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Oliver Bailey and Pradyumna Raval
22. Answer B. Due to poor patella tracking, a lat-
eral retinacular release was performed
The radiographic changes are consistent with
osteonecrosis of the pate lla. Performing a lateral
retinacular release can damage the lateral superior genicular artery, which supplies the patella
(the other arterial supply being the medial superior genicular artery, w hich is incised during a
medial parapatellar approach).
Denervation of the patella has not been dem-
onstrated to increase this complication.
There is no good evidence for or against
patella resurfacing; therefore, not resurfacing
the patella is a valid surgical decision.
Rotating the femur externally is an important
step in total knee replacements and helps with
patella tracking.
Anteriorising the femoral component can
overstuff the PFJ and lead to anterior knee pain,
but is unlikely to lead to such aggressive presentation as above.
23. Answer E. Two-stage revision
A WCC over 2500 and a PMN count of over 70%
is indicative of infection. This, coupled with the
increasing pain and osteolysis, leads to the most
likely diagnosis being prosthetic joint infection.
Arthroscopic washout and DAIR procedures are
not applicable in chronic infections. A bone scan
can be a useful investigation; however, it is likely
to be positive in the presence of the above and
therefore unlikely to be helpful. As culture did
not grow anything, there is an argument to
repeat the aspiration; however, this is not in the
answer stem. A one-stage revision for infection is
best performed when the organism is known and
is an easily treated organism; as we do not know
the organism, the most appropriate management
is offering a two-stage revision.
24. Answer A. Dorsal aspect of the foot
During correction of a valgus knee to neutral mechanical alignment, the common peroneal nerve can
be stretched. This would lead to sensory disturbance
over the dorsal aspect of the foot and foot drop.
25. Answer C. An Insall–Salvati ratio of 0.7
Insall–Salvati (normal 0.8–1.2) and Caton–
Deschamps (normal 0.6–1.3) are assessments of
patella height. An Insall–Salvati ratio of 0.7
demonstrates patella baja, which can make a
TKA more difficult.
Dejour grade C represents a degree of trochlear
dysplasia; this on its own does not increase TKA
difficulty. A bipartite patella is a normal variant.
TT–TG is a measurement of the distance
from the tibial tubercle to the trochlear groove
in the axial plane. It is a useful measurement in
patella instability. A TT–TG of 0–15mm is
normal, 15–20 borderline, >20 abnormal.
26. Answer A. 0–95° range of movement
You need at least 110° of knee flexion to perform
an Oxford knee replacement. This will allow you
good access to the femur during preparation.
Previous scars can make surgery more challenging; however, arthroscopy scars are fine. You
can perform an Oxford knee on knees with up to
15° of fixed flexion or correctable varus. Age is
not a contraindication.
27. Answer B. Arthroscopic synovectomy, removal
of loose bodies and histopathological analysis
This presentation is consistent with synovial
chondromatosis. This is a benign proliferative disease of the synovium characterised by multiple
intra-articular loose bodies of cartilage at various
stages of calcification. This is most prevalent
in the fourth or fifth decade, with males being
more commonly affected. The knee is by far the
most commonly affected joint. Malignant change
into synovial chondrosarcoma is rare.
Synovial chondromatosis is best managed
with arthroscopic rem oval of loose bodies and
synovectomy. The chance of local recurrence is
reasonably common, with studies quoting
between 3% and 23%.
28. Answer C. Reassure and discharge with anti-
inflammatory medication
Pseudogout (calcium pyrophosphate dihydrate
deposition) is characterised by effusion and
weakly positive birefringent crystals on joint
microscopy. It is more common in the elderly
population. X-ray findings can demonstrate
chondrocalcinosis and erosions, but in the early
stages can be normal. Causes can be idiopathic,
hereditary (AD pattern) or secondary to another
systemic disease such as haemochromatosis,
hyperparathyroidism, hypothyroidism, SLE or
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renal disease. Treatment of pseudogout includes
anti-inflammatory medication, steroid joint
injection and management of the causative condition if present.
If there were signs consistent with septic arthritis, then joint washout or admitting awa iting
full culture results would be appropriate.
An MRI would be appropriate if there was a
history of trauma with a normal knee X-ray.
Gout is negativ ely birefringent on joint
microscopy, and management includes starting
anti-inflammatory medication for an acute flareup with allopurinol started in the community
once the acute flare-up has improved.
29. Answer E. 3000 N – 4000 N
Four-strand hamstring has one of the highes t
load to failure of graft choice for ACL reconstruction. Other options include allograft (2000
N – 4000 N) which has a wide range of load to
failure as its strength can change significantly
depending on sterilisation technique, quadriceps
tendon (3000 N), or middle third patella tendon
(2500 N – 3000 N). The native ACL has a load to
failure of around 2000 N.
30. Answer C. MCL injury
All of the answer stems will increase the chance of
the UKA failing. However, a 9mm insert is one of
the largest inserts available and would raise the
suspicion that the MCL was injured intraoperatively and thesurgeon struggled to balancethe knee.
nanofracture or AMIC (Autologous MatrixInduced Chondrogenesis). OATS (Osteochondral
Autologous Transfer Surgery) isnormally reserved
for larger defects of >4cm
2
.
32. Answer E. Refer to regional centre for consider-
ation of meniscal transplantation
This patient has had a previous irreducible lateral
meniscal bucket handle tear which will have been
resected. Their leg alignment is normal so there
is no requirement for any corrective osteotomy.
The 2015 consensus statement from the IMREF
(Getgood et al. 2017) provided 3 indications for
meniscal transplantation: (1) symptomatic
meniscal deficient knee, (2) concomitant procedure to protect revision ACL reconstruction and
(3) concomitant procedure to protect cartilage
repair.
Meniscal transplantation is relatively rare,
however there is an expanding amount of evidence to suggest it is a good option in the correct
individual. Within the UK there is ongoing
research into this topic with the Meteor 2 study
currently underway which will assess if there is
any significant difference between meniscal
transplantation vs dedicated physiotherapy
alone.
Getgood A et al.; IMREF Group. International
Meniscus ReconstructionExperts Forum(IMREF)
2015 Consensus Statement on the Practice of
Meniscal Allograft Transplantation. Am J Sports
Med. 2017;45:1195–1205.
31. Answer D. Opening wedge HTO + nano-
fracture/AMIC
This patient’s issues are twofold. Firstly, they
have a full thickness cartilage defect which is
likely causing their pain, but just as important
they have malalignment of their limb with a
weight bearing line (Mikulicz) transversing the
medial compartment. When addressing cartilage
defects it is best to correct alignment issues and
instability issues first or in conjunction with
treatment of the cartilage defect. With a varus
malalignment an opening wedge high tibial
osteotomy is a good option for correction.
Closing wedge distal tibial osteotomies are a
good option for valgus malalignment.
With regards to treatment of the cartilage
defect, this is <4cm
2
therefore amenable to
33. Answer D. Hand-wrist bone age of 14
Hand-wrist bone age radiographs are very useful
at helping to identify the true bone age of the
patient and therefore how much growth they
have left. With a bone age of 14 the patient likely
has at least a couple more years of growth
remaining. Growth in children is complex but
can be divided into four time periods: (1) antenatal growth, (2) birth to 5 years of age, (3) 5
years of age to puberty, (4) puberty. Peak lowerlimb growth during puberty occurs around age
14 in boys and 12 in girls (Kelly & Diméglio
2008). One should be careful about performing
surgery around the proximal tibial or distal femoral growth plates in this age gro up. To reduce
risk of growth arrest delaying surgery until skeletally mature may be the better option.
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Oliver Bailey and Pradyumna Raval
A Caton–Deschamps ratio of 1.4, Dejour
grading B and TTTG 21mm all fit with patellofemoral instability. A foot progression angle of
12° is within normal range.
Kelly PM, Diméglio A. Lower-limb growth:
how predictable are predictions? J Child Orthop.
2008;2:407–415.
34. Answer B. Lateral radiograph with medial wear
posteriorly
A lateral radiograph with posterior wear would
lead to a high suspicion of ACL incompetency,
which increases the risk of early failure in mobile
bearing UKAs.
All the other answer stems are acceptable to
continue with a UKA.
35. Answer C. Medial locking plate
The patient describes instability symptoms with
the most likely ligament injury that would relate
to these symptoms being an ACL injury. ACL
injuries are most common in high energy type 4
and type 6 injuries, which would likely require a
medial plate. Anterolateral plates are commonly
used but in isolation would be for lower energy
type 1–3 injuries. Posterolateral buttress plates
are uncommon to use in isolation. Subarticular
raft screws can also be useful in complex fractures but in isolation they do not provide much
mechanical strength therefore are usu ally utilised
in conjunction with a buttress or locking plate.
Wang J, Wei J, Wang M. The distinct pre-
diction standards for radiological assessments
associated with soft tissue injuries in the acute
tibial plateau fracture. Eur J Orthop Surg
Trauma. 2015;25:913–920.
36. Answer D. Theatre listing for arthroscopy
As the patient has had a medial plate applied they
have likely sustained a type 4 tibial plateau fracture. The overall incidence of additional soft
tissue injuries in tibial plateau fracture is around
71%. Schatzker type 4 injuries carry a higher risk
of medial meniscal tears and ACL tears. As the
patient has a stable knee to examination the likely
diagnosis is a medial meniscal tear.
Abdel-Hamid MZ et al. Arthroscopic evalu-
ation of soft tissue injuries in tibial plateau fractures: retrospective analysis of 98 cases.
Arthroscopy 2006;22:669–675.
37. Answer D. You relied on the Schatzker classifi-
cation to aid management
The Schatzker classification was originally proposed in 1974 and based on a two-dimensional
representation of the fracture in the coronal
plane. Although it is widely used, it fails to
address the posterior column as described by
Luo et al. (2010), and therefore is not a good
classification system to aid fixation strategies.
Schatzker type 6 fractures are the most common
fracture type to have a posterior column component, as identified on CT scan, and present in
59% of bicondylar fractures (Higgins et al. 2009).
Around 25% of the articular surface is involved
in the posterior fragment therefore it is important to reduce and stabilise. Patients who have a
posterior column fracture that is not addressed
in the definitive fixation have a significantly
higher risk of failure of fixation.
Higgins TF, Kemper D, Klatt J. Incidence
and morphology of the posteromedial fragment
in bicondylar tibial plateau fractures. J Orthop
Trauma. 2009;23:45–51.
Luo CF, Sun H, Zhang B, Zeng BF. Three-
column fixation for complex tibial plateau fractures. J Orthop Trauma. 2010;24:683– 692.
38. Answer D. The metalwork becomes infected
There is a wide range of infection rate for these
types of fractures in the literature. Risk of infection in these high-energy type fractures ranges
from around 22% (Guild et al. 2022) to 80%
(Musahl et al. 2009). Historically, a single midline incision, as is the case in this scenario (previous BTB), carries the concern of producing a
‘dead bone sandwich’. Guild et al. (2022) however suggest no difference in deep infection rate
with single vs dual approaches (22% vs 23.5%).
Risks of metalwork failure are relatively low
when bicondylar, 2-column fractures are treated
with dual plates. Risk of failure if the patient also
has a posterior column fracture (i.e. a 3-column
injury) is higher if this fracture fragment is not
addressed at the same time as the other two
columns, however in this scenario the question
stem suggests the patient only has a 2-column
injury.
Risk of DVT after complex lower limb
trauma is high, however symptomatic DVT is
relatively low. A study by Wang et al. (2022)
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Knee I Structured SBA
demonstrates 8.4% incidence of clinically
important DVT after tibial plateau fracture.
The risk of stiffness is around 20% at 1 year
(Gaston et al. 2005).
The risk of having further instability can be
higher than the risk of infection, however this
was not in the answer stem. A study by Stannard
et al. (2010) suggests 71% incidence of at least
one major ligament tear following high-energy
tibial plateau fracture.
Gaston P, Will EM, Keating JF. Recovery of
knee function following fracture of the tibial
plateau. J Bone Joint Surg Br. 2005;87 :1233 – 1236.
Guild TT et al. Single versus dual incision
approaches for dual plating of bicondylar tibial
plateau fractures have comparable rates of deep
infection and revision surgery. Injury
2022;53:3475–3480.
Musahl V et al. New trends and techniques in
open reduction and internal fixation of fractures
of the tibial plateau. J Bone Joint Surg Br.
2009;91:426–433.
Stannard JP, Lopez R, Volgas D. Soft tissue
injury of the knee after tibial plateau fractures. J
Knee Surg. 2010;23:187–192.
Wang P et al. Incidence and risk factors of
clinically important venous thromboembolism
in tibial plateau fractures. Sci Rep. 2022;12:20206.
39. Answer B. The use of straight tourniquets on
conical thighs is recommended, especially in
extremely muscular or obese individuals
The usage of a tourniquet requires proper knowledge and care. Tourniquets should be used only
when clinically justified, such as in elective
extremity surgeries or in emergency to control
exsanguination.
Tourniquet width should be more than half
the limb diameter and should be applied over a
thin layer of padding. Application of more than
two layers of padding results in a significant
reduction in the actual transmitted pressure.
Compressive exsanguination is contraindicated in presence of infection, malignancy or
history of deep venous thrombosis.
Wide tourniquet cuffs are more effective at
lower inflation pressures than are narrow ones.
Curved tourniquets on conical extremities require
significantly lower arterial occlusion pressures
than straight (rectangular) tourniquets. The use
of straight tourniquets should be avoided in obese
or extremely muscular individuals.
BSSH and BSCOS (BO AST) The Safe Use of
Intraoperative Tourniquets [pdf]. London:
British Orthopaedic Association; 2021.
Pedowitz RA et al. The use of lower tourni-
quet inflation pressures in extremity surgery
facilitated by curved and wide tourniquets and
an integrated cuff inflation system. Clin Orthop
Relat Res. 1993;287:237–244.
40. Answer D. The entire anterolateral ligament is
visible from its proximal insertion to its distal
insertion, with excellent agreement between
ultrasound and anatomical findings
The radiograph demonstrates a Segond injury.
Segond identified the anterolateral ligament in
1879. It was earlier believed to be an anatomi c
variant of the lateral collateral ligament.
The primary function of the anterolateral
ligament is to provide anterolateral stability, preventing anterior subluxation of tibia relative to
the distal femur.
The stabilizing force is most significant at 30°
and 90° of knee flexion.
Cavaignac et al. (2017) found that the entire
anterolateral ligament was visible from its proximal
insertion to its distal insertion, with excellent agreement between ultrasound and anatomical findings.
The anterolateral ligament is an extraarticular
structure with a clear course from the lateral femoral epicondylar region, running antero-inferiorly
to the proximal tibia at a site midway between
Gerdy’s tubercle and the head of the fibula
The reported MRI sensitivity has a wide variance from 51–
Cavaignac E et al. Historical perspective on
the ‘discovery’ of the anterolateral ligament of
the knee. Knee Surg Sports Traumat Arthrosc.
2017;4:991–996.
Kennedy MI et al. The anterolateral ligament:
an anatomic, radiographic, and biomechanical
analysis. Am J Sports Med. 2015;43:1606–1615.
Van der Watt L et al. The structure and function of the anterolateral ligament of the knee: a
systematic review. Arthroscopy 2015;31:569-82.e3.
41. Answer B. A lateral meniscal cyst
Lateral meniscal cysts are 3–10 times more
common than cysts of the medial meniscus.
98%.
127
Oliver Bailey and Pradyumna Raval
Trauma, degeneration, developmental inclusion
of synovial cells within the meniscal tissue are
some of the theories behind meniscal cysts.
There exists a close correlation between cyst
formation and meniscal pathological conditions,
most commonly tears of the peripheral portion
of the middle third of the lateral meniscus.
Lateral meniscal cysts usually are palpable
immediately anteri or and proximal to the head
of the fibula and anterior to the lateral collateral
ligament.
Average size meniscal cysts are characteristically more prominent when the knee is extended
and less prominent when the knee is flexed; small
cysts may disappear within the joint on flexion.
This is known as the ‘Pisani’ sign.
Scott WN, ed. Insall & Scott Surgery of the
Knee, 4th Ed., Philadelphia, PA: Churchill
Livingstone; 2006.
42. Answer C. Medial patellar plica
Synovial plicae are synovial folds, usually classified according to their anatomical relationship to
the patella: suprapatellar, infrapatellar, medial
patellar and lateral patellar.
The medial patellar plica is most common of
these to be of clinical significance.
The medial patellar plica begins just superior to
the patella running distally along the medial side
wall of the joint and over the medial femoral condyle to insert onto the fat pad. It becomes thickened
and inelastic from trauma or chronic inflammation
and causes anterior knee pain. A common precipitating cause is a direct blow to the anteromedial
knee region, traumatising the plica.
Initial treatment is conservative including
activity modification to avoid repetitive flexion
and extension. Arthroscopic examination of the
knee and resection of the pathological plica may
be required, if symptoms are persistent and conservative measures have failed.
Kramer DE et al. The effects of medial synovial plica excision with and without lateral retinacular release on adolescents with anterior knee
pain. J Chi ld Orthop. 2016;10:155–162.
43. Answer C. The failure rate of allografts is simi-
lar to autografts
Allografts decrease post-operative morbidity,
improve cosmesis, decrease operating time and
preserve extensor mechanism. This may eliminate some post-operative symptoms of tendinitis
or chondromalacia.
The length of time for allograft maturation
and the percentage of incorporation of the graft
into the ligamentous structure vary.
The failure rates in athletes can be as much as
2–4 times that of autograft.
The potential for infection is low, including
hepatitis and bacterial infection.
The possibility of HIV transmission is
approximately 1 in 1.5 million.
Abouljoud MM, Everhart JS, Sigman BO,
Flanigan DC, Magnussen RA. Risk of retear
following anterior cruciate ligament reconstruction using a hybrid graft of autograft
augmented with allograft tissue: a systematic
review and meta-analysis. Arthroscopy
2018;34:2927–2935.
Joyce CD, Randall KL, Mariscalco MW,
Magnussen RA, Flanigan DC. Bone-patellar
tendon-bone versus soft-tissue allograft for
anterior cruciate ligament reconstruction: a systematic review. Arthroscopy 2016;32:394–402.
44. Answer D. Quadrupled hamstring tendon graft
is the strongest at 4140 Newton
Selection of grafts depends on the tissues available and surgeon’s training.
The most commonly grafts are central one
third patellar tendon and quadrupled hamstring
tendon grafts. Quadriceps tendon is less commonly used.
The ultimate load-to-failure strength of
patella tendon is 2977 N, quadrupled hamstring
tendon is 4140 N and quadriceps tendon is
2353 N.
Graft creep or stress relaxation of the graft
over time is more frequent with hamstring
tendons than with ligaments, such as the patellar
or quadriceps ligament.
Interference screws fixation provides sufficient strength with bone–patellar tendon–
grafts. Graft incorporation into bone varies considerably from 3 weeks for bone plugs to more
than 3 months for soft tissues.
Brand J Jr, Weiler A, Caborn DN, Brown
CH Jr, Johnson DL. Graft fixation in cruciate
ligament reconstruction. Am J Sports Med.
2000;28:761–774.
bone
128
Knee I Structured SBA
45. Answer C. Simultaneously injecting IRAP and
IL-10
IL-1 is the cytokine responsible for inducing
protease synthesis, which leads to catabolic
changes within articular cartilage. The IRAP
gene is interleukin-1 receptor antagonist protein.
The IRAP gene was inserted in extracted synovial
cells of rabbits using a retroviral vector, which
leads to significant anti-inflammatory effects in
rabbit knee joints.
IL-10 is known for its anti-inflammatory
properties and independent effects on T-cell
reactivity. Studies have shown that injecting the
genes for both IRAP and IL-10 together resulted
in greater inhibition of cartilage breakdown, suggesting that simultaneous gene delivery may be
required to treat OA by targeting the activities of
multiple inflammatory factors
Bandara G et al. Intraarticular expression of
biologically active interleukin 1-receptor-antagonist protein by ex vivo gene transfer. Proc Natl
Acad Sci USA 1993;90:10764–10768.
Evans CH et al. Gene therapy for rheu matic
diseases. Arthritis Rheum. 199;42:1–16.
46. Answer A. Age >70 years
Emergency departments frequently have patients
with traumatic injuries to their knees. In order to
identify patients who are more likely to have a
fracture and will therefore require a radiograph,
the OTTAWA rules were devised.
Following are the criteria for performing a
knee radiograph in a traumatic knee injury as per
the OTTAWA rules:
1. Age more than 55 years.
2. Inability to bear weight immediately after
injury.
3. Isolated patella tenderness.
4. Tenderness to the head of fibula.
5. Inability to flex the knee to 90°.
Stiell IG et al. Prospective validation of a decision rule for the use of radiography in acute knee
injuries. J Am Med Assoc. 1996;275:611–615.
Tigges S et al. External validation of the
OTTAWA knee rules in an urban trauma center
in the United States. Am J Roentgenol.
1999;172:1069–1071.
47. Answer B. Anterior dislocations are more often
associated with intimal injuries because of
vessels getting stretched over the distal femur
The rate of arterial injury is equivalent in both
anterior and posterior dislocations. The popliteal
artery supplies the majority of the blood supply
to the leg. It is a continuation of the superficial
femoral artery which passes via the adductor
canal into the popliteal fossa. A delay in revascularisation of more than 8 hours can lead to significant rise in the amputation rates from 13 to
86%.
The LEAP cohort reported a 20% incidence
of amputation with knee dislocation and vascular
injury. Anterior dislocations were associated
with intimal injuries because of the vessel stretch
over the distal femur whereas posterior dislocations resulted in transection injury secondary to
the thrust of the tibia posteriorly into the artery.
Green NE, Allen BL. Vascular injuries associated with dislocation of the knee. J Bone Joint
Surg Am. 1977;59:236–239.
Kennedy JC. Complete dislocation of the knee
joint. J Bone Joint Surg Am. 1963;45:889–904.
Patterson BM et al. Knee dislocations with
vascular injury: outcomes in the Lower Extremity
Assessment Project (LEAP) Study. J Trauma
2007;63:855–858.
48.
Answer D. Posterior cruciate ligament reconstruction has a strong association with formation of HO
Complications are common after knee dislocations. Apart from neurovascular injuries, arthrofibrosis, instability, misse d fractures and early
degenerative changes commonly occur. Deep
venous thrombosis, pulmonary embolism,
wound healing and infection are not as common
as the ones listed earlier.
A study by Whelan (2014) revealed that PCL
reconstruction was the only factor associated
with formation of HO and 25% of their patients
required an additional surgical intervention to
address the knee stiffness.
Complication rates after a knee arthroscopy
in patients with knee dislocation is around 4.7%
with highest being when PCL reconstruction was
performed (20%).
129
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Salzler MJ et al. Complications after arthro-
scopic knee surgery. Am J Sports Med.
2014;42:292–296.
Whelan DB, Dold AP, Trajkovski T, Chahal
J. Risk factors for the development of heterotopic
ossification after knee dislocation . Clin Orthop
Relat Res. 2014;472:2698–2704.
49. Answer B. Oestrogen is uricosuric
Men present with symptoms of gout generally
between 30 and 60 years of age. Male sex hormones are known to reduce urinary excretion of
urate, subsequently leading to a rise in serum
uric acid levels. This is precisely the cause why
gout in men is delayed until after a few years of
attaining puberty.
However, on the other hand oestrogen is
known to cause a uricosuric effect and hence
women after menopause present with gout, once
oestrogen levels start to decrea se.
Urate clearance is dependent on kidney function and patients with impaired renal function
have hyperuricaemia and subsequently suffer
from gout.
Oily fish such as sardine, mackerel and herring are rich sources of purine and hence lead to
gout because of increased purine breakdown
products.
Choi HK, Curhan G. Gout: epidemiology
and lifestyle choices. Curr Opin Rheumatol.
2005;17:341–345.
Hak AE, Choi HK. Menopause, postmenopausal hormone use and serum uric acid levels in
US women – the Third National Health and
Nutrition Exam ination Survey. Arthritis Res
Ther. 2008;10:R116.
50. Answer C. Positive test for rheumatoid factor
Rheumatoid factor (RF) test is negative in the
CASPAR criteria for psoriatic arthritis.
The Classification Criteria for Psoriatic
Arthritis (CAS PAR) explains the spectrum of
this disorder by including patients who currently
may not have an active psoriasis but have a past
or family history of the disorder.
The CASPAR criteria are as follows
Established inflammatory articular disease
(joint, spine or entheseal) with three or more of
the following:
1. Psoriasis (PsO)
Current: Psoriatic skin or scalp disease
present today as judged by a physician.
History: History of PsO that may be
obtained from patient, family physician,
dermatologist or rheumatologist.
Family history: History of PsO in a first- or
second-degree relative according to patient
report.
2. PsO: Typical psoriatic nail dystrophy
including onycholysis, pitting and
hyperkeratosis observed on current physical
examination.
3. Negative test for RF: By any method except
latex but preferably by enzym e-linked
immunosorbent assay (ELISA) or
nephelometry, according to the local
laboratory reference range.
4. Dactylitis.
Current: Swelling of an entire digit.
History: History of dactylitis recorded by a
rheumatologist.
5. Radiological evidence of juxta-articular new
bone formation: Ill-defined ossification near
joint margins (but excluding osteophyte
formation) on plain radiographs of hand or foot.
Taylor W et al.; CASPAR Study Group.
Classification criteria for psoriatic arthritis: development of new criteria from a large international
study. Arthritis Rheum. 2006;54:2665–2673.
51. Answer B. Bilateral CDK is never associated
with any syndromes
Congenital dislocation of the knee is extremely
rare. Prenatal diagnosis is possible by ultrasound.
Clubfoot and hip dysplasia can be present in
50–
70% of cases respectively.
Bilateral cases are almost always syndromic
and associated with Ehlers-Danlos and Larsen
syndrome.
In arthrogryposis and spinal dysraphism one
knee may be dislocated while the other may have
a flexion deformity.
Abnormal foetal position leads to a unilateral
CDK and associated stiffness.
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Teratological types present with quadriceps
fibrosis and atrophy which develops because of
lack of knee movement. This lack of movement
also leads to iliotibial band contracture and
hypoplasia of the patella.
Bell MJ, Atkins RM, Sharrard WJ.
Irreducible congenital disloca tion of the knee:
aetiology and management. J Bone Joint Surg
Br. 1987;69:403–406.
Bensahel H et al. Congenital dislocation of
the knee. J Pediatr Orthop. 1989;9:174–177.
Jacobsen K, Vopalecky F. Congenital disloca-
tion of the knee. Acta Orthop Scand. 1985;56:1–7.
Johnson E, Audell R, Oppenheim WL.
Congenital dislocation of the knee. J Pediatr
Orthop. 1987;7:194–200.
52. Answer B. Filaggrin
Filaggrin is a histidine rich polypeptide which
has a role in formation of the skin barrier and
keratin filament aggregation. Filaggrin is a highly
phosphorylated polypeptide and null mutations
are associated with nickel allergy. Histidine-rich
polypeptides are nickel chelating agents and may
cause accumulation of nickel in stratum corneum, possibly resulting in an allergic reaction
in sensitive patients.
Magainin and cecropin are some of the
earlier described peptides from higher organisms
for which antimicrobial activity was noted.
Saporin is a cytotoxic protein with application in treatment of cancer.
Integrins are receptors used by animal cells to
bind to extra-cellular matrix.
Alberts B et al. Molecular Biology of the Cell,
4th Ed. New York, NY: Garland Science; 2002.
Novak N et al. Loss-of-function mutations in
the filaggrin gene and allergic contact sensitization to nickel. J Invest Dermatol.
2008;128:1430–1435.
Polito L, Bortolotti M, Pedrazzi M,
Bolognesi A. Immunotoxins and other conju-
gates containing saporin-s6 for cancer therapy.
Toxins (Basel) 2011;3:697–720.
Zasloff M. Magainins, a class of antimicro-
bial peptides from Xenopus skin: isolation, characterization of two active forms, and partial
cDNA sequence of a precursor. Proc Natl Acad
Sci USA 1987;84:5449–5453.
53. Answer C. Factor VIII deficiency and X-linked
recessive
Haemophilia is a rare bleeding disorder with
around 1 in 10,000 people born with it. The knee
joint is most involved. Classic haemophilia is due
to Factor VIII deficiency and is X-linked recessive. Classic haemophilia is also known as
Haemophilia A.
The other type of haemophilia due to Factor
IX deficiency is known as Haemophilia B and is
also X-linked recessive.
Haemosiderin deposit due to bleeding in the
joint leads to articular cartilage destruction.
Treatment involves arthrocentesis in the
acute cases, to relieve the joint of pressure and
prevent articular damage due to haemosiderin.
Factor replacement has a role in prophylaxis
before any planned surgery. Management is
always multidisciplinary with an input from the
haematologist.
Calviglia HA, Solimeno LP. Orthopedic
Surgery in Patients with Hemophilia. Milan:
Springer; 2008.
Lafeber FP, Miossec P, Valentino LA.
Physiopathology of haemophilic arthropathy.
Haemophilia 2008;14(Suppl. 4):3–9.
54. Answer D. Pigmented villonodular synovitis
Pigmented villonodular synovitis commonly presents with non-specific symptoms of pain and
swelling in the knee joint. It commonly occurs in
the younger age group of between 30– 40 years.
Mechanical symptoms such as locking are rare.
Ultrasound examination often reveals heterogeneously hypoechoic masses in the Hoffa fat pad,
markedly thickened synovium and some nonspecific hyperaemia.
MRI scan reveals low signal intensity on the T2
weighted images and a ‘blooming’ artefact from
haemosiderin deposit seen on the gradient echo
images. MRI scan is the most accurate screening
method used to get a diagnosis.
Haemophilia A and B are bleeding disorders
due to Factor VIII and IX deficiency, respectively.
Radiologically a ‘squaring of patella’ is classically
visible.
Synovial sarcoma are rare intra-articular
tumours of the knee and often can present with
a long-standing history of pain and swelling. They
131
Oliver Bailey and Pradyumna Raval
can have rapid progression within a short span of
time. Often MRI scans can appear benign and
non-specific. A biopsy leads to definitive diagnosis
in suspicious cases.
Bui-Mansfield LT, O’Brien SD. Magnetic res-
onance appearance of intra-articular synovial sarcoma: case reports and review of the literature. J
Comput Assist Tomogr. 2008;32:640–644.
Lafeber FP, Miossec P, Valentino LA.
Physiopathology of haemophilic arthropathy.
Haemophilia 2008;14(Suppl. 4):3–9.
LiBrizzi CL, Bitzer AM, Kreulen RT, Meyer
CF, Morris CD. Sarcoma happens: a reminder for
arthroscopic surgeons. Cureus 2022;14:e24457.
Ma X et al. Pigmented villonodular synovitis: a
retrospective study of seventy-five cases (eightyone joints). Int Orthop. 2013;37:1165–1170.
55. Answer C. Patients undergoing SBTKA have a
lower post-operative 30-day mortality rate
Patients undergoing SBTKA have a higher postoperative 30-day mortality rate when compared with
those who undergo a staged procedure. This is
largely because of lack of stricter criteria of exclusion
of patients with significant cardiovascular disease.
New York University Langone Medical
Centre (NYULMC) has laid out exclusion criteria for patients undergoing SBTKA.
The rest of all the statements about SBTKA
are correct.
Scott WN. In Insall & Scott Surgery of the
Knee, 2nd Ed., pp. 1051–1054. New York, NY:
Elsevier; 2018.
Zeni JA Jr, Snyder-Mackler L. Clinical outcomes after simultaneous bilateral total knee
arthroplasty: comparison to unilateral total knee
arthroplasty and healthy controls. J Arthroplasty
2010;25:541–546.
56. Answer E. Maternal history of herpes
Congenital dislocation of the knee has been
described as early as the 1800s. It is often associated with syndromes such as Larsen’s syndrome.
Prenatally congenital disloca tion can be diagnosed by ultrasonography.
Congenital dislocation of the knee most often
is due to multifactorial causes. Many theories
involving intrauterine events have been suggested such as abnormal foetal position of hyperextension, raised intrauterine pressure causing
fibrosis secondary to compartment syndrome,
absence of both cruciate ligaments and fibrosis
of the quadriceps.
Maternal history of herpes has no causative
effect on congenital dislocation of the knee.
Katz MP, Grogono BJ, Soper KC. The eti-
ology and treatment of congenital dislocation of
the knee. J Bone Joint Surg Br. 1967;49:112–120.
Middleton DS. The pathology of congenital
genu recurvatum. Br J Surg. 1935;22:696–702.
Shattock S. Genu recurvatum on a foetus at
term. Trans Pathol Soc Lond.
57. Answer E. Wilson’s sign
Children with osteochondritis dissecans may
present with anterior knee pain localised either
to medial or the lateral side. They may have an
antalgic gait.
Wilson’s sign is wherein the knee is flexed to
90° followed by internal rotation of the tibia and
extension of the knee from 90° toward full extension. This may bring on pain at 30° short of full
extension but may not be present always.
Destot’s sign is seen in pelvis fracture where
ecchymosis is visible superior to the inguinal
ligament in scrotum or of thigh.
Grey Turner’s sign is seen as flank ecchym-
osis in cases of retroperitoneal haemorrhage.
Gower’s sign is seen in cases of muscular
dystrophy which is classically described as a
‘climbing up on oneself’.
Kehr’s sign is referred pain to left shoulder
seen in cases of ruptured spleen.
Conrad JM, Stanitski CL. Osteochondritis
dissecans: Wilson’s sign revisited. Am J Sports
Med. 2003;31:777–778.
Gowers WR. A Manual of the Nervous
System, 2nd ed., Vol. 1. Philadelphia, PA: The
Classics of Neurology and Neurosurgery Library/
Gryphon editions; 1895.
Rutkow IM. Rupture of the spleen in infec-
tious mononucleosis: a critical review. Archives of
Surgery (Chicago, Ill.: 1960),1978;113:718–720.
Turner GG. Local discoloration of the
abdominal wall as a sign of acute pancreatitis.
Br J Surg. 1919;7:394–395.
58. Answer C. Intense sporting activities during
growth leads to varus knees and this typically
occurs during the end of growth spurt
1891;42:280.
132
Knee I Structured SBA
Insall and Freeman popularised the ‘classic alignment’ philosophy with respect to total knee
arthroplasty. In this philosophy the surgeon aims
to obtain a perpendicular implant position with
reference to the mechanical axis of the tibia and
femur in the coronal plane.
Perpendicular cuts on the distal tibia and
femur lead to systematic distalisation of the lateral joint line.
Varus knee development happens during the
end of growth spurt due to intense sporting
activities as per Witvrouw et al. (2009).
Kinematic and constitutional alignment are
synonymous terms and are used interchangeably
by different authors.
Hueter-Volkmann law suggests that compression on the medial aspect of the knee leads
to retardation of growth on the medial side,
whereas less pressure on the lateral side leads to
accelerated growth. This results in an overall
constitutional varus alignment of the knee.
Freeman MA, Swanson SA, Todd RC. Total
replacement of the knee using the FreemanSwanson knee prosthesis. Clin Orthop Relat Res.
1973;94:153–170.
Insall J, Ranawat CS, Scott WN, Walker P.
Total condylar knee replacement: preliminary
report. Clin Orthop Relat Res. 1976;120 :149–154.
Witvrouw E, Dannee ls L, Thijs Y, Cambier
D, Bellemans J. Does soccer participation lead to
genu varum? Knee Surg Sports Traum a Arthrosc.
2009;17:422–427.
59. Answer A. Chronic kidney disease is not a risk
factor for quadriceps rupture
Dobbs et al. (2005) from Mayo clinic have
reported a quadriceps tendon disruption of less
than 1% in a series of 23,800 patients. Partial
ruptures are twice as common as complete
ruptures.
Diabetes mellitus, rheumatoid arthritis,
chronic kidney disease and multiple previous
knee surgeries are known risk factors for quadriceps rupture.
Partial ruptures can be managed nonoperatively with the knee in extension and protected weight bearing for 4–6 weeks.
Operative treatment for complete quadriceps
rupture has complications such as instability of
the knee, recurvatum, infection and a re-rupture
rate of 40%. The overall complication rate can be
as high as 55%.
Dobbs RE, Hanssen AD, Lewallen DG,
Pagnano MW. Quadriceps tendon rupture after
total knee arthroplasty: prevalence, complications, and outcomes. J Bone Joint Surg Am.
2005;87:37–45.
Lynch AF, Rorabeck CH, Bourne RB.
Extensor mechanism complications following
total knee arthroplasty. J Arthroplasty
1987;2:135–140.
Parker DA, Dunbar MJ, Rorabeck CH.
Extensor mechanism failure associated with total
knee arthroplasty: prevention and management.J
Am Acad Orthop Surg. 2003 ;11:238–247.
60. Answer B. This patient can be a potential pain
catastrophiser and her post-operative pain
symptoms should be quantified using a PCS
quantification scale
Pain symptom following a total knee arthroplasty
can sometimes be a difficult symptom to manage
especially in younger patients, patients on opioids
and patients with a history of fibromyalgia.
Some patients have a tendency of magnifying
or exaggerating their pain symptoms and often
may say that ‘ I wonder whether something serious may happen’ or ‘I can’t stop thinking about
the pain’. Such patients are pain catastrophisers.
The Pain Catastrophising Scale (PCS) is a
quantifying tool which is useful in treatment of
such patients. Pain catastrophising is a multidimensional construct and depends on three
dimensions primarily – rumination (‘I can’t stop
thinking how much it is going to hurt’ ), magnification (‘I think this pain will not get better but
will worsen’) and helplessness (‘I don’t know how
to get rid of this pain’).
The PCS scale includes 13 items. Patients
respond ‘not at all’ (scored as a 0 for each item)
to ‘all the time’ (scored as a 4 for each item). The
total score ranges from 0 (no catastrophising) to
52 (very high catastrophising).
Escitalopram and transcutaneous elec trical
nerve stimulation (TENS) have shown some
benefit in patients with low PCS scores.
Grosu I, Lavand’homme P, Thienpont E.
Pain after knee arthroplasty: an unresolved issue.
Knee Surg Sports Traumatol Arthrosc.
2014;22:1744–1758.
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