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Paul Banaszkiewicz
several assorted pieces of information and the evaluation of laboratory and other numerical data. It can
assess the problem-solving skills vital to the practising
clinician.
Answering 120 questions in two hours allows an
average of one minute to read a question and select an
answer.
Candidates need tospeed-read in order to save extra
time for questions that require more thought. This is
facilitated by arranging the clinical information (history, examination findings, listed investigations) in a
strict order, as succinctly as possible, as well as presenting it in a way that does not disadvantage dyslexic
candidates or those whose first language is not English.
Notes
1 Case, S, Swanson D. Item Writing Manual. 3rd ed.
Philadelphia, PA: National Board of Medical Examiners;
2002. (available online).
2 Paniagua MA, Swygert KA. Constructing Written Test
Questions for the Basic and Clinical Sciences. Philadelphia,
PA: National Board of Medical Examiners; 2016.
3 At the least it is an interesting read.
4 That in itself is definitely time well spent rather than having to
revise and sit Section 1 all over again.
5 Miller GE. The assessment of clinical skills/competence/per-
formance, Acad Med. 1990;65(9):S63–S67. Adapted by Drs R
Mehay & Burns.
6 Bloom BS. Taxonomy of Educational Objectives. Vol. 1:
Cognitive Domain. New York: McKay; 1956:20–24 at 3.
7 Morrison S, Free K. Writing multiple-choice test items that
promote and measure critical thinking, J Nurs Educ. 2001;40
(1):17–24.
8 Paniagua MA, Swygert KA. Constructing Written Test
Questions, 4th Ed. Philadelphia, PA: National Board of
Medical Examiners; 2016. Chapter 3, Technical item flaws.
9 We have omitted examples of these flaws due to space con-
straints, but it is recommended that you read pages 19–26.
Flaws are much better appreciated with examples.
28
Section 2
Chapter
3
Adult Elective Orthopaedics and Spine
Hip I Structured SBA
Edward Holloway
HIP I STRUCTURED SBA QUESTIONS
1. An imaging report refers to a pathological avulsion at the insertion of the Iliopsoas tendon.
What Gruen zone does this correspond to?
A. Zone 1
B. Zone 2
C. Zone 4
D. Zone 6
E. Zone 7
2. A patient with painful osteoarthritis of their hip
underwent femoral nailing, for a mid diaphyseal
fracture 15 years previously. Their surgeon plans
to perform hip replacement surgery while keeping the nail in place.
What is the most suitable type of patient for
this procedure?
A. Large BMI >35 female over 65 years
B. Large BMI >35 male over 65 years
C. Large BMI >35 male under 65 years
D. Low BMI female under 65 years
E. Low BMI male under 65 years
3. A nerve is damaged during the direct lateral hip
approach when muscles are inadvertently split
more than 5cm proximal to the greater trochanter.
Asking the patient to perform which of the
following movements is most likely to reveal a
deficit?
A. Dorsiflex ankle
B. Extend great toe
C. Extend hip
D. Extend knee
E. Stand on one leg
4. A patient received a hip arthroplasty typically
reserved for younger patients with good femoral
head bone stock which comprises approximately
3.5% of all hip arthroplasties .
What follow-up is recommended for an asymptomatic patient with an ODEP 10 or 10A* rated
implant?
A. Annually, for as long as the device is
implanted
B. Annually for the first 5 years, two yearly to 10
years
C. Annually for the first 5 years, two yearly to 10
years and three after
D. First year, once at 7 years, and once at 10 years
E. First year, once at 7 years, and three yearly
thereafter
5. You are consenting a 45-year-old patient with a
Garden II neck of femur fracture for surgery.
What is the most common risk of this surgery?
A. Avascular necrosis
B. Femoral nerve injury
C. Leg length discrepancy
D. Sciatic nerve injury
E. Trendelenburg gait
6. A patient has a hip arthroplasty through an
approach that is designed to be soft tissue preserving and is sometimes performed utilising a
fracture table.
The nerve most commonly at risk during this
approach crosses, in the majority of patients,
the lateral border of which muscle?
A. Rectus femoris
B. Sartorius
C. Tensor fascia lata
D. Vastus intermedius
E. Vastus lateralis
7. After inserting an uncemented cup, you carefully
define quadrants by drawing a line from the ASIS
to the centre of the cup and a second line perpendicular to this. You turn your back and your registrar inserts a screw in the anterosuperior quadrant.
29
Edward Holloway
What structure is most at risk?
A. External iliac vessels
B. Inferior gluteal nerve and vessels
C. Internal pudendal nerve and vessels
D. Obturator nerve and vessels
E. Sciatic nerve
8. An audit of a department’s THA complications
reveals a spike in intraoperative periprosthetic
femoral fractures (IOPFF) equivalent to intraoperative Vancouver Type A2.
Which factor is associated with the highest
relative risk of this comp lication?
A. Age 41–49 years
B. Cementless stem
C. Female sex
D. Paediatric disease
E. Previous trauma
9. A 45-year-old welder with a history of steroid use
presents with groin pain and an MRI that shows
a 20% area of femoral head collapse.
What is the most appropriate management?
A. Bisphosphonate infusion
B. Core decompression
C. Proximal femoral osteotomy
D. Total hip arthroplast y
E. Vascularised fibular graft
What is the most appropriate management?
A. Cemented dual mobility THA
B. Cemented THA
C. Two-hole DHS
D. Uncemented dual mobility THA
E. Uncemented THA
12. After thorough discussion, it is decided that the
best option for a 20-year-old manual labourer
with post-traumatic hip OA is a fusion.
What is the most appropriate position of fusion?
A. 0° external rotation, 0° adduction, 5° flexion
B. 5° external rotation, 5° adduction, 25° flexion
C. 10° external rotation, 15°abduction, 25°flexion
D. 15° external rotation, 0° abduction, 5° flexion
E. 15° external rotation, 15° abduction, 5° flexion
13. A patient underwent a THA for a NOF fracture
while abroad on holiday. The patient was given
strict rehabilitation instructions to avoid flexion
beyond 90° and extreme internal rotation.
What structure was most likely to have been
injured during the patient’s surgery?
A. Femoral nerve
B. Lateral cutaneous nerve
C. Pudendal nerve
D. Sciatic nerve
E. Superior gluteal nerve
10. An 80-year-old patient listed for a THA has had
previous lumbar spine surgery. Concerned about
dislocation risk, you request sitting and standing
lateral lumbar spine radiographs.
What is the name of the angle that is formed
for a line passing from the centre of the S1 end
plate and the centre of the segment between the
two femoral heads (the bicoxofemoral axis),
and the vertical?
A. APPt (anterior pelvic plane tilt)
B. FPP (functional pelvic plane)
C. PI (pelvic incidence)
D. SPT (spinopelvic tilt)
E. SS (sacral slope)
11. A 55-year-old patient with Parkinson’sdisease
presents with a Garden 4 neck of femur fracture.
Radiographs show that the ratio of the inner canal
diameter at the midportion of the lesser trochanter, divided by the diameter 10 cm distal is >0.75.
30
14. A 77-year-old man presents with an insidious
onset of hip and anterior thigh pain 15 years
after a total hip arthroplasty. He denies fever or
systemic upset, and initial bloods show normal
inflammatory markers. Figure 3.1 is an anteroposterior radiograph of the left hip.
Figure 3.1 Anteroposterior
(AP) radiograph left hip
Hip I Structured SBA
You advise the patient that he should undergo
revision surgery as he is at risk of what
complication?
A. Dislocation
B. Infection
C. Periprosthetic acetabular fracture
D. Periprosthetic femur fracture
E. Pseudotumour formation
15. You review a patient following hip arthroscopy
and extensive debridement of a labral cyst. He
has weakness of ankle dorsiflexion.
Injury has most likely occurred as a result of
what?
A. Excessive traction at groin post
B. Placement of anterior portal
C. Placement of anterolateral portal
D. Placement of distal anterolateral portal
E. Placement of posterolateral portal
16. During intraoperative assessment for stability of
a THA you have implanted through a modified
Hardinge approach, you notice that the hip is
unstable in extension and external rotation.
What change will increase the primary arc of
hip motion?
A. 20° versus 0° liner
B. 36mm versus 32mm head
C. High versus standard offset stem
D. Lateralised versus standard liner
E. Skirted head
17. A 70-year-old woman presents with a red,
swollen and painful area around the incision
site of a T HR performed 8 weeks earlier. She
has a CRP of 78, WCC of 16 and temperature
of 37.4°C. Her other observations are unremarkable. She did not attend 6-week followup and says the wound has not stopped leaking
since she left hospital.
What is the most appropriate management?
A. Aspiration and culture-specific long-term
antibiotic suppression
B. Debridement, anti biotics, implant retention
with exchange of modular components
C. Debridement, antibiotics, implant retention
with retention of modular components
D. Empiric antibiotics
E. Revision arthroplasty
18. A 53-year-old man with severe ulcerative colitis
is referred for a THA. His pelvic X-ray shows
Brooker grade 3 changes on the ipsilateral side
replaced 4 years earlier.
Which of the following prophylactic treatments
is most appropriate?
A. Diphosphonate 20mg/kg for 21 days
B. Ibuprofen 400mg TDS for 4 weeks
C. Indomethacin 25mg TDS for 6 weeks
D. Single 2 500cGy radiotherapy dose
E. Three 1 500cGy radiotherapy doses
19. A 23-year-old woman has been referred by her
physiotherapist with symptoms of hip impingement. A radiograph of her left hip is shown here
(Figure 3.2).
Figure 3.2 Anteroposterior
(AP) radiograph left hip
What is marked on her radiograph?
A. Alpha angle
B. Lateral centre edge angle
C. Sharp’s angle
D. Tonnis angle
E. Vertical centre edge angle
20. A young man with cerebral palsy is referred with
hip pain. You want to examine for contracture in a
muscle with an origin at the inferior pubic symphysis and inferior pubic rami, which attaches to a
point just posterior to the attachment of sartorius.
What is the most appropriate test?
A. Ely’s test
B. Ober’s test
C. Phelp’s test
D. Thomas’ test
E. Trendelenburg test
31
Edward Holloway
21. A 24-year-old woman falls while mountain biking
and sustains the injury shown in this radiograph
(Figure 3.3). In theatre, you struggle to reduce the
fracture with in-line traction and rotation.
Figure 3.3 Anteroposterior
(AP) radiograph left hip
What is the most appropriate next step?
A. Extension, abduction, in-line traction, then
external rotation
B. Fixation in best position achieved
C. Flexion to 90°, adduction, in-line traction,
then internal rotation
D. Open reduction using a modified Smith-
Petersen approach
E. Total hip arthroplasty
22. A 30-year-old woman is referred for consideration
of THA. Her radiographs have been classified as a
Type B using the Hartofilakidis classification.
What anatomical characteristic of the femur is
most commonly associated with this?
A. Excessive anteversion
B. Excessive femoral bow
C. Excessive retroversion
D. Excessive valgus
E. Excessive varus
23. The diagram shown here represents the scratch
profile of a material used in THA femoral heads
(Figure 3.4).
Figure 3.4 Scratch profile
If such a component fractures, what bearing
couple should be used during revision surgery?
A. Ceramic on ceramic
B. Ceramic on poly
C. Metal on metal
D. Metal on poly
E. Oxinium on poly
24. A 45-year-old presents with symptoms of hip
impingement, and radiographs show the femoral
head to be medial to Kohler’s line.
What is the most likely diagnosis?
A. Acetabular retroversion
B. Coxa magna
C. Coxa valga
D. Coxa vara
E. Otto pelvis
25. A 60kg woman develops progressive pain and
numbness in the lateral calf with weakness of
ankle dorsiflexion 48 hours after THA.
Which of the following is the most appropriate
action?
A. Book for emergency surgery
B. Nurse prone and review the following
morning
C. Nurse with knee in flexion and review the
following morning
D. Urgent MRI scan
E. Withhold prophylactic LMWH
26. A surg eon admits a mistake was made during a
THA. The patient complains that their operated
leg feels short.
What is most likely to have resulted in this?
A. +8mm versus 0mm femoral head
B. 125° versus 135° neck-shaft angle implant
C. High versus standard offset stem
D. Incomplete insertion of an uncemented
stem
E. Size 4 rather than size 3 implant inserted
27. One of your patients 3 months post-THA is
aspirated because of signs of PJI.
What organism would be associated with the
lowest chance of infection eradicat ion with a
DAIR procedure?
A. Acinetobacter
B. Coagulase negative Staphylococcus
C. Corynebacterium
D. Staphylococcus aureus
E. Streptococcus
32
Hip I Structured SBA
28. You start a job as a Hip Consultant. Your clinical
lead advises that you use an implant with a
ODEP 10A* rating.
What does the * indicate?
A. Acceptable evidence
B. Being evaluated through the Beyond
Compliance initiative
C. Benchmark revision rate less than 1 in 10 at
10 years
D. Benchmark revision rate less than 1 in 20 at
10 years
E. Strong evidence
29. You aspirate a THA that has become acutely
painful in a patient with systemic symptoms.
According to the 2018 Musculoskeletal Infection
Society (MSIS) criteria for the diagnosis of periprosthetic joint infection, which of these findings carries least weight in making a diagnosis of
infection?
A. Elevated CRP or D-dimer (serum)
B. Elevated ESR (serum)
C. Elevated synovial PMN (%) (synovial)
D. Elevated synovial WBC count or LE (synovial)
E. Positive alpha-defensin (synovial)
30. A well-read 38-year-old patient with AVN of his
hip asks you why you have not suggested a coredecompression procedure.
You explain that for this to be an option, his
disease should not have progressed beyond
which Steinberg stage?
A. 1
B. 2
C. 3
D. 4
E. 5
fracture becomes severely hypoxic and hypotensive when the stem is inserted.
What is the most likely causative mechanism?
A. Anaphylaxis to antibiotic in the bone cement
B. Complement activation
C. Direct effect of exothermic
D. Multiple emboli
E. Vasodilatation caused by circulating methyl
methacrylate monomers
33. Whilst washing the femoral canal during a first
stage revision for infection you are offered a
choice of irri gation solutions.
Which would be least suitable?
A. Acetic acid
B. Chlorhexidine
C. Hydrogen peroxide
D. Polyhexanide-betaine
E. Povidone-iodine
34. This 69-year-old lady had a THA 20 years ago.
She presents with start-up pain in the thigh and
groin. Her blood tests are unremarkable, and an
aspiration is negative. Figure 3.5 is an anteroposterior radiograph of her right hip.
Which approach to revision of the femoral
component would be most appropriate?
Figure 3.5 Anteroposterior
(AP) radiograph right hip
31. Early intra-prosthetic dislocation of dual
mobility hip replacements is likely to be most
commonly due to what?
A. Iatrogenic injury
B. Modular designs
C. Non-highly crosslinked polyethylene
D. Skirted heads
E. Smaller diameter inner bearings
32. A frail 88-year-old undergoing cemented hip
hemiarthroplasty for an intracapsular NOF
A. Cement-in-cemen t
B. Long, fully coated uncemented stem
C. Primary cemented stem
33
Edward Holloway
D. Proximal femur replacement
E. Removal of cement and long cemented stem
35. A fit and well 74-year-old gentleman had a revi-
sion THA 7 months ago for aseptic loosening of
a 25-year-old Charnley THA. He presents with a
week of thigh pain and mild systemic upset. CRP
is 350 and an aspirate reveals frank pus in the
joint.
What is the most suitable management?
A. Debridement, antibiotics, and implant
retention
B. Excision arthroplasty
C. Single stage revision
D. Suppressive antibiotics
E. Two stage revision
36. When examining for contractures around the
hip, which eponymous test is performed by lying
the patient supine, and abducting the affected
hip as far as possible, then assessing if more
abduction is possible when the knee is flexed?
A. Bryant’s
B. Ely’s
C. Ober’s
D. Patrick’s
E. Phelp’s
34
HIP I STRUCTURED SBA ANSWERS
1. Answer E. Zone 7
Iliopsoas originates from the anterior and inferior
aspects of the transverse processes of L1–L5 and
the bodies and discs of T12–L5. It inserts into the
lesser trochanters and is innervated by direct
fibres from the lumbar plexus (L1/L2/L3). It acts
as a flexor of the hip.
Gruen zones are used to describe areas of
loosening around a femoral stem. Zone 1 relates to
the greater trochanter, zone 7 the lesser trochanter
and zones 6 and 5, and zones 2 and 3 on the medial
and lateral aspects of the femur, respectively. Zone 4
is at the tip of the stem (Figure 3.6).
Figure 3.6 Gruen zones
2. Answer C. Large BMI >35 male under 65 years
An important indication of hip resurfacing is
patients with pre-existing metalwork in the
medullary canal of the femur which precludes a
metaphyseal stem. Advantages of a hip resurfacing
over a THA include increased stability due to a
larger head size, preservation of femoral head and
neck bone stock, simpler femoral revision, lower
mortality and the potential of a more normal
gait pattern and participation in high-demand
activities.
After high-profile failures including certain
implants the most suitable patient group to benefit
from resurfacing is being redefined, but it is generally considered to be most suitable for younger,
larger male patients.
Hip I Structured SBA
Logishetty K, Muirhead-Allwood SK, Cobb
JP. Hip resurfacing – what is its role in modern
orthopaedics? Bone & Joint 360.2020Feb;9(1):4–9.
3. Answer E. Stand on one leg
The superior gluteal nerve is at risk during deep
dissection in the direct lateral approach to the hip.
The fibres of gluteus medius are split from the
middle of the greater trochanter proximally. If the
split is continued more than 3–5cm proximal to the
trochanter there is risk of nerve damage. The superior gluteal nerve originates from the lumbosacral
plexus with contribution from nerve roots L4–S1
and innervates gluteus medius, gluteus minimus,
and tensor fascia lata. Weakness will manifest clinically during Trendelenburg test or hip abduction.
4. Answer E. First year, once at 7 years and three
yearly thereafter
ODEP 10Aor 10A* rated hip resurfacing devices are
the MatOrtho Adept Resurfacing Head (48–58mm)
and Smith & Nephew Birmingham Hip Resurfacing
Head (48–62mm). It is recommended that they be
followed up during the first year, once at 7 years and
three yearly thereafter. Patients at risk of adverse
reaction to metal debris (ARMD) (female patients,
males with femoral components smaller than 48mm
and those with a DePuy ASR implant) should be
reviewed annually for as long as the device is
implanted. Those not at risk but symptomatic
should also be seen annually. Other implants in
asymptomatic patients not at risk should be seen
annually for the first 5 years, two yearly to 10 years,
and then three yearly thereafter.
Logishetty K, Muirhead-Allwood SK, Cobb
JP. Hip resurfacing – what is its role in modern
orthopaedics? Bone & Joint 360. 2020;9(1):4–9.
5. Answer A. Avascular necrosis
Garden classified femoral neck fractures into four
types depending on the degree of displacement
seen on an anteroposterior radiograph. Type I
are incomplete fractures, type II are complete but
non-displaced fractures, type III are complete and
partially displaced fractures and type IV are complete and fully displaced.
Young patients with Garden II neck of femur
fractures would most commonly be managed with
closed reduction and fixation with either cannulated
hip screws or an alternate device, unless the patient
35
Edward Holloway
had significant comorbiditie s making an arthroplasty
with a lower risk of reoperation a better option.
Leg length discrepancy, sciatic nerve palsy
injury and Trendelenburg gait would all be complications of THR.
Parker MJ, Gurusamy KS. Internal fixation
versus arthroplasty for intracapsular proximal
femoral fractures in adults. Cochrane Database
Syst Rev. 2006;4:CD001708.
6. Answer B. Sartorius
The direct anterior approach (DAA) to the hip is
performed with the aim of reducing muscle
damage, length of stay, pain and complication
rate. A fracture table with specific attachments is
used by some to assist in femoral exposure.
There is a risk of damageto the lateral cutaneous
nerve of the thigh.This nervearises fromthe lumbar
plexus, or more rarely the femoral nerve itself, and
travels through the pelvis on the iliacus muscle. It
enters the thigh under the inguinal ligament at a
point anywhere between the anterior superior iliac
spine (ASIS) and the midinguinal point. The nerve
then pierces the fascia lata medial and inferior to the
ASIS. From here, the nerve takes a variable course
but most commonly the medial border of sartorius.
Meermans G, Konan S, Das R, Volpin A,
Haddad FS. The direct anterior approach in total
hip arthroplasty: a systematic review of the literature. Bone Joint J. 2017;99-B(6):732–740.
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
danger 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 evident
at the superolateral aspect of the obturator foramen, where the nerve, artery, and vein exit the
true pelvis through the obturator canal.
When an anatomical 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 poster-
ior 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 poster-
ior inferior quadrant are directed toward the
inferior gluteal and internal pudendal nerves and
vessels. These structures are rarely endangered,
due to surrounding intrapelvic tissue and their
distance from the posterior column.
7. Answer A. External iliac vessels
This SBA topic is of significant practical importance
and is also frequently asked in viva examinations.
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 ante rior inferior quadrants should be avoided whenever
possible, because screws placed improperly in these
quadrants may endanger the external iliac artery and
vein, as well as the obturator nerve, artery, and vein.
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 quadrants and specific intrapelvic structures.
Screws originating from the anterior superior
quadrant were found to lie near the external iliac
36
Figure 3.7 Safe acetabular quadrants for screw placement
Hip I Structured SBA
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.
8. Answer B. Cementless stem
Intraoperative Vancouver A2 fractures are nondisplaced fractures of the proximal metaphysis. All
answers are associated with an increased relative
risk of calcar fracture, but cementless stems give
the greatest relative risk (RR) (RR = 3.8). Age
11–49 RR = 1.5, female sex RR = 1.9, paediatric
disease RR = 2.6, previous trauma RR = 3.6.
9. Answer D. Total hip arthroplasty
Avascular necrosis of the hip is predominantly
idiopathic but may be associated with alcohol abuse,
steroid use, hypercoagulability, Caisson’sdiseaseand
sickle cell disease. Treatment options depend upon
the clinical and radiographic stage (Ficat, Steinberg)
of the disease and age/comorbidities of the patient.
The relatively conservative options listed would be
options in younger patients or those with earlier
stages of disease. Once any significant amount of
collapse has occurred in a patient over 40, the most
likely option is an arthroplasty procedure.
Petek D, Hannouche D, Suva D.
Osteonecrosis of the femoral head: pathophysiology and current concepts of treatment. EFORT
Open Rev. 2019;4:85–97.
(functional pelvic plane) rotates this plane
according to an individual’s pelvic tilt. It is considered a more accurate reference plane for assessing acetabular component position. PI (pelvic
incidence) is the angle between two lines: one from
the centre of the femoral head to the centre of the
S1endplate,andasecondperpendiculartoaline
across the S1 end plate, intersecting the centre of
the end plate. SPT (spinopelvic tilt) is the angle
between a line from the centre of the S1 end plate
and the centre of the segment between the two
femoral heads (the bicoxofemoral axis), and the
vertical. SS (sacral slope) is the angle between
two lines: one parallel to the S1 end plate, and
a second along a horizontal reference plane.
Ike H et al. Spine-pelvis-hip relationship in
the functioning of a total hip replacement. J Bone
Joint Surg Am. 2018;100:1606–1615.
11. Answer A. Cemented dual mobility THA
The Dorr classificationdependsupontheratio
between the inner canal diameter at the level of the
midpoint of the lesser trochanter and a point 10cm
belowthat.DorrCfemursasdefinedasaratio
>0.75 are most suitable for a cemented prosthesis.
A patient with significant risk of dislocation and a
grossly displaced NOF fracture would be a good
candidate for a dual-mobility acetabular component.
Our preferred choice in view of the patient’s
young age (55 years) would be for a dual motion
hydrid THA (cup being uncemented). A cemented
dual motion cup would be at risk of medium term
failure. The possibility of using a hybrid THA
dual motion THA was not given in the options.
10. Answer D. SPT (spinopelvic tilt)
Increasingly, the relationship between the spine,
hip and knee is assessed and considered in how it
may affect the functionality and stability of a
THR as the patient moves from lying to standing
and from sitting to standing. All options can be
measured radiographically to this end.
APPt (anterior pelvi c plane tilt) refers to the
rotation of the pelvis in the sagittal plane as
measured by the angle formed between the coronal plane and a line from the anterior superior
iliac spine (ASIS) to pubic symphysis.
The APP (anterior or anatomical pelvic
plane) is defined by the pubic symphysis and
the two anterior superior iliac spines. The FPP
12. Answer B. 5° external rotation, 5° adduction, 25°
flexion
This is the most appropriate position of hip fusion.
13. Answer D. Sciatic nerve
The position of greatest risk of dislocation for a
posterior approach THA is flexion and internal
rotation. The structure most at risk during this
approach is the sciatic nerve.
14. Answer D. Periprosthetic femur fracture
The radiograph shows a loose Charnley femoral
stem which is close to fracturing through the
posterior cortex of the femur (Figure 3.6). The
THA may be infected but the fact that the
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