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James Gill and Majeed Shakokani
Table 4.2 Paprosky classification of periprosthetic
acetabular fractures
1. Intraoperative during
component insertion
2. Intraoperative
during removal
3. Traumatic A. Component stable
4. Spontaneous A. Less than 50% bone
5. Pelvic discontinuity A. Less than 50% bone
A. Recognised, stable
component,
undisplaced fracture
B. Recognised, displaced
fracture, cup unstable
C. Not recognised
intraoperatively
A. Less than 50% bone
stock loss
B. Greater than 50% bone
stock loss
B. Component unstable
stock loss
B. Greater than 50% bone
stock loss
stock loss
B. Greater than 50% bone
stock loss
C. Associated with
pelvic radiation
involves being aware of high-risk cases and
considering the use of cemented acetabular
fixation in elderly o steoporotic patients (Chitre
et al. 2013). NHS England’ s ‘Best Practice Tariff’
(BPT) directive now requires 80% of total hip
arthroplasty (THA) be cemented or hybrid, for
those patients aged 70 years or over, with financial penalties if this is not achieved. A more
recent update from GIRFT has advised BPT
should even ‘go further’ advising 80% of THA
to be fully cemented for patients aged 70 years
or over. Registry data shows only marginally
superior implant survivorship for patients
aged greater than 74 years with a fully cemented
prosthesis but the cost savings are signifi cant
(Ben-Shlomo 2021).
Ben-Shlomo Y et al. The National Joint
Registry 18th Annual Report 2021. 2021;
National Joint Registry.
Chitre A, Wynn Jones H, Shah N, Clayson
A. Complications of total hip arthroplasty: peri-
prosthetic fractures of the acetabulum. Curr Rev
Musculoskeletal Med. 2013;6:357–363.
Hasegawa K, Kabata T, Kajino Y, Inoue D,
Tsuchiya H. Periprosthetic occult fractures of
the acetabulum occur frequently during primary
THA. Clin Orthop Rel Res. 2017;475:484–494.
56. Answer B. 65-year-old male who mobilises with
a single walking stick
Deciding which patients might benefit from total
hip arthroplasty for intra-capsular hip fracture
remains a contentious topic lacking in robust
evidence to guide decision making. Bearing this
in mind arguments could be made for all or
indeed none of the above patients to receive a
THA. The perceived advantages of THA for hip
fracture are better mobility, less pain and reduced
risk of acetabular erosion (Burgers et al. 2012;
Lewis et al. 2019). The disadvantages of THA are
longer anaesthetic, increased intraoperative blood
loss, increased risk of dislocation and reoperation,
increased cost compared with hemiarthroplasty
and difficulties with service provision (Gill et al.
2021; Miller et al. 2014; Reed and Haddad 2016).
Since 2011 the National Institute for Health
and Care Excellence (NICE) has recommended
offering THA for displa ced intracapsular hip
fracture for patients who walk with no more than
one stick, who are not cognitively impaired and
are fit to undergo anaesthesia and the procedure
(National Clinical Guidance Centre 2011). In the
UK the proportion of eligible patients that
receive a THA is approximately 30%.
THA versus hemiarthroplasty for the treatment of displaced intracapsular hip fracture is an
area of continuing debate in the orthopaedic
literature. A systematic review and meta-analysis
reported THA to be superior to hemiarthroplasty
in terms of risk of reoperation, hip function and
quality of life (Lewis et al. 2019). The largest RCT
to date to attempt to shed some light on this
topic was performed by the HEALTH investigators. The HEALTH investigators reported no
difference in secondary procedures, similar mortality and modest but not significantly superior
function following THA compared with hemiarthroplasty (Bhandari et al. 2019). One criticism
of this trial is the average age of patients
recruited was 80 years. It is possible younger
patients with a greater life expectancy and higher
functional demands may benefit more from a
THA compared with hemiarthroplasty.
64
Hip II Structured SBA
Rheumatoid arthritis is considered a soft
indication for THA for fear of increased acetabular erosion caused by hemiarthroplasty.
Degenerative neurological conditions such as
Parkinson’s disease are considered a relative contraindication for THA to treat hip fractures because
of reduced mobility (reducing the benefit of
THA) and increased falls risk (increasing the
risk of dislocation) (Awadallah et al. 2022).
Mobilising with a frame is a contraindication to
THA for hip fracture for most hip surgeons. A
patient with lung cancer and a suspected pathological fracture would need investigation to stage
the disease. If lung cancer was a new diagnosis
and it was an isolated metastasis to the proximal
femur curative treatment might still be possible
and so treatment decisions should be guided by
an MDT. In general, hemiarthroplasty is indicated for most patients who suffer a femoral neck
fracture with lung cancer and bone metastases
due to reduced life expectancy.
Awadallah M et al. Is there a higher risk of
dislocation of hip hemiarthroplasty in patients
with neuromuscular conditions? A clinical study
of 3827 patients. Injury 2022;53 :631–633.
Bhandari M et al., HEALTH Investigators.
Total hip arthroplasty or hemiarthroplasty for hip
fracture. New Engl J Med 2019;381:2199–2208.
Burgers PT et al. Total hip arthroplasty
versus hemiarthroplasty for displaced femoral
neck fractures in the healthy elderly: a metaanalysis and systematic review of randomized
trials. Int Orthop. 2012;36:1549–1560.
Gill JR, Pathan A, Parsons SJ, Wronka K.
Total hip arthroplasty for hip fracture: clinical
results and mid-term survivorship. Cureus
2021;13:e20492.
Lewis DP, Wæver D, Thorninger R, Donnelly
WJ. Hemiarthroplasty vs total hip arthroplasty for
the management of displaced neck of femur fractures: a systematic review and meta-analysis. J
Arthroplasty 2019;34:1837–1843.e2.
Miller CP, Buerba RA, Leslie MP.
Preoperative factors and early complica tions
associated with hemiarthroplasty and total hip
arthroplasty for displaced femoral neck fractures.
Geriatr Orthop Surg Rehab. 2014;5:73–81.
National Clinical Guideline Centre (UK).
The Management of Hip Fracture in Adults.
Royal College of Physicians (UK); 2011.
Reed M, Haddad FS. Randomised trials of
total hip arthroplasty for fracture: is our failure
to deliver symptomatic of a wider scrutiny? Bone
Joint J. 2016;98-B:1425–1426.
57. Answer D. Snapping iliotibial band
Coxa saltans (coxa = hip, saltans = to dance or
jump) refers to snapping hip and encompasses
three main causes, extra-articular (either external
or internal) or intra-articular. The most common
form of coxa saltans is the external (coxa saltans
externa) extra-articular variety which involves the
iliotibial band flicking over the greater trochanter
during hip flexion and extension or internal and
external rotation. Coxa saltans externa can manifest as a snapping, but often is described as a
sensation that the hip dislocates (Yen et al. 2015).
Coxa saltans interna is caused by snapping of
the iliopsoas tendon over the iliopectinal eminence or the femoral head. The iliopsoas tendo n
can also snap over the acetabular component of a
total hip arthroplasty (THA).
Intra-articular causes include labral tears,
ligamentum teres tears, loose bodies and even
subtle instability of the joint. Intra-articular
causes often cause a clicking or catching sensation. Hip microinstability can present as a subjective feeling of instability. The most common
causes of native hip microinstability are iatrogenic following non-arthroplasty hip surgery
and in patients with connective tissue disorders
(Cohen et al. 2022).
Cohen D et al. Hip microinstability diagnosis
and management: a systematic review. Knee Surg
Sports Trauma Arthroscopy 2023;31:16–32.
Yen YM, Lewis CL, Kim YJ. Und erstanding
and treating the snapping hip.
and arthroscopy review, 2015;23:194–199.
58. Answer E. Resorption of bone
It is not the necrosis itself but rather the repair
process and in particular the resorptive component that results in loss of structural integrity and
subchondral fracture. Osteocyte necrosis occurs
within a few hours of anoxia (Shah et al. 2015).
Reactive hyperaemia (visible on MRI) and capillary revascularisation occur in the periphery of
the necrotic zone and with the entry of blood
vessels, a repair process begins consisting of both
bone resorption and production that
Sports medicine
65
James Gill and Majeed Shakokani
incompletely replaces dead and living bone. New
living bone is laminated on dead trabeculae, this
process is known as creeping substitution. Bone
resorption exceeds formation leading to the net
removal of bone and loss of structural integrity.
There is a race between the ability of the body to
repair the necrotic bone and mechanical collapse of
the bone. Decreased blood flow is the final common
pathway which results in osteocyte necrosis. Fat cell
hypertrophy is thought to be one of the mechanisms
by which corticosteroids and alcohol cause osteonecrosis. Fat cell hypertrophy results in compromised
blood supply by extraosseous compression.
Shah KN, Racine J, Jones LC, Aaron RK.
Pathophysiology and risk factors for osteonecrosis.
Curr Rev Musculoskeletal Med. 2015;8:201–209.
59. Answer B. Gaucher’s disease – intravascular
coagulation
Gaucher’s disease is an autosomal recessive lysosomal storage disease. Gaucher’s disease has been
implicated in the development of osteonecrosis of
the femoral head due to its role in decreasing capillary blood flow, possibly by increasing the pressures
in the intraosseous extravascular space. Due to the
deficiency of beta-glucocerebrosidase, patients with
Gaucher’s disease accumulate large amounts of glu-
cocerebrosides in the lysosomes of their histiocytes,
aptly named Gaucher cells. There are three main
pathogenic mechanisms by which the blood supply
to bone can be interrupted (Figure 4.8):
I. Mechanical vascular interruption
(traumatic causes)
Interruption of vessels feeding bone due to
fracture or dislocation. Hip haemarthrosis
has been proposed as a potential cause of
extraosseous compression of the ascending
retinacular vessels by tamponade, however
this theory lacks strong support.
II. Intravascular occlusion
Vascular occlusion due to thrombus (sickle
cell disease, thrombophilias and systemic
lupus erythematosus), clot, fat
(corticosteroids and alcohol) or nitrogen
embolus (Caisson’s disease).
III. Extravascular compression
Occlusion can occur due to extravascular
pressure on vessels for example by fat cell
hypertrophy (corticosteroids and alcohol)
and Gaucher cells.
Aetiology
Pathology
Pathophysiology
Histopathology
Trauma Intravascular
Mechanical vascular
interruption
Intravascular occlusion
Decreased blood flow
Osteocyte necrosis
Ischemia
Repair
Loss of structural
integrity
Collapse
Fat cell hypertrophy,
Gaucher’s cells
Extravascular
compression
Figure 4.10 Pathophysiology of
osteonecrosis (Aaron 2015, Reprinted
with permission from Wolters Kluwer)
66
Hip II Structured SBA
Aaron RK. Osteonecrosis: etiology, patho-
physiology, and diagnosis. In Callaghan JJ,
Rosenberg AG, Rubash HE, eds. The Adult Hip.
Philadelphia, PA: Wolters Kluwer; 2015.
60. Answer A. Creeping substitution
Creeping substitution is a form of appositional
bone formation as new bone is laminated on
dead trabeculae. The dead trabeculae that are
not resorbed by osteoclasts serve as scaffolds for
deposition of new living bone Creepin g substitution is the process by which bone repair occurs in
osteonecrosis as well as the incorporation of cancellous bone allograft.
In 1930 Phemister coined the term, ‘creeping substitution’ to describe the repair of
necrotic bone: ‘ By the process of creeping substitution, the old bone is gradually absorbed
and replaced by new bone, so that in the course
of months or occasionally years the ne crotic
area is more or less completely transformed
into living bone ... the amount of new bone
formed ... depends largely on the extent of the
living bone with which it (the dead bone) is in
contact.’
Enchondral ossification is the process by
which long bones are formed in the embryo, longitudinal bone growth (physeal) and secondary
bone healing by fracture callus. In enchondral
ossification bone replaces a cartilage model.
Intramembranous ossification is the mechan-
ism of embryonic flat bone formation and bone
formation during distraction osteogenesis. In
intramembranous ossification, aggregates of
undifferentiated mesenchymal cells differentiate
into osteoblasts which form bone. Primary bone
healing is bone healing without callus. Absolute
stability (<2% strain) is required for primary bone
healing. Secondary bone healing is healing via
callus in the presence of relative stability (enchondral ossification). Appositional ossification is the
mechanism of periosteal bone enlargement (diameter) and the bone formationphase of remodelling.
In appositional ossification osteoblasts lay down
new bone on existing boneso creepingsubstitution
is a form of appositional ossification.
Core decompression is thought to relieve the
pain and to allow creeping substitution to the
necrotic area by bringing the blood supply
through the drill channels.
Phemister DB. Repair of bone in the presence of aseptic necrosis resulting from fractures,
transplantations, and vascular obstruction. J
Bone Joint Surg Am. 1930;12:769–787.
61. Answer A. Femoral neck fracture
The incidence of femoral neck fracture after hip
resurfacing is approximately 1–2% (Matharu et
al. 2020) (Figure 4.11). Most femoral neck fractures after hip resurfacing occur in the early
(a) (b)
Figure 4.11 (a) Left hip resurfacing
fracture. (b) Conversion to MoM
hip arthroplasty
67
James Gill and Majeed Shakokani
post-operative period, however they can occur at
any stage (Matharu et al. 2013). Risk factors for
femoral neck fracture are notching of the superior aspect of the femoral neck and varus placement of the femoral component relative to the
pre-operative neck shaft angle (Shimmin and
Back 2005). Femoral and sciatic nerve injuries
present with sensory and motor weakness with or
without pain. The incidence of sciatic nerve palsy
following THA is approximately 1.5% (Hasija et
al. 2018). The sciatic nerve is at greatest risk
during the posterior approach whereas the femoral nerve is at greater risk during the anterior
approach (Hasija et al. 2018).
Iliopsoas impingement does not tend to present until later when patients are more mobile. The
most common cause is the iliopsoas tendon impinging on a prominent anterior rim of the acetabular
cup. Patients with iliopsoas impingement tend to
complain of pain in the groin during activities
which require active hip flexion, such as walking
up stairs and lifting the leg in and out of a car.
Provocative clinical examination manoeuvres that
will reproduce the pain of iliopsoas impingement
are resisted seated hip flexion or a straight leg raise.
The incidence of iliopsoas impingementafter THA
is about4% (Dora et al. 2007). Haematomas do not
tend to cause severe pain unless they compress
other structures such as nerves, in which case they
are an important reversible cause of nerve palsy.
Dora C, Houweling M, Koch P, Sierra RJ.
Iliopsoas impingement after total hip replacement: the results of non-operative management,
tenotomy or acetabular revision. J Bone Joint
Surg Br. 2007;89:1031–1035.
Hasija R. et al. Nerve injuries associated with
total hip arthroplasty. J Clin Orthop Trauma
2018;9:81–86.
Matharu GS et al. The effect of surgical
approach on outcomes following total hip
arthroplasty performed for displaced intracapsular hip fractures: an analysis from the National
Joint Registry for England, Wales, Northern
Ireland and the Isle of Man. J Bone Joint Surg
Am. 2020;102:21–28.
Matharu GS, McBryde CW, Revell MP,
Pynsent PB. Femoral neck fracture after
Birmingham Hip Resurfacing Arthroplasty:
prevalence, time to fracture, and outcome after
revision. J Arthroplasty 2013;28:147–153.
Shimmin AJ, Back D. Femoral neck fractures
following Birmingham hip resurfacing. J Bone
Joint Surg Br. 2005;87-B:463–464.
62. Answer C. Proximal hamstring avulsion
Water-skiing accidents are a classic mechanism
for proximal hamstring insertion injuries (Sallay
et al. 1996). This either occurs due to forceful hip
flexion and knee extension while attempting to
start from a submerged position or as a result of
a fall at speed (Figure 4.12). Interest in surgical
repair of proximal hamstring avulsions is
increasing due to reports of promising results
(Wood et al. 2020). Rectus femoris avulsions
occur in adolescents (apophyseal injury) taking
part in sports involving kicking and sprinting.
Rectus femoris is a biarticular muscle, this predisposes it to injury due to resultant greater
Gradual acceleration
Hip and knee exed
A. Safe Position
Sudden pull from boat
Forced exion
Acute knee extension
B. Position of Injury
Figure 4.12 Hip is flexed while the knee is extended, causing
eccentric contraction of the hamstrings when suddenly pulled by
the boat (Chakravarthy et al. 2005)
68
Hip II Structured SBA
length change and strain compared with monoarticular muscles. Gluteus maximus avulsion
injuries are rare. Isolated greate r trochanter fractures occur most commonly in elderly patients
with osteoporotic bone. It is important to differentiate an isolated greater trochanter fracture
from one that has intertrochanteric extension.
Transversus process fractures are common in
high energy trauma as a result of psoas and
fascial avulsions occurring in extension and lateral flexion.
Chakravarthy J, Ramisetty N, Pimpalnerkar
A, Mohtadi N. Surgical repair of complete prox-
imal hamstring tendon ruptures in water skiers
and bull riders: a report of four cases and review
of the literature. Br J Sports Med
2005;39:569–572.
Sallay PI, Friedman RL, Coogan PG,
Garrett WE. Hamstring muscle injuries among
water skiers: functional outcome and prevention.
Am J Sports Med. 1996;24:130–136.
Wood D, French SR, Munir S, Kaila R. The
surgical repair of proximal hamstring avulsions.
Bone Joint J. 2020;102-B:1419–1427.
63. Answer A. Crowe IV dysplastic hip (superior
subluxation) – positive Galeazzi test, asymmetrical Bryant’s triangle, Thomas test negative
The Galeazzi test is used to assess discrepancy in
femur or tibia length by assessing knee position
with the patient supine, knees at 90° and feet
planted at the same position. Any disparity in
knee height indicates a positive test and either a
difference in femur or tibia length or both.
In a superior hip dislocation the Galeazzi test
will be positive because the femur will appear
shortened due to the superior centre of rotation
of the hi p joint. Figure 4.13 is a diagram of
Bryant’s triangle. Bryant’ s triangle is a hypothetical triangle of lines drawn on the body to determine upward displacement of the trochanter
(originally described as a method to diagnose
hip fracture). The Thomas test is used to detect
a hip fixed flexion deformity. Crowe type IV hip
dysplasia causes an asymmetrical Bryant’striangle. Hip arthrodesis is typically performed
with ~30
o
hip flexion and so would result in a
positive Thomas test. Hip arthrodesis would also
likely result in shortening of the femur and so a
positive Galeazzi test. A previous femoral physeal
Figure 4.13 A
triangle formed by
the tip of the
greater trochanter
and anterior
superior iliac spine
and the vertical and
horizontal lines
BRYANT’S
TRIANGLE
Nelaton’s Line
that intersect
injury would likely result in femoral shortening
and thus a positive Galeazzi test. A previous tibial
fracture malunion should have symmetrical
Bryant’s triangles.
The aetiology of leg length discrepancy (LLD)
can be classified as true or apparent. A true LLD
is defined as the anatomical difference between
the lengths of one or more of the segments of the
lower extremity (femur or tibia). An LLD that
refers to discrepancies that are not true differences in anatomic segment lengths are termed
apparent or a postural discrepancy (e.g. knee
flexion contracture or a dislocated hip). A functional LLD is the sum of the true and apparent
LLD and is the most important in treatment
decisions.
Clinical methods for measuring LLD include
measuring tape and blocks. Using a tape measure, true leg length is measured from the medial
malleolus to the anterior superior iliac spine.
However, this method for measuring true LLD
is slightly flawed as this method would wrongly
attribute a hip dislocation to be a true LLD
whereas by definition it is an apparent LLD.
Apparent leg length is measured by measuring from the medial malleolus to a bony reference point in the midline such as the
xiphisternum. A discrepancy of apparent leg
69
James Gill and Majeed Shakokani
length measurement can occur due to pelvic
obliquity (scoliosis), pelvic deformity, hip or
knee fixed flexion deformity or a true LLD.
Placing blocks of known height beneath the heel
of the short leg to level the pelvis allows an
‘indirect’ me asurement of leg length discrepancy.
This method is slightly more reliable and accurate than using a tape measure.
Radiographic methods such as plain radiography, CT scanogram or EOS are useful for
quantifying LLD more accurately. Finally, a
long-standing LLD can cause a compensatory
hip and knee fixed flexion deformity of the contralateral limb which can further complicate the
clinical picture.
64. Answer C. L2 root lesion
The Trendelenburg test is a clinical test used to
assess hip pathology. During a normal test when
performing single leg stance, the pelvis rises
slightly on the contralateral side. Four basic
elements are required for a normal test.
Functioning fulcrum (hip joint), normal lever
arm (offset), functioning hip abductor muscle
(gluteus medius and minimus) and intact nerve
supply to hip abductors. The hip abductors are
supplied by the superior gluteal nerve which has
a root level of L5 and not L2. Hip abductor
tendinopathy or tendon avulsions are a common
cause of a positive Trendelenburg sign. Abductor
tendinopathy also causes a Trendelenburg gait.
The resultant hip adduction increases the tension
of the iliotibial band and increases compression
of the trochanteric bursa and will eventually lead
to trochanteric bursitis which can cause significant lateral hip pain.
Osteoarthritis is known to induce periarticular muscle atrophy so hip arthritis causes hip
abductor atrophy and weakness.
A total hip arthroplasty with a reduced offset
compared with the native hip means the hip
abductors would not be correctly tensioned to
function optimally. To put it another way a
reduced offset results in a reduced hip abductor
lever arm and so can result in a positive
Trendelenburg sign.
The hip abductors are supplied by the superior gluteal nerve. The superior gluteal nerve is at
risk during the Hardinge approach when gluteus
medius is split too proximal from the trochanter.
70
Section 2
Chapter
5
Adult Elective Orthopaedics and Spine
Hip III Structured SBA
Nicholas Wei and Paul Banaszkiewicz
HIP III STRUCTURED SBA QUESTIONS
1. An 80-year-old female patient attends the arthroplasty follow-up clinic complaining of nonspecific left hip pain.
The appearance of the left uncemented femoral
stem calcar (Figure 5.1) would have been minimised by using
C. Increased hip joint reaction forces
D. Instability
E. Trochanteric pain
3. A 72-year-old female attends the arthroplasty
follow-up clinic. Her anteroposterior (AP) radiograph is shown in Figure 5.2. She has lowe r back
pain and non-specific right hip pain.
The appearance will
A. Affect implant survival
B. Depend on stem stiffness
C. Lead to increased rates of osteolysis
D. Lead to mid-thigh pain
E. Result in loosening of the implant
Figure 5.2 Anteroposterior
(AP) radiograph hip
Figure 5.1 Radiograph left calcar
A. A round stem
B. A tapered stem
C. A titanium alloy
D. Avoiding flutes
E. Using a cemented stem
2. Post-operative radiographic femoral offset meas-
urements of a patient fo llowing THA suggest an
excessive femoral offset.
Consequences of an excessive femoral offset
include?
A. Abductor weakness
B. Increased likelihood of using a walking aid
4. An 85-year-old female attends clinic complain-
ing of a 2-week history of hip pain on weight
bearing, groin tenderness on rotation. No history
of injury. Her radiographs are shown in
Figure 5.3.
The most likely diagnosis would be
A. Age-related thinning
71
Nicholas Wei and Paul Banaszkiewicz
Figure 5.3 Radiograph of 85-year-old female
B. Osteolysis
C. Osteomyelitis
D. Stress shielding
E. Tumour
5. An 85-year-old female attends clinic complaining
of a 2-week history of hip pain on weight bearing,
groin tenderness on rotation. No history of injury.
Her radiographs are shown in Figure 5.3.
The most appropriate plan of action would be
A. Bone scan
B. CT scan
C. Curettage and bone grafting to left hip
D. Observation with yearly follow-upclinic review
E. Revision femoral stem
6. A 67-year-old male attends follow-up arthro-
plasty clinic. Three weeks prior he had a minor
fall and attended the ED. Radiographs were taken
in clinic today and his right anteroposterior (AP)
hip radiograph is shown in Figure 5.4.
Figure 5.4 Anteroposterior
(AP) radiograph right hip
The acetabular cup demonstrates the following
features
A. Absent medial stress shielding (osteopenia)
B. Absent superolateral sclerosis (buttress)
C. Continuous radiolucent line around cup
D. No evidence of inferomedial buttress
E. Remodelling of radial trabeculae pattern
7. A 43-year-old woman presents to clinic with
groin pain. She had undergone a right MoM
hip resurfacing 3 years previously
Concerning her MRI scans (Figure 5.5).
Figure 5.5 MRI pelvis axial T2
A. Appearance would be consistent with her
painful symptoms and lack of function
B. Biopsy is indicated
C. Diagnosis is made by histological diagnosis
D. Is specific for an adverse reacti on to metal
debris
E. Pathogenesis involves a delayed hypersensi-
tive (type IV) response to Co-Cr particles
72
8. A 76-year-oldmale attends the arthroplasty followup clinic. He had a cemented total hip arthroplasty
performed 10 years previously using a lateral
Hardinge type approach. He complains of anterior
thigh and knee pain with walking. Clinical examinationreveals anantalgic gait with abductor lurch.
The most likely diagnosis would be
A. Abductor muscle atrophy with partial gluteal
detachment
B. Infection
C. Loose femoral component
Hip III Structured SBA
D. Thoracolumbar discogenic pain
E. Vastus lateralis muscle herniation
9. A 69-year-old woman is seen as an emergency
add on to the orthopaedic clinic. She underwent
cemented THA 10 days previously. Her wound
has been persistently draining since she was discharged from hospital. She is well within herself,
apyrexia with minimal hip pain.
The next most appropriate course of action is to
A. Aspirate the hip
B. DAIR hip
C. Discontinue anticoagulation treatment
D. Start oral antibiotics
E. Swab the wound
10. A 52-year-old male attends clinic with a fused
hip. Fusion was perform ed 30 years previously
following an RTA with an acetabular fracture
and secondary development of osteonecrosis.
He complains of severe low back pain and ipsilateral knee pain. Radiographs show a cobra head
plate in place with some concern about his
abductor muscle mass.
The most appropriate assessment would be:
A. Electromyography
B. Inspection and palpation abductor muscle mass
C. MRI scan to assess abductor status
D. Trendelenburg test
E. US scan abductor muscle
12. A 78-year-old female is seen in the outpatient
clinic with severe bilateral end stage arthritis.
She asks that both hips be operated on at the
same time as it would ‘get them both out of the
way in one sitting and save time’.
Compared with a 2-stage bilateral THA procedure a simultaneous bilateral total hip arthroplasty (SBTHA) has
A. Increased cardiovascular complications
B. Increased dislocation rate
C. Increased DVT risk
D. Increased risk of death
E. Increased transfusion requirements
13. You have been on call for the acute trauma take
during the last 24 hours. At the trauma meeting
before theatre radiographs of a 51-year-old
female who drinks 1 bottle of wine a day are
shown (Figure 5.6). She had a low velocity fall
onto her right hip. She is otherwise fit and well.
The most appropriate choice of management
would be
A. Cannulated screw fixation
B. Cemented bipolar hemiarthroplasty
C. Cemented total hip arthroplasty
D. Two-hole dynamic hip screw (DHS) with
supplementary screw fixation
E. Uncemented total hip arthroplasty
11. A 24-year-old male presents to the orthopaedic
clinic with a 2-year history of progressively
worsening osteoarthritic hip pain. Pain limits his
walking distance to around 1/2 mile with almost
continuous pain and causes sleep disturbance at
night. He is struggling to climb ladders at work as
a scaffolder and can no longer play football.
The most appropriate course of action would
be to
A. Advise he is too young to undergo THA and
he should continue with conservative management of his hip arthritis
B. List for an uncemented ceramic on HXLPE THA
C. List for hip fusion
D. List for steroid local anaesthetic injection hip
so he can restart playing football
E. Refer on to hip surgeon who performs MoM
resurfacing
Figure 5.6 Anteroposterior (AP) radiographs femur
14. You have been on call for the acute trauma take
during the last 24 hours. At the trauma meeting
before theatre the radiographs of a 38-year-old
female with known excessive alcohol intake are
shown (Figure 5.7). She has had a low velocity
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