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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
37
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
4
Adult Elective Orthopaedics and Spine
Hip II Structured SBA
James Gill and Majeed Shakokani
HIP II STRUCTURED SBA QUESTIONS
1. Metal hypersensitivity to orthopaedics implants
is classed as what kind of sensitivity?
A. Type I
B. Type II
C. Type III
D. Type IV
E. Type V
2. A 78-year-old female has been listed for THA
and noted to have protrusio on her anteroposterior (AP) radiograph.
Which of the following conditions is not commonly associated with acetabular protrusio?
A. Ankylosing spondylitis
B. Marfan syndrome
C. Neurofibromatosis
D. Paget’s disease
E. Rheumatoid arthritis
3. A 42-year-old male presents to the orthopaedic clinic
with a 2-month history of left hip pain. His anteroposterior radiograph is shown in Figure 4.1.
Which of the following is not associated with
his condition?
A. Glucocerebrosidase gene
B. HbSS
C. Protein S deficiency
D. Scleroderma
E. Simvastatin
4. A 24-year-old manual labourer presents with
severe post-traumatic arthritis hip. Hip fusion
has been discussed by the regional MDT.
What is the optimal position for hip
arthrodesis?
A. 10° flexion, 5° adduction, 5° external rotation
B. 10° flexion,10° adduction, 10°external rotation
C. 25° flexion, 0° abduction, 10° internal rotation
D. 25° flexion, 5° adduction, 5° external rotation
E. 25° flexion, 10° abduction, 10° external
rotation
5. Which of the following results in increased
abductor muscle force when performing a
single leg stance after arthroplasty?
A. Carrying a bag of shopping with the ipsilat-
eral arm
B. Medialisation of the acetabular cup
C. Reducing offset
D. Trunk lean to the ipsilateral side upon single
leg stance
E. Walking with a stick in the contralateral hand
post
Figure 4.1 Anteroposterior (AP) radiograph hips
6. A patient presents with a fractured metal stem of
a total hip arthroplasty. On closer inspection of
the previous anteroposterior radiographs of their
hip taken 6 months ago, there was evidence of
loosening.
In which Gruen zones would loosening be
expected in the pre-fracture radiographs in this
scenario?
43
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