingement is a mechanism for the
development of early osteoarthritis in nondysplastic hips. Surgical debridement of the
impinging, nonspherical portion of the femoral head restores offset and improves the clearance
of the head, thus preventing abutment of the neck against the acetabular rim. The patient has no
evidence of osteonecrosis, developmental dysplasia of the hip, rheumatoid arthritis, or femoral
neck fracture.
REFERENCES: Ganz R, Parvizi J, Beck M, et al: Femoroacetabular impingement: A cause for

osteoarthritis of the hip. Clin Orthop 2003;417:112-120.
45. Figure 25 shows the radiograph of an 84-year-old woman who has pain and is unable to
extend her knee. History reveals that she underwent total knee arthroplasty 8 years ago.
Aspiration and studies for infection are negative. During revision surgery, management
of the tibial bone loss should consist of
1- reconstruction with a metal augmented revision tibial implant.

2- reconstruction with a hinged prosthesis.
3- reconstruction with a structural allograft.
4- reconstruction with iliac crest bone graft.
5- filling the defect with cement.
DISCUSSION: Massive bone loss encountered in revision total knee arthroplasty remains a
significant challenge. Recent reports have shown high success rates using structural allograft to
reconstruct large structural bone defects. A hinged prosthesis is not required in this setting. In
this patient, a large amount of posterior cortex has been lost, making the area too large to fill
with cement or iliac crest bone graft. Because of her age, the treatment of choice is a revision
tibial implant and metal augments. Structural allograft would be suitable in a younger patient.
REFERENCES: Mow CS, Wiedel JD: Structural allografting in revision total knee arthroplasty.
Engh GA, Herzwurm PJ, Parks NL: Treatment of major defects of bone with bulk allografts and
stemmed components during total knee arthroplasty. J Bone Joint Surg Am 1997;79:1030-1039.
Clatworthy MG, Ballance J, Brick GW, et al: The use of structural allograft for uncontained
defects in revision total knee arthroplasty: A minimum five-year review. J Bone Joint Surg Am
2001;83:404-411.
46. A 62-year-old woman with a bone mass density (BMD) T-score of -2.0 sustained a
subcapital fracture of her hip. She is an avid tennis player, and history reveals no
previous fractures. What is the most appropriate follow-up care?
1- Antiresorptive bisphosphonate medication

2- A repeat dual-energy x-ray absorptiometry scan (DEXA) and treatment if the
T-score is less than -2.5
3- A repeat DEXA scan and treatment if the T-score is greater than -1.5
4- No treatment since the BMD is not in osteoporotic range
5- (PTH) taraparatide hormone followed by surgery
DISCUSSION: A DEXA scan is most appropriately used to establish a baseline score. Even if
the bone mineral density is not within the osteoporotic range (T-score less than -2.5), a prior
fragility fracture is a strong risk factor for a second fracture as a result of factors other than bone
density, such as worsening vision or balance, confusion, or other predispositions to falls. The
guidelines of the National Osteoporosis Foundation indicate that, following a fragility hip
fracture, active anti-osteoporotic medication should be initiated, whether or not a DEXA scan is
performed. A recent study showed that antiresorptive therapy following a hip fracture reduces
not only the risk of a second fracture but also overall mortality.
REFERENCE: Gardner MJ, Brophy RH, Demetrakopoulos D, et al: Interventions to improve

osteoporosis treatment following hip fracture: A prospective, randomized trial. J Bone Joint
Surg Am 2005;87:3-7.
47. A 58-year-old patient who underwent bilateral hip arthroplasty 12 years ago now reports
pain in his hips and difficulty with ambulation to the point where he now uses crutches.
A radiograph of the hip and pelvis is shown in Figure 26. What is the best treatment
option for this patient?
1- Revision hip arthroplasty with a bipolar implant

2- Revision hip arthroplasty with impaction grafting on the femoral and acetabular
side
3- Revision hip arthroplasty with a cemented jumbo acetabular component
4- Revision hip arthroplasty with a cementless acetabular component
5- Acetabular component revision with a tri-flange protrusio ring
DISCUSSION: The radiographs reveal acetabular component failure with bone loss. There
are several treatment options available. The best option for survivorship is a cementless
porous-coated acetabular component. This patient may or may not require structural bone graft,
which may need to be determined at the time of surgery. Bipolar implants and cemented
acetabular components for revision surgery have not demonstrated long-term success. The use
of a protrusio ring is reserved primarily for massive bone loss such as a Paprosky type III bone
loss with significant superior migration of the acetabular component. The best clinical results for
acetabular component revision have been achieved with cementless porous-coated implants.
REFERENCES: Haddad FS, Masri BA, Garbuz DS, et al: Acetabulum, in Fitzgerald RH, Kaufer
H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 923-936.
D’Antonio JA: Periprosthetic bone loss of the acetabulum: Classification and management.
Orthop Clin North Am 1992;23:279-290.
Rubash HE, Sinha RK, Paprosky W, et al: A new classification system for the management of
acetabular osteolysis after total hip arthroplasty. Instr Course Lect 1999;48:37-42.
48. Figure 27 shows the AP radiograph of a patient who has late instability. The problem
most likely occurred as a result of
1- greater trochanter detachment.

2- femoral stem loosening.
3- wear.
4- osteolysis.
5- infection.
DISCUSSION: Although dislocation can occur anytime after hip arthroplasty, the highest
incidence is observed within the first few months. Dislocation occurring many years after
arthroplasty has also been described. In contrast to early dislocation, it appears that late
dislocation frequently requires surgical intervention. Recent studies suggest that the incidence of
late dislocation may be greater than initially appreciated and that the cumulative rate of
dislocation rises with increasing follow-up. The presumed etiologic factors for late instability
include long-standing problems with the prosthesis (such as malpositioning of the components)
with late manifestation, trauma, deterioration in the neurologic status of the patient, and
polyethylene wear. The eccentric position of the femoral head in this patient confirms
polyethylene wear. The femoral stem is well-fixed, and the greater trochanter osteotomy has
united well. The minor osteolysis observed around the proximal femur is also the consequence
of wear and is not the cause of instability. Infection, without component loosening and massive
soft-tissue destruction, is not otherwise known to result in late instability.
REFERENCES: Berry DJ, von Knoch M, Schleck CD, et al: The cumulative long-term risk of
dislocation after primary Charnley total hip arthroplasty. J Bone Joint Surg Am 2004;86:9-14.
Parvizi J, Wade FA, Rapuri VR, et al: Revision hip arthroplasty for late instability secondary to
polyethylene wear. Clin Orthop 2006, in press.
49. Figure 28 shows the postoperative radiograph of a 36-year-old patient. The cerclage
cable was placed for a minimal medial calcar fracture seen during femoral preparation.
In the immediate postoperative period, what is the highest level of activity that would be
safely permitted?
1- Immediate full weight bearing

2- Protected weight bearing
3- Toe touch weight bearing
4- Non-weight-bearing
5- 50% weight bearing
DISCUSSION: The incidence of femoral fracture in primary cementless total hip arthroplasty
ranges from 1.5% to 27.8%. It is imperative that the implant and fracture are stable both
intraoperatively and postoperatively. Cerclage wiring or cerclage cabling is the current
recommended treatment for nondisplaced calcar fractures and minimally displaced proximal
fractures. Berend and associates reviewed the results of 58 total hips in 55 patients with
intraoperative calcar fracture managed with single or multiple cerclage wires or cables and
immediate full weight bearing. Follow-up averaged 7.5 years, and there were no revisions of the
femoral component. No patients had severe thigh pain.
REFERENCES: Berend KR, Lombardi AV Jr, Mallory TH, et al: Cerclage wires or cables for
the management of intraoperative fracture associated with a cementless, tapered femoral
prosthesis: Results at 2 to 16 years. J Arthroplasty 2004;19:17-21.
Schmidt AH, Kyle RF: Periprosthetic fractures of the femur. Orthop Clin North Am
2002;33:143-152.
Greidanus NV, Mitchell PA, Masri BA, et al: Principles of management and results of treating
the fractured femur during and after total hip arthroplasty. Instr Course Lect 2003;52:309-322.
50. Embolic material generated during total knee arthroplasty (TKA) shown in Figure 29 is
composed of which of the following substances?
1- Fat only
2- Fat and air
3- Fat and marrow
4- Fat and cement
5- Fat and bone
DISCUSSION: Emboli are created during TKA. Usually there is an increased incidence with the
use of intramedullary rods that disrupt the marrow contents. These are not fat emboli per se.
They are material composed of fat cells and marrow that act like pulmonary emboli to obstruct
small arterioles in the lung. They are different from free fat emboli that are seen in fractures and
that lead to chemical injury to the lung rather than obstructive injury.
REFERENCES: Markel DC, Femino JE, Farkas P, et al: Analysis of lower extremity embolic
material after total knee arthroplasty in a canine model. J Arthroplasty 1999;14:227-232.
Pell AC, Christie J, Keating JF, et al: The detection of fat embolism by transoesophageal
echocardiography during reamed intramedullary nailing: A study of 24 patients with femoral and
tibial fractures. J Bone Joint Surg Br 1993;75:921-925.
McGrath BJ, Hsia J, Boyd A, et al: Venous embolization after deflation of lower extremity
tourniquets. Anesth Analg 1994;78:349-353.
51. Figure 30 shows the MRI scan of a 68-year-old woman who has left hip pain. What is
the most appropriate treatment?
1- Open reduction and internal fixation

2- Total hip arthroplasty
3- Incisional biopsy
4- Proximal femoral resection and reconstruction
5- Arthrodesis
DISCUSSION: The patient has a large zone of osteonecrosis of the left femoral head. The
wedge-shaped zone of decreased signal intensity on the T1 image in the subchondral region of
the femoral head is typical. Based on these findings, total hip arthroplasty is the most
appropriate treatment. Open reduction and internal fixation will not help this condition.
Incisional biopsy is indicated only if the MRI scan shows a probable neoplasm. Resection of the
proximal femur is indicated only for aggressive malignancy. Arthrodesis may be considered in a
younger patient but not in a 68-year-old individual. Other treatments, not listed, such as core
decompression, vascularized fibular transplant, and osteotomy may be options in selected
patients.
REFERENCES: Urbaniak JR, Jones JP Jr (eds): Osteonecrosis: Etiology, Diagnosis, and

Treatment. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 213-223.
Watson RM, Roach NA, Dalinka MK: Avascular necrosis and bone marrow edema syndrome.
Radiol Clin North Am 2004;42:207-219.
52. There is increasing concern about the ethical relationship of orthopaedists to the
orthopaedic equipment industry. Which of the following describes the most appropriate
relationship?
1- Industry-paid travel, hotel (for the surgeon and spouse), and registration at a
university-sponsored CME course
2- Industry-paid travel and hotel for a faculty member at an industry-sponsored
meeting that is not CME approved
3- Consultation agreement ($50,000/annum) between the surgeon and the company
for evaluation of the implant system with required oral reporting of impressions
4- A restricted grant from a company to an orthopaedic residency program with the
stipulation that the third year residents be sent to an industry-sponsored course
5- Industry-paid dinner at a premium restaurant ($200/person) for surgeon and office
staff at which a new set of surgical instrumentation is presented
DISCUSSION: It is appropriate for orthopaedic surgeons to have relationships with industry as

long as the relationship is for the good of the patient and no “quid pro quo” intent exists. A grant
to cover registration at a CME event is appropriate but travel and hotel for a spouse is not. For
orthopaedists who are faculty at a meeting sponsored by industry, it is appropriate for travel and
expenses to be covered for that faculty member. Care must be exercised that the faculty member
contributes in an amount appropriate for the expenses paid. The faculty member must ensure
that information presented is unbiased and based on reasonable data and opinion. Consulting
agreements should spell out specifically the duties of the agreement and payment should be
appropriate for the time spent. There should be a defined work product for the consulting.
Agreements that are thinly veiled payments for use of a company’s products must be avoided. In
all cases, the agreements must stand up to public scrutiny. Restricted grants for specific
industry-sponsored programs aimed at residents are not appropriate. Unrestricted grants
intended for attendance at approved CME courses are appropriate. Dinners at which information
is presented about topics that can aid in patient care are appropriate as long as the expense is
reasonable ($100 or less/person) and the guest list includes individuals who can use the
information in a patient case. Clearly a “premium” dinner for office staff to review new surgical
instrumentation would not pass this test.
REFERENCE: Opinions on ethics and professionalism, in Guide to The Ethical Practice of

Orthopaedic Surgery, ed 6. American Academy of Orthopaedic Surgeons, Rosemont, IL, 2006,
pp 38-42.
53. A 30-year-old patient has had severe left hip pain and difficulty ambulating, necessitating
the use of a cane, for the past 6 months. A photomicrograph of the femoral head
sectioned at the time of surgery is shown in Figure 31. What is the most likely diagnosis?
1- Renal osteodystrophy
2- Pyogenic osteomyelitis
3- Osteoarthritis
4- Osteonecrosis
5- Tuberculosis osteomyelitis
DISCUSSION: The photomicrograph demonstrates a wedge-shaped infarct with femoral head

collapse; therefore, the diagnosis is osteonecrosis of the femoral head. Perthes disease and
osteoarthritis do not involve a wedge-shaped defect. Tuberculosis of the hip joint results in
greater destruction of the articular cartilage.
REFERENCES: Basset LW, Mirra JM, Cracchiolo A III: Ischemic necrosis of the femoral head:
Correlation between magnetic resonance imaging and histologic sections. Clin Orthop
1987;223:181-187.
Sugano N: Osteonecrosis, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopedics. St
Louis, MO, Mosby, 2002, pp 878-887.
54. When comparing mobile-bearing total knee arthroplasty (TKA) to fixed-bearing total
condylar arthroplasty, the mobile-bearing procedure provides
1- no improvement in survivorship.
2- approximately 15 degrees greater flexion.
3- appreciable reduction in wear rates.
4- a faster recovery profile.
5- better quadriceps strength.
DISCUSSION: Survivorship is similar in the two groups. In a recent study, mobile-bearing

TKAs showed a slightly higher maximum flexion than the total condylar fixed-bearing-type
designs (112 degrees versus 108 degrees with no difference in recovery rate). Using a fixed-
bearing or a mobile-bearing design did not seem to influence the recovery rate in early results
after knee arthroplasty. Mobile-bearing arthroplasties are suggested, in theory, to offer a
reduction in polyethylene wear; however, clinical studies have not yet proven this. Recovery
rates have yet to be statistically seen as improved with either method. Differences in strength
have not been shown.
REFERENCES: Aglietti P, Baldini A, Buzzi R, et al: Comparison of mobile-bearing and fixed-

bearing total knee arthroplasty: A prospective randomized study. J Arthroplasty 2005;20:145-
153.
Sorrells RB: The rotating platform mobile bearing TKA. Orthopedics 1996;19:793-796.
Dennis DA, Komistek RD: Kinematics of mobile-bearing total knee arthroplasty. Instr Course
Lect 2005;54:207-220.
55. Based on the type of articulation shown in Figure 32, wear is not affected by which of the
following factors?
1- Radial mismatch of the femoral head to the acetabular component

2- Sphericity of the bearings
3- Surface finish of the articulation
4- Carbon content of the metal-on-metal bearing
5- Head-to-neck ratio
DISCUSSION: Wear in total hip arthroplasty is a very complex phenomenon. The radial
mismatch of the femoral head to the acetabular component has been shown in multiple studies to
be a significant factor in wear. The mismatch can neither be too small nor too large. When the
mismatch is too small, seizing of the implants can occur. When the mismatch is too large,
contact stresses increase and produce exceptionally high wear. The ideal radial mismatch should
be approximately 50 microns. Surface roughness and ball sphericity are two items that are
extremely important with respect to wear. High carbon content has been shown to decrease
wear. This device has a very large head-to-neck ratio, so impingement-related wear is unlikely.
REFERENCES: Amstutz HC, Grigoris P: Metal on metal bearings in hip arthroplasty. Clin
Orthop 1996;329:S11-S34.
Amstutz HC, Campbell P, McKellop H, et al: Metal on metal total hip replacement workshop
consensus document. Clin Orthop 1996;329:S297-S303.
McKellop H, Park SH, Chiesa R, et al: In vivo wear of three types of metal on metal hip
prostheses during two decades of use. Clin Orthop 1996;329:S128-S140.
56. Figure 33 shows the venogram of a patient who has a long history of alcohol abuse.
Warfarin should be used cautiously because of the interaction with which of the
following factors?
1- IV
2- V
3- VI
4- VII
5- VIII
DISCUSSION: Warfarin acts by inhibiting clotting factors II, VII, IX, X. The actual
mechanism of action is by inhibition of hepatic enzymes, vitamin K epoxide, and perhaps
vitamin K reductase. This inhibition results in lack of carboxylation of vitamin K-dependent
proteins (II, VII, IX, X). The anticoagulant effect of warfarin can be reversed with vitamin K or
fresh-frozen plasma. The use of alcohol may lead to liver dysfunction and an even more limited
margin of available factors.
REFERENCES: Lieberman JR, Wollaeger J, Dorey F, et al: The efficacy of prophylaxis with
low-dose warfarin for prevention of pulmonary embolism following total hip arthroplasty.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 1999, pp 63-72.
57. A 78-year-old patient undergoing revision total knee arthroplasty has bone loss
throughout the knee at the time of revision. A distal femoral augment is used to restore
the joint line. One month after surgery, the patient reports pain and is unable to
ambulate. A lateral radiograph is shown in Figure 34. What is the most likely etiology
of this problem?
1- Inadequate restoration of the joint line

2- Patellar tendon rupture
3- Excessive internal rotation of the tibial component
4- Flexion gap instability
5- Hyperextension of the femoral component
DISCUSSION: Instability is a leading cause of failure following total knee arthroplasty.

Instability can present as global instability, extension gap (varus/valgus) instability, or flexion
gap (anterior/posterior) instability. Treatment options are numerous based on the exact
pathology. The radiograph reveals anterior/posterior instability with dislocation consistent with
flexion gap instability. A loose flexion gap can allow the femoral component to ride above the
tibial cam post mechanism, resulting in dislocation. Distal femoral augments treat extension gap
instability, whereas tibial augments can treat both flexion and extension gap instability.
Posterior condyle augments at the distal femur can also be used to treat flexion gap instability.
Flexion gap instability is further aggravated by extension mechanism incompetence. Note the
excessively thin patella on the lateral radiograph.
REFERENCES: Pagnano MW, Hanssen AD, Lewallen DG, et al: Flexion instability after
primary cruciate retaining total knee arthroplasty. Clin Orthop 1998;356:39-46.
McAuley J, Engh GA, Ammeen DJ: Treatment of the unstable total knee arthroplasty. Inst
Course Lect 2004;53:237-241.
Naudie DD, Rorabeck CH: Managing instability in total knee arthroplasty with constrained and
linked implants. Instr Course Lect 2004;53:207-215.
58. Figure 35 shows the AP radiograph of a patient who underwent a previous upper tibial
osteotomy (UTO). The patient may be at risk for which of the following during total
knee arthroplasty (TKA)?
1- Bone loss
2- Patella alta
3- Myositis ossificans
4- Fracture
5- Instability
DISCUSSION: The results of TKA for patients with a prior UTO are reported to be slightly
suboptimal. The major problems are patella baja, difficulty in exposure, and instability. Most of
the patients exhibit some degree of instability prior to TKA, and ligamentous balancing may be
difficult. Ligamentous structures are at risk of rupture during the difficult exposure. The
problem of ligamentous balancing is exacerbated by the change in the joint slope that can occur
after UTO.
REFERENCES: Parvizi J, Hanssen AD, Spangehl MJ: Total knee arthroplasty following
proximal tibial osteotomy: Risk factors for failure. J Bone Joint Surg Am 2004;86:474-479.
Meding JB, Keating EM, Ritter MA, et al: Total knee arthroplasty after high tibial osteotomy: A
comparison study in patients who had bilateral total knee replacement. J Bone Joint Surg Am
2000;82:1252-1259.
59. Figure 36 shows the radiograph of a patient who has hip pain and is unable to ambulate.
What is the most appropriate management for this patient?
1- Bisphosphonates
2- Protected weight bearing
4- Revision total hip arthroplasty
DISCUSSION: The patient has a periprosthetic fracture of the greater trochanter - Vancouver A.
The reason for the fracture of the greater trochanter is the extensive periarticular osteolysis that
has occurred as a result of polyethylene wear. The latter is demonstrated by eccentric seating of
the large femoral head in the acetabulum. The most appropriate management is to reverse the
osteolysis process, which involves exchange of the acetabular liner with or without revision of
the other components depending on their fixation and position. The greater trochanter can also
be fixed during revision surgery.
REFERENCES: Duncan CP, Masri BA: Fractures of the femur after hip replacement. Instr
Course Lect 1995;44:293-304.
Parvizi J, Rapuri VR, Purtill JJ, et al: Treatment protocol proximal femoral periprosthetic
fractures. J Bone Joint Surg Am 2004;86:8-16.
60. When polyethylene is exposed to radiation and subsequently heated, certain chemical
changes occur in the material. Which of the following statements best describes these
changes?
1- The process converts an otherwise interpenetrating networking structure of

polymer chains into a linear, high molecular weight polyethylene macromolecule.
2- The process increases the ductility of the material.
3- The process leads to fewer particles that are larger in size than the untreated
material.
4- The process improves (lowers) the wear rate but may increase the risk of fracture.
5- The process decreases the wear rate of the material, compared to untreated
polyethylene, when tested against a rough counterface.
DISCUSSION: Exposure of polyethylene to radiation and then heating it to quench the free
radicals leads to a cross-linked material. It converts a high molecular weight polyethylene
macromolecule to an interpenetrating network structure of polymer chains. The ductility of the
material is decreased, hence the greater risk of fracture. While the wear rate (measured as fewer
and smaller particles) against a smooth counterface is markedly reduced, cross-linked
polyethylene has shown a larger increase in wear rate when a rougher counterface is used
compared to noncross-linked material. Due to reduced mechanical strength, highly cross-linked
polyethylene is less resistant to abrasive wear.
REFERENCE: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip
pp 32-33.
61. Familial (Leiden) thrombophilia is of importance in joint arthroplasty because of an
abnormality in the clotting cascade. Which of the following statements best describes the
condition?
1- It is a disease caused by an abnormality of platelets that leads to increased blood

clotting.
2- It is a disease caused by an abnormality of vascular endothelium that leads to
increased blood clotting.
3- It is a disease caused by an abnormality of hepatic metabolism that leads to
decreased production of factor V and decreased blood clotting.
4- It is a disease caused by an abnormality of factor V that leads to decreased
inactivation of factor Va by activated protein C (aPC) and increased blood
clotting.
5- It is a familial, genetic disease that requires placement of a Greenfield filter in all
individuals who have the abnormality, prior to surgery.
DISCUSSION: Factor V Leiden is a disease caused by an abnormality of factor V in which a

single amino acid substitution of glutamine for arginine in the protein C cleavage region leads to
decreased inactivation of factor V and thus a greater tendency to form clots. More than half of
all individuals with Factor V Leiden will develop deep venous thrombosis in the presence of a
single additional risk factor such as long bone fracture or total joint arthroplasty.
pp 14-15.
62. Figure 37 reveals a periprosthetic fracture around a cemented femoral stem in an
81-year-old patient with Paget’s disease and mild coagulopathy. What is the most
appropriate reconstructive management on the femoral side?

2- Impaction allografting
3- Proximally coated femoral stem
4- Allograft prosthetic composite (APC)
5- Proximal femoral replacement (PFR)
DISCUSSION: This is an example of a Vancouver B3 periprosthetic fracture that consists of a

fracture around a loose femoral stem with poor proximal bone support. Therefore, open
reduction and internal fixation is not an option. PFR is an excellent choice for elderly inactive
patients with poor femoral bone stock. The surgery can be performed in an expeditious manner,
which is very important in a patient with mild coagulopathy. Impaction allografting and APC
are both options for younger patients who have bone stock that needs to be restored. The results
of revision arthroplasty using proximally coated stems, especially under these circumstances, are
poor.
REFERENCES: Duncan CP, Masri BA: Fractures of the femur after hip replacement. Instr
Course Lect 1995;44:293-304.
Parvizi J, Sim FH: Proximal femoral replacements with megaprostheses. Clin Orthop
2004;420:169-175.
Klein GR, Parvizi J, Rapuri V, et al: Proximal femoral replacement for treatment of
periprosthetic fractures. J Bone Joint Surg Am 2005;87:1777-1781.
63. A patient with a documented allergy to nickel requires a total knee arthroplasty. Which
of the following prostheses is most likely to provide long-term success in this individual?
1- All-polyethylene tibial component and pure titanium femoral component

2- All-polyethylene tibial component and cobalt-chromium alloy femoral component
3- Cobalt-chromium alloy tibial component and cobalt-chromium alloy femoral
component
4- Modular titanium tibial component and pure titanium femoral component
5- Modular titanium tibial component and oxidized zirconium femoral component
DISCUSSION: Nickel allergy is not an infrequent preoperative finding. The ramifications of

such allergies in arthroplasty patients are poorly understood at this time. Stainless steel and
cobalt-chromium alloys contain relatively high concentrations of nickel. Titanium, oxidized
zirconium, and polyethylene do not contain significant amounts of nickel. Titanium is not a
good surface for the articulating portion of the femoral component because of its propensity for
metallosis. Oxidized zirconium is the only suitable femoral component for patients allergic to
nickel. A modular titanium tibial component or an all-polyethylene tibial component would be
satisfactory for these patients.
REFERENCES: Laskin RS: An oxidized Zr ceramic surfaced femoral component for total knee
arthroplasty. Clin Orthop 2003;416:191-196.
Nasser S, Campbell PA, Kilgus D, et al: Cementless total joint arthroplasty prostheses with
titanium-alloy articular surfaces: A human retrieval analysis. Clin Orthop 1990;261:171-185.
64. Which of the following is accurate regarding low-molecular-weight heparin used for deep
venous thrombosis (DVT) prophylaxis in total joint arthroplasty?
1- The incidence of thrombocytopenia is lower with low-molecular-weight heparin

than with unfractionated heparin.
2- The half-life of low-molecular-weight heparin is less than that of unfractionated
heparin.
3- Low-molecular-weight heparin affects circulating thrombin (Factor IIa) to a
greater extent than unfractionated heparin.
4- The mechanism of action of low-molecular-weight heparin is primarily by
targeting Factor Xa.
5- There is a significant decrease in postoperative bleeding with the use of low-
molecular-weight heparin compared to warfarin.
DISCUSSION: Low-molecular-weight heparin is highly bioavailable with a half-life

of 3 to 18 hours. This is greater than the 1 hour half-life of unfractionated heparin.
Low-molecular-weight heparin offers an advantage over unfractionated heparin by selectively
targeting Factor Xa while having a lesser effect on circulating thrombin (Factor IIa). Circulating
thrombin Factor IIa is needed for local hemostasis at the site of the surgical wound. Clinical
studies have shown a reduction by one third in the incidence of thrombocytopenia with the use of
low-molecular-weight heparin. Low-molecular-weight heparin has been shown to demonstrate
similar clinical results compared to warfarin with respect to preventing thromboembolic disease
after total hip arthroplasty and complications such as bleeding.
REFERENCES: Zimlich RH, Fulbright BM, Friedman RJ: Current status of anticoagulation
therapy after total hip and total knee arthroplasty. J Am Acad Orthop Surg 1996;4:54-62.
Colwell CW Jr, Spiro TE, Trowbridge AA, et al: Use of enoxaparin, a low-molecular-weight
heparin, and unfractionated heparin for the prevention of deep venous thrombosis after elective
hip replacement: A clinical trial comparing efficacy and safety. J Bone Joint Surg Am
1994;76:3-14.
Torholm C, Broeng L, Jorgensen PS, et al: Thromboprophylaxis by low-molecular-weight
heparin in elective hip surgery: A placebo controlled study. J Bone Joint Surg Br 1991;73:434-
438.
65. A 42-year-old man reports the recent onset of right hip pain. A radiograph and MRI scan
are shown in Figures 38a and 38b. A WBC count, erythrocyte sedimentation rate, and
hip aspiration are within normal limits. Management should now consist of
1- core decompression.
2- biopsy of the femoral head.
3- protected weight bearing and observation.
4- total hip arthroplasty.
5- percutaneous cannulated pin fixation of the femoral neck.
DISCUSSION: Transient osteoporosis of the hip is an uncommon problem, usually affecting

women in the last trimester of pregnancy and middle-aged men. Symptoms include pain in the
involved hip with temporary osteopenia; however, there is no joint space involvement. In this
patient, the imaging findings are consistent with transient osteoporosis. Short TR/TE (repetition
time/echo time) images reveal diffusely decreased signal intensity in the femoral head and
intracapsular region of the femoral neck. Increased signal intensity is seen with increased T 2-
weighting. Within a few months, the pain, as well as the imaging findings, will completely
resolve without intervention. Distinguishing the diffuse features of transient osteoporosis of the
hip from the segmental findings of osteonecrosis is essential. Unlike transient osteoporosis of
the hip, osteonecrosis will have a double-density signal on MRI and may progress
radiographically. Surgical intervention and oral corticosteriods are not indicated for treatment.
Protected weight bearing until the pain resolves may decrease symptoms while the transient
osteoporosis resolves.
REFERENCES: Potter H, Moran M, Scheider R, et al: Magnetic resonance imaging in diagnosis

of transient osteoporosis of the hip. Clin Orthop 1992;280:223-229.
Bijl M, van Leeuwen MA, van Rijswijk MH: Transient osteoporosis of the hip: Presentation of
typical cases for review of the literature. Clin Exp Rheumatol 1999;17:601-604.
Montella BJ; Nunley JA, Urbaniak JR: Osteonecrosis of the femoral head associated with
pregnancy: A preliminary report. J Bone Joint Surg Am 1999;81:790-798.
66. During cemented total hip arthroplasty, peak pulmonary embolization of marrow contents
occurs when the
1- hip is dislocated.
2- femoral neck is osteotomized.
3- acetabulum is prepared.
4- acetabular component is inserted.
5- femoral stem is inserted.
DISCUSSION: Peak embolization is observed during femoral stem insertion. Embolization is

also observed during acetabular preparation and hip reduction.
REFERENCES: Lewallen DG, Parvizi J, Ereth MH: Perioperative mortality associated with hip
and knee arthroplasty, in Morrey BF (ed): Joint Replacement Arthroplasty, ed 3. Philadelphia,
PA, Churchill-Livingstone, 2003, pp 119-127.
Ereth MH, Weber JG, Abel MD, et al: Cemented versus noncemented total hip arthroplasty:
Embolism, hemodynamics, and intrapulmonary shunting. Mayo Clin Proc 1992;67:1066-1074.
67. What are the optimal conditions for leaving the acetabular shell in place, replacing the
acetabular liner, and grafting the osteolytic defect shown in Figure 39?
1- Nonmodular implant
2- Instability
3- Well-designed, well-fixed modular implant
4- Complete radiolucency of the acetabular component
5- Migration of the acetabular component
DISCUSSION: Dense pods of ingrowth into the porous coating of cementless ingrowth sockets
are seen. Channels through the non-ingrown portion allow access to the trabecular bone of the
ilium. Polyethylene wear debris can enter these areas through screw holes. Expansile, lytic
lesions can result, which can become large without compromising implant fixation. Loosening is
late and results from catastrophic loss of bone. A well-fixed acetabular component with a
modular design, a well-designed locking mechanism, and a good survivorship history is a
candidate for exchange of the liner and grafting of the osteolytic lesion.
REFERENCES: Ries MD: Complications in primary total hip arthroplasty: Avoidance and
management. Wear. Instr Course Lect 2003;52:257-265.
Dumbleton JH, Manley MT, Edidin AA: A literature review of the association between wear rate
and osteolysis in total hip arthroplasty. J Arthroplasty 2002;17:649-661.
Pelicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee
pp 175-180.
68. A 53-year-old patient is seen in the emergency department after sustaining a fall onto her
left hip. A current radiograph is shown in Figure 40. What is the best treatment option?
1- Bed rest and non-weight-bearing for 6 to 8 weeks

2- Component retention and open reduction and internal fixation
3- Proximal femoral replacement prosthesis
4- Revision arthroplasty with a long cemented stem
5- Revision arthroplasty with a long porous-coated cylindrical stem
DISCUSSION: The patient has sustained a Vancouver B2 periprosthetic femoral fracture

(a femoral fracture that occurs around or just distal to a loose stem, with adequate proximal bone
stock). The stem is no longer fixed to proximal bone; therefore, retention of the femoral
component is not recommended. Nonsurgical management is contraindicated because of the
high risk of nonunion and malunion with significant component settling in the distal fragment
and leg shortening. Revision femoral arthroplasty must attain distal fixation in adequate host
bone, which is usually successful with a porous-coated cylindrical stem.
REFERENCES: Parvizi J, Rapuri VR, Purtill JJ, et al: Treatment protocol for proximal femoral
periprosthetic fractures. J Bone Joint Surg Am 2004;86:8-16.
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;85:2156-
2162.
69. A 67-year-old patient seen in the emergency department reports the acute onset of pain
and is unable to ambulate. History reveals that the patient underwent surgical treatment
for a periprosthetic femoral fracture 6 months ago. A radiograph is shown in Figure 41.
What is the best treatment option at this time?
1- Open reduction and internal fixation with cortical onlay strut grafts and bone
morphogenic protein
3- Revision hip arthroplasty with an allograft prosthetic composite
4- Revision hip surgery with distal stem fixation using a long stem implant with strut
grafts
5- Revision hip arthroplasty with a proximally coated implant
DISCUSSION: The radiograph reveals a periprosthetic fracture at the tip of the stem with a
stable cemented implant. This is classified as a Vancouver type B1 periprosthetic fracture. An
attempt at internal fixation has already failed; therefore, the most predictable results would be
achieved with distal fixation. After removal of the well-fixed cemented implant, the proximal
bone may not be suitable for proximal fixation. Adequate bone stock is available such that an
allograft prosthetic composite or a tumor prosthesis is not necessary. The best option is a long
stem implant with distal fixation, which serves as an intramedullary device to restore alignment
and increase the likelihood of union. Cortical onlay strut grafts are used as an adjunct to
definitive fixation.
REFERENCES: Younger AS, Dunwoody I, Duncan CP: Periprosthetic hip and knee fractures:
The scope of the problem. Inst Course Lect 1998;47:251-256.
Lee SR, Bostrom MP: Periprosthetic fractures of the femur after total hip arthroplasty. Inst
Course Lect 2004;53:111-118.
70. With the increasing availability of total hip arthroplasty (THA) to younger patients with
hip osteoarthritis, there has been increased use of alternative bearing surfaces. Compared
to a ceramic-on-ceramic articulation, which of the following is a specific advantage of a
metal-on-metal bearing surface?
1- Increased wettability
2- Increased hardness
3- Increased fracture toughness
4- Decreased surface roughness
5- Lower coefficient of friction
DISCUSSION: Alternative bearing surfaces in THA have received much attention in recent
years as more and more hip arthroplasties are being performed on younger patients with hip
arthritis. The two most popular nonmetal-on-polyethylene bearing surfaces are metal-on-metal
and ceramic-on-ceramic. There are arguments supporting the use of either, but ceramic bearings
have been shown to have a theoretic increased risk of fracture compared with cobalt-chromium.
This has been shown to be clinically relevant with zirconium ceramics. Newer alumina ceramics
are being produced with lower porosity and grain size and with higher density and purity,
resulting in lower fracture risk but still greater than that of cobalt-chromium.
REFERENCES: Heisel C, Silva M, Schmalzried TP: Bearing surface options for total hip
replacement in young patients. Instr Course Lect 2004;53:49-65.
D’Antonio J, Capello W, Manley M, et al: New experience with alumina-on-alumina ceramic
bearings for total hip arthroplasty. J Arthroplasty 2002;17:390-397.
71. Which of the following prophylactic regimens for the prevention of deep venous
thrombosis after knee arthroplasty has received a grade 1A recommendation in favor of
its use from the American College of Chest Physicians (ACCP) in the 2004 guidelines?
1- Warfarin with a targeted international normalized ratio (INR) of 2.0 to 3.0 for
10 to 14 days
2- Low-molecular-weight heparin used for at least 3 days
3- Pneumatic compression sleeves used while the patient is in the hospital
4- Fondaparinux used for 5 to 7 days
5- Aspirin for 4 weeks
DISCUSSION: In the 2004 ACCP guidelines, there were three prophylactic regimens that
received a grade 1A favorable recommendation. These included low-molecular-weight heparin,
warfarin, or fondaparinux, as long as they are used for at least 10 days. If warfarin is used, the
target INR should be 2.0 to 3.0, according to the guidelines. Pneumatic compression sleeves
have gained popularity in the orthopaedic community but have not received a grade 1A rating
from the ACCP at this time. Use of aspirin by itself is discouraged by the ACCP.
REFERENCE: Geerts WH, Pineo GF, Heit JA, et al: Prevention of venous thromboembolism:
The seventh ACCP Conference on antithrombotic and thrombolytic therapy. Chest
2004;126:338S-400S.
72. In the radiograph shown in Figure 42, the fracture pattern around this well-fixed stem is
classified as Vancouver type
1- A.
2- B1.
3- B2.
4- B3.
5- C.
DISCUSSION: The Vancouver classifications describes periprosthetic hip fractures in the

following way. Type A fractures are in the trochanteric region. Type B1 fractures occur around
the stem or at the tip in the face of a well-fixed stem. These are usually treated with open
reduction and internal fixation, usually including struts, cable, and/or cable plates. Type B2
fractures occur in the same region with a loose stem. Type B3 fractures occur with a loose stem
where the proximal bone is of poor quality and/or severely comminuted. Type C fractures occur
well below the stem.
pp 149-154.
Parvizi J, Rapuri VR, Purtill JJ, et al: Treatment protocol for proximal femoral periprosthetic
fractures. J Bone Joint Surg Am 2004;86:8-16.
Masri BA, Meek RM, Duncan CP: Periprosthetic fractures evaluation and treatment. Clin
Orthop 2004;420:80-95.
73. Figures 43a and 43b show the T1- and T2-weighted MRI scans of a 78-year-old woman
who reports the sudden atraumatic onset of well-localized medial knee pain. Pain is
worse at night and also occurs with weight-bearing activity. What is the most likely
diagnosis?
1- Complex regional pain syndrome

2- Osteoarthritis
3- Osteosarcoma
4- Osteonecrosis
5- Inflammatory arthritis
DISCUSSION: Osteonecrosis of the tibial plateau occurs infrequently. The symptoms are
similar to those of idiopathic osteonecrosis of the medial femoral condyle and include pain and
tenderness of the medial aspect of the knee and a slight synovitis. The range of motion of the
knee remains within normal limits, and no gross deformity is present. Osteonecrosis of the tibial
plateau is easily misdiagnosed as degenerative meniscus or osteoarthritis of the compartment of
the knee. Review of lateral radiographs may reveal an osteopenic area in the subchondral bone
of the medial tibial plateau. The diagnosis is more easily established with a bone scan where
increased uptake of radionucleides is shown over the medial tibial plateau. In osteoarthritic
involvement of the medial compartment, uptake is over both the medial femoral condyle and the
medial tibial plateau, whereas if osteoarthritis involves the entire knee, uptake is diffuse over the
entire joint. Radiographic findings in complex regional pain syndrome are normal as opposed to
the findings for osteonecrosis or osteoarthritis. Osteosarcoma has a characteristic radiographic
appearance of a bone-forming tumor. Loose bodies can derive from osteochondral fractures; a
history of trauma is usually elicited. Osteoarthritis usually presents with joint space narrowing
accompanying the weight-bearing pain.
REFERENCES: Soucacos PN, Berris AE, Xenakis TH, et al: Knee osteonecrosis: Distinguishing
features in differential diagnosis, in Urbanik JR, Jones JD (eds): Osteonecrosis. Rosemont, IL,
American Academy of Orthopaedic Surgeons, 1997, pp 413-424.
Ecker ML, Lotke PA: Osteonecrosis of the medial part of the tibial plateau. J Bone Joint Surg
Am 1995;77:596-601.
74. Figure 44 shows the radiograph of a 65-year-old man who underwent a revision
arthroplasty to remove a loose, cemented femoral stem. When planning the postoperative
restrictions, the surgeon should be aware that
1- the approach used reduces the torque-to-failure (fracture) of the construct to less
than 50% of the intact femur.
2- the technique of repair can return the reconstructed prosthesis/bone composite to
nearly the strength of the intact femur.
3- there is no relationship between the density of the native bone and the strength of
the prosthesis/bone composite.
4- the addition of bone graft substitute or autograft has been shown to lessen the time
to complete healing.
5- there is a one in five chance of fracture with this technique; therefore, the surgeon
must carefully weigh the potential benefits versus this risk.
DISCUSSION: The transfemoral approach, also known as the extended trochanteric osteotomy,
is an important technique to master for revision hip surgery. When performed correctly, it
allows excellent exposure of the femoral canal and aids in exposure of the acetabulum. As
demonstrated in the study cited, however, it markedly reduces the torque that the composite can
withstand without failure. This type of basic science study is important to guide postoperative
rehabilitation.
REFERENCE: Noble AR, Branham D, Willis M, et al: Mechanical effects of the extended
trochanteric osteotomy. J Bone Joint Surg Am 2005;87:521-529.
75. A 75-year-old patient returns for follow-up after undergoing bilateral total hip
arthroplasty (THA). The right hip is a hybrid THA performed 12 years ago, whereas the
left hip is a cementless THA performed 10 years ago. Both acetabular components are
the same type, same size, and from the same manufacturer. Both femoral heads are
28-mm cobalt-chromium components. What is the most likely explanation for the
advanced polyethylene wear in one hip?
1- Presence of a third-party abrasive particle

2- Disproportionate use of the limbs by the patient
3- Defective femoral head
4- Method of fixation of the femoral component
5- Method of sterilization and shelf life of the polyethylene
DISCUSSION: Over the past three decades, gamma irradiation and air has been the most
common method of sterilizing polyethylene used in total joint arthroplasty. This method of
sterilization results in breakage of the chemical bonds within the polymer. While this promotes
cross-linking, it also leaves the polyethylene vulnerable to oxidation, especially if packaged in an
air environment. Oxidation has been shown to decrease polyethylene’s molecular weight,
ultimate tensile strength, elongation, and toughness which results in a stiffer, more brittle
material that is less resistant to wear. Severity of oxidation and a decrease in mechanical
properties have been shown to be related to the length of time that the component is exposed to
air (the shelf life). Currier and associates studied the clinical performance of gamma irradiated
in air polyethylene components that had been shelf aged. They demonstrated that for the first
5 years of shelf life, polyethylene oxidized rather slowly. However, polyethylene components
with a shelf life of more than 5 years would be expected to have minimal mechanical toughness
and would likely fail rapidly if implanted. Bohl and associates evaluated 135 patients who had
undergone total knee arthroplasty. Survivorship at 5 years was 100% for components with a
shelf life of less than 4 years, 89% for components with a shelf life of 4 to 8 years, and 79% for
components with a shelf life of more than 8 years. Sychterz and associates reported no
correlation between shelf life and true wear rates for components with a shelf life of less
than 3 years. In summary, both in vivo and in vitro data suggest that shelf life in excess of
3 to 5 years has a direct effect on wear of polyethylene.
REFERENCES: Currier BH, Currier JH, Collier JP, et al: Shelf life and in vivo duration: Impacts
on performance of tibial bearings. Clin Orthop 1997;342:111-122.
Bohl JR, Bohl WR, Postak PD, et al: The Coventry Award: The effects of shelf life on clinical
outcome for gamma sterilized polyethylene tibial components. Clin Orthop 1999;367:28-38.
Sychterz CJ, Young AM, Orishimo K, et al: The relationship between shelf life and in vivo wear
for polyethylene acetabular liners. J Arthroplasty 2005;20:168-173.
76. A 37-year-old man who works in a factory has isolated, lateral unicompartmental pain
about his knee with activities. Nonsurgical management has failed to provide relief. The
radiograph shown in Figure 45 reveals a tibiofemoral angle of approximately 15 degrees
which is clinically correctable to neutral. What is the best surgical option in this patient?
1- Unicompartmental arthroplasty
2- Total knee arthroplasty
3- Lateral closing wedge proximal tibial osteotomy
4- Medial opening wedge proximal tibial osteotomy
5- Medial closing wedge supracondylar femoral osteotomy
DISCUSSION: Patients with a valgus alignment about the knee can have lateral compartment
arthritis. Similar to a high tibial osteotomy, a supracondylar femoral osteotomy is indicated in
younger patients who have a more active lifestyle and isolated unicompartmental disease. In this
young patient who works in a factory and has a valgus knee, a medial closing wedge
supracondylar femoral osteotomy is the treatment of choice. The role of arthroplasty is limited
in younger patients.
REFERENCES: Mathews J, Cobb AG, Richardson S, et al: Distal femoral osteotomy for lateral
compartment osteoarthritis of the knee. Orthopedics 1998;21:437-440.
Cameron HU, Botsford DJ, Park YS: Prognostic factors in the outcome of supracondylar femoral
osteotomy for lateral compartment osteoarthritis of the knee. Can J Surg 1997;40:114-118.
77. Figure 46 shows the AP radiograph of an active 80-year-old patient with an acetabular
fracture. The fracture was initially managed nonsurgically; however, the patient is now
scheduled to undergo total hip arthroplasty. What is the treatment of choice for the
contained acetabular bone defect?
1- Bipolar femoral component

2- Acetabular cage
3- Large structural allograft
4- Use of the femoral head
5- Double-bubble acetabular cup
DISCUSSION: Acetabular fractures can result in a relative or actual acetabular bone defect. The
medial blow-out fracture of the acetabulum has united well in this patient. It is likely that a
medial shell of bone will be present during hip arthroplasty. The femoral head may be used as
morcellized or structural bone to augment the medial defect and is preferred to structural
allograft. Bipolar hip arthroplasty is notorious for medial migration in patients without a medial
bone defect; therefore, it will not be a good choice in this patient. Filling the defect with
methylmethacrylate cement, though an option, is not the best option in this active patient with an
extensive medial defect. A double-bubble acetabular cup is used for patients with deficiency of
the bone in the dome region.
REFERENCES: Mears DC: Surgical treatment of acetabular fractures in elderly patients with
osteoporotic bone. J Am Acad Orthop Surg 1999;7:128-141.
Bellabarba C, Berger RA, Bentley CD, et al: Cementless acetabular reconstruction after
acetabular fracture. J Bone Joint Surg Am 2001;83:868-876.
78. A 28-year-old woman who is an avid runner reports pain about the left hip with activities.
Nonsurgical management has failed to provide relief. An MRI arthrogram is shown in
Figure 47. What is the most likely diagnosis?
1- Osteonecrosis
2- Transient osteoporosis
3- Loose chondral fragment
4- Labral tear
5- Femoral neck stress fracture
DISCUSSION: The MRI arthrogram reveals dye extravasation into the labrum, consistent with a
labral tear. The MRI findings are not typical of osteonecrosis, stress fracture, or transient
osteoporosis. There is no increase in bone marrow edema in the neck or femoral head.
REFERENCES: Guanche CA, Sikka RS: Acetabular labral tears with underlying
chondralmalacia: A possible association with high-level running. Arthroscopy 2005;21:580-585.
McCarthy JC: The diagnosis and treatment of labral and chondral injuries. Instr Course Lect
2004;53:573-577.
79. Figure 48a shows the full-leg standing radiograph of a patient with a prior femoral
fracture. Figure 48b shows the lateral view of the same joint. The patient is scheduled to
undergo total knee arthroplasty. Because the mechanical axis of the lower extremity in
patients with a prior femoral fracture may be disrupted, which of the following should be
used during surgery to restore the mechanical axis of the lower extremity in this patient?
1- Customized components
2- Specialized intramedullary jigs
3- Hinged prosthesis
4- Extra-articular osteotomy
5- Routine knee prosthesis
DISCUSSION: The radiograph shows hardware that was used for fixation of a prior femoral
fracture. The mechanical axis of the lower extremity in this patient is nearly normal
(3 degrees valgus), and the deformity at the healed fracture site (14 degrees) does not appear to
affect the joint alignment and is acceptable. Use of a routine knee prosthesis will be possible in
this patient. To avoid hardware removal, extramedullary jigs and/or computerized navigation
may be used to measure and restore the long axis of the femur. The use of a hinged prosthesis
does not influence the mechanical axis directly. Extra-articular osteotomy is occasionally
needed to reverse severe deformities.
REFERENCES: Papadopoulos EC, Parvizi J, Lai CH, et al: Total knee arthroplasty following
distal femoral fractures. Knee 2002;9:267-274.
Lonner JH, Siliski JM, Lotke PA: Simultaneous femoral osteotomy and total knee arthroplasty
for treatment of osteoarthritis associated with severe extra-articular deformity. J Bone Joint Surg
Am 2000;82:342-348.
80. Figure 49 shows a histologic section of the lung in a patient who died during total hip
arthroplasty. What unexpected finding is seen in the pulmonary capillaries?
1- Pulmonary embolism
2- Methylmethacrylate cement
3- Hemorrhagic infarct
4- Granuloma formation
5- Amyloid
DISCUSSION: Sudden death during total hip arthroplasty has been reported. In a report from
the Mayo Clinic, intraoperative death occurred during cemented total hip arthroplasty in
23 patients. Fat and marrow embolization during preparation of the femur or cementing of the
femoral component was believed to be responsible for the cardiopulmonary collapse that
occurred during arthroplasty. Although fat and marrow emboli were found in the pulmonary
capillaries of most of the patients on autopsy, this histologic section shows two particles of
cement in the pulmonary capillaries.
REFERENCES: Parvizi J, Holiday AD, Ereth MH, et al: The Frank Stinchfield Award. Sudden
death during primary hip arthroplasty. Clin Orthop 1999;369:39-48.
Patterson BM, Healy JH, Cornell CN, et al: Cardiac arrest during hip arthroplasty with a
cemented long-stem component: A report of seven cases. J Bone Joint Surg Am
1991;73:271-277.
81. After trial placement of components in a primary total knee arthroplasty, the knee is
unable to come to full extension, but the flexion gap is appropriately balanced. After
adequate soft-tissue releases have been performed, what is the next most appropriate
action to balance the reconstruction?
1- Use a larger femoral component

2- Use a thinner polyethylene insert
3- Add posterior femoral augments
4- Resect more proximal tibia
5- Resect additional distal femur
DISCUSSION: The reconstruction requires additional resection of the distal femur to allow
increased extension while maintaining the current flexion gap tension. Resecting more proximal
tibia or decreasing the tibial polyethylene thickness will decrease flexion tension as well as
extension tension. Adding posterior femoral augments and using a larger femoral component
will increase flexion tension.
REFERENCES: Ayers DC, Dennis DA, Johanson NA, et al: Common complications of total
knee arthroplasty. J Bone Joint Surg Am 1997;79:278-311.
Pelicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee
Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 281-
286.
82. Figure 50 shows the cross table lateral radiograph of a 31-year-old paratrooper who has
recalcitrant groin pain. The pain is worse after activities such as standing or sitting
(driving). Examination reveals that pain can be reproduced by internal rotation of the leg
with the hip and knee in 90 degrees of flexion. Extensive nonsurgical management has
failed to provide relief. What is the treatment of choice?
1- Periacetabular osteotomy
2- Femoral neck osteotomy
3- Femoroacetabular osteoplasty
4- Hip arthroscopy and labral debridement
5- Hip arthrodesis
DISCUSSION: The radiograph reveals the classic “bump” that is seen in patients with
femoroacetabular impingement (FAI). Ganz and associates described two types of FAI. This
patient has cam impingement, which describes a nonspherical femoral head being forced into the
acetabulum during hip motion and resulting in labral and chondral injury. Hip arthroscopy and
labral debridement is unlikely to control the symptoms because the underlying anatomic
abnormality is often difficult to address with arthroscopy. The treatment involves surgical
dislocation of the hip with preservation of the blood supply to the femoral head, removal of the
asphericity on the femoral side (femoral osteoplasty), and removal of the acetabular rim
(acetabular osteoplasty) if the latter is found to contribute to impingement.
REFERENCES: Ganz R, Gill TJ, Gautier E, et al: Surgical dislocation of the adult hip a
technique with full access to the femoral head and acetabulum without the risk of avascular
necrosis. J Bone Joint Surg Br 2001;83:1119-1124.
Ganz R, Parvizi J, Beck M, et al: Femoroacetabular impingement: A cause for early
osteoarthritis of the hip. Clin Orthop 2003;417:112-120.
83. During total knee arthroplasty, the patella is noted to subluxate laterally despite a lateral
retinacular release. Which of the following methods is most likely to improve patellar
stability?
1- Slight external rotation of the tibial component

2- Slight internal rotation of the femoral component
3- Slight anterior translation of the tibial component
4- Use of a fixed-bearing knee as opposed to a mobile-bearing knee
5- Use of a thicker patellar component
DISCUSSION: Slight external rotation of the tibial component will cause a net medialization of
the tibial tubercle when the knee is articulated. This will help centralize the extensor mechanism
over the trochlear groove and minimize the tendency for lateral subluxation. Internal rotation of
the femoral component increases the risk of patellar instability. Anterior translation of the tibial
component moves the patellar tendon insertion posteriorly, and may increase force on the patella
but should not substantially alter patellar tracking. Clinical studies have shown no
patellofemoral benefits to the use of fixed- or mobile-bearing designs. Thicker patellar
components will not improve tracking, and may compound the problem.
pp 207, 323-337
Pagnano MW, Trousdale RT, Stuart MJ, et al: Rotating platform knees did not improve patellar
tracking: A prospective, randomized study of 240 primary total knee arthroplasties. Clin Orthop
2004;428:221-227.
Lotke PA, Garino JP (eds): Revision Total Knee Arthroplasty. Philadelphia PA, Lippincott-
Raven, 1999, pp 427-435.
84. A 73-year-old man has stiffness after undergoing primary posterior cruciate
ligament-retaining total knee arthroplasty 18 months ago. Extensive physiotherapy,
dynamic splinting, and manipulations under anesthesia have failed to result in
improvement. Examination reveals range of motion from 30 degrees to 60 degrees of
flexion. The components are well fixed, and the evaluation for infection is negative. In
discussing the possibility of revision arthroplasty, the patient should be advised that
1- the success of improving range of motion to a functional range of 0 degrees

to 90 degrees in the literature is between 75% to 80%.
2- the preoperative arc of motion will not influence the ultimate range of motion
after formal component revision.
3- change from a posterior cruciate ligament-retaining to a posterior cruciate
ligament-substituting design has a much greater chance of success.
4- manipulation under anesthesia will effectively improve range of motion if
postoperative stiffness develops following revision.
5- the major postoperative focus will be to regain near full extension.
DISCUSSION: Stiffness following primary total knee arthroplasty remains a vexing problem.
Treatment options have included extensive physical therapy, dynamic splinting, manipulation
under anesthesia, arthroscopic arthrolysis, open arthrolysis with polyethylene exchange, and
ultimately revision arthroplasty. Results are not as gratifying as would be expected. Babis and
associates performed an open arthrolysis and polyethylene exchange on seven patients who were
followed for a mean of 4.2 months. The results were poor. The mean improvement in arc of
motion was only 20 degrees. Nicholls and Dorr treated 13 patients for stiffness. Only 40% of
those patients obtained good to excellent results. Four patients (30%) required manipulation
because of recurrent stiffness postoperatively. They noted they could not predictably improve
the arc of motion with a revision operation. Haidukewych and associates reported on 15 patients
who underwent revision of well-fixed components after total knee arthroplasty for stiffness. Of
the 15 patients, 10 (66%) were satisfied with the outcome revision. Interestingly, they noted that
in patients for whom the total arc of motion did not improve but who regained near full
extension, there was a greater amount of satisfaction with the procedure than for those who did
not regain full extension.
REFERENCES: Babis GC, Trousdale RT, Pagnano MW, et al: Poor outcomes of isolated tibial
insert exchange and arthrolysis for the management of stiffness following total knee arthroplasty.
Nicholls DW, Dorr LD: Revision surgery for stiff total knee arthroplasty. J Arthroplasty
1990;5:S73-S77.
Haidukewych GJ, Jacofsky DJ, Pagnano MW, et al: Functional results after revision of well-
fixed components for stiffness after primary total knee arthroplasty. J Arthroplasty 2005;20:133-
138.
85. A 62-year-old patient is seen for routine follow-up after undergoing cementless total hip
arthroplasty 2 years ago. The patient reports limited range of motion that severely affects
daily activities. A radiograph is shown in Figure 51. Management should now consist of
1- observation only.
2- nonsteroidal anti-inflammatory drugs and protected weight bearing.
3- irradiation to the affected area.
4- surgical excision.
5- surgical excision and postoperative irradiation.
DISCUSSION: The patient has symptomatic postoperative heterotopic ossification after total hip
arthroplasty. Postoperative prophylactic treatments include nonsteroidal anti-inflammatory
drugs (usually indomethacin) or low-dose irradiation. The heterotopic ossification shown here is
quite mature; therefore, nonsurgical management will not be successful. Surgical excision of
grade III or IV heterotopic ossification should be followed with postoperative irradiation to
minimize the chances of recurrence.
REFERENCES: Ayers DC, Evarts CM, Parkinson JR: The prevention of heterotopic ossification
in high-risk patients by low-dose radiation therapy after total hip arthroplasty. J Bone Joint Surg
Am 1986;68:1423-1430.
Healy WL, Lo TC, DeSimone AA, et al: Single-dose irradiation for the prevention of heterotopic
ossification after total hip arthroplasty: A comparison of doses of five hundred and fifty and
seven hundred centigray. J Bone Joint Surg Am 1995;77:590-595.
86. What bilateral surgical intervention is considered inappropriate based on the findings
shown in the radiograph in Figure 52?
1- Vascularized fibular graft

2- Proximal femoral osteotomy
3- Core decompression
4- Hip arthrodesis
5- Femoral resurfacing
DISCUSSION: The radiograph reveals osteonecrosis of both femoral heads with reasonably
maintained joint surfaces. There may be some slight flattening of the femoral heads. Hip
arthrodesis is difficult to perform because of the necrotic bone. Its use in patients with
osteonecrotic hips is limited because of the 80% bilaterality; therefore, it is not an acceptable
alternative. All the other options are acceptable interventions.
REFERENCES: Mont MA, Jones LC, Sotereanos DG, et al: Understanding and treating
osteonecrosis of the femoral head. Instr Course Lect 2000;49:169-185.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of
87. Figure 53a shows the AP radiograph of a 70-year-old patient who is scheduled to undergo
unicompartmental knee arthroplasty. Figure 53b shows the immediate postoperative
radiograph, and the radiograph shown in Figure 53c, obtained 6 months after surgery,
shows a medial tibial plateau fracture. The etiology of the fracture is best related to
1- marked osteoporosis.
2- reduced contact area of a unicompartmental knee arthroplasty for load
transmission.
3- excessive medial placement of the tibial component of the unicompartmental knee
arthroplasty.
4- multiple drill holes that violate the medial cortex.
5- osteonecrosis of the medial tibial plateau.
DISCUSSION: While all of the above may contribute to the etiology of a tibial plateau fracture
following unicompartmental knee arthroplasty, the recent literature has clearly noted that pin
placement for fixation of tibial resection guides is the most critical factor associated with a tibial
plateau fracture following unicompartmental knee arthroplasty. Vince and Cyran suggest that
fractures associated with unicompartmental knee arthroplasty might be avoidable by limiting the
number and paying attention to the location of the pin holes that are created to secure the tibial
resection guides. Brumby and associates suggest avoiding multiple guide pin holes in the
proximal tibia for unicompartmental knee arthroplasty. They currently recommend the use of
one centrally placed pin and an ankle clamp to stabilize the resection guide. Yang and associates
note that a medial tibial plateau fracture in association with minimally invasive
unicompartmental knee arthroplasty can be eliminated by avoiding fixation pins close to the
medial tibial cortex.
REFERENCES: Brumby SA, Carrington R, Zayontz S, et al: Tibial plateau stress fracture: A
complication of unicompartmental knee arthroplasty using 4 guide pinholes. J Arthroplasty
2003;18:809-812.
Yang KY, Yeo SJ, Lo NN: Stress fracture of the medial tibial plateau after minimally invasive
unicompartmental knee arthroplasty: A report of 2 cases. J Arthroplasty 2003;18:801-803.
Vince KG, Cyran LT: Unicompartmental knee arthroplasty: New indications, more
complications? J Arthroplasty 2004;19:9-16.
88. During impaction of a cementless acetabular component, the posterior column was
fractured and found to be displaced. Which of the following is considered the most
appropriate surgical option?
1- Exchange of the cementless cup to a larger component

2- Retention of the component and bone grafting of the fracture
3- Retention of the component and postoperative weight protection until the
posterior column heals
4- Removal of the cup, fixation of the posterior column, and application of an
antiprotrusio cage
5- Removal of the cup and cementing of an all-polyethylene liner
DISCUSSION: Acetabular bone loss presents a challenge during reconstruction. A cementless

hemispherical cup can be used in most patients provided that the acetabular rim, particularly the
posterior column, is intact. When the posterior column is disrupted, fixation with a
reconstruction plate and/or the use of an antiprotrusio cage is recommended. The latter is
particularly important when the posterior column is fractured and displaced, such as in this
patient. Under these circumstances, reduction of the fracture and application of an antiprotrusio
cage is recommended. In this particular type of case, some surgeons may elect to retain the
hemispherical cup and apply an antiprotrusio cage over the cup (“cage over cup” technique).
REFERENCES: Berry DJ: Antiprotrusio cages for acetabular revision. Clin Orthop
2004;420:106-112.
Peterson CA, Lewallen DG: Periprosthetic fracture of the acetabulum after total hip arthroplasty.
89. Which of the following factors increases the risk of sciatic nerve injury in primary total
hip arthroplasty (THA)?
1- Male gender
2- Anterolateral approach
3- Posterior superior quadrant acetabular screw placement
4- Osteonecrosis
5- Developmental dysplasia of the hip
DISCUSSION: Injury to the sciatic nerve is a relatively rare but serious complication of THA.
Dissection of the sciatic nerve is not typically done during primary THA, although the nerve can
be identified during the surgical approach. An anterolateral approach to THA would not
necessarily be associated with any greater incidence of sciatic nerve injury than other
approaches. Screw fixation for the acetabular component is often a matter of surgeon preference.
Provided that the anatomic safe zones for screw fixation (posterior inferior and posterior
superior) are recognized, injury to the sciatic nerve from acetabular screws can be minimized.
Restoration of anatomic length is important in primary THA. Overlengthening can result in
sciatic nerve palsy. Developmental dysplasia of the hip can lead to a congenitally shortened
extremity with concomitant congenital shortening of the associated neurovascular structures.
Overlengthening of the extremity during THA for developmental dysplasia of the hip can lead to
sciatic palsy. Osteonecrosis is not an associated risk factor for sciatic nerve palsy.
REFERENCES: DeHart MM, Riley LH Jr: Nerve injuries in total hip arthroplasty. J Am Acad
Orthop Surg 1999;7:101-111.
Anas P, Felix B: Evaluation and prevention of postoperative complications, in Neurologic Injury
in Revision THA. New York, NY, Springer Verlag, 1999, pp 361-371.
90. A 68-year-old woman who underwent a right total hip arthroplasty 1 year ago has
dislocated her hip five times since surgery. Radiographs show a retroverted acetabular
component. What is the best treatment for this patient?
1- Use a constrained acetabular liner

2- Revise the femoral component to provide greater femoral offset
3- Revise the femoral head from a 28-mm head size to a 36-mm head size
4- Revise the acetabular component to 15 degrees of anteversion and 45 degrees of
abduction
5- Perform a greater trochanteric osteotomy to improve soft-tissue tension
DISCUSSION: The most common cause of recurrent dislocation following total hip arthroplasty
continues to be component malposition. Component malposition should be addressed prior to
any other treatment options, such as increasing soft-tissue tension with increased femoral offset
or greater trochanteric advancement. A larger femoral head size may help, but correcting the
component malposition should give more predictable results. A retroverted acetabular
component should be revised to 15 degrees to 20 degrees of anteversion, matching the patient’s
anatomy with an abduction angle close to 45 degrees.
REFERENCES: Daly PJ, Morrey BF: Operative correction of an unstable total hip arthroplasty.
Jolles BM, Zangger P, Leyvraz PF: Factors predisposing to dislocation after primary total hip
arthroplasty: A multivariate analysis. J Arthroplasty 2002;17-282-288.
Hamilton W, McAuley JP: Evaluation of the unstable total hip arthroplasty. Inst Course Lect
2004;53:87-92.
91. Figure 54 shows the preoperative radiograph of a 45-year-old woman who is considering
total hip arthroplasty with her orthopaedic surgeon. What femoral characteristic is a
typical concern in this patient?
1- Osteopenia
2- Excessive anteversion
3- Excessive varus
4- Excessive bowing
5- Stove-pipe femur
DISCUSSION: Developmental dysplasia of the hip (DDH) leads to early arthritis of the hip as
seen in this patient. Although DDH is believed to mostly affect the acetabulum, most patients
with DDH also have anatomic aberrations of the femur. Using three-dimensional computer
models generated by reconstruction of CT scans, dysplastic femurs were shown to have shorter
necks and smaller, straighter canals than the controls. The shape of the canal became more
abnormal with increasing subluxation. The studies also have shown that the primary deformity
of the dysplastic femur is rotational, with an increase in anteversion of 5 degrees to 16 degrees,
depending on the degree of subluxation of the hip. The rotational deformity of the dysplastic
femur arises within the diaphysis between the lesser trochanter and the isthmus and is not
attributable to a torsional deformity of the metaphysis. Osteopenia is not a concern in a patient
with an excellent cortical index (thick cortices and narrow canal). Femoral varus or bowing of
the femur is not a typical finding in patients with DDH.
REFERENCES: Noble PC, Kamaric E, Sugano N, et al: Three-dimensional shape of the

dysplastic femur: Implications for THR. Clin Orthop 2003;417:27-40.
Sugano N, Noble PC, Kamaric E, et al: The morphology of the femur in developmental dysplasia
of the hip. J Bone Joint Surg Br 1998;80:711-719.
92. A 68-year-old man with no significant medical history underwent a total knee
arthroplasty 4 years ago. A radiograph is shown in Figure 55. He reports that he had no
problems with the knee until 6 weeks ago when he noted the gradual onset of pain
following a colonoscopy. Examination reveals a painful, swollen knee. Knee aspiration
reveals a WBC count of 40,000/mm 3. Management should consist of
1- suppressive antibiotics.
2- open irrigation and debridement with polyethylene exchange.
3- one-stage resection arthroplasty and reimplantation.
4- two-stage resection arthroplasty and reimplantation.
5- arthroscopic irrigation and debridement.
DISCUSSION: The treatment of choice for a late hematogenous infection is two-stage resection
arthroplasty and reimplantation, with parenteral antibiotics prior to reimplantation. This is
particularly true when septic loosening has occurred as in this patient. Open irrigation and
debridement with polyethylene exchange has been used successfully when the duration of
symptoms is 3 weeks or less. Long-term suppressive antibiotics are most commonly used when
the patient’s medical condition precludes further surgery. Delayed reimplantation has been
shown to be superior to immediate reimplantation in multiple studies. Little data support the use
of arthroscopic irrigation and debridement.
REFERENCES: Swanson KC, Windsor RE: Diagnosis of infection after total knee arthroplasty,
in Callaghan JJ, Rosenberg AG, Rubash HE, et al (eds): The Adult Knee. Philadelphia, PA, JB
Lippincott, 2003, vol 2, pp 1485-1491.
Hanssen AD, Rand JA, Osmon DR: Management of the infected total knee arthroplasty, in
Morrey BF (ed): Joint Replacement Arthroplasty, ed 3. Philadelphia, PA, Churchill-Livingstone,
2003, pp 1070-1089.
93. Which of the following substances makes up the majority by weight of the extracellular
matrix for articular cartilage?
1- Keratin sulfate
2- Collagen type II
3- Water
4- Protein
5- Chondroitin sulfate
DISCUSSION: The extracellular matrix consists of water, proteoglycans, and collagen. Water
makes up the majority (approximately 65% to 80%) of wet weight; 95% of the collage is type II
with much smaller amounts of other collagens, including types IV, VI, IX, X, and XI. The exact
functions of these other collagens are unknown, but they are believed to be important in matrix
attachment and stabilization of the diameter of collagen fibrils.
REFERENCES: Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science:
Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of
94. A 58-year-old woman is seen in the emergency department after falling at home. History
reveals that she underwent right total knee arthroplasty 2 years ago. Radiographs are
shown in Figures 56a and 56b. What is the most appropriate treatment?
1- Closed reduction and casting

2- Bed rest and skeletal traction
4- Retrograde intramedullary nailing
5- Revision of the femoral component with a stemmed component
DISCUSSION: The radiographs show an oblique periprosthetic distal femoral fracture. Of the
options listed, open reduction and internal fixation is the most appropriate surgical option
because a well-fixed, posterior stabilized closed box femoral component is present. Nonsurgical
methods are not favored because of the highly displaced, unstable fracture pattern and prolonged
immobility. Revision with a stemmed component is an option but would sacrifice more bone
stock in this younger patient.
REFERENCES: Moran MC, Brick GW, Sledge CB, et al: Supracondylar femoral fracture
following total knee arthroplasty. Clin Orthop 1996;324:196-209.
Raab GE, Davis CM III: Early healing with locked condylar plating of periprosthetic fractures
around the knee. J Arthroplasty 2005;20:984-989.
Tharani R, Nakasone C, Vince KG: Periprosthetic fractures after total knee arhtroplasty.
95. A patient with a valgus knee and lateral compartment bone loss undergoes a total knee
arthroplasty using posterior condylar referencing instrumentation. Six months after
surgery, the patient reports significant anterior knee pain, and radiographs reveal severe
lateral patellar tilt. Management should consist of
1- lateral retinacular release.

2- femoral component revision.
3- medialization of the patellar component.
4- patellectomy.
5- tibial tubercle transfer.
DISCUSSION: Severe valgus deformity is frequently accompanied by hypoplasia of the lateral

femoral condyle. Posterior referencing instrumentation can substantially internally rotate the
femoral component with respect to the transepicondylar axis and Whiteside’s line. The femoral
component malrotation must be corrected to properly address this problem.
REFERENCES: Berger RA, Della Valle CJ, Rubash HE: Patellofemoral problems in total knee
arthroplasty, in Callaghan JJ, Rosenberg AG, Rubash HE, et al (eds): The Adult Knee.
Philadelphia, PA, JB Lippincott, 2003, vol 2, pp 1245-1258.
Whiteside LA, Arima J: The anteroposterior axis for femoral rotational alignment in valgus total
knee arthroplasty. Clin Orthop 1995;321:168-172.
96. Figures 57a through 57c show the radiographs of a patient who has pain, discomfort, and
a popping sensation localized to the posterior aspect of the knee after undergoing primary
left total knee arthroplasty 6 months ago. Examination reveals that the patient is able to
ambulate without a limp. There is no significant swelling, erythema, or effusion. Range
of motion is 0 degrees to 115 degrees, and a palpable crepitation or snapping is detected
at the posterior lateral joint line. What is the most likely diagnosis?
1- Popliteal snapping syndrome

2- Patellar clunk syndrome
3- Subluxation secondary to a tight posterior cruciate ligament
4- Soft-tissue irritation secondary to retained polymethylmethacrylate
5- Patellar subluxation secondary to a tight lateral retinaculum
DISCUSSION: Popliteal snapping syndrome represents the most likely diagnosis. Barnes and
Scott noted that the popliteus tendon can be a potential source of internal derangement after total
knee arthroplasty. They noted that it can be subluxated anteriorly and posteriorly over a retained
lateral femoral condyle osteophyte. Allardyce and associates described the condition as a
popliteus condition, snapping as it rolls over a retained lateral femoral condylar osteophyte.
Patellar clunk syndrome is a distinct syndrome associated with the patella and has been reported
in posterior stabilized knees. In addition to crepitation with range of motion, the patella literally
snaps or jumps as the knee is taken from flexion to extension.
REFERENCES: Beight JL, Yao B, Hozack WJ, et al: The patellar “clunk” syndrome after
posterior stabilized total knee arthroplasty. Clin Orthop 1994;299:139-142.
Barnes CL, Scott RD: Popliteus tendon dysfunction following total knee arthroplasty.
Allardyce TJ, Scuderi GR, Insall JN: Arthroscopic treatment of popliteus tendon dysfunction
following total knee arthroplasty. J Arthroplasty 1997;12:353-355.
97. Which of the following is the primary mechanism of polyethylene wear in the hip?
1- Fatigue cracking and delamination

2- Oscillatory fretting
3- Crevice corrosion
4- Oxidative degradation
5- Adhesion and abrasion
DISCUSSION: Although previous theories on acetabular wear implicated fatigue cracking and
delamination as primary wear mechanisms, these have actually manifested as major modes of
polyethylene wear in knees. The primary mechanism of wear in polyethylene acetabular
components appears to be adhesion and abrasion. In an analysis of 128 components retrieved at
autopsy or revision surgery, wear appeared to occur mostly at the surface of the components and
was the result of large strain plastic deformation and orientation of the surface layers into fibrils
that subsequently ruptured during multidirectional motion. It was also shown conclusively that
32-mm heads displayed significantly more wear (volumetric wear) than either 22-mm or
26-/28-mm heads (1-mm increase in size increased volumetric wear by 10%). The wear at the
articulating surface was characterized by highly worn polished areas superiorly and less worn
areas inferiorly separated by a ridge. Abrasion was very common, occurring after adhesion and
plastic deformation of polyethylene fibrils, and abrasion secondary to third-body wear. Wear
rates decreased with longer survival of components, indicating a “bedding in” phenomenon,
arguing against oxidative and fatigue wear. Crevice corrosion occurs in fatigue cracks with low
oxygen tension (under screw heads, etc). Oscillatory fretting consists of cyclical abrading of the
outer surface from small movements. Fatigue and delamination is predominant in total knee
arthroplasty where stresses are maximum just below the surface of the polyethylene component,
causing fatigue over time with subsequent delamination. In contrast, hip wear occurs primarily
at the surface of the polyethylene component.
REFERENCES: Jasty M, Goetz DD, Bragdon CR, et al: Wear of polyethylene acetabular
components in total hip arthroplasty: An analysis of one hundred and twenty-eight components
retrieved at autopsy or revision operations. J Bone Joint Surg Am 1997;79:349-358.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of
Bell CJ, Walker PS, Abeysundera MR, et al: Effect of oxidation on delamination of
ultrahigh-molecular-weight polyethylene tibial components. J Arthroplasty 1998;13:280-290.
Sutula LC, Collier JP, Saum KA, et al: The Otto Aufranc Award: Impact of gamma sterilization
on clinical performance of polyethylene in the hip. Clin Orthop 1995;319:28-40.
98. Which of the following complications may occur subsequent to resurfacing hip
arthroplasty for osteonecrosis of the hip but not after total hip arthroplasty?
1- Aseptic loosening of the acetabular component

2- Fracture of the femoral neck
3- Fracture of the acetabulum
4- Infection
5- Groin pain
DISCUSSION: Advocates of resurfacing hip arthroplasty cite preservation of the proximal

femoral bone stock as the main advantage of this procedure over total hip arthroplasty. Fracture
of the retained femoral neck has been reported following resurfacing arthroplasty. The exact
etiology of the latter is unknown. Technical errors, such as notching of the femoral neck or
possibly disruption of the blood supply to the femoral head during extensive soft-tissue exposure,
may result in femoral neck fracture.
REFERENCES: Gabriel JL, Trousdale RT: Stem fracture after hemiresurfacing for femoral head
osteonecrosis. J Arthroplasty 2003;18:96-99.
Amstutz HC, Campbell PA, Le Duff MJ: Fracture of the neck of the femur after surface
arthroplasty of the hip. J Bone Joint Surg Am 2004;86:1874-1877.
99. Which of the following statements best describes results that have been reported with
roentgen stereophotogrammetric analysis (RSA)?
1- Cemented total hip stems do not migrate.

2- Well-fixed total hip stems (cemented or cementless) migrate approximately
3 degrees and 5 mm in the first year.
3- Any early migration (ie, greater than 0 mm less than 6 months after surgery)
portends failure of the component.
4- Migration greater than 1 mm to 2 mm in the first year is associated with a higher
risk of loosening.
5- The system has been proven to not be as accurate as claimed and has been
abandoned.
DISCUSSION: Migration of total hip femoral components has been measured by RSA, a
technique that affords accuracy of 2 degrees and 0.5 mm. Several published studies on total hip
arthroplasty femoral components have established the importance of this technique. Both
cemented and cementless components migrate, with the rate of migration suggesting the
adequacy of fixation of a component. Migration of 1 mm to 2 mm (occurring in either the
varus-coronal plane and retroversion-transverse plane, or both) has been associated with a higher
risk of loosening of the component.
p 100.
100. Osteonecrosis of the large joints may develop in patients with which of the
following conditions?
1- Collagen I disease
2- Antiphospholipid syndrome (APS)
3- Hemochromatosis
4- Achondroplasia
5- Paget’s disease
DISCUSSION: Osteonecrosis of major joints can occur in patients exposed to corticosteroids,

alcohol, and antiseizure medications, as well as patients with hemaglobulinopathy, such as sickle
cell anemia. In addition, patients with primary APS who had not taken corticosteroids were also
found to be at high risk for osteonecrosis of the hip. In one study of 30 patients with primary
APS, asymptomatic osteonecrosis was evident in 20%. A recent article has also found a high
association between idiopathic osteonecrosis of the hip and collagen II mutation. None of the
other conditions has been shown to be associated with a higher risk of osteonecrosis.
REFERENCES: Tektonidou MG, Malagari K, Vlachoyiannopoulos PG, et al: Asymptomatic

avascular necrosis in patients with primary antiphospholipid syndrome in the absence of
corticosteroid use: A prospective study by magnetic resonance imaging. Arthritis Rheum
2003;48:732-736.
Liu YF, Chen WM, Lin YF, et al: Type II collagen gene variants and inherited osteonecrosis of
the femoral head. N Engl J Med 2005;352:2294-2301.

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1.

A patient is scheduled to undergo total knee arthroplasty (TKA) following failure of

REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American

1- Loose extension gap

1- Baseline serum ion levels increase with increasing activity levels.

REFERENCES: Colwell C: Evidence based guidelines for prevention of venous

1- tibial revision only, without stems or augmentations.

DISCUSSION: The radiograph reveals a Crowe IV deformity in a patient with developmental

1- closed reduction and casting for 6 weeks.

1- Hinged knee brace

REFERENCES: Kelly MA: Extensor mechanism complications in total knee arthroplasty.

1- larger and less numerous.

1- Using commercially available antibiotic-loaded bone cement

REFERENCES: Hanssen AD, Spangehl MJ: Practical applications of antibiotic-loaded bone

1- a base plate with an offset tibial stem attachment.

1- Revision arthroplasty using a cemented femoral component

1- Rest and nonsteroidal anti-inflammatory drugs

1- Decreased contact stress within the polyethylene

1- Clerical error leading to transfusion reaction

1- loosening of the femoral component.

REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American

1- Aggressive physical therapy

1- Patient age of younger than 60 years

REFERENCES: Lotke PA (ed): Knee Arthroplasty: Master Techniques in Orthopaedic Surgery.

DISCUSSION: Intraoperative femoral fractures can often be avoided by careful preoperative

1- Medialization of the acetabular component

1- protected weight bearing and anti-inflammatory drugs.

1- Femoral derotational osteotomy

1- Hip is internally rotated, passively flexed to 90 degrees, and adducted

REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American

1- Arthrotomy, debridement, and polyethylene exchange

1- Total knee arthroplasty

1- Cementless fixation of the tibial component

REFERENCE: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American

1- Internal rotation of the femoral component

DISCUSSION: Correct patellofemoral tracking has proven to be a crucial aspect in TKA

REFERENCES: Ganz R, Parvizi J, Beck M, et al: Femoroacetabular impingement: A cause for

1- reconstruction with a metal augmented revision tibial implant.

1- Antiresorptive bisphosphonate medication

REFERENCE: Gardner MJ, Brophy RH, Demetrakopoulos D, et al: Interventions to improve

1- Revision hip arthroplasty with a bipolar implant

1- greater trochanter detachment.

1- Immediate full weight bearing

1- Open reduction and internal fixation

REFERENCES: Urbaniak JR, Jones JP Jr (eds): Osteonecrosis: Etiology, Diagnosis, and

DISCUSSION: It is appropriate for orthopaedic surgeons to have relationships with industry as

REFERENCE: Opinions on ethics and professionalism, in Guide to The Ethical Practice of

DISCUSSION: The photomicrograph demonstrates a wedge-shaped infarct with femoral head

DISCUSSION: Survivorship is similar in the two groups. In a recent study, mobile-bearing

REFERENCES: Aglietti P, Baldini A, Buzzi R, et al: Comparison of mobile-bearing and fixed-

1- Radial mismatch of the femoral head to the acetabular component

1- Inadequate restoration of the joint line

DISCUSSION: Instability is a leading cause of failure following total knee arthroplasty.

1- The process converts an otherwise interpenetrating networking structure of

1- It is a disease caused by an abnormality of platelets that leads to increased blood

DISCUSSION: Factor V Leiden is a disease caused by an abnormality of factor V in which a

1- Open reduction and internal fixation

DISCUSSION: This is an example of a Vancouver B3 periprosthetic fracture that consists of a

1- All-polyethylene tibial component and pure titanium femoral component