ABOS Part I Orthopaedic Review

This ABOS Part I Orthopaedic Review module offers 22 advanced multiple-choice questions mirroring ABOS Part I and AAOS OITE exams. It covers high-yield clinical cases in shoulder and hip arthroplasty, including surgical approaches, neurovascular protection, component positioning, and complication management, crucial for board certification preparation.

ABOS Part I & AAOS OITE Orthopaedic Surgery Exam Review

Question 1

A 62-year-old male is undergoing a total shoulder arthroplasty via the deltopectoral approach. During the initial dissection of the deltopectoral interval, the surgeon identifies the cephalic vein. Which of the following is the most appropriate management strategy for the cephalic vein, and why?

Explanation

Correct Answer: C

The cephalic vein is a consistent landmark within the deltopectoral groove. The case study explicitly states, 'It can be retracted either laterally with the deltoid or medially with the pectoralis major. Medial retraction is often preferred to protect the axillary nerve, which lies laterally, and to avoid kinking the vein and impeding venous return.' This strategy minimizes traction on the deltoid and its associated neurovascular structures (axillary nerve) and reduces the risk of injury. Ligation (Option A) should be avoided if possible to prevent post-operative arm swelling due to venous congestion. Retracting the vein laterally with the deltoid (Option B) places it at risk of injury from retractors and potentially obscures the axillary nerve, which is located laterally. While ligating branches (Option D) is part of careful dissection, the primary decision is the direction of retraction, and the rationale for medial retraction is paramount. Transposing the vein to a subcutaneous pocket (Option E) is an overly complex and unnecessary maneuver for routine deltopectoral exposure.

Question 2

A 48-year-old competitive tennis player presents with recurrent anterior shoulder instability and significant anterior glenoid bone loss, confirmed by a pre-operative CT scan. The surgeon plans a Latarjet procedure via the deltopectoral approach. During the deep dissection, after retracting the conjoined tendon medially, which critical neurovascular structure is most vulnerable to injury if extreme or uncontrolled medial retraction is applied?

Explanation

Correct Answer: B

The case study details the deep anatomy, stating, 'The musculocutaneous nerve enters the deep surface of the coracobrachialis muscle approximately 5-8 cm distal to the coracoid tip. Care must be taken during dissection around the conjoined tendon, particularly if it is mobilized or tenotomized.' The conjoined tendon (coracobrachialis and short head of biceps) originates from the coracoid process. When this tendon is retracted medially, the musculocutaneous nerve, which penetrates the coracobrachialis, is directly in the line of tension and highly vulnerable to stretch or compression injury. While the axillary neurovascular bundle (containing the axillary nerve) is also deep and medial to the coracoid, the musculocutaneous nerve is specifically associated with the conjoined tendon itself. The radial nerve (Option C) is not typically at risk in this anterior approach. The posterior humeral circumflex artery (Option D) accompanies the axillary nerve posteriorly and is not directly threatened by medial conjoined tendon retraction. The suprascapular nerve (Option E) is located more superiorly and posteriorly, supplying the supraspinatus and infraspinatus muscles, and is not directly vulnerable to medial retraction of the conjoined tendon.

Question 3

A 78-year-old female with severe rotator cuff tear arthropathy is scheduled for a reverse total shoulder arthroplasty (RTSA) via the deltopectoral approach. The surgical team positions her in the beach chair position. Which of the following is a recognized disadvantage or potential complication specifically associated with the beach chair position for this procedure?

Explanation

Correct Answer: C

The case study explicitly lists 'Risk of Cerebral Hypoperfusion' as a disadvantage of the beach chair position, emphasizing that 'Careful monitoring of blood pressure is essential.' This is due to the patient's elevated head position, which can reduce cerebral blood flow if systemic blood pressure is not adequately maintained. Option A is incorrect; gravity typically assists exposure in the beach chair position, and brachial plexus injury is more related to improper head/neck positioning or arm traction, not directly 'gravity working against exposure.' Option B is incorrect; the beach chair position is not specifically associated with an increased risk of DVT in the operative arm compared to other positions. Option D is incorrect; the case states, 'Gravity Assists Exposure: The arm hangs naturally, facilitating humeral head dislocation and glenoid exposure,' which is an advantage, not a disadvantage. Option E is a general risk of improper arm positioning, but not a unique disadvantage of the beach chair position itself, and the non-operative arm is typically tucked, not excessively abducted.

Question 4

During a deltopectoral approach for open reduction and internal fixation of a 3-part proximal humerus fracture, the surgeon has successfully developed the deltopectoral interval and retracted the conjoined tendon medially. As the surgeon prepares to manage the subscapularis and anterior capsule, a blunt Hohmann retractor is placed under the inferior border of the subscapularis. What is the primary purpose of this specific maneuver?

Explanation

Correct Answer: C

The case study states, 'A blunt Hohmann retractor can be placed under the inferior border of the subscapularis to protect the axillary nerve during subsequent dissection.' It further elaborates that the 'Axillary Nerve courses inferiorly and then posteriorly around the surgical neck of the humerus, approximately 5-7 cm distal to the acromion... Its close proximity to the inferior capsule and surgical neck of the humerus makes it vulnerable during capsular releases, humeral head resection, and fracture fixation. It is often accompanied by the posterior humeral circumflex artery.' The anterior humeral circumflex artery also runs in this vicinity. Therefore, placing a retractor under the inferior border of the subscapularis is a critical step to shield these vital neurovascular structures. Option A is incorrect; while it might provide some counter-traction, its primary role is protection. Option B is incorrect; the musculocutaneous nerve is associated with the conjoined tendon, not typically at risk under the inferior subscapularis. Option D is incorrect; while retractors are used for reduction, this specific placement is for protection. Option E is incorrect; the subscapular artery is deeper and not the primary concern with this specific maneuver.

Question 5

A 35-year-old male presents with a large, retracted subscapularis tear following a work-related injury. Surgical repair via the deltopectoral approach is planned. The surgeon opts for a subscapularis tenotomy. Which of the following statements accurately describes the biomechanical implication of this approach and the subsequent repair?

Explanation

Correct Answer: C

The case study emphasizes the biomechanical advantage of the deltopectoral approach: 'The biomechanical advantage of the deltopectoral approach lies in its respect for the integrity of the deltoid muscle. By dissecting along an internervous plane, the muscle fibers are not transected, preserving the deltoid's origin, insertion, and innervation. This minimizes post-operative weakness and facilitates early rehabilitation.' Option A is incorrect as the approach is internervous, preserving the deltoid. Option B is incorrect; the subscapularis is a primary internal rotator and anterior stabilizer, not an external rotator or posterior stabilizer. Its repair is critical for internal rotation strength and anterior stability. Option D is incorrect; the subscapularis peel is often used in instability surgery (e.g., Bankart repair) to preserve tendon length and allow for better capsular closure, whereas tenotomy is more common for arthroplasty. Option E is partially correct in that the nerves are important, but they enter the deep surface of the muscle, making muscle splitting less risky than extensive subscapularis mobilization without careful nerve identification, and they are not typically 'identified and protected by retracting the subscapularis medially' in the same way the axillary nerve is protected inferiorly.

Question 6

A 55-year-old male with severe glenohumeral osteoarthritis is undergoing a total shoulder arthroplasty. After developing the deltopectoral interval and retracting the conjoined tendon medially, the surgeon performs a subscapularis tenotomy. Which of the following statements regarding the subsequent capsulotomy is most accurate?

Explanation

Correct Answer: C

The case study describes capsular management: 'Once the subscapularis is mobilized, the underlying anterior capsule is exposed. A T-Capsulotomy is a common approach... The inferior limb must be carefully performed to avoid injuring the axillary nerve.' This highlights the critical vulnerability of the axillary nerve, which courses inferior to the subscapularis and anterior capsule. Option A is incorrect; while a straight vertical capsulotomy is an option, a T-capsulotomy is common and offers excellent exposure, and the key is careful execution, not just the type of incision. Option B is incorrect; an inverted T-capsulotomy is less common, and a standard T-capsulotomy provides excellent exposure. Option D is incorrect; while posterior capsular releases can be performed, the primary capsulotomy in a deltopectoral approach is anterior, and the statement about external rotation is not the direct focus of this question. Option E is incorrect; the capsule is meticulously repaired to restore glenohumeral stability and prevent postoperative subluxation, not left open.

Question 7

A 68-year-old female presents with a highly comminuted 4-part proximal humerus fracture, deemed unsuitable for ORIF due to severe osteopenia. A reverse total shoulder arthroplasty (RTSA) is planned via the deltopectoral approach. Which of the following conditions would be a relative contraindication to proceeding with the deltopectoral approach in a different patient scenario?

Explanation

Correct Answer: B

The case study lists 'Extensive Scarring/Prior Surgery' as a contraindication, stating, 'Significant scarring from previous surgeries in the deltopectoral interval can obliterate the plane, making dissection difficult and increasing the risk of iatrogenic injury.' This directly addresses the scenario in Option B. Option A (well-controlled hypertension) is a common comorbidity and not a contraindication. Option C (mild osteoarthritis in the contralateral shoulder) is irrelevant to the operative shoulder. Option D (small, partial-thickness supraspinatus tear) is a common finding and not a contraindication to the deltopectoral approach for other pathologies. Option E (requiring an interscalene block) is a beneficial pre-operative measure, not a contraindication.

Question 8

A 28-year-old male collegiate football player sustains a displaced surgical neck fracture of the humerus. Open reduction and internal fixation (ORIF) is planned via the deltopectoral approach. During the approach, the surgeon identifies the deltoid and pectoralis major muscles. What is the correct innervation for these two muscles, respectively, highlighting the internervous plane?

Explanation

Correct Answer: B

The case study clearly defines the innervation of these muscles: 'Deltoid Muscle: ... It is innervated by the axillary nerve (C5, C6).' And 'Pectoralis Major Muscle: ... It is innervated by the medial and lateral pectoral nerves (C5-T1).' The deltopectoral approach exploits this internervous plane, allowing dissection without transecting muscle fibers or damaging their primary innervation. The other options list incorrect innervations for one or both muscles.

Question 9

A 72-year-old patient is undergoing a total shoulder arthroplasty in the beach chair position. During the procedure, the anesthesia team reports a significant drop in blood pressure. The surgeon is concerned about potential complications related to patient positioning. Which of the following neurological complications is a rare but serious risk associated with the beach chair position, particularly with sustained hypotension?

Explanation

Correct Answer: D

While the case study mentions 'Risk of Cerebral Hypoperfusion' and 'Neck and Head Positioning: Requires careful padding and stabilization to prevent nerve palsy (e.g., brachial plexus, ulnar nerve) or pressure injuries,' it does not explicitly list Posterior Ischemic Optic Neuropathy (PION). However, PION is a well-recognized, albeit rare, and devastating complication associated with the beach chair position, especially in the context of prolonged surgery, significant blood loss, and sustained hypotension. It results from inadequate perfusion to the optic nerve. The question asks for a 'rare but serious risk associated with the beach chair position, particularly with sustained hypotension.' Ulnar nerve palsy (A) and brachial plexus neuropraxia (B) are more commonly associated with direct pressure or stretch from improper limb/neck positioning, not primarily hypotension. Spinal cord injury (C) is extremely rare and typically related to direct trauma or pre-existing spinal conditions, not the beach chair position itself. Sciatic nerve palsy (E) is a lower extremity nerve injury, not typically associated with shoulder surgery in the beach chair position.

Question 10

A surgeon is performing a revision total shoulder arthroplasty via the deltopectoral approach on a patient with a failed glenoid component. After mobilizing the subscapularis, the surgeon needs to achieve maximal exposure of the glenoid. Which of the following maneuvers, if performed excessively, carries the highest risk of injury to the axillary neurovascular bundle?

Explanation

Correct Answer: B

The case study explicitly warns about the axillary neurovascular bundle: 'Situated medial and deep to the coracoid process. This bundle contains the axillary artery, axillary vein, and brachial plexus cords (lateral, posterior, medial). Retraction of the conjoined tendon medially allows access to the subscapularis, but extreme medial retraction risks injury to this bundle.' Therefore, aggressive medial retraction of the conjoined tendon and pectoralis minor directly threatens the axillary neurovascular bundle. Option A (superior deltoid retraction) is less likely to injure the main axillary bundle, though the axillary nerve's anterior branch could be at risk. Option C (lateral pectoralis major retraction) is not the primary direction of risk for the axillary bundle. Option D (lateral humeral shaft dissection) is too distal and lateral to directly impact the axillary bundle. Option E (inferior humeral head retraction) could put the axillary nerve at risk as it wraps around the surgical neck, but the question specifically asks about the 'axillary neurovascular bundle' which is more medial and deep, and directly threatened by medial retraction of the conjoined tendon and pectoralis minor.

Question 11

A 72-year-old female undergoes a primary total hip replacement (THR) via a posterior approach for severe osteoarthritis. Three weeks post-operatively, she presents to the emergency department with acute hip pain and inability to bear weight after attempting to pick up an object from the floor, resulting in a posterior dislocation. Radiographs confirm a posterior dislocation without periprosthetic fracture. After successful closed reduction, the surgeon reviews the case. Which of the following factors is LEAST likely to be the primary contributing cause of this early dislocation?

Explanation

Correct Answer: D

The case describes an early dislocation (three weeks post-operatively). The teaching case states: 'Early dislocations typically occur within the first three months post-operatively and are frequently attributed to surgical technique, component malposition, or early non-compliance with precautions. Late dislocations, occurring beyond three months, are more often associated with factors such as soft tissue laxity, component wear, neuromuscular dysfunction, or trauma.' Progressive soft tissue laxity due to implant wear (Option D) is a characteristic of late dislocations, as significant wear typically takes a longer period to develop and contribute to laxity. Therefore, it is the least likely primary contributing cause for an early dislocation.

Options A, B, C, and E are all well-established risk factors for early dislocation:

A. Inadequate repair of the posterior capsule and short external rotators: The posterior approach, if not meticulously repaired, is associated with higher posterior dislocation risk. The case specifically mentions a posterior approach.
B. Acetabular component malposition: Deviations from the safe zone (e.g., excessive anteversion or retroversion, high inclination) are a leading cause of early dislocation due to impingement or reduced stability.
C. Patient non-compliance with post-operative hip precautions: The patient's action of bending at the waist to pick up an object is a classic violation of posterior hip precautions (avoiding hip flexion > 90° and internal rotation), which can directly lead to posterior dislocation.
E. Use of a smaller femoral head: Smaller femoral heads inherently have a shorter 'jump distance,' making the hip less stable and more prone to dislocation, especially in the early post-operative period before full soft tissue healing and strength are achieved. The case emphasizes that larger femoral heads significantly enhance stability.

Question 12

A 65-year-old male with a history of lumbar spinal fusion (L3-S1) for degenerative scoliosis is undergoing a primary total hip replacement for severe osteoarthritis. Pre-operative planning includes standard AP pelvis and lateral hip radiographs. The surgeon is concerned about optimizing acetabular component positioning to minimize dislocation risk. Given the patient's spinal history, which additional pre-operative imaging and consideration would be most beneficial for surgical planning?

Explanation

Correct Answer: C

The teaching case specifically highlights the importance of considering spinal pathology in pre-operative planning: 'In patients with spinal pathology (e.g., fusion, severe kyphosis), altered pelvic tilt dynamics can significantly impact functional acetabular orientation, necessitating customized component placement strategies. A lateral standing and seated radiograph may be helpful.' Lumbar spinal fusion can significantly alter the patient's pelvic tilt and mobility, which in turn changes the functional acetabular anteversion and inclination in different positions (e.g., standing vs. sitting). Understanding these spinopelvic kinematics is crucial for patient-specific acetabular component positioning to avoid impingement and dislocation throughout the patient's functional range of motion.

A. Dynamic fluoroscopy of the hip in flexion and extension: While useful intraoperatively for some approaches (like DAA), it's not the primary pre-operative tool for assessing spinopelvic dynamics in the context of spinal fusion.
B. MRI of the hip to assess abductor muscle integrity: While abductor integrity is important for stability, it's not the most relevant additional study for optimizing acetabular positioning in a patient with spinal fusion.
D. Bone scan to rule out occult infection or loosening: This is typically indicated for suspected infection or loosening, not for primary THR planning related to spinal pathology.
E. CT angiogram to map the neurovascular structures around the hip: This is generally reserved for complex cases with suspected vascular anomalies or for planning vascularized grafts, not routine THR planning for dislocation prevention.

Question 13

A 58-year-old male undergoes a direct anterior approach (DAA) total hip replacement. Intraoperatively, the surgeon notes excellent stability on trial reduction, with no impingement throughout a full range of motion. The acetabular component is placed at 45° inclination and 20° anteversion, and a 36mm femoral head is used. Post-operatively, the patient is advised to avoid extreme hip hyperextension and external rotation for 6 weeks. Which of the following statements best explains the rationale for this specific post-operative precaution in a DAA?

Explanation

Correct Answer: C

The teaching case states under 'Anterior/Anterolateral Approach Precautions': 'Historically, anterior dislocations are less common. However, some surgeons may advise caution with: Avoid Hip Hyperextension and Extreme External Rotation: To prevent anterior impingement or dislocation, especially in the early post-operative period.' The direct anterior approach (DAA) preserves the posterior capsule and external rotators, making posterior dislocation less common. However, the anterior capsule is typically incised or released, and the anterior soft tissues are retracted. Excessive hip hyperextension and external rotation can cause anterior impingement (e.g., between the anterior aspect of the femoral neck/stem and the anterior acetabular rim or anterior capsule repair) or stress the healing anterior soft tissues, leading to an anterior dislocation.

A. To prevent posterior dislocation due to disruption of the posterior capsule: This is incorrect. The DAA preserves the posterior capsule, making posterior dislocation less likely. This precaution is more relevant for a posterior approach.
B. To protect the healing abductor mechanism from excessive tension: While abductor integrity is important, this specific precaution (hyperextension/external rotation) is not primarily aimed at protecting the abductors. Abductor protection is more relevant for lateral approaches where the abductors are detached/split.
D. To minimize the risk of sciatic nerve irritation from excessive stretch: The sciatic nerve is located posteriorly. Hyperextension and external rotation of the hip are not typically positions that stretch the sciatic nerve.
E. To prevent periprosthetic fracture of the femoral neck: While periprosthetic fractures can occur, this specific precaution is not directly aimed at preventing them. Femoral fractures during DAA are more often associated with femoral preparation or broaching.

Question 14

A 68-year-old male with a history of recurrent posterior dislocations after a primary total hip replacement performed via a posterior approach, despite two closed reductions and a period of bracing, is scheduled for revision surgery. Pre-operative CT scan reveals appropriate acetabular component inclination (40°) but significant femoral component retroversion (-5°). The patient also has mild abductor weakness. Which of the following revision strategies would most directly address the identified primary mechanical cause of his recurrent dislocations?

Explanation

Correct Answer: B

The teaching case states under 'Indications for Revision THR for Recurrent Dislocation': 'Component Malposition: Acetabular component malalignment (excessive anteversion/retroversion, inclination), or femoral component malversion.' And under 'Femoral Component Positioning': 'The femoral component should be implanted with appropriate anteversion, typically matching the native femoral version (10-20°). Excessive retroversion significantly increases posterior dislocation risk.' The vignette explicitly identifies 'significant femoral component retroversion (-5°)' as a finding on the CT scan. This is a direct mechanical cause for recurrent posterior dislocations. Therefore, revision of the femoral component to correct its version (Option B) would most directly address this primary mechanical issue.

A. Exchange of the acetabular liner to a posterior-lipped liner: While a posterior-lipped liner can augment posterior stability, it is a compensatory measure. It does not correct the underlying femoral component malversion, which is the primary mechanical issue identified.
C. Placement of a constrained acetabular liner: Constrained liners are reserved for severe instability due to irreversible soft tissue laxity or neuromuscular dysfunction, or when other measures have failed. While it would prevent dislocation, it has higher mechanical failure rates and is not the most direct solution for a correctable component malposition.
D. Abductor repair and augmentation with an allograft: The patient has mild abductor weakness, which can contribute to instability, but the primary mechanical cause identified is femoral retroversion. Addressing the femoral version would be more impactful for posterior dislocation.
E. Exchange to a larger femoral head (e.g., 40mm): A larger femoral head increases the jump distance and improves stability. This is a good general strategy for instability, but again, it does not correct the fundamental malposition of the femoral component, which is the root cause in this scenario. Correcting the femoral version would be a more definitive solution.

Question 15

A 78-year-old male with a history of Parkinson's disease and mild cognitive impairment undergoes a primary total hip replacement via a direct lateral approach. Intraoperatively, the surgeon notes that despite meticulous abductor repair and optimal component positioning, the hip feels somewhat lax on trial reduction, and the 'shuck test' is positive. Given the patient's comorbidities and intraoperative findings, which of the following liner options would be most appropriate to consider for enhancing stability?

Explanation

Correct Answer: C

The teaching case states under 'Liner Options': 'Constrained Liner: Reserved for specific indications, such as recurrent dislocations due to severe abductor insufficiency, neuromuscular disorders, or in revision settings where other measures have failed. Constrained liners physically lock the head within the liner...' The patient has Parkinson's disease (a neuromuscular disorder) and mild cognitive impairment, both of which are risk factors for dislocation due to impaired motor control, balance, and compliance with precautions. The intraoperative finding of a 'somewhat lax' hip and a positive 'shuck test' (suggesting inadequate soft tissue tension) further indicates inherent instability despite optimal component positioning and abductor repair. In this high-risk scenario, a constrained acetabular liner (Option C) is the most appropriate choice to physically prevent dislocation, acknowledging its higher mechanical failure rates but accepting them due to the severe instability risk.

A. Standard polyethylene liner: This would be used for a stable hip, which is not the case here.
B. Posterior-lipped polyethylene liner: This is primarily used to augment posterior stability, typically with a posterior approach, and would not address the generalized laxity or the patient's high-risk profile for overall instability.
D. Highly cross-linked polyethylene liner with a smaller femoral head: While highly cross-linked polyethylene is excellent for wear, a smaller femoral head would decrease the jump distance and further compromise stability, which is the opposite of what is needed.
E. Metal-on-metal bearing with a large femoral head: While large femoral heads improve stability, metal-on-metal bearings have fallen out of favor due to concerns about metal ion release and pseudotumor formation. It's not the primary solution for a mechanically unstable hip in a high-risk patient.

Question 16

A 55-year-old active male undergoes a primary total hip replacement for avascular necrosis. The surgeon utilizes a posterior approach and meticulously repairs the posterior capsule and short external rotators. Intraoperative assessment confirms excellent stability. Post-operatively, the patient is advised on standard posterior hip precautions. Which of the following activities, if performed incorrectly, would most likely lead to a posterior dislocation in this patient?

Explanation

Correct Answer: D

The teaching case states under 'Posterior Approach Precautions': 'Avoid Hip Flexion > 90°,' 'Avoid Adduction Past Midline,' and 'Avoid Internal Rotation.' It also lists 'Activities to Avoid: Crossing legs, sleeping on the side without a pillow between knees, low chairs, bending at the waist to pick things up.' Bending forward to tie shoelaces while seated on a low stool (Option D) combines several high-risk movements for a posterior approach: significant hip flexion (likely >90°), adduction (if the leg crosses the midline), and internal rotation. This combination creates a lever-out mechanism that can lead to posterior dislocation.

A. Sleeping on the back with legs straight: This position does not violate posterior hip precautions.
B. Walking with a cane on level ground: This is a recommended activity for early mobilization and does not typically place the hip at risk for dislocation.
C. Sitting in a high-backed chair with feet flat on the floor: A high-backed chair helps maintain hip flexion below 90°, and feet flat on the floor prevents excessive adduction or internal rotation. This is a safe activity.
E. Performing gentle hip abduction exercises in supine: Gentle hip abduction is a common and safe exercise in the acute phase of rehabilitation, helping to strengthen the abductors without violating posterior precautions.

Question 17

A 62-year-old female undergoes a revision total hip replacement for recurrent dislocations. During the procedure, the surgeon identifies a significant posterior acetabular wall deficiency. After addressing component malposition and ensuring adequate soft tissue tension, the surgeon needs to augment the posterior stability. Which of the following options is specifically mentioned in the case as a salvage strategy for severe posterior wall defects?

Explanation

Correct Answer: C

The teaching case, under 'Complications & Management' and 'Salvage Strategies (Revision Surgery) for Recurrent Dislocation,' explicitly states: 'Augmentation: Use of a posterior acetabular cage or allograft for severe posterior wall defects.' A posterior acetabular wall deficiency directly compromises the bony containment of the femoral head posteriorly, making the hip highly susceptible to posterior dislocation. Augmenting this defect with a cage or allograft provides structural support and helps restore the acetabular anatomy, thereby enhancing stability.

A. Iliopsoas release: This is rarely considered for anterior impingement and is not relevant for a posterior wall deficiency.
B. Use of a larger femoral head: While a larger femoral head increases the jump distance and improves overall stability, it does not directly address a structural bony defect like a posterior wall deficiency. It's a general measure, not specific to this defect.
D. Girdlestone resection arthroplasty: This is a salvage procedure for recalcitrant infection and instability in medically infirm patients, involving removal of the femoral head and neck, resulting in a flail hip. It is not a reconstructive option for a posterior wall defect in a patient undergoing revision for recurrent dislocation.
E. Arthrodesis of the hip: This is an extremely rare salvage procedure for young, active patients with persistent pain and instability where other options are exhausted, fusing the hip joint. It is not a solution for a posterior wall defect in a revision THR.

Question 18

A 70-year-old male undergoes a primary total hip replacement via a direct lateral approach. Post-operatively, he develops a persistent Trendelenburg gait and complains of hip weakness, despite diligent physical therapy. This abductor insufficiency increases his risk for superior dislocation. Which of the following intraoperative steps is most critical in preventing this specific complication with a direct lateral approach?

Explanation

Correct Answer: B

The teaching case, under 'Direct Lateral/Anterolateral Approaches (Hardinge/Modified Hardinge)' and 'Dislocation Mitigation,' states: 'Meticulous repair of the abductor mechanism to the greater trochanter is critical to prevent post-operative abductor insufficiency and superior dislocation.' The direct lateral approach involves detaching or splitting the abductor muscles (gluteus medius and minimus) from the greater trochanter. Failure to meticulously repair these muscles can lead to abductor insufficiency, resulting in a Trendelenburg gait and increased risk of superior or superolateral dislocation due to the loss of the primary stabilizing force against superior migration.

A. Ensuring adequate femoral anteversion: This is crucial for preventing posterior dislocation and impingement, but less directly related to superior dislocation caused by abductor insufficiency.
C. Thorough removal of peripheral osteophytes: This prevents impingement and lever-out, which can cause dislocation in various directions, but is not specific to preventing superior dislocation due to abductor weakness.
D. Placement of a posterior-lipped acetabular liner: This is used to augment posterior stability, typically with a posterior approach, and is not relevant for preventing superior dislocation in a direct lateral approach.
E. Restoration of the native femoral neck-shaft angle: This contributes to overall hip biomechanics and offset, but the direct repair of the abductor mechanism is the most critical step for preventing abductor insufficiency and superior dislocation in a lateral approach.

Question 19

A 48-year-old male, an avid golfer, is undergoing a primary total hip replacement. He expresses concern about returning to his sport and wants to minimize any risk of dislocation. The surgeon plans to use a modern uncemented system. Based on current literature and guidelines, which of the following implant choices is most strongly supported by evidence to reduce dislocation rates and would be beneficial for this active patient?

Explanation

Correct Answer: C

The teaching case, under 'Femoral Head Size' and 'Summary of Key Literature / Guidelines,' states: 'A vast body of literature unequivocally supports the use of larger femoral heads (>32mm, preferably 36mm or greater) in reducing dislocation rates. Larger heads increase the 'jump distance' – the linear distance the center of the femoral head must travel before dislocating – effectively enhancing intrinsic stability.' It also notes that 'advancements in polyethylene technology (e.g., highly cross-linked polyethylene) have mitigated these wear concerns, making larger heads the standard for most bearing surfaces.'

Therefore, a 36mm ceramic femoral head with a highly cross-linked polyethylene liner (Option C) is the optimal choice. This combination provides the benefits of a large femoral head for increased stability (larger jump distance) and the excellent wear characteristics of ceramic-on-highly cross-linked polyethylene, which is crucial for an active patient.

A. A 28mm ceramic femoral head with a standard polyethylene liner: A 28mm head is considered smaller and offers less stability (shorter jump distance) compared to larger heads. Standard polyethylene has higher wear rates than highly cross-linked polyethylene.
B. A 32mm metal femoral head with a metal-on-metal bearing: While 32mm is better than 28mm, metal-on-metal bearings have significant concerns regarding metal ion release and pseudotumor formation, and are generally avoided in modern practice.
D. A 22mm ceramic femoral head with a constrained liner: A 22mm head is very small and inherently unstable. While a constrained liner would prevent dislocation, it is reserved for specific high-risk cases due to higher mechanical failure rates and is not the primary choice for a healthy, active patient where intrinsic stability can be achieved with larger heads.
E. A 32mm metal femoral head with a standard polyethylene liner: Similar to option A, a 32mm head is good, but standard polyethylene has higher wear rates, and a 36mm head offers even greater stability.

Question 20

A 60-year-old female undergoes a primary total hip replacement. Post-operatively, she develops a significant leg length discrepancy (LLD) of 2.5 cm, with the operative leg being longer. She experiences persistent low back pain and a feeling of instability, despite using a shoe lift on the contralateral side. Which of the following mechanisms best explains how excessive leg lengthening can contribute to instability or related complications?

Explanation

Correct Answer: C

The teaching case, under 'Complications & Management' and 'Leg Length Discrepancy (LLD),' states: 'Excessive lengthening can cause nerve stretch, while shortening reduces abductor tension, both increasing dislocation risk.' A 2.5 cm lengthening is significant. Excessive lengthening can stretch nerves (e.g., sciatic nerve, leading to foot drop, or femoral nerve) or cause prosthetic impingement (e.g., the femoral neck/stem impinging on the acetabular rim or capsule due to the altered biomechanics), which can lead to pain and instability. The patient's symptoms of low back pain and instability are consistent with these issues.

A. Reduced abductor tension leading to Trendelenburg gait: This is associated with leg shortening, not lengthening. Excessive lengthening would typically increase abductor tension, potentially leading to pain but not reduced tension.
B. Increased jump distance, paradoxically leading to impingement: While increased jump distance generally improves stability, excessive lengthening can alter the hip's biomechanics in a way that promotes impingement, which then acts as a lever-out mechanism for dislocation. The primary issue is the impingement or nerve stretch, not a paradoxical effect of jump distance itself.
D. Accelerated polyethylene wear due to altered kinematics: While altered kinematics can affect wear, nerve stretch or impingement are more direct and immediate complications of excessive lengthening leading to instability or pain.
E. Increased risk of periprosthetic infection: There is no direct causal link between leg length discrepancy and increased risk of periprosthetic infection.

Question 21

A 67-year-old male with a history of severe rheumatoid arthritis and chronic steroid use undergoes a primary total hip replacement via a posterior approach. During the procedure, the surgeon notes that the soft tissues, including the posterior capsule and external rotators, are attenuated and difficult to repair robustly. Despite using a 36mm femoral head and achieving optimal component positioning, the hip feels somewhat lax on trial reduction. Which of the following intraoperative strategies, beyond what has already been done, would be the most appropriate next step to enhance stability in this specific scenario?

Explanation

Correct Answer: B

The teaching case, under 'Liner Options,' states: 'A posterior-lipped liner can be used in posterior approaches to augment posterior stability by increasing the posterior jump distance, especially if soft tissue repair is compromised or the patient is at higher risk. The lip must be oriented correctly (posteriorly).' In this scenario, the patient has attenuated soft tissues (due to rheumatoid arthritis and chronic steroid use), making robust repair difficult. This directly compromises the soft tissue envelope's contribution to stability. Despite optimal component positioning and a large femoral head, the hip still feels lax. A posterior-lipped liner (Option B) is specifically designed to compensate for posterior soft tissue laxity in a posterior approach by increasing the effective posterior jump distance, thereby enhancing stability.

A. Perform an iliopsoas release to reduce anterior impingement: Iliopsoas release is for anterior impingement and would not address posterior laxity.
C. Increase the femoral offset by using a longer neck option: While restoring offset is crucial for abductor tension, the vignette implies that component positioning (including offset) was already optimized. Further increasing offset might lead to leg lengthening or impingement.
D. Perform a Girdlestone resection arthroplasty: This is a salvage procedure for severe, recalcitrant problems, not a primary strategy to enhance stability in a primary THR.
E. Switch to a smaller femoral head to reduce impingement: Switching to a smaller femoral head would decrease the jump distance and further compromise stability, which is the opposite of what is needed.

Question 22

A 50-year-old male with a history of developmental dysplasia of the hip (DDH) and subsequent severe osteoarthritis is undergoing a primary total hip replacement. Pre-operative templating reveals a shallow, anteverted acetabulum. The surgeon plans to use a posterior approach. To optimize stability and minimize dislocation risk in this challenging case, which of the following combined anteversion targets is generally considered optimal?

Explanation

Correct Answer: C

The teaching case, under 'Biomechanics of Prosthetic Stability' and 'Summary of Key Literature / Guidelines,' states: 'Combined Anteversion: The sum of acetabular anteversion and femoral anteversion. Optimal combined anteversion (typically 35-45°) provides stability across a functional range of motion, minimizing both anterior and posterior impingement.' While Lewinnek's safe zone provides guidelines for individual component placement, the concept of combined anteversion is increasingly recognized as critical for overall hip stability, especially in complex cases like DDH where native anatomy might be altered. Achieving a combined anteversion of 35-45 degrees helps ensure that the hip remains stable through its functional range of motion, balancing the risk of anterior and posterior impingement.

A. 10-20 degrees: This range is too low for combined anteversion and would likely lead to posterior impingement and instability.
B. 20-30 degrees: This is still on the lower side for optimal combined anteversion and may not provide sufficient stability against posterior dislocation.
D. 50-60 degrees: This range is too high for combined anteversion and would likely lead to anterior impingement and instability.
E. 65-75 degrees: This range is excessively high and would almost certainly result in anterior impingement and dislocation.

Question 23

A 65-year-old male presents with increased weakness in internal rotation and a positive bear-hug test 6 months after an anatomic total shoulder arthroplasty via a deltopectoral approach. What is the most likely cause of his symptoms?

Explanation

Subscapularis failure is a known complication after anatomic TSA performed via a deltopectoral approach. It typically presents with increased external rotation, weakness in internal rotation, and positive lift-off or bear-hug tests.

Question 24

A 68-year-old female with a metal-on-highly-crosslinked-polyethylene THA presents with new-onset groin pain. Radiographs show a well-fixed implant. Aspiration is negative for infection, but MRI demonstrates a solid/cystic pseudotumor. What is the most likely etiology?

Explanation

Mechanically assisted crevice corrosion (trunnionosis) can occur at the head-neck modular junction, even in metal-on-polyethylene bearings. It leads to adverse local tissue reactions (ALTR) and pseudotumor formation.

Question 25

The design of a Grammont-style reverse total shoulder arthroplasty alters shoulder biomechanics to compensate for rotator cuff deficiency by:

Explanation

A Grammont-style RTSA medializes and distalizes the center of rotation. This increases the deltoid lever arm and resting tension, allowing it to initiate and maintain abduction without a functioning rotator cuff.

Question 26

A 70-year-old male sustains a recurrent posterior dislocation of his THA. Radiographs reveal the acetabular component is placed in 5 degrees of retroversion and 40 degrees of abduction. The stem has 15 degrees of anteversion. What is the most appropriate surgical management?

Explanation

The acetabular component is in retroversion, predisposing the patient to posterior dislocation. The most appropriate treatment is revision of the cup to achieve the target 15-20 degrees of anteversion.

Question 27

A 62-year-old male with primary glenohumeral osteoarthritis has a Walch B2 glenoid with 25 degrees of retroversion. If an anatomic total shoulder arthroplasty is planned, which of the following is the most appropriate management of the glenoid deformity?

Explanation

For a B2 glenoid with excessive retroversion (>15-20 degrees), correcting version with eccentric anterior reaming removes excessive subchondral bone. A posterior augmented glenoid component preserves bone stock and restores version.

Question 28

During a direct anterior approach for a total hip arthroplasty, the ascending branch of the lateral femoral circumflex artery is encountered. In which internervous plane does this surgical approach initially proceed?

Explanation

The direct anterior approach utilizes the superficial internervous plane between the tensor fasciae latae (superior gluteal nerve) and the sartorius (femoral nerve). The ascending branch of the lateral femoral circumflex artery is ligated in this interval.

Question 29

A 55-year-old female complains of start-up groin pain when transitioning from seated to standing 1 year after an uncemented THA. Pain is reproduced with active hip flexion against resistance. Radiographs show a well-fixed cup with anterior overhang. What is the next best step in management if conservative treatment fails?

Explanation

Iliopsoas impingement is commonly caused by anterior overhang of the acetabular component. If conservative management (NSAIDs, injections, PT) fails, an arthroscopic or open iliopsoas tenotomy is the treatment of choice.

Question 30

Which of the following technical modifications during baseplate fixation in a reverse total shoulder arthroplasty most effectively decreases the incidence of scapular notching?

Explanation

Scapular notching is caused by mechanical impingement of the humeral component against the scapular neck. Placing the baseplate inferiorly (creating an overhang) and with an inferior tilt minimizes this impingement.

Question 31

Failure to restore femoral offset during a total hip arthroplasty most commonly leads to which of the following clinical findings?

Explanation

Decreasing femoral offset reduces the lever arm of the abductor musculature. This leads to abductor weakness, increased joint reaction forces, and a higher risk of bony or soft-tissue impingement resulting in instability.

Question 32

A 65-year-old male develops insidious onset of shoulder stiffness and vague pain 1 year after an anatomic TSA. Inflammatory markers are mildly elevated. Aspiration yields no growth at 3 days. What is the most likely causative organism and the required culture duration for diagnosis?

Explanation

Cutibacterium acnes is a common, slow-growing, indolent pathogen in shoulder arthroplasty infections. Cultures must be held for at least 14 days to ensure reliable detection of this anaerobic organism.

Question 33

A 75-year-old female sustains a periprosthetic femur fracture around her cementless THA. Radiographs show a fracture at the tip of the stem. The stem is loose, but the proximal femoral bone stock is adequate. What is the Vancouver classification and appropriate treatment?

Explanation

A Vancouver B2 fracture occurs around or just below the stem tip with a loose implant but adequate bone stock. The standard of care is revision to a longer, bypassed diaphyseal engaging stem.

Question 34

When utilizing a reverse total shoulder arthroplasty for an acute 4-part proximal humerus fracture in an elderly patient, healing of the greater tuberosity is associated with which of the following clinical outcomes?

Explanation

In RTSA for proximal humerus fractures, anatomic healing of the greater tuberosity to the shaft is highly correlated with improved postoperative external rotation and superior overall patient-reported outcomes.

Question 35

Following a posterior approach THA, a patient has a foot drop and diminished sensation over the dorsal foot. Which portion of the sciatic nerve is most vulnerable to injury during this procedure, and why?

Explanation

The peroneal division of the sciatic nerve is more susceptible to injury (stretch or compression) because it lies laterally, has fewer supporting connective tissues, and is securely tethered distally at the fibular neck.

Question 36

What is the most common reason for late revision of an anatomic total shoulder arthroplasty?

Explanation

Symptomatic aseptic loosening of the polyethylene glenoid component is the most common long-term complication and the most frequent reason for late revision of an anatomic total shoulder arthroplasty.

Question 37

Which of the following patients is the most appropriate candidate for a metal-on-metal hip resurfacing arthroplasty?

Explanation

Hip resurfacing is best indicated for young, active, large-statured males with primary OA and strong bone stock. Contraindications include females of childbearing age, renal failure, osteoporosis, and large femoral cysts.

Question 38

During a reverse total shoulder arthroplasty, the surgeon must restore adequate tension to the deltoid. Which clinical assessment is best used intraoperatively to confirm appropriate deltoid tension?

Explanation

Intraoperative assessment of proper deltoid tension in RTSA involves checking the conjoint tendon, which should have a firm but elastic "bounce". Overtensioning leads to a rigid tendon and increases the risk of acromial stress fracture.

Question 39

Compared to standard ultra-high-molecular-weight polyethylene (UHMWPE), highly cross-linked polyethylene used in THA offers which of the following mechanical trade-offs?

Explanation

High-dose irradiation cross-links the polyethylene, significantly reducing adhesive and abrasive wear. However, this process decreases mechanical properties such as ductility, toughness, and fatigue crack propagation resistance.

Question 40

During the inferior capsular release for a total shoulder arthroplasty, the axillary nerve is at greatest risk. What is its typical anatomic relationship to the inferior glenohumeral capsule?

Explanation

The axillary nerve passes through the quadrangular space and typically lies approximately 10 to 15 mm inferior to the inferior glenohumeral capsule. Dissection must remain directly on the capsule to avoid nerve injury.

Question 41

A 68-year-old male with long-standing ankylosing spondylitis presents for a right total hip arthroplasty (THA). Radiographs demonstrate complete autofusion of the lumbar spine and a rigid spinopelvic junction. Compared to a patient with normal spinopelvic mobility, how does this patient's condition affect acetabular mechanics and instability risk?

Explanation

In a patient with a rigid spinopelvic junction, the pelvis cannot naturally retrovert to accommodate hip flexion when sitting. This lack of dynamic posterior pelvic tilt leads to a functional decrease in acetabular anteversion, predisposing the hip to anterior impingement and subsequent posterior dislocation.

Question 42

A 74-year-old female presents to the emergency department after a ground-level fall. She underwent a cementless total hip arthroplasty 10 years ago. Radiographs reveal a periprosthetic femur fracture extending just distal to the tip of the femoral stem. The stem demonstrates significant subsidence and radiolucencies in zones 1-7, but the proximal femur has good cortical bone stock. According to the Vancouver classification, what is the most appropriate surgical management?

Explanation

This is a Vancouver B2 periprosthetic fracture (fracture around a loose stem with adequate bone stock). The gold standard treatment is revision arthroplasty utilizing a long cementless stem that bypasses the most distal fracture line by at least two cortical diameters.

Question 43

A 65-year-old male is undergoing a reverse total shoulder arthroplasty (RTSA) for cuff tear arthropathy. To minimize the risk of scapular notching, which of the following describes the optimal positioning of the glenoid baseplate?

Explanation

Scapular notching in RTSA is primarily caused by mechanical impingement of the humeral component against the inferior scapular neck. It can be minimized by placing the glenoid baseplate inferiorly (flush or slightly overhanging the inferior rim) and using neutral or slight inferior tilt.

Question 44

A 58-year-old male complains of insidious onset shoulder stiffness and dull pain 18 months following an anatomic total shoulder arthroplasty. Inflammatory markers (ESR, CRP) are within normal limits. Radiographs show progressive radiolucent lines around the glenoid component. Joint aspiration is performed. If Cutibacterium acnes is the causative organism, which of the following is true regarding its microbiologic profile and culture requirements?

Explanation

Cutibacterium acnes is a Gram-positive, anaerobic (or aerotolerant) rod commonly implicated in indolent shoulder periprosthetic joint infections. Because it is a slow-growing organism, cultures should routinely be held for up to 14 days to maximize the diagnostic yield.

Question 45

A 62-year-old male with a modern cementless total hip arthroplasty presents with new-onset groin pain. His implant utilizes a large-diameter cobalt-chromium head on a standard titanium alloy stem. Radiographs show a well-fixed implant, but serum metal ion testing reveals elevated cobalt levels that are disproportionately higher than chromium levels. What is the most likely diagnosis?

Explanation

Mechanically assisted crevice corrosion at the modular head-neck junction (trunnionosis) typically presents with elevated serum cobalt levels that significantly exceed chromium levels. This is often seen when large-diameter cobalt-chromium heads are used on titanium stems, leading to adverse local tissue reactions.

Question 46

A 69-year-old female with primary glenohumeral osteoarthritis and an intact rotator cuff is scheduled for an anatomic total shoulder arthroplasty. Preoperative CT scan reveals a Walch B2 glenoid with 25 degrees of retroversion. If the surgeon attempts to correct the retroversion to neutral using asymmetric anterior reaming alone, what is the most significant biomechanical risk?

Explanation

Correcting severe glenoid retroversion (>15 degrees) via asymmetric reaming alone sacrifices critical anterior subchondral bone stock. This decreases the structural support for the glenoid component, increasing the risk of vault perforation, subsidence, and premature loosening.

Question 47

During a primary total hip arthroplasty utilizing the direct anterior approach, the surgeon develops the internervous plane between the tensor fasciae latae and the sartorius. To expose the anterior capsule, branches of which of the following vascular structures must typically be identified and ligated?

Explanation

The direct anterior approach utilizes the internervous plane between the tensor fasciae latae (superior gluteal nerve) and the sartorius (femoral nerve). The ascending branches of the lateral circumflex femoral artery cross this interval and must be ligated to prevent postoperative hematoma and allow adequate capsular exposure.

Question 48

A 75-year-old female undergoes a reverse total shoulder arthroplasty. Six months postoperatively, she reports sudden lateral shoulder pain without trauma, accompanied by a decline in active forward elevation. Radiographs demonstrate a fracture at the base of the acromion. Which of the following biomechanical alterations is the primary risk factor for this complication?

Explanation

Acromial stress fractures after RTSA are strongly associated with excessive lengthening of the arm and significant medialization of the center of rotation. These changes dramatically increase the tension and resting tone of the deltoid, predisposing the acromion to stress fractures.

Question 49

A 35-year-old highly active male receives a ceramic-on-ceramic total hip arthroplasty. Postoperatively, he complains of an audible squeaking sound from his hip when walking. Which of the following component malpositions is most highly correlated with the development of squeaking in ceramic-on-ceramic articulations?

Explanation

Squeaking in ceramic-on-ceramic THA is most commonly associated with edge loading of the bearing surfaces. Edge loading typically occurs due to cup malposition, specifically excessive acetabular inclination and anteversion, which disrupts fluid film lubrication.

Question 50

During an anatomic total shoulder arthroplasty, the surgeon elects to perform a lesser tuberosity osteotomy (LTO) rather than a subscapularis tenotomy. Based on current literature, what is the primary advantage of the LTO technique compared to tenotomy?

Explanation

A lesser tuberosity osteotomy allows for bone-to-bone healing of the subscapularis insertion, which has been shown in multiple studies to result in higher rates of structural healing on ultrasound and improved postoperative subscapularis strength compared to a soft-tissue tenotomy.

Question 51

A 64-year-old female suffers a displaced 3-part proximal humerus fracture and is treated with a reverse total shoulder arthroplasty. The surgeon uses strong sutures to repair the greater tuberosity to the proximal humerus and the implant. Successful osseous healing of the greater tuberosity is most closely associated with which clinical outcome?

Explanation

In the setting of RTSA for proximal humerus fractures, anatomic reduction and healing of the greater tuberosity strictly correlate with improved active external rotation. This is because it restores the tension and function of the attached teres minor and infraspinatus.

Question 52

According to the Musculoskeletal Infection Society (MSIS) / International Consensus Meeting (ICM) criteria, which of the following synovial fluid profiles is most consistent with a chronic periprosthetic joint infection in a total hip arthroplasty?

Explanation

For chronic periprosthetic joint infection of the hip or knee, the 2018 ICM diagnostic thresholds are a synovial fluid WBC count greater than 3,000 cells/µL or a PMN percentage greater than 80%. Acute infections (within 6 weeks of surgery) have higher thresholds, typically >10,000 cells/µL.

Question 53

A 70-year-old male with an anatomic total shoulder arthroplasty presents with gradually worsening shoulder pain and decreased range of motion. Radiographs demonstrate superior migration of the humeral head and eccentric superior wear of the glenoid component. What phenomenon is primarily responsible for the subsequent loosening of the glenoid component in this scenario?

Explanation

Superior migration of the humeral head (often due to progressive rotator cuff dysfunction) causes eccentric superior loading of the glenoid component. This off-axis loading creates a "rocking horse" phenomenon, which is the most common biomechanical mechanism leading to aseptic glenoid loosening in anatomic TSA.

Question 54

A 55-year-old male with a history of severe heterotopic ossification (HO) following an acetabular fracture is scheduled for a total hip arthroplasty. To prevent the recurrence of HO, which of the following prophylactic regimens is most appropriate and supported by evidence?

Explanation

Patients at high risk for heterotopic ossification (e.g., prior HO, ankylosing spondylitis, hypertrophic osteoarthritis) should receive prophylaxis. Evidence supports either NSAIDs (such as indomethacin for 3-6 weeks) or a single fraction of 700-800 cGy radiation given within 24-48 hours before or after surgery.

Question 55

Reverse total shoulder arthroplasty radically alters the biomechanics of the glenohumeral joint compared to its native state. Which of the following accurately describes the primary biomechanical advantage conferred by the Grammont RTSA design?

Explanation

The classic Grammont reverse shoulder design medializes and inferiorly translates the center of rotation. This dramatically increases the moment arm of the deltoid, recruiting more anterior and posterior fibers for elevation and allowing the deltoid to compensate for a deficient rotator cuff.

Question 56

During a total hip arthroplasty via the posterior approach, aggressive retraction or careless division of the short external rotators can lead to profuse bleeding. The inferior gluteal artery and the medial circumflex femoral artery are both at risk. Which specific vascular structure typically provides the main blood supply to the native femoral head and is frequently encountered and coagulated near the quadratus femoris?

Explanation

The medial circumflex femoral artery (MCFA) provides the primary blood supply to the native femoral head. Its ascending branch lies adjacent to the superior border of the quadratus femoris muscle and must be carefully identified and coagulated during a posterior THA approach to prevent significant postoperative hematoma.

Question 57

A dual-mobility acetabular cup is utilized in a primary total hip arthroplasty for a patient with Parkinson's disease. By what specific tribological and geometric mechanism does a dual-mobility construct primarily reduce the risk of dislocation?

Explanation

A dual-mobility component features a small primary metal or ceramic head that articulates within a larger, mobile polyethylene liner, which in turn articulates within the metal acetabular shell. The massive effective diameter of the outer liner significantly increases the 'jump distance' required for dislocation.

Question 58

The axillary nerve is a critical structure at risk during shoulder arthroplasty. During the inferior capsular release, what is the approximate average distance from the inferior margin of the glenoid rim to the axillary nerve?

Explanation

Anatomical studies show that the axillary nerve runs immediately inferior to the glenohumeral capsule. The average distance from the inferior bony rim of the glenoid to the axillary nerve is approximately 10 to 15 mm, making careful retractor placement essential to avoid neuropraxia or transection.

Question 59

A 55-year-old male presents with audible squeaking from his right ceramic-on-ceramic total hip arthroplasty two years postoperatively. Radiographs show a well-fixed cup with 55 degrees of inclination. What is the most likely biomechanical cause of this squeaking phenomenon?

Explanation

Squeaking in ceramic-on-ceramic THA is highly associated with edge loading caused by component malposition, such as excessive cup inclination or version. Edge loading leads to stripe wear and loss of fluid-film lubrication, producing the audible squeak.

Question 60

During a total hip arthroplasty, the surgeon increases the femoral offset by 5 mm without altering the vertical leg length. What is the primary biomechanical effect of this modification?

Explanation

Increasing femoral offset lateralizes the femur, which increases the moment arm and resting tension of the abductor musculature. This improves abductor mechanical advantage, thereby decreasing the overall joint reactive force while increasing the bending moment on the stem.

Question 61

A 75-year-old female undergoes reverse total shoulder arthroplasty. Six months postoperatively, she develops localized pain over the superior-posterior shoulder and a visible contour defect. Radiographs reveal an acromial stress fracture. Which of the following intraoperative factors most significantly increases the risk of this complication?

Explanation

Acromial stress fractures in RTSA are frequently caused by excessive deltoid tension resulting from over-lengthening the arm. Inferiorizing and medializing the center of rotation optimally recruits the deltoid, but excessive lengthening places supraphysiologic stress on the acromion.

Question 62

An 80-year-old female sustains a periprosthetic femur fracture around a cemented total hip arthroplasty. Radiographs show a spiral fracture around a loose femoral stem, but the proximal femoral bone stock is of good quality. What is the optimal surgical management according to the Vancouver classification?

Explanation

This is a Vancouver B2 fracture (fracture around a loose stem with adequate bone stock). The standard of care is revision arthroplasty using a long, uncemented, diaphyseal-engaging stem (such as a fluted tapered stem) that bypasses the fracture by at least two cortical diameters.

Question 63

In reverse total shoulder arthroplasty (RTSA), biomechanical stability and function rely on altering the native center of rotation (COR). How is the COR characteristically changed compared to the native shoulder?

Explanation

Grammont's original design for RTSA medializes and inferiorizes the center of rotation. Medialization decreases torque on the glenoid component to prevent loosening, while inferiorization recruits more deltoid fibers and increases its moment arm to restore active elevation.

Question 64

A 68-year-old male with a Walch B2 glenoid is scheduled for total shoulder arthroplasty. If the posterior glenoid erosion is not adequately corrected during surgery, which of the following is the most likely mechanism of early failure?

Explanation

Failure to correct the excessive retroversion and biconcavity of a Walch B2 glenoid leaves the joint unstable posteriorly. This leads to posterior subluxation of the humeral head, eccentric wear, and early mechanical loosening of the glenoid component.

Question 65

A 70-year-old male undergoes a primary total hip arthroplasty via the direct anterior approach. Postoperatively, he has profound numbness over the anterolateral thigh but normal quadriceps strength. Which inter-nervous plane was utilized, and what nerve is likely affected?

Explanation

The direct anterior approach (Smith-Petersen) utilizes the internervous plane between the Sartorius (femoral nerve) and TFL (superior gluteal nerve). The lateral femoral cutaneous nerve crosses this interval superficially and is highly susceptible to traction or transection.

Question 66

Scapular notching is a well-recognized complication following reverse total shoulder arthroplasty. Which of the following surgical techniques best minimizes this risk?

Explanation

Scapular notching occurs when the medial humeral metaphysis impinges on the inferior scapular neck during adduction. Placing the baseplate with an inferior overhang of 2-4 mm shifts the impingement point, significantly reducing the incidence of notching.

Question 67

A 62-year-old female presents with severe pain two years after a primary metal-on-polyethylene total hip arthroplasty. Aspiration is performed to rule out periprosthetic joint infection (PJI). According to the 2018 International Consensus Meeting criteria, which synovial fluid biomarker has the highest specificity for diagnosing PJI?

Explanation

Synovial fluid alpha-defensin is an antimicrobial peptide released by neutrophils. It has extremely high sensitivity and specificity for PJI, and is considered a major diagnostic criterion in the 2018 ICM guidelines.

Question 68

During a total hip arthroplasty using a posterior approach, a patient develops a foot drop immediately postoperatively. Physical examination shows 0/5 ankle dorsiflexion and 5/5 ankle plantar flexion. Sensation is decreased over the first dorsal web space. Which structure was most likely injured during the procedure?

Explanation

The peroneal division of the sciatic nerve is lateral and bound more tightly than the tibial division, making it highly susceptible to stretch injury during THA, resulting in a foot drop and sensory loss over the dorsal foot.

Question 69

A 45-year-old female with Crowe IV developmental dysplasia of the hip undergoes a complex total hip arthroplasty with a subtrochanteric shortening osteotomy. What is the primary purpose of utilizing a subtrochanteric shortening osteotomy in this setting?

Explanation

In Crowe IV DDH, the hip center is extremely high. Bringing the femur down to a cup placed in the true acetabulum risks massive sciatic nerve traction injury. A subtrochanteric shortening osteotomy prevents this overtensioning while restoring native hip biomechanics.

Question 70

Six months after an anatomic total shoulder arthroplasty, a patient presents with sudden weakness in internal rotation and increased anterior shoulder pain. The belly-press test is newly positive. What is the most likely cause of this presentation?

Explanation

A positive belly-press test and internal rotation weakness indicate a subscapularis failure, which is a known and devastating complication after anatomic TSA if a tenotomy or peel fails to heal. This can lead to anterior instability and pain.

Question 71

In the evaluation of a painful metal-on-metal total hip arthroplasty, laboratory tests show significantly elevated serum cobalt but normal serum chromium levels. What is the most likely source of the metal debris?

Explanation

Elevated cobalt with relatively normal chromium in a hip arthroplasty suggests mechanically assisted crevice corrosion (trunnionosis) at the modular head-neck junction. Bearing surface wear typically elevates both cobalt and chromium more equally.

Question 72

When placing the glenosphere baseplate during a reverse total shoulder arthroplasty, peripheral locking screws are utilized for fixation. Aiming the anterior screw excessively far anteriorly risks injury to which neurovascular structure?

Explanation

The anterior screw in a baseplate is directed towards the coracoid process. If placed excessively long or strayed anteriorly past the coracoid base, it can injure the musculocutaneous nerve, which enters the conjoined tendon just inferior to the coracoid.

Question 73

A 77-year-old female presents with a new dislocation of her dual mobility total hip arthroplasty. Radiographs reveal an 'intra-prosthetic' dislocation. What is the defining mechanical failure in this type of dislocation?

Explanation

An intra-prosthetic dislocation is specific to dual mobility cups. It occurs when the small inner head escapes the captive larger polyethylene liner due to wear or impingement at the retentive rim of the polyethylene.

Question 74

Which of the following is the most critical technical factor for achieving active forward elevation following a shoulder hemiarthroplasty for a 4-part proximal humerus fracture in an elderly patient?

Explanation

Tuberosity healing is the single most important predictor of functional outcome (specifically active forward elevation) in shoulder hemiarthroplasty for fractures. Failure of tuberosity union leads to severe cuff dysfunction and pseudoparalysis.

Question 75

A 60-year-old female with severe rheumatoid arthritis undergoes a total shoulder arthroplasty. Preoperative imaging showed central glenoid wear and an intact rotator cuff. Ten years later, she presents with severe pain and limited elevation. Radiographs show superior migration of the humeral component and glenoid loosening. What is the most likely initial mode of failure?

Explanation

Patients with inflammatory arthritis frequently develop progressive late rotator cuff tears. Superior migration of the humeral head eccentric loads the upper glenoid (the 'rocking horse' phenomenon), eventually causing catastrophic loosening of the glenoid component.

Question 76

What is the primary mechanism by which highly cross-linked polyethylene (HXLPE) reduces osteolysis in total hip arthroplasty compared to conventional polyethylene?

Explanation

HXLPE improves wear resistance by preventing molecular chain unravelling, which drastically reduces the overall volume and number of wear particles generated. Although individual HXLPE particles are smaller and more biologically active, the massive reduction in total particle load decreases osteolysis risk.

Question 77

A 65-year-old male with primary glenohumeral osteoarthritis undergoes an anatomic total shoulder arthroplasty. During closure, a lesser tuberosity osteotomy is repaired. What postoperative rehabilitation restriction is most crucial to protect this specific repair?

Explanation

Repair of the subscapularis (whether via peel, tenotomy, or lesser tuberosity osteotomy) is at risk during external rotation stretch or active internal rotation contraction. Postoperative protocols generally restrict active internal rotation and limit passive external rotation to protect the repair.

Question 78

A 50-year-old male presents with severe hip pain. Radiographs demonstrate an advanced cam-type femoroacetabular impingement (FAI) leading to end-stage osteoarthritis. If a total hip arthroplasty is performed, which aspect of component positioning is most critical to prevent impingement and dislocation given his history of cam morphology?

Explanation

Restoring appropriate combined anteversion (typically 25-35 degrees) is critical to preventing component impingement and dislocation in THA. Proper combined version provides clearance during functional ranges of motion, which is crucial in patients with pre-existing impingement anatomy.

Question 79

A 72-year-old female undergoes a reverse total shoulder arthroplasty for rotator cuff tear arthropathy. Compared to an anatomic total shoulder arthroplasty, how does the reverse design alter the biomechanics of the shoulder joint to restore forward elevation?

Explanation

Reverse total shoulder arthroplasty medializes and distalizes the center of rotation. This increases the deltoid moment arm, allowing the deltoid to effectively elevate the arm in the absence of a functional rotator cuff.

Question 80

A 55-year-old active male presents with a chief complaint of a reproducible "squeaking" noise from his right hip during deep flexion, two years after undergoing a primary cementless total hip arthroplasty. Radiographs reveal a well-fixed implant. Which of the following component factors is most strongly associated with this specific complication?

Explanation

Squeaking is a known complication of ceramic-on-ceramic bearings. It is most commonly associated with edge loading caused by component malposition, specifically acetabular cup inclination greater than 45 to 50 degrees or excessive anteversion.

Question 81

A 64-year-old male presents with persistent mild shoulder pain and stiffness 14 months after an anatomic total shoulder arthroplasty. Inflammatory markers are normal, and aspiration yields normal leukocyte counts. At 11 days, the synovial fluid cultures grow Cutibacterium acnes. Which of the following is the most appropriate next step in definitive management?

Explanation

Cutibacterium acnes is an indolent organism that commonly causes shoulder periprosthetic joint infections, often requiring 14 days to grow in culture. Two-stage revision is generally the most reliable treatment for established, late-onset C. acnes periprosthetic joint infections.

Question 82

A 68-year-old male with a history of a Metal-on-Polyethylene total hip arthroplasty utilizing a 36-mm cobalt-chromium head presents with new-onset groin pain and a palpable anterior thigh mass. Serum cobalt levels are markedly elevated, while chromium levels are normal. Which of the following is the most likely source of the elevated metal ions?

Explanation

Trunnionosis (taper corrosion) can occur in metal-on-polyethylene THA, particularly with large (e.g., 36 mm) cobalt-chromium heads on titanium stems. It typically presents with significantly higher serum cobalt levels compared to chromium, distinguishing it from metal-on-metal bearing wear.

Question 83

A 75-year-old male presents for his 3-year follow-up after a reverse total shoulder arthroplasty. Radiographs demonstrate inferior scapular notching extending beyond the inferior glenoid screw (Sirveaux Grade 3). Which of the following surgical techniques most effectively minimizes the risk of this complication during the index procedure?

Explanation

Scapular notching is a frequent complication of RTSA caused by mechanical impingement of the humeral component against the scapular neck. Inferior placement of the baseplate with a 2 to 4 mm inferior overhang of the glenosphere is the most effective technique to prevent it.

Question 84

An 80-year-old female sustains a fall and presents with a periprosthetic fracture around her cemented total hip arthroplasty. Radiographs reveal a spiral fracture extending just distal to the tip of the stem. The stem appears subsided and loose, but there is adequate circumferential bone stock in the proximal femur. According to the Vancouver classification, what is the most appropriate surgical treatment?

Explanation

This is a Vancouver B2 fracture, characterized by a loose stem but adequate proximal bone stock. The standard of care is revision arthroplasty using a long stem (often extensively porous-coated or fluted tapered) that bypasses the fracture, combined with fracture fixation.

Question 85

A 60-year-old male with primary glenohumeral osteoarthritis presents for total shoulder arthroplasty. Preoperative CT scan demonstrates a biconcave glenoid with 25 degrees of retroversion. What is the maximum acceptable amount of retroversion correction achievable via asymmetric anterior glenoid reaming before risking catastrophic failure from violation of the subchondral bone vault?

Explanation

In cases of Walch B2 glenoids, correcting more than 15 degrees of retroversion via asymmetric reaming violates the dense subchondral bone. This significantly increases the risk of early glenoid component loosening and failure, necessitating augmented implants or bone grafting for severe defects.

Question 86

During a primary total hip arthroplasty utilizing the direct anterior approach, the surgeon develops the superficial internervous plane. To minimize the risk of denervation, the surgeon must remember that this interval is bordered by muscles supplied by which two nerves?

Explanation

The direct anterior approach utilizes the internervous plane between the tensor fasciae latae (supplied by the superior gluteal nerve) and the sartorius (supplied by the femoral nerve). This true internervous and intermuscular plane helps preserve abductor function.

Question 87

A 70-year-old female presents with sudden onset of lateral shoulder pain 4 months following a reverse total shoulder arthroplasty, denying any trauma. Radiographs reveal a Levy Type II stress fracture of the acromion. Which of the following intraoperative factors is most strongly associated with an increased risk of this complication?

Explanation

Acromial stress fractures after RTSA are strongly associated with overtensioning of the deltoid muscle, often caused by excessive distalization or lengthening of the arm. Excessive tension increases the biomechanical load across the acromion, leading to fatigue failure.

Question 88

A 65-year-old female undergoes a complex primary total hip arthroplasty requiring 4 cm of leg lengthening. Postoperatively, she exhibits a foot drop and numbness in the first dorsal web space, but retains normal plantar flexion. Which nerve division is most likely injured, and what anatomic feature makes it particularly susceptible?

Explanation

The peroneal division of the sciatic nerve is the most commonly injured nerve during THA leg lengthening, presenting as a foot drop. It is more susceptible to stretch injuries than the tibial division because its fibers are securely tethered at the sciatic notch and the fibular neck.

Question 89

A 58-year-old female complains of localized anterior groin pain starting 6 months after a cementless total hip arthroplasty. The pain is exacerbated by straight leg raising and transitioning from a seated to a standing position. A diagnostic image-guided injection of anesthetic into the iliopsoas bursa provides complete temporary relief. Cross-sectional imaging is most likely to show which of the following?

Explanation

Iliopsoas impingement after THA classically presents with anterior groin pain exacerbated by active hip flexion. It is most frequently caused by an anteriorly prominent or overhanging acetabular component mechanically irritating the iliopsoas tendon.

Glenohumeral Arthroplasty for Irreparable Rotator Cuff Deficiency: An Intraoperative Masterclass

ABOS Part I & AAOS OITE Orthopaedic Surgery Review: Shoulder & Hip Arthroplasty Cases | Part 22148

Key Takeaway

ABOS Part I & AAOS OITE Orthopaedic Surgery Review: Shoulder & Hip Arthroplasty Cases | Part 22148

Chapter Index