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Oliver Bailey and Pradyumna Raval
Pinto PR, McIntyre T, Ferrero R, Almeida A,
Araújo-Soares V. Predictors of acute postsurgical
pain and anxiety following primary total hip and
knee arthroplasty. JPain2013;14:502–515.
Sullivan MJ, Bishop SR, Pivik J. The pain
catastrophizing scale: development and validation. Psychol Assess. 1995;7:524–532.
61. Answer A. Dental procedures
Acute haematogenous infection after total knee
arthroplasty is a significant and persistent problem in many patients. The rate of bacteraemia
after invasi ve procedures is highest with dental
procedures.
Urogenital procedures and gastrointestinal
procedures are also related with haematogenous
infection with gastrointestinal procedures having
the lowest association.
Invasive procedures known to cause bacteraemia are to be avoided for 3–6 months after
total knee arthroplasty.
Durack DT. Prevention of infective endocarditis. New Engl J Med. 1995;332:38–44.
Waldman BJ, Mont MA, Hungerford DS.
Total knee arthroplasty infections associated
with dental procedures. Clin Orthop Relat Res.
1997;343:164–172.
62. Answer E. Steinmann second
Joint line tenderness that moves posteriorly with
knee flexion and anteriorly with knee extension
is the basis of the Steinmann second test. A
meniscal tear which is mobile with knee range
of movement gives rise to a positive test.
External tibial rotation and knee extension
increases tenderness along the medial joint line
in the presence of a medial meniscus tear in a
Bragard’s test. While performing this test the
medial meniscus comes more anterior and closer
to the examining finger and therefore causes pain
whereas internal rotation and flexion movem ent
cause less tenderness by moving the meniscus
farther from the area of palpation.
A palpable click on the joint line is elicited by
the McMurray’s test. External tibial rotation and
passive motion from flexion to extension causes
pain medially in a case of medial meniscus tear
whereas with the tibia in internal rotation and
passive motion from flexion to extension elicits
pain laterally in a case of lateral meniscal tear.
In the Apley grind test the tibiofemoral surfaces are forced together to elicit pain. If the
patient has pain then it is an indication of a
positive test.
Duck walking increases pressure on the posterior aspect of the knee. A positive test is indicative of a tear in the posterior horn of the
meniscus.
Tria AJ Jr, Klein KS. An Illustrated Guide to
the Knee. New York: Churchill Livingstone; 1992.
63. Answer B. FOPE (focal periphyseal oedema)
Salter-Harris Type 1 fractures are often associated with a history of trauma. Radiologically a
physeal widening is visible. In cases with subtle
widening a comparison with the contralateral
knee is often helpful.
Brodie’s abscess and osteoid osteoma are
often associated with history of a previous infection, night pain relieved with aspirin etc. This is
not the case in this young man. Also, his blood
investigations are reported to be normal.
Focal periphyseal oedema (FOPE) is a manifestation of normal skeletal maturation. They are
generally central in location because the physis
are in a process of closing. This differentiates
FOPE lesion from Salter-Harris Type 1 injuries.
Zbojniewicz AM, Laor T. Focal periphyseal
edema (FOPE) zone on MRI of the adolescent
knee: a potentially painful manifestation of physiologic physeal fusion? Am J Roentgenol.
2011;197:998–1004.
64. Answer E.
(MARS) group stated that approximately 30%
of patients undergoing revision ACL reconstruction had no impingement
Anterior cruciate ligament graft impingement
primarily occurs due to improper tibial tunnel
placement. This may lead to loss of normal knee
extension and can cause tearing of the graft. In
an abnormally anteriorly placed tibial tunnel the
distal two-thirds of the graft shows a high signal
on MRI. An osteophyte in the intercondylar
notch can result in graft impingement. If the
anterior wall of the tibial tunnel is placed anterior to the Blumensaat line, a roof impingement
may occur due to the graft impacting the roof of
the intercondylar notch. A hyperextension lateral
radiograph is associated with increased effusion,
The Multicenter ACL Revision Study
134
Knee I Structured SBA
lack of complete extension in cases of anterior
ACL graft impingement.
The MARS study group stated that approximately 51% of patients undergoing revision
reconstruction had no impingement, 47% had
some impingement, while 2% had complete
impingement.
Stoller DW. Magnetic Resonance Imaging in
Orthopaedics and Sports Medicine, 3rd ed.
Philadelphia, PA: Lippincott Williams &
Wilkins; 2006.
Weber WN et al. Lateral tibial rim (Segond)
fractures: MR imaging characteristics. Radiology
1991;180:731–734.
Group M. Radiographic findings in revision
anterior cruciate ligament reconstructions from
the MARS cohort. J Knee Surg. 2013;26:239–248.
Miller MD, Olszewski AD. Posterior tibial
tunnel placement to avoid anterior cruciate ligament graft impingement by the intercondylar
roof. An in vitro and in vivo study. Am J Sports
Med. 1997;25:818–822.
65. Answer: C. The knee is not able to flex or
extend in a locking episode because of patellar
pathology whereas in a bucket handle tear of
meniscus the knee can be further flexed.
Patients with patellofemoral (PF) disorders primarily present with one or all the following
symptoms: pain, instability and locking or
catching.
The pain is located anteriorly and is not well
defined. Anterior knee pain and moder ate pain
with climbing stairs have been shown to have a
high specificity with isolated PF injury.
Instability episodes can be subjective or
objective. Initial episodes are generally traumatic
leading to dislocation of the patient. Subsequent
episodes are subjective with reflex contraction of
the quadriceps resulting in a subluxation.
Locking is the third common symptom and
can be differentiated from a meniscal tear by
physical examination. The knee is a fixed position, and no further flexion or extension is possible. In a bucket handle tear of meniscus, the
knee can be further flexed but has restricted
terminal extension.
Locking episodes are generally momentary
but sudden quadriceps contraction can cause
painful and prolonged locking episodes.
Stefanik JJ et al. Thediagnosticperformanceof
anterior knee pain and activity-related pain in identifying knees with structural damage in the patellofemoral joint: the Multicenter Osteoarthritis Study.
JRheumatol.2014;41:1695–1702.
66. Answer: C. COL5A1
Spontaneous rupture of the quadriceps commonly occurs because of the sudden eccentric
contraction of the muscle. This sudden contraction exceeds the phase of plastic deformation and
can lead to incomplete or complete rupture.
In patients more than 40 years of age the site of
rupture is at the muscle tendon interface whereas
in younger patients it is a mid-substance tear.
Bilateral quadriceps ruptures are reported in
patients with underlying systemic illness, obesity
and use of anabolic steroids. The COL5A1 gene
is implicated in bilateral quadriceps injury.
GDF5 (encoding growth & differentiation
factor 5) is associated with osteoarthritis.
HOXB9 and COL1A1 both are associated
with dynamic dysplasia of hip (DDH).
COL1A2 is associated with osteogenesis
imperfecta.
Galasso O et al. Collagen type V polymorphism in spontaneous quadriceps tendon ruptures.
Orthopedics 2012;35:e580–e584.
Yoo JH, Sawan H, Parvizi J. Genetics of
common musculoskeletal disorders in adults.
Orthopedic Muscul Sys. 2014;S2:S2–009.
67. Answer A. A decrease in the moment arm of the
extensor mechanism is caused by the patella by
anterior displacement from the knee’
rotation
The patella and the tendinous portion of the
extensor mechanism share the load from full
knee flexion to 45°.
At less than 45° the patella is the only component of the extensor mechanism which is in
contact with the distal femur.
An increase in the moment arm of the extensor mechanism is caused by the anterior displacement of the patella from the knee’s centre
of rotation.
Twice the amount of torque is required for
the terminal 15° of knee extension as compared
with the torque required from full flexion of the
knee to 15° short of extension.
s centre of
135
Oliver Bailey and Pradyumna Raval
Kaufer H. Mechanical function of the patella.
J Bone Joint Surg Am 1971; 53:1551–1560.
Lieb FJ, Perry J. Quadriceps function: an ana-
tomical and mechanical study using amputated
limbs. J Bone Joint Surg Am. 1968;50:1535–1548.
Peeples RE, Margo MK. Function after patel-
lectomy. Clin Orthop Relat Res. 1978;132:180–186.
68. Answer C. Dorsal defect of patella
A dorsal defect of patella is an anatomical variant.
It is most often an incidental finding when
patients are imaged for other causes. Exactly why
a dorsal defect of patella develops is unknown.
Failed or delayed ossification of the patella leading
to a developmental alteration of the epiphysis is
thought to be a causative factor. Histologically a
non-specific fibrous tissue with no features of
inflammation is identified. This is a self-limiting
condition and treatment is non-operative.
Johnson JF, Brogdon BG. Dorsal defect of
the patella: incidence and distribution. Am J
Roentgenol. 1982;138:339.
136
Section 2
Chapter
7
Adult Elective Orthopaedics and Spine
Knee II Structured SBA
David Deehan, Philip Dobson and Daniel Hipps
KNEE II STRUCTURED SBA QUESTIONS
1. The most common site for osteochondritis dissecans of the knee is?
A. Anterolateral aspect of the lateral femoral
condyle
B. Anteromedial aspect of the medial femoral
condyle
C. Posterolateral aspect of the medial femoral
condyle
D. Posteromedial aspect of the lateral femoral
condyle
E. Trochlea groove
2. In MPFL reconstruction, with regard to the
lateral X-ray, the femoral tunnel should be
positioned?
A. 1mm anterior to a line extended from the
posterior cortex, and 2.5mm proximal to the
origin of the medial femoral cortex
B. 1mm anterior to a line extended from the
posterior cortex, and 2.5mm distal to the
Blumensaat line
C. 1mm anterior to a line extended from the
posterior cortex, and 2.5mm distal to the
origin of the medial femoral condyle
D. 1mm posterior to a line extended from the
posterior cortex, and 2.5mm proximal to the
origin of the medial femoral cortex
E. 1mm posterior to a line extended from the
posterior femoral cortex, and 2.5mm distal to
the origin of the medial femoral condyle
4. A rectangular shaped opening wedge medial
high tibial osteotomy will have the effect of?
A. Increasing valgus alignment and have no
effect on tibial slope
B. Increasing valgus alignment and increasing
posterior tibial slope
C. Increasing valgus alignment and reducing
posterior tibial slope
D. Increasing varus alignment and have no
effect on tibial slope
E. Increasing varus alignment and reducing
posterior tibial slope
5. With regard to the injury apparent on the MRI
(Figure 7.1)?
A. A posterior slope less than 12° can increase
risk of graft failure
B. Reconstruction eliminates the increased risk
of progression to arthritis
C. Reconstruction reduces risk of secondary
meniscal injuries
3. An anterior closing wedge, high tibial osteotomy has what effect?
A. Increases shear force on the ACL
B. Increases shear force on the ACL and PCL
C. Increases shear force on the PCL
D. Reduces shear force on the ACL
E. Reduces shear force on the PCL
Figure 7.1 MRI scan knee sagittal T2 view
137
David Deehan, Philip Dobson and Daniel Hipps
D. Reconstruction will reduce posterior tibial
translation
E. The knee is clinically likely to exhibit increased
tibial translation and internal rotation
6. With regard to PCL function?
A. The ALB is the primary restraint to tibial
posterior translation at 90° and when the
knee is near to full extension
B. The ALB serves as the primary restraint to
tibial posterior translation at 90° and the
PMB is the primary restraint when the knee
is near to full extension
C. The PMB has an insertion point closer to the
trochlear groove than the PLB
D. The PMB is the primary restraint to tibial
posterior translation at 90° and when the
knee is near to full extension
E. With single bundle reconstruction, the PMB
should be preferentially reconstructed
7. Stress radiography with valgus testing of the knee
reveals increased gapping of 7mm in full extension and 10mm at 30°.
These findings are likely to be in keeping with
which of the following injury patterns?
A. Grade II MCL injury combined with poster-
ior oblique ligament injury
B. Grade II MCL injury with ACL rupture
C. Grade II superficial and deep MCL injury
D. Grade III MCL injury combined with poster-
ior oblique ligament injury
E. Grade III superficial and deep MCL injury
8. With the knee flexed to 90° and the tibia in 10°
external rotation, an anterior drawer is performed, causing forward subluxation of the anteromedial tibial plateau.
This finding is suggesting of which of the
following injury patterns?
A. Combined ACL and MCL injury
B. Combined ACL and PCL injury
C. Combined MCL, posteromedial capsule and
posterior oblique ligament injury
D. Full thickness ACL rupture
E. Posterolateral corner injury
9. A 23-year-old footballer presents acutely
following an injury on the football field. The
MRI demonstrates avulsion of the MCL from
the femoral origin and a mid-substance tear to
the ACL.
Appropriate treatment for this patient would
be as follows?
A. Brace at 30° for 6 weeks followed by ACL
reconstruction.
B. Early MCL repair/reconstruction and ACL
reconstruction
C. Extension brace for 6 weeks followed by ACL
and MCL reconstruction if MCL clinically
incompetent at that stage.
D. Extension brace for 6 weeks followed by ACL
reconstruction if MCL clinically competent at
that stage.
E. ROM brace for 6 weeks followed by MCL
reconstruction alone if MCL found to be
incompetent at that stage.
10. A 27-year-old male sustains an injury to his knee
when he falls from his motorbike at low speed.
Clinical examination reveals increased tibial
external rotation of 15° with the knee flexed to
30°. The same finding is evident with the knee
flexed to 90°. Varus stress X-rays show an
increase in lateral joint opening of 5mm compared with the uninjured side.
Which of the following reconstructive options
is most appropriate?
A. Popliteofibular ligament and fibular collateral
ligament reconstruction
B. Popliteofibular ligament, posterior oblique
ligament and fibular collateral ligament
reconstruction
C. Popliteus tendon, fibular collateral ligament
and posterior cruciate ligament reconstruction
D. Posterior oblique ligament, fibular collateral
ligament and posterior cruciate reconstruction
E.
Popliteofibular ligament, posterior oblique
ligament, fibular collateral ligament and posterior cruciate ligament reconstruction
11. Whilst examining a patient, you hold the knee
flexed to 90°, apply a valgus force and hold the
tibia in external rotation. Whilst continuing to
apply a valgus and external rotation, you passively extend the knee, noting that the tibia subluxes anteriorly in relation to the tibia.
This finding is most suggestive of injury to
which structures?
A. ACL
138
Knee II Structured SBA
B. Combined ACL and PCL injury
C. Fibular collateral ligament and popliteofibu-
lar ligament
D. PCL
E. Posterior oblique ligament
12. A 32-year-old male sustains a knee injury. Clinical
examination 4 days after the injury reveals
increased tibial external rotation of 15° at 30° of
knee flexion compared with the contralateral leg,
but no significant increase in external rotation at
90° of knee flexion. Stress radiography reveals an
increase in lateral joint opening of 5.2mm compared with the uninjured knee.
The most appropriate treatment for this injury is.
A. Application of a brace in 30° of flexion
B. Application of a brace which allows ROM
C. Reconstruction of the fibular collateral liga-
ment and popliteus tendon
D. Reconstruction of the fibular collateral liga-
ment, popliteus tendon and PCL
E. Reconstruction of the posterior oblique liga-
ment and ACL
13. An 18-year-old female elite soccer player sustains
an injury to her knee. On examination, significant laxity on Lachman’s test is noted in addition
to a grade 3 pivot shift. Hyperextension of both
knees is also noted.
Appropriate management of this injury is?
A. ACL reconstruction with bone patella tendon
graft
B. ACL reconstruction with hamstring graft and
lateral extra-articular tenodesis
C. ACL reconstruction with quadriceps tendon
graft
D. Combined ACL and PCL reconstruction
E. Trial of conservative treatment
14. When performing a posterior root repair of the
medial meniscus using a tibial tunnel to bring
sutures down, the most appropriate place to
position the tibial tunnel is?
A. Anterior and lateral to the medial tibial
eminence
B. Anterior and medial tothe medial tibialeminence
C. Immediately anterior to the PCL tibial
insertion
D. Posterior and lateral to the medial tibial
eminence
E. Posterior and medial to the medial tibial
eminence
15. A 32-year-old patient presents with acute onset
posteromedial knee pain, mainly present when
weight bearing. Symptoms have been present for
1 week.
In view of the MRI findings which show a full
thickness injury, which of the following is the
most appropriate management?
Figure 7.2 MRI scan knee T2 coronal view
A. Early surgical repair even if pain is the only
symptom
B. Early surgical repair only if mechanical
symptoms present
C. Non-weight bearing for 6 weeks and reassess
D. Surgical repair at 6 weeks if locking symp-
toms present
E. Weightbear as tolerated andreassess at6 weeks
16. A 40-year-old male who has undergone previous
partial meniscectomy following a full thickness
medial meniscus radial tear, presents with medial
sided knee pain. His mechanical axis passes
through the centre of the knee and he has no
significant articular wear. He wishes to maintain
an active lifestyle.
Which of the following is likely to be the most
appropriate treatment?
A. Further medial meniscal debridement
B. Lateral closing wedge high tibial osteotomy
C. Meniscal allograft transplant
139
David Deehan, Philip Dobson and Daniel Hipps
D. Total knee replacement
E. Unicondylar knee replacement
17. A 64-year-old female presents with symptoms in
keeping with mid flexion antero-posteriorinstability following a cruciate retaining knee arthroplasty.
She is noted to have a 12° posterior slope on the
tibial cut and a 6° valgus cut on the femur.
Which of the following is most likely to lead to
symptom resolution?
A. One stage revision to upsize the femoral com-
ponent AP size
B. One stage revision to change to a posterior
stabilised implant and resurfaced patella
C. One stage revision to a rotating hinge prosthesis
D. One stage revision, changing tibial slope to 3°
and increased femoral component size
E. Soft tissue procedure to reconstruct the MCL
18. A 25-year-old female with recurrent patella dis-
locations is noted to have a Q angle of 15° at 20°
of knee flexion. A lateral knee X-ray shows a
Caton-Deschamps ratio of 1.0 and no evidence
of a crossing sign.
Which surgical option is likely to be indicated?
A. Isolated MPFL reconstruction
B. Isolated trochleoplasty
C. Tibial tuberosity distalisation and medialisa-
tion, combined with MPFL reconstruction
D. Tibial tuberosity distalisation and MPFL
reconstruction
E. Trochleoplasty combined with MPFL
reconstruction
19. A 20-year-old with disabling recurrent patella dislocations is noted to have a Caton-Deschamps ratio
of 1.5, a TT-TG distance of 11mm on CT scan. There
is evidence of a crossing sign on lateral X-ray, but no
supratrochlear spur or double contour sign.
Which of the following would be the preferred
treatment?
A. Continued physiotherapy
B. Tibial tuberosity distalisation and
medialisation
C. Tibial tuberosity distalisation and MPFL
reconstruction
D. Tibial tuberosity distalisation, medialisation,
combined with MPFL reconstruction and
trochleoplasty
E. Trochleoplasty and MPFL reconstruction
20. A 22-year-old presents following a first-time patella
dislocation. Imaging reveals TT-TG distance of
22mm and a Caton-Deschamps ratio of 1.4.
Which of the following is the most appropriate
treatment?
A. MPFL reconstruction
B. Referral to physiotherapy
C. Tibial tuberosity medialisation
D. Tibial tuberosity medialisation and MPFL
reconstruction
E. Tibial tuberosity medialisation and
distalisation
21. An 11-year-old boy presents with recurrent
patella dislocations, having had 12 episodes of
dislocation in the last year. Examinations and
investigation reveal a positive apprehension test,
normal rotational profile, 2° genu valgum, a TTTG of 23mm, patella alta, no significant trochlea
dysplasia.
Which of the following is the most appropriate
treatment?
A. Application of 8 plates
B. Continued conservative management
C. MPFL reconstruction with screw fixation of
semitendinosis hamstring graft into Schottle’s
point
D. Tibial tuberosity distalisation
E. Tibial tuberosity distalisation and
medialisation
22. A 23-year-old rugby player sustains a valgus
injury to his knee. On examination 6 weeks
following his injury, he is noted to have medial
joint line opening of 10mm at 30° of flexion and
when an external rotatory force is applied in the
same position, anterior subluxation of the medial
tibial plateau is noted. In full extension, valgus
force also produces some degree of medial joint
opening.
Based on the information given, w hat is the
most appropriate treatment?
A. Combined ACL and MCL reconstruction
B. Combined ACL, MCL and POL
reconstruction
C. Combined MCL and POL reconstruction
D. Combined MCL, ACL and posterolateral
corner reconstruction
E. Combined MCL, posterolateral corner
reconstruction
140
Knee II Structured SBA
23. A 26-year-old motorcycle rider injures their knee
when they come off their bike at speed.Examination
reveals increased external rotation of the tibia at 30°
of flexion which is 15° more than the uninjured
contralateral limb. With the knee at 90°, resisted
extension also causes the tibia to move anteriorly
10mm in relation to the femoral condyles.
Which of the following is the most appropriate
treatment?
A. ACL reconstruction
B. Combined ACL and posterolateral corner
reconstruction
C. Combined ACL, PCL and posterolateral
corner reconstruction
D. Combined PCL and posterolateral corner
reconstruction
E. PCL reconstruction
24. A 60-year-old male presents with medial sided
knee pain of 6 weeks duration, prior to which he
was pain free. An X-ray shows grade D changes
affecting the medial compartments with good
preservation of the lateral and patellofemoral
compartments. He has no fixed flexion deformity
and no ligamentous instability. His mechanical
axis passes through the centre of the medial
compartment. He plays squash once a week.
Which of the following might be the most
appropriate treatment?
A. Debridement of medial meniscal tear
B. Lateral closing wedge high tibial osteotomy
C. Physiotherapy
D. Total knee replacement
E. Unicondylar knee replacement
25. With regard to the image (Figure 7.3), which of
the following is most likely to lead to symptom
improvement?
A. ACL and PCL reconstruction
B. ACL reconstruction and lateral meniscal repair
C. Medial meniscal repair and ACL reconstruction
D. PCL reconstruction and lateral meniscal
repair
E. PCL reconstructionand medialmeniscal repair
26. With regard to the image (Figure 7.4), which of
the following is evident?
A. ACL rupture and PCL rupture
B. ACL rupture, PCL rupture and medial
meniscal injury
Figure 7.3 MRI
scan knee sagittal
T2 view
Figure 7.4 MRI
scan knee T2
coronal view
C. Isolated ACL rupture
D. Medial meniscal injury and ACL rupture
E. Normal knee
27. A 17-year-old girl presents with medial sided
knee pain and intermittent effusions of 12
months duration. Her MRI scan is shown in
Figure 7.5.
With regard to this condition, which of the
following is true?
A. Elevation, bone grafting and fixation would
not be appropriate
B. Low levels of vitamin D have been shown to
be associated with this condition
C. Non-operative treatment is likely to lead to
resolution of symptoms
D. Surgical treatment with osteochondral auto-
logous transfer would not be appropriate
E. The healing rate in skeletally immature bone
is low when treated conservatively
141
David Deehan, Philip Dobson and Daniel Hipps
Figure 7.5 MRI
scan knee sagittal
T2 view
28. The MRI in Figure 7.6 is concerning for which
of the following features?
Figure 7.6 MRI
scan knee sagittal
T2 view
D. Transection of the anterior bundle in isol-
ation will not cause increased anterior tibial
translation
E. Transection of the posterior bundle in isol-
ation will not cause increased anterior tibial
translation
30. With regard to articular cartilage?
A. Aggrecan is the primary proteoglycan in cartil-
age and contributes to its net negative charge
B. Cartilage is isotropic
C. Chondrocytes are derived from the monocyte
lineage
D. Following articular injury, cartilage heals pre-
dominantly with type 2 cartilage
E. The deep zone contains the highest cell dens-
ity and lowest proteoglycan content
31. With regard to the MRI image (Figure 7.7),
which of the following would be appropriate
treatment?
Figure 7.7 MRI
scan knee sagittal
T2 view
A. ACL rupture
B. Meniscal injury
C. Multiligamentous injury
D. PCL rupture
E. Venous thrombosis
29. With regard to the anterior cruciate ligament,
which of the following is correct?
A. Both bundles are tight in full extension
B. The posterolateral bundle is tight and the
anteromedial bundle is moderately lax in full
extension
C. The posteromedial bundle is tight and the
anterolateral bundle is moderately lax in full
knee extension
142
A. ACL reconstruction
B. Bone grafting and fixation
C. Meniscal repair
D. PCL reconstruction
E. Removal of loose body
32. A 26-year-old presents with this MRI (Figure 7.8).
Which of the following w ould be most
appropriate?
A. ACL reconstruction
B. ACL reconstruction and MCL repair
C. Medial meniscus repair
D. Posterolateral corner reconstruction
E. Referral to bone tumour specialist
Knee II Structured SBA
Figure 7.8 MRI
scan knee T2
coronal view
33. You are performing a primary total knee arthroplasty and have made all your femoral and tibial
cuts when you find the extension gap is perfect
but the flexion gap is too tight. You have used
anterior referencing on the femur and your
anterior femoral cut is flush with anterior femoral cortex.
What action should you take?
A. Apply a smaller 4 in 1 femoral cutting block
and recut for a smaller femoral component
B. Apply the distal femoral cutting block and
resect a further 2mm and apply a smaller 4
in 1 cutting block and recut
C. Perform release of the iliotobial band and
posterior capsule
D. Take 2mm more off the tibia
E. Take 2mm more off the tibia and 2mm more
off the femur
34. You are performing a primary total knee arthroplasty and you have completed all your cuts
when you find the flexion and extension gaps
equal but are too tight to accommodate a standard spacer block.
What action should you take?
A. Downsize the femur and recur the tibia
B. Perform soft tissue releases of popliteus, ITB
and MCL
C. Recut the femur with a smaller 4 in 1 block,
to downsize the femoral component
D. Resect more from the distal femur
E. Resect more tibia
35. A 6-year-old child presents with this X-ray
(Figure 7.9) after sustaining a knee injury.
Which of the following is the most appropriate
management?
A. Application of cylinder cast
B. Closed reduction and application of cylinder
cast
C. Mobilisation as able
D. Open reduction and application of cylinder
cast
E. Open reduction and internal fixation, appli-
cation of cylinder cast
Figure 7.9 (a) Lateral radiograph knee and (b) Anteroposterior (AP) radiograph knee
143
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