Question

1. A 74-year-old man reports progressive left hip pain with weight-bearing activities. A
radiograph is shown in Figure 1. What is the most likely under lying diagnosis?
A. Infection
B. Lymphoma
C. Paget disease
D. Massive bone infarct
E. Old pelvic trauma

2. You are interested in learning a new technique for minimally invasive total knee
arthroplasty. The Keyhole Genuflex system seems appealing to you because the
instrumentation comes with wireless controls. Which of the following represents an
acceptable arrangement?
A. The local Keyhole representative has invited you and your spouse out to
dinner at a local restaurant to discuss your interest in their new minimally
invasive total knee system, the Keyhole Genuflex knee.
B. Keyhole has offered to pay your tuition to attend a CME course sponsored by
the American Association of Hip and Knee Surgeons where both the Genuflex
and the competing Styph total knee are discussed and demonstrated.
C. Keyhole will pay your expenses to attend a workshop, in Phoenix at
their company headquarters, to learn how to implant the Genuflex knee
and to see how the implant is manufactured and tested.
D. Keyhole will pay you $500 for each knee that you implant if you switch from
your current total knee system.
E. After you have implanted 25 Genuflex knees, Keyhole will list you on their
website as a consultant, pay you a consulting fee of $5,000 per year, and
invite you to a golf tournament for their consultants at a resort.

3. A 20-year-old woman with a history of subtotal meniscectomy has a painful knee.

What associated condition is a contraindication to proccedLng with a rneniscal
allograft?
A. Grade I posterior cruciate ligament tear
B. Grade II medial collateral ligament tear
C. Lateral meniscal tear
D. 5° of genu varum
E. 5 x 5-mm patellar chondral lesion

4. Figures 2A through 2C show the radiograph and MRI scans of a 16-year-old patient
who has a painful hip. Examination reveals a significant limp, limited abduction and
internal rotation, and severe pain with internal rotation and adduction. A
photomicrograph from a biopsy specimen is shown in Figure 2D. What is the
deposited pigment observed in this condition?
 A. Hemoglobin
B. Myoglobin
C. Melanin
D. Copper
E. Hemosiderin

5. Titanium and its alloys are unsuitable candidates for which of the following implant
applications?
A. Fracture plates
B. Femoral heads in a hip prosthesis
C. Bone screws
D. Intramedullary nails
E. Porous coatings for bone ingrowth

6. A 30-year-old man reports pain and weakness in his right arm. Examination reveals
grade 4 strength in wrist flexion and elbow extension, decreased sensation over the
middle finger, and decreased triceps reflex. These symptoms are most compatible
with impingement on what spinal nerve root?
A. C5
B. C6
C. C7
D. C8
E. T1

7. Why is tendon considered an anisotropic material?

A. Young modulus is greater than that of bone.
B. Young modulus is greater than that of ligament.
C. Mechanical properties change with preconditioning.
D. Intrinsic mechanical properties vary depending on the direction of
loading.
E. Intrinsic mechanical properties vary depending on the ra te of loading.
8. Which of the following changes to heart rate, blood pressure, and bulbocavernosus
reflex are typicaI of spinal shock?
A. Tachycardia, hypertension, intact bulbocavernosus reflex
B. Tachycardia, hypotension, intact bulbocavernosus reflex
C. Tachycardia, hypotension, absent bulbocavernosus reflex
D. Bradycardia, hypotension, absent bulbocavernosus reflex
E. Bradycardia, hyperthermia, intact bulbocavernosus reflex

9. What is the primary intracellular signaling mediator for bone morphogenetic pmtein
(BMP) activity?
A. Interleukin-1 (IL-1)
B. Runx2
C. NFK-B
D. SMADs
E. P53

10. Which of the following properties primarily provides the excellent corrosion
resistance of metallic alloys such as stainless steel and cobalt-chromium-
molybdenum?
A. High surface hardness
B. High levels of nickel
C. Adherent oxide layer
D. Low galvanic potential
E. Metallic carbides

11. Immobilization of human tendons leads to what changes in structure and/or function?
A. Decrease in tensile strength
B. Decrease in the likelihood of rupture
C. Increase in cellularity
D. Increase in aggrecan
E. Increase in collagen fibril diameter

12. Human menisci are made np predominantly of what collagen type?

A. I
B. II
C. III
D. V
E. VI

13. What changes in muscle physiology would be expected in an athlete who begins a
rigorous aerobic program for an upcoming marathon?
A. Hypertrophy of type I muscle fibers
B. Reduced fatigue resistance
C. Decreased capillary density
D. Decreased VOz max
E. Decreased mitochondrial density per muscle cell
14. A 16-year- old girl has had ant rior leg pain and a mass for the past 8 months.
Figures 3A and 3B show a radiograph and a hematoxylin and cosin stained
histologic specimen. Which of the following disorders is believed to be a precursor of
this lesion?
A. Nonossifying fibroma
B. Fibrous dysplasia
C. Unicameral bone cyst
D. Osteogenesis imperfecta
E. Osteofibrous dysplasia

15. Acetaminophen is an antipyretic medication . It exerts its pharmacologic effects by

inhibiting which of the following enzymes?
A. Cyclooxygenase-2
B. Interleukin-l beta (IL-l β)
C. Tumor necrosis factor-alpha (TNF-a)
D. 5-Hydroxytryptamine
E. Ma trix metalloproteinases

16. Nutritional rickets is associated with which of the following changes in chemical
blood level?
A. Low vitamin D levels
B. High to normal calcium levels
C. High phosphate levels
D. Decreased parathyroid hormone (PTH)
E. Decreased alkaline phosphatase levels

17. What assay most directly assesses gene expression at the posttranslational level?
A. Real-time polymerase chain reaction (PCR)
B. Standard PCR
C. Northern blot
D. Western blot
E. Microarray expression profile analysis

18. What is the relative amount of type II collagen synthesis in disease-free adult
articular cartilage compared to that in developing teenagers?
A. Less than 5%
B. 25%
C. 50%
D. 75%
E. 90%
19. What gene is expressed the earliest during the differentiation of a chondrocyt during
endochondral ossification?
A. Aggrecan
B. Sox-9
C. Collagen type II
D. Collagen type IV
E. Collagen type XI

20. The vascular supply to the medial meni cus comes primarily from what artery?
A. Lateral genicular
B. Lateral branch of the superior genicular
C. Medial branch of the super ior genicular
D. Medial branch of the inferior genicular
E. Medial genicular

21. What term best describes the process involved when a growth factor produced by
an osteoblast stimulates the differentiation of an adjacent undifferentiated
mesenchymal cell during fracture repair?
A. Mechanical
B. Autocrine
C. Paracrine
D. Endocrine
E. Systemic

22. What additional percentage of energy expenditure above baseline is required for
ambulation after an above-the-knee amputation?
A. 0%
B. 5%
C. 20%
D. 65%
E. 90%

23. Ceramic bone substitutes have which of the following properties?

A. There is vascular ingrowth and subsequent graft resorption with host
bone ingrowth.
B. Their interconnectivity is similar to that of cancellous bone.
C. They are brittle with significant tensile strength.
D. They are resorbed at a fairly constant rate.
E. Because of their strength, rigid stabilization of the surrounding bone is not
necessary.

24. Human tendons are made up primarily of wbat collagen type (~95%)?
A. I
B. II
C. III
D. IV
E. V
25. The therapeutic effect of etanercept in the treatment of rheumatoid arthritis is
primarily mediated through
A. antagonism of tumor necrosis factor-alpha (TNF-α).
B. antagonism of matrix metalloproteinases.
C. inhibition of cyclooxygenase-2 (COX-2).
D. stimulation of interleukin-l (IL-l).
E. stimulation of tissue inhibitors of metalloproteinases.

26. A 21-year-old woman has a nontraumatic rupture of the Achilles tendon. Which of
the following commonly prescribed medications has been associated with this
condition?
A. Ibuprofen
B. Fluoroquinolones
C. Bisphosphonates
D. Metoprolol
E. Simvistatin

27. Bioabsorbable polymers are used in a wide range of orthopaedic devices, including
anchors, staples, pins, plates, and screws. What is the primary drawback for
bioabsorbable implants?
A. High cost
B. Increased rateS of infection
C. High elastic modulus
D. Brittleness
E. Foreign body reaction

28. What ligament is the primary restraint to applied valgus loading of the knee?
A. Posteromedial capsule
B. Posterior cruciate ligament (PCL)
C. Superficial medial collateral ligament (MCL)
D. Deep MCL
E. Medial meniscus

29. What region of the thoracic curve is most dangerous for pedicle screw insertion
while performing a posterior fusion for adolescent idiopathic scoliosis?
A. Concave side at the stable vertebra
B. Concave side at the apex of the curve
C. Convex side at the stable vertebra
D. Convex side at the apex of the curve
E. Thoracolumbar junction
30. What mechanism is associated with the spontaneous resorption of herniated
nucleus pulposus?
A. Macrophage infiltration and phagocytosis
B. Granuloma formation
C. Antibody-mediated destruction
D. Complement cascade activation
E. Major histocompatibility complex-mediated pathways

31. Clinical evidence suggests that grafts for replacing a torn anterior cruciate ligament
often stretch after surgery. What is the most probable mechanism for this behavior?
A. Gross failure at the attachment sites
B. Fatigue failure of the ligament tissue
C. Creep of the graft material
D. Water absorption by the graft material
E. Elastic stretch of collagen fibers

32. Which of the following clinical disorders is the result of a mutation in fibroblast
growth factor recepter 3 (FGFR3)?
A. Cleidocranial dysplasia
B. Schmid metaphyseal chondrodysplasia
C. Achondroplasia
D. Fibrous dysplasia
E. Camptomelic dysplasia

33. What is the main mechanism for nutrition of the adult disk?
A. Capillary network from the adjacent segmental arteries
B. Capillary network from the arterioles in the vertebral body
C. Diffusion through the anulus fibrosus
D. Diffusion through pores in the end plates
E. Diffusion through nerves in the dorsal root ganglion

34. A knockout mouse for the vitamin D receptor has which of the following
phenotypes?
A. Osteopetrosis
B. Renal failure
C. Rickets
D. Jansen-type metaphyseal dysplasia
E. Compensatory hyperparathyroidism and no skeletal phenotype
35. Intramembranous ossification ducing fracture repair is characterized by absence of
which of the following element?
A. Alkaline phosphatase
B. Osteonectin
C. Osteopontin
D. Collagen type I expression
E. Collagen type II expression

36. Patients with rheumatoid arthritis may exhibit an increase in viral load for which of
the following viruses?
A. HIV
B. Papilloma virus
C. Epstein-Barr virus (EBV)
D. Hepatitis C virus (HCV)
E. Hepatitis B virus (HBV)

37. Osteopenia is defined by the World Health Organization (WHO) as a bone mineral
density (BMD) that is
A. within 1 standard deviation of age-matched normals.
B. within 1 and 2.5 standard deviations below age-matched normals.
C. within 1 standard deviation of young normals.
D. within 1 and 2.5 standard deviations below young normals.
E. more than 2.5 standard deviations below age-matched normals.

38. Which of the following best describes the mechanism of action of gentamycin?
A. Inhibits cell wall synthesis by inhibiting peptidyl traspeptidase
B. Increases cell membrane permeability
C. Binds to the 305 ribosome subunit interfering with protein synthesis
D. Inhibits DNA gyrase
E. Forms oxygen radicals leading to loss of helical structure and breakage of
DNA strands

39. What type of muscle contraction occurs while the muscle is lengthening?
A. Isometric
B. Isotonic
C. Concentric
D. Isokinetic
E. Eccentric

40. Osteoclasts originate from which of the following cell types?

A. Fibroblasts
B. Monocytes
C. Megakaryocytes
D. Plasma cells
E. bsteoprogenitor cells
41. A study is being designed to compare the effectiveness of an antibiotic. The choice
of the number of patients (the sample size) depends on several factors. What type of
calculation assesses the potential of the study to successfully address the
effectiveness of the antibiotic?
A. Regression analysis
B. Power analysis
C. Correlation analysis
D. Nonparametric analysis
E. Analysis of variance

42. What is the most common cause of mechanical failure of an orthopaedic biomaterial
during clinical use?
A. Fatigue
B. Tension
C. Compression
D. Shear
E. Torsion

43. Which of the following body positions is associated with the highest intradiskal
pressure?
A. Standing, bending forward
B. Standing, bending back
C. Sitting, bending forward
D. Sitting, bending back
E. Supine, lateral decubitus

44. Stiffness relates the amount of load applied to a structure like a long bone or an
intramedullary nail to the amount of resulting deformation that occurs in the structure.
What is the most important material property affecting the axial and bending stiffness
of a structure?
A. Elastic modulus
B. Ductility
C. Ultimate stress
D. Yield stress
E. Toughness

45. Osteoclasts are primarily responsible for bone resorption of malignancy. Which of
the following stimulates osteoclast formation?
A. Receptor activator of nuclear factor-lcB ligand gene (NF-KB ligand)
B. Osteoprotegerin (OPG)
C. Interleukin-5 (IL-5)
D. Matrix metalloproteinase-2 (MMP-2)
E. Collagen type I
46. Collagen orientation is parallel to the joint surface in what articular cartilage zone?
A. Diagonal
B. Middle
C. Deep
D. Superficial
E. Calcified

47. Which of the following agents increases the risk for a nonunion following a posterior
spinal fusion?
A. Ibuprofen
B. Intranasal calcitonin
C. Simvastatin
D. Gentamycin
E. Tamoxifen

48. A study was conducted in 500 patients to measure the effectiveness of a new
growth factor in reducing healing time of distal radial fractures. The authors reported
that average healing time was reduced from 9.2 to 8.9 weeks (P < 0.0001). Recause
the difference was highly statistically significant, they recommended routine clinical
use of this drug despite its high cost. A more appropriate interpretation of these
results is that they are
A. clinically significant.
B. statistically significant but perhaps not clinically significant.
C. statistically and clinically significant.
D. not statistically or clinically significant.
E. nonconclusive.

49. What type of multiple lesions is associated with Maffucci syndrome?

A. Nonossifying fibromas
B. Enchondromas
C. Langerhans cell histiocytosis
D. Osteochondromas
E. Giant cell tumors

50. Joint contact pressure in normal or artificial joints can best be minimized by what
mechanism?
A. Increasing joint force and contact area
B. Increasing joint force· and decreasing contact area
C. Decreasing joint force and contact area
D. Decreasing joint force and increasing contact area
E. Decreasing joint force only