4 5845716460000774251

Question/Answer Summary:
1. Question: What soft tissue augmentation is used in the reconstruction of the subscapularis when associated with
anterior instability following shoulder arthroplasty:
A. Tendo Achilles allograft
B. Hamstring tendons
C. Middle-third patellar tendon autograft
D. Triceps autograft
E. Fascia lata
Correct Answer: A. Tendo Achilles allograft

Your Answer: B. Hamstring tendons
Answer Status: Incorrect
Explanation: Moeckel and colleagues reported the use of tendo Achilles allograft for the treatment of anterior
instability following shoulder arthroplasty in combination with attempted subscapularis repair.
2. Question: Which of the following factors is associated with posterior instability following shoulder arthroplasty:
A. Retroverted humeral component
B. Posterior capsular laxity
C. Retroverted glenoid component
D. Disruption of the posterior capsule
E. All of the above
Correct Answer: E. All of the above

Your Answer: B. Posterior capsular laxity
Explanation: All of the above factors may contribute to posterior instability following shoulder arthroplasty.
3. Question: Which of the following strategies are used to treat posterior instability following shoulder
arthroplasty:
A. Increasing the anteversion of the humeral component
B. Using posterior capsular plication
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C. Creating a neutral orientation for the glenoid
D. Delaying postoperative rehabilitation program
E. All of the above

Your Answer: B. Using posterior capsular plication
Explanation: All of the above are potential treatment strategies for treating posterior instability following shoulder
arthroplasty.
4. Question: What is the rate of recurrent instability following revision surgery for an unstable shoulder prosthesis:
A. Less than 5%
B. Between 5% and 10%
C. Between 10% and 20%
D. Between 20% and 30%
E. Greater than 30%
Correct Answer: E. Greater than 30%

Your Answer: C. Between 10% and 20%
Explanation: In the study by Sanchez and colleagues, more than 50% of the shoulders in the study remained
unstable despite attempts at revision.
5. Question: Labral and soft tissue pathology are best visualized using:
A. Standard pelvis magnetic resonance image (MRI)
B. Plain film radiograph
C. 3D computed tomography (CT) scan
D. Hip arthrogram
E. MR arthrogram
Correct Answer: E. MR arthrogram

Your Answer: B. Plain film radiograph
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Explanation: Although standard pelvis MRI has a role in visualizing soft tissues and bone, MR arthrogram best
images the intra-articular structures of the hip. Hip arthrogram alone, CT, and plain film do not provide adequate
soft tissue resolution.
6. Question: Advantages of plain film radiograph in diagnosis and treatment of femoral acetabular impingement do
NOT include:
A. Visualization of cam impingement lesion
B. Detection of labral injury
C. Observation of joint space narrowing
D. Detection of developmental dysplasia of the hip (DDH)
E. Assessment for pincer impingement
Correct Answer: B. Detection of labral injury

Your Answer: B. Detection of labral injury
Answer Status: Correct
Explanation: Plain film radiographs can successfully detect cam and pincer impingement and cartilage space
narrowing, as well as allow quantified measurement of femoral head coverage. A magnetic resonance arthrogram is
necessary, however, to successfully visualize labral pathology.
7. Question: Upon review of a plain film series for developmental dysplasia of the hip (DDH), contraindication to
periacetabular osteotomy is suggested by:
A. Cup medialization
B. Excessive acetabular index
C. Center edge angle of 5?
D. Anterior coverage of less than 5? on false profile
E. No cartilage space maintained on abduction view
Correct Answer: E. No cartilage space maintained on abduction view

Your Answer: B. Excessive acetabular index
Explanation: None of the options necessarily preclude periacetabular osteotomy as a treatment option for DDH
provided that the patient wishes to proceed; however, little or no cartilage space, or poor concentric reduction of
hip joint would suggest poor outcome with this procedure.
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8. Question: The most valuable imaging study for assessment of radiographic leg length in patients preparing to
undergo total hip arthroplasty is:
A. Anteroposterior (AP) of the hip
B. 3D computed tomography
C. Magnetic resonance image of the pelvis
D. AP of the pelvis
E. Lauenstein lateral hip
Correct Answer: D. AP of the pelvis

Your Answer: C. Magnetic resonance image of the pelvis
Explanation: Of all the study techniques listed, only the AP of the pelvis allows radiographic comparison of hips.
This imaging may prove helpful in assessment of leg-length disparity due to lower extremity inequity or pelvic
obliquity.
9. Question: In the presence of osteolysis around the acetabular component, the most thorough means of
visualizing bone loss is via:
A. Pelvic Judet views
B. Cross-table lateral radiograph
C. Standard magnetic resonance imaging (MRI) of the pelvis
D. Bone scan
E. Computed tomography (CT) of the hip
Correct Answer: E. Computed tomography (CT) of the hip

Your Answer: B. Cross-table lateral radiograph
Explanation: Computed tomography scan remains the most thorough means of assessing bone loss in the pelvis.
MRI is relatively ineffective due to artifact scatter; cross-table lateral radiographs and bone scan are of little use;
and pelvic Judet views, although helpful, are not as thorough as CT.
10. Question: Advances in cement technique include all of the following EXCEPT:
A. Retrograde canal filling
B. Pressurization
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C. Canal plugging
D. Canal lavage
E. Pressurized mixing
Correct Answer: E. Pressurized mixing

Your Answer: C. Canal plugging
Explanation: Retrograde canal filling, canal pressurization and plugging, and lavage are all developments in
cement technique. The mixing process has been enhanced by mixing under vacuum conditions, however, rather
than pressure.
11. Question: In the Gruen classification of cement mantle, zone 4 is located:
A. Superior lateral
B. Superior medial
C. Mid lateral
D. Distal medial
E. Tip of the stem
Correct Answer: E. Tip of the stem

Your Answer: B. Superior medial
Explanation: In the classification described by Gruen, zone 4 is located at the tip of the stem; zone 1 is proximal
lateral, and zone 7 proximal medial.
12. Question: Cemented stem failure is most likely to result from:
A. Varus stem
B. Thin medial cement mantle
C. Stem contact with endosteal cortex
D. Excessive mantle laterally
E. Valgus stem placement
Correct Answer: C. Stem contact with endosteal cortex

Your Answer: D. Excessive mantle laterally
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Explanation: All of the above variables do not elevate the risk of stem failure with the exception of stem-cortical
contact. This avoidable circumstance is thought to result in an excessively thin mantle and risk for cement fracture
and subsequent loosening.
13. Question: Initial enthusiasm of cemented femoral stems in total hip arthroplasty was tempered by:
A. Stem fracture
B. Poor survivorship in patients younger than 50 years of age
C. Recurrent dislocation
D. Infection
E. Fracture
Correct Answer: B. Poor survivorship in patients younger than 50 years of age

Your Answer: B. Poor survivorship in patients younger than 50 years of age
Explanation: Early outcomes were characterized by poor survivorship in the young population, a situation that
corrected with subsequent polyethylene improvements and cement techniques.
14. Question: Variables that affect the rate at which cement polymerizes include the following EXCEPT:
A. Room temperature
B. Humidity
C. Rate of mixing
D. Material makeup of the mixing bowl
E. Inclusive agents, such as antibiotics
Correct Answer: D. Material makeup of the mixing bowl

Your Answer: C. Rate of mixing
Explanation: Temperature, humidity, mixing rate, and added agents affect the rate of polymerization. The
materials with which the polymer and powder contact are not known to affect this rate.
15. Question: Which is the preferred imaging modality to determine the fracture pattern in a patient with a
proximal humerus nonunion:
A. Plain radiographs
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B. Fluoroscopically-positioned plain radiographs
C. Magnetic resonance image
D. Tomograms
E. Computed tomography (CT) scan
Correct Answer: E. Computed tomography (CT) scan

Your Answer: A. Plain radiographs
Explanation: A CT scan provides important information in regard to the fracture pattern, the amount of bone
remaining in the humeral head, as well as information about the possibility of performing an ORIF with bone graft
compared to proceeding with an arthroplasty procedure.
16. Question: Which is the most common complication among patients who undergo shoulder arthroplasty for
proximal humerus nonunion:
A. Infection
B. Instability
C. Humeral component loosening
D. Glenoid component loosening
E. Greater tuberosity nonunion
Correct Answer: E. Greater tuberosity nonunion

Your Answer: B. Instability
Explanation: The most common reason for an unsatisfactory outcome after shoulder arthroplasty for a proximal
humerus nonunion is a greater tuberosity nonunion.
17. Question: Which organism is most frequently found in patients with an infected humeral nonunion:
A. Escherichia coli
B. Streptococcus
C. Propionibacterium acnes
D. Brucella
E. None of the above

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Correct Answer: C. Propionibacterium acnes
Your Answer: C. Propionibacterium acnes
Explanation: One of the most common organisms found in an infected proximal humerus nonunion
isPropionibacterium acnes. Staphylococcus aureus is another organism that is frequently found in patients with an
infected humeral nonunion.
18. Question: Who would be a good candidate for shoulder arthroplasty for a proximal humerus nonunion:
A. An elderly patient
B. A patient with a high fracture pattern
C. A patient with poor quality bone in the humeral head
D. A patient with glenohumeral arthritis
E. All of the above

Your Answer: C. A patient with poor quality bone in the humeral head
Explanation: The ideal candidate for shoulder arthroplasty for a proximal humerus nonunion is an elderly patient
with a small humeral head fragment of poor bone quality with associated glenohumeral arthritis.
19. Question: Who would be an ideal candidate for internal fixation and bone grafting in the setting of a proximal
humerus nonunion:
A. A patient with a low fracture pattern
B. A patient with minimal to no glenohumeral arthritis
C. A young patient
D. A patient with an intact rotator cuff
E. All of the above

Your Answer: A. A patient with a low fracture pattern
Explanation: The ideal patient for an attempt at open reduction internal fixation is a young patient with a low
fracture pattern, an intact rotator cuff, and minimal to no glenohumeral arthritis.
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Thank you.
Hyperguide Staff.
1. Question: The most common complication following high tibial osteotomy for treatment of medial
compartment knee arthrosis is:
A. Neurovascular injury
B. Overcorrection
C. Undercorrection
D. Compartment syndrome
E. Patella baja
Correct Answer: C. Undercorrection

Your Answer: C. Undercorrection
Explanation:
Complications in high tibial osteotomy include undercorrection, overcorrection, osteonecrosis of the tibial plateau,
patella baja, neurovascular injury, anterior compartment syndrome, and other complications common to all
procedures. The most common of these is undercorrection.
2. Question: Which of the following is considered a contraindication to high tibial osteotomy for the treatment of
medial compartment knee arthrosis:
A. 10? fixed varus deformity
B. Normal lateral compartment
C. Prior knee infection
D. Lateral tibial subluxation of 2 cm
E. 5? flexion contracture
Correct Answer: D. Lateral tibial subluxation of 2 cm

Your Answer: B. Normal lateral compartment
Explanation:
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High tibial valgus producing osteotomy attempts to redirect the forces crossing the knee joint from the medial
compartment to slightly lateral to the center of the knee. Indications include isolated medial knee pain, less than
15? fixed varus deformity, a normal lateral compartment, and a normal patellofemoral compartment.
Contraindications include:
 Restricted knee motion (flexion contracture greater than 15? or flexion limited to less than 90?)
 Lateral tibial subluxation greater than 1 cm
 Peripheral vascular disease
 Tibial bone loss
 Lateral thrust gait pattern
3. Question: Following acute traumatic patellar dislocation, the most important injured structure in regard to future
instability of the patellofemoral joint is the:
A. Medial parapateller retinaculum
B. Vastus medialis obliquis
C. Medial patellofemoral ligament
D. Medial patellotibial ligament
E. Medial patellomeniscal ligament
Correct Answer: C. Medial patellofemoral ligament

Your Answer: D. Medial patellotibial ligament
Explanation:
The medial patellofemoral ligament is the primary restraint to lateral subluxation of the patella. The other
structures above contribute less substantially to patellofemoral stability. In the majority of cases of acute traumatic
patellar dislocation, the medial patellofemoral ligament is disrupted.
4. Question: The most common sequelae following traumatic shoulder dislocation in an 18-year-old man is:
A. Normal shoulder without further problems
B. Recurrent shoulder dislocation
C. Axillary nerve injury
D. Rotator cuff tear
E. Adhesive capsulitis
Correct Answer: B. Recurrent shoulder dislocation

Your Answer: B. Recurrent shoulder dislocation
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Explanation:
Up to 90% of young patients with a traumatic shoulder dislocation will have a recurrent dislocation. Rotator cuff
tears occur commonly with shoulder dislocation in the older population, but are relatively uncommon in younger
patients.
5. Question: A 55-year-old woman has rheumatoid arthritis with shoulder, elbow, and hand/wrist symptoms. No
single site of involvement is more symptomatic than the others. After failure of nonoperative treatment, the
appropriate order of surgical intervention is:
A. Hand/wrist, elbow, shoulder
B. Shoulder, elbow, hand/wrist
C. Elbow, shoulder, hand/wrist
D. Hand/wrist, shoulder, elbow
E. Shoulder, hand/wrist, elbow
Correct Answer: D. Hand/wrist, shoulder, elbow

Your Answer: B. Shoulder, elbow, hand/wrist
Explanation: Generally speaking, the more symptomatic joints are addressed first in rheumatoid arthritis.
However, when upper extremity joints are equally disabling, the hand and wrist disability is addressed first.
Although it is somewhat controversial, it is generally agreed that the shoulder should be addressed before the
elbow. This eliminates referred pain from the shoulder to the elbow, allowing for better evaluation of elbow
symptoms. Addressing the shoulder pathology earlier may prevent ensuing rotator cuff tears that can compromise
results of arthroplasty. Lastly, increasing shoulder mobility may decrease the stresses on an arthritic elbow.
6. Question: The normal version of the glenoid is:
A. 20? to 30? retroversion
B. 10? to 20? retroversion
C. Neutral to 10? retroversion
D. Neutral to 10? anteversion
E. 10? to 20? anteversion
Correct Answer: C. Neutral to 10? retroversion

Your Answer: E. 10? to 20? anteversion
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Explanation: The normal version of the glenoid has been established to be between neutral and 10? of
retroversion. Excessive glenoid retroversion can indicate excessive posterior wear caused by primary osteoarthritis.
Retroversion in excess of 25? can indicate glenoid dysplasia.
7. Question: Posterior translation of the humeral head is associated with which of the following arthritic etiologies:
A. Primary osteoarthritis
B. Rheumatoid arthritis
C. Post-infectious arthritis
D. Arthritis secondary to osteonecrosis
E. Post-traumatic arthritis
Correct Answer: A. Primary osteoarthritis

Your Answer: C. Post-infectious arthritis
Explanation: Primary osteoarthritis of the shoulder is a well-described entity. Neer described posterior subluxation
of the humeral head following posterior glenoid erosion. Although the exact sequence of events has recently come
into question, the end result is a static posterior subluxation of the humeral head with arthritis.
8. Question: Which of the following statements best describes the most common scenario in regard to the rotator
cuff in patients with primary osteoarthritis of the shoulder:
A. Intact rotator cuff
B. Thin, attenuated rotator cuff
C. Rupture of the supraspinatus tendon only
D. Rupture of the subscapularis tendon only
E. Massive rupture of the rotator cuff
Correct Answer: A. Intact rotator cuff

Your Answer: B. Thin, attenuated rotator cuff
Explanation: In most situations of primary osteoarthritis, the rotator cuff is intact or has minimal tearing.
9. Question: When performing total shoulder arthroplasty, a subscapularis tenotomy is performed as part of the
surgical exposure. The following anatomic landmark provides the greatest information regarding the point of
initiation of the subscapularis tenotomy:
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A. Pectoralis major tendon
B. Pectoralis minor tendon
C. Deltoid insertion on the humerus
D. Biceps tendon
E. Anterolateral aspect of the acromion
Correct Answer: D. Biceps tendon

Your Answer: A. Pectoralis major tendon
Explanation: It is important to identify the superior aspect of the subscapularis tendon prior to performing
subscapularis tenotomy in the surgical exposure for shoulder arthroplasty. With an intact rotator cuff, identification
of the superior aspect of the subscapularis tendon at the rotator interval can be difficult. If the biceps tendon is
located just medial to the humeral insertion of the pectoralis major and followed superior, the rotator interval can
be located and opened, allowing visualization of the superior aspect of the subscapularis tendon. In the event that
the biceps tendon is ruptured or dislocated, the base of the coracoid process can be used to identify the medial
aspect of the rotator interval.
10. Question: All of the following are involved in rotator cuff tear arthropathy except:
A. Osteonecrosis
B. Chondrolysis
C. Rupture of the rotator cuff
D. Hydroxyapatite crystal deposition
E. Acromiohumeral arthritis
Correct Answer: B. Chondrolysis

Your Answer: D. Hydroxyapatite crystal deposition
Explanation: Cuff tear arthropathy includes osteonecrosis and acromiohumeral arthritis with a rotator cuff tear.
Other investigators discovered hydroxyapatite crystal deposition as well. Chondrolysis is not a part of rotator cuff
tear arthropathy, but can occur if the individual develops secondary osteoarthritis.
11. Question: The outcome of patients with osteoarthritis of the shoulder is better after total shoulder arthroplasty
compared to humeral arthroplasty with regard to:
A. Strength
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B. Pain relief
C. Active forward elevation
D. Active external rotation
E. Ability to sleep
Correct Answer: B. Pain relief

Your Answer: B. Pain relief
Explanation: In his prospective study of 51 shoulder arthroplasties, Gartsman found that pain relief and internal
rotation were significantly better in patients that had undergone glenoid resurfacing compared to hemiarthroplasty.
Patient satisfaction, function, and strength were also higher, but these differences were not statistically different.
12. Question: The outcome of patients with rheumatoid arthritis of the shoulder and an intact rotator cuff is better
after total shoulder arthroplasty compared to humeral arthroplasty with regard to:
A. Strength
B. Pain relief
E. Ability to sleep

Your Answer: C. Active forward elevation
Explanation: Provided the rotator cuff is intact, glenoid resurfacing is preferred in patients with rheumatoid
arthritis of the shoulder because of better pain relief than isolated humeral arthroplasty.
13. Question: Which of the following is most closely associated with glenoid loosening following total shoulder
arthroplasty?
A. Dysfunction of the rotator cuff
C. Osteoarthritis
D. Chondrocalcinosis
E. Osteonecrosis
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Correct Answer: A. Dysfunction of the rotator cuff
Your Answer: C. Osteoarthritis
Explanation: Although glenoid loosening occurs more frequently in patients with rheumatoid arthritis than
osteoarthritis, this loosening occurs secondary to the dysfunction of the rotator cuff. Similarly, osteoarthritic
patients may suffer from the same type of glenoid loosening in the absence of a functioning rotator cuff. Eccentric
loading caused by the cuff deficiency can lead to progressive loosening and a "rocking horse glenoid."
14. Question: All of the following are considered contraindications to glenoid resurfacing during shoulder
arthroplasty except:
A. Dysfunctional deltoid
B. Dysfunctional rotator cuff
C. Prior infection
D. Inadequate glenoid bone stock
E. Patient age < 50 years
Correct Answer: E. Patient age < 50 years

Your Answer: D. Inadequate glenoid bone stock
Explanation: While glenoid loosening rates are higher in younger patients, this does not preclude glenoid
resurfacing in all cases. The remaining choices are all contraindications to glenoid resurfacing.
15. Question: The anatomical neck to humeral shaft angle averages:
A. 30? to 35?
B. 35? to 40?
C. 40? to 45?
D. 45? to 50?
E. 50? to 55?
Correct Answer: C. 40? to 45?

Your Answer: D. 45? to 50?
Explanation: The average neck-shaft angle in the humerus is 40? to 45?; however, a large range has been reported
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(30? to 55?). This variability has led to the anatomical concept of prosthetic adaptability pioneered by Walch.1
16. Question: An absolute contraindication to glenoid resurfacing when performing shoulder arthroplasty is:
A. Patient <50 years of age
B. Presence of a small supraspinatus tear
C. Insufficient bone stock
D. Presence of osteonecrosis of the humeral head
E. Presence of an inflammatory arthropathy
Correct Answer: C. Insufficient bone stock

Your Answer: B. Presence of a small supraspinatus tear
Explanation: Sufficient bone stock must be present to implant a glenoid component when performing shoulder
arthroplasty. While hemiarthroplasty in a young patient without arthritic changes of the glenoid can be considered,
age is not considered an absolute contraindication to glenoid resurfacing. While the presence of a large rotator cuff
tear represents a contraindication to glenoid resurfacing because of the "rocking horse" effect, which results in
glenoid loosening, a small reparable rotator cuff tear does not prohibit resurfacing. Glenoid resurfacing is not
contraindicated in osteonecrosis or rheumatoid arthritis provided there is a competent rotator cuff.
17. Question: The glenoid morphology depicted in the slide is most often associated with the following etiology:
C. Osteonecrosis
D. Post-traumatic arthritis
E. Post-infectious arthritis

Your Answer: D. Post-traumatic arthritis
Explanation:
The slide depicts a type B2 biconcave glenoid as classified by Walch secondary to primary OA.
18. Question: Positioning of the humeral stem at the time of total shoulder arthroplasty should allow congruent
articulation with the glenoid component. Congruent articulation occurs in most shoulders with a humeral stem
positionedin:
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A. Neutral version
B. 10? to 20? of retroversion
C. 20? to 30? of retroversion
D. 10? to 20? of anteversion
E. 20? to 30? of anteversion
Correct Answer: C. 20? to 30? of retroversion

Your Answer: A. Neutral version
Explanation: It is important to place the humeral stem in appropriate version to "mate" with the glenoid
component. This is most often represented by 20? to 30? of humeral retroversion.
19. Question: Posterior translation of the humeral head is associated with which of the following arthritic
etiologies:
C. Post-infectious arthritis
D. Arthritis secondary to osteonecrosis
E. Post-traumatic arthritis

Your Answer: D. Arthritis secondary to osteonecrosis
Explanation: Primary osteoarthritis of the shoulder is a well-described entity. Neer described posterior subluxation
of the humeral head following posterior glenoid erosion.1 Although the exact sequence of events has recently come
into question, the end result is a static posterior subluxation of the humeral head with arthritis.
20. Question: All of the following are involved in rotator cuff tear arthropathy except:
A. Osteonecrosis
B. Chondrolysis
C. Rupture of the rotator cuff
D. Hydroxyapatite crystal deposition

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E. Acromiohumeral arthritis
Correct Answer: B. Chondrolysis

Your Answer: D. Hydroxyapatite crystal deposition
Explanation: Cuff tear arthropathy includes osteonecrosis and acromiohumeral arthritis with a rotator cuff tear.
Other investigators discovered hydroxyapatite crystal deposition as well. Chondrolysis is not a part of rotator cuff
tear arthropathy, but can occur if the individual develops secondary osteoarthritis.
21. Question: The outcome of patients with rheumatoid arthritis of the shoulder and an intact rotator cuff is better
after total shoulder arthroplasty compared to humeral arthroplasty with regard to:
A. Strength
B. Pain relief
E. Ability to sleep

Your Answer: C. Active forward elevation
Explanation: Provided the rotator cuff is intact, glenoid resurfacing is preferred in patients with rheumatoid
arthritis of the shoulder because of better pain relief than isolated humeral arthroplasty.
22. Question: All of the following are considered contraindications to glenoid resurfacing during shoulder
arthroplasty except:
A. Dysfunctional deltoid
B. Dysfunctional rotator cuff
C. Prior infection
D. Inadequate glenoid bone stock
E. Patient age <50 years
Correct Answer: E. Patient age <50 years

Your Answer: D. Inadequate glenoid bone stock
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Explanation: While glenoid loosening rates are higher in younger patients, this does not preclude glenoid
resurfacing in all cases. The remaining choices are all contraindications to glenoid resurfacing.
23. Question: This slide is the radiograph of a 70-year-old man with unremitting shoulder pain despite
nonoperative interventions. Recommended treatment includes:
A. Administration of narcotic pain medications
B. Arthroscopic rotator cuff repair
C. Open rotator cuff repair
D. Humeral head arthroplasty
E. Total shoulder arthroplasty
Correct Answer: D. Humeral head arthroplasty

Your Answer: B. Arthroscopic rotator cuff repair
Explanation: The radiograph demonstrates arthropathy in the presence of rotator cuff deficiency (as indicated by
upward migration of the humeral head). The patient has already failed reasonable medical treatment and surgical
intervention is warranted. The presence of significant arthrosis with upward migration of the humeral head
combined with the patient?s age precludes consideration of rotator cuff repair, although debridement could be
considered. Total shoulder arthroplasty is contraindicated because the deficient cuff would almost certainly result
in glenoid loosening from eccentric loading. Humeral head arthroplasty would provide some pain relief with
limited return of function, and at this time, is the best surgical option for this patient.
24. Question: The goal in performing glenoid resurfacing during total shoulder arthroplasty for the patient whose
computed tomogram is shown in this slide should be:
A. Placement of the glenoid component in situ
B. Placement of the glenoid component in neutral to 10? of anteversion
C. Placement of the glenoid component in neutral to 10? of retroversion
D. Placement of the glenoid component in 10? to 20? of retroversion
E. Placement of the glenoid component in excess of 20? of retroversion
Correct Answer: C. Placement of the glenoid component in neutral to 10? of retroversion

Your Answer: B. Placement of the glenoid component in neutral to 10? of anteversion
Explanation: The computed tomogram depicts a type B2 glenoid with excessive posterior wear resulting in
biconcavity and excessive glenoid retroversion. The goal of glenoid arthroplasty should be to reestablish normal
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glenoid retroversion between neutral and 10?. This may be done with reaming or, in severe cases, may necessitate
the use of a posterior bone graft. Implanting the glenoid component in excessive retroversion may result in
postoperative instability.
25. Question: This slide is an intraoperative photograph during total shoulder arthroplasty. The findings in this
slide most likely represent which of thefollowing diagnoses:
B. Rotator cuff tear arthropathy
C. Rheumatoid arthritis
D. Osteonecrosis
E. Postinfectious arthropathy

Your Answer: C. Rheumatoid arthritis
Explanation: The large amount of crown osteophytes present in this slide suggest a diagnosis of primary
osteoarthritis. It is necessary to remove these osteophytes in order to identify the anatomical neck of the humerus
and make the correct humeral head resection.
26. Question: This slide shows a magnetic resonance image from a patient with shoulder pain. Based on the
findings of this image, the following procedure is contraindicated:
A. Subacromial corticosteroid injection
B. Arthroscopic debridement of the rotator cuff
C. Shoulder arthrodesis
D. Humeral head arthroplasty
E. Unconstrained total shoulder arthroplasty
Correct Answer: E. Unconstrained total shoulder arthroplasty

Your Answer: B. Arthroscopic debridement of the rotator cuff
Explanation: The magnetic resonance image depicts near complete fatty infiltration of the supraspinatus muscle
and, more importantly, the infraspinatus muscle. Initially, fatty degeneration of the cuff musculature was described
as a poor prognostic indicator for rotator cuff function using computed tomography. These observations were also
applied to magnetic resonance imaging. Walch advises against performing unconstrained total shoulder
arthroplasty in patients with a dysfunctional cuff as indicated by fatty degeneration of the infraspinatus because of
poorer results regarding pain relief and active mobility.1 Furthermore, this degeneration can lead to early glenoid
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loosening from eccentric loading.
27. Question: A 42-year-old male has a history of 6 months of pain in the lower thoracic region. Recently, the
patient developed weakness in the right lower extremity, bladder and bowel movement. Plain x-rays were normal,
but an magnetic resonance imaging (MRI) showed a posterolateral thoracic disk herniation at the level of T10-T11
(Slides 1 and 2). Which of the following is the best suggested treatment?
A. Bed rest
B. Thoraco-lumbar orthosis
C. Laminectomy and decompression
D. Diskectomy through thoracotomy or costotransverectomy
E. Thoracotomy, vertebractomy, strut graft and internal fixation
Correct Answer: D. Diskectomy through thoracotomy or costotransverectomy

Your Answer: C. Laminectomy and decompression
Explanation: Conservative treatment should be considered for patients without major neurologic deficits.
Posterior laminectomy and decompression provides inadequate exposure of the herniated Disk. Vertebractomy,
strut bone graft and instrumentation are not necessary. Thoracotomy and costotransversectomy are commonly used
for disk herniations at the levels of T4-T12.
28. Question: The patient was diagnosed with spinal stenosis of the lumbosacral spine. In addition to educating the
patient about his condition, the most appropriate initial treatment is:
A. Walking program
B. Nonsteroidal anti-inflammatory drugs
C. Lumbar traction
D. Spinal decompression and fusion
E. Cortisone administration
Correct Answer: B. Nonsteroidal anti-inflammatory drugs

Your Answer: A. Walking program
Explanation: Initial treatment begins with patient education, a physical therapy regime (gentle conditioning
exercises), judicious activity change, and sometimes spinal support with a corset or light-weight brace. Anti-
inflammatory nonsteroidal drugs provide some relief of symptoms for many patients.
29. Question: The patient's clinical diagnosis is degenerative spondylolithesis. In what patient population is this
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condition most commonly symptomatic?
A. Pre-teen males
B. Females 40 to 70 years old
C. Males over 70 years old
D. Females 20 to 30 years old
E. Males 20 to 30 years old
Correct Answer: B. Females 40 to 70 years old

Your Answer: C. Males over 70 years old
Explanation: Degenerative spondylolithesis is most frequently symptomatic in the 40 to 70 year old range and is
six times more common in females than in males. This population appears to have enough disk degeneration and
motion to become symptomatic whereas the older population tend to have aquired enough ankylosis at the level to
prevent instability symptoms.
30. Question: The biceps electromyographic activity is greatest during which of the following elbow motions:
A. Elbow extension from 90? of flexion
B. Elbow supination at 90? of flexion
C. Elbow supination at 45? of flexion
D. Flexion from 90? in supination
E. Flexion from 90? in pronation
Correct Answer: D. Flexion from 90? in supination

Your Answer: C. Elbow supination at 45? of flexion
Explanation: Electromyographic activity of the biceps is greatest from flexion at 90? in supination indicating that
this arc of motion is where there is the most sustained contraction of the biceps muscle.
31. Question: Which of the following is not an appropriate method of treating an elbow joint contracture that has
been present for less than 1 year:
A. Closed manipulation
B. Local heat
C. Static adjustable splinting (turnbuckle splint)

22
D. Dynamic hinged elbow splint
E. Active gentle-assisted stretch
Correct Answer: A. Closed manipulation

Your Answer: B. Local heat
Explanation: The least appropriate treatment for elbow joint contracture is closed manipulation. The elbow is a
sensitive joint, and strenous closed manipulation leads to more bone formation or even possible fracture. The other
less drastic measures are more appropriate treatment methods.
32. Question: The principle complication of constrained and semiconstrained total elbow arthroplasty is:
A. Heterotopic bone formation
B. Elbow subluxation and instability
C. Loosening of the ulnar component
D. Stress shielding in the humerus
E. Loosening of the humeral component
Correct Answer: C. Loosening of the ulnar component

Your Answer: D. Stress shielding in the humerus
Explanation: Ulnar component loosening is the most common complication of total elbow arthroplasty. Although
other complications also occur, they are less common.
33. Question: The best method for testing the integrity of the anterior oblique band of the medial collateral
ligament is:
A. Valgus stress in 30? of flexion and full supination
B. Valgus stress in 60? of flexion and neutral rotation
C. Varus stress in 30? of flexion and slight pronation
D. Valgus stress in 30? of flexion and full pronation
E. Varus stress in full extension and full pronation
Correct Answer: D. Valgus stress in 30? of flexion and full pronation

Your Answer: B. Valgus stress in 60? of flexion and neutral rotation
23
Explanation: The anterior oblique band of the medial collateral ligament is best tested by valgus stress when the
elbow is at 30? of flexion and full pronation.
34. Question: Which tendon transfer results in the greatest recovery of thumb-index finger pinch function?
A. Flexor digitorum superficials of ring finger
B. Extensor indicis proprius
C. Extensor digitorum communis
D. Extensor carpi radialis brevus
E. Flexor digitorum superficials of middle finger
Correct Answer: D. Extensor carpi radialis brevus

Your Answer: B. Extensor indicis proprius
Explanation: The extensor carpi radialis brevus or extensor carpi radialis longus transfer gives the greatest return
of power pinch due to the strength of the wrist motors. This should also be coupled with a thumb MP arthrodesis to
provide best results.
35. Question: Which of the following terms is used to describe a localized conduction block in a peripheral nerve
in which the axon is disrupted with the intact endoneurial tube:
A. First-degree injury (neuropraxia)
B. Second-degree (axonotmesis)
C. Third-degree
D. Fourth-degree
E. Fifth-degree
Correct Answer: B. Second-degree (axonotmesis)

Your Answer: B. Second-degree (axonotmesis)
Explanation:
 First-degree: Neuropraxia, the nerve structure is intact, full recovery is expected
 Second-degree: Axonotmesis, severance of the axon leading to Wallerian degeneration, continuity of
endoneurial sheath is maintained, repair is orderly, complete motor and sensory loss with denervation and
fibrillation potentials
 Third-degree: Injury to axons and the endoneurial tube, arrangement of individual fascicles is maintained
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(perineurium intact), recovery is variable
 Fourth-degree: Injury to axons, endoneurial tube, fascicles with the nerve trunk being intact, Wallerian
degeneration and a higher incidence of proximal nerve cell body degeneration, repair is unlikely and surgical
repair of the nerve is necessary (excision and grafting)
 Fifth-degree: Loss of nerve trunk continuity, neuroma formation in the proximal stump, wallerian
degeneration distally
36. Question: When a patient has his or her hip flexed, which nerve can be palpated at the midpoint between the
ischial tuberosity and the greater trochanter:
A. Obturator nerve
B. Femoral nerve
C. Peroneal nerve
D. Sciatic nerve
E. No nerve typically exists in that region
Correct Answer: D. Sciatic nerve

Your Answer: C. Peroneal nerve
Explanation:
The sciatic nerve is in the posterior compartment of the thigh and can be palpated at the midpoint between the
ischial tuberosity and the greater trochanter when the hip is flexed.
 The obturator nerve is in the medial compartment of the thigh.
 The femoral nerve is in the anterior compartment of the thigh.
 The peroneal (common peroneal) nerve bifurcates into the deep peroneal and the superficial peroneal
nerves which lie in the anterior and lateral compartments of the leg, respectively.
37. Question: The principal thrombogenic stimulus leading to the production of venous thromboembolic disease
during total hip arthroplasty occurs at which time:
A. During induction of anesthesia
B. During and after preparation of femoral canal
C. 12 hours postoperative
D. 24 hours postoperative
E. 7 days postoperative
Correct Answer: B. During and after preparation of femoral canal

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Your Answer: A. During induction of anesthesia
Explanation:
Evidence has shown that the process of thrombosis does not begin with the start of the procedure, rather, it is
delayed until preparation of the femoral canal. Elevation in thrombogenic factors is most pronounced during
preparation of the femoral canal and especially with insertion of a cemented femoral component. Mechanical
manipulation of the limb (dislocation of the femoral head) may also cause intimal damage or occlusion of the
femoral vein.
38. Question: Place the following in the correct order of increasing modulus of elasticity (from least to greatest):
A. Cobalt-chrome, titanium, compact bone, stainless steel
B. Titanium, compact bone, cobalt-chrome, stainless steel
C. Compact bone, titanium, cobalt-chrome, stainless steel
D. Compact bone, titanium, stainless steel, cobalt-chrome
E. Titanium, compact bone, stainless steel, cobalt-chrome
Correct Answer: D. Compact bone, titanium, stainless steel, cobalt-chrome

Your Answer: B. Titanium, compact bone, cobalt-chrome, stainless steel
Explanation: The correct order of modulus of elasticity is as follows in Gpa (psi x 106 ):
Compact
21 (3)
bone:
96
Titanium:
(14)
Stainless 193
Steel: (28)
Cobalt- 235
Chrome: (34)
39. Question: In a patient with a previous compression hip screw in place at the time of total hip arthroplasty, what
precautionary measures should be undertaken after hardware removal to prevent a periprosthetic fracture:
A. Cemented femoral component with cement augmentation of the screw holes, full weight bearing
B. Plate augmentation with circlage wires, protected weight bearing
C. Regular femoral prosthesis with toe touch weight bearing for 6 weeks
D. Cortical strut allograft, protected weight bearing

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E. Bypassing the last screw hole with a cemented femoral component by two cortical diameters, protected
weight bearing
Correct Answer: E. Bypassing the last screw hole with a cemented femoral component by two cortical
diameters, protected weight bearing
Your Answer: A. Cemented femoral component with cement augmentation of the screw holes, full weight bearing
Explanation:
Stress risers are generated when a screw is removed from the femur, weakening the bone for at least 4 weeks.
Larger defects (50% of the cortical width) can reduce torsional strength up to 44%. Bypassing the defect by two
cortical diameters with a cemented stem doubles the bone?s strength.
40. Question: Which of the following radiographic changes can be expected after placement of a fully porous-
coated cobalt chrome femoral stem:
A. Proximal femoral osteopenia
B. Distal femoral osteopenia
C. Radiolucency around the acetabular cup
D. Increased mineralization proximally
E. Osteopenia adjacent to the entire femoral component
Correct Answer: A. Proximal femoral osteopenia

Your Answer: B. Distal femoral osteopenia
Explanation:
The most severe stress shielding occurs with an extensively porous-coated, chrome-cobalt stem. This occurs as the
load is transferred from the hip joint to the proximal femur. The load that was previously carried by the hip joint is
now shared by the implant. This change will lead to remodeling of the proximal femur, resulting in a decreased
density and thinning of the proximal portion of the femur. In a group of patients characterized as having severs
stress shielding based on plain radiographs, no adverse effects were noted n terms of hip scores, presence of
osteolysis, or need for revision.
41. Question: Noncircumferential porous coating has been shown to lead to which adverse affect:
A. Increased rates of infection
B. Increased rates of stress shielding
C. Increased rates of distal osteolysis and late femoral loosening

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D. Increased rates of thigh pain
E. Increased rates of acetabular osteolysis and late cup loosening
Correct Answer: C. Increased rates of distal osteolysis and late femoral loosening
Your Answer: C. Increased rates of distal osteolysis and late femoral loosening
Explanation:
Noncircumferential porous coating may allow a pathway for particulate debris (polywear) to the distal part of the
stem, promoting osteolysis.
42. Question: Position for hip arthrodesis is best stated as:
A. Neutral abduction/adduction, 20? to 30? flexion, neutral internal/external rotation
B. Neutral abduction/adduction, full extension, neutral internal/external rotation
C. 20? abduction, 20? to 30? flexion, neutral internal/external rotation
D. Neutral abduction/adduction, 20? to 30? flexion, 15? to 20? internal rotation
E. Neutral abduction/adduction, 45? flexion, neutral internal/external rotation
Correct Answer: A. Neutral abduction/adduction, 20? to 30? flexion, neutral internal/external rotation
Your Answer: B. Neutral abduction/adduction, full extension, neutral internal/external rotation
Explanation:
The favored position of arthrodesis is 20? to 30? flexion, neutral (or minimal adduction) adduction/abduction, and
neutral internal/external rotation (can be slight external rotation). Insufficient flexion makes sitting difficult, while
too much will make standing difficult due to increased lumbar lordosis. Abduction and internal rotation should be
avoided.
43. Question: The position putting a total hip arthroplasty most at risk for an anterior dislocation is:
A. Flexion, adduction, internal rotation
B. Flexion, abduction, internal rotation
C. Extension, adduction, external rotation
D. Extension, adduction, internal rotation
E. Flexion, adduction, external rotation

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Correct Answer: C. Extension, adduction, external rotation
Your Answer: D. Extension, adduction, internal rotation
Explanation:
The most common direction for dislocation of a total hip arthroplasty is posterior. It may be associated with a
posterior approach, poor technique, and/or previous surgery. Posterior dislocations can be accentuated by placing
the hip in flexion, adduction, and internal rotation (i.e., rising from a low-seated chair). Less common anterior
dislocations can occur after an anterior approach or with anteversion of the cup or femoral component (or both).
The position for dislocation is accentuated by extension, adduction, and external rotation.
44. Question: Loosening of a cemented metal backed polyethylene acetabular component occurs at which of the
following junctions:
A. The cement bone interface
B. The cement metal interface
C. The metal polyethylene interface as a result of micromotion
D. Result of fracture and dissolution through the structure of the cement itself
E. Both the cement-bone and cement-metal interface
Correct Answer: A. The cement bone interface

Your Answer: A. The cement bone interface
Explanation:
Autopsy studies have shown that the loosening of cemented components occurs at the cement bone interface. This
loosening occurs first at the periphery and proceeds toward the dome. This is most likely an extension of the
pseudocapsule. The bone resorption at the cement-bone interface appears to be a result of a response to
polyethylene debris.
45. Question: Placement of a screw in the anterior superior quadrant of the acetabulum will place which structure
at risk:
A. Internal iliac artery
B. Bladder
C. Common iliac vein
D. External iliac vein
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E. Common iliac artery
Correct Answer: D. External iliac vein

Your Answer: C. Common iliac vein
Explanation:
Placement of screws in the acetabular cup in the anterior superior or anterior inferior quadrant is not advised due to
the proximity of the external iliac vein and the obturator artery, respectively.
46. Question: During revision surgery for a total hip arthroplasty, the accepted standard for the presence of an
infection on frozen tissue histological analysis is:
A. Five mononuclear cells per high-powered field
B. Ten mononuclear cells per high-powered field
C. Five polymorphonuclear cells per high-powered field
D. Ten polymorphonuclear cells per high-powered field
E. One bacterium per high-powered field
Correct Answer: C. Five polymorphonuclear cells per high-powered field

Your Answer: A. Five mononuclear cells per high-powered field
Explanation:
Frozen section analysis is important in revision surgery to determine why a component has become loose. Ten
polymorphonuclear cells (PMNs) per high-powered field lowers the sensitivity for infection but does not reduce
the specificity to diagnose an infection. Five PMNs per high-powered field is the current standard that is accepted
as diagnostic for an infection. Mononuclear cells can be present in the face of aseptic loosening or polywear
disease. PMNs are diagnostic of a biologic infectious response.
47. Question: Which of the following is not a significant risk factor for the development of heterotopic
ossification:
A. Hypertrophic osteoarthritis
B. Ankylosing spondylitis
C. Posttraumatic arthritis
D. Previous osteonecrosis
E. Previous formation of heterotopic ossification

30
Correct Answer: D. Previous osteonecrosis
Your Answer: B. Ankylosing spondylitis
Explanation:
Heterotopic ossification is seen more in men than in women. It is also more common in patients with hypertrophic
osteoarthritis, posttraumatic arthritis, ankylosing spondylitis, longer operative times, and especially previous
heterotopic bone formation. Anterior and lateral approaches have a higher incidence.
48. Question: Long stemmed tibial components for revision total knee arthroplasty are not cemented for which of
the following reasons:
A. Extensive stress shielding
B. Difficulty in removal
C. Infection risk
D. Asymmetric wear
E. Hypotension with insertion
Correct Answer: A. Extensive stress shielding

Your Answer: B. Difficulty in removal
Explanation:
A cemented tibial stem will stress shield the tibial cortex for the entire length of the stem. Proximal bone resorption
will occur as a result.
49. Question: Unicompartmental arthroplasty is contraindicated in which patient:
A. A patient with osteonecrosis of medial condyle
B. A patient with osteoarthritis of medial condyle
C. A patient with rheumatoid arthritis concentrated in the medial compartment
D. A patient with posttraumatic arthritis of the medial tibial plateau
E. A patient with prior patellectomy with medial compartment osteoarthritis
Correct Answer: C. A patient with rheumatoid arthritis concentrated in the medial compartment
Your Answer: C. A patient with rheumatoid arthritis concentrated in the medial compartment
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Explanation:
Unicompartmental arthroplasty is a viable alternative to total knee arthroplasty in select patients. The most
common indications for unicompartmental replacement are osteonecrosis, osteoarthritis, and posttraumatic arthritis
isolated to one compartment. Patients with prior patellectomies may do well with a unicompartmental replacement.
Contraindications to unicompartmental replacement are inflammatory arthritides (i.e., rheumatoid arthritis) due to
whole knee involvement, young patients unwilling to stop work or sport, or a history of recent infection.
50. Question: If a metal-backed tibial component is used for total knee arthroplasty, what is the minimum
thickness of polyethylene to be used to prevent accelerated wear:
A. 4 mm to 6 mm
B. 12 mm to 14 mm
C. 8 mm to 10 mm
D. 10 mm to 12 mm
E. Whatever polyethylene thickness balances the knee correctly
Correct Answer: C. 8 mm to 10 mm
Your Answer: C. 8 mm to 10 mm
Explanation:
If a metal-backed tibial component is used in total knee arthroplasty, a minimum component thickness of 8 mm to
10 mm of polyethylene should be used. Contact stresses increase dramatically and non-linearly as a thickness of 6
mm or less is used.
Thank you.
Hyperguide Staff.
1. Question: Which of the following is not a contraindication for high tibial osteotomy to treat medial
compartment arthritis:
A. Obesity
B. Age greater than 65
C. Rheumatoid arthritis
D. Prior medial and lateral menisectomy

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E. A young patient unwilling to stop high activity occupation
Correct Answer: E. A young patient unwilling to stop high activity occupation

Your Answer: B. Age greater than 65
Explanation:
High tibial osteotomy can be performed in younger individuals with isolated medial compartment disease. High
impact an excessive loading activities can be tolerated after osteotomy, whereas these activities are prohibited with
prosthetic joint replacement. Contraindications include those older than 65 years of age, inflammatory arthritis, and
previous medial and lateral menisectomies, as they would be better served with total joint arthroplasty. Obesity is
associated with early failure in high tibial osteotomy.
2. Question: In preoperative evaluation for total knee arthroplasty, a patient is seen to have three previous incisions
over the anterior knee. Two are longitudinal, 2.5 cm apart over the anterior aspect of the patella. One is transverse.
All incisions are healed. Which incision should be used to decrease the likelihood of skin necrosis:
A. The medial most longitudinal incision
B. The lateral most longitudinal incision
C. The transverse incision as the skin will slough with either of the previous longitudinal incisions
D. A new midline incision between the two longitudinal incision
E. The longitudinal incision that will allow for best exposure
Correct Answer: B. The lateral most longitudinal incision

Your Answer: A. The medial most longitudinal incision
Explanation:
Prior surgical incisions are a potential for post-operative wound problems. Usually, the lateral most longitudinal
incision is best used. A large lateral flap has been associated with postoperative wound problems. The lateral flap
has shown less oxygen concentration in studies, therefore, making a small lateral flap is preferred. Transverse
incisions can be crossed with relative impunity if the angle is greater than 60?.
3. Question: A patient who underwent a posterior stabilized total knee arthroplasty 10 months ago has new
complaints of knee pain and popping. This pain was exacerbated with climbing stairs and rising from a chair. An
audible and palpable clunk is heard with terminal extension. Range of motion is from 0? to 110?, and there is no
evidence of instability with examination. A pop is felt with active extension in the terminal 15? to 30? of motion.
The best treatment is:
A. Revision arthroplasty
33
B. Nonsteroidal anti-inflammatory medicines
C. Revision to a condylar constrained type prosthesis
D. Arthroscopic debridement or open revision of the patellar component
E. Patellectomy
Correct Answer: D. Arthroscopic debridement or open revision of the patellar component

Your Answer: C. Revision to a condylar constrained type prosthesis
Explanation:
Patellar "clunk" syndrome is a type of peripatellar fibrous hyperplasia characterized by a discrete suprapatellar
fibrous nodule. This nodule lodges into the femoral component intercondylar notch dung flexion and displaces with
an audible, often painful, clunk with extension. This condition is isolated to posterior stabilized femoral
components, and not evident in posterior cruciate ligament retaining prostheses. Initial treatment is physical
therapy, which is sometimes successful. Most commonly, either an arthroscopic debridement or open revision of
the patellar component and fibrous hyperplasia is needed for resolution of symptoms.
4. Question: A patient has a displaced supracondylar femur fracture 6 cm proximal to a well-fixed, posterior
stabilized component. This knee was asymptomatic prior to fracture. Treatment should include which of the
following:
A. Cast bracing
B. Traction
C. Revision to a long stemmed femoral component
D. Retrograde nail fixation with retention of femoral component
E. Plate fixation (Dynamic Condylar Screw or fixed angle blade) with retention of femoral component
Correct Answer: E. Plate fixation (Dynamic Condylar Screw or fixed angle blade) with retention of femoral
component
Your Answer: B. Traction
Explanation:
In fractures above a well-fixed femoral component, all attempts should be made to retain the component. The
fracture must be aligned correctly and stabilized to permit early range of motion of the extremity. Casting or
traction will likely result in loss of motion, while early range of motion without internal fixation can lead to
malunion. Posterior stabilized femoral components with closed housing prohibit retrograde intramedullary nailing.
5. Question: Resection of too little distal femur will have what effect on the "flexion/extension gap" with regard to
ligamentous balancing:
34
A. Increase flexion gap (loose in flexion)
B. Increase extension gap (recurvatum)
C. Decrease flexion gap (tight in flexion)
D. Decrease extension gap (flexion contracture)
E. Will not affect gap if appropriate polyethylene is used
Correct Answer: D. Decrease extension gap (flexion contracture)

Your Answer: C. Decrease flexion gap (tight in flexion)
Explanation:
The extension gap is created with the distal femur and the proximal tibial cuts. The flexion gap is created with the
posterior femur and the proximal tibial cuts. Altering the tibial cut will alter the flexion and extension gaps equally.
Altering the distal femur cut alone will have an effect exclusively on the extension gap.
6. Question: Excessive internal rotation of the tibial component should be avoided because of which resultant
effect:
A. Net internal rotation of tibial tubercle, increased wear
B. Net external rotation of tibial tubercle, patellar subluxation
C. Net internal rotation of the leg causing the patient to in-toe
D. Net external rotation of the leg causing thigh pain
E. Will likely have no effect if ligaments are balanced
Correct Answer: B. Net external rotation of tibial tubercle, patellar subluxation

Your Answer: C. Net internal rotation of the leg causing the patient to in-toe
Explanation: Internal rotation of the tibial component will cause external rotation of the tibial tubercle with an
increased Q angle. An increased Q angle will cause an increase in patellar subluxation force and maltracking.
7. Question: A 65-year-old patient presents with complaints of giving way in her knee. She underwent a total knee
arthroplasty 2 years ago. Intraoperatively, the medial collateral ligament was disrupted, but repaired primarily. This
has gone on to give the patient instability when she ambulates. Physical therapy and bracing have not helped. On
radiographic examination, the components are well fixed and in appropriate position. Physical examination reveals
a range of motion from 0? to 130? with no anteroposterior laxity. There is laxity at 0?, 45?, and 90? to valgus
stress. Appropriate treatment should now consist of:
35
A. Ipsilateral semitendinosis and gracillis autograft reconstruction of the medial collateral ligament
B. Contralateral semitendinosis and gracillis autograft reconstruction of the medial collateral ligament
C. Allograft Achilles tendon reconstruction of the medial collateral ligament
D. Contralateral bone-patellar-tendon autograft reconstruction of the medial collateral ligament
E. Revision to a constrained-condylar type prosthesis
Correct Answer: E. Revision to a constrained-condylar type prosthesis

Your Answer: C. Allograft Achilles tendon reconstruction of the medial collateral ligament
Explanation: This patient has an incompetent medial collateral ligament throughout range of motion. If the
disruption is caught early enough in surgery, primary repair can be made with satisfactory results. Ligamentous
reconstruction without conversion to a constrained prosthesis with varus/valgus stability has been shown to be
ineffective.
8. Question: When comparing the subvastus approach to the medial parapatellar approach to the knee for total
knee arthroplasty, which of the following statements is true:
A. Range of motion is better long term for the subvastus approach.
B. The need for lateral retinacular release is more common in the medial parapatellar approach.
C. The subvastus approach is more technically difficult and exposure is more difficult than a medial
parapatellar approach.
D. Patella subluxation is more common in the medial parapatellar approach.
E. The subvastus approach is associated with more wound complications than the medial parapatellar
approach.
Correct Answer: C. The subvastus approach is more technically difficult and exposure is more difficult than a
medial parapatellar approach.
Your Answer: B. The need for lateral retinacular release is more common in the medial parapatellar approach.
Explanation: The subvastus approach is associated with less wound complications than the medial parapatellar
incision. The skin can be tight in flexion with a medial parapatellar incision; however, this is not common with the
subvastus incision. In a series of 28 bilateral knees, Ritter and colleagues, compared a subvastus approach with the
traditional medial parapatellar approach. Complications and range of motion between sides were equal. They did
note, however, that exposure was much more difficult with the subvastus approach.
9. Question: The most common extensor mechanism complication in total knee arthroplasty is:
36
A. Patella fracture
B. Patellar instability
C. Patellar clunk
D. Quadriceps tendon rupture
E. Patellar tendon rupture
Correct Answer: B. Patellar instability

Your Answer: D. Quadriceps tendon rupture
Explanation:
Patellar instability is the most frequent extensor mechanism complication. Most often it is manifested as
subluxations or dislocation. Sometimes abnormal component wear or patella fractures are a result of abnormal
patellar tracking. These consequences are usually the inevitable result of component malposition, limb
malalignment, improper patellar preparation, improper component design, or trauma. Each of these mechanisms
may be at play whether or not the patella is resurfaced.
10. Question: A patient with a 35? valgus deformity and a 20? flexion contracture of the knee undergoes primary
total knee arthroplasty successfully. In the recovery room, the patient is seen to have no dorsiflexion of the foot or
toes and numbness over the dorsum of the foot. There is no pain with passive range of motion of the foot and calf
compartments are soft. The next appropriate step is:
A. Re-observation in 30 minutes, leg elevation, and ice
B. Bring the patient back to the operating room to explore the peroneal nerve
C. Fasciotomies of the leg
D. Remove the dressings and flex the leg
E. Strict extension splinting, removal of the constrictive dressings
Correct Answer: D. Remove the dressings and flex the leg

Your Answer: A. Re-observation in 30 minutes, leg elevation, and ice
Explanation:
Peroneal palsy after total knee arthroplasty is a rare but significant complication after total knee arthroplasty.
Incidence is higher in revision surgeries and those with flexion and valgus contractures. Postoperative constrictive
dressings and hematomas may also cause or contribute to nerve ischemia or injury. Treatment of the peroneal palsy
should initially be nonoperative. Removal of constrictive dressings and flexion of the knee will relieve pressure on
the peroneal nerve. AFO will help with ambulation. Surgical exploration of the nerve is of no value and may
exacerbate injury.
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11. Question: A 70-year-old patient with a past history of prostate cancer treated with pelvic irradiation wishes to
have a total hip arthroplasty for severe unilateral hip osteoarthritis. What is the most likely consequence of
cementless fixation of the acetabular cup:
A. Fracture
B. Bleeding
C. Thromboembolic phenomenon
D. Abductor weakness
E. Aseptic loosening of the acetabular cup
Correct Answer: E. Aseptic loosening of the acetabular cup

Your Answer: B. Bleeding
Explanation:
Forty-four percent of patients in one study showed failure of fixation to bone of the acetabular cup after previous
pelvic irradiation. This study demonstrates the high failure of porous ingrowth in the presence of previous
irradiation in the acetabulum. It is therefore recommended to cement the acetabular cup or to use a protrusio-type
cage with cement in this subset of patients. This is secondary to the loss of vascularity and viability of the bone
caused by irradiation.
12. Question: In patients with osteoarthritis, mechanical forces induce changes in the form and structure of many
biologic materials including bone and cartilage. This effect is known as:
A. Wolffs law
B. Kochs postulate
C. Hilgenreiners law
D. Singhs index
E. Evans law
Correct Answer: A. Wolffs law

Your Answer: C. Hilgenreiners law
Explanation: According to Wolffs law, stresses and strains contribute to bone density, strength, and ultimate shape
of bone and internal trabecular arrangement.
38
13. Question: The reduction mechanism of venous thromboembolism from epidural anesthesia in total joint
replacement is:
A. Inhibition of platelet adhesion
B. Stimulation of endothelial fibrinolysis
C. Sympathetic effect of epidural blockage
D. Decreased lower extremity blood flow
E. Increased lower extremity blood flow
Correct Answer: C. Sympathetic effect of epidural blockage

Your Answer: D. Decreased lower extremity blood flow
Explanation: The sympathetic effect of epidural blockage results in increased lower extremity blood flow, which
is responsible for the reduction of venous thromboembolism by mitigating the adverse effects of stress.
14. Question: Which of the following is not a clinical sign of pulmonary embolism:
A. Pleuritic chest pain and pleural rub
B. Bradycardia
C. Tachypnea
D. Dyspnea
E. Pleural rub
Correct Answer: B. Bradycardia

Your Answer: D. Dyspnea
Explanation: Tachycardia, as well as pleuritic chest pain, pleural rub, tachypnea, and dyspnea, are the most
common clinical symptoms of pulmonary embolism. Bradycardia is not a clinical sign of pulmonary embolism.
15. Question: In total joint replacement, osteolysis that results in bone loss and bone resorption is caused by:
A. Breakdown of polymethylmethacrylate
B. Polyethylene debris
C. Metal debris
D. Hydroxyapatite
39
E. Allergic reaction to titanium
Correct Answer: B. Polyethylene debris

Your Answer: C. Metal debris
Explanation: Osteolysis, which results in bone loss and bone resorption, is caused by polyethylene debris.
16. Question: Bone grafts (autograft) used to restore bone stock in total joint replacements are the result of what
biologic process:
A. Osteogenesis
B. Osteoinduction
C. Osteoconduction
D. Osteogenesis and osteoinduction
E. Osteogenesis, osteoinduction, and osteoconduction
Correct Answer: E. Osteogenesis, osteoinduction, and osteoconduction

Your Answer: C. Osteoconduction
Explanation: Bone formation from osteoblasts (osteogenesis), recruiting host mesenchymal cells and
differentiating them into bone-forming cells (osteoinduction), and the ingrowth of blood vessels and
osteoprogenitor cells (osteoinduction) are important in influencing bone graft function.
17. Question: Ceramics are used as an osteoconductive bone-graft material. The optimal pore size is:
A. 50 [mu]m to 100 [mu]m
B. 100 [mu]m to 150 [mu]m
C. 150 [mu]m to 500 [mu]m
D. 500 [mu]m to 700 [mu]m
E. 800 [mu]m to 1000 [mu]m
Correct Answer: C. 150 [mu]m to 500 [mu]m

Your Answer: E. 800 [mu]m to 1000 [mu]m
Explanation: The optimal pore size of osteoconductive ceramics is between 150 [mu]m to 500 [mu]m. Smaller or
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larger pore sizes are not as effective.
18. Question: The American College of Cardiology recommends that a patient wait how long after a myocardial
infarction before undergoing a total hip replacement:
A. 3 weeks
B. 6 weeks
C. 3 months
D. 6 months
E. 1 year
Correct Answer: B. 6 weeks

Your Answer: B. 6 weeks
Explanation: The American College of Cardiology presently recommends that a patient wait 6 weeks after a
myocardial infarction before undergoing a total hip replacement. There is increased risk of complication if a total
hip replacement is performed before 6 weeks.
19. Question: Patients with rheumatoid arthritis must be radiologically evaluated for this condition:
A. Odontoid abnormality
B. C1 - C2 subluxation
C. C2 - C3 subluxation
D. C3 - C4 subluxation
E. C4-C5 subluxation
Correct Answer: B. C1 - C2 subluxation

Your Answer: C. C2 - C3 subluxation
Explanation: Patients with rheumatoid arthritis must be carefully evaluated for cervical spine subluxation, which
is characterized by atlantoaxial translation on flexion-extension views of the cervical spine.
20. Question: In hypotensive total joint replacement surgery, the mean blood pressure is kept at:
A. 50 mm Hg
B. 60 mm Hg
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C. 70 mm Hg
D. 80 mm Hg
E. 90 mm Hg
Correct Answer: B. 60 mm Hg
Your Answer: D. 80 mm Hg
Explanation: Using a combination of volatile anesthetics, narcotics, and vasodilators, the mean blood pressure is
kept at 60 mm Hg during hypotensive total joint replacement surgery. This is the lowest pressure that can be
obtained and still be within safety parameters.
21. Question: The optimal position of a patient?s knee during total knee replacement surgery is:
A. 3? of anatomic valgus
B. 5? of anatomic valgus
C. 7? of anatomic valgus
D. 8? of anatomic valgus
E. Neutral
Correct Answer: C. 7? of anatomic valgus

Your Answer: C. 7? of anatomic valgus
Explanation: The optimal position of a patient?s knee during total knee replacement surgery is 7? of anatomic
valgus as measured between the mechanical and anatomic axis. More or less valgus is not optimal.
22. Question: The optimal position for the acetabular cup during total hip replacement surgery is:
A. Neutral version
B. 5? anteversion
C. 15? anteversion
D. 30? anteversion
E. 45? anteversion
Correct Answer: C. 15? anteversion

Your Answer: C. 15? anteversion
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Explanation: The optimal cup position of a patient?s hip during total hip replacement surgery is 15? of cup
anteversion as measured on a lateral radiograph of the groin. More or less anteversion is not optimal. The femoral
stem version needs to be part of the equation.
23. Question: Gallium-67 citrate used in scanning techniques can result in increased gallium-67 localization in:
A. Infection
B. Fracture
C. Aseptic loosening
D. Infection and fracture
E. Infection, fracture, and aseptic loosening
Correct Answer: E. Infection, fracture, and aseptic loosening

Your Answer: B. Fracture
Explanation: Although increased gallium-67 citrate localization is found in infection, there are also significant
false-positive results in fracture and aseptic loosening. It is more specific for infection but increased localization is
seen in all three conditions.
24. Question: The most specific scanning method to detect infection in total joint replacement is:
A. White blood cell scanning
B. Technetium bone scanning
C. Sequential technetium bone scans
D. Sequential gallium-67 citrate scans
E. A combination of white blood cell scanning and technetium bone scanning
Correct Answer: E. A combination of white blood cell scanning and technetium bone scanning
Your Answer: B. Technetium bone scanning
Explanation: White blood cell scanning combined with technetium bone scanning is more specific for the
diagnosis of infection than sequential technetium bone scans or sequential gallium-67 citrate scans.
25. Question: Outcomes, as opposed to traditional results, are more reliable because they include:
A. Measured and recorded clinical results

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B. Economic consequences only
C. Social consequences and political consequences
D. Political consequences only
E. Measured and recorded clinical results, economic consequences, and social consequences
Correct Answer: E. Measured and recorded clinical results, economic consequences, and social consequences
Your Answer: B. Economic consequences only
Explanation: The study of outcomes is characterized by broadening the definition of surgical results from strictly
clinical to the economic, social, and political consequences. All of these factors must be considered in analyzing
surgical results in the study of outcomes.
26. Question: The anterolateral (Watson-Jones) approach to the hip dissects in an interval between:
A. The gluteus medius and gluteus minimus
B. The gluteus medius and tensor fascia lata muscles
C. The tension fascia lata muscles and rectus femoris
D. The gluteus medius and quadratus femoris
E. The gluteus maximus
Correct Answer: B. The gluteus medius and tensor fascia lata muscles
Your Answer: C. The tension fascia lata muscles and rectus femoris
Explanation: The anterolateral exposure dissects an interval between the gluteus medius and tensor fascia lata
muscles to preserve the superior gluteal innervation of the tensor fascia muscles. The other intervals are not used in
the anterolateral approach.
27. Question: The direct lateral (modified Hardinge) approach to the hip has the following disadvantage(s):
A. Limited proximal acetabular exposure
B. Increased incidence of heterotopic ossification
C. Slower abductor rehabilitation
D. Increased heterotopic ossification and slower abductor rehabilitation
E. Limited proximal acetabular exposure, increased heterotopic ossification, and slower abductor rehabilitation
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Correct Answer: E. Limited proximal acetabular exposure, increased heterotopic ossification, and slower
abductor rehabilitation
Your Answer: B. Increased incidence of heterotopic ossification
Explanation: Limited proximal acetabular exposure, increased incidence of heterotopic ossification, and limp
secondary to weak abductors are commonly associated with the direct lateral approach. The dislocation rate is less
than with a posterior approach.
28. Question: When using the direct lateral (modified Hardinge) approach to the hip, the incidence of total hip
dislocation is:
A. 2%
B. 0.1%
C. 0.3%
D. 3%
E. 4%
Correct Answer: C. 0.3%

Your Answer: D. 3%
Explanation: In a retrospective review of 770 consecutive primary total hip arthroplasties, the dislocation rate was
0.3%. Higher dislocation rates are associated with the posterior approach.
29. Question: When using the direct lateral (modified Hardinge) approach for total hip replacement, what
percentage of patients will have a moderate or severe limp at 2 years postoperative:
A. 0.5%
B. 1%
C. 5%
D. 10%
E. 15%
Correct Answer: D. 10%

Your Answer: B. 1%
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Explanation: According to Mulliken and colleagues, the incidence of moderate or severe limp at 2 years
postoperative is 10%. This is a significant incidence, but the dislocation rate is much lower than the other
approaches to the hip.
30. Question: The posterior approach to the hip has the following advantage(s) over the direct lateral approach
when performing total hip arthroplasty:
A. Easy exposure
B. Decreased operative time
C. Decreased heterotopic ossification
D. Easy exposure, decreased operative time, and decreased heterotopic ossification
E. Decreased operative time and decreased heterotopic exposure
Correct Answer: D. Easy exposure, decreased operative time, and decreased heterotopic ossification
Your Answer: B. Decreased operative time
Explanation: Easy exposure, decreased operative time, and decreased heterotopic ossification are advantages of
using the posterior approach. It is, however, important to note that the posterior approach is associated with a
higher rate of dislocation.
31. Question: The posterior approach splits the following muscle(s) when exposing the hip:
A. Gluteus medius
B. Gluteus maximus
C. Gluteus minimus
D. Tensor fascia lata
E. External rotators
Correct Answer: B. Gluteus maximus

Your Answer: D. Tensor fascia lata
Explanation: The posterior approach splits the gluteus maximus. The remainder of the approach releases the short
external rotators followed by a posterior capsulotomy, which then allows entry into the posterior hip joint.
32. Question: The trochanteric slide osteotomy involves:
A. Osteotomy of anterior greater trochanter bone

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B. Keeping the gluteus medius and vastus lateralis in continuity
C. Osteotomy of anterior greater trochanter bone and keeping the gluteus medius in continuity
D. Osteotomy of anterior greater trochanter bone and keeping the vastus lateralis in continuity
E. Osteotomy of anterior greater trochanter bone and keeping the gluteus medius and vastus lateralis in
continuity
Correct Answer: E. Osteotomy of anterior greater trochanter bone and keeping the gluteus medius and vastus
lateralis in continuity
Your Answer: B. Keeping the gluteus medius and vastus lateralis in continuity
Explanation: The trochanteric slide osteotomy is a modification of the Charnley transtrochanteric approach. The
trochanteric slide osteotomy was developed because of concerns with trochanteric reattachment and possible
nonunion of the trochanteric fragments. The trochanteric slide osteotomy also improves visualization in difficult
primary arthroplasties, as well as in revision arthroplasty.
33. Question: The vastus slide utilizes a:
A. Modified anterior approach to the hip joint
B. A trochanteric osteotomy
C. The vastus lateralis is reflected off the proximal femur from its posterior attachment to the lateral
intermuscular septum.
D. Modified anterior approach to the hip joint and trochanteric osteotomy
E. Posterior approach to the hip
Correct Answer: C. The vastus lateralis is reflected off the proximal femur from its posterior attachment to
the lateral intermuscular septum.
Your Answer: B. A trochanteric osteotomy
Explanation: The vastus slide is a modified lateral approach to the hip and does not involve a trochanteric
osteotomy. The vastus slide provides good exposure of the proximal femur in revision hip surgery but is not
recommended for complicated acetabular reconstruction.
34. Question: To perform an extended trochanteric osteotomy:
A. The posterior approach is extended distally along the posterior border of the gluteus medius.
B. The posterior portion of the vastus lateralis is identified.
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C. The gluteus maximus muscle is detected.
D. The interval between the posterior vastus and gluteus maximus is developed.
E. All of the above

Your Answer: B. The posterior portion of the vastus lateralis is identified.
Explanation: In addition to all of the above steps, the lateral-third of the proximal femur is osteotomized using an
oscillating saw or burr.
35. Question: The advantage(s) of an extended trochanteric osteotomy in approaching a revision hip surgery
include:
A. Easier access to bone-cement interface
B. Decreased operative time
C. Better exposure of acetabulum
D. Easier access to bone-cement interface, decreased operative time, and better exposure of acetabulum
E. Easier access to bone-cement interface and decreased operative time
Correct Answer: D. Easier access to bone-cement interface, decreased operative time, and better exposure of
acetabulum
Your Answer: B. Decreased operative time
Explanation: In addition to the answers above, there is more predictable healing of the osteotomized fragment,
neutral recovery of femoral canal, and better tensioning of the abductors with distal advancement.
36. Question: The anatomy of the hip provides considerable rotation in:
A. One anatomic plane
B. Two anatomic planes
C. Three anatomic planes
D. Four anatomic planes
E. Six anatomic planes
Correct Answer: C. Three anatomic planes

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Your Answer: D. Four anatomic planes
Explanation: The anatomy of the hip provides rotation in three anatomic planes (sagittal, coronal, and transverse).
To understand the hip anatomy and rotation, one must consider all three anatomical planes.
37. Question: Most patients have a hip flexion-extension arc of:
A. 100? to 110?
B. 110? to 120?
C. 120? to 140?
D. 130? to 150?
E. 110? to 140?

Your Answer: C. 120? to 140?
Explanation: Most patients have a flexion-extension arc of 120? to 140?, an abduction-adduction arc of 60? to
80?, and an internal-external rotation arc of 60? to 90?. The vast majority of patients have a flexion-extension arc
of 120? to 140?.
38. Question: Femoral implants with greater anteversion will impinge (trochanter against the pelvis):
A. Posteriorly in extension with lesser external rotation
B. Anteriorly in extension with lesser external rotation
C. Posteriorly in flexion with lesser external rotation
D. Anteriorly in flexion with lesser external rotation
E. Posteriorly in extension with lesser internal rotation
Correct Answer: A. Posteriorly in extension with lesser external rotation

Your Answer: B. Anteriorly in extension with lesser external rotation
Explanation: Proximal femoral implants with greater anteversion impinge trochanter against pelvis with lesser
external rotation, whereas proximal femoral implants with lesser anteversion tend to impinge anteriorly in flexion
with lesser internal rotation.
39. Question: Level walking requires the following hip range of motion:
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A. 40? of flexion-extension and the same internal-external rotation/abduction-adduction
B. 55? of flexion-extension and the same internal-external rotation/abduction-adduction
C. 70? of flexion-extension and the same internal-external rotation/abduction-adduction
D. 80? of flexion-extension and the same internal-external rotation/abduction-adduction
E. 90? of flexion-extension and the same internal-external rotation/abduction-adduction
Correct Answer: B. 55? of flexion-extension and the same internal-external rotation/abduction-adduction

Your Answer: B. 55? of flexion-extension and the same internal-external rotation/abduction-adduction
Explanation: Level walking requires approximately 50? to 60? of flexion-extension with a relatively small amount
of internal-external rotation or abduction-adduction.
40. Question: To put on a pair of shoes, the arc of motion required in the hip joint is:
A. 100?
B. 130?
C. 140?
D. 170?
E. 180?
Correct Answer: D. 170?

Your Answer: D. 170?
Explanation: The total motion of the three anatomic planar arcs of the hip is 240? to 300?. The arc of motion
required to put on a pair of shoes is 160? to 170?.
41. Question: Recent mathematical modeling of hip joint forces during activities of daily living relative to body
weight show elevations by a factor of:
A. 1 to 2
B. 2 to 3
C. 2 to 4
D. 3 to 5
E. 4 to 6
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Correct Answer: C. 2 to 4
Your Answer: B. 2 to 3
Explanation: Recent mathematical modeling studies show that hip joint forces are approximately 2 to 4 times
body weight. The hip joint forces will increase with strenuous activities, especially exercise.
42. Question: Implantation of a total hip prosthesis can significantly alter hip forces. The lowest forces occur at
the:
A. Anatomic hip center
B. Lateral anatomic hip center
C. Superior anatomic hip center
D. Posterior anatomic hip center
E. Inferior anatomic hip center
Correct Answer: A. Anatomic hip center

Your Answer: C. Superior anatomic hip center
Explanation: The lowest forces occur at the anatomic hip center and increase farther away from the anatomic
center. Therefore, the forces increase in all directions from the anatomic center.
43. Question: Implantation of a total hip prosthesis can significantly alter hip forces. The greatest increase in hip
forces occur at the:
A. Anatomic hip center
B. Lateral anatomic hip center
C. Superior anatomic hip center
D. Posterior anatomic hip center
E. Inferior anatomic hip center
Correct Answer: B. Lateral anatomic hip center

Your Answer: C. Superior anatomic hip center
Explanation: The highest forces occur when the total hip replacement is lateral to the anatomic hip center. The
forces in all of the other directions are decreased compared to the lateral anatomic hip center.
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44. Question: When implanting a total hip prosthesis, the greatest strains occur at what part of the femoral implant:
A. Neck of the femoral anatomy
B. Greater trochanteric
C. Calcar
D. Midportion of the prosthesis
E. Tip of the prosthesis
Correct Answer: E. Tip of the prosthesis

Your Answer: D. Midportion of the prosthesis
Explanation: Strains are reduced in the calcar by as much as 90%, but the tip of the prosthesis experiences
increased strain. The neck of the femoral anatomy, greater trochanter area, and midportion of the prosthesis
experience strain but not as great as the tip of the prosthesis.
45. Question: What percentage of bone is turned over in the skeleton each year:
A. 5%
B. 10%
C. 15%
D. 20%
E. 25%
Correct Answer: A. 5%
Your Answer: D. 20%
Explanation: Bone normally exhibits a turnover rate of roughly 5% of the skeleton each year. A skeleton may
exhibit more turnover of bone in certain disease states, but 5% is the average for the normal person.
46. Question: The stem and mantle is easily extracted in a failed hip arthroplasty if:
A. A circumferential lytic line surrounds the cement mantle
B. A circumferential lytic line surrounds the entire prosthesis
C. Ultrasound equipment is used

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D. There is a nonunion of the greater trochanteric osteotomy
E. One uses an extended trochanteric osteotomy
Correct Answer: A. A circumferential lytic line surrounds the cement mantle

Your Answer: C. Ultrasound equipment is used
Explanation: If a circumferential lytic line is evident on radiographs, then the bond between the stem and the
cement is stronger than the bond between the cement and the bone. In this condition, the stem and mantle are easily
extracted as a unit.
47. Question: After removing a femoral stem, the best way to prevent fracture of the femur is:
A. Debulk the metaphyseal cement
B. Debulk the diaphyseal cement
C. Trochanteric osteotomy
D. Remove the fibrous layer of tissue
E. Use a quarter-inch osteotome
Correct Answer: A. Debulk the metaphyseal cement

Your Answer: C. Trochanteric osteotomy
Explanation: Metaphyseal cement tends to be bulky, and the bone tends to be thin and weak. Initial debulking of
the cement with a high-speed burr prevents fracture during attempts at removal of the cement.
48. Question: When removing the cement mantle by cementing a threaded extractor into the mantle, the
polymethylmethacrylate (PMMA) can be removed because:
A. The bond of the PMMA to the bone is weak.
B. The bond of the PMMA to the bone is strong.
C. The bond of the new PMMA to the old PMMA is weak.
D. The bond of the new PMMA to the old PMMA is strong.
E. The bond of the new PMMA to the old PMMA is stronger than the bond of PMMA to bone.
Correct Answer: E. The bond of the new PMMA to the old PMMA is stronger than the bond of PMMA to
bone.
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Your Answer: A. The bond of the PMMA to the bone is weak.
Explanation: Because the bond of the PMMA to PMMA is stronger then the bond of PMMA to bone, the mantle
can be removed in a piecemeal fashion using a threaded extractor. It is often necessary to cement in the extractor
multiple times when performing this removal technique.
49. Question: Which of the following statements is not true of polymethylmethacrylate (PMMA):
A. PMMA is a grout.
B. PMMA is strongest in tension and weakest in compression.
C. PMMA is strongest in compression.
D. PMMA is weakest in tension.
E. PMMA is strongest in compression and weakest in tension.
Correct Answer: B. PMMA is strongest in tension and weakest in compression.

Your Answer: C. PMMA is strongest in compression.
Explanation: PMMA is a grout and is strong in compression and weak in tension. Tension forces ultimately cause
failure of PMMA.
50. Question: When making perforations in the cortex of the femur, the perforations should be placed:
A. Posteriorly
B. Laterally
C. Medially
D. Anteriorly
E. Posterior laterally
Correct Answer: D. Anteriorly

Your Answer: C. Medially
Explanation: Perforations of the femur should be placed anteriorly or anterolaterally. The axis of neutral stress for
the proximal femur is in a sagittal plane in the anterior femur.
Thank you.
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Hyperguide Staff.
1. Question: When making a femoral window, the tip of the new stem must bypass the window by:
A. 1 cm
B. 2 cm
C. One femoral diameter
D. Two femoral diameters
E. Three femoral diameters
Correct Answer: D. Two femoral diameters

Your Answer: C. One femoral diameter
Explanation: In the femoral window technique and the extended trochanteric technique, the revision stem must
bypass the defect in the femoral cortex by at least two femoral diameters to prevent fracture adjacent to the
osteotomy.
2. Question: When making perforations in the cortex of the femur, the perforations should be placed how far apart:
A. 0.5 cm
B. 5 cm
C. One hole diameter
D. Two hole diameters
E. Three hole diameters
Correct Answer: D. Two hole diameters

Your Answer: B. 5 cm
Explanation: The holes placed in the anterior cortex in this article were 9 mm in diameter. This study showed that
placing the hole less than two diameters apart increased the stress in the area between the holes, which could lead
to an increased incidence of fracture.
3. Question: Reconstructive open methods to obtain femoral neck union of failed femoral neck fractures include
all of the following except:
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A. Meyers pedicle graft
B. Varus osteotomy
C. Valgus intertrochanteric osteotomy
D. Free vascularized fibulae graft
E. Vascularized tensor fascia latae muscle bone graft
Correct Answer: B. Varus osteotomy

Your Answer: A. Meyers pedicle graft
Explanation: The Meyers pedicle graft revascularizes the nonunion site. The valgus intertrochanteric osteotomy
converts shear forces at the nonunion site to compressive forces and promotes fracture healing. These are the two
most common reconstructive open methods. Varus osteotomy is not an open reconstructive method to obtain
femoral neck union of a failed femoral neck fracture.
4. Question: When deciding between a hemiarthroplasty and total hip replacement (THR) to serve as a salvage
procedure for femoral neck nonunions, one may choose a THR because:
A. There is less risk of dislocation.
B. There is better pain relief.
C. It is a smaller procedure.
D. Reimbursement is better.
E. There is less change of leg length inequality.
Correct Answer: B. There is better pain relief.

Your Answer: B. There is better pain relief.
Explanation: THR provides better pain relief then a hemiarthroplasty, but THR is a bigger procedure with more
risk of dislocation. There is an increased chance of leg length inequality with a THR, and reimbursement should
never be a deciding factor for a particular surgery.
5. Question: Which of the following is the preferred method for treating intertrochanteric nonunions in young
patients:
A. Hemiarthroplasty
B. Total hip replacement (THR)
C. Blade plate and autogenous bone graft

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D. Gamma nail
E. Varus osteotomy
Correct Answer: C. Blade plate and autogenous bone graft

Your Answer: B. Total hip replacement (THR)
Explanation: Blade plate and autogenous bone graft is the preferred method for treating intertrochanteric
nonunions in young patients. The femoral head will retain its vascularity and remain viable, so solutions such as
hemiarthroplasty and THR should be reserved for older patients.
6. Question: Which of the following is the best treatment for older patients with a failed intertrochanteric fracture
and bone loss near the lesser trochanter:
A. Gamma nail
B. Blade plate and autogenous bone graft
C. Standard total hip replacement
D. Calcar replacement implant
E. Calcar replacement implant with long stem
Correct Answer: E. Calcar replacement implant with long stem

Your Answer: B. Blade plate and autogenous bone graft
Explanation: A calcar replacement implant is required to provide leg length and gain hip stability, and a long-stem
implant is often required to bypass screw holes in the femur.
7. Question: Which of the following factors is of least importance when considering the preoperative planning of a
revision total knee replacement:
A. Bone loss and bone defects
B. Integrity of the extensor mechanism
C. Integrity of the collateral ligaments
D. Soft tissue envelope including the skin
E. Bone density
Correct Answer: E. Bone density

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Your Answer: C. Integrity of the collateral ligaments
Explanation: Adequate imaging and planning must include an assessment of the size and location of bone defects,
the integrity of the extensor mechanism collateral ligaments, and the soft tissue envelope including the skin.
8. Question: According to Engh?s classification of bone defects in failed total knee arthroplasty, type 2 defects
usually require:
A. Cement filling
B. Morcelized bone graft
C. Augmented femoral or tibial components
D. Structural bone graft
E. Hinge component
Correct Answer: C. Augmented femoral or tibial components

Your Answer: B. Morcelized bone graft
Explanation: Cement and morcelized bone graft are usually reserved for type 1 defects. Type 2 defects usually
require an augmented femoral or tibial component, whereas type 3 defects require a structural bone graft and often
a hinged component.
9. Question: When using a structural bone graft in type 3 bone defects (Engh?s classification), which of the
following statements is incorrect:
A. Step cut the bone allograft.
B. Gain stability with plates.
C. Use a stem to bypass the junction between host bone and graft by 1 cortical diameter.
D. Use a stem to bypass the junction between host bone and graft by 2 cortical diameters.
E. Gain stability with screws.
Correct Answer: C. Use a stem to bypass the junction between host bone and graft by 1 cortical diameter.
Your Answer: B. Gain stability with plates.
Explanation: In type 3 defects (F3 or T3), it is necessary to step cut the allograft and gain stability by using plates
and screws or cerclage wires. The stem between host bone and graft must bypass the junction by at least 2 cortical
diameters.
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10. Question: Hip fusion is indicated for all of the following except:
A. Young patients
B. Patients with unilateral hip disease
C. Patients who are not overweight
D. Young and active patients
E. Patients with bilateral hip disease
Correct Answer: E. Patients with bilateral hip disease

Your Answer: D. Young and active patients
Explanation: Hip fusion is best indicated for the young and active, or heavy patient who does not have bilateral
hip disease. Secondary pain occurs in the lumbosacral area in later years, but a good fusion obviates the possible
need for multiple revision total hip replacements.
11. Question: After at least 15 years of follow-up, what percent of patients with hip arthrodesis will have
significant back or ipsilateral knee pain:
A. 20%
B. 40%
C. 60%
D. 80%
E. 90%
Correct Answer: C. 60%

Your Answer: C. 60%
Explanation: At 17 to 50 years? follow-up, approximately 60% of patients with arthrodesis will have significant
back or ipsilateral knee pain. Significant back or knee pain at 15 years must be balanced against revision total hip
replacement at 15 years.
12. Question: For a successful hip arthrodesis, the hip should be fused in:
A. 10? flexion, neutral abduction/adduction, 0? of external rotation
B. 20? flexion, neutral abduction/adduction, 0? of external rotation
C. 30? flexion, 10? abduction, 10? external rotation

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D. 15? flexion, 10? abduction, 10? external rotation
E. 15? flexion, 10? abduction, 0? external rotation
Correct Answer: B. 20? flexion, neutral abduction/adduction, 0? of external rotation

Your Answer: B. 20? flexion, neutral abduction/adduction, 0? of external rotation
Explanation: A successful hip arthrodesis depends on rigid fixation and proper positioning of the limb at 20? to
30? of flexion relative to the torso, neutral abduction/adduction, and 0? to 5? external rotation.
13. Question: The most important factor in achieving a satisfactory result when converting a fused hip to a total
hip arthroplasty is:
A. Placing the limb in proper positioning at time of fusion
B. Preserving the abductor mechanism at time of fusion
C. Existence of low back pain
D. Existence of ipsilateral knee pain
E. Existence of contralateral hip pain
Correct Answer: B. Preserving the abductor mechanism at time of fusion

Your Answer: B. Preserving the abductor mechanism at time of fusion
Explanation: Preservation of the abductor mechanism is the most important factor when converting an arthrodesis
to a total hip arthroplasty.
14. Question: Surgical exposure in total knee replacement is best facilitated by all of the following except:
A. Performing the surgery with the knee flexed
B. Externally rotating the flexed knee and peeling off medial tissues subperiosteally
C. Removing a significant portion of the fat pad
D. Cutting the patellofemoral ligament
E. Keeping the fat pad intact
Correct Answer: E. Keeping the fat pad intact

Your Answer: B. Externally rotating the flexed knee and peeling off medial tissues subperiosteally
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Explanation: Performing the surgery with the knee flexed, externally rotating the flexed knee and peeling off
medial tissues subperiosteally, removing a significant portion of the fat pad, and cutting the patellofemoral
ligament facilitate surgical exposure when performing a total knee replacement.
15. Question: To obtain good patellar tracking during total knee replacement, a surgeon must not:
A. Perform a lateral release
B. Place the femoral component in slight internal rotation
C. Position the patellar implant slightly medial on the patella
D. Place the femoral component in slight external rotation
E. Check patellar tracking before performing the final cementing of the component
Correct Answer: B. Place the femoral component in slight internal rotation

Your Answer: B. Place the femoral component in slight internal rotation
Explanation: A lateral release is not always required. The femoral component must be slightly externally rotated
instead of internally rotated. The patella will track better if the patellar implant is positioned slightly medial.
16. Question: Bone cuts are more important than soft tissue balancing when performing a total knee replacement.
The consideration least important in your decision making is
A. Soft tissue balance
B. Gender specific knee replacement
C. Flexion-extension space balancing
D. Bone cuts
E. Adequate exposure
Correct Answer: B. Gender specific knee replacement

Your Answer: B. Gender specific knee replacement
Explanation: Soft tissue balancing and flexion-extension space balancing are as important as the bone cuts.
17. Question: In reviewing instability patterns of nonseptic revision total knee replacements, most total knee
replacements required revision because of:
A. Malposition of implants
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B. Flexion-extension mismatch
C. Residual varus, valgus, or flexion contracture
D. Soft tissue problems
E. Bony cut malalignment
Correct Answer: D. Soft tissue problems

Your Answer: B. Flexion-extension mismatch
Explanation: Most nonseptic revision total knee replacements are a result of soft tissue problems (41%), followed
by flexion-extension space mismatch (34%), and insufficient correction of an initial fixed deformity (21%). Only
4% were secondary to bony cut malalignment.
18. Question: Which of the following is the best way to predict that a patient is able to obtain full extension after
total knee replacement:
A. Resecting more femoral bone
B. Deflating the tourniquet when checking for full extension
C. Lifting the leg by the ankle in the extended position while pressing proximally on the sole of the foot
D. Sterilizing a goniometer and checking full extension at the time of surgery
E. The knee will gradually come to full extension with physical therapy after surgery.
Correct Answer: C. Lifting the leg by the ankle in the extended position while pressing proximally on the sole
of the foot
Your Answer: B. Deflating the tourniquet when checking for full extension
Explanation: Performing the ?bounce? or ?push? test is the best test, performed at the time of trial reduction, to
predict if a patient will achieve full extension postoperatively. One lifts the leg by the ankle in the extended
position while pressing proximally on the sole of the foot.
19. Question: Which of the following patients are least at risk for extensor-mechanism disruption after total knee
replacement:
A. Patients with patellar baja
B. Obese patients
C. Patients with previous extensor-mechanism realignment
D. Patients with markedly diminished range of motion

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E. Thin patients
Correct Answer: E. Thin patients

Your Answer: C. Patients with previous extensor-mechanism realignment
Explanation: Obese patients, patients with patellar baja, and patients with previous extensor-mechanism
realignment, as well as patients with markedly diminished range of motion, are most at risk for extensor-
mechanism disruption.
20. Question: Component factors associated with increased stress on the extensor mechanism include all of the
following except:
A. An undersized femoral component
B. A thick patella
C. Anterior translation of the femoral component
D. Elevation of the joint line
E. Oversized femoral component
Correct Answer: A. An undersized femoral component

Your Answer: B. A thick patella
Explanation: Increased stress on the extensor mechanism involves an oversized femoral component, anterior
translation of the femoral component, a thick patella, and elevation of the joint line. An undersized femoral
component does not increase the stress on the extensor mechanism.
21. Question: Which of the following is the most common level of extensor-mechanism disruption after total knee
replacement:
A. Quadriceps tendon rupture
B. Patellar tendon disruption
C. Patellar fracture
D. Extensor tubercle avulsion
E. Quadriceps tendon insertion on the patella
Correct Answer: C. Patellar fracture

Your Answer: C. Patellar fracture
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Explanation: Patellar fracture is the most common level of extensor-mechanism disruption after total knee
replacement; however, all of the above have been observed. This is often related to excessive resection of the
patella when placing the patella component.
22. Question: Which of the following statements is not true regarding chronic patellar tendon ruptures:
A. Chronic patellar tendon ruptures are usually associated with abnormal tendons.
B. Chronic patellar tendon ruptures disrupt the extensor mechanism.
C. Chronic patellar tendon ruptures require an allograft substitution.
D. Chronic patellar tendon ruptures may occur after total knee replacement.
E. The patellar tendon is histologically normal.
Correct Answer: E. The patellar tendon is histologically normal.

Your Answer: B. Chronic patellar tendon ruptures disrupt the extensor mechanism.
Explanation: Chronic patellar tendon ruptures can severely interfere with the extensor mechanism after total knee
replacement. They are usually associated with an abnormal tendon and abnormal histology. Often, chronic patellar
tendon ruptures must be substituted with an allograft to obtain reasonable function.
23. Question: Which of the following is the best indication for hip arthroscopy:
A. Synovitis
B. Osteonecrosis
C. Dysplasia
D. Labral tears
E. Rheumatoid arthritis
Correct Answer: D. Labral tears

Your Answer: E. Rheumatoid arthritis
Explanation: Indications for hip arthroscopy include labral tears, loose bodies, synovial chondromatosis, chondral
flap lesions, and foreign body removal. Hip arthroscopy is less important as a diagnostic tool for a disease entity,
such as rheumatoid arthritis or osteonecrosis, because laboratory studies are more specific.
24. Question: Conventional magnetic resonance imaging can detect a labral tear of the hip what percent of the
time:
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A. 5%
B. 15%
C. 30%
D. 45%
E. 60%
Your Answer: C. 30%
Explanation: Conventional magnetic resonance imaging is only 5% effective in detecting labral tears, but, if
combined with gadolinium, its sensitivity is increased to 49%. The dye can more easily identify a labral tear, but it
does not approach 100% effectiveness. Clinical symptoms and history are also important when considering hip
arthroscopy.
25. Question: In dysplastic hips, labral tears most often occur in which of the following locations:
A. Posterior
B. Lateral
C. Anterior
D. Equally distributed
E. Inferior
Correct Answer: C. Anterior

Your Answer: B. Lateral
Explanation: Seventy-two percent of dysplastic hips had labral tears. Sixty-six percent of the tears were anterior,
5% were posterior, and 0.6% were lateral. In dysplastic hips, abnormal pressure is placed on the anterior labrum
because of subluxation.
26. Question: In terms of design for posterior stabilized implants, it is important for the components to incorporate
__________ before impingement occurs.
A. No rotation
B. Some hyperextension
C. No flexion
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D. Some flexion
E. 5? of valgus
Correct Answer: B. Some hyperextension

Your Answer: C. No flexion
Explanation: It is important to incorporate some hyperextension in the posterior stabilized prosthesis because
there is a tendency to place the femoral component in flexion and the tibial component in some posterior slope,
which creates overall hyperextension.
27. Question: When using a primary total knee replacement implant in a patient with distal femoral bone loss:
A. The joint line will be moved proximally.
B. There will be flexion instability.
C. There will be loss of flexion.
D. The joint line will be moved distally.
E. The joint line remains unchanged.
Correct Answer: A. The joint line will be moved proximally.

Your Answer: C. There will be loss of flexion.
Explanation: One moves the joint line proximally with distal femoral bone loss resulting in extension instability
and loss of flexion. Tibial bone loss moves the joint line distally. There is no flexion instability in a patient with
distal femoral bone loss.
28. Question: In revision total knee replacement, if one uses a revision femoral component that is thicker than the
distal femoral bone loss, then:
A. The joint line will move proximally.
B. The joint line will move distally.
C. There will be lack of knee flexion.
D. The joint line remains unchanged.
E. There will be increased knee extension.
Correct Answer: B. The joint line will move distally.

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Your Answer: B. The joint line will move distally.
Explanation: The joint line is moved distally. The knee does not extend fully and there will be resultant flexion
instability.
29. Question: In a total knee replacement, when sizing the femur from posterior up, if the patient is between sizes
and the larger size is implanted, then:
A. Quadriceps excursion will be increased
B. Range of motion will be limited
C. Quadriceps excursion remains unchanged
D. Range of motion increases
E. Range of motion remains unchanged
Correct Answer: B. Range of motion will be limited

Your Answer: B. Range of motion will be limited
Explanation: Implanting the larger size component will limit both quadriceps excursion and range of motion
because it will ?stuff? the joint. The knee will have limited range of motion.
30. Question: In a total knee replacement, one of the consequences of sizing from anterior down, when in between
sizes is that:
A. It decreases resection of the posterior condyle.
B. It creates an extension gap.
C. It creates a flexion gap.
D. It overstuffs the joint.
E. It decreases extension.
Correct Answer: C. It creates a flexion gap.

Your Answer: C. It creates a flexion gap.
Explanation: Sizing from anterior down will increase resection of the posterior condyle. This results in a flexion
gap and flexion instability.
31. Question: A flexion gap observed when trialing for a total knee replacement can be corrected by:
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A. A thinner tibia insert and increased femoral resection
B. A thicker tibia insert and increased femoral resection
C. Resecting more tibia
D. Resecting more femur
E. A thicker tibia insert
Correct Answer: B. A thicker tibia insert and increased femoral resection

Your Answer: B. A thicker tibia insert and increased femoral resection
Explanation: Without going to a posterior stabilized total knee replacement, one can put in a thicker tibia insert
and increase the femoral resection to correct a flexion gap. Resecting more tibia increases the flexion gap.
Resecting more femur without a thicker tibia insert creates more instability.
32. Question: It is possible to downsize without notching by cutting the distal femur in:
A. 5? varus
B. 5? valgus
C. 3? flexion
D. 10? flexion
E. 3? extension
Correct Answer: C. 3? flexion

Your Answer: C. 3? flexion
Explanation: The normal trochlear flange of most components diverges approximately 3?. Therefore, if one recuts
the distal femur in slight (3?) flexion, then, because the trochlear now diverges 6?, one can use a smaller
component.
33. Question: The consequence of flexing the femoral component of a posterior cruciate-retaining system is:
A. Flexion contracture
B. Flexion gap
C. Extension contracture
D. Decreased range of motion
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E. No consequences
Correct Answer: E. No consequences

Your Answer: C. Extension contracture
Explanation: There are no consequences of slightly flexing the femoral component in most cruciate-retaining
systems because most prosthetic designs allow for hyperextension of the articulating surfaces. This is not the case
with posterior cruciate-substituting systems.
34. Question: Mathematical modeling shows that a round stem versus a rectangular stem in the mid and distal
cross-section can increase cement stress up to:
A. 50%
B. 100%
C. 150%
D. 200%
E. 250%
Correct Answer: E. 250%

Your Answer: C. 150%
Explanation: Mathematical modeling of cement stress predicted that a stem with a circular cross-sectional
geometry transmits stresses to the cement mantle up to three times greater than stems with a rectangular cross-
section.
35. Question: Place the following strategies for treating deep infection in total hip replacement in order of their
effectiveness from 1 to 4, with 1 being the most effective. 1. No antibiotics 2. Systemic antibiotics alone 3.
Antibiotic bone cement alone 4. Antibiotic bone cement plus systemic antibiotics
A. 1,2,3,4
B. 2,4,3,1
C. 4,2,3,1
D. 3,2,4,1
E. 4,3,2,1
Correct Answer: C. 4,2,3,1

Your Answer: B. 2,4,3,1
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Explanation: According to Espehaug and colleagues in their assessment of 10,905 primary cemented total knee
replacements, the most effective strategy is antibiotic-bone cement plus systemic antibiotics followed by systemic
antibiotics alone, antibiotic-bone cement alone, and no antibiotics.
36. Question: Which of the following bone cements is associated with the lowest risk ratio in assessing the risk of
deep infection in revision total hip replacement:
A. Simplex (Howmedica, Allendale, NJ) bone cement
B. Palacos gentamicin bone cement
C. Palacos bone cement
D. CMW bone cement
E. Vancomycin in bone cement
Correct Answer: B. Palacos gentamicin bone cement

Your Answer: C. Palacos bone cement
Explanation: According to Malchau and colleagues, Palacos gentamicin bone cement is associated with the lowest
risk ratio for revision total hip replacement. Adding other antibiotics are not as effective as Palacos with
gentamicin.
37. Question: A midline skin incision is the preferred skin incision in total knee replacement because:
A. A midline skin incision is less disruptive of the arterial network.
B. A midline skin incision is less disruptive of the sensory nerves.
C. A midline skin incision gives better exposure.
D. A midline skin incision preserves the extensor mechanism.
E. A midline skin incision is less disruptive of the lymphatic system.
Correct Answer: A. A midline skin incision is less disruptive of the arterial network.
Your Answer: C. A midline skin incision gives better exposure.
Explanation: The blood supply arises from the terminal branches of the peripatellar anastomotic arterial ring and a
midline skin incision is the least disruptive to the arterial network. This results in better wound healing and,
therefore, less chance for an infection.
38. Question: When performing a total knee replacement, posterior stability can be achieved by all of the
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following except:
A. Soft tissue
B. The implant
C. Retention of posterior cruciate ligament
D. Resection of the posterior cruciate ligament
E. Resection of the anterior cruciate ligament
Correct Answer: D. Resection of the posterior cruciate ligament

Your Answer: C. Retention of posterior cruciate ligament
Explanation: Posterior stability can be achieved through the soft tissues or the implant. The posterior cruciate
ligament can be retained and posterior instability can still be achieved. The anterior cruciate ligament plays no role
in posterior stability and is always resected during a total knee replacement.
39. Question: Recurrent hemarthrosis of the knee following total knee replacement may be secondary to all of the
following except:
A. Entrapment of the synovium between the tibiofemoral articulation
B. Entrapment of the fat pad between the tibiofemoral articulation
C. A lax knee
D. Entrapment of the synovium between the patellofemoral articulation
E. Contracted knee
Correct Answer: E. Contracted knee

Your Answer: B. Entrapment of the fat pad between the tibiofemoral articulation
Explanation: Entrapment of synovium or the fat pad between the tibiofemoral and patellofemoral articulation, and
a lax knee have been associated with hemarthrosis following total knee replacement and can be treated by
synovectomy or by inserting a thicker component.
40. Question: After total knee replacement, posterolateral knee pain is due to all of the following except:
A. Component overhang
B. Scarring, more commonly seen in a valgus knee
C. Posterolateral osteophytes
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D. Undersized component
E. Popliteus tendonitis
Correct Answer: D. Undersized component

Your Answer: C. Posterolateral osteophytes
Explanation: Component overhang, scarring, and posterolateral osteophytes can cause popliteal impingement and
a persistent synovitis resulting in popliteus tendinitis and posterolateral pain. An undersized component may
present some other problems but not posterolateral knee pain.
41. Question: Pes anserine bursitis that occurs after total knee replacement can be associated with all of the
following except:
A. Anteromedial overhang of the component
B. Residual varus alignment
C. Inadequate removal of medial osteophytes
D. Pes anserine bursitis is an idiopathic occurrence and not related to total knee replacement
E. Anterolateral overhang of the component
Correct Answer: E. Anterolateral overhang of the component

Your Answer: B. Residual varus alignment
Explanation: Pes anserine bursitis is usually associated with anteromedial component overhang with residual
varus alignment or inadequate removal of medial osteophytes.
42. Question: All of the following statements are true regarding the Bernese osteotomy except:
A. The Bernese osteotomy was popularized by Ganz.
B. The Bernese osteotomy is a reorientation osteotomy.
C. The Bernese osteotomy allows for unrestricted correction while keeping the pelvic ring intact.
D. The Bernese osteotomy can be used in approximately 15% of dysplastic hips.
E. The Bernese osteotomy can be used only in anteverted dysplastic hips.
Correct Answer: E. The Bernese osteotomy can be used only in anteverted dysplastic hips.
Your Answer: B. The Bernese osteotomy is a reorientation osteotomy.
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Explanation: The Bernese periacetabular osteotomy, which was popularized by Ganz, is a reorientation osteotomy
that allows for unrestrained correction while keeping the pelvic ring intact and can be used in approximately 17%
of dysplastic hips. The Bernese osteotomy can be used in anteverted and retroverted dysplastic hips.
43. Question: The two most commonly used scoring techniques to assess and report the results of knee
arthroplasty are the Hospital for Special Surgery knee score and the Knee Society score. Although they are the
most commonly used scoring techniques, their main weakness is:
A. Examiner and intraobserver bias
B. Can only be used in patients with osteoarthritic knees
C. Based on questionairre completed by the patient
D. Derived from patient outcomes
E. Has no intervention of a health care provider
Correct Answer: A. Examiner and intraobserver bias

Your Answer: A. Examiner and intraobserver bias
Explanation: The Hospital for Special Surgery knee score and the Knee Society score have examiner and
intraobserver bias. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score is based
on a questionnaire completed by the patient and is derived from patient outcomes without intervention of a
healthcare provider.
44. Question: Which of the following scoring techniques is the weakest when used to compare specific physical
dynamics of a prosthesis:
A. Hospital for Special Surgery knee score
B. Knee Society score
C. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score
D. Iowa knee score
E. Mayo Clinic knee score
Correct Answer: C. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score
Your Answer: B. Knee Society score
Explanation: The Hospital for Special Surgery knee score and the Knee Society score provide more detailed
information about the physical dynamics of a prosthesis than the WOMAC score. A combination of the three scores
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correlate well in their measurement of total knee replacement outcomes.
45. Question: What percentage of nonsteroidal anti-inflammatory drug (NSAID) users annually develop a serious
gastrointestinal (GI) complication:
A. 2%
B. 4%
C. 10%
D. 15%
E. 20%
Your Answer: D. 15%
Explanation: Annually, 1% to 2% of NSAID users develop a serious GI complication. The risk of bleeding,
perforation, hospitalization, or death is three times higher among NSAID users than non-NSAID users.
46. Question: Nonsteroidal anti-inflammatory drugs (NSAIDs) work by:
A. Inhibiting the conversion of arachidonic acid to prostaglandin
B. Increasing prostaglandin synthesis
C. Increasing the level of prostaglandin in the joint
D. Increasing glycosaminoglycan synthesis
E. Decreasing glycosaminoglycan synthesis
Correct Answer: A. Inhibiting the conversion of arachidonic acid to prostaglandin

Your Answer: C. Increasing the level of prostaglandin in the joint
Explanation: Prostaglandins are the key components of the inflammatory process and work by inhibiting the
conversion of arachidonic acid to prostaglandin.
47. Question: Cyclooxygenase (Cox-1) is found:
A. Only in the gastrointestinal tract
B. Only in the kidneys
C. Only in the platelets

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D. Only in the articular cartilage
E. Widely expressed throughout the body
Correct Answer: E. Widely expressed throughout the body

Your Answer: E. Widely expressed throughout the body
Explanation: Cox-1 is the ubiquitous form of the cyclooxygenase enzyme that is widely expressed throughout the
body. Cox-1 is not found in only one specific organ.
48. Question: Steroid injections work in osteoarthritic joints by the following mechanism:
A. Increasing phagocytes
B. Inhibiting lysosomal enzyme release
C. Increasing synthesis of inflammatory mediators
D. Stabilizing phagocytes
E. Stabilizing synthesis of inflammatory mediators
Correct Answer: B. Inhibiting lysosomal enzyme release

Your Answer: A. Increasing phagocytes
Explanation: Steroids work by inhibiting lysosomal enzyme release, decreasing phagocytes, and decreasing the
synthesis of inflammatory mediators.
49. Question: Intra-articular steroids decrease the synthesis of prostaglandin and interleukin-1 by:
A. 90%
B. 20%
C. 30%
D. 50%
E. 70%

Your Answer: C. 30%
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Explanation: Intra-articular steroids decrease the synthesis of prostaglandin and interleukin-1 by as much as 50%.
50. Question: Intra-articular steroids change synovial fluid characteristincs by:
A. Stabilizing phagocytes
B. Stabilizing synthesis of inflammatory mediators
C. Increasing the hyaluronic acid concentration in a joint
D. Decreasing the hyaluronic acid concentration in a joint
E. Intra-articular steroids do not change synovial fluid characteristics
Correct Answer: C. Increasing the hyaluronic acid concentration in a joint

Your Answer: B. Stabilizing synthesis of inflammatory mediators
Explanation: Intra-articular steroids change synovial fluid characteristics by increasing hyaluronic acid
concentration.
Thank you.
Hyperguide Staff.
1. Question: To reduce the chance of irritation when injecting a knee with hyaluronic acid, which of the following
approaches is recommended:
A. A medial approach in a partially bent knee
B. A direct straight injection
C. A direct lateral injection
D. A medial approach in an extended knee
E. A direct injection through the patellar tendon
Correct Answer: C. A direct lateral injection

Your Answer: B. A direct straight injection
Explanation: The chance of an injection site irritation is 5.2% with a medial approach in a partially bent knee,
2.4% with a straight injection, and 1.5% with a direct lateral approach. There is also an increased chance of
irritation with a direct patellar tendon injection.
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2. Question: Indications for high tibial osteotomy include all of the following except:
A. 10? to 15? of varus deformity on weight-bearing radiographs
B. 90? preoperative range of motion
C. Flexion contracture less than 15?
D. 60? preoperative range of motion
E. Age younger than 60 years
Correct Answer: D. 60? preoperative range of motion

Your Answer: C. Flexion contracture less than 15?
Explanation: Indications for a high tibial osteotomy include age younger than 60 years, 10? to 15? varus
deformity, 90? preoperative arc range of motion, and flexion contracture less than 15?.
3. Question: Contraindications to high tibial osteotomy include:
A. Lateral compartment narrowing
B. Lateral tibial subluxation more than 1 cm
C. Medial compartment bone loss of more than 3 mm
D. Ligament instability
E. All of the above

Your Answer: B. Lateral tibial subluxation more than 1 cm
Explanation: Lateral compartment narrowing, lateral tibial subluxation of more than 1 cm, medial compartment
bone loss of more than 3 mm, and ligament instability are contraindications to high tibial osteotomy.
4. Question: The incidence of lateral gonarthrosis in women is:
A. Lower than men
B. Same as men
C. Two times higher in women
D. Three times higher in women
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E. Five times higher in women
Correct Answer: E. Five times higher in women

Your Answer: E. Five times higher in women
Explanation: The incidence of primary lateral gonarthrosis in women is five times higher than in men, and the
average age of patients is 55 to 60 years. The body habitus of women tend to align more weight on the lateral
compartment when compared to men.
5. Question: The majority of patients with lateral compartment arthritis have:
A. Rheumatoid arthritis
B. Neurologic condition (e.g., Polio)
C. Collagen vascular disease
D. Osteoarthritis
E. Trauma
Correct Answer: D. Osteoarthritis

Your Answer: C. Collagen vascular disease
Explanation: Rheumatoid arthritis usually involves the lateral compartment because it is a bicompartmental
disease. Although most patients with osteoarthritis have medial compartment arthritis, they still have a significant
higher incidence of lateral arthritis than any other disease. The incidence of lateral compartment arthritis is lower in
trauma, collagen vascular disease, or patients with neurologic conditions like polio.
6. Question: Which of the following is not a good indication for a varus-producing supracondylar femoral
osteotomy (SFO):
A. Valgus deformity less than 15?
B. Valgus joint-line tilt more than 10?
C. 90? arc of range of motion
D. Old patients
E. Young patients
Correct Answer: D. Old patients

Your Answer: B. Valgus joint-line tilt more than 10?
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Explanation: Varus producing supracondylar femoral osteotomy is indicated for a valgus deformity less than 15?,
valgus joint line tilt more than 10? in a patient with at least a 90? arc of motion. The procedure is also best
indicated in stout, young patients who are involved in heavy labor jobs.
7. Question: When performing a supracondylar femoral osteotomy, it is recommended to correct the tibiofemoral
angle:
A. 2?
B. 2? to 4?
C. 4? to 6?
D. 6? to 8?
E. More than 8?
Your Answer: D. 6? to 8?
Explanation: Correcting the tibiofemoral angle between 4? to 6? transfers 80% of the weight to the medial angle.
8. Question: The most common problem encountered with total knee arthroplasty (TKA) after high tibial
osteotomy is:
A. Offset of tibial plateau from tibial shaft
B. Patella infera
C. Dealing with skin incision
D. Tracking of patella
E. High riding patella
Correct Answer: B. Patella infera

Your Answer: C. Dealing with skin incision
Explanation: Patella infera is encountered 80% of the time after a high tibial osteotomy. Patella infera makes it
difficult for a surgeon to visualize and dislocate the patella laterally, and it also makes for a difficult salvage for a
total knee replacement.
9. Question: When careful evaluation after primary total knee arthroplasty (TKA) is performed, the results of TKA
after previous high tibial osteotomy (HTO) have a Knee Society good-to-excellent score what percentage of the
time:
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A. 20%
B. 40%
C. 60%
D. 80%
E. 90%

Your Answer: B. 40%
Explanation: Primary TKA with respect to Knee Society scores and operative complications shows that a primary
TKA group scored 88% good to excellent results compared to 63% for the post-HTO group.
10. Question: Subchondral drilling for cartilage defects is effective for:
A. Varus alignment
B. Valgus alignment
C. Subchondral sclerosis
D. Fibrocartilage formation
Correct Answer: D. Fibrocartilage formation

Your Answer: D. Fibrocartilage formation
Explanation: Subchondral drilling allows the blood supply to form clot-containing stem cells from which
fibrocartilage forms. It is not indicated in patients with systemic disease like rheumatoid arthritis. It is ineffective
for varus or valgus alignment or subchondral sclerosis.
11. Question: When performing a mosaicplasty for cartilage defects, the defects must be:
A. Less than 1 cm
B. Less than 1.5 cm
C. Less than 2 cm
D. Less than 2.5 cm
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E. Less than 3 cm
Correct Answer: C. Less than 2 cm

Your Answer: D. Less than 2.5 cm
Explanation: When performing a mosaicplasty for cartilage defects, the best results are obtained with defects less
than 2 cm. The plugs should measure 2.5 mm in length. Mosaicplasty results for defects larger than 2 cm have not
been as gratifying.
12. Question: Mobile-bearing total knee replacement (TKR) implants are designed to have how many
articulations:
A. 0
B. 1
C. 2
D. 3
E. 4
Correct Answer: C. 2
Your Answer: C. 2
Explanation: Mobile-bearing TKR implants are designed to have two articulations, one between the femoral and
tibial component and the other between the tibial component and base plate on the tibia.
13. Question: After 5 years, cemented all-polyethylene components in total knee replacement have a loosening
rate of:
A. 10%
B. 20%
C. 30%
D. 40%
E. 50%
Correct Answer: B. 20%

Your Answer: B. 20%
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Explanation: At 5 years, cemented all-polyethylene tibial components in total knee replacement have a loosening
rate of 20%. A loosening rate of 20% is unacceptable, therefore, cemented all-polyethylene tibial components are
no longer used in total knee replacements. New all poly tibial components are presently being investigated, but not
for general use presently.
14. Question: When performing a total knee replacement (TKR) on a patient with previous skin incisions on the
knee, if a different skin incision is to be made it is recommended that the distance between the incisions should be:
A. 2 cm
B. 3 cm
C. 4 cm
D. 5 cm
E. 7 cm
Correct Answer: E. 7 cm
Your Answer: A. 2 cm
Explanation: Most authors recommend a 7-cm distance between skin incisions. If the distance between the
incisions is less than 7 cm, then the chance of skin slough increases.
15. Question: The medial parapatellar skin incision for total knee replacement (TKR):
A. Limits lateral side exposure and interferes with the blood supply of the lateral skin flap
B. Necessitates a lateral release
C. Makes the lateral skin flap smaller
D. Increases the blood supply to the patella
E. Provides excellent exposure for a TKR
Correct Answer: A. Limits lateral side exposure and interferes with the blood supply of the lateral skin flap
Your Answer: B. Necessitates a lateral release
Explanation: The medial parapatellar skin incision limits exposure of the lateral compartment and interferes with
the blood supply of the lateral skin flap.
16. Question: Which of the following is not true regarding a subvastus arthrotomy for total knee replacement
(TKR):
A. A lift of the entire quadriceps mechanism

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B. A poor exposure of the lateral aspect of the knee joint
C. A danger of causing injury to the femoral artery
D. Provides fair exposure in a thin patient
E. Provides good visualization in an obese patient
Correct Answer: E. Provides good visualization in an obese patient

Your Answer: B. A poor exposure of the lateral aspect of the knee joint
Explanation: All of the answers are associated with the subvastus arthrotomy. A subvastus arthrotomy is a
particularly difficult approach in obtaining visualization in an obese patient.
17. Question: Which of the following is a true statement concerning the quadriceps snip technique:
A. The quadriceps snip technique involves lengthening the tendon in a
B. The quadriceps snip technique enters the quadriceps tendon with a
C. The quadriceps snip technique significantly weakens the extensor tendon.
D. The quadriceps snip technique permits extended exposure.
E. The quadriceps snip technique involves a horizontal cut in the extensor tendon.
Correct Answer: D. The quadriceps snip technique permits extended exposure.

Your Answer: B. The quadriceps snip technique enters the quadriceps tendon with a
Explanation: The quadriceps snip technique entails dividing the tendon proximally in an oblique fashion to permit
extended exposure.
18. Question: Which of the following is a true statement regarding intramedullary instrumentation when
performing bone cuts in total knee replacement (TKR):
A. Intramedullary instrumentation is equally as accurate as extramedullary devices in all knees.
B. Intramedullary instrumentation is less accurate than extramedullary devices in varus knees.
C. Intramedullary instrumentation is less accurate than extramedullary devices in valgus knees.
D. Intramedullary instrumentation is more accurate than extramedullary devices in varus knees.
E. Intramedullary instrumentation is more accurate than extramedullary devices in valgus knees.
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Correct Answer: C. Intramedullary instrumentation is less accurate than extramedullary devices in valgus
knees.
Your Answer: B. Intramedullary instrumentation is less accurate than extramedullary devices in varus knees.
Explanation: Valgus in the tibia shaft may be up to 70%, and intramedullary rods cannot be fully placed into the
tibia. Extramedullary techniques are recommended.
19. Question: When total knee replacement surgery is complete, the alignment of the knee must be:
A. Neutral
B. 2? of valgus in the tibia
C. 5? of valgus in the femur
D. 7? of valgus in the tibia
E. 7? of valgus in the femur
Correct Answer: C. 5? of valgus in the femur

Your Answer: D. 7? of valgus in the tibia
Explanation: The tibial cut is perpendicular to the tibial axis, the femoral cut is made in 4? to 6? valgus, and the
knee aligned in 4? to 6? of valgus provided the ligaments are balanced.
20. Question: Overall objectives in total knee replacement (TKR) should include all of the following except:
A. Valgus aligned knee
B. Range of motion 0? to 125?
C. Midline tracking patella
D. Collateral ligament balance at full extension and 90?
E. Neutral aligned knee
Correct Answer: E. Neutral aligned knee

Your Answer: B. Range of motion 0? to 125?
Explanation: To have a satisfactory alignment one should have a valgus aligned knee, not a neutral aligned knee.
Range of motion should be 0? to 125? with midline tracking patella. The collateral ligament should be balanced at
full extension an 90?.
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21. Question: What is the measured resection technique when performing a total knee replacement:
A. Removes 20% more bone than cut
B. Removes an exact amount of bone to fit in the prosthetic device
C. Entails ligament balancing in extension
D. Entails ligament balancing in flexion
E. Incorporates ligament balancing in flexion and extension
Correct Answer: B. Removes an exact amount of bone to fit in the prosthetic device
Your Answer: B. Removes an exact amount of bone to fit in the prosthetic device
Explanation: The measured resection technique is a philosophy that removes the exact amount of bone necessary
to fit in the prosthetic device for the femur and tibia, and does not detail ligament balancing. The flexion-extension
gap technique incorporates ligament balancing with the bony cuts that give equal flexion and extension gaps.
22. Question: When performing a total knee replacement, if you discover that the gap in flexion is larger than the
gap in full extension, you should:
A. Remove more bone from the tibia
B. Remove more bone from the femur in flexion
C. Remove more bone from the femur in extension
D. Remove more bone from the posterior femur
E. Put in a posterior stabilized prosthesis
Correct Answer: C. Remove more bone from the femur in extension

Your Answer: B. Remove more bone from the femur in flexion
Explanation: By removing more bone from the femur in extension and using a higher polyethylene component,
the flexion and extension gaps can be equalized. If this does not correct the problem, then one should proceed to a
posterior stabilized prosthesis.
23. Question: When performing a total knee replacement, if you discover that the gap in flexion is smaller than the
gap in extension:
A. More bone should be removed from the femur in extension
B. A larger polyehtylene component should be used
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C. More bone should be removed from the posterior femur
D. The femoral component should be upsized
E. A smaller polyethylene component should be used
Correct Answer: C. More bone should be removed from the posterior femur
Your Answer: B. A larger polyehtylene component should be used
Explanation: If the flexion gap is smaller than the extension gap, the knee should be balanced by removing more
posterior bone from the femur or downsizing the femoral component.
24. Question: Which of the following can lead to patellar dislocation in total knee replacement:
A. Internal rotation of femoral component
B. External rotation of femoral component
C. Too large a femoral component
D. External rotation of tibial component
E. Too large a tibial component
Correct Answer: A. Internal rotation of femoral component

Your Answer: D. External rotation of tibial component
Explanation: Internal rotation of either the femoral or tibial component may lead to patellar dislocation. External
rotation of the femoral or tibial component does not usually lead to dislocation, and increased size of the femoral or
tibial component will not predispose to patella dislocation.
25. Question: Epidural analgesia in the postoperative period after total joint replacement is widely used and is
associated with all of the following complications except:
A. Nausea
B. Respiratory depression
C. Peroneal nerve palsy
D. Femoral nerve palsy
E. Hypotension
Correct Answer: D. Femoral nerve palsy

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Your Answer: B. Respiratory depression
Explanation: Nausea, hypotension, respiratory depression, and peroneal nerve palsy are associated with epidural
analgesia. Be aware of an epidural bleed secondary to anticoagulation efforts for deep venous thrombosis
prophylaxis.
26. Question: Painful "clunking" sensations upon active extension from 60? to 30? in patients with total knee
replacements are:
A. Fibrous nodules under patellar tendon
B. Seen only in posterior-stabilized total knee replacement because of fibrous build up in the nodule
C. Fibrous nodule under distal quadriceps tendon
D. Seen only in posterior cruciate retaining total knee replacements
E. Oversized tibial components
Correct Answer: C. Fibrous nodule under distal quadriceps tendon

Your Answer: B. Seen only in posterior-stabilized total knee replacement because of fibrous build up in the nodule
Explanation: This painful clunking sensation from 60? to 30? is caused by a fibrous nodule under the distal
quadriceps tendon. Contributing factors include a large patellar component with proximal overhang and an abrupt
change in the radius of curvature of the femoral component that irritates the quadriceps tendon.
27. Question: All of the following are reported advantages of metal-backed patella components except:
A. Metal-backed patella components minimize deformity of overlying polyethylene.
B. Metal-backed patella components permit more evenly distribution of load transmissions.
C. Metal-backed patella components allow for cementless fixation.
D. Metal-backed patella components increase deformity of the overlying polyethylene.
E. Metal-backed patella components reduce the polyethylene thickness at the periphery of the implant.
Correct Answer: D. Metal-backed patella components increase deformity of the overlying polyethylene.
Your Answer: B. Metal-backed patella components permit more evenly distribution of load transmissions.
Explanation: Metal-backed patella components minimize deformity of the overlying polyethylene and do not
increase deformity. These components enable an even distribution of load transmissions and reduce the
polyethylene thickness at the periphery of the implant. Metal-backed patella components also allow for cementless
fixation of the patellae component.
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28. Question: Failure modes of metal-backed patella designs include all of the following except:
A. Dissociation of polyethylene and metal plate
B. Component fractures
C. Femoral component exposed to the metal of the patella component
D. Increased risk of patella dislocation
E. Metallic synovitis
Correct Answer: D. Increased risk of patella dislocation

Your Answer: C. Femoral component exposed to the metal of the patella component
Explanation: The polyethylene wear exposing the metal to wear against the femoral component is the ultimate
result of all of the above failure modes except increased patella dislocation.
29. Question: The incidence of patella component loosening is:
A. 4%
B. 10%
C. 2%
D. 8%
E. 15%
Your Answer: D. 8%
Explanation: The incidence of patella component loosening is less than 2%. Factors predisposing to loosening
include cementation into deficient bone, component malposition, patellar subluxation or fracture, patellar avascular
necrosis, asymmetric patellar bone resection, and loosening of other components. Treatment options include
observation, component revision, patellectomy or component removal, and patellar arthroplasty if bone stock is
sufficient.
30. Question: The preferred means for fixation of patellar components is:
A. Large, central patellar lugs
B. Two parallel patellar lugs
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C. Three large patellar-fixation lugs
D. Three small peripheral-fixation lugs
E. One central and two peripheral-fixation lugs
Correct Answer: D. Three small peripheral-fixation lugs

Your Answer: B. Two parallel patellar lugs
Explanation: Large, central patellar-fixation lugs remove a significant amount of bone, which contributes to
patellar fractures. Three small peripheral-fixation lugs are preferred in most designs.
31. Question: The majority of patellofemoral instability cases are secondary to:
A. Trauma
B. Failure to perform a lateral release
C. Surgical technique
D. Prosthetic design
E. Patient related
Correct Answer: C. Surgical technique

Your Answer: D. Prosthetic design
Explanation: Trauma, failure to perform a lateral release, and prosthetic design are associated with patellofemoral
instability, but the majority of patellofemoral instability cases are secondary to errors in surgical judgement and
technique.
32. Question: Which of the following conditions related to the femur does not influence patellofemoral mechanics
and stability:
A. Selecting an oversized femoral component
B. Improper femoral component rotation
C. Medial positioning of the femoral component
D. Excessive axial valgus alignment
E. Excessive flexion gap
Correct Answer: E. Excessive flexion gap

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Your Answer: B. Improper femoral component rotation
Explanation: The femoral component size, rotation, position, and alignment influence patellofemoral mechanics.
For instance, an oversized femoral component leads to "overstuffing" that results in decreased flexion of the knee.
Excessive flexion gap does not influence patellofemoral mechanics.
33. Question: The position of the tibial component influences patellar biomechanics. The best position to place the
component is:
A. Internal rotation of the tibial component
B. External rotation of the tibial component
C. Medialization of tibial component
D. Lateralization of tibial component
E. External rotation and lateralization
Correct Answer: E. External rotation and lateralization

Your Answer: C. Medialization of tibial component
Explanation: The tibial component must be positioned in external rotation and lateralized when possible. Internal
rotation or medialization predispose to patellar subluxation.
34. Question: Which of the following is not a risk factor for fracture of the distal femur proximal to total knee
replacement (TKR):
A. Rheumatoid arthritis and osteopenia
B. Anterior femoral notching
C. Osteoarthritis
D. Steroid use
E. Revision arthroplasty
Correct Answer: C. Osteoarthritis

Your Answer: C. Osteoarthritis
Explanation: The risk factors associated with fracture of the distal femur proximal to TKR are anterior femoral
notching (especially if more than 3 mm in depth), rheumatoid arthritis, steroid use, osteopenia, revision
arthroplasty, neuromuscular disorders, stiff knee, or poor flexion of the TKR.
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35. Question: Risk factors for peroneal nerve palsy after total knee replacement (TKR) include all of the following
except:
A. Severe valgus deformity
B. Flexion contracture
C. Epidural anethesia
D. Previous lumbar laminectomy and valgus osteotomy
E. Increased flexion gap
Correct Answer: E. Increased flexion gap

Your Answer: B. Flexion contracture
Explanation: Severe valgus deformity, flexion contracture, and epidural anesthesia are risk factors associated with
peroneal nerve palsy following TKR. Previous lumbar laminectomy and previous valgus osteotomy of the tibia
also increase a patient?s chance of peroneal nerve palsy.
36. Question: The most common cause of stiffness after total knee replacement (TKR) is:
A. Implant selection
B. Poor preoperative range of motion
C. Flexion contracture of the contralateral extremity
D. A large spacer
E. Tight posterior cruciate ligament (PCL) after implanting a PCL-retaining knee
Correct Answer: B. Poor preoperative range of motion

Your Answer: C. Flexion contracture of the contralateral extremity
Explanation: Poor preoperative range of motion is the main cause of stiffness after TKR.
37. Question: The femoral component can be malaligned in how many different directions:
A. 1
B. 2
C. 4
D. 6
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E. 8
Correct Answer: E. 8
Your Answer: C. 4
Explanation: The femoral component can be malaligned in one of eight different directions.
38. Question: What size tibial insert is associated with easy failure and accelerated osteolysis:
A. 6 mm
B. 8 mm
C. 10 mm
D. 12 mm
E. 15 mm
Correct Answer: A. 6 mm
Your Answer: D. 12 mm
Explanation: Inserts thinner than 6 mm are associated with easy failure and osteolysis, caused by fracture and
wear of the polyethylene.
39. Question: Which of the following tests helps in the diagnosis of reflex sympathetic dystrophy:
A. Magnetic resonance imaging
B. Computerized tomography scanning
C. Bone scanning
D. Ultrasonography
E. Tomography
Correct Answer: C. Bone scanning

Your Answer: C. Bone scanning
Explanation: Usually, reflex sympathetic dystrophy is a diagnosis of exclusion characterized by a syndrome of

pain out of proportion to the clinical findings; a bone scan may demonstrate increased uptake in the affected area.
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40. Question: Erythema, warmth, stiffness, and cutaneous hypersensitivity after total knee replacement associated
with pain is usually caused by:
A. Infection
B. Reflex sympathetic dystrophy
C. Gout
D. Patellar malalignment
E. Vascular insufficiency
Correct Answer: B. Reflex sympathetic dystrophy

Your Answer: C. Gout
Explanation: These symptoms, in addition to pain out of proportion to clinical findings, characterize a slow
postoperative course. Poor function after total knee replacement is usually secondary to reflex sympathetic
dystrophy.
41. Question: Aspirating synovial fluid prior to total knee replacement revision surgery after ensuring that a patient
is not concurrently on antibiotic therapy has a sensitivity, specificity, and accuracy of:
A. 20% to 40%
B. 60% to 80%
C. Less than 20%
D. 40% to 60%
E. 90% to 100%
Correct Answer: E. 90% to 100%

Your Answer: B. 60% to 80%
Explanation: Providing the patient is off antibiotics, the sensitivity, specificity, and accuracy of snynovial fluid
aspiration is 100%. Antibiotic administration before or during the aspiration will mask the analysis.
42. Question: The principal thrombogenic stimulus that leads to the production of venous thromboembolic disease
during total hip arthroplasty occurs:
A. During the induction of anesthesia
B. During the preparation of the femoral canal
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C. 12 hours postoperative
D. 24 hours postoperative
E. 7 days postoperative
Correct Answer: B. During the preparation of the femoral canal

Your Answer: B. During the preparation of the femoral canal
Explanation: The process of thrombosis starts during the preparation of the femoral canal. Elevation in
thrombogenic factors is most pronounced during preparation of the femoral canal, especially with insertion of a
cemented femoral component. Mechanical manipulation of the limb (dislocation of the femoral head) may also
cause intimal damage or occlusion of the femoral vein.
43. Question: Place the following in the correct order of increasing modulus of elasticity (least to greatest):
A. Cobalt-chrome, titanium, compact bone, stainless steel
B. Titanium, compact bone, cobalt-chrome, stainless steel
C. Compact bone, titanium, cobalt-chrome, stainless steel
D. Compact bone, titanium, stainless steel, cobalt-chrome
E. Titanium, compact bone, stainless steel, cobalt-chrome
Correct Answer: D. Compact bone, titanium, stainless steel, cobalt-chrome

Your Answer: C. Compact bone, titanium, cobalt-chrome, stainless steel
Explanation: Modulus of elasticities are as follows in Gpa (psi 3 106):

Compact bone: 21 (3)
Titanium: 96 (14)
Stainless steel: 193 (28)
Cobalt-chrome: 235 (34)
44. Question: Which of the following precautionary measures should be taken to prevent a periprosthetic fracture
when removing components from a patient with a previous compression hip screw:
A. Cemented femoral component with cement augmentation of the screw holes and full weight bearing
B. Plate augmentation with circlage wires and protected weight bearing
C. Toe touch weight bearing for 6 weeks
D. Cortical strut allograft and protected weight bearing

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E. Bypass the last screw hole with a cemented femoral component by two cortical diameters and protected
weight bearing
Correct Answer: E. Bypass the last screw hole with a cemented femoral component by two cortical diameters
and protected weight bearing
Your Answer: A. Cemented femoral component with cement augmentation of the screw holes and full weight
bearing
Explanation: Stress risers are generated when a screw is removed from the femur, weakening the bone for at least
4 weeks. Larger defects (50%) of the cortical width can reduce torsional strength up to 44%. Bypassing the defect
by two cortical diameters with a cemented stem doubles the bone?s strength.
45. Question: Which of the following radiographic changes is apparent after placement of a fully porous-coated,
cobalt-chrome femoral stem:
A. Proximal-femoral osteopenia
B. Distal-femoral osteopenia
C. Radiolucency around the acetabular cup
D. Increased mineralization proximally
E. Osteopenia adjacent to the entire femoral component
Correct Answer: A. Proximal-femoral osteopenia

Your Answer: B. Distal-femoral osteopenia
Explanation: The most severe stress shielding occurs with an extensively porous-coated chrome-cobalt stem.
Stress shielding occurs as the load is transferred from the hip joint to the proximal femur. The load that was
previously carried by the hip joint is now shared with the implant. This change leads to remodeling of the proximal
femur, resulting in a decreased density and thinning of the proximal portion of the femur. In a group of patients
characterized as having severe stress-shielding based on plain radiographs, no adverse effects were noted in terms
of hip scores, presence of osteolysis, or need for revision.
46. Question: Noncircumferential-porous coating leads to which of the following adverse effects:
A. Increased rates of infection
B. Increased rates of stress shielding
C. Increased rates of distal osteolysis and late femoral loosening
D. Increase rates of thigh pain
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E. Increase rates of thigh pain
Correct Answer: C. Increased rates of distal osteolysis and late femoral loosening
Your Answer: B. Increased rates of stress shielding
Explanation: Noncircumferential-porous coating allows a pathway for particulate debris (polywear) to the distal
part of the stem, promoting osteolysis. The polyethylene wear debris migrates through the pathway promoting
osteolysis and, ultimately, failure.
47. Question: The best position for hip arthrodesis is:
A. Neutral abduction/adduction, 20? to 30? flexion, and neutral internal/external rotation
B. Neutral abduction/adduction, full extension, and neutral internal/external rotation
C. Neutral abduction/adduction, full extension, and neutral internal/external rotation
D. Neutral abduction/adduction, 15? to 20? flexion, and neutral internal/external rotation
E. 10? abduction, 20? to 30? flexion, neutral internal/external rotation
Correct Answer: A. Neutral abduction/adduction, 20? to 30? flexion, and neutral internal/external rotation
Your Answer: B. Neutral abduction/adduction, full extension, and neutral internal/external rotation
Explanation: The favored position of hip arthrodesis is 20? to 30? flexion, neutral (or minimal adduction)
adduction/abduction, and neutral internal/external rotation (can be slight external rotation). Insufficient flexion
makes sitting difficult, while too much flexion makes standing difficult due to increased lumbar lordosis.
Abduction and internal rotation should be avoided.
48. Question: Which of the following total hip arthroplasty (THA) positions increases the chances of an anterior
dislocation:
A. Flexion, adduction, and internal rotation
B. Flexion, abduction, and internal rotation
C. Extension, adduction, and external rotation
D. Extension, adduction, and internal rotation
E. Extension, abduction, and internal rotation
Correct Answer: C. Extension, adduction, and external rotation

Your Answer: C. Extension, adduction, and external rotation
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Explanation: The most common direction for THA dislocation is posterior. Dislocation may be associated with a
posterior approach, poor technique, or previous surgery. Posterior dislocations are accentuated by placing the hip in
flexion, adduction, and internal rotation (i.e., rising from a low-seated chair). Less common anterior dislocations
occur after an anterior approach or with anteversion of the cup or femoral component (or both). The position for
dislocation is accentuated by extension, adduction, and external rotation.
49. Question: Loosening of a cemented metal-backed polyethylene acetabular component occurs at which of the
following junctions:
A. The cement-bone interface
B. The cement-metal interface
C. The metal-polyethylene interface as a result of micromotion
D. Result of fracture and dissolution through the structure of the cement
E. Both the cement-bone and cement-metal interface
Correct Answer: A. The cement-bone interface

Your Answer: B. The cement-metal interface
Explanation: Autopsy studies show that the loosening of cemented components occurs at the cement-bone
interface. Loosening occurs first at the periphery and proceeds toward the dome. The bone resorption at the
cement-bone interface is a response to polyethylene debris.
50. Question: Placing a screw in the anterior-superior quadrant of the acetabulum places which of the following
structures at-risk:
A. External iliac vein
B. Internal iliac artery
C. Bladder
D. Obturator vein
E. Common iliac artery
Correct Answer: A. External iliac vein

Your Answer: C. Bladder
Explanation: Placing screws in the acetabular cup in the anterior-superior or anterior-inferior quadrant is not
advised due to the proximity of the external iliac vein and the obturator artery, respectively.
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Thank you.
Hyperguide Staff.
1. Question: During revision surgery for total hip arthroplasty, the accepted standard for the presence of an
infection on frozen tissue histological analysis is:
A. Five mononuclear cells per high-powered field
B. Ten mononuclear cells per high-powered field
C. Five polymorphonuclear cells per high-powered field
D. Ten polymorphonuclear cells per high-powered field
E. One polymorphonuclear cell per high-powered field
Correct Answer: C. Five polymorphonuclear cells per high-powered field

Your Answer: B. Ten mononuclear cells per high-powered field
Explanation: Frozen section analysis is important in revision surgery to determine why a component has become
loose. Ten polymorphonuclear cells per high-powered field lower the sensitivity for infection but do not reduce the
specificity to diagnose an infection. Five polymorphonuclear cells per high-powered field are the current standard
accepted as diagnostic for an infection. Mononuclear cells can be present in the face of aseptic loosening or
polywear disease. Polymorphonuclear cells are diagnostic of biologic infectious response.
2. Question: Which of the following is not an indication for an intertrochanteric osteotomy:
A. Malunion of a fracture in the trochanter region
B. Shortening, lengthening, or derotation osteotomies to realign the extremity
C. Avascular necrosis involving more than 50% of the femoral head
D. Avascular necrosis involving less than 50% of the femoral head
E. Avascular necrosis involving less than 25% of the femoral head
Correct Answer: C. Avascular necrosis involving more than 50% of the femoral head
Your Answer: C. Avascular necrosis involving more than 50% of the femoral head
Explanation: Malunion fractures in the trochanter region and shortening, lengthening, or derotation osteotomies to
realign the extremity are indications for an intertrochanteric osteotomy. Avascular necrosis involving more than
50% of the femoral head is a contraindication for intertrochanteric osteotomy.
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3. Question: Normal activities, such as walking 1 km/hour, create forces across the hip joint of _______ times
body weight:
A. 1
B. 2
C. 3
D. 4
E. 5
Correct Answer: C. 3
Your Answer: C. 3
Explanation: Normal activities increase forces over the hip to three times body weight. Jogging increases forces
across the hip by five to eight times body weight.
4. Question: The principles of osteotomy do not include which of the following:
A. Improving congruency by restoring proper biomechanics
B. Reorienting the weight bearing surfaces to transfer load in compression rather than shear
C. Timely intervention with minimal arthrosis
D. Advanced osteoarthritis
E. Bone-to-bone aposition
Correct Answer: D. Advanced osteoarthritis

Your Answer: B. Reorienting the weight bearing surfaces to transfer load in compression rather than shear
Explanation: Principles of osteotomy include improving congruency by restoring proper mechanics, reorienting
the weight bearing surfaces to transfer load in compression rather than shear, bone-to-bone aposition, and timely
intervention with minimal arthrosis.
5. Question: The technical goals of osteotomy should include all of the following except:
A. Eliminating impingement
B. Correcting deformity
C. Sacrificing motion
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D. Restoring pain-free functional range of motion
E. Altering range of motion
Correct Answer: C. Sacrificing motion

Your Answer: B. Correcting deformity
Explanation: Technical goals of osteotomy include eliminating impingement, correcting deformity, and restoring a
pain-free functional range of motion. Motion should not be gained or lost, but the range can be altered.
6. Question: The best index to measure acetabular deficiency in the coronal plane is:
A. Tear drop ratio
B. Center edge angle of Wiberg
C. Hilgenreiner angle
D. Leg length measurements
E. Greater trochanter-pubic ratio
Correct Answer: B. Center edge angle of Wiberg

Your Answer: D. Leg length measurements
Explanation: Literature from Europe and North America suggests that a patient with acetabular dysplasia whose
anteroposterior radiograph shows a center edge angle of Wiberg less than 15? is a good candidate for periacetabular
osteotomy.
7. Question: In cemented total hip arthroplasty, the initial event in the loosening process of the femoral component
occurs at the:
A. Bone-cement interface
B. Prosthesis-cement interface
C. Thin cement mantle with fatigue fractures of cement
D. Simultaneously at the bone cement and prosthesis cement interface
E. Large cement mantles
Correct Answer: C. Thin cement mantle with fatigue fractures of cement

Your Answer: B. Prosthesis-cement interface
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Explanation: From the long-term observations of radiograph changes occurring around well-performed cemented
total hip arthroplasties, fatigue fracture of cement, especially in areas of thin cement mantles, leads to loss of
stability of the femoral component within the cement mantle.
8. Question: Loosening of the acetabular component in a cemented total hip arthroplasty most often occurs at:
A. Bone-cement interface
B. Prosthesis-cement interface
C. Within the cement
D. Simultaneously at all three locations
E. Within the bone
Correct Answer: A. Bone-cement interface

Your Answer: D. Simultaneously at all three locations
Explanation: Loosening on the acetabular side most often occurs at the bone-cement interface. Histiocyte cell
membrane proliferation incited by particulate generation proceeds from the periphery of the bone-cement interface
to the dome of the acetabulum with eventual loosening.
9. Question: The best fatigue strength for the femoral component is:
A. Coated stainless steel
B. Coated chromium cobalt
C. Cold-forged stainless steel
D. Fatigue strength is identical in all
E. Porous-coated stainless steel
Correct Answer: C. Cold-forged stainless steel

Your Answer: C. Cold-forged stainless steel
Explanation: Cold-worked, cold-forged micrograin femoral components provide greater fatigue strength than
original casting techniques. Coated stainless steel and coated chromium cobalt have less fatigue strength then the
other answer choices.
10. Question: Femoral components made of which material have the least amount of stiffness:
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A. Stainless steel
B. Chromium cobalt
C. Titanium
D. All of the above have approximately the same amount of stiffness
E. Porous-coated stainless steel
Correct Answer: C. Titanium

Your Answer: B. Chromium cobalt
Explanation: Titanium has one-half the material modulus, or stiffness, of chromium cobalt or stainless steel
irrespective of the type of porous coating. Titanium also has a high corrosion resistance that is attributed to an
oxide layer which is chemically nonreactive to the surrounding tissue.
11. Question: Cement fatigue is the main cause of loosening in a cemented femoral component. Cement is
strongest in:
A. Extension
B. Tension
C. Compression
D. Shear
E. Flexion
Correct Answer: C. Compression

Your Answer: C. Compression
Explanation: Cement is stronger in compression than in tension. Stem designs incorporate a taper to the mid and
distal stem geometry to transfer the load from the stem to the cement primarily in compression.
12. Question: The most durable cemented femoral component design has which of the following surface finishes:
A. RA surface more than 1.5 (average roughness)
B. Grit-blasted surface
C. Matte finish surface
D. Polished, smooth surface
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Correct Answer: D. Polished, smooth surface

Your Answer: B. Grit-blasted surface
Explanation: Femoral components with polished, smooth surfaces and low RA surfaces have proved to be more
durable than devices with a rougher finish.
13. Question: Noncemented femoral components must be able to resist translation and rotation in all of the
following except:
A. Translation in the axial plane
B. Translation in the medial-lateral plane
C. Translation in the anteroposterior plane
D. Rotation in the coronal plane
E. Pivot shift test
Correct Answer: E. Pivot shift test

Your Answer: B. Translation in the medial-lateral plane
Explanation: Implants must resist translation in the axial, medial-lateral, and anteroposterior planes, as well as
resisting rotation in the parasagittal, transverse, and coronal planes.
14. Question: Which uncemented femoral component design provides the best axial and torsional stability in the
metaphyses:
A. Single wedge-shaped implant
B. Wedge-shaped metaphyseal-filling implant
C. Tapered implant
D. Extensively porous-coated implant
E. Diaphyseal-filling implant
Correct Answer: B. Wedge-shaped metaphyseal-filling implant

Your Answer: C. Tapered implant
Explanation: The metaphysis provides axial and torsional stability for most wedge-shaped, proximally porous-
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coated, metaphyseal-filling implants. The other types of implants give stability in other areas than the metaphyses.
15. Question: Modularity in noncemented femoral components is popular because the design:
A. Is associated with less loosening
B. Allows more versatility in matching proximal and distal femoral geometry
C. Increases particulate debris
D. Leads to less osteolysis
E. Leads to more osteolysis
Correct Answer: B. Allows more versatility in matching proximal and distal femoral geometry
Your Answer: B. Allows more versatility in matching proximal and distal femoral geometry
Explanation: Modularity in noncemented femoral components is popular because it allows more versatility in
matching proximal and distal femoral geometry. However, additional research is needed to determine if particulate
debris leads to osteolysis and failure.
16. Question: Patch porous-coated femoral implants failed because they:
A. Provided a poor distal fit
B. Increased micromotion of the implant
C. Caused stress fracture at the porous-coated site
D. Provided channels for egress of particulate debris
E. Caused excessive polyethylene wear
Correct Answer: D. Provided channels for egress of particulate debris

Your Answer: B. Increased micromotion of the implant
Explanation: Patch porous-coated femoral implants failed because they provided channels for the particulate
debris to move distally, resulting in diaphyseal osteolysis. A poor proximal fit permits the polyethylene particulate
debris to erode around the femoral component.
17. Question: Which of the following is the preferred thickness for hydroxyapatite coatings:
A. 5 ?m
B. 20 ?m
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C. 50 ?m
D. 200 ?m
E. 400 ?m
Correct Answer: C. 50 ?m
Your Answer: D. 200 ?m
Explanation: Thick hydroxyapatite coatings of 200 ?m or more are at risk for fracture and delamination, and thin
coatings of 20 ?m or less may be resorbed too quickly. The best compromise appears to be 50 ?m, which is thick
enough so that resorption does not take place too quickly.
18. Question: Periprosthetic bone loss occurs by all of the following mechanisms except:
A. Stress shielding
B. Osteolysis
C. Implant extraction
D. Impaction grafting
E. Erosion by infection
Correct Answer: D. Impaction grafting

Your Answer: C. Implant extraction
Explanation: Stress shielding, osteolysis, and implant extraction result in bone loss and must be minimized to
maintain bone stock. Impaction grafting is a technique used to increase bone stock.
19. Question: Stress shielding occurs in the proximal femur secondary to:
A. Cemented femoral implants
B. Noncemented femoral implants
C. Stiffer implants that allow more distal bone growth
D. Modular designs
E. All of the above.
Correct Answer: E. All of the above.

Your Answer: B. Noncemented femoral implants
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Explanation: Stress shielding occurs secondary to cemented femoral implants, noncemented femoral implants, and
stiffer, longer implants that allow more distal bone growth. Stress shielding is also related to the geometry of the
implant and bone quality. Modular designs alone do not cause stress shielding.
20. Question: Thigh pain in noncemented implants is frequently a consequence of:
A. Stem loosening
B. Fibrous stabilization of implant
C. Bony stabilization of implant
D. Stem loosening and fibrous stabilization
E. Stem loosening and bony stabilization of implant
Correct Answer: D. Stem loosening and fibrous stabilization

Your Answer: C. Bony stabilization of implant
Explanation: Thigh pain in noncemented implants is frequently a consequence of stem loosening and fibrous
stabilization. Thigh pain has not been associated with bony stabilization of the implant because there is no stem
loosening if there is adequate bony stabilization.
21. Question: All of the following strategies are used to reduce the micromotion between the flexible bone of the
femur and a stiff femoral implant except:
A. Providing external porous coatings to the tip of the stem
B. Reducing contact between the tip of the stem and cortical bone
C. Tapering the stem tip
D. Cementing the femoral component
E. Expanding the stem tip so that it compresses on the cortex
Correct Answer: E. Expanding the stem tip so that it compresses on the cortex
Your Answer: B. Reducing contact between the tip of the stem and cortical bone
Explanation: Providing external porous coatings to the tip of the stem, reducing contact between the tip of the
stem and cortical bone, and tapering the stem tip are strategies that have been used to reduce micromotion.
Cementing the femoral component will also reduce micromotion.
22. Question: All of the following methods are used to reduce the modulus of elasticity of the distal stem except:
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A. Stems with slots
B. Slimming and boring out the center of the distal stem
C. Enlarging the distal stem tip
D. Hollow distal stems
E. Diaphyseal cutouts
Correct Answer: C. Enlarging the distal stem tip

Your Answer: C. Enlarging the distal stem tip
Explanation: Stems with slots, diaphyseal cutouts, and hollow distal stems have been used to reduce stem
stiffness. Enlarging the distal stem tip increases the modulus of elasticity of the distal stem.
23. Question: The major biomechanical function of the femoral component in total hip arthroplasty is to:
A. Optimize leg length
B. Anchor the prosthetic femoral head to the femur
C. Accomodate the femoral head
D. Equalize leg length
E. Replace poor bone stock
Correct Answer: B. Anchor the prosthetic femoral head to the femur

Your Answer: C. Accomodate the femoral head
Explanation: Anchoring the prosthetic femoral head to the femur and substituting for the femoral head and neck
are the major biomechanical functions of the femoral component in total hip arthroplasty. One can decrease or
increase leg lengths by changing the size of a femoral component, specifically the neck length.
24. Question: Which of the following is the most common cause of osteonecrosis of the femoral head:
A. Corticosteroids
B. Displaced transcervical fracture
C. Nitrogen bubbles
D. Coagulopathies
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E. Sickle cell disease
Correct Answer: B. Displaced transcervical fracture

Your Answer: D. Coagulopathies
Explanation: Displaced transcervical fractures of the cervical neck of the femur are the most common cause of
osteonecrosis of the femoral head. Although corticosteroid use, nitrogen bubbles, coagulopathies, and sickle cell
disease can also cause osteonecrosis, the highest incidence is seen with displaced transcervical fractures.
25. Question: In the United States, what percentage of primary total hip replacements are performed due to
osteonecrosis:
A. 3%
B. 5%
C. 10%
D. 15%
E. 20%

Your Answer: B. 5%
Explanation: In the United States, approximately 10% of primary total hip replacements are performed due to
osteonecrosis. The majority of total hip replacements occur secondary to osteoarthritis.
26. Question: Osteonecrosis is bilateral in what percentage of patients between 25 and 45 years of age with a
diagnosis of AVN of one hip:
A. 10%
B. 20%
C. 30%
D. 40%
E. 50%

Your Answer: C. 30%
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Explanation: Adults between 25 and 45 years old are most frequently affected with osteonecrosis, and the
condition is bilateral in more than 50% of patients. The condition is usually secondary to alcoholism, corticosteroid
use, sickle cell disease, and coagulopathies, as opposed to transcervical neck fractures seen in the elderly.
27. Question: All of the mechanisms listed below have been implicated in causing osteonecrosis except:
A. Intravascular coagulation
B. Hemodilation of blood
C. Embolization of fat
D. Nitrogen bubbles
E. Sickle cells
Correct Answer: B. Hemodilation of blood

Your Answer: D. Nitrogen bubbles
Explanation: Factors causing intravascular coagulation or thrombosis, not hemodilation, are the most important
mechanisms implicated in causing osteonecrosis.
28. Question: Which of the following is the most common factor implicated in the development of osteonecrosis:
A. Excessive alcohol intake
B. Gout medication
C. Nonsteroidal anti-inflammatory drugs (COX 1)
D. Ciprofloxin administration
E. Nonsteroidal anti-inflammatory drugs (COX 2)
Correct Answer: A. Excessive alcohol intake

Your Answer: C. Nonsteroidal anti-inflammatory drugs (COX 1)
Explanation: Excessive alcohol intake and chronic steroid administration are the common factors implicated in the
development of osteonecrosis. Although there have been case reports indicating nonsteroidal anti-inflammatory
drugs, it is questionable if this was the cause.
29. Question: What percentage of patients exposed to heavy alcohol consumption will develop osteonecrosis:
A. 5%
B. 10%
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C. 15%
D. 20%
E. 25%
Your Answer: E. 25%
Explanation: Less than 5% of patients exposed to heavy alcohol consumption develop osteonecrosis.
30. Question: What percentage of patients exposed to high dosages of corticosteroids develop avascular necrosis:
A. 10%
B. 20%
C. 30%
D. 40%
E. 50%

Your Answer: C. 30%
Explanation: Five percent to 10% of patients who receive high doses of corticosteroids develop avascular
necrosis. Why only a small percentage of patients develop avascular necrosis is poorly understood, and there may
be some genetic predisposition.
31. Question: Subtle coagulation defects are found in what percentage of patients with osteonecrosis:
A. 20%
B. 30%
C. 40%
D. 50%
E. 70%

Your Answer: C. 40%
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Explanation: Seventy percent of patients with osteonecrosis have some subtle coagulation defect.
32. Question: The radiolucent crescent sign on radiographs of the hip:
A. Is present only in the stage II disease avascular necrosis
B. Occurs in the articular cartilage
C. Is caused by collapse of the subchondral trabeculae
D. Is more clearly seen on magnetic resonance imaging
E. Is present only after articular cartilage loss
Correct Answer: C. Is caused by collapse of the subchondral trabeculae

Your Answer: C. Is caused by collapse of the subchondral trabeculae
Explanation: The crescent sign is caused by subchondral trabeculae collapse before flattening of the articular
surface. The success of core decompression is markedly diminished after this finding is seen on radiographs.
33. Question: The articular cartilage of the femoral head remains intact until after trabecular collapse because:
A. Nutrition comes from the metaphyseal bone
B. Nutrition comes from the synovial fluid
C. Nutrition comes from the epiphysis
D. Nutrition comes from the synovial membrane
E. Nutrition comes from the diaphysis by way of vessels in the metaphysis
Correct Answer: B. Nutrition comes from the synovial fluid

Your Answer: C. Nutrition comes from the epiphysis
Explanation: Cartilage receives its nutrition through the synovial fluid. Only after collapse of the head is articular
cartilage subjected to abnormal mechanical pressures that lead to degeneration.
34. Question: On radiograph, what stage of osteonecrosis is associated with a dense necrotic lesion with a sclerotic
border but no crescent sign:
A. Stage I
B. Stage II
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C. Stage III
D. Stage IV
E. Stage V
Correct Answer: B. Stage II

Your Answer: B. Stage II
Explanation: Stage II of osteonecrosis has good cartilage space without collapse, and a dense necrotic lesion with
sclerotic border but does not have a crescent sign. Stage I is detected on magnetic resonance imaging, and stages
III and IV are advanced forms of osteonecrosis.
35. Question: The early stages of osteonecrosis are best detected by:
A. Anteroposterior and lateral radiographs
B. Bone scans
C. Magnetic resonance image (MRI)
D. Computed tomography
E. Single photon computed tomography
Correct Answer: C. Magnetic resonance image (MRI)

Your Answer: D. Computed tomography
Explanation: If present, radiographic changes are detected by MRI in more than 90% of cases. MRI remains the
most sensitive test for osteonecrosis and becomes positive before changes are present on the roentgenogram.
36. Question: What percentage of hips diagnosed clinically with osteonecrosis go on to femoral head collapse:
A. 30%
B. 40%
C. 50%
D. 70%
E. 80%

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Your Answer: B. 40%
Explanation: Approximately 70% of hips diagnosed clinically with osteonecrosis go on to femoral head collapse.
The majority of hips progress to the severe form of the disease and will ultimately require total joint arthroplasty.
37. Question: The most promising results with electrical stimulation for treatment of osteonecrosis are with:
A. Direct current
B. Capacitive coupling
C. Pulsing electromagnetic fields
D. Indirect current
E. Concurrent bone grafting
Correct Answer: C. Pulsing electromagnetic fields

Your Answer: C. Pulsing electromagnetic fields
Explanation: The results of a multicenter study show promising results with pulsing electromagnetic fields.
Pulsing electromagnetic fields were found effective as a symptomatic management in precollapsed lesion and as
effective as core decompression.
38. Question: Core decompression for osteonecrosis of the femoral head does not act through which of the
following mechanisms:
A. Decreasing the intraosseous pressure
B. Opening channels for vascular ingrowth
C. Stimulating the repair process
D. Increasing structural integrity
E. Increasing vascularity to the avascular area
Correct Answer: D. Increasing structural integrity

Your Answer: A. Decreasing the intraosseous pressure
Explanation: Core decompression is affected by a number of mechanisms including decreasing the intraosseous
pressure, opening channels for vascular ingrowth, and stimulating the repair process through increased vascularity.
Core decompression does not increase structural integrity of the area.
39. Question: Urbaniak and associates reported a success rate of treating osteonecrosis before collapse:
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A. 10%
B. 30%
C. 50%
D. 70%
E. 90%

Your Answer: D. 70%
Explanation: Urbaniak and associates reported a success rate of 70% with mild collapse and 80% before collapse.
Their results have not been duplicated as yet. The results of their study are much better than those reported with
fibular graft.
40. Question: The incidence of deep infection complicating primary total hip arthroplasty is:
A. 0.25%
B. 0.5%
C. 1%
D. 2%
E. 3%
Your Answer: B. 0.5%
Explanation: The incidence of deep infection in primary total hip replacement is 1%. After revision hip surgery,
the percentage increases 3% to 4%. Repeated revisions are associated with increasing infection rates.
41. Question: The most common organism implicated in an infected total hip replacement is:
A. Staphylococcus aureus
B. Streptococcus
C. Staphylococcus epidermidis
D. Escherichia coli
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E. Salmonella typhi
Correct Answer: C. Staphylococcus epidermidis

Your Answer: D. Escherichia coli
Explanation: Staphylococcus epidermidis accounts for 50% to 75% of all arthroplasty infections. This is the most
common organism cultured from the skin of preoperative patients.
42. Question: Organisms survive on biosynthetic surfaces, such as total hips, because of:
A. Sulphate molecules on the surface
B. Their natural occurrence in the human body
C. Polysaccharide biofilm on the surface
D. They are protected by the sodium hyalurinate
E. Mucopolysaccharide present in the synovial fluid
Correct Answer: C. Polysaccharide biofilm on the surface

Your Answer: B. Their natural occurrence in the human body
Explanation: Antibiotic resistance, the organism?s ability to form a glycocalyx or polysaccharide biofilm, and a
slime layer enable the organism to survive on implants. This is one of the reasons why it is difficult to clear up an
infection using only antibiotics.
43. Question: Preoperatively, what percentage of patients undergoing total hip replacement have methicillin-
resistant Staphylococcus aureus (MRSE) organisms on their skin:
A. 10%
B. 25%
C. 35%
D. 40%
E. 65%

Your Answer: B. 25%
Explanation: Preoperatively, 25% of skin swabs taken in 100 patients undergoing total hip replacement were
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MRSE resistant. This is probably a direct result of the overuse of antibiotics by practicing physicians.
44. Question: After analyzing 148,359 primary total hip arthroplasties, the Swedish Registry found the lowest risk
of revision was:
A. Ventilated suits
B. Laminar flow
C. Palacos-gentamicin cement
D. Sugeon dependent
E. Palacos cement
Correct Answer: C. Palacos-gentamicin cement

Your Answer: D. Sugeon dependent
Explanation: The Swedish Registry found the lowest risk of revision was in patients who had palacos-gentamicin
cement. No effect was found with ventilated suits or laminar flow.
45. Question: The erythrocyte sedimentation rate (ESR) returns to normal how long after a total hip replacement:
A. 6 weeks
B. 2 months
C. 6 months
D. 9 months
E. 1 year
Correct Answer: E. 1 year

Your Answer: C. 6 months
Explanation: The ESR takes more than a year to return to normal after a total hip replacement.
46. Question: An erythrocyte sedimentation rate (ESR) of what level is considered a good cutoff for guiding an
index of suspicion for infection:
A. 10 mm/hr
B. 20 mm/hr
C. 30 mm/hr
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D. 40 mm/hr
E. 60 mm/hr
Correct Answer: C. 30 mm/hr

Your Answer: C. 30 mm/hr
Explanation: With an ESR of 30 mm/hr to 35 mm/hr, sensitivities have been reported from 0.60 to 0.96 and
specificities from 0.65 to 1.00.
47. Question: C-reactive protein (CRP) peaks 48 hours postoperatively and rapidly declines to normal in ______
weeks without persistent infection or inflammation.
A. 1 to 2
B. 2 to 3
C. 4 to 6
D. 5 to 7
E. 8 to 10
Correct Answer: B. 2 to 3
Your Answer: C. 4 to 6
Explanation: The CRP returns to normal in 2 to 3 weeks without persistent infection or inflammation. High levels
beyond 2 to 3 weeks suggest persistent infection.
48. Question: As the most direct and predictable preoperative diagnostic test for hip infection, the false-positive
rate for hip aspiration is:
A. 0%
B. 0% to 15%
C. 15% to 25%
D. 25% to 40%
E. 40% to 50%
Correct Answer: B. 0% to 15%

Your Answer: C. 15% to 25%
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Explanation: Hip aspiration has a false-positive rate of 0% to 15%. Many authors have warned against its routine
use before revision surgery.
49. Question: What levels of polymorphonuclear leukocytes (PMN) per high-power field (HPF) are inconsistent
with infection when performing intraoperative frozen sections of total joint replacement:
A. No value as predictor
B. <5 PMN/HPF
C. <8 PMN/HPF
D. <10 PMN/HPF
E. <15 PMN/HPF
Correct Answer: B. <5 PMN/HPF

Your Answer: C. <8 PMN/HPF
Explanation: When using <5 PMN/HPF as a cut off for an infected total joint, the sensitivity was 100% and
specificity was 96%.
50. Question: False-positive results with intraoperative culture as confirmation of periprosthetic joint infection are
reported to be:
A. 5%
B. 10%
C. 15%
D. 20%
E. 25%

Your Answer: B. 10%
Explanation: The false-positives results are reported to be between 6% and 13% and are probably related to break
in sterility while obtaining, transferring, and plating the specimen.
Thank you.
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Hyperguide Staff.
1. Question: It is recommended to use which of the following drugs in patients who are too sick for a surgical
procedure and antibiotic suppression:
A. Amikacin
B. Ofloxacin
C. Imipenem
D. Vancomycin
E. Rifampin
Correct Answer: E. Rifampin

Your Answer: B. Ofloxacin
Explanation: Amikacin, ofloxacin, imipenem, and vancomycin are only effective against growing bacteria.
Rifampin, which affects messenger RNA synthesis, is the only drug capable of inducing strong enough
pharmacodynamic effects to inhibit both growing and nongrowing Staphylococcus epidermidis.
2. Question: The highest dislocation rate for total hip arthroplasty is associated with which of the following
surgical approaches:
A. Anterior approach
B. Posterior approach
C. Transtrochanteric approach
D. Hardinge approach
E. All of the approaches have the same incidence of dislocation.
Correct Answer: C. Transtrochanteric approach

Your Answer: B. Posterior approach
Explanation: The anterior approach has a dislocation rate of 3.5%, posterior approach 4.6%, and transtrochanteric
approach 7.6%.
3. Question: The prevalence of dislocation following a primary bipolar hemiarthroplasty is:
A. The same as primary total hip arthroplasty
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B. Higher than primary total hip arthroplasty
C. Lower than primary total hip arthroplasty
D. Higher than semipolar hemiarthroplasty
E. Not dependent on the surgical approach
Correct Answer: C. Lower than primary total hip arthroplasty

Your Answer: B. Higher than primary total hip arthroplasty
Explanation: The prevalence of dislocation following a primary bipolar hemiarthroplasty is 1.5% compared to
3.5% or higher (depending on the surgical approach) for a total hip arthroplasty.
4. Question: Which of the following patient-related factors is a risk factor for dislocation after total hip
arthroplasty:
A. Gender
B. Height
C. Acute femoral neck fracture
D. Weight
E. Previous knee surgery
Correct Answer: C. Acute femoral neck fracture

Your Answer: B. Height
Explanation: In addition to an acute femoral neck fracture, other patient-related factors associated with dislocation
after total hip arthroplasty include patients older than 80 years and previous hip surgery.
5. Question: Which of the following factors is associated with the highest incidence of total hip dislocation after
surgery:
A. Acetabular component malposition in a vertical position
B. Femoral component malposition in a varus position
C. Acetabular component in a retroverted position
D. Muscular imbalance
E. Femoral component malposition in a valgus position
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Correct Answer: D. Muscular imbalance
Your Answer: B. Femoral component malposition in a varus position
Explanation: A computed tomography study of dislocated total hip arthroplasties (THAs) compared to
uncomplicated THAs showed no difference between the alignment of the components in either group. Muscular
imbalance rather than malposition of components was the major factor in determining dislocation.
6. Question: Which of the following is associated with an increased risk of dislocation after a total hip
arthroplasty:
A. Elevated rim liner
B. Skirt (reinforcement of the bone at the neck)
C. 32-mm femoral head
D. Metal-on-metal hip arthroplasty
E. Ceramic-on-ceramic hip arthroplasty
Correct Answer: B. Skirt (reinforcement of the bone at the neck)

Your Answer: A. Elevated rim liner
Explanation: There is an increased risk of dislocation with a skirt. The elevated rim liner decreases the risk of a
dislocation, and a 32-mm femoral head may or may not have a decreased rate of dislocation.
7. Question: Which of the following factors is not associated with dislocation of a total hip arthroplasty:
A. Infection
B. Trauma
C. Profound weight loss
D. Chronic illness
E. Gender
Correct Answer: E. Gender

Your Answer: B. Trauma
Explanation: Infection, trauma, and profound weight loss are associated with an increased risk of dislocation.
Infection with septic fluid accumulation stretches the capsule. Trauma from a fall is a direct cause of dislocation,
and profound weight loss with its accompanying loss of muscle mass (as a result of cancer or chronic illness).
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8. Question: What percentage of patients with an initial dislocation of the hip will have recurrent dislocation:
A. 5%
B. 10%
C. 20%
D. 33%
E. 50%

Your Answer: A. 5%
Explanation: One-third of patients with a dislocated total hip arthroplasty will have recurrent dislocations. This
number is potentially minimized by having patients wear an abduction splint for 6 to 12 weeks after the initial
dislocation.
9. Question: The highest incidence of deep infection in total hip arthroplasty is associated with what patient group:
A. Patients with rheumatoid arthritis
B. Patiens with psoriatic arthritis
C. Patients with diabetes mellitus
D. Patients with avascular necrosis
E. Women
Correct Answer: C. Patients with diabetes mellitus

Your Answer: B. Patiens with psoriatic arthritis
Explanation: The highest incidence of deep infection is in patients with diabetes mellitus (5.6%) compared to
patients with rheumatoid arthritis (1.2%) and patients with psoriatic arthritis (5.5%). Any immune-compromised
patient is at a higher risk for infection following total hip arthroplasty.
10. Question: The most common complication after total hip arthroplasty is:
A. Infection
B. Dislocation
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C. Deep vein thrombosis
D. Pulmonary embolism
E. Urinary tract infection
Correct Answer: C. Deep vein thrombosis

Your Answer: C. Deep vein thrombosis
Explanation: The incidence of deep vein thrombosis is as high as 70% and as low as 8%.
11. Question: The incidence of deep vein thrombosis is reported to be highest on postoperative day:
A. 1
B. 2
C. 3
D. 4
E. 5
Correct Answer: D. 4
Your Answer: C. 3
Explanation: The incidence of deep vein thrombosis is reported to be highest on postoperative day 4.
12. Question: Which of the following is the gold standard to rule out a pulmonary embolism:
A. Radiograph
B. Ventilation perfusion scan
C. Electrocardiogram
D. Ultrasonography
E. Pulmonary angiogram
Correct Answer: E. Pulmonary angiogram

Your Answer: C. Electrocardiogram
Explanation: The gold standard for detecting pulmonary embolus is the pulmonary angiogram, although a
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combination chest radiograph, ventilation perfusion scan, and electrocardiogram is usually performed.
13. Question: What incidence of bleeding complications is attributed to the treatment of postoperative
thomboembolic disease with heparin when it is administered intravenously in the first 6 days after total hip
arthroplasty:
A. 5%
B. 15%
C. 25%
D. 45%
E. 60%

Your Answer: A. 5%
Explanation: The risk of bleeding complications from therapeutic anticoagulation is high in the immediate
postoperative period with a 45% incidence.
14. Question: All of the following conditions are associated with an increased risk of heterotopic ossification after
total hip arthroplasty except:
A. Ankylosing spondylitis
B. Forestier disease
C. Posttraumatic arthritis
D. Men with bilateral osteophytic osteoarthritis
Correct Answer: E. Rheumatoid arthritis

Your Answer: B. Forestier disease
Explanation: Ankylosing spondylitis, Forestier disease, posttraumatic arthritis, and men with bilateral osteophytic
osteoarthritis are associated with an increased risk of heterotopic ossification following total hip arthroplasty.
15. Question: What is the lowest dose of radiation that is effective in preventing heterotopic bone formation after
total hip arthroplasty:
A. 1000 Rads
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B. 2000 Rads
C. 3000 Rads
D. 4000 Rads
E. 5000 Rads
Correct Answer: A. 1000 Rads

Your Answer: C. 3000 Rads
Explanation: A protocol of 1000 Rads is as effective as 2000 Rads.
16. Question: The incidence of trochanteric nonunion after greater trochanteric osteotomy in primary total hip
arthroplasty is:
A. 5%
B. 10%
C. 15%
D. 20%
E. 25%
Your Answer: D. 20%
Explanation: There is a 5% incidence of trochanteric nonunion after greater trochanteric osteotomy in primary
total hip arthroplasty.
17. Question: The main purpose of a trochanteric osteotomy is to:
A. Decrease the operative time
B. Enhance exposure
C. Lateralize the adduction mechanism
D. Prevent dislocation
E. Decrease the blood loss
Correct Answer: B. Enhance exposure

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Your Answer: D. Prevent dislocation
Explanation: Enhancing exposure and lateralizing the abductor mechanism are the main reasons for performing an
osteotomy. The osteotomy must be balanced against the increased blood loss, operative time, and slower
rehabilitation.
18. Question: Breakage of stems in total hip arthroplasty is related to all of the following except:
A. Excessive head-stem offset
B. Modularity
C. Size of stem
D. Material strength
E. Inadequate cross-sectional area
Correct Answer: B. Modularity

Your Answer: C. Size of stem
Explanation: All of the factors, except modularity, contribute to early stem breakage in the first generation of total
hips.
19. Question: In early first-generation total hip implant designs, fatigue fractures occurred in which of the
following areas of the femoral stem:
A. Posterolateral
B. Posteromedia
C. Anterolateral
D. Anteromedial
E. Anterior
Correct Answer: C. Anterolateral

Your Answer: B. Posteromedia
Explanation: In early first-generation total hip implant designs, fatigue fractures occurred anterolaterally because
that was the area of greatest tension. Fatigue fractures are less common in compression.
20. Question: Total hip arthroplasty for a congenital dislocated hip has a nerve injury incidence of:
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A. 5%
B. 10%
C. 15%
D. 20%
E. 25%
Your Answer: C. 15%
Explanation: The incidence of nerve injury following congenital dislocated hip is 5.2% compared to 0.6% to 3.7%
for routine total hip arthroplasty.
21. Question: Which of the following arteries is at the greatest risk for vascular injury during a total hip
arthroplasty for protrusio acetabuli:
A. Femoral artery
B. Obturator artery
C. Common iliac artery
D. Peroneal artery
E. Popliteal artery
Correct Answer: C. Common iliac artery

Your Answer: C. Common iliac artery
Explanation: The common and superficial iliac arteries are most at risk in patients with protrusio acetabuli. The
obturator is not at risk when removing the transverse ligament from the inferior margin of the cup.
22. Question: Debonding (separation of the femoral stem from the surrounding cement mantle) is caused by:
A. Tension forces from muscle contraction
B. Strain at the cement-metal interface
C. Torsional forces in retroversion
D. Rotational forces in anteversion
E. Compression forces from muscle contraction

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Correct Answer: C. Torsional forces in retroversion
Your Answer: B. Strain at the cement-metal interface
Explanation: When arising from a chair or climbing the stairs, the stem shifts to a more retroverted position within
the cement mantle secondary to the peak torsional forces in retroversion.
23. Question: Which of the following terms is defined as a fundamental wear mechanism in joint replacement
known as bonding of the surfaces when they are pressed together under load:
A. Abrasion
B. Fatigue
C. Adhesion
D. Cohesion
E. Compression
Correct Answer: C. Adhesion

Your Answer: B. Fatigue
Explanation: Abrasion, fatigue, and adhesion are fundamental wear mechanisms. Adhesion is the binding of the
surfaces when they are pressed together under load.
24. Question: The volumetric wear of polyethylene is greatest with what size head:
A. 32 mm
B. 28 mm
C. 26 mm
D. 22 mm
E. 20 mm
Correct Answer: A. 32 mm
Your Answer: D. 22 mm
Explanation: The volumetric wear of polyethylene is proportional to the size of the femoral head and larger
femoral heads have a longer sliding distance that results in greater wear.
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25. Question: Preparing and sterilizing polyethylene with gamma radiation:
A. Increases the molecular weight of the material
B. Decreases free radicals that can react with carbon dioxide
C. Increases recombination of the polyethylene particles
D. Stabilizes free radicals that react with carbon dioxide
E. Increases free radicals that react with carbon dioxide
Correct Answer: E. Increases free radicals that react with carbon dioxide
Your Answer: B. Decreases free radicals that can react with carbon dioxide
Explanation: Gamma radiation prevents recombination, decreases the molecular weight of the material, and
increases free radicals that react with carbon dioxide to form ketone esters and carbolic acid groups.
26. Question: In osteolysis, small wear debris is broken down and ingested by:
A. Polymorphonuclear neutrophils
B. Foreign body giant cells
C. Macrophages
D. Histiocytes
E. Osteoblasts
Correct Answer: C. Macrophages

Your Answer: C. Macrophages
Explanation: Small wear debris is phagocytosed by macrophages. Large wear debris is surrounded by foreign
body giant cells.
27. Question: Based on the volume of polyethyelene wear in some total hip arthoplasties and the average portal
size, the number of particles generated with each gait cycle is:
A. 500
B. 50,000
C. 100,000
D. 300,000
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E. 500,000
Correct Answer: E. 500,000

Your Answer: B. 50,000
Explanation: The average number of particles generated with each gait cycle is approximately 500,000.
28. Question: All of the following are consequences of using too large of a femoral component in total knee
replacement except:
A. Overstuffing the joint
B. Limitation of quadriceps excursion
C. Decreasing range of motion
D. A cause of postoperative knee pain
E. Increasing range of motion
Correct Answer: E. Increasing range of motion

Your Answer: C. Decreasing range of motion
Explanation: Too large of a femoral component in total knee replacement may result in overstuffing the joint,
limiting quadriceps excursion, and decreasing range of motion.
29. Question: It is acceptable for the joint line to be elevated how many millimeters during total knee replacement
surgery:
A. 0 mm
B. 1 mm
C. 2 mm
D. 3 mm
E. 4 mm
Correct Answer: C. 2 mm
Your Answer: C. 2 mm
Explanation: It is acceptable for the joint line to be raised approximately 2 mm during total knee replacement, but
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any higher elevation may create mid-flexion laxity.
30. Question: When performing a total knee replacement and you are in between sizes, it is best to:
A. Downsize the femoral component and recut the femur in 3? of flexion
B. Downsize the femoral component and recut the femur in 6? of flexion
C. Upsize the prosthesis
D. Downsize the femoral component and minimalize notching the anterior cortex
E. Upsize the prosthesis and recut the femur in 6? of extension.
Correct Answer: A. Downsize the femoral component and recut the femur in 3? of flexion
Your Answer: B. Downsize the femoral component and recut the femur in 6? of flexion
Explanation: An option for downsizing without notching is to recut the distal femur in slight flexion, applying a
modified distal cutting block that will add several degrees of flexion to the distal cut. Recutting the distal femur in
slight (3?) flexion has the following rationale: the normal trochlear flange of most components already diverges
approximately 3?. By adding another 3? of flexion one can use a smaller component because the trochlear flange
will now diverge 6?, avoiding a notch in the anterior cortex. The advantage is that the posterior condylar resection
remains anatomic and the level of the joint line is preserved.
31. Question: The primary features of a posterior stabilized total knee replacement include all of the following
except:
A. Femoral cam
B. Polyethylene post on the tibial component
C. Conforming articular geometry
D. Use of cement
E. Constrained hinge
Correct Answer: E. Constrained hinge

Your Answer: B. Polyethylene post on the tibial component
Explanation: The primary features of posterior stabilized total knee devices include femoral cam, polyethylene
post on the tibial component, conforming articular geometry, and use of cement. These characteristics have
produced total knee prostheses with unsurpassed clinical survivorship and patient function.
32. Question: The clinical survivorship of posterior stabilized prostheses at 10 years is:
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A. 80%
B. 85%
C. 90%
D. 95%
E. 98%

Your Answer: C. 90%
Explanation: The clinical survivorship of posterior stabilized prostheses is spectacular by any standards with a
success rate of approximately 95% of prostheses that were free from revision due to aseptic loosening at 10 to 15
years.
33. Question: If the posterior cruciate ligament (PCL) is too loose in flexion in a cruciate-retaining prosthesis, the
result is:
A. Flexion gap
B. Extension gap
C. Increased posterior sliding of the femorotibial contact point
D. Restricted flexion
E. Hyperextension deformity
Correct Answer: A. Flexion gap

Your Answer: A. Flexion gap
Explanation: If the PCL is too loose, anterior translation of the femorotibial contact point will occur, whereas if
the PCL is too tight, flexion will be restricted.
34. Question: If the posterior cruciate ligament (PCL) is too tight in flexion in a cruciate-retaining total knee
replacement, the result is:
A. Flexion gap
B. Restricted extension
C. Restricted flexion
D. Hyperextension deformity
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E. Increased flexion
Correct Answer: C. Restricted flexion

Your Answer: C. Restricted flexion
Explanation: If the PCL is too loose, anterior translation of the femorotibial contact point will occur, whereas if
the PCL is too tight, flexion will be restricted.
35. Question: If a flexion gap is observed while performing a trial reduction of components before cementing a
total knee replacement, a surgeon should consider:
A. Using a smaller tibial insert
B. Resecting more tibial bone
C. Resecting more femur in extension
D. Using a deep dish insert
E. Increasing the size of the femoral component
Correct Answer: D. Using a deep dish insert

Your Answer: B. Resecting more tibial bone
Explanation: Hofmann and colleagues reviewed their use of ultracongruent polyethylene over 7 years in 100
patients who underwent PCL-substituting total knee arthroplasties. Fifty-three cases were primary and 47 were
revisions. There were no cases of anteroposterior (AP) instability in either revision or primary cases when a deep-
dish polyethylene was inserted. The incidence of AP instability using standard inserts was 2% to 3%.
36. Question: Patellar clunk syndrome is caused by:
A. Too large a patellar component
B. Too small a patellar component
C. Fibrous tissue build-up occurring in a large intercondylar notch of the prosthesis
D. Too large a femoral component
E. Dislocation of the quadriceps mechanism over a malrotated femoral component
Correct Answer: C. Fibrous tissue build-up occurring in a large intercondylar notch of the prosthesis
Your Answer: B. Too small a patellar component
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Explanation: Patellar clunk occurs from a large intercondylar notch of the prosthesis, which causes fibrous tissue
build-up proximally and can result in 1% to 2% of patients requiring arthroscopic debridement.
37. Question: All of the following is a reported complication of posts in posterior cruciate-retaining prostheses
except:
A. Patellar fracture
B. Knee dislocation
C. Patellar clunk syndrome
D. Post fracture
E. Flexion instability
Correct Answer: E. Flexion instability

Your Answer: C. Patellar clunk syndrome
Explanation: Complications reported with the use of posts include patellar fractures, knee dislocations, and
patellar clunk syndrome.
38. Question: In a posterior cruciate-retaining prosthesis, most stress at the posterior cruciate ligament occurs in:
A. Extension
B. 15? flexion
C. 30? flexion
D. 45? flexion
E. 90? flexion
Correct Answer: E. 90? flexion

Your Answer: C. 30? flexion
Explanation: A consequence of the kinematics of a crossed four-bar link is the phenomenon of rollback, that is,
the progressive movement of the femoral condyle posteriorly relative to the tibia with increasing flexion.
39. Question: Cruciate ligament deficiency can lead to abnormalities during all of the following except:
A. Stair climbing
B. Rising from a chair

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C. Walking on uneven ground
D. Stepping up a curb
E. Full extension
Correct Answer: E. Full extension

Your Answer: C. Walking on uneven ground
Explanation: Cruciate ligament deficiency can lead to abnormalities during stair climbing, rising from a chair, and
walking on uneven ground.
40. Question: C-reactive protein should return to normal how many weeks after a total knee replacement surgery:
A. 1 week
B. 2 weeks
C. 3 weeks
D. 6 weeks
E. 12 weeks
Correct Answer: C. 3 weeks

Your Answer: C. 3 weeks
Explanation: C-reactive protein should return to normal within 3 weeks of surgery.
41. Question: One can best avoid bone stiffness after total knee replacement (TKR) by:
A. Careful attention to proper sizing of the components
B. Restoration of the mechanical axis and anatomic joint line
C. Maintenance of physiologic soft tissue tension in complete extension and at 90? of flexion
D. All of the above
Correct Answer: D. All of the above

Your Answer: B. Restoration of the mechanical axis and anatomic joint line
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Explanation: Avoiding stiffness after TKR is easier than managing the stiff total knee. Careful attention to proper
sizing of components, restoration of the mechanical axis and anatomic joint line, and maintenance of physiologic
soft-tissue tension in complete extension and at 90? of flexion will minimize the risk of stiffness following TKR.
42. Question: Flexion contractures after total knee replacement are best treated by:
A. Manipulation
B. Physical therapy
C. Dynamic extensor splint
D. Physical therapy, and dynamic extensor splint
E. All of the above
Correct Answer: D. Physical therapy, and dynamic extensor splint

Your Answer: B. Physical therapy
Explanation: Flexion contractures are treated with physical therapy and the use of a dynamic extension splint at
night.
43. Question: The incidence of periprosthetic fracture about total knee replacement is:
A. 0.2%
B. 3%
C. 5%
D. 7%
E. 9%
Your Answer: C. 5%
Explanation: Periprosthetic fractures about total knee arthoplasty (TKA) are relatively rare (0.5% to 3%).
44. Question: Wear debris particles in cross-linked polyethylenes are:
A. Less than 0.1 ?m
B. 0.1 ?m to 0.5 ?m
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C. 1 ?m to 2 ?m
D. 2 ?m to 3 ?m
E. Larger than 3 ?m
Correct Answer: B. 0.1 ?m to 0.5 ?m

Your Answer: B. 0.1 ?m to 0.5 ?m
Explanation: Studies have shown that cross-linked polyethylenes are stiffer and weaker than conventional
polyethylene, and wear debris particles generated usually are less than 1 ?m (0.1 ?m to 0.5 ?m), which is the most
biologically active particle size.
45. Question: Which of the following is the most common cause for revising a total hip arthroplasty (THA) when
polyethylene is used:
A. Infection
B. Thigh pain
C. Debris-associated osteolysis
D. Wear
E. Chronic dislocation
Correct Answer: C. Debris-associated osteolysis

Your Answer: C. Debris-associated osteolysis
Explanation: Debris-associated osteolysis is the most common cause for revision THA when polyethylene is used.
Chronic dislocation, thigh pain, wear, and infection are less common causes for revision.
46. Question: Which of the following bearing surfaces has the lowest rate of wear in total hip arthroplasty:
A. Polyethylene-metal bearings
B. Metal-metal bearings
C. Ceramic-metal bearings
D. Ceramic-polyethylene bearings
E. Alumina ceramic-ceramic bearings
Correct Answer: E. Alumina ceramic-ceramic bearings

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Your Answer: C. Ceramic-metal bearings
Explanation: According to retrieval studies of Clarke and colleagues, alumina ceramic-ceramic bearings have the
lowest rate of wear of any bearing surface.
47. Question: Staphylococcus epidermidis adheres:
A. More strongly to polyethylene
B. More strongly to alumina ceramic
C. Similarly to both polyethylene and alumina ceramic
D. This has not been studied in a laboratory setting.
E. More strongly to polymethylmethacrylate
Correct Answer: A. More strongly to polyethylene

Your Answer: C. Similarly to both polyethylene and alumina ceramic
Explanation: Staphylococcus epidermidis adheres 2.5 times more strongly to high density polyethylene than
alumina ceramic.
48. Question: The wear rate of ceramic-ceramic bearings in total hip arthroplasty is:
A. 0.05 to 0.06 mm/year
B. 0.04 to 0.05 mm/year
C. 0.03 to 0.02 mm/year
D. 0.01 to 0.02 mm/year
E. Too small to measure
Correct Answer: D. 0.01 to 0.02 mm/year

Your Answer: B. 0.04 to 0.05 mm/year
Explanation: The wear rate of ceramic-ceramic bearing surfaces in a 10-year follow-up was observed to be 0.01
mm/year.
49. Question: Which of the following observations concerning metal-metal prostheses is not true:
A. Low incidence of osteolysis
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B. There is concern about increased metal ions in the body
C. There is a theoretical concern of cancer
D. Hypersensitivity
E. High incidence of osteolysis
Correct Answer: E. High incidence of osteolysis

Your Answer: B. There is concern about increased metal ions in the body
Explanation: The controversies with metal-metal total hip replacement relate to increased metal ions. In Europe,
Hans Willert reported a 0.5% prevalence of hypersensitivity to metal-metal (personal communication, January
2001).
One advantage of metal-on-metal total hip replacement is a low incidence of osteolysis. Osteolysis in the cemented
cup and the modular cup series has been better than that observed with standard polyethylene acetabular
components.
There also is a theoretical concern of cancer. The 20-year studies from Scandinavia (particularly Finland) have not
found any positive correlation to cancer.
50. Question: The best predictor for the necessity of blood transfusion in total knee replacement is:
A. Preoperative hemoglobin
B. Operative time
C. Use of a hemovac
D. Rheumatoid arthritis
E. Surgical approach
Correct Answer: A. Preoperative hemoglobin

Your Answer: B. Operative time
Explanation: The biggest predictor for transfusion is the preoperative hemoglobin. There is a 69% chance of an
allogenic transfusion if the hemoglobin is less than 13 g/dL and only a 13% chance if more than 15 g/dL.
Thank you.
Hyperguide Staff.
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1. Question: The following image depicts:
A. A lateral arthroscopic view of a massive U-shaped tear of the rotator cuff
B. A lateral arthroscopic view of a crescent-shaped tear of the rotator cuff
C. A lateral arthroscopic view of an L-shaped tear of the rotator cuff
D. A degenerative posterior horn tear of the medial meniscus
E. A bucket-handle tear of the medical meniscus
Correct Answer: A. A lateral arthroscopic view of a massive U-shaped tear of the rotator cuff
Your Answer: B. A lateral arthroscopic view of a crescent-shaped tear of the rotator cuff
Explanation: The image depicts a lateral arthroscopic view of a massive U-shaped tear. U-shaped rotator cuff tears
extend much farther medially than crescent-shaped tears, with the apex of the tear adjacent to or medial to the
glenoid rim.
2. Question: All of the following are static restraints providing stability for the shoulder except:
A. Labrum
B. Glenoid
C. Glenohumeral ligaments
D. Rotator cuff and scapular muscles
E. Joint capsule
Correct Answer: D. Rotator cuff and scapular muscles

Your Answer: D. Rotator cuff and scapular muscles
Explanation: The shoulder allows more range of motion than any other joint in the body and is susceptible to
injury. It has both static and dynamic restraints. The rotator cuff and scapular muscles are the dynamic restraints.
The glenoid, labrum, glenohumeral ligaments, and joint capsule are the static restraints.
3. Question: Which of the following provides the greatest restraint to anterior dislocation of the shoulder:
A. Superior glenohumeral ligament
B. Supraspinatus
C. Infraspinatus
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D. Inferior glenohumeral ligament
E. Joint capsule
Correct Answer: D. Inferior glenohumeral ligament

Your Answer: A. Superior glenohumeral ligament
Explanation: The inferior glenohumeral ligament provides the greatest restraint to dislocation of the shoulder. The
inferior glenohumeral ligament is under the most stress at 90? of abduction with external rotation and extension.
Bracing to restrict this position benefits a patient with instability.
4. Question: The percentage of patients 20 to 40 years of age who have recurrent shoulder instability is:
A. 10%
B. 20%
C. 40%
D. 50%
E. 60%

Your Answer: B. 20%
Explanation: Suffering from recurrent instability in the shoulder joint depends on a patient?s age and activity
level. Ninety percent of patients younger than 20 years of age have recurrent instability. In patients 20 to 40 years
of age, 40% have recurrent instability.
5. Question: The percentage of athletes with recurrent instability choosing to return to collision sports after an
anterior shoulder dislocation is:
A. 20%
B. 40%
C. 60%
D. 80%
E. 100%

Your Answer: A. 20%
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Explanation: A patient?s activity level is the predicting factor for recurrent instability. Eighty-two percent of
athletes suffer from recurrent instability compared with 30% of nonathletes. The percentage approaches 100% for
athletes choosing to return to collision sports.
6. Question: The most frequently transplanted human tissue is:
A. Bone
B. Blood
C. Kidney
D. Cornea
E. Skin
Correct Answer: B. Blood

Your Answer: C. Kidney
Explanation: After blood, bone is the most frequently transplanted human tissue. However, bone autografting may
eventually become a thing of the past. Bone replacement with synthetic materials and growth factors is becoming
common procedure in the orthopedic operating room.
7. Question: The first documented bone transplant was performed by:
A. Van Meekeren
B. Macewan
C. Phemister
D. Ferguson
E. Albee
Correct Answer: A. Van Meekeren

Your Answer: C. Phemister
Explanation: The first documented bone transplant was performed in 1668 by Dutch surgeon Job van Meekeren,
when he used a dog cranium (a xenograft) to repair a soldier?s skull defect. Scottish surgeon William Macewan
performed the first bone allograft in 1880 when he replaced the infected humerus of a 4-year-old boy with a tibia
graft taken from a child with rickets. In his 1914 publication, Phemister noted the importance of ?hemostasis,
asepsis, and coaptation of parts? in successful bone grafting. Phemister and Albee elucidated the important factors
in bone grafting in the early 20th century, paving the way for the recent work that has delineated the importance of
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osteoconductive scaffolding, osteoinductive growth factors, and osteogenic progenitor stem cells in bone graft
healing.
8. Question: In most clinical applications, a bone autograft is preferable to a bone allograft because:
A. A bone autograft is more osteoconductive, osteoinductive, and osteogenic than a bone allograft.
B. A bone autograft has a higher risk of infection than a bone allograft.
C. A bone autograft incorporates more slowly than a bone allograft.
D. Bone autografts are in limitless supply.
E. There are more immunological considerations.
Correct Answer: A. A bone autograft is more osteoconductive, osteoinductive, and osteogenic than a bone
allograft.
Your Answer: A. A bone autograft is more osteoconductive, osteoinductive, and osteogenic than a bone allograft.
Explanation: Autografting is the standard method used to replace bone loss due to trauma, infection, tumor
resection, revision arthroplasty, and arthrodesis. Rapid incorporation and consolidation with the lack of
immunological considerations make bone harvested from the patient ideal. Bone autografts are osteoconductive
and contain osteoinductive proteins and cells, which are able to give rise to bone-forming cells. Because of its
lower risks, a bone autograft (especially of cancellous bone) is preferable to a bone allograft. Bone autografts,
however, are in limited supply, particularly in children.
9. Question: When nonvascularized cortical allografts lose mechanical strength during the first year following
surgery, it is most likely due to:
A. Revascularization
B. Failure of the graft to incorporate
C. Infection
D. Complex regional pain syndrome
E. Failure to provide initial structural support
Correct Answer: A. Revascularization

Your Answer: B. Failure of the graft to incorporate
Explanation: Nonvascularized cortical grafts may provide immediate structural support but lose mechanical
strength over the first few months. Loss of mechanical strength is due to the revascularization process, which
causes osteoporosis and subsequent graft weakening. The process requires resorption of at least some graft bone to
allow ingrowth of blood vessels and takes a significantly longer period of time in cortical bone than in cancellous
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bone.
10. Question: What percentage of osetocytes present in a vascularized cortical autograft survive:
A. 24%
B. 40%
C. 60%
D. 80%
E. 90%

Your Answer: B. 40%
Explanation: Vascularized cortical autografts are effective structural grafts that heal quickly without the
revascularization process and consequent mechanical compromise found in avascular cortical autografts and
allografts. Typically, more than 90% of osteocytes present in a vascularized cortical allograft survive
transplantation and bring their own blood supply, perhaps making the contribution of the recipient bed tissues less
important than healing.
11. Question: Vascularized free fibular grafts have been used to treat all of the following except:
A. Congenital pseudoarthrosis of the tibia
B. Tumor-related defects in the proximal humerus
C. Osteonecrosis of the femoral head
D. Pseudoarthrosis of the scaphoid
E. Nonunions of the femur
Correct Answer: D. Pseudoarthrosis of the scaphoid

Your Answer: B. Tumor-related defects in the proximal humerus
Explanation: Vascularized free fibula grafts have been used in numerous locations for a variety of difficult
problems. Potential situations in which a patient might benefit from vascularized autografts include osteonecrosis
of the femoral head, reconstruction of tumor-related defects in the proximal humerus and lower extremity,
treatment of congenital tibial pseudoarthrosis, and nonunions of the femur, tibia, and femoral neck.
12. Question: Demineralized bone matrix is:
A. Osteogenic
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B. Osteogenic and osteoconductive
C. Osteoinductive, osteogenic, and osteoconductive
D. Osteoconductive and osteoinductive
E. Only osteoconductive
Correct Answer: D. Osteoconductive and osteoinductive

Your Answer: C. Osteoinductive, osteogenic, and osteoconductive
Explanation: Demineralized bone matrix is recognized as having a variable amount of osteoinductive capacity and
some osteoconductive properties. The biologic activity varies with specific processing and storage methods, in
addition to variation among donors.
13. Question: Which of the following has the highest risk of disease transmission:
A. Cortical allograft
B. Cortical autograft
C. Cancellous allograft
D. Cancellous autograft
E. Cortical allograft and cancellous allograft have the same risk of disease transmission.
Correct Answer: A. Cortical allograft

Your Answer: B. Cortical autograft
Explanation: Cortical bone is of greater density than cancellous bone, and it is believed that the density accounts
for the slightly higher risk of disease transmission, as pathogens are less easily destroyed when embedded in a
more dense tissue bed. Two cases of HIV transmission resulting from cortical allografts have been reported.
14. Question: The following image (Slide 1) depicts:
A. The removal of congenital pseudoarthrosis of the tibia
B. A vascularized iliac autograft
C. A fibular autograft
D. The harvesting of the vascularized fibula from the contralateral leg
E. A fibular autograft for spinal fusion

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Correct Answer: D. The harvesting of the vascularized fibula from the contralateral leg
Your Answer: C. A fibular autograft
Explanation: The image depicts the harvesting of a vascularized fibula from the contralateral leg, which is then
used to move a defect in congenital pseudoarthrosis of the tibia on the opposite side. The following image (Slide 2)
shows clinical union 3.5 years later.
15. Question: Vascularized transplantation of the knee and femoral diaphysis is most frequently complicated by:
A. Immunosuppressive medications
B. Pulmonary emboli
C. Bony nonunions
D. Acute infections
E. Deep venous thrombosis (DVT)
Correct Answer: A. Immunosuppressive medications

Your Answer: C. Bony nonunions
Explanation: Hofmann and Kirschner reported their experiences with transplantation of vascularized diaphyseal
femora and vascularized knees. While using an immunosuppressive regimen consisting of antithymocyte globulin,
cyclosporine, azathioprine, and methylprednisolone, which was tapered over 6 months to cyclosporine
monotherapy, three patients underwent transplantation of vascularized femoral diaphysis and five patients
underwent transplantation of the entire knee, including the extensor mechanism and joint capsule. According to
their most recent report, four of these eight patients (two from each group) are currently weight bearing on their
transplants. As the authors state, these vascularized bone transplants were ?fraught with complications,? largely
related to the immunosuppressive medications.
16. Question: When treating an infected joint prosthesis with antibiotic cement, the antibiotic elution should stay
above the minimum inhibitory concentration (MIC) for a minimum of:
A. 1 week
B. 2 weeks
C. 3 weeks
D. 4 weeks
E. 6 weeks
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Correct Answer: C. 3 weeks
Your Answer: C. 3 weeks
Explanation: Antibiotic elutions differ among brands of cement. However, the antibiotic concentrations should
stay above the MIC for at least 3 weeks. The effect is local and there is no significant absorption of a specific
antibiotic out of the bone cement and into the plasma.
17. Question: After implantation, the antibiotic inside bone cement will be present and can be measured for up to:
A. 1 day
B. 1 week
C. 2 weeks
D. 3 weeks
E. Several months
Correct Answer: E. Several months

Your Answer: D. 3 weeks
Explanation: The antibiotic inside bone cement will be present in the bone cement for months or even years after
implantation into a patient. Antibiotic has been measured present even after 5 years.
18. Question: The chances of an arthroplasty revision becoming re-infected by a different organism or the initial
infection after a two-stage revision is approximately:
A. 5%
B. 10%
C. 20%
D. 40%
E. 50%

Your Answer: A. 5%
Explanation: In one series, 23% of arthroplasty revisions became re-infected by a different organism even after a
two-stage revision. However, re-infection is usually, although not always, caused by the same microorganism that
caused the initial infection. Once the white blood cell count, sedimentation rate, and C-reactive protein count return
to normal, it is usually safe to re-implant the prosthesis.
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19. Question: Which of the following antibiotics has the highest concentration locally from Palacos-R (Biomet,
Warsaw, IN) cement:
A. Tobramycin
B. Lincomycin
C. Bacitracin
D. Gentamicin
E. Keflex
Correct Answer: D. Gentamicin

Your Answer: B. Lincomycin
Explanation: The Slide represents different antibiotics that may be used with bone cement and the release of
antibiotics over a 10-day period. Gentamicin leads the way with a high concentration locally. Bacitracin, for
instance, does not leach in high concentrations from Palacos-R bone cement.
20. Question: The maximum amount of antibiotic powder that can be added as a temporary spacer to 40 g of
cement powder is:
A. 1 g
B. 2 g
C. 4 g
D. 6 g to 8 g
E. 9 g to 10 g
Correct Answer: D. 6 g to 8 g
Your Answer: D. 6 g to 8 g
Explanation: Surgeons should not add more than 6 g to 8 g of antibiotic powder per 40 g of cement powder. One
also needs to be careful when adding additional antibiotic powder of the same type, especially to Palacos-R
(Biomet, Warsaw, IN) cement, as an overdose may occur. The cement powder should be mixed with the liquid and
then the antibiotic powder added to facilitate setting of the cement.
21. Question: The optimal depth of cement penetration for prosthesis insertion is:
A. 1 mm
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B. 2 mm
C. 3 mm
D. 4 mm
E. 8 mm
Correct Answer: D. 4 mm
Your Answer: C. 3 mm
Explanation: Pressure magnitude is the most influential of all factors considered in cement penetration behavior.
The optimal depth of cement penetration is 4 mm. The higher the pressure is inside the femoral canal, the more
effectively the cement will interdigitate.
22. Question: Which of the following most effectively provides the strongest fixation when cementing a prosthesis
in a femur:
A. A thin cancellous layer
B. No cancellous layer at all
C. A poor quality cancellous layer
D. High-quality, radiodense cancellous bone
E. A straight-stem femoral prosthesis
Correct Answer: D. High-quality, radiodense cancellous bone

Your Answer: B. No cancellous layer at all
Explanation: The most effective way to provide the strongest fixation when cementing a prosthesis in a femur is
to insert it into high-quality, radiodense cancellous bone using a tapered femoral stem, which creates higher
intramedullary pressures than a straight stem.
23. Question: Which of the following is not a risk factor for fracturing cement around a prosthesis:
A. A sharp corner in the metal
B. A cement mantle less than 3 mm thick
C. A thick cement mantle
D. Voids or air bubbles in the cement mantle
E. Local debonding of the cement-metal interface

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Correct Answer: C. A thick cement mantle
Your Answer: B. A cement mantle less than 3 mm thick
Explanation: Sharp corners in the metal act as chisels and, as time goes by, are driven into the cement causing
cracks. A cement mantle less than 3 mm thick, voids or air bubbles in the cement mantle, and local debonding of
the cement-metal interface are also risk factors. A thick cement mantle of 4 mm or greater is desired because a thin
mantle cannot sustain the prosthesis.
24. Question: To obtain an adequate cement penetration of 4 mm at a pressure of 0.2 MPA to 0.3 MPA in arthritic
bone, one needs to maintain:
A. 10 kg of pressure for 20 seconds
B. 20 kg of pressure for 30 seconds
C. 30 kg of pressure for 30 seconds
D. 40 kg of pressure for 30 seconds
E. 50 kg of pressure for 50 seconds
Correct Answer: E. 50 kg of pressure for 50 seconds

Your Answer: C. 30 kg of pressure for 30 seconds
Explanation: To extrapolate the above to the clinical situation, one must maintain a force of 40 kg to 60 kg of
pressure for at least a period of 40 to 60 seconds. Adequate penetration of less than 40 kg of pressure for less than
40 seconds does not give adequate cement penetration.
25. Question: Which of the following commercially available cements has the lowest tensile strength value:
A. Palacos-R (Biomet, Warsaw, IN)
B. Sulfix-60 (Sulzer, Austin, TX)
C. Simplex P (Stryker, Kalamazoo, MI)
D. CMW3 (Wright Medical Technology, Inc, Arlington, TN)
E. Zimmer Dough (Zimmer, Warsaw, IN)
Correct Answer: E. Zimmer Dough (Zimmer, Warsaw, IN)

Your Answer: B. Sulfix-60 (Sulzer, Austin, TX)
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Explanation: Zimmer Dough has the lowest value of tensile strength; however, all of the above are FDA-approved
cements and of sufficient quality.
26. Question: Which of the following bone cements has demonstrated the lowest cycles to failure:
A. Simplex P (Stryker, Kalamazoo, MI)
B. Palacos-R (Biomet, Warsaw, IN)
C. Boneloc (Biomet, Warsaw, IN)
D. Zimmer Dough (Zimmer, Warsaw, IN)
E. Sulfix-60 (Zimmer, Warsaw, IN)
Correct Answer: C. Boneloc (Biomet, Warsaw, IN)

Your Answer: D. Zimmer Dough (Zimmer, Warsaw, IN)
Explanation: Simplex P and Palacos-R display outstanding results when tested in the cyclic conditions. Boneloc
demonstrated the lowest cycles to failure.
27. Question: The most significant factor reducing porosity in bone cement is:
A. Storage temperature only
B. Centrifugation of low viscosity cement
C. Vacuum-mixing medium viscosity
D. A combination of vacuum-mixing and centrifugation
E. Vacuum-mixing only
Correct Answer: D. A combination of vacuum-mixing and centrifugation

Your Answer: C. Vacuum-mixing medium viscosity
Explanation: The most significant factor reducing porosity in bone cement is a combination of centrifugation and
vacuum-mixing. If cement is centrifuged and vacuum-mixed, then low viscosity cement is not significantly
different from medium viscosity cement. A comparison of storage temperatures at 4? C and 21? C shows little
effect on cement bubbles or cement voids, or porosity of bone cement.
28. Question: Prosthetic placement in a cement-filled canal creates highest peak elevations in pressure when:
A. Using a cement restrictor
B. Using a retrograde filling

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C. Using mechanical pressurization
D. Inserting the prosthesis late in the setting phase
E. Inserting the prosthesis early, while the cement is extremely soft
Correct Answer: D. Inserting the prosthesis late in the setting phase

Your Answer: B. Using a retrograde filling
Explanation: Prosthetic placement in the cement-filled femoral canal creates transiently higher peak elevations in
pressure when inserted late in the setting phase. It creates higher pressures than those obtained with a cement
restrictor, retrograde filling, or mechanical pressurization.
29. Question: The time it takes for the polymer/monomer mixing until polymerization is sufficient to maintain the
implant in its correct position is known as:
A. Doughing time
B. Working time
C. Setting time
D. Mixing time
E. Polymerization time
Correct Answer: C. Setting time

Your Answer: B. Working time
Explanation: The setting process is described by three critical time periods, which include doughing time,
working time, and setting time. The doughing time begins when the polymer and the monomer are mixed until the
time when the mixture will not adhere to a gloved hand anymore. Working time implies the time from the start of
kneading until the cement is too stiff to be delivered in the bone. The setting time implies the time from the
polymer/monomer mixing until polymerization is sufficient to maintain the correct implant position.
30. Question: Cement takes longer to set when using a:
A. Roughened stem
B. Precoated femoral stem
C. Polished femoral stem
D. Irregular femoral stem
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E. Cement setting time is not affected by the femoral stem.
Correct Answer: C. Polished femoral stem

Your Answer: C. Polished femoral stem
Explanation: Cement sets sooner when using a roughened or precoated femoral stem. It sets later when using a
finely polished femoral stem because the cement-prosthesis bond is not influenced by the wetness of the cement.
31. Question: Acrylic bone cement is composed of:
A. A polymer powder and a polymer liquid component
B. A monomer powder and a monomer liquid component
C. A polymer powder and a monomer liquid component
D. A monomer powder and a polymer liquid component
E. Polymethylmethacrylate (PMMA) only
Correct Answer: C. A polymer powder and a monomer liquid component

Your Answer: A. A polymer powder and a polymer liquid component
Explanation: Polymethylmethacrylate (PMMA) is one of the ingredients of acrylic bone cement. The two
components of bone cement are a polymer powder component and a monomer liquid component. A blend of
ingredients in the polymer and monomer (which includes PMMA) gives cement its unique characteristics.
32. Question: The chemical composition of acrylic bone cement is:
A. Benzoyl peroxide and barium sulfate
B. Methylmethacrylate-styrene-copolymer
C. Methylmethacrylate-styrene-copolymer and polymethylmethacrylate
D. Methylmethacrylate-styrene-copolymer, polymethylmethacrylate, and barium sulfate
E. Polymethylmethacrylate and dimethyl-p-toluidine
Correct Answer: D. Methylmethacrylate-styrene-copolymer, polymethylmethacrylate, and barium sulfate

Your Answer: B. Methylmethacrylate-styrene-copolymer
Explanation: When the monomer liquid is added to the polymer powder, the polymer powder dissolves and
releases benzoyl peroxide from the polymer. The benzoyl peroxide initiates a reaction with n,n-dimethyl-p-
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toluidine in the monomer, which accelerates the chemical reaction and polymerization. When complete, acrylic
bone cement is composed of 75% methylmethacrylate-styrene-copolymer, 15% polymethylmethacrylate, and 10%
barium sulfate.
33. Question: Bone cement was first used commercially:
A. During World War II in the production of airplane windshields
B. In dentistry for filling cavities
C. By John Charnley for bonding total hip joints to bone
D. By neurosurgeons for replacement of skull defects
E. As a base material for dentures
Correct Answer: E. As a base material for dentures

Your Answer: C. By John Charnley for bonding total hip joints to bone
Explanation: Otto Rohm, MD, developed polymethylmethacrylate and introduced it into commercial application.
In the 1930s, bone cement was first used commercially as a base material for dentures.
34. Question: The longest period of survival for cemented total joints is associated with which type of cementation
technique:
A. Grade A
B. Grade B
C. Grade C1
D. Grade C2
E. Grade D
Correct Answer: A. Grade A

Your Answer: D. Grade C2
Explanation: The grade A cementation technique is the most advantageous and is associated with the longest
period of survival in total joint replacement. One cannot clearly distinguish between the edge of the cement and the
edge of the surrounding bone.
35. Question: Which of the following prosthetic areas is classified as a grade 4 Gruen zone radiographic defect:
A. The medullary distal tip of the prosthesis and the cement
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B. The lateral middle part of the prosthesis
C. The lateral lower third of the prosthesis
D. The medial distal third of the prosthesis
E. The middle part, medial of the prosthesis
Correct Answer: A. The medullary distal tip of the prosthesis and the cement
Your Answer: B. The lateral middle part of the prosthesis
Explanation: Gruen zones are an effective international classification system whereby radiographic defects or
errors are evaluated and documented according to zones around a prosthesis. The classification begins with grade
1, which is lateral in the area of the greater trochanter to just below the lesser trochanter. Grade 4 is a radiographic
defect located at the medullary distal tip of the prosthesis and the cement.
36. Question: Which of the following grades classifies the mode of failure of cemented femoral components in
which the whole proximal part of the prosthesis is denude of bone cement and rocks back and forth in the distal
part that is fixed with bone cement:
A. Grade Ia
B. Grade II
C. Grade III
D. Grade IV
E. Grade Ib
Correct Answer: D. Grade IV

Your Answer: A. Grade Ia
Explanation: Modes of failure of cemented femoral components are classified into four grades. In a grade Ia,
subsidence of the metal prosthesis in the cement mantle is present. Grade Ib implies that the cement and stem are
pistoning distalward. Grade II implies medial migration of the proximal stem and lateral migration of the distal
stem. Grade III is classified by a pivot of the calcar part of the prosthesis. Grade IV implies that the whole proximal
part of the prosthesis is denude of bone cement and rocks back and forth in the distal part that is fixed with bone
cement.
37. Question: Which of the following latex-free gloves are destroyed by bone cement:
A. Allegard latex-free gloves (Johnson & Johnson, New Brunswick, NJ)
B. Biogel (Regent Medical, Norcross, GA)
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C. Neotech (Regent Medical)
D. Duraprene
E. No latex-free gloves are destroyed by bone cement.
Correct Answer: A. Allegard latex-free gloves (Johnson & Johnson, New Brunswick, NJ)
Your Answer: C. Neotech (Regent Medical)
Explanation: Not all brands of latex-free gloves are equally effective. Bone cement destroys Allegard latex-free
gloves.
38. Question: Which of the following is not a factor in the setting time of cement:
A. Storage temperature of bone cement
B. Ambient temperature
C. Handling and kneading of bone cement
D. Use of a cement gun
E. Introducing bone cement in a warm environment
Correct Answer: D. Use of a cement gun

Your Answer: B. Ambient temperature
Explanation: Storage temperature, ambient temperature, handling and kneading of bone cement, and introducing
cement in a warm environment are factors of the setting time of cement. Use of a cement gun is not a factor.
39. Question: With the use of perineural catheters, improvement in all of the following outcomes can be
anticipated except:
A. Lower pain scores
B. Narcotic sparing effect
C. Reduced incidence of nausea and vomiting
D. Increased sleep disturbances
E. Shortened length of stay
Correct Answer: D. Increased sleep disturbances

Your Answer: C. Reduced incidence of nausea and vomiting
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Explanation: Double blind placebo controlled randomized trials the use of perineural catheters led to improved
pain scores, decreased narcotic usage and narcotic related side effects, and fewer sleep disturbances.
Length of stay was shortened by the use of perineural catheters as compared to epidural or IV PCA analgesia in
several studies. In pilot studies, the use of perineural catheters in carefully selected patients allowed ambulatory
total shoulder arthroplasty and single day admissions for total hip arthroplasty and total knee arthroplasty.
40. Question: The addition of a sciatic nerve block to a femoral nerve block will:
A. Enhance analgesia following knee surgery
B. Improve mobility
C. Provide complete anesthesia to the knee
D. Increase the likelihood of nerve injury
E. Decrease DVT formation
Correct Answer: A. Enhance analgesia following knee surgery

Your Answer: B. Improve mobility
Explanation: Pain from the posterior aspect of the knee joint is diminished with the addition of a sciatic nerve
block to complement a femoral nerve block. The use of combined femoral sciatic nerve block impairs ambulation
because of the degree of extensive motor block of the quadriceps and muscles of the lower leg. In addition,
proprioception that aids in balance is diminished with peripheral nerve block. The obturator nerve, which
contributes to the innervation of the knee capsule, is more frequently anesthetized with a lumbar plexus (posterior
approach) than an anterior femoral nerve block. Because of the variability of the cutaneous innervation of the
obturator nerve, the only reliable test for measuring obturator nerve block is motor block of the adductors of the
thigh. The addition of a sciatic nerve block will not improve obturator nerve blockade. Nerve injury after peripheral
nerve block of lower extremity is uncommon (<1 in 5,000). The incidence is no higher after combined femoral
sciatic nerve blocks than after single nerve blocks. Theoretically, the likelihood of DVT formation should be
decreased in patients receiving a combined femoral and sciatic nerve blocks compared to patients who receive no
regional anesthesia because of the profound degree of vasodilatation induced by the sympathetic block to the lower
extremity. To date, no large studies have been performed to prove or disprove this theoretical advantage.
41. Question: What percent of asymptomatic osteonecrosis (Stage I Steinberg) with steroid use, alcohol abuse, or
an idiopathic etiology progress to painful symptoms:
A. 10%
B. 30%
C. 50%
D. 70%
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E. 90%

Your Answer: C. 50%
Explanation: In several combined studies that involved 83 asymptomatic stage 1 osteonecrosis of the femoral
head associated with steroid use, alcohol abuse, or idiopathic etiology, only 27 (33%) hips progressed to symptoms
after 6 to 36 months.
TABLE II. Review of the Literature of the Evolution for other Asymptomatic Stage-I Hips Treated Nonoperatively
Number of Duration of
Study Symptomatic Progression
Hips Follow-up(mo)
Stulberg et al 3 26.8 2 of 3
Kopecky et al 25 16 7 of 25
Takatori et al 32 20.9 14 of 32
Fordyce and
5 36 2 of 5
Solomon
Mulliken et al 11 22 0 of 11
Davidson 7 6.5 2 of 7
Total 27 of 83
42. Question: In addition to developing pain, what percent of patients with asymptomatic osteonecrosis and sickle
cell disease will have hips that collapse:
A. 10%
B. 30%
C. 50%
D. 70%
E. 90%

Your Answer: C. 50%
Explanation: Seventy-seven percent of 121 asymptomatic hips studied by Hernigou and colleagues went on to
collapse. Their results suggest that patients with sickle cell disease with asymptomatic stage I and II osteonecrosis
is more rapid and frequent than previously assumed with osteonecrosis related to steroid or alcohol use.
43. Question: Which of the following percentages represents the number of patients with homozygous sickle cell
disease that will develop osteonecrosis of the femoral head by age 35:
A. 10%
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B. 30%
C. 50%
D. 70%
E. 90%

Your Answer: C. 50%
Explanation: Osteonecrosis of the femoral head is a common complication in patients with sickle cell disease, and
the prevalence of complications peaks in adolescence. Osteonecrosis of the femoral head develops by the age of 35
in nearly half of all patients with homozygous sickle cell disease.
44. Question: Bilateral hip involvement with osteonecrosis is seen in what percent of patients with sickle cell
disease:
A. 5%
B. 10%
C. 20%
D. 30%
E. 50%

Your Answer: E. 50%
Explanation: Bilateral hip involvement in patients with sickle cell disease with osteonecrosis is found in 40% to
90% of all patients. Without intervention, the rate of femoral head collapse in patients with sickle cell disease is
87% within 5 years after initial diagnosis of the osteonecrosis, but it can be as high as 90% within 2 years after the
initial diagnosis.
45. Question: Failure rates, based on pain and limitation of motion, after total hip replacements (THR) in patients
with sickle cell disease is:
A. 10%
B. 25%
C. 50%
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D. 75%
E. 90%

Your Answer: C. 50%
Explanation: Seventy-five percent of patients with sickle cell disease who had undergone THR were found to
have ongoing pain and substantial limitation of motion. Because of these unfavorable results, there is considerable
interest in evaluating treatment regimens that will postpone the need for THR in this population.
46. Question: What is the prevalence of sickle cell disease among African Americans:
A. 1/6
B. 1/60
C. 1/600
D. 1/6000
E. 1/60,000
Correct Answer: C. 1/600

Your Answer: D. 1/6000
Explanation: Sickle cell disease denotes all genotypes containing one sickle cell gene and another variant
hemoglobin encoding gene (eg, HbC, HbS, HbD). These result in phenotypes where HbS constitutes at least 50%
of the present hemoglobin. It is estimated that 1 of every 600 African Americans has sickle cell disease. Six major
subsets of sickle cell disease exist, with mutation type determining disease severity.
47. Question: In patients with sickle cell disease, what are the most commonly affected locations for
osteonecrosis:
A. Distal radial and distal humerus
B. Head of femur and head of humerus
C. Distal femur and proximal tibia
D. Head of humerus and proximal tibia
E. Metacarpals and phalanges
Correct Answer: B. Head of femur and head of humerus

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Your Answer: C. Distal femur and proximal tibia
Explanation: The prevalence of osteonecrosis in patients with sickle cell disease is as high as 37% to 50%.
Osteonecrosis most commonly occurs in the humeral and femoral heads, due to their limited arterial network,
which can easily succumb to occlusion by sickled cells.
48. Question: Appropriate indications for preoperative transfusion therapy in patients with sickle cell include:
A. Hemoglobin <5g/dL with clinical signs/symptoms of anemia.
B. Pulmonary acute chest syndrome with multisegmental disease or hypoxia.
C. Acute chronic anemia with severe aplastic anemia.
D. Hemoglobin <5g/dL with clinical signs/symptoms of anemia, and acute chronic anemia with severe aplastic
anemia.
E. Hemoglobin <5g/dL with clinical signs/symptoms of anemia, acute chronic anemia with severe aplastic
anemia, and pulmonary acute chest syndrome with multisegmental disease or hypoxia.
Correct Answer: E. Hemoglobin <5g/dL with clinical signs/symptoms of anemia, acute chronic anemia with
severe aplastic anemia, and pulmonary acute chest syndrome with multisegmental disease or hypoxia.
Your Answer: A. Hemoglobin <5g/dL with clinical signs/symptoms of anemia.
Explanation: The need for transfusion therapy is based on the overall clinical history of the individual patient.
Commonly cited indications include:
 Patients with hemoglobin <5 g/dL and significant signs of anemia
 Pulmonary acute chest syndrome with multisegmental disease or hypoxia
 Acute or chronic anemias with severe aplastic anemias
49. Question: What is the most common postoperative complication in patients with sickle cell disease:
A. Acute chest syndrome
B. Vaso-occulsive crisis
C. Neurological events
D. Renal events
Correct Answer: A. Acute chest syndrome

Your Answer: D. Renal events
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Explanation: Postoperative management consists of intravenous hydration, supplemental oxygen, intravenous
antibiotics, chest physiotherapy, and incentive spirometry. Common complications encountered in the early
postoperative period include acute chest syndrome (12%), vaso-occlusive crisis (9%), and less commonly,
neurological and renal events.
50. Question: Intraoperatively, all patients with sickle cell disease require which of the following:
A. Cardiac rhythm monitoring
B. Oxygen saturation monitoring
C. Active warming
D. Blood pressure monitoring
E. All of the above

Your Answer: C. Active warming
Explanation: The most common intraoperative complications are excessive blood loss (53%), followed by
hypothermia (11%). Therefore, patients require extensive monitoring of cardiac rhythm, blood pressure,
temperature, and oxygen saturation. They also need active intraoperative warming, which usually consists of a
combination of a warming blanket, humidifier, blood/fluid warmer, and heat lamp.
Thank you.
Hyperguide Staff.
1. Question: Which of the following postoperative thromboembolic prophylaxis options is of greatest benefit in
patients with sickle cell disease:
A. Low-molecular-weight heparin
B. Low-dose heparin
C. Warfarin
D. Warfarin and foot pumps
E. Aspirin
Correct Answer: D. Warfarin and foot pumps

Your Answer: C. Warfarin
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Explanation: Few published reports exist on the risk of deep vein thrombosis (DVT) in patients with sickle cell
disease following orthopedic procedures. In sickle cell disease, platelets do not contribute to the pathophysiology
of microvascular occlusion. However, due to splenic sequestration, patients with sickle cell disease often have
thrombocytopenia. Factors associated with vaso-occlusion include the increased adhesion of the sickle cells to the
endothelium and the activation of the clotting cascade with thrombin formation. Thrombin induces endothelial
retraction resulting in the exposure of proadhesive extracellular components. It also upregulates endothelial
expression of P-selectin, which increases binding among erythrocytes, white cells, platelets, and endothelial cells.
Both of these events can facilitate thrombus formation. Following hip surgery, there is already a definable risk of
DVT attributable to surgical trauma and immobility. The goal of lower limb arthroplasty is optimal pain control
with early mobilization to minimize the risk of respiratory and thromboembolic complications. Results of a meta-
analysis of DVT after hip surgery suggest that patients with sickle cell disease undergoing THR are best managed
with foot pumps and warfarin postoperatively to decrease the likelihood of thromboses in these patients.
2. Question: Which of the following is the most common indication for total hip arthroplasty in patients with
sickle cell disease:
A. Septic arthritis
B. Avascular necrosis
C. Osteoarthritis
D. Pain crisis
E. Fracture
Correct Answer: B. Avascular necrosis

Your Answer: B. Avascular necrosis
Explanation: The mean age of patients with sickle cell disease undergoing hip surgery is approximately 34 years,
with the most frequent procedure being THR for avascular necrosis. Some patients undergo bipolar
hemiarthroplasty, which can be complicated by acetabular protrusio. Because hip surgery often is more complex in
patients with sickle cell disease, it often is associated with longer anesthesia time and greater blood loss. Mean
blood loss in THR in patients with sickle disease is approximately 1200 mL, which is significantly greater than in
patients without sickle cell disease.
3. Question: The common genetic basis of sickle cell disease is a mutation on what chromosome:
A. Chromosome 2
B. Chromosome 8
C. Chromosome 11
D. Chromosome X
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E. Chromosome 14
Correct Answer: C. Chromosome 11

Your Answer: C. Chromosome 11
Explanation: The common genetic basis of sickle cell disease is a mutation on chromosome 11 that results in an
amino-acid substitution of valine for glutamic acid at the sixth position of the beta-globin subunit of hemoglobin
that results in hemoglobin S (HbS). In the heterozygote carrier, this sickle gene mutation offers potential resistance
to endemic Plasmodium falciparum malaria infections. Diagnosis of the disease is confirmed by hemoglobin
electrophoresis.
4. Question: In the heterozygote carrier, the presence of this sickle gene mutation offers potential resistance to:
A. Bartonella infections
B. Clostridium infections
C. Pneumococcal infections
D. Plasmodium falciparum malaria infections
E. Typhoid fever
Correct Answer: D. Plasmodium falciparum malaria infections

Your Answer: B. Clostridium infections
Explanation: The common genetic basis of sickle cell disease is a mutation on chromosome 11 that results in an
amino-acid substitution of valine for glutamic acid at the sixth position of the beta-globin subunit of hemoglobin
that results in hemoglobin S (HbS). In the heterozygote carrier, this sickle gene mutation offers potential resistance
to endemic Plasmodium falciparum malaria infections. Diagnosis of the disease is confirmed by hemoglobin
electrophoresis.
5. Question: The minimally invasive surgical technique for unicondylar knee arthroplasty (UKA):
A. Everts the patella
B. Resurfaces the patella
C. Subluxes the patella
D. Removes a portion of the patella
E. Violates the suprapatellar synovial pouch
Correct Answer: C. Subluxes the patella

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Your Answer: C. Subluxes the patella
Explanation: New surgical technique and instrumentation leads to less invasion of the extensor mechanism. The
patella is not everted, and the suprapatellar synovial pouch remains untouched.
6. Question: The early failures of unicondylar knee arthroplasty (UKA) were due to:
A. Patient selection
B. Implant design
C. Surgical technique
D. Implant design and surgical technique
E. Patient selection, implant design, and surgical technique
Correct Answer: E. Patient selection, implant design, and surgical technique

Your Answer: B. Implant design
Explanation: The initial high failure rate of UKA in early reports was related to improper patient selection,
incorrect surgical technique, and poor implant design.
7. Question: In unicondylar knee arthroplasty (UKA) for a varus knee:
A. The medial collateral ligament should be released
B. The medial collateral ligament should be tightened
C. The medial collateral ligament should not be changed
D. The lateral collateral ligament should be tightened
E. Knee alignment is corrected to 6° of valgus
Correct Answer: C. The medial collateral ligament should not be changed

Your Answer: C. The medial collateral ligament should not be changed
Explanation: In total knee arthroplasty (TKA), knee alignment is corrected to an anatomic 6? or 7? of valgus. In
UKA, this alignment leads to excessive medial compartment tightness and overload of the opposite lateral
compartment. A varus knee in UKA should remain in neutral or a few degrees of varus. In TKA, a flexion
contracture can be readily corrected with additional resection of both femoral condyles. In UKA, resection of the
single distal femoral condyle helps to correct the flexion contracture but also changes the distal femoral valgus.
Ligament releases in UKA are not as predictable as in TKA because only one compartment is replaced in the UKA,
and the forces on the opposite compartment are more difficult to balance.
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8. Question: In comparing high tibial osteomtomy to unicondylar knee arthroplasty (UKA):
A. Patients with high tibial osteotomy recover faster than patients with UKA.
B. High tibial osteotomy has better 10-year results than UKA.
C. High tibial osteotomy has better early results than UKA.
D. High tibial osteotomy is better for patients who work as heavy laborers.
E. High tibial osteotomy has fewer operative complications than UKA.
Correct Answer: D. High tibial osteotomy is better for patients who work as heavy laborers.
Your Answer: C. High tibial osteotomy has better early results than UKA.
Explanation: Although a successful UKA can eliminate pain and improve the patient?s function, heavy labor and
high impact athletic activities are not encouraged. High tibial osteotomy allows a patient to perform more
aggressive activities.
9. Question: Contraindications to unicondylar knee arthroplasty (UKA) includes all of the following except:
A. Bilateral knee disease
B. Tibial subluxation
C. Varus deformity >15°
D. Inflammatory arthritis
E. >10° flexion contracture
Correct Answer: A. Bilateral knee disease

Your Answer: D. Inflammatory arthritis
Explanation: A patient?s symptoms and physical findings should be isolated to one tibiofemoral compartment, but
disease can be present in both the right and left knee as long as its just one compartment. Patient history must be
thoroughly evaluated to ensure that there are no associated patellofemoral symptoms in the opposite compartment.
10. Question: Patellofemoral arthritis in the knee undergoing unicondylar knee arthroplasty (UKA):
A. Is an absolute contraindication
B. Is a relative contraindication
C. Does not affect the result of UKA

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D. Is always present in UKA
E. Is more symptomatic than patellar impingement
Correct Answer: B. Is a relative contraindication

Your Answer: B. Is a relative contraindication
Explanation: Kozinn and Scott have emphasized that pain in the patellofemoral joint is a relative contraindication
for UKA surgery. Degenerative changes of the patellofemoral joint also affected patient function, but the symptoms
were less severe than in patients with patellar impingement. If patients report significant symptoms related to the
patellofemoral joint, then UKA is contraindicated.
11. Question: When performing unicondylar knee arthroplasty (UKA), it is best to use polyethylene:
A. With a thickness of >10 mm
B. With a thickness of >8 mm
C. With a thickness of >6 mm
D. With a thickness of >4 mm
E. With a thickness of >2 mm
Correct Answer: C. With a thickness of >6 mm

Your Answer: C. With a thickness of >6 mm
Explanation: Manufacturing of polyethylene is improving, and cross-linking processes are increasing the wear
properties. Most surgeons believe that it is safest to use a thickness of at least 6 mm with conventional
polyethylene.
12. Question: Radiographs of the UKA over a period of years after surgery show:
A. Some progression of arthritis in the opposite compartment
B. No arthritis in the opposite compartment
C. Advanced arthritis in the opposite compartment
D. No arthritis in the patellofemoral joint
E. Unacceptable rate of subsidence of the tibial compartment
Correct Answer: A. Some progression of arthritis in the opposite compartment

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Your Answer: C. Advanced arthritis in the opposite compartment
Explanation: Marmor reported no significant increase in the opposite compartment. Kozinn and Scott reported
failures due to progression in the opposite compartment; however, this may have been due to over correction of the
knee. Berger and colleagues reported minimal change in the opposite compartment with 12-year follow-up
radiographs.
13. Question: The minimally invasive surgical technique for unicondylar knee arthroplasty(UKA)
A. Everts the patella
B. Resurfaces the patella
C. Subluxes the patella
D. Removes a portion of the patellar
E. Violates the suprapatellar pouch
Correct Answer: C. Subluxes the patella

Your Answer: D. Removes a portion of the patellar
Explanation: The minimally onvasive surgical technique for UKA subluxes the patella and leads to less invasion
of the extensor mechanism. The patella is not everted and the suprapatellar synovial pouch remains untouched.
14. Question: The most common organism identified in bone cultures taken from patients with sickle cell disease
with osteomyelitis is:
A. Salmonella typhimurium
B. Staphylococcus aureus
C. Haemophilus influenzae
D. Plasmodium falciparum
E. Staphylococcus epidermis
Correct Answer: B. Staphylococcus aureus

Your Answer: C. Haemophilus influenzae
Explanation: Although Salmonella infections are highly specific to patients with sickle cell disease, the most
common organism identified in bone cultures taken from patients with sickle cell disease with osteomyelitis is S
aureus. Due to autoinfarction, 95% of individuals develop functional asplenia by age 5 years. This condition has
been associated with a decrease in opsonin production and phagocytic activity. Thus, in infants with sickle cell
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disease the major cause of death is pneumococcal sepsis. It has been recommended that patients with sickle cell
disease have pneumococcal vaccine administered every 3 to 5 years.
15. Question: Second-generation cement technique implies which of the following:
A. Cement is hand-packed in the shaft of the femur.
B. The medullary canal is rinsed out by medullary lavage.
C. Cement is hand-mixed, medullary lavage is performed, and a canal plug is used.
D. The canal is brushed, jet lavage is performed, and a vacuum or centrifuge machine is used.
E. External pressurization is used.
Correct Answer: C. Cement is hand-mixed, medullary lavage is performed, and a canal plug is used.
Your Answer: C. Cement is hand-mixed, medullary lavage is performed, and a canal plug is used.
Explanation: First-generation cement technique implies that cement is hand-packed in the shaft of the femur. A
cement plug is not used and a lavage of the femoral canal is not performed. Second-generation technique implies
that cement is hand-mixed in a bowl, medullary lavage is performed, and a canal plug is used. Third-generation
technique refers to performing high-pressure jet lavage of the femoral canal, brushing the canal of all particles,
using a vacuum or centrifuge machine in the mixing procedure, and using external pressurization on a closed canal.
16. Question: When comparing syringe-mixing versus bowl-mixing of bone cement, which of the following is not
true:
A. Syringe-mixed bone cement has a greater density.
B. Syringe-mixed bone cement has a greater bending modulus.
C. Syringe-mixed bone cement has a lesser bending modulus.
D. Syringe-mixed bone cement has a higher bending strain.
E. Centrifuged or syringe-mixed bone cement, under vacuum conditions, is of greater strength than aerated
bowl-mixed cement.
Correct Answer: C. Syringe-mixed bone cement has a lesser bending modulus.

Your Answer: B. Syringe-mixed bone cement has a greater bending modulus.
Explanation: When analyzing bone cement for void content and failure in four-part bending, the results show that
syringe-mixed bone cement has a greater density and a greater bending modulus and is of greater strength than
aerated bowl-mixed cement.
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17. Question: In an obese patient undergoing unicondylar knee arthroplasty (UKA):
A. The results are worse than in a normal weight patient.
B. The results are better than in a normal weight patient.
C. The results are not predictably better or worse.
D. The results depend on the design of the prosthesis.
E. Results are gender dependent.
Correct Answer: A. The results are worse than in a normal weight patient.
Your Answer: C. The results are not predictably better or worse.
Explanation: The knee should have less than 15° of deformity in varus or valgus and less than 10° flexion
contracture. Inflammatory or crystalline-induced arthritis, knee subluxation, gross ligamentous laxity, and obesity
are relative contraindications to the procedure. Scott and colleagues found that increased body weight contributed
to failure in UKA and suggested that the best candidates are less than 180 lb.
18. Question: The percentage of patients with a natural history of untreated asymptomatic osteonecrosis of the
femoral head with sickle cell disease that will develop progression to pain is:
A. 10%
B. 30%
C. 50%
D. 70%
E. 90%

Your Answer: B. 30%
Explanation: In a study involving 121 patients with untreated asymptomatic osteonecrosis of the femoral head,
110 of the patients went on to develop significant hip pain. Spontaneous resolution of osteonecrosis of the femoral
head was not observed in asymptomatic hips.
19. Question: Which of the following statement is true regarding osteonecrosis and sickle cell disease:
A. Sickle cell patients with total hip replacement have outcomes equivalent to patients with osteonecrosis
secondary to steroid use.
B. Physical therapy alone is the most effective means of treatment in sickle cell patients with osteonecrosis.
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C. Core decompression alone is the most effective means of treatment in sickle cell patients with
osteonecrosis.
D. Physical therapy alone is as effective as hip core decompression followed by physical therapy.
E. Bone grafting has the best outcome for sickle cell patients.
Correct Answer: D. Physical therapy alone is as effective as hip core decompression followed by physical
therapy.
Your Answer: B. Physical therapy alone is the most effective means of treatment in sickle cell patients with
osteonecrosis.
Explanation: In a randomized prospective study performed by Neumayr and colleagues, physical therapy alone
appeared to be as effective as hip core decompression followed by physical therapy in improving hip function and
postponing the need for additional surgical intervention at a mean of 3 years after treatment.
20. Question: In the varus knee, unicondylar knee arthroplasty (UKA) should correct the deformity:
A. 7° of anatomic valgus
B. 10° of anatomic valgus
C. 0°
D. Permit implant positioning with 2 mm of laxity in flexion and full extension
E. 5° of anatomic varus
Correct Answer: C. 0°
Your Answer: C. 0°
Explanation: In the medial UKA with preoperative varus, most of the reviews suggest an alignment of 0° with
reference to the anatomic axis of the lower extremity or slightly less than 0° with reference to the mechanical axis.
In the study by Kennedy and White on 100 UKAs, they reported that superior results were obtained when the
postoperative mechanical axis of the operated limb fell in the center of the knee or slightly medial to the center.
21. Question: The most common risk factors for stress fractures is:
A. Leg length discrepancy
B. Training regimen
C. Muscle strength
D. Low bone mineral density

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E. Footwear
Correct Answer: B. Training regimen

Your Answer: D. Low bone mineral density
Explanation: Numerous risk factors for stress fracture exist. Most commonly, the scenario is doing ?too much too
soon.? Survey data have shown 86% of runners suffering stress fracture have had a change in duration, frequency,
or intensity of training immediately prior to injury. The best independent predictors for stress fracture development
in women appear to be age of menarche and calf girth.
22. Question: Which of the following exerts protective effects on bone:
A. Ligaments
B. Muscle flexibility
C. Muscle-tendon unit
D. Articular cartilage
E. Hormonal factors
Correct Answer: C. Muscle-tendon unit

Your Answer: C. Muscle-tendon unit
Explanation: The muscle-tendon unit exerts a protective effect on cortical bone by acting as the major shock
absorber. With muscle contraction, cortical bone surface bending strains are reduced. In most weight-bearing bones
it is believed that with muscle fatigue, the shock-absorbing effect is lessened and more force is transmitted directly
to bone, increasing the likelihood of microdamage accumulation.
23. Question: Which of the following is not associated with increased risk of stress fractures:
A. Eating disorder
B. Hyperthyroidism
C. Prolonged corticosteroid use
D. Hypothyroidism
E. Celiac sprue
Correct Answer: D. Hypothyroidism

Your Answer: C. Prolonged corticosteroid use
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Explanation: Any history of frequent or prolonged corticosteroid use, hyperparathyroidism, rheumatoid arthritis,
hyperthyroidism, celiac sprue, previous stress fractures or overuse injuries as well as signs or symptoms of an
eating disorder also should draw one?s attention to the possibility of a reduced bone mass.
24. Question: Which of the following are both markers of bone formation:
A. Osteocalcin and bone specific alkaline phosphatase
B. Collagen degradation products and leptin
C. IGF-1 and serum C-telopeptide
D. Urine N-telopeptide and serum C-telopeptide
E. IGF-1 and leptin
Correct Answer: A. Osteocalcin and bone specific alkaline phosphatase

Your Answer: B. Collagen degradation products and leptin
Explanation: Several metabolic hormones that influence bone formation (IGF-1, T3, leptin) as well as bone
formation markers (serum Type I procollagen carboxyl and amino terminal propeptides, osteocalcin, bone specific
alkaline phosphatase) and bone resorption markers (collagen degradation products, urine N-telopeptide, and serum
C-telopeptide) can be followed to form an impression on the overall bone turnover status.
25. Question: Which of the following is not a component of the female athlete triad:
A. Disordered eating
B. Osteopenia
C. Menstrual dysfunction
D. Low bone density
E. Excessive training
Correct Answer: E. Excessive training

Your Answer: D. Low bone density
Explanation: The female athlete triad, first described in 1993, initially consisted of three interrelated conditions:
eating disorders, amenorrhea, and osteoporosis. The definition has since been broadened to disordered eating,
menstrual dysfunction, and low bone density (osteopenia or osteoporosis) to include all those at risk for the
detrimental effects to bone.
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26. Question: Which of the following is not appropriate in the conservative management of stress fractures:
A. Relative rest
B. Maintenance of athletic fitness
C. Modification of training errors
D. Pain relief with nonsteroidal anti-inflammatory drugs (NSAIDs)
E. Gradual return to activity
Correct Answer: D. Pain relief with nonsteroidal anti-inflammatory drugs (NSAIDs)

Your Answer: B. Maintenance of athletic fitness
Explanation: Literature regarding nonsteroidal anti-inflammatory drug (NSAID) use in stress fracture healing is
lacking; however, there has been research into its risks associated with complete fractures and nonunion after
surgery. Prostaglandins play a crucial role in bone metabolism and repair. Cyclooxygenase-2 (COX-2) products
have been found to be essential to bone repair in animal studies. Animal studies have shown that NSAIDs
including indomethacin, aspirin, ibuprofen, and COX-2 inhibitors cause delayed fracture healing that may or may
not be reversible on cessation
27. Question: How much should training time and intensity be increased per week to avoid bone stress injury:
A. 10%
B. 20%
C. 30%
D. 40%
E. 50%

Your Answer: D. 40%
Explanation: Generally, it is best to increase training time and intensity by <10% per week to avoid bone stress
injury. Particularly important to female athletes are intrinsic conditions such as disordered eating and menstrual
dysfunction resulting in low bone density.
28. Question: Which of the following sites are not at increased risk for complications following stress fractures
(i.e., delayed union, nonunion, or progression to complete fracture):
A. Olecranon
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B. Sesamoids of the great toe
C. Mid tibia
D. Radius
E. Navicular
Correct Answer: D. Radius

Your Answer: B. Sesamoids of the great toe
Explanation: Delayed union and nonunion are seen in approximately 10% of all stress fractures and occur more
commonly in sesamoids of the great toe, proximal and mid tibia, base of the fifth metatarsal, navicular, and
olecranon.
29. Question: Which of the following stress fractures is associated with a particularly high level of morbidity:
A. Vertical patellar stress fracture
B. Second metatarsal
C. Lateral femoral neck
D. Fibula
E. Proximal tibia
Correct Answer: C. Lateral femoral neck

Your Answer: C. Lateral femoral neck
Explanation: Lateral- or tension-sided femoral neck fractures are most commonly associated with a high level of
morbidity following completion of fracture. In fact, one study found 60% of appropriately treated displaced
femoral neck fractures were still unable to return to their preinjury level of participation
30. Question: Metal-on-metal articulations generate how much more wear than metal-on-polyethylene
articulations:
A. Less wear
B. 10 times more wear
C. 10 times less wear
D. 10,000 times more wear
E. 10,000 times less wear

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Correct Answer: D. 10,000 times more wear
Your Answer: C. 10 times less wear
Explanation: Metal-on-metal articulations generate approximately 6.7x1012 to 2.5 x 1014 particles every year,
which is 13,500 times the number of particles produced from a typical metal-on-polyethylene bearing.
31. Question: The volumetric wear of a metal-on-metal articulation compared to polyethylene particles is:
A. Lower
B. Approximately the same
C. Higher
D. Not comparable
E. Depends on the metal involved
Correct Answer: A. Lower

Your Answer: D. Not comparable
Explanation: The actual volumetric wear of a metal-on-metal articulation is lower because of the nano-scale size
of the particles (generally < 50 nm) when compared with polyethelene particles, which are rarely <0.1 µm.
32. Question: Prosthesis-derived metal wear products are found in:
A. Synovial fluid
B. Synovial fluid and periprosthetic tissues
C. Liver and spleen
D. Lymph nodes
E. Synovial fluid, periprosthetic tissues, lymph nodes, and liver and spleen
Correct Answer: E. Synovial fluid, periprosthetic tissues, lymph nodes, and liver and spleen
Your Answer: B. Synovial fluid and periprosthetic tissues
Explanation: Prosthesis-derived metal wear products are found extensively within the synovial fluid and
periprosthetic tissues of arthroplasty patients. At post-mortem further accumulation has been identified in the
regional lymph nodes, liver and spleen. Because metal particles are very small (nano scale), the true extent of
dissemination is not yet known.
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33. Question: When metal nanoparticles are taken up by cells the biological response to the metal wear particles:
A. Induces cytotoxicity
B. Causes oxidative stress
C. Stabilizes the cell membrane
D. Induces chromosomal damage
E. Induces chromosomal damage, cytotoxicity, and causes oxidative stress
Correct Answer: E. Induces chromosomal damage, cytotoxicity, and causes oxidative stress
Your Answer: B. Causes oxidative stress
Explanation: The uptake of metal nanoparticles(<150 nm) by cells occurs by endocytotic processes, particularly
nonspecific receptor-mediated endocytosis and pinocytosis. Larger particles (>150 nm) can stimulate phagocytosis
in specialized cells such as macrophages. Once internalized, metal particles can induce cytotoxicity, chromosomal
damage, and oxidative stress. The toxicity of particles is modified by passivation and particle size. These factors
both influence the dissolution of metal from the surface, which may account for biological activity. Evidence of
cell damage, such as irregular cell membranes and enlarged mitochondria, may be induced by the physical
properties of the particles.
34. Question: The pattern of inflammation in the periprosthetic tissue of loose metal-on-metal articulations is
characterized by:
A. Perivascular infiltration of eosinophils
B. Perivascular infiltration of lymphocytes
C. Perivascular infiltration of plasma cell
D. Perivascular infiltration of polymorphonuclears
E. Perivascular infiltration of lymphocytes and accumulation of plasma cells
Correct Answer: E. Perivascular infiltration of lymphocytes and accumulation of plasma cells

Your Answer: B. Perivascular infiltration of lymphocytes
Explanation: The pattern of inflammation in the periprosthetic tissue of loose metal-on-metal articulations is
significantly different to that of metal-on-metal polyethylene articulations, and is characterized by perivascular
infiltration of lymphocytes and the accumulation of plasma cells. Experimental data suggest that orthopedic metals
induce immunological effects that support a cell-mediated hypersensitivity response.
35. Question: The International Agency for Research on Cancer classified Cr (VI) and Ni (II) as:
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A. Non carcinogenic
B. Carcinogenic
C. Possibly carcinogenic
D. Moderately carcinogenic
E. Moderately carcinogenic
Correct Answer: B. Carcinogenic

Your Answer: D. Moderately carcinogenic
Explanation: The International Agency for Research on Cancer, which publishes information on the risks posed by
chemicals on the development of human cancers, has classified Cr (VI) and Ni (II) as carcinogenic, metallic Ni and
soluble Co as possibly carcinogenic, and metallic Cr, Cr (III) compounds and implanted orthopedic alloys as
unclassifiable.
36. Question: Which of the following metals is likely to induce developmental toxicity in pregnancy as suggested
by animal studies:
A. Cr
B. Co
C. Ni and V
D. Cr and Co
E. Cr, Co, NI, V and Al
Correct Answer: E. Cr, Co, NI, V and Al

Your Answer: B. Co
Explanation: Experimental animal studies suggest that several metals, including Cr, Co, Ni, V and Al, may induce
development toxicity. For example, Cr (VI) exposure in male and/or female mice either before or during gestation
can affect the number of implantations and viable fetuses resulting from conception. Many metals can also induce
teratogenic malformations, including Cr, Ni, and V.
37. Question: The accumulation of what metal was attributed to the 1996 episode of ?beer-drinkers?
cardiomyopathy:
A. Al
B. Co
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C. Cr
D. V
E. Ni
Correct Answer: B. Co
Your Answer: D. V
Explanation: The accumulation of Co in the myocardium can induce cardiomyopathy, which was particularly
evident after the 1996 episode of ?beer-drinkers? cardiomyopathy, during which Co was used as a foam-stabilizing
agent in beer.
38. Question: The deposition of what metal in bone has been linked to osteomalacia, bone pain, and pathological
fractures:
A. Al
B. Co
C. Cr
D. V
E. Ni
Correct Answer: A. Al
Your Answer: C. Cr
Explanation: Deposition of A1 in the bone occurs as a consequence of chronic exposure and has been linked to
osteomalacia, bone pain, pathological fractures, proximal myopathy, and the failure to respond to vitamin D
therapy.
39. Question: Which of the following metals has been documented to cause serve retinal degeneration:
A. Al
B. Co
C. Ni
D. Al and Co
E. Al, Co, and Ni
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Correct Answer: E. Al, Co, and Ni
Your Answer: D. Al and Co
Explanation: Al, Co, and Ni can cause severe retinal degeneration at high-concentrations in experimental animals.
40. Question: The incidence of dermal reactions and positive skin-patch testing to Co, Ni, and Cr in patients with
total joint replacement with stable prostheses is:
A. 5% above those of the general population
B. 10% above those of the general population
C. 15% above those of the general population
D. 30% above those of the general population
E. 50% above those of the general population
Correct Answer: C. 15% above those of the general population

Your Answer: B. 10% above those of the general population
Explanation: Metal-induced skin reactions can include contact dermatitis, urticaria, and/or vasculitis. The
incidence of dermal reactions and positive skin-patch testing to Co, Ni, and Cr in patients with total joint
replacement with stable and loose prostheses increases by 15% and 50% respectively, above those of the general
population.
41. Question: The incidence of dermal reactions and positive skin-patch testing to Co, Ni, and Cr in patients with
total joint replacement with unstable prostheses is:
A. 5% above those of the general population
B. 10% above those of the general population
C. 15% above those of the general population
D. 30% above those of the general population
E. 50% above those of the general population
Correct Answer: E. 50% above those of the general population

Your Answer: B. 10% above those of the general population
Explanation: Metal-induced skin reactions can include contact dermatitis, urticaria ,and/or vasculitis. The
incidence of dermal reactions and positive skin-patch testing to Co, Ni, and Cr in patients with total joint
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replacement with stable and loose prostheses increases by 15% and 50% respectively, above those of the general
population.
42. Question: Hepatocellular necrosis has been observed with high levels of _______ in the body.
A. Al
B. Co
C. Cr
D. V
E. Ni
Correct Answer: C. Cr
Your Answer: E. Ni
Explanation: Hepatocellular necrosis often occurs in response to high levels of metal in the body, as observed
after acute ingestion of Cr (VI) in humans.
43. Question: Which metal ion concentrates in the epithelial cells of the proximal tubules and can impair renal
function, induce tubular necrosis, and cause marked interstitial changes in experimental animals and humans:
A. Al
B. Co
C. Cr
D. V
E. Ni
Correct Answer: C. Cr
Your Answer: A. Al
Explanation: Cr is concentrated in the epithelial cells of the proximal renal tubules and can impair renal function,
induce tubular necrosis, and cause marked interstitial changes in experimental animals and humans. Indicators of
tubular dysfunction have been identified in human objects exposed to Cr (VI) through occupation. Al, Ni, and Co
are all rapidly excreted by the kidney, hence renal toxicity tends to require significantly larger doses.
44. Question: Severe neurological manifestations have been attributed with accumulation of what metal ion in the
brain:
A. Al
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B. Co
C. Cr
D. V
E. Ni
Correct Answer: A. Al
Your Answer: B. Co
Explanation: Several neurological manifestations have been attributed to Al intoxication in humans, including
memory loss, jerking, ataxia, and neurofibrillary degeneration. The development of some neuropathological
conditions, including amyotrophic lateral sclerosis, Parkinsonian, dementia, dialysis encephalopathy, and senile
plaques of Alzheimer?s disease, may be related to the accumulation of Al in the brain.
45. Question: What is the preferred imaging modality to determine the glenoid wear pattern in a patient with
rheumatoid arthritis:
B. Fluoroscopically positioned plain radiographs
D. Tomograms
E. Computed tomography scan
Correct Answer: E. Computed tomography scan

Your Answer: B. Fluoroscopically positioned plain radiographs
Explanation: A computed tomography scan provides important information in regard to the version of the glenoid,
wear pattern, amount of wear, glenohumeral subluxation, as well as desired entry point.
46. Question: What is the most common reason for revision among patients who undergo shoulder arthroplasty for
rheumatoid arthritis:
A. Infection
B. Instability
C. Humeral component loosening
D. Glenoid component loosening

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E. Painful glenoid arthritis
Correct Answer: E. Painful glenoid arthritis

Your Answer: D. Glenoid component loosening
Explanation: The most common reason for revision surgery among patients with rheumatoid arthritis is painful
glenoid arthritis. The rate of revision for painful glenoid arthritis is higher than that for glenoid component
loosening.
47. Question: What is the most frequent intraoperative complication during the course of shoulder arthroplasty for
rheumatoid arthritis?
A. Pulmonary embolism
B. Cervical spine instability
C. Deltoid tearing
D. Nerve injury
E. Periprosthetic humeral fracture
Correct Answer: E. Periprosthetic humeral fracture

Your Answer: B. Cervical spine instability
Explanation: Poor quality bone is one of the primary challenges when performing a shoulder arthroplasty in a
patient with rheumatoid arthritis. Periprosthetic humeral fracture is the most frequent intraoperative complication
in this patient population.
48. Question: Among patients with a stiff shoulder or severe scarring, what approach can be used to minimize
potential intraoperative complications:
A. Transacromial approach
B. Posterior approach
C. Superior approach
D. Direct lateral approach
E. Anteromedial approach
Correct Answer: E. Anteromedial approach

Your Answer: D. Direct lateral approach
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Explanation: The anteromedial approach is a safe and effective approach when performing shoulder arthroplasty
in patients with severe stiffness and poor quality tissue.
49. Question: In addition to routine medical clearance prior to surgery, what additional test should be considered in
patients with rheumatoid arthritis:
A. Hip radiographs
B. Knee radiographs
C. Wrist radiographs
D. Hand radiographs
E. Cervical spine: Flexion-extension views
Correct Answer: E. Cervical spine: Flexion-extension views

Your Answer: C. Wrist radiographs
Explanation: A significant incidence of cervical spine disease exists among patients with rheumatoid arthritis.
Surgeons should consider obtaining cervical spine flexion-extension views to evaluate for potential instability prior
to the patient undergoing anesthesia.
50. Question: The most common technical cause of dislocation after primary total hip arthroplasty (THA) is:
A. Implant failure
B. Infection
C. Component malposition
D. Muscle weakness
E. Neurologic dysfunction
Correct Answer: C. Component malposition

Your Answer: C. Component malposition
Explanation: Although neurologic dysfunction, soft tissue laxity, and loosening due to implant failure or infection
contribute to THA instability, component malposition is the leading cause of dislocation from surgical technique.
Thank you.
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Hyperguide Staff.
1. Question: Which of the following is not a consequence of acetabular shell malposition:
A. Fibrous ingrowth
B. Increased fretting wear
C. Increased bearing wear
D. Impingement
E. Limited range of motion
Correct Answer: A. Fibrous ingrowth

Your Answer: A. Fibrous ingrowth
Explanation: Malposition leads to limited range of motion, impingement, and increased bearing and fretting wear.
Fibrous ingrowth is most commonly a consequence of inadequate fixation and excessive micromotion.
2. Question: Excessive anteversion of the acetabular cup may lead to:
B. Posterior implant impingement
C. Leg length discrepancy
D. Premature osteolysis
E. Dislocation with excessive internal rotation
Correct Answer: B. Posterior implant impingement

Your Answer: C. Leg length discrepancy
Explanation: Excessive anteversion leads to anterior dislocation due to posterior component impingement. This
most commonly occurs through extension and external rotation of the lower extremity. Excessive anteversion has
little or no direct effect on medialization of the cup, leg length disparity, or premature osteolysis.
3. Question: Mechanical guide inaccuracy in cup placement during total hip arthroplasty occurs due to:
A. Anatomic soft tissue variance
B. Displaced fracture of acetabulum
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C. Poor implant fixation
D. Excessive motion between guide and implant
E. Pelvic positional instability
Correct Answer: E. Pelvic positional instability

Your Answer: B. Displaced fracture of acetabulum
Explanation: With adequate exposure, compensation for soft tissue variance is accomplished. Fracture is
uncommon, as is gross motion between implant and bone. Provided the guide is used correctly, there is no
appreciable motion between it and the implant. Changes in pelvic and patient position, however, will render the
mechanical guide inaccurate.
4. Question: Excessive abduction of the acetabular shell may result in all of the following except:
A. Edge loading
B. Superior instability
C. Osteolysis
D. Superior cup migration
E. Linear polyethylene wear
Correct Answer: D. Superior cup migration

Your Answer: D. Superior cup migration
Explanation: Edge loading, superior dislocation or subluxation, linear polyethylene wear and resultant premature
osteolysis may all result from an excessively abducted cup. Superior cup migration is most commonly a
consequence of a cup with low abduction.
5. Question: Longevity of traditional total hip arthroplasty in young patients is limited by:
A. Implant failure
B. Infection
C. Fracture
D. Osteolysis and aseptic loosening
E. Limited range of motion
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Correct Answer: D. Osteolysis and aseptic loosening
Your Answer: B. Infection
Explanation: Although implant failure, infection, and fracture occur with extended lifetime of hip implants,
polyethylene wear debris and eventual aseptic loosening are the most commonly recognized limitation in the
survival of total hip arthroplasty. Limited range of motion is a less common presentation for implant failure in the
hip.
6. Question: Advantages of metal-on-metal vs metal-on-polyethylene articulation include:
A. Metal ion generation
B. Capacity for large head diameter
C. Lower infection rate
D. Increased bearing wetability
E. Lower cost
Correct Answer: B. Capacity for large head diameter

Your Answer: B. Capacity for large head diameter
Explanation: Metal ions generated, although of unknown consequence, are not considered an advantage. Metal-
on-metal bearings have not been shown to demonstrate a lower infection rate or lower cost, nor do they have
increased wetability (commonly associated with ceramic bearings). The metal-on-metal implants allow larger head
and cup diameter, thus providing improved range of motion with lower risk for dislocation.
7. Question: Which of the following cannot be modified during hip resurfacing:
B. Femoral component angle
C. Leg length
D. Cup size
E. Cup angle
Correct Answer: C. Leg length

Your Answer: C. Leg length
Explanation: All of the above variables can be modified during the planning and placement of hip resurfacing
with the exception of leg length. Due to the anatomic reproduction of the cup center and femoral head anatomy,
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modifications on leg length cannot be performed with hip resurfacing.
8. Question: The most common failure mechanism in hip resurfacing is:
A. Acetabular component loosening
B. Infection
C. Recurrent dislocation
D. Femoral component loosening
E. Fracture
Correct Answer: E. Fracture

Your Answer: C. Recurrent dislocation
Explanation: Among outcome studies, the most common failure mechanism for hip resurfacing is femoral neck
fracture. Dislocation, infection, and loosening have been reported at lower rates.
9. Question: Potential contraindication for primary hip resurfacing include all of the following except:
A. Excessive femoral cyst formation
B. Osteoporosis with low bone density t-score
C. Previous femoral neck fracture
D. Severe developmental hip dysplasia
E. Osteonecrosis with femoral head collapse
Correct Answer: C. Previous femoral neck fracture

Your Answer: B. Osteoporosis with low bone density t-score
Explanation: Excessive cyst formation in the femoral head, documented osteoporosis, severe developmental hip
dysplasia, and advanced osteonecrosis are contraindications to hip resurfacing. Previous femoral neck fracture,
however, if healed, does not provide a risk for femoral neck fracture.
10. Question: Failure of first-generation cementless femoral stems is attributed to:
A. Material composition
B. Malrotation
C. Wear particle migration

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D. Fatigue failure
E. Fracture
Correct Answer: C. Wear particle migration

Your Answer: D. Fatigue failure
Explanation: Initial stem design of cementless stems included patch porous coating. This design feature resulted
in wear particle migration distally, causing inevitable aseptic loosening. The remaining options were not
instrumental in cementless stem loosening.
11. Question: Evidence of cementless acetabular implant loosening is radiographically observed as:
A. Surrounding cystic lesions
B. Heterotopic bone formation
C. Increased radiodensity
D. Implant spot welds
E. Radiolucency surrounding the shell
Correct Answer: E. Radiolucency surrounding the shell

Your Answer: A. Surrounding cystic lesions
Explanation: Of the choices listed, only radiolucency provides evidence of acetabular loosening. Cystic lesions,
known as osteolysis, may exist without the presence of loosening.
12. Question: Increased scintigraphic activity surrounding an implant may signal all of the following except:
A. Recent implantation
B. Quiescent heterotopic bone
C. Osteolysis
D. Loosening
E. Infection
Correct Answer: B. Quiescent heterotopic bone

Your Answer: C. Osteolysis
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Explanation: Bone scan studies are sensitive, but poorly specific. The differential includes recent implantation (up
to 1 year), osteolysis, loosening, fracture, and infection. Mature heterotopic ossification is generally cold on bone
scan.
13. Question: Imaging of pelvic bone loss around the acetabulum is best accomplished with:
A. Pelvic Judet views
B. Computed tomography (CT) scan
C. Pelvic inlet view
D. Cross-table lateral of affected hip
E. Pelvic outlet view
Correct Answer: B. Computed tomography (CT) scan

Your Answer: D. Cross-table lateral of affected hip
Explanation: Studies have shown CT scans to be the most thorough means of assessing bone loss in the presence
of osteolysis in the pelvis.
14. Question: The ideal range of micromotion to stimulate bone ingrowth into cementless implants is:
A. Less than 20 microns
B. 30 microns to 150 microns
C. 200 microns to 500 microns
D. 600 microns to 800 microns
E. Greater than 900 microns
Correct Answer: B. 30 microns to 150 microns

Your Answer: C. 200 microns to 500 microns
Explanation: Ideal values of micromotion that stimulate bone ingrowth are 28 microns to 150 microns. Values
greater than 150 microns are associated with fibrous ingrowth.
15. Question: Which of the following is a risk factor for the development of a postoperative periprosthetic fracture
of the humerus:
A. Diabetes
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B. Female gender
C. Age
D. Diagnosis of avascular necrosis
E. Polyethylene-induced osteolysis
Correct Answer: E. Polyethylene-induced osteolysis

Your Answer: C. Age
Explanation: Osteolysis, osteopenia, and aggressive cortical reaming have been reported as potential risk factors
for the development of a postoperative periprosthetic fracture.
16. Question: What nerve is most frequently injured at the time of a periprosthetic fracture of the humerus:
A. Median nerve
B. Ulnar nerve
C. Radial nerve
D. Musculocutaneous nerve
E. Axillary nerve
Correct Answer: C. Radial nerve

Your Answer: C. Radial nerve
Explanation: The radial nerve is the most frequently injured nerve at the time of a periprosthetic fracture. There
continues to be debate as to whether the presence of a radial nerve injury constitutes a reason for revision surgery.
17. Question: What is the average length of time for a periprosthetic humeral fracture to heal with operative
treatment:
A. Less than 30 days
B. Between 30 and 90 days
C. Between 90 and 120 days
D. Between 120 and 240 days
E. Greater than 240 days
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Correct Answer: E. Greater than 240 days
Your Answer: C. Between 90 and 120 days
Explanation: In a study by Kumar and colleagues, the mean time to healing among patients who underwent
surgery was 278 days (range, 135 to 558 days).
18. Question: According to the classification system of Wright and Cofield, what constitutes a type A
periprosthetic humeral fracture:
A. Fracture at the tip of the prosthesis, extends proximally
B. Prosthesis tip without extension
C. Prosthesis tip with extension distally
D. Fracture present with a loose prosthesis
E. Distal to the tip of prosthesis
Correct Answer: A. Fracture at the tip of the prosthesis, extends proximally

Your Answer: A. Fracture at the tip of the prosthesis, extends proximally
Explanation: According to the classification, a type A fracture is one at the tip of the prosthesis and extends
proximally. Type B fractures occur at the prosthesis tip without extension or with a minimal amount of proximal
extension and a variable amount of distal extension. Type C fractures are distal to the tip of prosthesis.
19. Question: What is the preferred treatment for a type C periprosthetic fracture with a well-fixed humeral
component:
A. Open reduction internal fixation with a plate
B. Long stem prosthesis
C. Strut allograft and cerclage wires
D. Nonoperative treatment
E. Long stem with a strut
Correct Answer: D. Nonoperative treatment

Your Answer: B. Long stem prosthesis
Explanation: In patients with a type C periprosthetic fracture (distal to the tip of the prosthesis) and a well-fixed
humeral component, the injury can be treated similar to a closed humerus fracture.
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20. Question: The approximate distance of the axillary nerve from the lateral border of the acromion is:
A. 1 cm
B. 3 cm
C. 5 cm
D. 7 cm
E. 10 cm
Correct Answer: C. 5 cm
Your Answer: C. 5 cm
Explanation: The axillary nerve is located approximately 5 cm from the lateral border of the acromion.
21. Question: Which of the following nerves enters the coracobrachialis muscle distal to the tip of the coracoids:
A. Radial nerve
B. Ulnar nerve
C. Median nerve
D. Musculocutaneous nerve
E. Axillary nerve
Correct Answer: D. Musculocutaneous nerve

Your Answer: A. Radial nerve
Explanation: The musculocutaneous nerve enters the coracobrachialis muscle 4 cm to 8 cm distal to the tip of the
coracoid process.
22. Question: Which of the following approaches is used when the deltoid is taken down off the clavicle and
anterior acromion:
A. Superior approach
B. Anterosuperior approach
C. Direct approach
D. Anteromedial approach
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E. Medial approach
Correct Answer: D. Anteromedial approach

Your Answer: A. Superior approach
Explanation: The anteromedial approach involves taking the deltoid down off the clavicle and anterior acromion.
23. Question: The deltoid inserts on this surface of the clavicle:
A. Superior surface
B. Anterior surface
C. Inferior surface
D. All of the above
E.

Your Answer: B. Anterior surface
Explanation: The origin of the deltoid on the clavicle is J-shaped and extends from the midline on the superior
aspect of the clavicle around the front of the clavicle to the inferior portion of the anterior aspect of the clavicle.
Full-thickness fascial flaps must be obtained when the deltoid is released from the clavicle.
24. Question: Which of the following is an indication for an anteromedial approach:
A. Post-traumatic arthritis with severe scarring
C. Revision shoulder arthroplasty
D. All of the above
E.

Your Answer: C. Revision shoulder arthroplasty
Explanation: The anteromedial approach facilitates shoulder arthroplasty in patients with severe scarring,
distortion of anatomy, as well as patients with frail bone and soft tissue.
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25. Question: What are the contraindications for a corrective osteotomy for a proximal humerus malunion:
A. Glenohumeral arthritis
B. Massive rotator cuff tear
C. Articular incongruity
D. Avascular necrosis
E. All of the above

Your Answer: C. Articular incongruity
Explanation: Corrective osteotomy is an option for surgeons who must treat a patient with a proximal humerus
malunion. This option may best be considered in a young, active patient who has no radiographic evidence of
degenerative changes in the glenohumeral joint. In an older, less active patient who has evidence of degenerative
joint disease, a shoulder arthroplasty may be a more suitable and definitive procedure. Patients with proximal
humerus malunions often present with complaints of pain as well as loss of function. Frequently, patients have
impingement-type pain due to a malunion of the greater tuberosity with an associated decrease in the subacromial
space. Some of the contraindications to a corrective osteotomy include a massive irreparable rotator cuff tear,
significant degenerative changes of the articular surfaces, avascular necrosis, active infection, or nerve injury.
26. Question: What is the most significant factor affecting the results of shoulder arthroplasty for a malunion:
A. Placement of a glenoid component
B. Placement of a reverse shoulder arthroplasty
C. Resurfacing arthroplasty of the humerus
D. Avoidance of performing a tuberosity osteotomy
E. Performing a biceps tenodesis
Correct Answer: D. Avoidance of performing a tuberosity osteotomy

Your Answer: B. Placement of a reverse shoulder arthroplasty
Explanation: Boileau and colleagues reported that the most significant factor affecting results of shoulder
arthroplasty for malunion was the need for greater tuberosity osteotomy.
27. Question: When considering arthroscopic treatment of a malunion, what is the procedure most frequently
performed:
A. Biceps tenodesis
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B. Superior labral anterior posterior (SLAP) repair
C. Arthroscopic capsular release
D. Acromioplasty
E. Tuberoplasty
Correct Answer: D. Acromioplasty

Your Answer: B. Superior labral anterior posterior (SLAP) repair
Explanation: Arthroscopic acromioplasty has been reported by Beredjiklian and colleagues. The procedure
essentially increases the available subacromial space to improve impingement of the greater tuberosity against the
acromion.
28. Question: What are the complications commonly associated with tuberosity osteotomy at the time of shoulder
arthroplasty for malunion:
A. Nonunion of the tuberosity
B. Tuberosity resorption
C. Malunion of the tuberosity
D. All of the above
E.

Your Answer: B. Tuberosity resorption
Explanation: Antuna and colleagues reported that 10 of 24 shoulders that had a greater tuberosity osteotomy had a
complication related to tuberosity nonunion, malunion, or resorption.
29. Question: Which of the following intraoperative techniques can be used to avoid tuberosity osteotomy:
A. Placement of the stem in slight varus
B. Bending the stem to accommodate the deformity
C. Placement of the stem in slight valgus
D. All of the above
E.
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Your Answer: B. Bending the stem to accommodate the deformity
Explanation: Implantation of the humeral component in slight varus or valgus to accommodate the tuberosity
malunion was not associated with an increased incidence of humeral component loosening. In addition, humeral
components with a modified curvature in the stem have been used with success.
30. Question: What are the potential benefits of performing a lesser tuberosity osteotomy:
A. Bone-to-bone healing
B. Improved glenoid exposure
C. Ability to detect on radiographs disruption of the anterior repair
D. All of the above
E.

Your Answer: A. Bone-to-bone healing
Explanation: A lesser tuberosity osteotomy allows bone-to-bone healing as well as facilitates glenoid exposure.
Moreover, disruption of the anterior repair is immediately evident on postoperative radiographs with the
appearance of a displaced lesser tuberosity.
31. Question: What are the potential benefits of performing magnetic resonance imaging (MRI) of a shoulder
arthroplasty with a suspected rotator cuff tear:
A. Assess degree of fatty atrophy
B. Define the location of the tear
C. Evaluate the size of the tear
D. All of the above
E.

Your Answer: B. Define the location of the tear
Explanation: An MRI allows a surgeon to gain a greater understanding of the size of the rotator cuff tear, the
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specific location of the tear, and the degree of fat infiltration within the tendon.
32. Question: In an elderly patient with a postoperative rotator cuff tear and escape, which of the following options
is most effective to create a stable shoulder arthroplasty:
A. Coracohumeral reconstruction with an Achilles tendon graft
B. Bipolar arthroplasty
C. Hemiarthroplasty
D. Reverse shoulder arthroplasty
E.
Correct Answer: D. Reverse shoulder arthroplasty

Your Answer: A. Coracohumeral reconstruction with an Achilles tendon graft
Explanation: Many patients with a rotator cuff tear following shoulder arthroplasty may develop anterior-superior
escape. Once this pattern develops, it may be difficult to restore stability with attempted rotator cuff repair alone. In
this setting, one may consider the use of a reverse arthroplasty, particularly if the patient is older than 70 years of
age.
33. Question: What is the reported frequency of rotator cuff tear following shoulder arthroplasty:
A. Less than 1%
B. 1% to 2%
C. 3% to 4%
D. Greater than 5%
E.
Correct Answer: C. 3% to 4%
Your Answer: B. 1% to 2%
Explanation: The reported frequency of postoperative rotator cuff tears following shoulder arthroplasty is 3% to
4%.
34. Question: What are some potential benefits of performing arthroscopic compared to open acromioplasty in a
patient who develops impingement syndrome following hemiarthroplasty:
A. Ability to evaluate the status of the glenoid
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B. Capacity to address intra-articular pathology
C. More rapid postoperative recovery
D. Less violation of the deltoid
E. All of the above

Your Answer: A. Ability to evaluate the status of the glenoid
Explanation: Arthroscopic acromioplasty has been used for the treatment of impingement following shoulder
arthroplasty. It has the potential benefits of less tissue disruption, more rapid recovery, as well as increased ability
to address intra-articular pathology compared to an open procedure.
35. Question: Which medication has been identified as a risk factor for a nerve injury after shoulder arthroplasty:
A. Prednisone
B. Warfarin
C. Clopidogrel bisulfate
D. Aspirin
E. Methotrexate
Correct Answer: E. Methotrexate

Your Answer: C. Clopidogrel bisulfate
Explanation: Methotrexate has been identified as a risk for development of a nerve injury after shoulder
arthroplasty.
36. Question: Which is the most common mechanism for nerve injury after shoulder arthroplasty:
A. Laceration
B. Expanding hematoma
C. Contusion
D. Tearing
E. Temporary neuropraxia due to stretch
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Correct Answer: E. Temporary neuropraxia due to stretch
Your Answer: B. Expanding hematoma
Explanation: The most common reason for a nerve deficit following shoulder arthroplasty is a temporary
neuropraxia due to stretch.
37. Question: Which approach has been identified as a risk factor for the development of a nerve injury with
shoulder arthroplasty:
A. Transacromial
B. Anteromedial
C. Superior
D. Posterior
E. Deltopectoral
Correct Answer: E. Deltopectoral

Your Answer: C. Superior
Explanation: The deltopectoral approach has been identified as a risk for development of a nerve injury after
shoulder arthroplasty.
38. Question: Which nerve is most likely to have evidence of a deficit after shoulder arthroplasty:
A. Radial nerve
B. Ulnar nerve
C. Musculocutaneous nerve
D. Median nerve
E. Axillary nerve
Correct Answer: E. Axillary nerve

Your Answer: C. Musculocutaneous nerve
Explanation: The most common nerve that has been found to have a deficit after shoulder arthroplasty is the
axillary nerve.
39. Question: Which of the following is the reported incidence of nerve injuries following total shoulder
arthroplasty:
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A. Less than 1%
E. Greater than 10%
Correct Answer: D. Between 4% and 5%

Explanation: The reported incidence of nerve injuries following shoulder arthroplasty is 4.3%.
40. Question: Which is the most common reason for revision surgery among patients who undergo
hemiarthroplasty:
A. Humeral component loosening
B. Periprosthetic fracture
C. Infection
D. Instability
E. Glenoid arthritis
Correct Answer: E. Glenoid arthritis

Your Answer: C. Infection
Explanation: Painful glenoid arthritis represents the most common reason for revision surgery for
hemiarthroplasties.
41. Question: Which of the following are nonanatomic instability procedures:
A. Bristow
B. Putti-Platt
C. Magnuson-Stack
D. Latarjet
E. All of the above

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Your Answer: C. Magnuson-Stack
Explanation: Among patients who have undergone prior instability surgery, it is important to review prior
operative reports to determine the specific instability procedure performed. This will facilitate safe and effective
soft tissue releases and balancing at the time of shoulder arthroplasty.
42. Question: Which is the mean 10-year survival for shoulder arthroplasty after prior instability surgery:
A. Greater than 95%
E. Less than 65%
Correct Answer: E. Less than 65%

Your Answer: B. Between 85% and 95%
Explanation: Overall, the survival rate for shoulder arthroplasty after prior instability surgery was only 61% at 10
years.
43. Question: Compared to shoulder arthroplasty for primary osteoarthritis, shoulder arthroplasty after prior
instability surgery is associated with which of the following:
A. Lower revision rate
B. Similar revision rate
C. Higher revision rate
D.
E.
Correct Answer: C. Higher revision rate

Your Answer: B. Similar revision rate
Explanation: Research has shown that shoulder arthroplasty for postcapsulorraphy arthritis has inferior results and
a higher revision rate compared to shoulder arthroplasty for osteoarthritis.
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44. Question: Which are the most common complications after shoulder arthroplasty for instability associated
arthritis:
A. Instability
B. Component failure
C. Glenoid arthritis
D. All of the above
E.

Your Answer: C. Glenoid arthritis
Explanation: Shoulder arthroplasty for postcapsulorraphy arthritis provides pain relief and improved motion.
However, shoulder arthroplasty in these young patients is associated with a high rate of unsatisfactory results and
revision surgery due to glenoid arthritis, component failure, or instability.
45. Question: What anatomic factor has been identified as placing a patient at an increased risk for re-tearing a
rotator cuff after repair:
A. Greater tuberosity foot print less than 2 cm in width
B. Wide lateral extension of the acromion
C. Increased humeral retroversion
D. Increased inclination of the humeral neck
E. Narrow bicipital groove
Correct Answer: B. Wide lateral extension of the acromion

Your Answer: B. Wide lateral extension of the acromion
Explanation: Zumstein and colleagues identified a wide lateral extension of the acromion as a risk factor for
developing a recurrent rotator cuff tear.
46. Question: What are some of the potential benefits of using ultrasound to evaluate the integrity of the rotator
cuff:
A. Portable device
B. Low cost compared to magnetic resonance imaging (MRI)

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C. Dynamic evaluation
D. Noninvasive procedure
E. All of the above

Your Answer: C. Dynamic evaluation
Explanation: Ultrasound has become increasingly popular as a tool to evaluate rotator cuff tears. Some of the
advantages of ultrasound include the fact that it is easily portable and less expensive than MRI. Additionally, unlike
a computed tomography arthrogram, no injection is required. Another interesting aspect of ultrasound is that it
allows dynamic evaluation of the rotator cuff. Several research studies have shown the promise of using ultrasound
to follow the status of rotator cuff after repair.
47. Question: What is the reported incidence in the literature for a satisfactory outcome following open rotator cuff
repair:
A. Less than 60%
E. Greater than 90%

Explanation: Neer and researchers reviewed the results of 245 shoulders that underwent rotator cuff repair. In this
patient series, an acromioplasty was also performed in 243/245 of the shoulders. In this large series, the authors
reported an excellent or satisfactory result in 92% of the shoulders.
48. Question: What tool has been recently shown to improve the accuracy of shoulder injections and has become
increasingly popular in clinical application:
A. Ultrasound
B. Bi-plane fluoroscopy
C. Computed tomography scans
D. Magnetic resonance imaging

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E. Fluoroscopy
Correct Answer: A. Ultrasound

Your Answer: B. Bi-plane fluoroscopy
Explanation: A new treatment modality that has made a large impact on the treatment of patients with shoulder
pain is ultrasound-guided injections. Ultrasound guidance allows the health care provider to more accurately place
the injection. This has important therapeutic as well as diagnostic implications.
49. Question: What is the reported re-tear rate of massive rotator cuff tears at the near 10-year mark:
A. Less than 20%
E. Greater than 50%

Your Answer: B. Between 20% and 30%
Explanation: Recently, Zumstein and researchers reviewed the outcome of twenty-seven consecutive open repairs
of massive rotator cuff tears. At a mean follow-up of 3.1 years, the re-tear rate was 37%. At a mean follow-up of
9.9 years, among 23 patients who returned for evaluation, the re-tear rate had increased to 57%. Patients with an
intact rotator cuff repair had a substantially better outcome according to Constant scores as well as abduction
strength. The authors noted that the preoperative integrity of the tendon appeared to be protective against future
muscle deterioration and risk of developing a re-tear. Additionally, the authors noted that a wide lateral extension
of the acromion was identified as a previously unknown risk factor for re-tearing.
50. Question: What pathologic finding is consistently observed with anterior instability following shoulder
arthroplasty:
A. Anterior glenoid bone loss
B. Atrophy of the anterior deltoid
C. Disruption of the infraspinatus/teres minor
D. Disruption of the subscapularis
E. Disruption of the long head of the biceps
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Correct Answer: D. Disruption of the subscapularis
Your Answer: B. Atrophy of the anterior deltoid
Explanation: Tearing of the subscapularis is a common finding associated with anterior instability following
shoulder arthroplasty.
Thank you.
Hyperguide Staff.
1. Question: A patient undergoing a total knee replacement with a preoperative hemoglobin >15 g/dL has what
chance of requiring a transfusion:
A. 5%
B. 10%
C. 20%
D. 30%
E. 40%

Your Answer: A. 5%
Explanation: There is a 69% chance of an allogenic transfusion if the hemoglobin is less than 13 g/dL and only a
13% chance if more than 15 g/dL. A surgeon must weigh the risks when lowering the preoperative hemoglobin
below this level with autologous donation 1 or 2 weeks before surgery.
2. Question: The most effective method of reducing deep infection in total joint replacement is:
A. Antibiotic bone cement
B. Antibiotic bone cement plus systemic antibiotics
C. Systemic antibiotics
D. No antibiotics
E. Adequate skin preparation
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Correct Answer: B. Antibiotic bone cement plus systemic antibiotics
Your Answer: B. Antibiotic bone cement plus systemic antibiotics
Explanation: The use of antibiotic bone cement plus systemic antibiotics is the most effective strategy in reducing
deep infection. This is followed by the use of systemic antibiotics alone, antibiotic bone cement alone, and no
antibiotics.
3. Question: Which of the following bone cements is associated with the lowest risk ratio for revision hip surgery:
A. Sulfix
B. Simplex
C. CMW
D. Palacos
E. Palacos gentamicin
Correct Answer: E. Palacos gentamicin

Your Answer: C. CMW
Explanation: Malchau and colleagues also performed Poisson modeling, assessing the risk of deep infection in
revision surgery using different types of bone cement. Using Sulfix bone cement (Sulzer, Winterhur, Switzerland)
as the numerator, the investigators assessed Simplex (Stryker Howmedica Osteonics, Allentown, NJ), CMW
(Johnson & Johnson DePuy, Warsaw, Ind), Palacos (Merck/Biomet, Warsaw, Ind), and Palacos gentamicin
(Merck/Biomet) bone cements. They developed a risk ratio for revision using any of these bone cements. Palacos
gentamicin bone cement was associated with the lowest risk ratio for revision.
4. Question: Early catastrophic failure of the precoat stem was due to:
A. A thin cement mantle
B. Use of low viscosity cement
C. Excessive residual bone
D. Proximal debonding
E. Proximal debonding associated with laser etching of the identifying numbers and letters on the stem
Correct Answer: E. Proximal debonding associated with laser etching of the identifying numbers and letters
on the stem
Your Answer: B. Use of low viscosity cement
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Explanation: The catastrophic failure of the precoat stem was due to proximal debonding associated with laser
etching of the identifying numbers and letters on the stem of the prosthesis. Virtually all reported stem failures
occurred in left hips because the laser etching caused a local stress concentration effect on the higher stress anterior
surface.
5. Question: Mallet injuries with greater than ___ percent of the articular surface involved and palmar subluxation
as a result will most likely require surgical intervention:
A. 30
B. 70
C. 10
D. 50
E. 90
Correct Answer: D. 50
Your Answer: B. 70
Explanation: Type IVC injuries include distal phalanx base fractures involving more than 50% of the articular
surface. Most surgeons feel that accurate reduction is mandatory to prevent joint deformity, secondary arthritis, and
stiffness.
6. Question: A 70-year-old man has difficulty ambulating following a knee replacement. The lateral radiograph of
the knee is shown (Slide). The most likely cause of the disability is:
A. Lateral patellar instability
B. Patellar tendon rupture
C. Quadriceps tendon rupture
D. Flexion instability
E. Axial instability
Correct Answer: D. Flexion instability

Your Answer: B. Patellar tendon rupture
Explanation: Patients may present with severe knee pain after a mild traumatic event. Patients may have the
inability to extend the knee or walk. Laxity in flexion (flexion instability) can result in dislocation of the
femorotibial articulation. The cam of the femoral component rides up and over the top of the post of the tibial
polyethylene insert. The dislocation is usually the result of a traumatic episode.
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Flexion instability occurs in about 1% to 2% of knee replacements when the knee is not properly balanced
following a replacement. The extension and flexion gap must be equal. When balancing a knee, especially one that
is tight in extension, the surgeon may choose to place a smaller tibial polyethylene component to achieve full
extension with resulting instability of the knee in flexion because the knee flexion gap is larger than the
polyethylene insert.
Treatment of flexion instability in posterior stabilized knee replacements can be nonoperative with casting or
bracing initially. Two-thirds of patients can be managed successfully nonoperatively. If symptoms persist, revision
to a larger polyethylene component can be very effective. If the knee remains unstable, revision to a more
constrained prosthesis may be necessary.
7. Question: While performing posterior cruciate sacrificing knee replacement surgery, the surgeon notes a 15?
flexion contracture during trial reduction after the bone cuts and soft tissue balancing. The best option is:
A. Placement of a smaller polyethylene insert
B. Resection of additional bone from the proximal tibia
C. Resection of additional bone from the distal femur
D. Resection of additional bone from the proximal tibia and distal femur
E. Accepting the contracture and applying an extension cast postoperatively
Correct Answer: C. Resection of additional bone from the distal femur

Your Answer: A. Placement of a smaller polyethylene insert
Explanation: This is a common problem. Selection of a smaller polyethylene spacer results in a correction of the
flexion contracture but also results in flexion instability as the flexion gap will be larger than the extension gap.
First, surgeons should remove any posterior osteophytes from the distal femur. Second, the posterior capsule
should be incised. If both of these maneuvers fail to correct the contracture, the surgeon should remove additional
bone from the distal femur. The joint line may be raised up to 8 mm when performing posterior stabilized
arthroplasties without compromising the result.
8. Question: When performing total knee replacement surgery, the following statement is true:
A. The distal femoral cut only effects the extension gap.
B. The proximal tibia cut only effects the extension gap.
C. The proximal tibia cut only effects the flexion gap.
D. The distal femoral cut only effects the flexion gap.
E. The posterior femoral condyle cut effects the flexion and extension gaps.
Correct Answer: A. The distal femoral cut only effects the extension gap.
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Your Answer: C. The proximal tibia cut only effects the flexion gap.
Explanation: These are important concepts when balancing the knee following total knee replacement.
 The distal femoral cut only effects the extension gap.
 The proximal tibia cut effects the flexion and extension gaps.
 The posterior femoral condyle cut effects the flexion only.
Attention to these principles is very important to prevent both contractures and flexion instability.
9. Question: While performing revision total knee arthroplasty, the surgeon notices a flexion gap that is larger than
the extension gap. The following statement is most likely true:
A. The femoral component is probably too large.
B. There is posterior translation of the femoral component.
C. There is inadequate distal femoral augmentation.
D. There is excessive thickness of the patellar component.
E. There is excessive thickness of the distal femoral augmentation blocks.
Correct Answer: E. There is excessive thickness of the distal femoral augmentation blocks.
Your Answer: B. There is posterior translation of the femoral component.
Explanation: Flexion instability is common following revision total knee replacement. The following principles
are important:
 Undersizing the femoral component is common. This occurs secondary to the posterior femoral condyle
bone loss.
 Anterior translation of the femoral component increases the flexion gap. The use of posterior femoral
condyle augments or an offset stem can solve this problem.
 Distal femoral augments that are too thick will narrow the extension gap. One should set the joint line
approximately 25 mm to 30 mm below the epicondylar axis.
Excessive size of the patellar component will restrict knee flexion, however, it will not change the flexion and
extension gaps.
10. Question: The stem associated with the highest incidence of osteolysis is the:
A. Proximal coated femoral stem
B. Distal coated femoral stem
C. Fully coated femoral stem
D. Patch-porous coated femoral stem
E. Cemented femoral stem
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Correct Answer: D. Patch-porous coated femoral stem
Your Answer: D. Patch-porous coated femoral stem
Explanation: The noncircumferentially coated titanium alloy patch-porous coated straight Harris-Galante stem
was associated with significant osteolysis, thigh pain, subsidence, and endosteal erosion. The patched porous
coating is believed to allow ingress of joint fluid and wear debris into the endosteal canal, increasing the effective
joint space.
11. Question: During controlled perforation for removal of stem and prosthesis, when making 9-mm holes in the
femoral diaphysis:
A. The size of the hole should be 20% of the diameter of the shaft
B. The size of the hole must not exceed 30% of the diameter of the shaft
C. The size of the hole should be 60% of the diameter of the shaft
D. Two holes must be one hole diameter apart
E. The holes must be in the posterolateral surface of the femur
Correct Answer: B. The size of the hole must not exceed 30% of the diameter of the shaft
Your Answer: B. The size of the hole must not exceed 30% of the diameter of the shaft
Explanation: The size of the hole must not exceed 30% of the diameter of the shaft. Holes should not be placed
any closer than two hole diameters apart, and they should be located in the anterolateral surface of the femur to
decrease the stress riser.
12. Question: The gold standard for the diagnosis of avascular necrosis of the femoral head is:
A. Bone scan
B. Routine roentgenogram
D. Segmented bone collapse
E. Elevated sedimentation rate
Correct Answer: C. Magnetic resonance image

Your Answer: D. Segmented bone collapse
Explanation: The gold standard for the diagnosis of avascular necrosis is magnetic resonance imaging. Changes
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can be seen earliest with this technique before there are changes on routine roentgenogram and even before a
patient is symptomatic.
13. Question: The low incidence of infection in ceramic-ceramic total hip replacement is:
A. True only in early infection
B. True only in late infection
C. Has not been reported in the literature and is only anecdotal
D. True because bacteria adhere more strongly to ceramic
E. True because bacteria adhere more strongly to polyethylene
Correct Answer: E. True because bacteria adhere more strongly to polyethylene

Your Answer: B. True only in late infection
Explanation: There is a lower incidence of infection reported in ceramic-ceramic total hip replacements by the
Swedish Hip Registry. This may be related to the fact that bacteria typically adhere more strongly to polyethylene
than cement, suggesting that both early and late infection may be lower for alumina than polyethylene total hip
replacement.
14. Question: The first step in the development of hip osteoarthritis is:
A. Abnormal glycosaminoglycans
B. Formation of ganglions
C. Abnormal weight gain
D. Fatiguing of labrum under normal stress
E. Abnormal mechanical stress
Correct Answer: D. Fatiguing of labrum under normal stress

Your Answer: D. Fatiguing of labrum under normal stress
Explanation: The first step toward osteoarthritis of the dysplastic hip is fatiguing of the labrum under normal
stress. Klaue et al described the different pathomorphologies from a torn labrum to ganglion formation, which has
been attributed to acetabular rim syndrome.
15. Question: The common iliac artery gives rise to all of the following vessels except:
A. The external iliac artery
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B. The internal iliac artery
C. The superior gluteal artery
D. The common femoral artery
E. The internal hypogastric artery
Correct Answer: E. The internal hypogastric artery

Your Answer: C. The superior gluteal artery
Explanation: The common iliac artery divides at the L5-S1 vertebral disk. The anterior division, the external iliac
artery, continues distally to become the common femoral artery, whereas the posterior division becomes the
internal iliac artery. The internal iliac artery branches again into a posterior division, which gives rise to the
superior gluteal artery, and an anterior division, which gives off the obturator artery before dividing into the
inferior gluteal artery and internal pudendal artery.
16. Question: The structure at highest risk for injury in total hip arthroplasty (THA) is the:
A. Femoral artery
B. Femoral vein
C. External iliac artery
D. Inferior gluteal artery
E. Obturator artery
Correct Answer: C. External iliac artery

Your Answer: C. External iliac artery
Explanation: The external iliac artery and vein are immobile and lie close to the pelvis, and thus are at high risk
for injury in THA. The external iliac vein lies within 7 mm of the anterior column of the pelvis at the anterior
inferior iliac spine and within 4 mm at the acetabula dome. The external iliac artery is at less risk due to its thicker
intima and increased distance from the bone. The external iliac artery lies within 10 mm of the bone at the anterior
inferior iliac spine and within 7 mm at the acetabular dome. The common femoral artery lies anterior and medial to
the hip capsule. Only the iliopsoas lies between the vessel and capsule at this point. The femoral vein lies medial to
the artery and is not likely to be injured. The obturator vessels are also at risk, lying fixed within 1 mm of the bony
surface at the quadrilateral surface, with their only protection being the interposition of the obturator internus
muscle.
17. Question: The nerve most commonly injured during total hip arthroplasty (THA) is the:
A. Superior gluteal nerve
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B. Obturator nerve
C. Femoral nerve
D. Inferior gluteal nerve
E. Peroneal component of sciatic nerve
Correct Answer: E. Peroneal component of sciatic nerve

Your Answer: C. Femoral nerve
Explanation: The primary nerves of the region are the sciatic, femoral, inferior and superior gluteal, and obturator.
The most common nerve injury during THA is to the peroneal division of the sciatic nerve, followed by superior
gluteal, obturator, and femoral nerves. Injury to these structures can lead to loss of function and poor outcomes.
18. Question: Which two quadrants of the acetabulum are most at risk for injury by screws during fixation of total
hip arthroplasty (THA):
A. Anterior-superior and posterior-inferior
B. Posterior-superior and posterior inferior
C. Anterior-superior and posterior-superior
D. Anterior-inferior and posterior-superior
E. Anterior-superior and anterior-inferior
Correct Answer: E. Anterior-superior and anterior-inferior

Your Answer: C. Anterior-superior and posterior-superior
Explanation: The acetabular quadrant system described by Wasielewski and colleagues is useful for determining
the location of planned acetabular screw fixation in THA to avoid neurovascular complications. The quadrants are
formed by drawing a line from the anterior-superior iliac spine through the center of the acetabulum and bisecting
that line at the center of the acetabulum to form four equal quadrants. The line from the anterior-superior iliac spine
to the center of the acetabulum serves as the dividing line between anterior and posterior, and the bisecting line as
the division between superior and inferior.
In cadaver studies, the posterior-superior and posterior-inferior quadrants were shown to have the thickest bone and
best potential for obtaining secure fixation with the least risk for injury to vessels. The anterior-superior quadrant
(the quadrant of death) and the anterior-inferior quadrant were shown to be the most dangerous quadrants for
fixation due to the thin bone and close proximity of the vessels to bone in that region.
19. Question: What is the most commonly used surgical approach to the acetabulum:
A. Posterior
214
B. Ilioinguinal
C. Anterior
D. Medial
E. Anterolateral
Correct Answer: A. Posterior

Your Answer: D. Medial
Explanation: The posterior approach to the acetabulum is the least technically demanding approach for total hip
arthroplasty (THA) and offers good visualization of the acetabulum, especially of the posterior wall. The posterior
approach is the most commonly used approach for THA in the United States. Patients are placed in the lateral
position. The approach involves splitting of the gluteus maximus in line with its fibers and no internervous plane is
present. The sciatic nerve is protected by the short external rotators after they are detached from their insertions on
the femur and reflected medially.
20. Question: In the ilioinguinal approach, what does the first window allow access to:
A. Pelvic brim and superior pubic ramus
B. Quadrilateral plate and retropubic space
C. Inferior pubic ramus and sciatic notch
D. Ilioschial tuberosity and retropubic space
E. Anterior sacroiliac joint, internal iliac fossa, and upper anterior column
Correct Answer: E. Anterior sacroiliac joint, internal iliac fossa, and upper anterior column
Your Answer: B. Quadrilateral plate and retropubic space
Explanation: The ilioinguinal approach provides improved visualization of the pelvic inner surface and anterior
column and medial wall of the acetabulum. The patient is placed supine or in a lazy lateral decubitus position. The
principle of this approach is to dissect closely along the inner wall of the pelvis and lift each muscular and
neurovascular structure off of the bone. Three windows are present in this approach, each providing access to
different structures. The first window allows access to the anterior sacroiliac joint, internal iliac fossa, and upper
anterior column.
21. Question: The most sensitive method for identifying and quantifying the extent of osteolysis is:
B. Magnetic resonance imaging

215
C. Technetium-99m bone scanning
D. Computed tomography
E. Helical computed tomography
Correct Answer: E. Helical computed tomography

Your Answer: C. Technetium-99m bone scanning
Explanation: If extensive osteolysis is suspected, computed tomography is recommended because plain

radiographs underestimate the extent of lysis. Helical computed tomography with metal artifact minimization is the
most sensitive method for identifying and quantifying the extent of lysis.
22. Question: The most common cause of vascular injury during total hip arthroplasty (THA) is:
A. Laceration
B. Pseudoaneurysm
C. Arteriovenous fistula
D. True aneurysm
E. Thromboembolic phenomena
Correct Answer: E. Thromboembolic phenomena

Your Answer: C. Arteriovenous fistula
Explanation: A previous review of vascular injuries sustained during THA revealed the most common etiology of
vascular injury as thromboembolic phenomena, followed by laceration, pseudoaneurysm, and arteriovenous fistula.
23. Question: The most common cause of damage to femoral vessels is:
A. Extruded cement
B. Migration of the acetabular cup
C. Capsule dissection
D. Aberrant retractor placement
E. Screw placement
216
Correct Answer: D. Aberrant retractor placement
Your Answer: D. Aberrant retractor placement
Explanation: Damage to the femoral vessels is most commonly due to aberrant retractor placement. Care should
be taken to ensure that the retractor tip is placed directly on bone, and that the iliopsoas is not interposed between
the retractor tip and bone. Extruded cement, acetabular cup migration, and capsule dissection have also been
implicated in damage to the femoral vessels.
24. Question: The risk of nerve injury following revision total hip arthroplasty (THA) is approximately:
A. 0.5%
B. 1%
C. 1% to 10%
D. 10% to 20%
E. More than 20%
Correct Answer: C. 1% to 10%

Your Answer: B. 1%
Explanation: Following primary THA, the incidence of nerve palsy is reported to be approximately 1.3%, but may
be as high as 5.2% for primary THA performed for developmental dysplasia or dislocation. For revision surgery,
the incidence may be as high as 7.6%.
25. Question: The most likely underlying diagnosis in this patient is:
A. Gout
C. Heterotopic ossification
D. Pigmented villonodular synovitis
E. Synovial chondromatosis
Correct Answer: C. Heterotopic ossification

Your Answer: C. Heterotopic ossification
Explanation: This radiograph presents a Brooker class IV heterotopic ossification in a 79-year-old woman after
revision of a monopolar hemiarthroplasty to a press-fit, porous-coated acetabular component and a cemented
femoral stem. The patient sustained a cerebrovascular accident 12 weeks before surgery. She had no other risk
217
factors for heterotopic ossification formation after total hip arthroplasty. Other risk factors for heterotopic
ossification include previous surgery, men with hypertrophic osteoarthritis, traumatic brain injury, spinal
hyperostosis, and posttraumatic arthritis.
26. Question: This radiograph is most typical of:
A. Stress fracture
B. Osteocarcinoma
C. Osteitis pubis
D. Osteomyelitis of the pubic symphysis
E. Ewing's sarcoma
Correct Answer: D. Osteomyelitis of the pubic symphysis

Your Answer: C. Osteitis pubis
Explanation: Osteomyelitis of the pubic symphysis is a rare condition, accounting for less than 1% of all acute
hematogenous osteomyelitis cases. The condition is well described in elderly patients following urologic,
gynecologic, and pelvic procedures. Osteomyelitis of the pubic symphysis has also been reported in intravenous
drug abusers, after cardiac catheterization, and can occur spontaneously in athletes and children.
27. Question: Which of the following symptoms is least common in patients with osteomyelitis of the pubis:
A. Distal anterior pelvic pain
B. Adductor muscle spasm
C. Rectus muscle spasm
D. Abductor muscle spasm
E. Wide-based waddling gait
Correct Answer: D. Abductor muscle spasm

Your Answer: C. Rectus muscle spasm
Explanation: Osteomyelitis of the pubic symphysis is a rare condition, occurring in 2% to 11% of all patients with
osteomyelitis of the pelvis. The osteitis pubis is the least affected area. Signs and symptoms of osteomyelitis of the
pubic symphysis include distal anterior pelvic pain, adductor and rectus muscle spasms, and a wide-based
waddling gait. Fever, leukocytosis, elevated erythrocyte sedimentation rate, and positive blood cultures may also
be present. Unilateral rarefaction and sclerosis with cystic changes may be seen on radiographs 10 to 14 days after
symptoms begin. Radionucleotide scans, computed tomography, and magnetic resonance imaging may aid in the
diagnosis.
218
28. Question: Common risk factors associated with extensor mechanism disruption after total knee arthroplasty
(TKA) include all of the following except:
A. Limited preoperative range of motion
B. Difficult surgical exposure
C. Medial parapateller exposure
D. Disruption of vascular supply to the patella
E. Obesity
Correct Answer: C. Medial parapateller exposure

Your Answer: B. Difficult surgical exposure
Explanation: The etiology of extensor mechanism disruption after TKA is unknown. Researchers suggest that
disruption of the vascular supply to the patella and patellar mechanism during the exposure may cause weakening
of the patella and extensor mechanism. In addition, the frequency of extensor mechanism disruption has been
reportedly increased in patients who have a preoperative limited range of motion or difficult surgical exposure.
29. Question: Contributing factors causing female athletes to have more anterior cruciate ligament injuries than
men include all of the following except:
A. Intercondylar notch width
B. Ligament size
C. Increased quadriceps angle
D. Strong overactive hamstrings
E. Fitness level
Correct Answer: D. Strong overactive hamstrings

Your Answer: C. Increased quadriceps angle
Explanation: Female athletes are two to eight times more likely than men to sustain an anterior cruciate ligament
injury when playing sports such as soccer, basketball, and volleyball. The exact etiology of gender-based injuries is
unclear. Various intrinsic factors (intercondylar notch width, ligament size, quadriceps angle, joint laxity, hormonal
effects) and extrinsic factors (muscular strength/weakness, fitness level, hamstring:quadriceps ratio) have been
proposed as contributing factors. A strong hamstring actually protects the anterior cruciate ligament and is a
preventative measure.
30. Question: The best results of hip fracture repair occur:

219
A. In the first 6 hours
B. Within the first day
C. Within the second day
D. Within the third day
E. Three days after repair
Correct Answer: B. Within the first day

Your Answer: C. Within the second day
Explanation: Medical consequences of time issues relevant to hip fractures have been examined by several
authors. Operation within the first day of injury is superior and provides better results than delaying the procedure.
However, the economic consequences of such a delay have not been examined.
31. Question: This T2-weighted sagittal magnetic resonance image of a right knee reveals:
A. Avascular necrosis of the distal femur
B. Synovial sarcoma
C. Anterior cruciate ligament rupture
D. Posterior cruciate ligament rupture
E. Popliteal cyst
Correct Answer: E. Popliteal cyst

Your Answer: C. Anterior cruciate ligament rupture
Explanation: Baker's or popliteal cyst, described first by Adams and later by Baker, is a distended bursa
originating posterior to the medial head of the gastrocnemius muscle or semimembranous tendon and generally
presents with posterior knee pain and a palpable mass. This case is unusual in that the dissection was proximal,
unlike the typical distal progression of the popliteal cyst.
32. Question: What is the main characteristic shift in the outcome assessment of total hip arthroplasty (THA) in
the past decade:
A. Description of more technical details
B. Analysis and measurement of the impact and longevity of the procedure on a patient's quality-of-life
C. Introduction of more hip prosthesis designs

220
D. Introduction of new functional scoring systems
E. Decreasing number of dislocations
Correct Answer: B. Analysis and measurement of the impact and longevity of the procedure on a patient's
quality-of-life
Your Answer: B. Analysis and measurement of the impact and longevity of the procedure on a patient's quality-of-
life
Explanation: Over the past two decades, a continuous shift toward outcome assessment in medicine has occurred.
Publications previously devoted to technical details and surgical technique have started analyzing and measuring
the impact and longevity of medical procedures on patients' quality-of-life and have compared the cost-
effectiveness of different procedures.
33. Question: In the study design for evaluating the effectiveness of total hip replacement, the endpoint can be
only:
A. Revision hip surgery
B. Radiographic loosening of the implant
C. Any well-defined chosen point, such as revision hip surgery or functional level and pain
D. Pain or functional level
E. Range of motion
Correct Answer: C. Any well-defined chosen point, such as revision hip surgery or functional level and pain
Your Answer: B. Radiographic loosening of the implant
Explanation: In the study design, it is paramount that a universal, well-defined endpoint is chosen. In the well-
established Scandinavian Hip Registries, this endpoint is revision total hip arthroplasty. Whether this endpoint is
sensitive enough is debatable. For more in-depth studies, several other endpoints, such as pain or postoperative
functional level, may also be used.
34. Question: The single most important criterion to identify the type of hip implant for future analysis in a hip
arthroplasty register is:
A. The name of the manufacturer and the year of implant production
B. The name of the implant and the year of implant production
C. The implant's catalogue number provided by the manufacturer
D. The name of the manufacturer and implant

221
E. The surgeon's name and implant manufacturer
Correct Answer: C. The implant's catalogue number provided by the manufacturer

Your Answer: B. The name of the implant and the year of implant production
Explanation: For the implanted prosthesis, manufacturer, name, material, and catalogue numbers are essential for
precise future identification. The role of the catalogue numbers cannot be underestimated as successive generations
of implants were put on the market with the same brand name (eg, Charnley hip). Without recording the catalogue
numbers, it is impossible to determine what generation of implant is being compared to another.
35. Question: The main advantage of multicenter studies in analyzing total hip arthroplasty is:
A. The inclusion of different surgeons
B. The inclusion of different countries
C. The ability to obtain a large number of patients
D. The inclusion of different hip implants
E. Giving more accurate data
Correct Answer: C. The ability to obtain a large number of patients

Your Answer: B. The inclusion of different countries
Explanation: The main advantage of multicenter studies - although they are time-consuming, expensive, and often
frustrating - is obtaining large numbers of patients in a relatively short time. This is important when examining
statistical differences between varying results.
36. Question: When comparing viral vectors with nonviral vectors for gene delivery, the advantages of nonviral
vectors include all of the following except:
A. Safety
B. Less immunogenicity
C. More efficiency
D. Easier production
E. Special packaging cell lines
Correct Answer: C. More efficiency

Your Answer: B. Less immunogenicity
222
Explanation: Because of the safety concerns, immunogenicity issues, and production complications associated
with viral vectors, nonviral delivery systems were developed by complexing of genes (DNA) to various chemical
formulations. Nonviral delivery systems stabilize DNA and increase its uptake and include plasmids, peptides,
cationic liposomes, DNA-ligand complexes (recognize specific cell-surface receptors, leading to receptor-mediated
uptake), and gene gun (particles of gold coated with DNA, forced into the cells with high velocity bombardment).
However, nonviral vector efficiency is lower than viral vectors.
37. Question: All of the following have been used as viral vectors for gene delivery except:
A. Adeno-associated virus
B. Rotavirus
C. Herpes simplex virus
D. Lentivirus
E. Retroviral vector
Correct Answer: B. Rotavirus

Your Answer: C. Herpes simplex virus
Explanation: A retroviral vector derived from the Moloney murine leukemia retrovirus is among the best-
developed viral vectors. Other viral vectors include adenovirus, adeno-associated virus, and herpes simplex virus.
Novel vector systems based on lentivirus, which is a type of retrovirus that includes human immunodeficiency
virus, are being developed.
38. Question: The principle of homologous recombination in gene therapy is used to:
A. Replace a defective gene by a wild-type gene
B. Suppress the expression of a mutant gene
C. Supplement a wild-type gene
D. Alter the expression of a mutant gene
E. Replace a defective gene by a normal gene
Correct Answer: E. Replace a defective gene by a normal gene

Your Answer: B. Suppress the expression of a mutant gene
Explanation: Novel approaches to treating genetic diseases involve gene repair or replacement rather than gene
supplementation. One such approach is based on the principle of homologous recombination (replacement of a
223
defective gene by a normal gene).
39. Question: The virus associated with the most immune reactions is:
A. Adeno-associated virus
B. Gutted adenovirus
C. Adenovirus
D. Retrovirus
E. Herpes simplex virus
Correct Answer: C. Adenovirus

Your Answer: C. Adenovirus
Explanation: Adenoviral vectors can cause inflammatory reaction due to immune activation, an event linked to the
first death related to gene therapy. This occurred in September 1999 at the University of Pennsylvania in a clinical
trial in which an 18-year-old patient received infusion of more than a trillion adenoviral vectors directed to his
liver, which triggered a systemic inflammatory response that became uncontrollable, leading to organ failure and
death. Newer-generation gutted or gutless adenovirus vectors are nonimmunogenic.
40. Question: Compared with the ex vivo gene delivery system, the in vivo system is:
A. Technically complex
B. Target specific
C. Safer
D. Less invasive
E. More invasive
Correct Answer: D. Less invasive

Your Answer: D. Less invasive
Explanation: Two basic strategies exist for gene delivery. Direct, or in vivo, gene therapy involves direct
introduction of vectors into the body. Indirect, or ex vivo, gene therapy involves removal of target cells from the
body, vector introduction by incubation of the cells in vitro, and reimplantation. The in vivo system is less invasive.
41. Question: The gene that has been studied in greatest detail for application in osteoarthritis is:
A. p53
224
B. Interleukin (IL)-13
C. Tissue inhibitors of metalloproteinases-4
D. IL-1 receptor antagonist
E. Bone morphogenetic protein-2
Correct Answer: D. IL-1 receptor antagonist

Your Answer: B. Interleukin (IL)-13
Explanation: Gene therapy has been suggested as a means of delivering sustained therapeutic levels of anti-
arthritis gene products to diseased joints. Local gene delivery to the synovial tissue is the approach of choice for
osteoarthritis and other conditions affecting a few joints. Gene therapy is less suited to address the extra-articular
components of systemic conditions, such as rheumatoid arthritis. The gene that has been studied in greatest detail
encodes the human IL-1 receptor antagonist.
42. Question: The osteoinductive potential of LIM mineralization protein (LMP)-1 gene has been studied for
clinical application in:
A. Fracture repair
B. Spinal fusion
C. Cartilage regeneration
D. Ligament healing
E. Meniscal injury
Correct Answer: B. Spinal fusion

Your Answer: C. Cartilage regeneration
Explanation: Identification of LMP-1, a novel intracellular protein, is a step forward in osteoinductive proteins.
Unlike bone morphogenetic protein, which is a secreted protein that binds to cell-surface receptor to initiate a
response, LMP-1 is an intracellular signaling molecule. Boden and colleagues transfected bone marrow cells from
rats ex vivo with LMP-1 gene using DNA plasmid vector and used them during posterior thoracic and lumbar
spinal fusion in rats.
43. Question: The gene studied for application in osteoporosis and wear-induced osteolysis is:
A. Osteoprotegerin
B. Bone morphogenetic protein
225
C. Transforming growth factor-?1
D. LIM mineralization protein
E. Interleukin (IL)-receptor antagonist
Correct Answer: A. Osteoprotegerin

Your Answer: C. Transforming growth factor-?1
Explanation: Various cytokines and cytokine antagonists hold promise as new therapeutic agents for osteoporosis.
Baltzer and colleagues showed that intramedullary injection of Ad-IL-1Ra gene in a murine ovariectomy model
strongly reduced the loss of bone mass. Using a similar model, Bolon and associates studied the effect of
adenovirus-mediated transfer of osteoprotegerin, which showed more bone volume with reduced osteoclast
numbers in axial and appendicular bones after 4 weeks compared with sham-operated mice.
44. Question: Gene transfer to a cell using viral vectors is called:
A. Transduction
B. Transfection
C. Transformation
D. Conjugation
E. Augmentation
Correct Answer: A. Transduction

Your Answer: C. Transformation
Explanation: In vivo gene delivery involves the direct injection of vectors containing the genes into the body with
the expectation that they will reach and transduce the target cell. Ex vivo gene delivery is a process whereby the
target cells are removed from the body, genetically altered in vitro, and reimplanted into the body.
45. Question: Which of the following genes has been shown to stimulate proteoglycan synthesis for prevention of
disk degeneration:
A. LIM mineralization protein
B. Bone morphogenetic protein-7
C. Decorin
D. Transforming growth factor (TGF)-?1
E. Osteoprotegerin
226
Correct Answer: D. Transforming growth factor (TGF)-?1
Your Answer: A. LIM mineralization protein
Explanation: Intervertebral disk degeneration has been associated with a progressive decrease in proteoglycan
content of nucleus pulposus. The potential application of gene therapy for prevention of disk degeneration is to
increase or maintain the proteoglycan content of nucleus pulposus. Thompson and colleagues reported that addition
of TGF-?1 to canine disk tissue in culture stimulated in vitro proteoglycan synthesis.
46. Question: The advantages of an arthroscopic-assisted rotator cuff repair include all of the following except:
A. The surgeon can approach the shoulder from multiple angles.
B. The deltoid attachment is preserved.
C. Operative time is shorter.
D. Postoperative rehabilitation is accelerated.
E. As opposed to other repair methods, a better early range of motion is achieved.
Correct Answer: C. Operative time is shorter.

Your Answer: A. The surgeon can approach the shoulder from multiple angles.
Explanation: Arthroscopy facilitates a thorough assessment and treatment of a rotator cuff tear by approaching the
shoulder from multiple angles. It preserves the deltoid attachment to the acromion and postoperative rehabilitation
is potentially accelerated if the deltoid does not need to be protected. Arthroscopy achieves a better early range of
motion than other repair methods; however, it requires a longer operative time.
47. Question: The disadvantages of a complete arthroscopic repair of a rotator cuff include all of the following
except:
A. Complete arthroscopic repair limits some suture configuration options in the tendon.
B. Postoperative pain is increased.
C. Complete arthroscopic repair is technically difficult to perform.
D. Complex instrumentation is required.
E. Operative time is longer.
Correct Answer: B. Postoperative pain is increased.

Your Answer: B. Postoperative pain is increased.
227
Explanation: Arthroscopic repair techniques generally require the use of suture anchors and limit some suture
configuration options in the tendon. Complete arthroscopic repair is technically difficult, requires significantly
greater and more complex instrumentation, and has a potentially longer operative time. However, it decreases
postoperative pain.
48. Question: The types of rotator cuff tear patterns are:
A. Crescent-shaped and massive contracted immobile tears
B. U-shaped and L-shaped tears
C. Vertical and horizontal cleavage tears
D. Crescent-shaped, U-shaped, L-shaped, and massive contracted immobile tears
E. Vertical cleavage, U-shaped, and L-shaped tears
Correct Answer: D. Crescent-shaped, U-shaped, L-shaped, and massive contracted immobile tears
Your Answer: C. Vertical and horizontal cleavage tears
Explanation: Four major types of rotator cuff tear patterns have been described and are based on the shape and
mobility of the tear margins: crescent-shaped, U-shaped, L-shaped, and massive contracted immobile tears. Vertical
and horizontal cleavage tears are related to meniscal tears in the knee.
49. Question: Which of the following rotator cuff tears is the simplest to repair:
A. U-shaped tear
B. L-shaped tear
C. Crescent-shaped tear
D. Vertical cleavage tear
E. Parrot-beak tear
Correct Answer: C. Crescent-shaped tear

Your Answer: D. Vertical cleavage tear
Explanation: Crescent-shaped tears are the simplest of all tears to repair and demonstrate minimal retraction and
excellent mobility. They can be repaired directly to the bone with minimal tension. The anchors are placed
percutaneously using a spinal needle. Suture passing techniques are then used and the rotator cuff is tied down.
Vertical cleavage and parrot-beak tears refer to meniscal injuries in the knee.
50. Question: The following image depicts:

228
A. An arthroscopic view of a massive rotator cuff tear
B. An arthroscopic view of an L-shaped rotator cuff tear
C. An arthroscopic view of a U-shaped rotator cuff tear
D. An arthroscopic view of a crescent-shaped rotator cuff tear
E. An arthroscopic view of a medial meniscus tear of the knee
Correct Answer: D. An arthroscopic view of a crescent-shaped rotator cuff tear

Your Answer: B. An arthroscopic view of an L-shaped rotator cuff tear
Explanation: The image depicts a lateral arthroscopic view of a crescent-shaped tear, which demonstrates minimal
retraction and excellent mobility, and is easily repaired
229

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Question/Answer Summary:

A. Tendo Achilles allograft

C. Middle-third patellar tendon autograft

Correct Answer: A. Tendo Achilles allograft

A. Retroverted humeral component

B. Posterior capsular laxity

C. Retroverted glenoid component

D. Disruption of the posterior capsule

E. All of the above

Correct Answer: E. All of the above

A. Increasing the anteversion of the humeral component

B. Using posterior capsular plication

D. Delaying postoperative rehabilitation program

E. All of the above

Correct Answer: E. All of the above

B. Between 5% and 10%

C. Between 10% and 20%

D. Between 20% and 30%

E. Greater than 30%

Correct Answer: E. Greater than 30%

A. Standard pelvis magnetic resonance image (MRI)

B. Plain film radiograph

C. 3D computed tomography (CT) scan

Correct Answer: E. MR arthrogram

A. Visualization of cam impingement lesion

B. Detection of labral injury

C. Observation of joint space narrowing

D. Detection of developmental dysplasia of the hip (DDH)

E. Assessment for pincer impingement

Correct Answer: B. Detection of labral injury

B. Excessive acetabular index

C. Center edge angle of 5?

D. Anterior coverage of less than 5? on false profile

E. No cartilage space maintained on abduction view

Correct Answer: E. No cartilage space maintained on abduction view

A. Anteroposterior (AP) of the hip

C. Magnetic resonance image of the pelvis

E. Lauenstein lateral hip

Correct Answer: D. AP of the pelvis

A. Pelvic Judet views

B. Cross-table lateral radiograph

C. Standard magnetic resonance imaging (MRI) of the pelvis

E. Computed tomography (CT) of the hip

Correct Answer: E. Computed tomography (CT) of the hip

A. Retrograde canal filling

Correct Answer: E. Pressurized mixing

11. Question: In the Gruen classification of cement mantle, zone 4 is located:

E. Tip of the stem

Correct Answer: E. Tip of the stem

12. Question: Cemented stem failure is most likely to result from:

B. Thin medial cement mantle

C. Stem contact with endosteal cortex

D. Excessive mantle laterally

E. Valgus stem placement

Correct Answer: C. Stem contact with endosteal cortex

B. Poor survivorship in patients younger than 50 years of age

Correct Answer: B. Poor survivorship in patients younger than 50 years of age

D. Material makeup of the mixing bowl

E. Inclusive agents, such as antibiotics