Orthopedics Hyperguide Review | Dr Hutaif General Ortho -...
Updated: Feb 2026
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Key Medical Takeaway
This topic focuses on ORTHOPEDICS HYPERGUIDE MCQ 451-500, Periprosthetic humeral fracture is the most frequent intraoperative complication in shoulder arthroplasty for rheumatoid arthritis. For total hip arthroplasty, component malposition leads to dislocation and increased wear. Preventing complications involves precise surgical technique and careful pre-operative planning, ensuring optimal implant stability from microns to microns.
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ORTHOPEDICS HYPERGUIDE MCQ 451-500
QUESTION 1
In addition to routine medical clearance prior to surgery, what additional test should be considered in patients with rheumatoid arthritis:
1
Hip radiographs
2
Knee radiographs
3
Wrist radiographs
4
Hand radiographs
5
Cervical spine: Flexion-extension views
A significant incidence of cervical spine disease exists among patients with rheumatoid arthritis. Surgeons should consider obtaining cervical spine flexion-extension views to evaluate for potential instability prior to the patient undergoing anesthesia
QUESTION 2
The most common technical cause of dislocation after primary total hip arthroplasty (THA) is:
1
Implant failure
2
Infection
3
Component malposition
4
Muscle weakness
5
NeurologiCdysfunction
Although neurologiCdysfunction, soft tissue laxity, and loosening due to implant failure or infection contribute to THA instability, component malposition is the leading cause of dislocation from surgical technique
QUESTION 3
Which of the following is not a consequence of acetabular shell malposition:
1
Fibrous ingrowth
2
Increased fretting wear
3
Increased bearing wear
4
Impingement
5
Limited range of motion
Malposition leads to limited range of motion, impingement, and increased bearing and fretting wear. Fibrous ingrowth is most commonly a consequence of inadequate fixation and excessive micromotion
QUESTION 4
Excessive anteversion of the acetabular cup may lead to:
1
Cup medialization
2
Posterior implant impingement
3
Leg length discrepancy
4
Premature osteolysis
5
Dislocation with excessive internal rotation
Excessive anteversion leads to anterior dislocation due to posterior component impingement. This most commonly occurs through extension and external rotation of the lower extremity. Excessive anteversion has little or no direct effect on medialization of the cup, leg length disparity, or premature osteolysis
QUESTION 5
Mechanical guide inaccuracy in cup placement during total hip arthroplasty occurs due to:
1
AnatomiCsoft tissue variance
2
Displaced fracture of acetabulum
3
Poor implant fixation
4
Excessive motion between guide and implant
5
PelviCpositional instability
With adequate exposure, compensation for soft tissue variance is accomplished. Fracture is uncommon, as is gross motion between implant and bone. Provided the guide is used correctly, there is no appreciable motion between it and the implant. Changes in pelviCand patient position, however, will render the mechanical guide inaccurate
QUESTION 6
Excessive abduction of the acetabular shell may result in all of the following except:
1
Edge loading
2
Superior instability
3
Osteolysis
4
Superior cup migration
5
Linear polyethylene wear
Edge loading, superior dislocation or subluxation, linear polyethylene wear and resultant premature osteolysis may all result from an excessively abducted cup. Superior cup migration is most commonly a consequence of a cup with low abduction
QUESTION 7
Longevity of traditional total hip arthroplasty in young patients is limited by:
1
Implant failure
2
Infection
3
Fracture
4
Osteolysis and aseptiCloosening
5
Limited range of motion
Although implant failure, infection, and fracture occur with extended lifetime of hip implants, polyethylene wear debris and eventual aseptiCloosening are the most commonly recognized limitation in the survival of total hip arthroplasty. Limited range of motion is a less common presentation for implant failure in the hip
QUESTION 8
Advantages of metal-on-metal vs metal-on-polyethylene articulation include:
1
Metal ion generation
2
Capacity for large head diameter
3
Lower infection rate
4
Increased bearing wetability
5
Lower cost
Metal ions generated, although of unknown consequence, are not considered an advantage. Metal-on-metal bearings have not been shown to demonstrate a lower infection rate or lower cost, nor do they have increased wetability (commonly associated with ceramiCbearings). The metal-on-metal implants allow larger head and cup diameter, thus providing improved range of motion with lower risk for dislocation
QUESTION 9
Which of the following cannot be modified during hip resurfacing:
1
Cup medialization
2
Femoral component angle
3
Leg length
4
Cup size
5
Cup angle
All of the above variables can be modified during the planning and placement of hip resurfacing with the exception of leg length. Due to the anatomiCreproduction of the cup center and femoral head anatomy, modifications on leg length cannot be performed with hip resurfacing
QUESTION 10
The most common failure mechanism in hip resurfacing is:
1
Acetabular component loosening
2
Infection
3
Recurrent dislocation
4
Femoral component loosening
5
Fracture
Among outcome studies, the most common failure mechanism for hip resurfacing is femoral neck fracture. Dislocation, infection, and loosening have been reported at lower rates
QUESTION 11
Potential contraindication for primary hip resurfacing include all of the following except:
1
Excessive femoral cyst formation
2
Osteoporosis with low bone density t-score
3
Previous femoral neck fracture
4
Severe developmental hip dysplasia
5
Osteonecrosis with femoral head collapse
Excessive cyst formation in the femoral head, documented osteoporosis, severe developmental hip dysplasia, and advanced osteonecrosis are contraindications to hip resurfacing. Previous femoral neck fracture, however, if healed, does not provide a risk for femoral neck fracture
QUESTION 12
Failure of first-generation cementless femoral stems is attributed to:
1
Material composition
2
Malrotation
3
Wear particle migration
4
Fatigue failure
5
Fracture
Initial stem design of cementless stems included patch porous coating. This design feature resulted in wear particle migration distally, causing inevitable aseptiCloosening. The remaining options were not instrumental in cementless stem loosening
QUESTION 13
Evidence of cementless acetabular implant loosening is radiographically observed as:
1
Surrounding cystiClesions
2
HeterotopiCbone formation
3
Increased radiodensity
4
Implant spot welds
5
Radiolucency surrounding the shell
Of the choices listed, only radiolucency provides evidence of acetabular loosening. CystiClesions, known as osteolysis, may exist without the presence of loosening
QUESTION 14
Increased scintigraphiCactivity surrounding an implant may signal all of the following except:
1
Recent implantation
2
Quiescent heterotopiCbone
3
Osteolysis
4
Loosening
5
Infection
Bone scan studies are sensitive, but poorly specific. The differential includes recent implantation (up to 1 year), osteolysis, loosening, fracture, and infection. Mature heterotopiCossification is generally cold on bone scan
QUESTION 15
Imaging of pelviCbone loss around the acetabulum is best accomplished with:
1
PelviCJudet views
2
Computed tomography (CT) scan
3
PelviCinlet view
4
Cross-table lateral of affected hip
5
PelviCoutlet view
Studies have shown CT scans to be the most thorough means of assessing bone loss in the presence of osteolysis in the pelvis
QUESTION 16
The ideal range of micromotion to stimulate bone ingrowth into cementless implants is:
1
Less than 20 microns
2
30 microns to 150 microns
3
200 microns to 500 microns
4
600 microns to 800 microns
5
Greater than 900 microns
Ideal values of micromotion that stimulate bone ingrowth are 28 microns to 150 microns. Values greater than 150 microns are associated with fibrous ingrowth
QUESTION 17
Which of the following is a risk factor for the development of a postoperative periprosthetiCfracture of the humerus:
1
Diabetes
2
Female gender
3
Age
4
Diagnosis of avascular necrosis
5
Polyethylene-induced osteolysis
Osteolysis, osteopenia, and aggressive cortical reaming have been reported as potential risk factors for the development of a postoperative periprosthetiCfracture
QUESTION 18
What nerve is most frequently injured at the time of a periprosthetiCfracture of the humerus:
1
Median nerve
2
Ulnar nerve
3
Radial nerve
4
Musculocutaneous nerve
5
Axillary nerve
The radial nerve is the most frequently injured nerve at the time of a periprosthetiCfracture. There continues to be debate as to whether the presence of a radial nerve injury constitutes a reason for revision surgery
QUESTION 19
What is the average length of time for a periprosthetiChumeral fracture to heal with operative treatment:
1
Less than 30 days
2
Between 30 and 90 days
3
Between 90 and 120 days
4
Between 120 and 240 days
5
Greater than 240 days
In a study by Kumar and colleagues, the mean time to healing among patients who underwent surgery was 278 days (range, 135 to 558 days)
QUESTION 20
According to the classification system of Wright and Cofield, what constitutes a type A periprosthetiChumeral fracture:
1
Fracture at the tip of the prosthesis, extends proximally
2
Prosthesis tip without extension
3
Prosthesis tip with extension distally
4
Fracture present with a loose prosthesis
5
Distal to the tip of prosthesis
According to the classification, a type A fracture is one at the tip of the prosthesis and extends proximally. Type B fractures occur at the prosthesis tip without extension or with a minimal amount of proximal extension and a variable amount of distal extension. Type Cfractures are distal to the tip of prosthesis
QUESTION 21
What is the preferred treatment for a type CperiprosthetiCfracture with a well-fixed humeral component:
1
Open reduction internal fixation with a plate
2
Long stem prosthesis
3
Strut allograft and cerclage wires
4
Nonoperative treatment
5
Long stem with a strut
In patients with a type CperiprosthetiCfracture (distal to the tip of the prosthesis) and a well-fixed humeral component, the injury can be treated similar to a closed humerus fracture
QUESTION 22
The approximate distance of the axillary nerve from the lateral border of the acromion is:
1
1 cm
2
3 cm
3
5 cm
4
7 cm
5
10 cm
The axillary nerve is located approximately 5 cm from the lateral border of the acromion. Correct Answer: 5 cm
QUESTION 23
Which of the following nerves enters the coracobrachialis muscle distal to the tip of the coracoids:
1
Radial nerve
2
Ulnar nerve
3
Median nerve
4
Musculocutaneous nerve
5
Axillary nerve
The musculocutaneous nerve enters the coracobrachialis muscle 4 cm to 8 cm distal to the tip of the coracoid process. Correct Answer: Musculocutaneous nerve
QUESTION 24
Which of the following approaches is used when the deltoid is taken down off the clavicle and anterior acromion:
1
Superior approach
2
Anterosuperior approach
3
Direct approach
4
Anteromedial approach
5
Medial approach
The anteromedial approach involves taking the deltoid down off the clavicle and anterior acromion. Correct Answer: Anteromedial approach
QUESTION 25
The deltoid inserts on this surface of the clavicle:
1
Superior surface
2
Anterior surface
3
Inferior surface
4
All of the above
The origin of the deltoid on the clavicle is J-shaped and extends from the midline on the superior aspect of the clavicle around the front of the clavicle to the inferior portion of the anterior aspect of the clavicle. Full-thickness fascial flaps must be obtained when the deltoid is released from the clavicle.
QUESTION 26
Which of the following is an indication for an anteromedial approach:
1
Post-traumatiCarthritis with severe scarring
2
Rheumatoid arthritis
3
Revision shoulder arthroplasty
4
All of the above
The anteromedial approach facilitates shoulder arthroplasty in patients with severe scarring, distortion of anatomy, as well as patients with frail bone and soft tissue.
QUESTION 27
What are the contraindications for a corrective osteotomy for a proximal humerus malunion:
1
Glenohumeral arthritis
2
Massive rotator cuff tear
3
Articular incongruity
4
Avascular necrosis
5
All of the above
Corrective osteotomy is an option for surgeons who must treat a patient with a proximal humerus malunion. This option may best be considered in a young, active patient who has no radiographiCevidence of degenerative changes in the glenohumeral joint. In an older, less active patient who has evidence of degenerative joint disease, a shoulder arthroplasty may be a more suitable and definitive procedure.
Patients with proximal humerus malunions often present with complaints of pain as well as loss of function. Frequently, patients have impingement-type pain due to a malunion of the greater tuberosity with an associated decrease in the subacromial space. Some of the contraindications to a corrective osteotomy include a massive irreparable rotator cuff tear, significant degenerative changes of the articular surfaces, avascular necrosis, active infection, or nerve injury.
QUESTION 28
What is the most significant factor affecting the results of shoulder arthroplasty for a malunion:
1
Placement of a glenoid component
2
Placement of a reverse shoulder arthroplasty
3
Resurfacing arthroplasty of the humerus
4
Avoidance of performing a tuberosity osteotomy
5
Performing a biceps tenodesis
Boileau and colleagues reported that the most significant factor affecting results of shoulder arthroplasty for malunion was the need for greater tuberosity osteotomy.
QUESTION 29
When considering arthroscopiCtreatment of a malunion, what is the procedure most frequently performed:
1
Biceps tenodesis
2
Superior labral anterior posterior (SLAP) repair
3
ArthroscopiCcapsular release
4
Acromioplasty
5
Tuberoplasty
ArthroscopiCacromioplasty has been reported by Beredjiklian and colleagues. The procedure essentially increases the available subacromial space to improve impingement of the greater tuberosity against the acromion.
QUESTION 30
What are the complications commonly associated with tuberosity osteotomy at the time of shoulder arthroplasty for malunion:
1
Nonunion of the tuberosity
2
Tuberosity resorption
3
Malunion of the tuberosity
4
All of the above
Antuna and colleagues reported that 10 of 24 shoulders that had a greater tuberosity osteotomy had a complication related to tuberosity nonunion, malunion, or resorption.
QUESTION 31
Which of the following intraoperative techniques can be used to avoid tuberosity osteotomy:
1
Placement of the stem in slight varus
2
Bending the stem to accommodate the deformity
3
Placement of the stem in slight valgus
4
All of the above
Implantation of the humeral component in slight varus or valgus to accommodate the tuberosity malunion was not associated with an increased incidence of humeral component loosening. In addition, humeral components with a modified curvature in the stem have been used with success.
QUESTION 32
What are the potential benefits of performing a lesser tuberosity osteotomy:
1
Bone-to-bone healing
2
Improved glenoid exposure
3
Ability to detect on radiographs disruption of the anterior repair
4
All of the above
A lesser tuberosity osteotomy allows bone-to-bone healing as well as facilitates glenoid exposure. Moreover, disruption of the anterior repair is immediately evident on postoperative radiographs with the appearance of a displaced lesser tuberosity.
QUESTION 33
What are the potential benefits of performing magnetiCresonance imaging (MRI) of a shoulder arthroplasty with a suspected rotator cuff tear:
1
Assess degree of fatty atrophy
2
Define the location of the tear
3
Evaluate the size of the tear
4
All of the above
An MRI allows a surgeon to gain a greater understanding of the size of the rotator cuff tear, the specifiClocation of the tear, and the degree of fat infiltration within the tendon.
QUESTION 34
In an elderly patient with a postoperative rotator cuff tear and escape, which of the following options is most effective to create a stable shoulder arthroplasty:
1
Coracohumeral reconstruction with an Achilles tendon graft
2
Bipolar arthroplasty
3
Hemiarthroplasty
4
Reverse shoulder arthroplasty
Many patients with a rotator cuff tear following shoulder arthroplasty may develop anterior-superior escape. Once this pattern develops, it may be difficult to restore stability with attempted rotator cuff repair alone. In this setting, one may consider the use of a reverse arthroplasty, particularly if the patient is older than 70 years of age.
QUESTION 35
What is the reported frequency of rotator cuff tear following shoulder arthroplasty:
1
Less than 1%
2
1% to 2%
3
3% to 4%
4
Greater than 5%
The reported frequency of postoperative rotator cuff tears following shoulder arthroplasty is 3% to 4%. Correct Answer: 3% to 4%
QUESTION 36
What are some potential benefits of performing arthroscopiCcompared to open acromioplasty in a patient who develops impingement syndrome following hemiarthroplasty:
1
Ability to evaluate the status of the glenoid
2
Capacity to address intra-articular pathology
3
More rapid postoperative recovery
4
Less violation of the deltoid
5
All of the above
ArthroscopiCacromioplasty has been used for the treatment of impingement following shoulder arthroplasty. It has the potential benefits of less tissue disruption, more rapid recovery, as well as increased ability to address intra-articular pathology compared to an open procedure.
QUESTION 37
Which medication has been identified as a risk factor for a nerve injury after shoulder arthroplasty:
1
Prednisone
2
Warfarin
3
Clopidogrel bisulfate
4
Aspirin
5
Methotrexate
Methotrexate has been identified as a risk for development of a nerve injury after shoulder arthroplasty. Correct Answer: Methotrexate
QUESTION 38
Which is the most common mechanism for nerve injury after shoulder arthroplasty:
1
Laceration
2
Expanding hematoma
3
Contusion
4
Tearing
5
Temporary neuropraxia due to stretch
The most common reason for a nerve deficit following shoulder arthroplasty is a temporary neuropraxia due to stretch. Correct Answer: Temporary neuropraxia due to stretch
QUESTION 39
Which approach has been identified as a risk factor for the development of a nerve injury with shoulder arthroplasty:
1
Transacromial
2
Anteromedial
3
Superior
4
Posterior
5
Deltopectoral
The deltopectoral approach has been identified as a risk for development of a nerve injury after shoulder arthroplasty. Correct Answer: Deltopectoral
QUESTION 40
Which nerve is most likely to have evidence of a deficit after shoulder arthroplasty:
1
Radial nerve
2
Ulnar nerve
3
Musculocutaneous nerve
4
Median nerve
5
Axillary nerve
The most common nerve that has been found to have a deficit after shoulder arthroplasty is the axillary nerve. Correct Answer: Axillary nerve
QUESTION 41
Which of the following is the reported incidence of nerve injuries following total shoulder arthroplasty:
1
Less than 1%
2
Between 1% and 2%
3
Between 2% and 4%
4
Between 4% and 5%
5
Greater than 10%
The reported incidence of nerve injuries following shoulder arthroplasty is 4.3%. Correct Answer: Between 4% and 5%
QUESTION 42
Which is the most common reason for revision surgery among patients who undergo hemiarthroplasty:
1
Humeral component loosening
2
PeriprosthetiCfracture
3
Infection
4
Instability
5
Glenoid arthritis
Painful glenoid arthritis represents the most common reason for revision surgery for hemiarthroplasties. Correct Answer: Glenoid arthritis
QUESTION 43
Which of the following are nonanatomiCinstability procedures:
1
Bristow
2
Putti-Platt
3
Magnuson-Stack
4
Latarjet
5
All of the above
Among patients who have undergone prior instability surgery, it is important to review prior operative reports to determine the specifiCinstability procedure performed. This will facilitate safe and effective soft tissue releases and balancing at the time of shoulder arthroplasty.
QUESTION 44
Which is the mean 10-year survival for shoulder arthroplasty after prior instability surgery:
1
Greater than 95%
2
Between 85% and 95%
3
Between 75% and 85%
4
Between 65% and 75%
5
Less than 65%
Overall, the survival rate for shoulder arthroplasty after prior instability surgery was only 61% at 10 years. Correct Answer: Less than 65%
QUESTION 45
Compared to shoulder arthroplasty for primary osteoarthritis, shoulder arthroplasty after prior instability surgery is associated with which of the following:
1
Lower revision rate
2
Similar revision rate
3
Higher revision rate
Research has shown that shoulder arthroplasty for postcapsulorraphy arthritis has inferior results and a higher revision rate compared to shoulder arthroplasty for osteoarthritis.
QUESTION 46
Which are the most common complications after shoulder arthroplasty for instability associated arthritis:
1
Instability
2
Component failure
3
Glenoid arthritis
4
All of the above
Shoulder arthroplasty for postcapsulorraphy arthritis provides pain relief and improved motion. However, shoulder arthroplasty in these young patients is associated with a high rate of unsatisfactory results and revision surgery due to glenoid arthritis, component failure, or instability.
QUESTION 47
What anatomiCfactor has been identified as placing a patient at an increased risk for re-tearing a rotator cuff after repair:
1
Greater tuberosity foot print less than 2 cm in width
2
Wide lateral extension of the acromion
3
Increased humeral retroversion
4
Increased inclination of the humeral neck
5
Narrow bicipital groove
Zumstein and colleagues identified a wide lateral extension of the acromion as a risk factor for developing a recurrent rotator cuff tear.
QUESTION 48
What are some of the potential benefits of using ultrasound to evaluate the integrity of the rotator cuff:
1
Portable device
2
Low cost compared to magnetiCresonance imaging (MRI)
3
DynamiCevaluation
4
Noninvasive procedure
5
All of the above
Ultrasound has become increasingly popular as a tool to evaluate rotator cuff tears. Some of the advantages of ultrasound include the fact that it is easily portable and less expensive than MRI. Additionally, unlike a computed tomography arthrogram, no injection is required. Another interesting aspect of ultrasound is that it allows dynamiCevaluation of the rotator cuff. Several research studies have shown the promise of using ultrasound to follow the status of rotator cuff after repair.
