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Edward Holloway
Figure 3.8 Lateral radiograph
of left hip
acetabulum does not look loose goes against this.
Pseudotumour formation is associated with metalon-metal bearing couples.
15. Answer E. Placement of posterolateral portal
By far the most common direct nerve injury
resulting from hip arthroscopy portal placement is
of the lateral femoral cutaneous nerve when placing
or working through the anterior portal. Sciatic
nerve injury causing a foot drop is a rare complication of posterolateral portal placement, made
more likely by placing the leg in external rotation.
Papavasiliou AV, Bardakos NV.
Complications of arthroscopic surgery of the hip.
Bone Joint Res.2012;1:131–144.
16. Answer B. 36mm versus 32mm head
Scenarios of hip instability are regularly asked in
the Part 1 paper. It is an extremely important
topic as surgeons need to know how to deal with
an on table unstable hip.
The primary arc of hip motion is the range
that the hip can move before the neck impinges
upon the acetabulum and is an important determinant of THA stability. A lipped or angled liner may
improve stability by increasing coverage but actually
decreases the primary arc of motion and, in this
instance, may make anterior dislocation more
likely by causing posterior impingement levering
the hip out of joint. A high offset stem or lateralised
liner will not alter the primary arc of movement
but may improve stability by moving the femoral
neck away from impinging soft tissues or osteophytes (potential to the detriment of proper restoration of hip biomechanics). A skirted head (asfound
on the longer lengths) decreases the primary arc.
A bigger head size increases the impingement-free
range of motion and jumping distance of THA
(Sariali et al. 2009).
Sariali E, Lazennec J Y, Khiami F, Catonne
Y. Mathematical evaluation of jumping distance
in total hip arthroplasty: influence of abduction
angle, femoral head offset, and head diameter.
Acta Orthop. 2009;80:277–282.
17. Answer E. Revision arthroplasty
All the options are valid in managing the infected
joint replacement. Patients not sufficiently fit to
do well with further significant or poten tially
multiple procedures can be managed with
culture-specific, long-term suppressive antibiotics or an excision arthroplasty, if the infection is
not able to be suppressed or the patient is unable
to take long-term antibiotics.
The success rates of DAIR (debridement, anti-
biotics, and implant retention) procedures vary
enormously in the literature, from 11–100%.
The success rate is correlated with type of
organism (Streptococcus species tend to do better),
exchange of modular components and time from
procedure in early infection, or time from first
presentation of symptoms in late infection.
An older patient with long duration of symptoms is less likely to have successful infection
eradication with a DAIR so may be best served
with a one- or two-stage revision procedure
depending upon the infecting organism and the
surgeon’s preference.
Grammatopoulos G et al. Outcome
following debridement, antibiotics, and implant
retention in hip periprosthetic joint infection –
an 18-year experience. J Arthroplasty
2017;32:2248–2255.
Kunutsor SK, Beswick AD, Whitehouse MR,
Wylde V, Blom AW. Debridement, antibiotics
and implant retention for periprosthetic joint
infections: a systematic review and meta-analysis
of treatment outcomes. JInfect.2018;77:479–488.
18. Answer E. Three 1 500cGy radiotherapy doses
Heterotopic ossification (HO) following THA
occurs with an incidence of 5–90% and is associated with the risk factors of male sex, history of
previous HO, older age, previous hip fusion,
hypertrophic OA, ankylosing spondylitis, posttraumatic OA, Paget’ s disease, osteonecrosis,
and rheumatoid arthritis.
It is classified according to the Brooker classification according to the extent of heterotopic
bone formation on an AP radiograph.
Prophylaxis can be considered for patients
at high risk of HO and the main forms are
38
Hip I Structured SBA
radiotherapy and non-steroidal anti-inflammatory
drugs (NSAIDs). Diphosphonates have not been
shown to be effective. NSAIDs would be contraindicated in a patient with severe inflammatory
bowel disease. Multiple doses of radiation therapy
havebeenshowntobemoreeffectivethansingle
doses.
Board TN, Karva A, Board RE, Gambhir AK,
Porter ML. The prophylaxis and treatment of het-
erotopic ossification following lower limb arthroplasty. J Bone Joint Surg Br.2007;89:434–440.
19. Answer D. Tonnis angle
The following are measured during the radiographic assessment of patients with symptoms
of femoroacetabular impingement:
The Tonnis angle (also called the acetabular
index or acetabular roof angle) is the angle
between the horizontal and a tangential line from
the medial to the lateral sourcil (weight bearing
zone of the acetabulum).
Alpha angle is measured on a Dunn view by
drawing a line from the centre of the narrowest
point of the femoral neck to the centre of the
femoral head using a best-fit circle. The angle is
between the line down the axis of the femoral
neck and a line drawn to the location where the
femoral head becomes ‘out of round’.
The lateral centre edge angle (of Wiberg) is
the angle betw een a line drawn from the centre of
the femoral head to the lateral edge of the acetabulum and a second line that is parallel to the
longitudinal pelvic axis.
Sharp’s angle, or acetabular angle, is the angle
between a horizontal line drawn throug h the
teardrops and a line drawn from the teardrop
to the lateral acetabular roof.
The vertical centre edgeangle is measured from
a false profile radiograph and is between a vertical
line through the centre of the femoral head and a
line from the centre of the femoral head to the
anterior-most point on the acetabulum.
Mannava S et al. Comprehensive clinical
evaluation of femoroacetabular impingement:
part 2, plain radiography. Arthrosc Tech. 2017;6:
e2003–e2009.
20. Answer C. Phelp’s test
Phelp’s test assesses gracilis tightness. Ely’stest
assesses rectus femoris tightness. Ober’s test assesses
tightness of the tensor fascia lata. Thomas’ test
assesses fixed flexion of the hip. Trendelenburg test
assesses hip abductor dysfunction.
21. Answer C. Flexion to 90°, adduction, in-line
traction, then internal rotation
Leadbetter described a technique in 1939 to aid
in the reduction of intracapsular neck of femur
fractures. The limb is flexed to relax the musculature around the hip and then internal rotation
functions to relax the ligamentous structures.
From the above position, further flexion and
adduction open the fracture, allowing reduction
to be achieved by maintaining traction while
bringing the limb into extension with slight
abduction and continued internal rotation.
22. Answer A. Excessive anteversion
The Hartofilakidis classification recognises three
types of congenital hip disease in adults: type A –
dysplasia, type B – low dislocation, and type C –
high dislocation. In type A disease, the femoral
head remains within the original acetabulum. In
type B, it articulates with a false acetabulum which
partially covers the original acetabulum. In type C,
the femoral head has migrated superiorly and
posteriorly to the hypoplastic original acetabulum.
Adult hip dysplasia is most commonly associated
with excessive femoral anteversion.
23. Answer A. Ceramic on ceramic
Figure 3.4 (see Questions section) represents the
scratch profile of ceramic.
Revision surgery for fractured or damaged ceramic components requires thorough debridement
and removal of ceramic fragments. Revision with
metal heads should be avoided and ceramic components used wherever possible. Trunnions that are
damaged need to be replaced, but if only minimal
damage exists; then a ceramic head with a titanium
liner or trunnion adapter can be used.
Rambani R et al. Revision total hip arthroplasty for fractured ceramic bearings: a review of
best practices fo r revision cases. J Arthroplasty
2017;32:1959–
24. Answer E. Otto pelvis
Otto pelvis (arthrokatadysis or protrusio acetabuli) is a rare condition associated with hip
osteoarthritis. Protrusio acetabuli is defined
1964.
39
Edward Holloway
radiographically when the medial aspect of the
femoral head projects beyond the ilioischial
(Kohler’s) line. Though sometimes idiopathic,
acetabular protrusion is more usually associated
with inflammatory arthropathies, osteoporosis,
osteomalacia, and Paget’ s disease. When performing THR, care must be taken to lateralise
the medialised hip centre.
25. Answer A. Book for emergency surgery
Nerve dysfunction following THR may be a result of
intraoperative compression from retractors, traction
injury secondary to manipulation or lengthening.
If noted in the immediate postoperative
period, tension can be taken off the sciatic nerve
by nursing the patient with the knee in flexion.
Progressive, painful sciatic nerve dysfunction
should raise the suspicion of compression from
haematoma. This is associated with patients of
lower mass, and with anticoagulant use.
Improved outcomes are associated with prompt
exploration and evacuation of haematoma.
Butt AJ, McCarthy T, Kelly IP, Glynn T,
McCoy G. Sciatic nerve palsy secondary to post-
operative haematoma in primary total hip replacement. J Bone Joint Surg Br.2005;87:1465–1467.
Su EP. Post-operative neuropathy after total
hip arthroplasty. Bone Joint J. 2017;99-B(Suppl.
1):46–49.
26. Answer B. 125° versus 135° neck–shaft angle
implant
A longer femoral head length and incomplete insertion of an uncemented femoral stem will lengthen
the patient. A larger sized femoral stem or increased
offset stem will not generally change leg length.
27. Answer: D. Staphylococcus aureus
Outcomes of DAIR procedures are dictated
by many surgical and patient factors.
Unsurprisingly, age, frailty, immunity, diabetes,
and nutritional status are all associated with
chances of a successful DAIR procedure.
Paramount to success are a radical debridement
and exchange of modular components (to
reduce biofilm and remove the fibrin layer
between components that supports infection).
Most studies suggest a lower chance of infection
eradication with staphylococcal, and especially
MRSA, infection.
Staphylococcus aureus or coagulase-negative
staphylococci (CNS) are the most common
causative pathogens of PJI, accounting for
approximately two-thirds of all cases. Despite
gradually improving success rates for DNIR over
the years, the reported outcome of staphylococcal
PJI is still heterogeneous, ranging from 23–90%.
Coagulase-negative staphylococci (CoNS)
such as S. epidermidis can be divided into
methicillin-resistant coagulase-negative staphylococci (MRSE) and methicillin-susceptible coagulase-negative staphylococci (MSSE).
Scheper H et al. in a meta-analysis on the
success rates with DNIR for PJI reported considerably better results for hip and coagulase negative staphylococci (CNS) PJI than for knee and S.
aureus PJI. Success rates of MRSA and MSSA PJI
after DAIR were similar.
Coagulase-negative staphylococcus bacteria
represent a concerning cohort of increasingly
common and decr easingly treatment-susceptible
pathogens in PJI. Both biofilm production and
avidity towards antibiotic resistance acquisition
enhance the virulence of CNS.
Methicillin-resistance is not decisive for virulence, but methicillin-resistant S. aureus (MRSA)
strains often express a higher level of virulence
factors that facilitate their survival and spread.
In summary, literature is confusing and often
non-committal. The approach shared by many PJI
revision groups, is to go for a DAIR ASAP whenever
they are confident that they are dealing with an acute
PJI, regardless of the pathogen. A speedy response
combined with the experience of the surgeon performing the DAIR and a good MDT support are
probably more important factors when it comes to
achieving a successful outcome than the pathogen.
Xu Y, Wang L, Xu W. Risk factors affect
success rate of debridement, antibiotics and
implant retention (DAIR) in periprosthetic joint
infection. Arthroplasty 2020;2:37.
Scheper H et al. Outcome of debridement,
antibiotics, and implant retention for staphylococcal hip andknee prosthetic joint infections, focused
on rifampicin use: a systematic review and metaanalysis. Open Forum Infect Dis.2021;8(7).
Hays MR et al. Increased incidence of
methicillin-resistant Staphylococcus aureus in
knee and hip prosthetic joint infection.
J Arthroplasty 2023;38(6S):S326– S330.
40
Hip I Structured SBA
28. Answer: D. Benchmark revision rate less than 1
in 20 at 10 years
ODEP (Orthopaedic Data Evaluation Panel) is
an independent group of clinical and non-clinical
experts who invite implant manufacturers to
supply data regarding their implants. The data
are assessed and an ODEP rating is awarded
(or not). The number, 3, 5, 7, 10 (full compliance
with NICE benchmark), 13 or 15, signifies the
number of years of data available. ‘A’ signifies
strong evidence, ‘B’ acceptable strength of evidence. A ‘*’ is awarded for an implant revision rate
of less than 1 in 20 (5%) at 10 years. The Beyond
Compliance initiative is a post-market surveillance
service supported by ODEP. Implants registered
with The National Joint Registry and being evaluated through Beyond Compliance are recognised
with the rating ‘Pre-entry A*’.
29. Answer B. Elevated ESR (serum)
The 2018 criteria are a development of the 2011
definitions and have higher sensitivity (97.7%)
and specificity (99.5%) for the diagnosi s of periprosthetic joint infection. A diagnosis is made
either with one major criterion being met (two
positive cultures of the same organism, or a sinus
tract with evidence of communication to the
joint or visualisation of the prosthesis), or a score
of equal or greater than 6 from minor criteria.
An elevated CRP or D-dimer (serum) scores 2,
an elevated ESR (serum) scores only 1, an elevated synovial PMN (%) (synovial) scores 2, an
elevated synovial WBC count or LE (Leucocyte
esterase) (synovial) sco res 3, and a positive alphadefensin (synovial) scores 3.
Parvizi J et al. The 2018 definition of peri-
prosthetic hip and knee infection: an evidencebased and validated criteria. J Arthroplasty
2018;33:1309–1314.e2.
30. Answer B. 2.
Core decompression is a treatment option for
AVN of the femoral head before subchondral
collapse has occurred. Steinberg (a modification
of the Ficat classification) stage 3 is defined by
the radiographic ‘Crescent Sign’, indicating subchondral collapse.
Chughtai M et al. An evidence-based guide
to the treatment of osteonecrosis of the femoral
head. Bone Joint J. 2017;99-B(10):1267–1279.
31. Answer A. Iatrogenic injury
Intra-prosthetic dislocation is a complication
unique to dual mobility (DM) designs where
the larger diameter polyethylene bearing
becomes detached from the smaller diameter
metal or ceramic bearing: the most common
cause is likely to be iatrogenic, when closed
reduction of a dislocated dual mobility
THR is attempted, and the outer bearing is
levered off the acetabular component dislocating it from the inner bearing: the so-called
‘bottle-opener’ effect. Modular DM implants
maybemorepronetofailurethrough
other mechanisms. Non-highly crosslinked
polyethylene bear ings are more prone to later
intra-prosthetic dislocation. Skirted heads
and smaller diameter heads are less likely
to be associated with early intra-prosthetic
dislocation.
De Martino I et al. Early intraprosthetic dis-
location in dual-mobility implants: a systematic
review. Arthroplasty Today 2017;3:197–202.
32. Answer D. Multiple emboli
Bone Cement Implantation Syndrome (BCIS)
is a rare, potentially fatal, complication
of surgery using bone cement. Its aetiology
is incompletely understood and likely to be
multi-factorial. The m ost likely causative mechanism is the creation of emboli of marrow,
bone, cement, air, platelet-aggregates, due to
the high intra-medullary pressures generated
whilst cementing, and especially, inserting the
prosthesis. These emboli have mechanical and
mediator induced effects.
Hines CB. Understanding bone cement implant-
ation syndrome. AANA J. 2018;
33. Answer: C Hydrogen peroxide
There is no clear evidence to support the use
of one irrigation solution over another. These
solutions may be effective in breaking down biofilm in established infection and preventing
infection in primary joint replacements by reducing bacterial burden prior to wound closure.
One ml of hydrogen peroxide produces 10 ml
of oxygen, and there have been reports of fatal
complications relating to air emboli when used
in enclosed anatomical spaces, such as the femoral canal.
86:433–441.
41
Edward Holloway
Christopher ZK., Deckey DG., Pollock JR,
Spangehl MJ. Antiseptic irrigation solutions
used in total joint arthroplasty: a critical analysis review. JBJS Rev. 2022;10(3):10.2106/
JBJS.RVW.21.00225.
34. Answer B. Long, fully coated uncemented stem
The radiograph shows a loose femoral stem
with extensive metaphyseal bone loss and more
than 4cm of intact diaphysis. This could be
classified as Paposky Type 3A. The most suitable revision would be to a long uncemented,
extensively coated stem that could be modular
or non-modular. A cement-in-cement revision
would require an intact proximal cement-bone
interface. A primary cemented stem would
require an intact metaphysis. A proximal femur
replacement would be more suitable for 3B
and 4 defects. Removal of cement and a longcemented stem is associated with less favourable outcomes.
Suleiman LI, Erivan R, Paprosky WG.
Classifying femoral bone deficiency: picking the
right tool for the job. Semin. Arthroplasty
2018;29:172–176.
35. Answer A. Debridement, antibiotics, and
implant retention
Debridement, antibiotics, and implant retention
is an established treatment for infections in primary joint replacements, but also has similar
indications in revision arthroplasties. One would
expect a lower chance of success in infection
eradication compared with that in a primary
hip or knee replacement. Factors associated with
worse outcomes are delays to DAIR from start of
symptoms, multiple DAIRs, antibiotic mismatch.
Veerman K, Raessens J, Telgt D, Smulders
K, Goosen JHM. Debridement, antibiotics, and
implant retention after revision arthroplasty:
antibiotic mismatch, timing, and repeated
DAIR associated with poor outcome. Bone Joint
J. 2022;104-B(4):464–471.
36. Answer E. Phelp’s
Phelps test evaluates for tightness in the graci lis
muscle (adductor). The patient lies supine and
the affected hip is abducted as far as possible. The
knee is then flexed over the side of the couch. If
more abduction is possible by flexing the knee
(and relaxing the gracilis) then this signifies that
the gracilis is tight.
Bryant described an anatomical triangle useful
in the assessment of limb length inequality.
Ely described a test for rectus femoris tightness. Passive flexion of the knee in the presence
of a tight rectus femoris leads to ipsilateral buttock rising.
Ober described a test for contracture of the
fascia lata or iliotibial band. The patient lies on
the unaffected side. The affected hip is flexed and
abducted 45°. This hip is then slow ly extended.
Normally in bringing the hip into extension, it
will be possible to adduct the hip to the midline.
In the presence of a tight iliotibial band, the leg
remains abducted.
Patrick described a test to distinguish between
pain originating from the sacroiliac joint versus
the posterior hip. The patient lies supine while
placing the ipsilateral foot on the contralateral
knee – the figure of four position. The examiner
places one hand on the flexed knee and the other
on the ASIS of the contralateral side and presses
gently downwards on the flexed knee.
42
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
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