Score: 0%
ORTHOPEDICS HYPERGUIDE MCQ 351-400
QUESTION 1
Which of the following rotator cuff tears is the simplest to repair:
1
U-shaped tear
2
L-shaped tear
3
Crescent-shaped tear
4
Vertical cleavage tear
5
Parrot-beak tear
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
QUESTION 2
Slide 1
The following image depicts:
The following image depicts:
1
An arthroscopiCview of a massive rotator cuff tear
2
An arthroscopiCview of an L-shaped rotator cuff tear
3
An arthroscopiCview of a U-shaped rotator cuff tear
4
An arthroscopiCview of a crescent-shaped rotator cuff tear
5
An arthroscopiCview of a medial meniscus tear of the knee
The image depicts a lateral arthroscopiCview of a crescent-shaped tear, which demonstrates minimal retraction and excellent mobility, and is easily repaired
QUESTION 3
Slide 1
The following image depicts:
The following image depicts:
1
A lateral arthroscopiCview of a massive U-shaped tear of the rotator cuff
2
A lateral arthroscopiCview of a crescent-shaped tear of the rotator cuff
3
A lateral arthroscopiCview of an L-shaped tear of the rotator cuff
4
A degenerative posterior horn tear of the medial meniscus
5
A bucket-handle tear of the medical meniscus
The image depicts a lateral arthroscopiCview 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
QUESTION 4
All of the following are statiCrestraints providing stability for the shoulder except:
1
Labrum
2
Glenoid
3
Glenohumeral ligaments
4
Rotator cuff and scapular muscles
5
Joint capsule
The shoulder allows more range of motion than any other joint in the body and is susceptible to injury. It has both statiCand dynamiCrestraints. The rotator cuff and scapular muscles are the dynamiCrestraints. The glenoid, labrum, glenohumeral ligaments, and joint capsule are the statiCrestraints
QUESTION 5
Which of the following provides the greatest restraint to anterior dislocation of the shoulder:
1
Superior glenohumeral ligament
2
Supraspinatus
3
Infraspinatus
4
Inferior glenohumeral ligament
5
Joint capsule
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
QUESTION 6
The percentage of patients 20 to 40 years of age who have recurrent shoulder instability is:
1
10%
2
20%
3
40%
4
50%
5
60%
Suffering from recurrent instability in the shoulder joint depends on a patientâs 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
QUESTION 7
The percentage of athletes with recurrent instability choosing to return to collision sports after an anterior shoulder dislocation is:
1
20%
2
40%
3
60%
4
80%
5
100%
A patientâs 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
QUESTION 8
The most frequently transplanted human tissue is:
1
Bone
2
Blood
3
Kidney
4
Cornea
5
Skin
After blood, bone is the most frequently transplanted human tissue. However, bone autografting may eventually become a thing of the past. Bone replacement with synthetiCmaterials and growth factors is becoming common procedure in the orthopedic
operating room
operating room
QUESTION 9
The first documented bone transplant was performed by:
1
Van Meekeren
2
Macewan
3
Phemister
4
Ferguson
5
Albee
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 soldierâs 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 âhemostasis, asepsis, and coaptation of partsâ 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 osteoconductive scaffolding, osteoinductive growth factors, and osteogeniCprogenitor stem cells in bone graft healing
QUESTION 10
In most clinical applications, a bone autograft is preferable to a bone allograft because:
1
A bone autograft is more osteoconductive, osteoinductive, and osteogeniCthan a bone allograft.
2
A bone autograft has a higher risk of infection than a bone allograft.
3
A bone autograft incorporates more slowly than a bone allograft.
4
Bone autografts are in limitless supply.
5
There are more immunological considerations.
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
QUESTION 11
When nonvascularized cortical allografts lose mechanical strength during the first year following surgery, it is most likely due to:
1
Revascularization
2
Failure of the graft to incorporate
3
Infection
4
Complex regional pain syndrome
5
Failure to provide initial structural support
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 bone
QUESTION 12
What percentage of osetocytes present in a vascularized cortical autograft survive:
1
24%
2
40%
3
60%
4
80%
5
90%
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
QUESTION 13
Vascularized free fibular grafts have been used to treat all of the following except:
1
Congenital pseudoarthrosis of the tibia
2
Tumor-related defects in the proximal humerus
3
Osteonecrosis of the femoral head
4
Pseudoarthrosis of the scaphoid
5
Nonunions of the femur
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
QUESTION 14
Demineralized bone matrix is:
1
Osteogenic
2
OsteogeniCand osteoconductive
3
Osteoinductive, osteogenic, and osteoconductive
4
Osteoconductive and osteoinductive
5
Only osteoconductive
Demineralized bone matrix is recognized as having a variable amount of osteoinductive capacity and some osteoconductive properties. The biologiCactivity varies with specifiCprocessing and storage methods, in addition to variation among donors
QUESTION 15
Which of the following has the highest risk of disease transmission:
1
Cortical allograft
2
Cortical autograft
3
Cancellous allograft
4
Cancellous autograft
5
Cortical allograft and cancellous allograft have the same risk of disease transmission.
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
QUESTION 16
Slide 1 Slide 2
The following image (Slide 1) depicts:
The following image (Slide 1) depicts:
1
The removal of congenital pseudoarthrosis of the tibia
2
A vascularized iliaCautograft
3
A fibular autograft
4
The harvesting of the vascularized fibula from the contralateral leg
5
A fibular autograft for spinal fusion
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
QUESTION 17
Vascularized transplantation of the knee and femoral diaphysis is most frequently complicated by:
1
Immunosuppressive medications
2
Pulmonary emboli
3
Bony nonunions
4
Acute infections
5
Deep venous thrombosis (DVT)
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 âfraught with complications,â largely related to the immunosuppressive medications
QUESTION 18
When treating an infected joint prosthesis with antibiotiCcement, the antibiotiCelution should stay above the minimum inhibitory concentration (MIC) for a minimum of:
1
1 week
2
2 weeks
3
3 weeks
4
4 weeks
5
6 weeks
AntibiotiCelutions differ among brands of cement. However, the antibiotiCconcentrations should stay above the MICfor at least 3 weeks. The effect is local and there is no significant absorption of a specifiCantibiotiCout of the bone cement and into the plasma
QUESTION 19
After implantation, the antibiotiCinside bone cement will be present and can be measured for up to:
1
1 day
2
1 week
3
2 weeks
4
3 weeks
5
Several months
The antibiotiCinside bone cement will be present in the bone cement for months or even years after implantation into a patient. AntibiotiChas been measured present even after 5 years
QUESTION 20
The chances of an arthroplasty revision becoming re-infected by a different organism or the initial infection after a two-stage revision is approximately:
1
5%
2
10%
3
20%
4
40%
5
50%
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
QUESTION 21
Slide 1
Which of the following antibiotics has the highest concentration locally from Palacos-R (Biomet, Warsaw, IN) cement:
Which of the following antibiotics has the highest concentration locally from Palacos-R (Biomet, Warsaw, IN) cement:
1
Tobramycin
2
Lincomycin
3
Bacitracin
4
Gentamicin
5
Keflex
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
QUESTION 22
The maximum amount of antibiotiCpowder that can be added as a temporary spacer to 40 g of cement powder is:
1
1 g
2
2 g
3
4 g
4
6 g to 8 g
5
9 g to 10 g
Surgeons should not add more than 6 g to 8 g of antibiotiCpowder per 40 g of cement powder. One also needs to be careful when adding additional antibiotiCpowder 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 antibiotiCpowder added to facilitate setting of the cement
QUESTION 23
The optimal depth of cement penetration for prosthesis insertion is:
1
1 mm
2
2 mm
3
3 mm
4
4 mm
5
8 mm
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
QUESTION 24
Which of the following most effectively provides the strongest fixation when cementing a prosthesis in a femur:
1
A thin cancellous layer
2
No cancellous layer at all
3
A poor quality cancellous layer
4
High-quality, radiodense cancellous bone
5
A straight-stem femoral prosthesis
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
QUESTION 25
Which of the following is not a risk factor for fracturing cement around a prosthesis:
1
A sharp corner in the metal
2
A cement mantle less than 3 mm thick
3
A thick cement mantle
4
Voids or air bubbles in the cement mantle
5
Local debonding of the cement-metal interface
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
QUESTION 26
To obtain an adequate cement penetration of 4 mm at a pressure of 0.2 MPA to 0.3 MPA in arthritiCbone, one needs to maintain:
1
10 kg of pressure for 20 seconds
2
20 kg of pressure for 30 seconds
3
30 kg of pressure for 30 seconds
4
40 kg of pressure for 30 seconds
5
50 kg of pressure for 50 seconds
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
40 to 60 seconds. Adequate penetration of less than 40 kg of pressure for less than 40 seconds does not give adequate cement penetration
QUESTION 27
Which of the following commercially available cements has the lowest tensile strength value:
1
Palacos-R (Biomet, Warsaw, IN)
2
Sulfix-60 (Sulzer, Austin, TX)
3
Simplex P (Stryker, Kalamazoo, MI)
4
CMW3 (Wright Medical Technology, Inc, Arlington, TN)
5
Zimmer Dough (Zimmer, Warsaw, IN)
Zimmer Dough has the lowest value of tensile strength; however, all of the above are FDA-approved cements and of sufficient quality
QUESTION 28
Which of the following bone cements has demonstrated the lowest cycles to failure:
1
Simplex P (Stryker, Kalamazoo, MI)
2
Palacos-R (Biomet, Warsaw, IN)
3
BoneloC(Biomet, Warsaw, IN)
4
Zimmer Dough (Zimmer, Warsaw, IN)
5
Sulfix-60 (Zimmer, Warsaw, IN)
Simplex P and Palacos-R display outstanding results when tested in the cycliCconditions. BoneloCdemonstrated the lowest cycles to failure
QUESTION 29
The most significant factor reducing porosity in bone cement is:
1
Storage temperature only
2
Centrifugation of low viscosity cement
3
Vacuum-mixing medium viscosity
4
A combination of vacuum-mixing and centrifugation
5
Vacuum-mixing only
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° Cand 21° Cshows little effect on cement bubbles or cement voids, or porosity of bone cement
QUESTION 30
ProsthetiCplacement in a cement-filled canal creates highest peak elevations in pressure when:
1
Using a cement restrictor
2
Using a retrograde filling
3
Using mechanical pressurization
4
Inserting the prosthesis late in the setting phase
5
Inserting the prosthesis early, while the cement is extremely soft
ProsthetiCplacement 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
QUESTION 31
The time it takes for the polymer/monomer mixing until polymerization is sufficient to maintain the implant in its correct position is known as:
1
Doughing time
2
Working time
3
Setting time
4
Mixing time
5
Polymerization time
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
QUESTION 32
Cement takes longer to set when using a:
1
Roughened stem
2
Precoated femoral stem
3
Polished femoral stem
4
Irregular femoral stem
5
Cement setting time is not affected by the femoral stem.
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
QUESTION 33
AcryliCbone cement is composed of:
1
A polymer powder and a polymer liquid component
2
A monomer powder and a monomer liquid component
3
A polymer powder and a monomer liquid component
4
A monomer powder and a polymer liquid component
5
Polymethylmethacrylate (PMMA) only
Polymethylmethacrylate (PMMA) is one of the ingredients of acryliCbone 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
QUESTION 34
The chemical composition of acryliCbone cement is:
1
Benzoyl peroxide and barium sulfate
2
Methylmethacrylate-styrene-copolymer
3
Methylmethacrylate-styrene-copolymer and polymethylmethacrylate
4
Methylmethacrylate-styrene-copolymer, polymethylmethacrylate, and barium sulfate
5
Polymethylmethacrylate and dimethyl-p-toluidine
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-toluidine in the monomer, which accelerates the chemical reaction and polymerization. When complete, acryliCbone cement is composed of 75% methylmethacrylate-styrene-copolymer,
15% polymethylmethacrylate, and 10% barium sulfate
15% polymethylmethacrylate, and 10% barium sulfate
QUESTION 35
Bone cement was first used commercially:
1
During World War II in the production of airplane windshields
2
In dentistry for filling cavities
3
By John Charnley for bonding total hip joints to bone
4
By neurosurgeons for replacement of skull defects
5
As a base material for dentures
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
QUESTION 36
The longest period of survival for cemented total joints is associated with which type of cementation technique:
1
Grade A
2
Grade B
3
Grade C1
4
Grade C2
5
Grade D
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
QUESTION 37
Which of the following prosthetiCareas is classified as a grade 4 Gruen zone radiographiCdefect:
1
The medullary distal tip of the prosthesis and the cement
2
The lateral middle part of the prosthesis
3
The lateral lower third of the prosthesis
4
The medial distal third of the prosthesis
5
The middle part, medial of the prosthesis
Gruen zones are an effective international classification system whereby radiographiCdefects 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 radiographiCdefect located at the medullary distal tip of the prosthesis and the cement
QUESTION 38
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:
1
Grade Ia
2
Grade II
3
Grade III
4
Grade IV
5
Grade Ib
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
QUESTION 39
Which of the following latex-free gloves are destroyed by bone cement:
1
Allegard latex-free gloves (Johnson & Johnson, New Brunswick, NJ)
2
Biogel (Regent Medical, Norcross, GA)
3
Neotech (Regent Medical)
4
Duraprene
5
No latex-free gloves are destroyed by bone cement.
Not all brands of latex-free gloves are equally effective. Bone cement destroys Allegard latex-free gloves
QUESTION 40
Which of the following is not a factor in the setting time of cement:
1
Storage temperature of bone cement
2
Ambient temperature
3
Handling and kneading of bone cement
4
Use of a cement gun
5
Introducing bone cement in a warm environment
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
QUESTION 41
With the use of perineural catheters, improvement in all of the following outcomes can be anticipated except:
1
Lower pain scores
2
NarcotiCsparing effect
3
Reduced incidence of nausea and vomiting
4
Increased sleep disturbances
5
Shortened length of stay
Double blind placebo controlled randomized trials the use of perineural catheters led to improved pain scores, decreased narcotiCusage and narcotiCrelated 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
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
QUESTION 42
The addition of a sciatiCnerve block to a femoral nerve block will:
1
Enhance analgesia following knee surgery
2
Improve mobility
3
Provide complete anesthesia to the knee
4
Increase the likelihood of nerve injury
5
Decrease DVT formation
Pain from the posterior aspect of the knee joint is diminished with the addition of a sciatiCnerve block to complement a femoral nerve block.
The use of combined femoral sciatiCnerve 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 sciatiCnerve block will not improve obturator nerve blockade.
Nerve injury after peripheral nerve block of lower extremity is uncommon (
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The use of combined femoral sciatiCnerve 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 sciatiCnerve block will not improve obturator nerve blockade.
Nerve injury after peripheral nerve block of lower extremity is uncommon (
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