2009 OITE Review

MUSC Department of Orthopaedic Surgery

Question #: 125
 Type II (beta) errors in clinical
studies are minimized by performing
which of the following?
1- Power analysis
2- Bonferroni correction
3- Mann-Whitney U test
4- Logistical regression analysis
5- Increase sample size by 20%
Preferred Response: 1
 Type I error—Probability of rejecting the null hypothesis when it is really true. The probability
of making a type I error is denoted by the Greek letter α
 Type II error—Probability of failing to reject a null hypothesis that is really false. The
probability of making a type II error is denoted by the Greek letter β
 Power—Probability that the sample mean will be sufficiently different from the mean under
null hypothesis to allow rejection of the null hypothesis
 Bonferroni correction is a method used to address the problem of multiple comparisons. The
correction is based on the idea that if an experimenter is testing n dependent or independent
hypotheses on a set of data, then one way of maintaining the familywise error rate is to test
each individual hypothesis at a statistical significance level of times what it would be if only one
hypothesis were tested
 Mann–Whitney U test a non-parametric test for assessing whether two independent samples
of observations have equally large values.
 logistic regression (sometimes called the logistic model or logit model) is used for
prediction of the probability of occurrence of an event by fitting data to a logit function
logistic curve. It is a generalized linear model used for binomial regression. Like many forms of
regression analysis, it makes use of several predictor variables that may be either numerical or
categorical. For example, the probability that a person has a heart attack within a specified
time period might be predicted from knowledge of the person's age, sex and body mass index
Question #: 132
 The immune response to metallic
orthopaedic implants is typically what
type?
1- Type I (Ig-E mediated)
2- Type II (antibody mediated)
3- Type III (immune complex mediated)
4- Type IV (delayed-type
hypersensitivity reaction)
5- Type V (Ig-M mediated)
Preferred Response: 4
 Type I hypersensitivity is mediated by IgE, which triggers degranulation of mast cells and
basophils when cross-linked by antigen.[74]
 Type II hypersensitivity occurs when antibodies bind to antigens on the patient's own cells,
marking them for destruction. This is also called antibody-dependent (or cytotoxic)
hypersensitivity, and is mediated by IgG and IgM antibodies.[74]
 Type III hypersensitivity reactions-Immune complexes (aggregations of antigens,
complement proteins, and IgG and IgM antibodies) deposited in various tissues trigger.[74]

 Type IV hypersensitivity (also known as cell-mediated or delayed type hypersensitivity)

usually takes between two and three days to develop. Type IV reactions are involved in many
autoimmune and infectious diseases, but may also involve contact dermatitis (poison ivy).
These reactions are mediated by T cells, monocytes, and macrophages
 A routine skin test reveals a prevalence of metal sensitivity of 0.2% for chromium, 1.3% for
nickel, and 1.8% for cobalt. After placement of metal implants, sensitization (change from
negative to positive) occurs in 2.7% for chromium, 3.8% for nickel, and 3.8% for cobalt.
Desensitization (change from positive to negative) occurs in 0% for chromium, 2.1% for nickel,
and 3.8% for cobalt. Many patients with implanted metal hardware have positive skin test
results for those metals but are completely asymptomatic

 Type I hypersensitivity to latex involves IgE antibodies that are specific for proteins
from the sap of the rubber tree (Hevea brasiliensis) used to make gloves

 Wiki/emedicine
Question #: 139
 Which of the following bone
morphogenetic proteins (BMP)
exhibits no osteogenic activity?
1- BMP2
2- BMP3
3- BMP4
4- BMP6
5- BMP7
Preferred Response: 2
Question #: 149
 Marfan syndrome demonstrates what
type of inheritance pattern?
1- Autosomal dominant
2- Autosomal recessive
3- X-linked dominant
4- X-linked recessive
5- Germline mutation
Preferred Response: 1
 Autosomal Dominant; 25% new mutations
 Mutation is fibrillin 1 gene on chromosome
15q21 (contrast with Ehlers-Danlos which is
COL5A1, COL5A2, or COL3A1; defect is in
Type V collagen; may be AD or AR)
 + Walker sign (thumb & small finger
overlap when encircling contralateral wrist
 + Steinburg thumb sign (adduct thumb,
make fist, and thumb protrudes from ulnar
side of hand)
 Scoliosis in 60-70% (hard to brace); 60%
have dural ectasia so get MRI before OR
 Mitral valve prolapse, aortic root dilatation
Question #: 160
 A patient sustains a fracture of the
acetabulum. An axial CT scan is shown in
Figure 160. What structure takes origin
from the region depicted by the arrow?
1- Pectineus
2- Sartorius
3- Iliopectineal fascia
4- Direct (straight) head of the rectus femoris
5- Indirect (reflected) head of the rectus
femoris
Preferred Response: 4
 Rectus femoris has 2 heads: Direct/straight
takes origin from AIIS, Indirect/reflected
takes origin from groove on the upper brim
of the acetabulum
 Femoral nerve (L2,3,4)
 Arterial supply: ascending branch of lateral
femoral circumflex
 Pectineusorigin from superior surface of
pubis; innervated by femoral & obturator
(L2,3,4); acts to adduct thigh
 Sartoriusorigin from ASIS; innervated by
femoral (L2,3); inserts into pes anserinus
Question #: 165
 Polymorphisms in the genes for the
calcitonin receptor, estrogen receptor-1,
type I collagen alpha-1 chain, or the
vitamin D receptor have been shown to be
associated with which of the following bone
diseases?
1- Osteopetrosis
2- Osteoporosis
3- Osteomalacia
4- Vitamin D-deficient rickets
5- X-linked hypophosphatemic rickets
Preferred Response: 2
 Osteopetrosis-failure of osteoclasts resulting in dense bone
with no medullary canal; 3 deactivating mutations are
known: carbonic anhydrase II, alpha 3 subunit of proton
pump; Chloride channel 7
 Osteoporosis-normal bone in reduced quantity; >2.5 SDs
below peak bone mass (T score <-2.5; remember
osteopenia is 1.0-2.5 SDs below peak or T score of -1 to
-2.5); multifactorial disease but associated gene defects are
Vit D receptor, COL1A1, and LRP5 (low density lipoprotein
receptor related protein)
 Osteomalacia-adult form of rickets; normal quantity, but
abnormal bone; cause is related to Vit D pathway
 Vitamin D-deficient rickets-low intake of Vit D produces
bone with poor mineralization
 X-linked hypophosphatemic rickets-X-linked dominant
disorder that leads to phosphate wasting due to mutation in
phosphate regulating endopeptidase (PHEX) gene
Question #: 175
 Of the available osteoconductive bone
graft substitutes, which is most
rapidly resorbed?
1- Calcium sulfate
2- Calcium phosphate
3- Tricalcium phosphate
4- Coralline hydroxyapatite
5- Collagen-based matrices
 Question #: 175
 Of the available osteoconductive bone
graft substitutes, which is most rapidly
resorbed?
1- Calcium sulfate : 1-3 Months
2- Calcium phosphate : 6-21 months
3- Tricalcium phosphate : 6-21 months
4- Coralline hydroxyapatite : upto 10 yrs
5- Collagen-based matrices : ?

De Long, et al 2007, J Bone Joint Surg Am. 2007;89:649-658.

Preferred Response: 1
Bell WH: Oral Surgery, Oral Medicine, Oral Pathology, 650-657, 1964
Resorption of ninety intramuscular implants of different types of bone
and bone substitutes were studied radiographically in twenty-two
adult mongrel dogs. On the basis of mean resorption time, the
implants were resorbed in the following order:
 plaster of Paris (Calcium sulfate),
 autogenous cancellous bone,
 cathode-ray-sterilized canine cancellous bone,
 cathode-ray-sterilized human cancellous bone,
 homologous cancellous bone,
 fetal bovine bone,
 bovine cancellous bone,
 freeze-dried cancellous bone,
 collapatite,
 anorganic bone, and
 polyurethane foam.
Question #: 180
 Which of the following is an inhibitor
of particle-induced osteolysis?
1- Interleukin-1 alpha
2- Interleukin-6
3- Osteoprotegerin
4- Tumor necrosis factor (TNF)-alpha
5- Receptor-activator of nuclear factor
KB(RANK) ligand
 Q180 - Preferred Response: 3
3- Osteoprotegerin
- Differentiation of bone marrow macrophages (osteoclast
precursors) into mature osteoclasts requires recognition and
binding of the osteoblast and T-cell secreted factor RANKL
by its cognate receptor, RANKL, which is expressed on the
surface of osteoclast precursors.

- This process is regulated by an

osteoblast-scereted factor,
Osteoprotegrin, reducing
its bioavailability

Einhornet al 2007, OBS book, page 371

Question #: 188
 Which of the following nerves serves as an
anatomic landmark leading to the radial
nerve during a paratricipital approach for
humeral shaft fracture fixation?
1- Musculocutaneous
2- Lateral antebrachial cutaneous
3- Medial antebrachial cutaneous
4- Medial brachial cutaneous
5- Posterior antebrachial cutaneous
Preferred Response: 5 (posterior
antebrachial cutaneous nerve)
Question #: 215
 The Heuter-Volkmann Law is summarized best by
which of the following statements?
1- Bone remodels in response to mechanical stimuli.
2- Bone formation is induced in an electronegative zone
and resorbed in an electropositive zone.
3- Compression across the growth plate slows
longitudinal growth.
4- Tensile load across the growth plate increases
longitudinal growth.
5- The bending strength of diaphyseal bone is determined
by its diameter raised to the third power.
Preferred Response: 3
 The Hueter-Volkmann law : Compression
across the growth plate slows longitudinal
growth, (and tensile load across the growth
plate increases longitudinal growth according
to every source I can find…not sure why this
was not also correct).
 Wolff’s Law: bone remodels in response to
mechanical stimuli
 Peizoelectric Theory: Bone formation is
induced in an electronegative zone and
resorbed in an electropositive zone.
Question #: 239
 An otherwise healthy 17-year-old wrestler suspects
that he has been bitten on the neck by a spider. He
has no recent history of hospitalization. Other
members of his wrestling team have also recently
reported skin lesions. Examination reveals superficial
abscess formation on the right side of his neck. No
other skin lesions are noted. The patient is afebrile.
What is the most likely cause of the abscess?
1- Highly drug-resistant Pseudomonas aeruginosa
2- Extremely drug-resistant Mycobacterium tuberculosis
3- Vancomycin-resistant Enterococcus faecium
4- Penicillin-resistant Clostridium perfringens
5- Methicillin-resistant Staphylococcus aureus
Preferred Response: 5
Community-acquired Methicillin-resistant Staphylococcus aureus: An
Emerging Pathogen in Orthopaedics J Am Acad Orthop Surg Marcotte and
Trzeciak 16 (2): 98. 2008

See
JB

See dirty rednecks from Colleton and call

room showers.
Question #: 262
 Which of the following conditions is a
contraindication to the use of most
bisphosphonates?
1- Paget’s disease
2- Osteomyelitis
3- Bone infarct
4- Myasthenia gravis
5- Severe renal insufficiency/failure
Preferred Response: 5
 Approximately 50% to 80% of disphosphanates
are cleared from the blood stream by renal
excretion, and approx 1% through biliary
excretion
 Remainder of the drug is incorporated into the
crystalline structure of bone and may persist
for the lifetime of the patient, with an
estimated half-life in bone of 10 years.
 Risks: Osteonecrosis of Jaw, Subtroch
fractures (look for this one on upcoming tests!
The orthopaedic implications of diphosphonate therapy.
Weaver MJ, Miller MA, Vrahas MS.
J Am Acad Orthop Surg. 2010 Jun;18(6):317-8.
Question #: 275
 Osteoclasts are the primary cells involved
in bone resorption. What is one of the most
critical factors for osteoclast differentiation
and activation?
1- PTH
2- BMP2
3- RANKL
4- Calcitonin
5- TNF-alpha
Preferred Response: 3
Question #: 59
 Paget’s disease of bone is associated
with abnormal function of which of
the following cell types?
1- Osteoblasts
2- Osteoclasts
3- Osteocytes
4- Histiocytes
5- Megakarocytes
Preferred Response: 2
 Histology:
- demonstrates excess osteoclasts resorptive activity; (occurs
predominantly in the early resorptive phase);
- bone marrow is replaced by fibrous tissue and disorganized
trabeculae;
- paratrabecular fibrosis;
- irregular - highly celluar lamellar bone w/ irregular cement
lines;
- woven bone with osteoblastic rimming;
- occasional prominent cement lines.
 Radiographs:
- aggressive bone resorption;
- lytic lesions w/ sharp borders that destroy the cortex;
- new bone formation and sclerosis which causes thickening of
the cortex and course trabeculae;
- cortices will appear thickened and trabeculae will appear
coarse;
 Labs – increased alk phos, increase urine and serum
hydroxyproline
 Treament – bisphosphonates, calcitonin prior to elective surgery
Question #: 116
 Which of the following postoperative
modalities to prevent deep venous
thrombosis is associated with the
highest risk of hematoma?
1- Aspirin
2- Dipyridamole
3- Compression device
4- Clopidogrel bisulfate
5- Low-molecular-weight heparin
Question #: 116
 Which of the following postoperative
modalities to prevent deep venous
thrombosis is associated with the
highest risk of hematoma?
1- Aspirin
2- Dipyridamole
3- Compression device
4- Clopidogrel bisulfate
5- Low-molecular-weight heparin
Preferred Response: 5
 Compression stockings- increases peak venous flow and decreases the activty of the fibrinolytic
system
 Unfractionated heparin- i.e. heparin, binds AT III which decreases the activity of thrombin and
Xa. Higher risk of bleeding than with others
 Lovenox. Aka fractionated heparin, heparin broken down into smaller molecules. Binds to AT
III and thrombin. Longer half-life, improved bioavailibility, compared with coumadin there is a
higher risk of bleeding but a lower risk of venographically identified DVTs
 Warfarin- inhibits vitamin K (II, VII, IX, X)- must be monitored
 ASA- irreversibly binds and inactivates COX. Blocks the production of thromboxane A2 which is
required for platelet aggregation. More likley to develop venographically evident DVT but need
randomized trials.
 Dipyrimidole- decreases activity of thromboxane A2 thereby decreasing platelet aggregation.
 Plavix- inhibits ADP receptors on platelets and therefore inhibits activation
Question #: 131
 In the case of a mother (who is a carrier for
Duchenne’s muscular dystrophy gene) and
a father (who does not have the
Duchenne’s muscular dystrophy gene),
what is the chance that the son will be
affected by Duchenne’s muscular
dystrophy?
1- 25%
2- 50%
3- 75%
4- 100%
5- Unable to determine since the father may
be a carrier.
Question #: 131
 In the case of a mother (who is a carrier for
Duchenne’s muscular dystrophy gene) and
a father (who does not have the
Duchenne’s muscular dystrophy gene),
what is the chance that the son will be
affected by Duchenne’s muscular
dystrophy?
1- 25%
2- 50%
3- 75%
4- 100%
5- Unable to determine since the father may
be a carrier.
DMD
 X linked recessive muscular dystrophy. 1/3500 males. Only males are affected from female
carriers. Xp21 chromosome. Abnormal coding of the dystrophin which stabilizes the
dystroglycan complex.
 Progressive muscle wasting and weakness starting in infancy and progressing to wheelchair
dependency by age 12. Pseudohypertrophy- enlargement of the calves and deltoids by fatty
replacement and fibrosis.
Question #: 152
 A newborn infant is brought to the office
with the features shown in Figure 152.
Many children with this condition have
multiple systemic anomalies. Which of the
following body sites is most likely to have
associated abnormalities?
1- Vertebral complex
2- Renal system
3- Cardiac system
4- Hematopoetic system
5- Central nervous system
Question #: 152
Question #: 152
 A newborn infant is brought to the office
with the features shown in Figure 152.
Many children with this condition have
multiple systemic anomalies. Which of the
following body sites is most likely to have
associated abnormalities?
1- Vertebral complex
2- Renal system
3- Cardiac system
4- Hematopoetic system
5- Central nervous system
Preferred Response: 4
 Radial longitudinal deficiency aka radial dysplasia or
radial clubhand
 Range from thumb hypoplasia to complete radial absence
 1:30k-100k
 M>F (3:2)
 Bilateral 40-60%, R>L @ 2:1 when unilateral

 Thrombocytopenia absent radius

(TAR)
●
Autosomal recessive
●
1q21.1 gene deletion
Question #: 179
 Rheumatoid factors are antibodies
directed against
1- multiple immunoglobulins.
2- IgA.
3- IgE.
4- IgM.
5- IgG.
Question #: 179
 Rheumatoid factors are antibodies
directed against
1- multiple immunoglobulins.
2- IgA.
3- IgE.
4- IgM.
5- IgG.
 Preferred Response: 5
 RF is an IgM antibody directed against the Fc portion of the
patient’s own IgG
 Purpose of RF is unknown but though to help clear immune
complexes through stabilization and opsinization
 RF is commonly secreted during acute infections and probably is part
of the normal immune response
 RF is present in 70% to 90% of patients with RA; a negative RF result
does not rule out rheumatoid arthritis.
 Sensitive but not specific.
 RF may take several months to appear in the serum after arthritis
develops.
 The level of RF is prognostic, that is, the higher the level, the worse
the prognosis.
Question #: 274
 Disease modifying antirheumatic drug
therapy such as infliximab is primarily
targeted against
1- leukocytes.
2- rheumatoid factor.
3- antinuclear antibodies.
4- C-reactive protein.
5- tumor necrosis factor-alpha.
 Preferred Response: 5 (TNF-alpha)
 Rheumatoid Arthritis: 90% positive for RF
 Morning stiffness, pain, joint swelling, hand deformities
such as subluxation, ulnar drift, swan-neck deformity
 Periarticular osteopenia
 Juxta-articular erosion
 Joint space narrowing
 Treatment
 NSAIDS, Aspirin
From COR Book
 Disease-modifying antirheumatic drugs
 Methotrexate (inhibits dihydrofolate reductase and folate
metabolism, is current treatment choice)
 Cytokine-neutralizing
 Etanercept (soluble p75 TNF receptor immunoglobulin G
fusion protein)
 Infliximab (chimeric monoclonal antibody to TNf-alpha)
 Rituximab (monoclonal antibody to CD20 antigen;inhibits
B-cells)