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Nicholas Wei and Paul Banaszkiewicz
low-grade organisms (83% sensitivity compared
with 38% sensitivity with direct culture plates).
After the surgeon places the sample in the
sterile broth pot, it can be shaken enabling the
Ballotini beads to dislodge the bacteria from the
tissue samples, enhancing the chance of a positive culture, without risking contamination by
multiple laboratory steps.
The benefit of obtaining multiple samples for
culture is not only to increase the yield of difficult to identify organisms but also to be able to
decide when a bacterium is more likely to be a
contaminant or not. For example, if 3 of 5 specimens culture an identical organism, there is a
96% chance that this is the true causative organism, compared with a 25% chance with 2 positive
identical samples (Walker et al. 2020).
In recent years, polymerase chain reaction
(PCR) has been used in the diagnosis of PJI. A
recent meta-analysis of PJI diagnosed by synovial
fluid PCR concluded that the diagnostic capability of synovial fluid PCR is not superior to that of
synovial fluid culture.
Gram staining of synovial fluid has shown a
poor sensitivity (~30%) in diagnosing S. aureus
PJI, and therefore, its clinical utility appears to be
low.
Intraoperative frozen section will indicate
whether an infection is likely but not tell you
the organism responsible. Mirra et al. (1976)
were the first to describe a heavy infiltrate of
acute inflammatory cells on frozen section pathology in infected periprosthetic tissues, while in
contrast there was an absence of PMN cells in
non-infected cases. Lonner et al. (1996) showed a
significantly higher PPV (89 vs. 70%) when the
threshold for infection was raised to 10 PMN/
HPF. A skilled and experienced pathologist
should analyse all the tissue sections.
Fink B et al. The value of synovial biopsy,
joint aspiration and C-reactive protein in the
diagnosis of late peri-prosthetic infection of total
knee replacements. J Bone Joint Surg Br.
2008;90:874–878.
Lonner JH et al. The reliability of analysis of
intraoperative frozen sections for identifying
active infection during revision hip or knee
arthroplasty. J Bone Joint Surg Am
1996;78:1553–1558.
Mirra JM et al. The pathology of the joint
tissues and its clinical relevance in prosthesis
failure. Clin Orthop Relat Res 1976;117:221–240.
Walker LC et al. The importance of multi-
site intra-operative tissue sampling in the diagnosis of hip and knee periprosthetic joint infection – results from a single centre study. J Bone
Joint Infect. 2020;5:151–159.
42. Answer D. Gluteal muscle (abductor) deficiency
Constrained liners should only be considered
when a ll other factors related to the total hip
arthroplasty have been corrected or optimised.
Component malposition leading to instability of
hip arthroplasty is best addressed by correcting
the malposition.
Indications for constrained liners in the revision situation include cases with previously failed
operations for instability, elderly low-demand
patients with instability, cases with poor or
absent hip musculature, and cases with wellpositioned acetabular and femoral co mponents
and with hip instability. Whilst constrained
liners may be used in revision hip surgery to
reduce the risk of dislocation this should only
be in carefully considered situations where less
constrained options have been considered but
discounted.
If an acetabular cup has been revised to an
uncemented metal shell the immediate use of a
constrained acetabular insert is best avoided as
osseointegration has not taken place and there is
a significant risk of cup pull out from the acetabulum even with the use of screws.
Some recommended technical tips for placement of constrained liners. (1) Avoid impingement; (2) avoid placement of constrained liner
with component malalignment; (3) avoid placement of constrained liner in acetabular allograft
or when the shell has inadequate osteointegration.
43. Answer D. Use of a small femoral head
Four variables that affect THA stability are (1)
Component design; (2) Component position; (3)
Soft tissue tensioning; (4) Soft tissue functioning.
The SBA options focus on components.
Femoral component design
Large femoral heads
○ Head to neck ratio
104
Hip III Structured SBA
○ Avoidance of skirts as these decrease head to
neck ratio
○ Increased jump distance
Femoral offset
Acetabular component design
Elevated rim liner
Lateralised liner (increases soft tissue tension)
Articulation
Dual motion
Captive cup
This SBA focuses only on component factors and
steers clear of mentioning abductor deficiency, a
vertically orientated cup or reduced femoral
offset in the stem options as in these situations
the risk of dislocation is hard to quantify.
A 2005 study of more than 20,000 THA
found a significantly decreased rate of dislocation with the use of larger femoral heads.
Stratified by femoral head size, dislocation rates
were 3.6% for 28 mm, 4.8% for 26 mm and
18.8% for 22 mm. Other stud ies have noted the
effectiveness of even la rger head sizes ranging
from 28– 40 mm.
Despite the theoretical reasons to expect a
larger femoral head to be associated with a lower
rate of dislocation, this predicted effect had not
been identified in many older studies as sample
size was too small and also dislocation is a multifactorial phenomenon.
The risk of dislocation may be influenced by a
number of other factors, including patient-related
factors(such as diagnosis, ageand sex) and surgical
technique. Dislocation is more common in association with the posteriorapproach and witha highly
abducted acetabular component orientation and is
less common following soft-tissue repair.
Howie et al. (2012) reported that the incidence
of dislocationwithin one yearafter primary arthroplasty was five times lower in patients with a 36mm articulation (0.8%) than in those with a 28mm articulation (4.4%). This difference was both
clinically important and statistically significant.
Larger diameter femoral heads have a larger
femoral head to neck ratio, which increases hip
motion before impingement between components occurs. Jump distance is increased. The
jump distance (JD) is the degree of lateral
translation of the femoral head centre required
before dislocation occurs.
Concerns about polyethylene wear in larger
diameter articulations involving 36mm femoral head s prevented their use with earlier generations of UHMWPE.
When choosing a femoral head of a certain
diameter, the surgeon must consider many factors
other than hip stability such as the expected volumetric wear rate of the bearing surface, risk of trunnionosis, long-term THA survivorship, frictional
torque, hip ROM and hip function. Furthermore,
hip stability is determined by many factors, of which
femoral head diameter is only one feature.
The use of a skirt significantly increases the
dislocation risk. Skirts are attachments used to
extend the length of the femoral neck and reduce
the head to neck ratio. This would have been
good to use as a plausible distractor but we could
find no direct evidence quantifying the dislocation risk. Skirts are only infrequently used in
special situations in arthroplasty surgery.
Berry DJ, von Knoch M, Schleck CD,
Harmsen WS. Effect of femoral head diameter
and operative approach on risk of dislocation
after primary total hip arthroplasty. J Bone Joint
Surg Am. 2005;87:2456–2463.
Howie DW, Holubowycz OT, Middleton R.
Large Articulation Study Group. Large femoral
heads dec rease the incidence of dislocation after
total hip arthroplasty: a randomized controlled
trial. J Bone Joint Surg Am. 2012;94:1095–1102.
Tsikandylakis G, Mohaddes M, Cnudde P,
Eskelinen A, Kärrholm J, Rolfson O. Head size
in primary total hip arthroplasty. EFORT Open
Rev. 2018 May 21;3(5):225–231.
44. Answer D. Risk of injury to inferior gluteal and
pudendal vessels is high with posterior-inferior
quadrant
No apologies for repeating this SBA topic as the
subject is of significant practical importance and
is also frequently asked in viva examinations. It is
an ‘A’ list topic.
The posterior superior and posterior inferior
acetabular quadrants contain the best available bone
stock and are relatively safe for the transacetabular
placement of screws. The anterior superior and
anterior inferior quadrants should be avoided
whenever possible, because screws placed
105
Nicholas Wei and Paul Banaszkiewicz
Posterior
Superior
Line A
Anterior
Posterior
Inferior
Anterior
Inferior
Figure 5.29 The acetabular-quadrant system. The quadrants are
formed by the intersection of lines A and B. Line A extends from the
anterior superior iliac spine (ASIS) through the centre of the
acetabulum to the posterior aspect of the fovea, dividing the
acetabulum in half. Line B is drawn perpendicular to line A at the
mid-point of the acetabulum, dividing it into four quadrants
Superior
Line B
evident at the superolateral aspect of the obtur-
ator foramen, where the nerve, artery and vein
exit the true pelvis through the obturator canal.
When an anatomi cal variant was present (the
aberrant obturator artery or accessory obturator
vein) these vessels were even more susceptible
to injury. The accessory or aberrant obturator
vessels travel across a section of the pelvic brim
(located just opposite the anterior inferior quadrant) with little interposed soft tissue. This section
of the osseous acetabulum is thin (6–12 mm), which
increases the possibility of vascular injury.
Screws that are located centrally in the pos-
terior superior quadrant may be directed
toward the superior gluteal nerve, artery and vein
as they exit the pelvis through the greater sciatic
notch.
Screws that are located centrally in the pos-
terior inferior quadrant are directed toward the
inferior gluteal and internal pudendal nerves and
vessels. These structures are rarely endangered,
due to surro unding intrapelvic tissue and their
distance from the posterior column.
Wasielewski RC, Cooperstein LA, Kruger
MP, Rubash HE. Acetabular anatomy and the
trans acetabular fixation of screws in total hip
arthroplasty. J Bone Joint Surg Am.
1990;72:501–508. PMID: 2324135.
improperly in these quadrants may endanger the
external iliac artery and vein,as well as the obturator
nerve, artery and vein (Wasielewski et al. 1990).
The acetabular-quadrant system provides the
surgeon with a simple intraoperative guide to the
safe transacetabular placement of screws during
primary and revision acetabular arthroplasty. A
constant relationship was found to exist between
specific acetabular quadrant s and specific intrapelvic structures.
Screws originating from the anterior super-
ior quadrant were found to lie near the external
iliac artery and vein. However, because of the
more medial position of the vein with respect
to the artery and the paucity of interposed tissue
along the pelvic brim, the external iliac vein was
more in dang er of injury than was the artery.
Screws originating from the anterior inferior
quadrant were directed toward the obturator
nerve and vascular structures. This is most
106
45 Answer D. Reduced femoral offset
If a patient has a long-standing significant leg
length discrepancy, then as a general rule leaving
the leg slightly shorter on the affected side is a
preferred option rather than equalising leg
lengths. Patients will have got used to the
shortening and will struggle to adapt to normalisation of leg lengths. Stem mismatch is more of
an issue with an oversized stem rather than an
undersized stem. The patient should not have
any residue symptoms from Perthes disease compared with an inflammatory arthritis where residue inflammation in a joint may still be present.
There is no suggestion on the radiographs of
failure of femoral stem osteointegration.
The patient has a reduced femoral offset and
is complaining of a limp and leg weakness. This
is likely to be due to failure to restore femoral
offset. The femoral stem has been undersized but
there is no real evidence of proximal/distal femoral stem mismatch.
Notes
1 This SBA is similar to SBA Question 59 in Chapter 4. Both
provide a structured framework to discuss the pathogenic
causes of ON.
We prefer the newer more simplified system contained in
question 59 in which the pathological mechanisms are divided
Hip III Structured SBA
into three components: (1) mechanical vascular interruption,
(2) intravascular occlusion and (3) extravascular compression.
However, this structured framework is perfectly acceptable
and one also worth knowing especially if you are wanting to
score higher than an average 6 pass.
107
Section 2
Chapter
6
Adult Elective Orthopaedics and Spine
Knee I Structured SBA
Oliver Bailey and Pradyumna Raval
KNEE I STRUCTURED SBA QUESTIONS
1. While performing a posteromedial approach to
the knee, which of the following structures
helps you identify the corre ct plane?
A. Saphenous nerve
B. Saphenous vein
C. Semitendinosus tendon
D. Sural nerve
E. Tibial artery
2. When performing a knee posterolateral corner
reconstruction, which of the following structures
has the most anterior femoral insertion point?
A. Arcuate ligament
B. Lateral collateral ligament
C. Lateral head of the gastrocnemius
D. Popliteofibular ligament
E. Popliteus
3. All of the following are considered part of the
posteromedial corner of the knee apart from
which structure?
A. Medial collateral ligament
B. Oblique popliteal ligament
C. Posterior oblique ligament
D. Posteromedial joint capsule
E. Semimembranosus tendon and its
expansions
C. Lateral collateral ligament
D. Popliteus
E. Tibial nerve
5. When climbing stairs, roughly how does a
patient’s body weight correlate with the joint
reaction force of their patel lofemoral joint?
A. 0.5 times body weight
B. 2–3 times body weight
C. 20 times body weight
D. 7–8 times body weight
E. Unrelated to body weight
6. Which of the following is not a validated knee
outcome measure?
A. IKDC
B. KOOS
C. Lysholm Score
D. Oxford Knee Score
E. SF-30
7. You review a young adult who presents with a
painless knee swelling and intermittent locking with
no history of trauma. MRI is shown in Figure 6.1.
Figure 6.1
MRI scan knee
4. A 24-year-old male sustained a grade III posterolateral corner injury of his knee following a
skiing injury 2 years previously. He is listed for
surgery for chronic pain and instability.
Which of the following is the most essential
structure to identify prior to performing a posterolateral corner reconstruction?
A. Common peroneal nerve
B. Iliotibial band
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Knee I Structured SBA
This demonstrates a joint effusion with a mass-like
synovial proliferation with lobulated margins.
What is the most likely diagnosis?
A. Lipoma arborescens
B. Pigmen ted villonodular synovitis
C. Rheumatoid arthritis
D. Synovial cell sarcoma
E. Synovial chondromatosis
8. You are supervising a trainee perform a knee
arthroscopy on a 25-year-old female. You notice
they have made their anterolateral arthroscopy
portal quite inferior to where you had wanted. A
complication occurs due to this portal placement.
What piece of equipment will you ask for to
deal with this complication?
A. ACL repair kit
B. All-inside meniscal repair kit
C. Chondral fixation kit
D. Microfracture kit
E. Outside-in meniscal repair kit
9. A youngfemale presents with snapping ofher knee
with episodes of locking. Sagittal MRI images of
her lateral compartment show three 5mm-thick
contiguous images of her meniscus from anterior
to posterior horns with no tears obvious.
What is your next management step?
A. Inject with steroid
B. List for arthroscopy
C. List for arthroscopy + saucerisation
D. List for arthroscopy + saucerisation +/–
meniscocapsular repair
E. Refer to physiotherapy
10. You review a young female with the results of her
MRI after a twisting knee injury. You are pleased
to see she is now asymptomatic but note that
within the lateral compartment of the knee her
MRI demonstrates ‘a minimal meniscal width to
maximal tibial width (on coronal slice) of 40%,
and a ratio of the sum of the width of both lateral
horns to the maximal meniscal diameter (on
sagittal slice) of 80%’.
What is your management plan?
A. Discharge to physiotherapy
B. Discharge with no follow up
C. List for arthro scopic meniscal repair
D. List for arthroscopic saucerisation
E. List for diagnostic arthroscopy
11. You review a 10-year-old boy with lateral knee
pain. MRI shows five sagittal slices of 5mm-thick
contiguous lateral meniscus from anterior to
posterior horns.
Which of the following X-ray findings is associated with the diagnosis?
A. Hypoplastic patella
B. Lateral tibial plateau fracture
C. Narrowing lateral joint space
D. Segond fracture
E. Tibial eminence hypoplasia
12. You are performing an arthroscopic PCL recon-
struction and utilise X-ray guidance while
drilling the tibial tunnel.
Which complication are you hoping to reduce
with the use of X-ray fluoroscopy?
A. Graft impingement
B. Malplacement of the tunnel
C. Overconstraint
D. Popliteal artery injury
E. Tibial fracture
13. During ACL surgery, you prematurely amputate
the semitendinosus hamstring graft at a length of
about 7cm.
What is the likely intraoperative mistake?
A. You had not appreciated the patient had a
positive Dial test
B. You had not fully released the extratendinous
tethers to the medial head of gastrocnemius
C. You had released the semitendinosus from
the sartorial facia prior to using the tendon
stripper
D. You had used a closed loop tendon stripper
rather than an open loop tendon stripper
E. Your graft harvest wound was too small
14. At a 6-week post-operative review of one of
your ACL reconstructions they complain of
ongoing numbness over the medial border of
their foot on the same side as their ACL
reconstruction.
What is the likely graft that this patient has
had?
A. Bone–patella–tendon–bone allograft
B. Bone–patella–tendon–bone autograft
C. Hamstring allograft
D. Hamstring autograft
E. Quadriceps
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Oliver Bailey and Pradyumna Raval
15. You have been asked to review one of your ACL
reconstructions at 3 months post-operatively by
the physiotherapist. They are concerned that the
patient is unable to fully extend their knee.
What is the likely intraoperative mistake?
A. The entry point for the femoral tunnel is at
the 12 o’clock position
B. The entry point for the tibial tunnel is 2mm
anterior to the anterior horn of the lateral
meniscus
C. You havea cortical‘blowout’ while reaming the
femoral tunnel; therefore, you secured the graft
with a larger-than-normal femoral button
D. You prematurely amputate the hamstring
graft during harvest, leading you to change
your graft choice from quadrupled stranded
hamstring graft to a bone–patella–tendon–
bone graft
E. You tensioned the graft in 30° of knee flexion
rather than full extension
16. You are reviewing a 19-year-old female who
plays netball nationally and who underwent an
isolated ACL reconstruction 11 months ago. She
was really happy with her rehabilitation, but on
return to her first contact game at 10 mon ths
post-operatively her ACL graft failed. Lachman
and pivot shift tests are positive, Dial test is
negative. On review of her preoperative MRI,
you note an ACL rupture with the presence of a
Segond fracture, but no other abnormality.
What is the most likely cause of their re-rupture?
A. The surgeon failed to address the anterolat-
eral complex
B. The surgeon failed to address the posterolat-
eral complex
C. The surgeon used hamstring autograft
D. The surgeon used patella tendon autograft
E. The tibial graft tunnel was too anterior
17. You are performing a total knee replacement
using a measured resection technique with a PS
design using anterior femoral referencing; however, on trialling the implants, the knee is ok in
flexion but loose in extension.
Which of the following is the best option to
gain a stable knee?
A. Anteriorise the femoral component and use
distal augments
B. Downsize the femur and use a thicker insert
C. Resect more bone off the tibia and downsize
the femur
D. Resect more bone off the tibia and upsize the
femur
E. Resect the PCL
18. You are performing a total knee replacement
using a measured resection technique with a PS
design using anterior femoral referencing; however, on trialling the implants, you notice the
knee is loose in flexion but ok in extension.
Which of the following is the best option to
gain a stable knee?
A. Posteriorise the femoral component
B. Proximalise the femur and use a thicker
insert
C. Resect more bone off the femur and upsize
the femur
D. Resect more bone off the tibia and upsize the
femur
E. Upsize the femur
19. You see an unhappy patient in clinic who under-
went a total knee replacement 3 years ago. They
have no history of wound problems, no history
of trauma and no infective symptoms, but state
they have never really been happy with their
knee. Symptoms include anterior knee pain,
clunking and difficulty walking. There is no evidence of osteolysis on X-ray.
Which of the following investigations is most
likely to demonstrate an abnormality?
A. Bloods
B. CT rotational profile of the leg
C. Knee aspiration with a request for extended
cultures
D.
Knee aspiration with a request for Gram stain
E. Knee aspiration with a request for white cell
count
20. You are performing a total knee replacement in a
valgus knee and trying to balance the components. It is well balanced in extension but remains
tight laterally in flexion.
What is the next best appropriate intraoperative step?
A. Downsize your femoral component with
anterior referencing
110
Knee I Structured SBA
B. Release the LCL
C. Release the PCL
D. Release the popliteus
E. Resect more of the tibia and distalise the
femur with augments
21. A patient presents after a fall with a periprosthetic knee fracture extending proximally from
the femoral component.
What intraoperative decision has the original
knee surgeon made that has increased the
chances of this happening?
A. In an attempt to improve patella tracking, they
externally rotated the femoral component
B. In an attempt to improve the extension gap,
they performed a posterior release
C. In an attempt to improve the flexion gap,
they released the PCL and subsequently
changed from a CR to a PS implant design
D. On measuring the femoral component size
using posterior referencing, it measured 4.5
and the decision was made to use a size 4
implant, as a size 5 may overstuff the PFJ
E. They proximalised the femoral component
due to preoperative fixed flexion
22. One-year post-operatively from a total knee
replacement (without patella resurfacing) a
patient presents to your clinic with severe
worsening anterior knee pain and grinding over
the PFJ. Skyline radiographs of the patella demonstrate fragmentation of the patella and accelerated arthritic changes.
What decision intraoperatively has most likely
led to this presentation?
A. Denervation of the patella was performed
with diathermy
B. Due to poor patella tracking, a lateral retina-
cular release was performed
C. The femoral component was anteriorised to
increase the flexion gap
D. The femoral component was externally rotated
E. The patella was not resurfaced
23. You review a patient in clinic who is 4 years post-
operative from a total knee replacement. They
are complaining of increasing pain for the past 6
months. X-ray demonstrates an area of osteolysis
behind the femoral component. Aspiration of the
joint has the following results: Gram stain negative, WCC 4 000, PMN count 90%. Culture does
not grow anything.
Which is the most appropriate next step?
A. Arthroscopic washout of the knee
B. DAIR procedure
C. Nuclear medicine bone scan
D. One-stage revision
E. Two-stage revision
24. A patient complains of numbness after undergo-
ing a total knee replacement for an arthritic
valgus knee.
Whatisthelikelyareathathassensorydisturbance?
A. Dorsal aspect of the foot
B. L4 dermatome
C. Lateral aspect of foot
D. Medial aspect of the foot
E. Sole of the foot
25. Which of the follo wing radiographic findings
makes a TKA more difficult?
A. A Caton–Deschamps index of 0.7
B. A Dejour grade of C type
C. An Insall–Salvati ratio of 0.7
D. Bipartite patella
E. TT-TG of 12mm
26. You are examining a patient in the anaesthetic
room just prior to surgery. The patient has been
listed for an Oxford knee replacement.
Which of the fol lowing examination findings
are you most worried about?
A. 0–
95° range of movement
B. 10° fixed flexion
C. 11° correctable varus
D. Age 68
E. Previous arthroscopy scars
27. A 45-year-old male presents with a chronic his-
tory of knee pain, swelling and locking. There is
no histo ry of trauma and they are systemically
well. MRI shows multiple lobular cartilage
lesions within the joint.
What is the next best management option?
A. Anti-inflammatory medication + intra-
articular steroid injection
B. Arthroscopic synovectomy, removal of
loose bodies and histopathological analysis
111
Oliver Bailey and Pradyumna Raval
C. Joint aspiration
D. Neoadjuvant radiotherapy followed by wide
local excision
E. Open biopsy
28. A 67-year-old patient presents with an acutely
swollen knee with no history of trauma. They
are systemically well. X-ray of the knee is normal
apart from an effusion. A joint aspirate has a
negative Gram stain but demonstrates positively
birefringent crystals.
What is the next best management?
A. Admit patient to await full culture and
sensitivities
B. Book on trauma list for emergency joint
washout
C. Reassure and discharge with anti-
inflammatory medication
D. Reassure and discharge with anti-inflammatory
medication and ask GP to start allopurinol
E. Refer for a knee MRI
29. There are multiple options for graft choice when
reconstructing an ACL. Load to failure is one
factor that can help decision making.
What is the load to failure of a 4-strand hamstring autograft?
A. 2000 N
B. 2000 N – 4000 N
C. 2500 N – 3000 N
D. 3000 N
E. 3000 N – 4000 N
30. A patient attends with a dislocation of an Oxford
mobile bearing UKA. On review of the operation
note you do not see any documentation of any
complication but note the bearing size to be
9mm thickness.
What is thelikely intraoperative complication that
has increased the chance of bearing dislocation?
A. 15° malalignment of the femoral component
in the coronal plane
B. ACL injury
C. MCL injury
D. Tibial fracture
E. Unrecognised lateral joint wear
31. A 24-year-old patient presents with a 1-year his-
tory of medial sided knee pain. The only abnormality demonstrated on MRI is a 1cm 2cm full
thickness cartilage defect over the weight bearing
portion of their medial femoral condyle. Other
imaging demonstrates a Mikulicz line 20% from
medial to lateral.
What is the next appropriate management?
A. Closing wedge DFO + nanofracture/AMIC
B. Nanofracture/AMIC
C. OATS
D. Opening wedge HTO + nanofracture/AMIC
E. Posterolateral corner reconstruction + nano-
fracture/AMIC
32. A 17-year-old female is referred to you with
ongoing lateral knee pain which is stopping them
perform any moderate degree of exercise. Mikulicz
line is 48% from medial to lateral and she has no
subjective or objective instability. You note that in
a previous arthroscopy they had a bucket handle
lateral meniscal tear that was irreducible.
What is the next appropriate management?
A. Distal femoral osteotomy
B. List for repeat arthroscopy
C. Proximal tibial osteotomy
D. Refer to physiotherapy with patient-initiated
return appointment
E. Refer to regional centre for consideration of
meniscal transplantation
33. A 15-year-old female presents to you with recurrent dislocation of their patella. She has been told
by one of your colleagues that she needs a distalising and medialising TTO + MPFL reconstruction.
Which of the following results makes you
uneasy at performing this plan?
A. Caton-Deschamps ratio of 1.4
B. Dejour grading B
C. Foot thigh progression angle of 12°
D. Hand-wrist bone age of 14
E. TTTG distance 21mm
34. You have a patient on your list fora mobile bearing
medial unicompartmental knee replacement.
Which of the following radiographic features
would make you concerned?
A. Fixed flexion of 5°
B. Lateral radiograph with medial wear
posteriorly
C. Long leg mechanical varus alignment of 10°
D. MRI findings of medial osteonecrosis
E. Osteophytes within the notch
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Knee I Structured SBA
35. You are following up a 25-year-old patient 1 year
after tibial plateau fixation. They are unhappy
with the stability of the knee and describe it
giving way w hen going down stairs.
What is the most likely fixation of their tibial
plateau?
A. Anterolateral locking plate
B. Lateral to medial subarticular raft screws
C. Medial locking plate
D. Medial to lateral subarticular raft screws
E. Posterolateral buttress plate
36. You are following up a 31-year-old patient 6
months after tibial plateau fixation with one
medial locking plate. They are mobilising well,
however complain of medial sided pain on
weight bearing. You note that their knee is stable
and has an excellent range of motion.
What is the likely next management plan for
this patient?
A. Continue physiotherapy
B. Ongoing physiotherapy
C. Theatre listing for ACL reconstruction
D. Theatre listing for arthroscopy
E. Theatre listing for removal of plate
37. A patient comes into your department with a
Schatzker 6 tibial plateau fracture. You fix it with
a medial and an anterolateral plate. At the 3month follow up the knee is subluxed with failure of fixation.
What mistake has occurred?
A. You failed to address the ACL rupture
B. You failed to assess the patient’s neurovascu-
lar status
C. You failed to organise an MRI prior to surgi-
cal fixation
D. You relied on the Schatzker classification to
aid management
E. You started weightbearing thepatient too early
C. Symptomatic DVT
D. The metalwork becomes infected
E. The patient complains of stiffness
39. You are the senior registrar supervising a junior
colleague applying a tourniquet for a patient who
is set up for a total knee arthroplasty surgery.
This patient is a short lady with truncal obesity
and slightly conical shaped limbs.
Which of the following statements regarding
application of a tourniquet is false?
A. Compressive exsanguination should not be
used in the presence of infection
B. The use of straight tourniquets on conical
thighs is recommended, especially in
extremely muscular or obese individuals
C. Tourniquets should be applied over a thin,
even layer of padding
D. Tourniquet width should be more than half
the limb diameter
E. Wide tourniquet cuffs are more effective at
lower inflation pressures than are narrow ones
40. A 26-year-old amateur footballer presents to the
ED of your hospital following a football injury.
Anteroposterior (AP) radiograph is shown in
Figure 6.2. The knee is swollen and clinical
examination is difficult.
Which of the following statements about this
injury is true?
A. The anterolateral ligament has no role in
knee stability
B.
The anterolateral ligament is an intraarticular structure with a clear course from
the lateral femoral epicondylar region,
Figure 6.2 Anteroposterior
(AP) radiograph knee
38. A patient who has had a BTB ACL reconstruction is involved in an RTA and sustains an ipsilateral bicondylar 2 column tibial plateau
fracture. Your colleague fixes it with a dual plate
technique utilising the patient’s previous scars.
What is the most likely complication?
A. Metalwork fails and the knee subluxes
anteriorly
B. Metalwork fails and the knee subluxes
posteriorly
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