AAOS Study Question

Preservation, Arthroplasty, and Salvage Surgery of the Hip and Knee

l. Which of the following radiographic images is best for detecting anterior acetabullar
deficiency in the dysplastic hip?
a. Pelvic inlet
b. Judet
c. AP pelvis
d. False profile
e. Frog la teral

2. At the level of tibial bone resection in total knee arthroplasty, where does the
common peroneal nerve lie?
a. Deep to the arcuate ligament
b. Closer to bone in larger legs
c. On the muscle belly of the popliteus
d. On the bony posterolateral corner of the tibia
e. Superficial to the lateral head of the gastrocnemius

3. The anatomy of the sciatic nerve as it exits the pelvis is best described as exiting
through the
a. greater sciatic notch and passing between the inferior gemellus and the
obturator externus.
b. greater sciatic notch and passing between the piriformis and the
superior gemellus.
c. obturator foramen and passing between the obturator internus and the
obturator externus.
d. lesser sciatic notch and passing between the piriformis and the superior
gemellus.
e. lesser sciatic notch and passing between the superior gemellus and the
inferior gemellus.

4. What complication is more likely following excessive medial retraction of the anterior
covering structures during the anterolateral (Watson-Jones) approach to the hip?
a. Numbness over the anterolateral thigh
b. Ischemia to the leg
c. Quadriceps weakness
d. Abductor insufficiency
e. Foot drop
5. A 40-year-old man has had hip pain with increased activity over the past year.
Examination reveals restriction of rnotion and tenderness with combu1ed hip flexion,
adduction, and internal rotation. An AP radiograph is shown in Figure 1. What is the
most likely diagnosis?
a. Developmental dysplasia of the hip
b. Osteonecrosis
c. Perthes disease
d. Pseudogout
e. Femoral acetabular impingement

6. Bleeding is encountered while developing the internervous plane between the tensor
fascia lata and the sartorius during the anterior approach to the hip. The most likely
cause is injury to what artery?
a. Ascending branch of the lateral femoral circumflex
b. Superior gluteal
c. Femoral
d. Profunda femoris
e. Medial femoral circumflex

7. When using the direct lateral (or Hardinge) approach for hip arthroplasty, three
muscles are detached from the femur. In addition to the vastus lateralis, they include
the
a. iliopsoas and sartorius.
b. piriformis and obturator internus.
c. gluteus maximlls and tensor fascia lata.
d. gluteus minimus and rectus femoris.
e. gluteus medius and gluteus minimus.

8. Figure 2 shows the radiograph of a patient who underwent a total knee revision with a
posterior stabilized mobile-bearing prosthesis and who now has reccurent knee
dislocations. What is the most likely cause?
a. Loose extension gap
b. Loose flexion gap
c. Malrotation of the tibial component
d. Malrotation of the femoral component
e. Poor prosthetic design
9. Figures 3A and 3B show the radiographs of a 72-yea r- lid man with aseptic
loosening of the tibial component of his total knee arthroplasty. Optimal
management should include
a. tibial revision only, without stems or
augmentations.
b. tibial revision only, with stems and
augmentations.
c. revision of the tibial and femoral
components, without stems or
augmentations.
d. revision of the tibial and femoral components, with stems and
augmentations.
e. primary arthrodesis.

l0. Figure 4 shows the AP radiograph of a patient with diabetes mellitus who has knee
pain. A semiconstrained knee prosthesis was used in this patient to prevent which of
the following complications?
a. Infection
b. Instability
c. Stiffness
d. Bone loss
e. Malalignment

ll. A 75-year-old woman who fell on her right knee now reports pain and is unable to
bear weight. History reveals that she underwent total knee arthroplasty on the right
knee 6 years ago. Radiographs are shown in Figure 5. Management should now
consist of
a. closed reduction and casting for 6 weeks.
b. open reduction and internal fixation, using a
locked intramedullary rod.
c. open reduction and internal fixation, using two
cancellous screws.
d. open reduction and internal fixation, using a
locked plate and screws.
e. open reduction and internal fixation and revision of the femoral
component.
12. A 64-year-old man undergoes a primary total knee arthroplasty. Three months after
surgery he reports persistent pain, weakness, and difficulty ambulating.
Postoperative radiographs are shown in Figures ('A through 6e. Wbat is tbe best
course of action at this time?
a. Hinged knee brace
b. Patellar component revision with a tantalum
implant and lateralization of the patella
c. Revision knee arthroplasty with greater internal
rotation of the tibial component
d. Revision total knee arthroplasty with a
lateral release and external rotation of the
femoral component
e. Revision total knee arthroplasty with a lateral
release and internal rotation of the femoral component

13. Compared to metal-on-polyethylene total hip bearing surfaces, the debris particles
generated by metal-on-metal articulations are
a. larger and less numerous.
b. larger and more numerous.
c. smaller and less numerous.
d. smaller and more numerous.
e. not detectable.

14. A 60-year-old patient had the procedure shown in Figure 7 performed 5 years ago.
During transiti on to a total knee arthroplasty (IKA), what patellar problem is
commonly encountered intraoperatively?
a. Fracture
b. Patella baja
c. Patella alta
d. Osteonecrosis
e. Maltracking

15. Figures RA and SB show the radiographs of a 75-year-old man who underwent a
revision total knee arthroplasty with a long-stemmed tibial component. In
rehabilitation, he report fullness and tenderness in the proximal medial leg (at the
knee). The strategy tbat would best limit this postoperative problem is use of
a. a base plate with an offset tibial stem attachment.
b. a bone ingrowth surface on the augment.
c. a nonstemmed tibial base plate.
d. allograft bone instead of metal augments.
e. bone cement to smooth the outline of the proximal medial tibia.
16. Figure 9 shows the AP radiograph of an ambulatory 76-year-old patient. What is the
most appropriate surgica l treatment optioll for this patient?
a. Revision arthroplasty using a cemented femoral component
b. Impaction allografting of the femoral component
c. Proximal femoral replacement arthroplasty
d. Resection arthroplasty
e. Hip arthrodesis

17. Increasing articular conformity of the ti bial polyethylene insert of a fixed- bearing
total knee arthroplasty (TKA) prosthesis will have which of the following
biomechanical effects?
a. Decreased contact stress within the polyethylene
b. Decreased risk of patellofemoral insta bility
c. Decreased risk of mechanical loosening
d. Increased risk of subsurface polyethylene cracking
e. Increased tibial rollback during flexion

18. A 63-year-old woman reports giving way of the knee and pain after undergoing
primary total knee arthroplasty (TKA) 1 year ago. Examination reveals that the knee
is stable in full extension but has gross anteroposterior instability at 90° of flexion.
The patient can fully extend her knee with normal quadriceps strength. Studies for
infection are negative. AP and lateral radiographs are shown in Figures 10A and
10B, respectively. What is the appropriate management?
a. Anti-inflammatory drugs
b. Knee brace
c. Physical therapy for quadriceps strengthening
d. Revision to a thicker polyethylene insert
e. Revision to a larger, posterior stabilized Implant
19. Stiffness can occur following total knee arthroplasty. What is the most appropriate
management for a patient who has deteriorating arc of motion after undergoing a
revision knee arthroplasty 9 months ago?
a. Aggressive physical therapy
b. Manipulation under anesthesia
c. Investigation for periprosthetic infection
d. Revision knee arthroplasty
e. Resection arthroplasty

20. A 59-year-old woman who underwent a total hip arthroplasty 5 years ago now has
recurrent dislocation following bariatric surgery and a weight loss of 200 lb. An
attempt at conversion to a larger head size and trochanteric advancement has failed.
Her components are well aligned. What is the best course of action?
a. Resection arthroplasty
b. Hip abduction brace
c. Constrained acetabular liner
d. Thermal ablation of the posterior capsule
e. Conversion to a bipolar prosthesis

21. Figure 'Il shows the radiograph of an otherwise healthy 62-year-old woman who fell.
Management should consist of
a. revision total hip arthroplasty with a cemented femoral component and
adjuvant fracture fixation.
b. revision total hip arthroplasty with a cementless femoral component
and adjuvant fracture fixation.
c. open reduction and internal fixation of the fracture and retention of the
original components.
d. removal of the components, open reduction and internal fixation of the
fracture, and delayed replantation of the components when the fracture is
healed.
e. resection arthroplasty and internal fixation of the fracture.
22. A 75-year-old woman undergoes hybrid total hip arthroplasty for osteoarthritis. A
postoperative radiograph obtained in the recovery rom is shown in Figure 12.
Treatment should now consist of
a. open reduction and internal fixation with strut graft
and cerclage wIre.
b. open reduction and internal fixation with a plate,
screws, and bone graft.
c. exchange of the femoral components with
insertion of a long stem cementless implant.
d. cast immobilization.
e. minimal weight bearing and observation.

23. A 58-year-old man reports a 2-month onset of groin pain with no history of trauma.
Examination reveals that range of motion of the hip is mildly restricted, and he has
pain with both weight bearing and at rest. An MRI scan is shown in Figure 13.
Treatment should consist of
a. protected weight bearing and anti-inflammatory drugs.
b. core decompression of the femoral head.
c. vascularized free fibular grafting to the femoral head.
d. bipolar hemiarthroplasty of the hip.
e. total hip arthroplasty.

24. Figure 14 shows the radiograph of a 32-year-old patient with right hip pain that has
failed to respond to nonsurgical management. What is the most appropriate surgical
treatment at this time?
a. Femoral derotational osteotomy
b. Total hip arthroplasty
c. Arthrodesis
d. Surgical dislocation of the hip
e. Periacetabular osteotomy
25. A patient reports pain in the hip with functional positioning. With the patient supine,
pain in which of the following positions would be typical for femoral acetabular
impingement?
a. Hip is internally rotated, passively flexed to 90°, and adducted
b. Hip is internally rotated, passively flexed to 90°, and abducted
c. Hip is externally rotated, maximally flexed to 90°, and adducted
d. Hip is externally rotated, passively flexed to 90°, and abducted
e. Hip is externally rotated, maximally flexed, and abducted

26. A 38-year-old man who is an avid tennis player has had persistent pain over the
medial aspect of his knee for the past 6 years. He notes that the pain occurs on a
daily basis with any significant activity. NSAIDs have failed to provide relief.
Radiographs are shown in Figures l5A and l5B. What is the best course of action?
a. Total knee arthroplasty
b. Unicompartmental arthroplasty
c. Insertion of a unispacer
d. Tibial osteotomy
e. Knee arthroscopy

27. Which of the following statements best describes the outcome of the routine use of
continuous passive motion (CPM) machines after total knee arthroplasty (TKA)?
a. CPM is likely to improve early range of motion and final range of motion.
b. CPM may improve early range of motion but is unlikely to improve
final range of motion.
c. CPM is likely to decrease postoperative pain.
d. CPM is likely to improve extension but not flexion.
e. CPM is likely to restore quicker ambulatory ability

28. When performing knee arthroplasty, which of the following procedures provides the
most consistent fixation for the tibial component?
a. Cementless fixation of the tibial component
b. Augmenting cementless fixation of the tibial component with pegs or
screws
c. Cementing the metaphyseal portion and press fitting the keel of the tibial
component
d. Cementing the metaphyseal and keel portions of the tibial
component
e. Cemented fixation of the tibial component with screws
29. Figure 16 shows the radiograph of an 84-year-old woman who has pain and is
unable to extend her knee. History reveals that she underwent total knee
arthroplasty 8 years ago. Aspiration and studies for infection are negative. During
revision surgery, management of the tibial bone loss should consist of
a. reconstruction with a metal augmented revision tibial implant.
b. reconstruction with a hinged prosthesis.
c. reconstruction with a structural allograft.
d. reconstruction with iliac crest bone graft.
e. filling the defect wi th cement.

30. A 62-year-old woman with a bone mineral density CBMD) T-score of -2 .0 sustained
a subcapital fracture of her hip. She is an avoid tennis player, and history reveals no
previous fractures. What is the most appropriate follow-up care?
a. Antiresorptive bisphosphonate medication
b. A repeat dual-energy x-ray absorptiometry scan (DEXA) and treatment if
the T-score is less than -2.5
c. A repeat DEXA scan and treatment if the T-score is greater than -1.5
d. No treatment because the BMD is not in osteoporotic range
e. Parathyroid hormone followed by surgery

31. A 58-year-old patient who underwent bilateral hip arthroplasty 12 years ago now
reports pain in his hips and difficulty with ambulation to the point where he now
uses crutches. A radiograph of the hip and pelvis is shown in Figure 17. What is the
best treatment option for this patient?
a. Revision hip arthroplasty with a bipolar implant
b. Revision hip arthroplasty with impaction grafting on
the femoral and acetabular side
c. Revision hip arthroplasty with a cemented jumbo
acetabular component
d. Revision hip arthroplasty with a cementless
acetabular component
e. Acetabular component revision with a triflange protrusion ring
32. Embolic material (shown in Figure 18) generated during total knee arthroplasty
(TKA) is composed of which of the following substances?
a. Fat only
b. Fat and air
c. Fat and marrow
d. Fat and cement
e. 5.Fat and bone

33. A 30-year-old patient has had severe left hip pain and difficulty ambulating,
necessitating the use of a cane, for the past 6 months. A photomicrograph of the
femoral head sectioned at the time of surgery is shown in Figure 19. What is the
most likely diagnosis?
a. Renal osteodystrophy
b. Pyogenic osteomyelitis
c. Osteoarthritis
d. Osteonecrosis
e. Tuberculosis osteomyelitis

34. When cornparing mobile-bearing total knee arthroplasty (TKA) to fixed-bearing total
condylar arthroplasty, the mobile-bearing procedure provides
a. no improvement in survivorship.
b. approximately 15° greater flexion.
c. appreciable reduction in wear rates.
d. a faster recovery profile.
e. better quadriceps strength.

35. Based on the type of articulation shown in Figure 20, wear is not affected by which.
of the following factors?
a. Radial mismatch of the femoral head to the
acetabular component
b. Sphericity of the bearings
c. Surface finish of the articulation
d. Carbon content of the metal-on-metal bearing
e. Head-to-neck ratio
36. A 78-yea r-old patient undergoing revision total knee arthroplasty has bone loss
throughout the knee a t the time of revision. A distal femoral augment is used to
restore the joint line. One month after surgery, tbe patient reports pain and is
unable to ambulate. A lateral radiograph is shown in Figure 21. What is the most
likely etiology oJ this problem?
a. Inadequate restoration of the joint line
b. Patellar tendon rupture
c. Excessive internal rotation of the tibial component
d. Flexion gap instability
e. Hyperextension of the femoral component

37. Figure 22 reveals a peripmstbetic fracture around a cemented femoral stem in an

81-year-old patient with Paget disease and mild coagulopathy. What is the most
approprjate reconstructive management on the femoral side?
a. Open reduction and internal fixation
b. Impaction allografting
c. Proximally coated femoral stem
d. Allograft prosthetic composite (APC)
e. Proximal femoral replacement (PFR)

38. A patient with a documented allergy to nickel requires a total knee arthroplasty.
Which of the following prostheses is most likely to provide long-term success in this
individual?
a. AU-polyethylene tibial component and pure titanium femoral component
b. All-polyethylene tibial component and cobalt-chromium alloy femoral
component
c. Cobalt-chromium alloy tibial component and cobalt-chromium alloy
femoral component
d. Modular titanium tibial component and pure titanium femoral component
e. Modular titanium tibial component and oxidized zirconium femoral
component

39. A 42-year-old man reports the recent onset of eight hip pain. A radiograph and MRI
scan are shown in Figures 23A and 23B. White blood cell count, erythrocyte
sedimentation rate, and hip aspiration results are within normal limits. Management
should now consist of
a. core decompression.
b. biopsy of the femoral head.
c. protected weight bearing and observation.
d. total hip arthroplasty.
e. percutaneous cannulated pin fixation of the femoral neck.
40. During cemented total hip arthroplasty, peak pulmonary embolization of marrow
contents occurs when the
a. hip is dislocated.
b. femoral neck is osteotomized.
c. acetabulum is prepared.
d. acetabular component is inserted.
e. femoral stem is inserted.

41. What are the optimal conditions for leaving the acetabular shell in place, replacing
the acetabular liner, and grafting the osteolytic defect shown in Figure 24?
a. Nonmodular implant
b. Insta bility
c. Well-designed, well-fixed modular implant
d. Complete radiolucency of the acetabular component
e. Migration of the acetabular component

42. A 53-year-old patient is seen in the emergency department after sustaining a fall
onto her left hip. A current radiograph is shown in Figure 25. What is the best
treatment option?
a. Bed rest and weight bearing for 6 to 8 weeks
b. Component retention and open reduction and internal
fixation
c. Proximal femoral replacement prosthesis
d. Revision arthroplasty with a long cemented stem
e. Revision arthroplasty with a long porous-co a ted
cylindrical Stem
43. Figure 26 shows the radiograph of a 65-year-old man who underwent a revision
arthroplasty to remove a loose, cemented femoral stem. When planning the
postoperative restrictions, the surgeon should be aware that
a. the approach used reduces the torque-to-
failure (fracture) of the construct to less than
50% of the intact femur.
b. the technique of repair can return the
reconstructed prosthesis/bone composite to
nearly the strength of the intact femur.
c. there is no relationship between the density of
the native bone and the strength of the
prosthesis/bone composite.
d. the addition of bone graft substitute or autograft has been shown to lessen
the time to complete healing.
e. there is a one in five chance of fracture with this technique;
therefore, the surgeon must carefully weigh the potential benefits
versus this risk.

44. A 37-year-old man who works in a factory has isolated, lateral unicompartmental
pain about his knee with activities. Nonsurgical management has failed to provide
relief. The radiograph shown in Figure 27 reveals a tibiofemoral angle of
approximately 15° that is clinically orrecta ble to neutral. What is the best surgical
option in this patient?
a. Unicompartmental arthroplasty
b. Total knee arthroplasty
c. Lateral closing wedge proximal tibial osteotomy
d. Medial opening wedge proximal tibial osteotomy
e. Medial closing wedge supracondylar femoral
osteotomy

45. Figure 28 shows the AP radiograph of an active 80-year-old patient with an

acetabular fracture. The fracture was initially managed nonsurgically; however, the
patient is now scheduled to undergo total hip arthroplasty. What is the treatment of
choice for the contained acetabular bone defect?
a. Bipolar femoral component
b. Acetabular cage
c. Large structural allograft
d. Use o£ the femoral head
e. Double-bubble acetabular cup
46. After trial placement of components in a primary total knee arthroplasty, the knee is
unable to come to full extension, but the flexion gap is appropriately balanced. After
adequate soft-tissue releases have been performed, what is the most appropriate
next action to balance the reconstruction?
a. Use a larger femoral component
b. Use a thinrier polyethylene insert
c. Add posterior femoral augments
d. Resect more proximal tibia
e. Resect additional distal femur

47. During total knee arthroplasty, the patella is noted to subluxate laterally despite a
lateral retinacular release. Which of the following methods is most likely to improve
patellar stability?
a. Slight external rotation of the tibial component
b. Slight internal rotation of the femoral component
c. Slight anterior translation of the tibial component
d. Use of a fixed-bearing knee as opposed to a mobile-bearing knee
e. Use of a thicker patellar component

48. A 73-year-old man bas stiffness after undergoing primary posterior cruciate
ligament-retaining total knee arthroplasty 18 month , ago. Extensive physiotherapy,
dynamic splinting, and manipulations under anesthesia have failed to result in
improvement. Examination reveals range of motion from 30° to 60° of flexion. The
components are well fixed, and the evaluation for infection is negative. In
discussing the possibility of revision arthroplasty, the patient should be advised that
a. the success of improving range of motion to a functional range of 0° to 90°
in the literature is between 75% to 80%.
b. the preoperative arc of motion will not influence the ultimate range of
motion after formal component revision.
c. change from a posterior cruciate ligament-retaining to a posterior cruciate
ligament-substituting design has a much greater chance of success.
d. manipulation under anesthesia will effectively improve range of motion if
postoperative stiffness develops following revision.
e. the major postoperative focus will be to regain near-full extension.

49. A 62-yea r-old patient is seen for routine follow-up after undergoing cementless total
hip arthroplasty 2 years ago. The patient reports limited range of motion that
severely affects daily activities. A radiograph is shown in Figure 29. Management
should now consist of
a. observation only.
b. NSAIDs and protected weight bearing.
c. irradiation to the affected area.
d. surgical excision.
e. surgical excision and postoperative irradiation.
50. What bilateral surgica l intervention is considered inappropriate based on the
findings shown in the radiograph in Figure 30?
a. Vascularized fibular graft
b. Proximal femoral osteotomy
c. Core decompression
d. Hip arthrodesis
e. Femoral resurfacing