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James Gill and Majeed Shakokani
A. 1, 2, 3, 4, 5, 6 and 7
B. 1, 2, 6 and 7
C. 4 and 5
D. 4, 5 and 6
E. 4, 5, 6 and 7
7. Which of the following is the best mode of
imaging to assess for a pseudotumour associated with a metal-on-metal hip resurfacing?
A. Computed tomography
B. MARS MRI
C. SPECT
D. Ultrasound
E. White cell scan
8. A 60-year-old male falls off a camel while on
holiday in Lanzarote and suffers a fracture to
the ceramic head of his left total hip arthroplasty
(THA). The THA was performed 2 years previously; components included an unceme nted
titanium cup with polyethylene liner and an
uncemented stem with a ceramic head. Prior to
the fall, he was completely happy with the hip.
Which of the following is the most appropriate
procedure?
A. Revise all implants
B. Revise to a cobalt-chrome head with change
of polyethylene liner
C. Revise to a metal-lined ceramic head with
change of polyethylene liner
D. Revise to a metal-on-metal bearing surface
E. Revision of ceramic head with change of
polyethylene liner
9. Which kind of lubrication predominates in a
metal-on-polyethylene total hip arthroplasty?
A. Boosted
B. Boundary
C. Elastohydrodynamic
D. Squeeze film
E. Weeping
10. One year after primary total hip arthroplasty per-
formed using a Southern Moore approach a patient
asks why his foot turns inwards when he walks.
Which of the following would be the most likely
cause?
A. Excessive acetabular cup anteversion
B. Excessive retroversion of femoral stem
C. Failure of the repair of the short external
rotators
D. Palsy of gluteus medius and minimus
E. Weakness of gluteus maximus
11. When drilling a screw to augment fixation of an
uncemented acetabular cup, profuse bleeding is
encountered and the patient becomes hypotensive.
Which vessel has been injured?
A. External iliac
B. Femoral
C. Internal iliac
D. Obturator
E. Pudendal
12. A 78-year-old male is listed for THA. He is a
Jehovah’s Witness and does not want any blood
products to be given.
What is the best way to reduce blood transfusion requirement in a Jehovah’s Witness undergoing total hip arthroplasty?
A. Autologous blood transfusion
B. Cell salvage
C. Erythropoietin
D. Hypotensive anaesthesia
E. Wound infiltration with local anaesthetic
with adrenaline
13. You are beginning a THA in theatre in a diabetic.
A ST3+ orthopaedic trainee is assisting you and
asks about the infection risk.
Which factor has the biggest influence in reducing prosthetic joint infection?
A. Antibiotic loaded bone cement
B. Body exhaust suit
C. Plastic isolator
D. Systemic antibiotics
E. Ultraclean air
14. What is the nerve supply to the superior gemelli?
A. Nerve to gemelli
B. Nerve to obturator internus
C. Nerve to piriformis
D. Nerve to quadratus femoris
E. Obturator nerve
15. Which of the following structures exits the
greater sciatic foramen and does not re-enter
the lesser sciatic foramen?
44
Hip II Structured SBA
A. Nerve to obturator internus
B. Nerve to quadratus femoris
C. Obturator externus
D. Obturator internus
E. Pudendal nerve
16. Which anatomical structure does not enter the
pelvis via the lesser sciatic foramen?
A. Internal pudendal artery
B. Internal pudendal vein
C. Nerve to obturator internus
D. Obturator internus
E. Pudendal nerve
17. Which anatomical variation of the sciatic nerve
exiting the greater sciatic foramen is most frequently observed?
A. Common peroneal division exiting above pir-
iformis and tibial nerve division exiting
beneath piriformis
B. Common peroneal division exiting above pir-
iformis and tibial nerve exiting through
piriformis
C. Common peroneal division passing through
piriformis and tibial nerve division exiting
beneath piriformis
D. Sciatic nerve exiting above piriformis
E. Sciatic nerve exiting through piriformis
18. In the days following a total hip arthroplasty, a
patient was found to have 0/5 power in ankle
dorsiflexion and foot eversion but 5/5 power in
ankle plantar flexion.
Provided the injury was a neuropraxia at the
level of the hip joint, which muscle would you
expect to recover first on assessment with
electromyography?
A. Adductor magnus
B. Peroneus longus
C. Popliteus
D. Short head of biceps femoris
E. Tibialis posterior
19. A professional tennis player develops pain
around the hip 2 months after metal-on-metal
hip resurfacing.
Which imaging modality can detect heterotopic
ossification earliest?
A. Bone scintigraphy
B. Computed tomography
C. Magnetic resonance imaging
D. Radiographs
E. Ultrasound scan
20. What structures form the teardrop on an ante-
roposterior radiograph of the pelvis?
A. Calcified ligamentum teres
B. Cotyloid fossa, superior aspect of the obtur-
ator foramen and the cortical surface of the
true pelvis
C. Dense trabeculae of the origin of the superior
public ramus
D. Osteophyte within the cotyloid fossa
E. True floor of the acetabulum and the superior
pubic ramus
21. Which of the following conditions is associated
with increased acetabular anteversion?
A. Ankylosing spondylitis
B. Legg–Calvé–Perthes disease
C. Pincer femoral acetabular impingement
D. Rheumatoid arthritis
E. Slipped upper femoral epiphysis
22. Acetabular protrusio can be defined using an
anteroposterior radiograph as which of the
following?
A. Acetabular fossa medial to the ilioischial line
B. Acetabular fossamedial to the iliopectineal line
C. Centre-edge angle greater than 30 degrees
D. Femoral head medial to ilioischial line
E. Femoral head medial to iliopectineal line
23. A 37-year-old male who is training for the long-
distance triathlon world championships, Ironman
Hawaii, presents with a 6-week history of groin pain.
Which of the following diagnoses requires
urgent operative intervention?
A. Cam lesion
B. Iliotibial band syndrome
C. Inferior medial femoral neck stress fracture
involving 40% of neck width
D. Piriformis syndrome
E. Superior lateral femoral neck stress fracture
involving 25% of neck width
24. What mechanical property predisposes ceramic
to fracture?
45
James Gill and Majeed Shakokani
A. Failure at a point below the ultimate tensile
strength secondary to repetitive loading
B. Large area under the stress–strain curve
C. Low modulus of elasticity
D. Material that exhibits linear stress–
strain relationship until the point of
failure
E. Progressive deformation in response to a
constant force over a prolonged
period
25. Sickle cell disease is associated with which complication following total hip arthroplasty?
A. Early prosthetic loosening
B. Higher risk for heterotopic ossification
C. Increased blood loss
D. Nerve palsy
E. Periprosthetic infection
26. Which of the following ligaments is the
strongest?
A. Iliofemoral
B. Ischiofemoral
C. Ischiosacral
D. Ligamentum teres
E. Pubofemoral
27. Which of the following combinations of
implant position is optimal for total hip
arthroplasty?
A. Cup inclination 30°, cup anteversion 20°,
femoral stem anteversion 5°
B. Cup inclination 40°, cup anteversion 15°,
femoral stem anteversion 15°
C. Cup inclination 40°, cup anteversion 20°,
femoral stem anteversion 0°
D. Cup inclination 50°, cup anteversion 30°,
femoral stem anteversion 25°
E. Cup inclination 50°, cup anteversion 40°,
femoral stem anteversion 15°
28. When performing a total hip arthroplasty,
what is the optimal comb ined version of the
acetabular cup and femoral stem?
A. 5°
B. 20°
C. 35°
D. 50°
E. 65°
29. A patient has suffered multiple dislocations of a
total hip arthroplasty and has failed conservative
measures.
Which of the following is an indication for a
constrained liner?
A. 60° acetabulum inclination
B. Femoral stem retroversion
C. Gluteus medius and minimus deficiency
D. Impingement of the femoral neck on a lipped
liner
E. Neutral version of the acetabulum
30. When performing the Hardinge approach to the
hip, neurovascularstructures areplacedin jeopardy
if the gluteus medius is split too far proximally.
What is the maximum safe split above tip of the
greater trochanter that does not place the nerve
at risk?
A. 2cm
B. 3cm
C. 4cm
D. 5cm
E. 7cm
31. Which of the following describes a Ward’s
triangle?
A. A sign of osteoporosis
B. Lateral to the primary compressive trabeculaeand
medial to the secondary compressive trabeculae
C. Lateral to the secondary compressive trabecu-
lae and superior to the primary trabeculae
D. Medial to the primary compressive trabeculae
and inferior to the primary tensile trabeculae
E. Medial to the secondary tensile trabeculae and
lateral to the secondary compressive trabeculae
32. Smith-Petersen first described a direct anterior
approach to the hip.
Which vessel is sacrificed as part of this
approach to the hip?
A. Ascending branch of the lateral femoral cir-
cumflex artery
B. Descending branch of the lateral femoral cir-
cumflex artery
C. Descending branch of the medial femoral
circumflex artery
D. Superficial external pudendal artery
E. Transverse branch of the lateral femoral cir-
cumflex artery
46
Hip II Structured SBA
33. Which size of PE particles are thought to be
most biologically active
A. 0.1µm
B. 0.5µm
C. 1.0µm
D. 1.5µm
E. 0.05µm
34. A 44-year-old male has deteriorating hip pain
secondary to osteonecrosis. Symptoms have
failed to improve despite conservative measures
including protected weight bearing. A subchondral lucent line can be seen on the anteroposterior radiographs of the hip.
What is the most appropriate management?
A. Core decompression
B. Free fibula graft
C. Hip arthrodesis
D. Rotational femoral osteotomy
E. Total hip arthroplasty
35. Which of the following factors is not respon-
sible for osteolysis around a total hip arthroplasty secondary to polyethylene wear debris?
A. IL-1
B. IL-6
C. Osteoprotegerin
D. PDGF
E. Receptor activator of nuclear factor kappa-B
ligand
36. With which femoral component would the
most proxi mal bone loss be anticipated as a
result of stress shielding?
A. Cemented dual taper cobalt-chromium stem
B. Cemented stainless steel composite beam stem
C. Uncemented, fully porous coated cobalt-
chromium stem
D. Uncemented, fully porous coated titanium stem
E. Uncemented proximally porous coated
cobalt-chromium stem
38. Which muscle is paired with its correct
innervation?
A. Adductor brevis – posterior division of
obturator nerve
B. Adductor longus – posterior division of
obturator nerve
C. Adductor magnus – tibial nerve and anterior
division of obturator nerve
D. Gracilis
nerve
E. Pectineus – femoral nerve
39. The femoral circumflex vessels are named
according to the relationship with which anatomical structure?
A. Calcar femorale
B. Iliopsoas
C. Lesser trochanter
D. Pectineus
E. Profunda femoris artery
40. Taper slip cemented stem fixation is optimised
by all except which of the following?
A. Cement mantle >2mm
B. Flexible femoral stem
C. Limited porosity cement
D. Smooth femoral stem
E. Stem centralisation
41. Which of the following is incorrect regarding
the capsule of hip joint?
A. Gluteus minimus and rectus femoris have
direct attachments onto the capsule
B. The capsule attaches more distally on the
neck posteriorly compared with anteriorly
C. The iliofemoral ligament shares an attachment
with the direct head of the rectus femoris
D. The ischiofemoral ligament is divided as part
of the Southern–Moore approach to the hip
E. The Y-ligament of Bigelow is divided as
part of the Smith-Petersen approach to the hip
– posterior division of obturator
37. What is the intermuscular plane of the medial
approach to the hip?
A. Adductor brevis and adductor longus
B. Adductor brevis and adductor magnus
C. Adductor longus and gracilis
D. Gracilis and adductor magnus
E. Sartorius and adductor longus
42. A 58-year-old male was seen in the outpatient
clinic with nonspecific complaints of pain in the
lumbar spine, buttock, lateral hip and thigh.
Nerve impingement of which nerve can mimic
hip joint pathology?
A. Femoral nerve
B. L2
47
James Gill and Majeed Shakokani
C. Lateral cutaneous nerve of the thigh
D. Obturator nerve
E. Posterior cutaneous nerve of the thigh
43. A 38-year-old female is diagnosed with pincer-
type femoral acetabular impingement.
On MRI of the hip, what pattern of changes
would be expected to be seen?
A. Anterior intrasubstance labral tear and a pos-
terior acetabular cartilage lesion
B. Anterior intrasubstance labral tear and an
anterior acetabular cartilage lesion
C. Anterior labral avulsion and anterior acetab-
ular cartilage delamination
D. Posterior intrasubstance labral tear and pos-
terior acetabular cartilage delamination
E. Posterior labral tear and an anterior acetabu-
lar cartilage lesion
44. You are performing a cemented THA for a 70year-old retired farmer. A trial reduction is
repeated with the definitive cup and stem
cemented in place and a 32mm standard (neck
length) head; however, stability is suboptimal.
Stability is re-assessed with a 32mm ‘plus 4mm’
(neck length) head and stabilityis now satisfactory.
The neck angle for the femoral implant is 125°.
How much will a ‘plus 4mm’ head increase leg
length and offset, respectively, compared with a
standard head?
A. 0mm, 4.0mm
B. 2.3mm, 3.3mm
C. 2.8mm, 2.8mm
D. 3.3mm, 2.3mm
E. 4.0mm, 0mm
45. A patient pres ents with pain 10 years following a
THA and radiographs show lucency in Gruen
zones 4 and 5.
Which mode of failure is the likely cause?
A. Bending cantilever
B. Calcar pivot
C. Medial mid stem pivot
D. Pistoning: Cement within bone
E. Pistoning: Stem within cement
A fracture is seen in the cement mantle just distal
to the prosthesis.
What mode of femoral stem loosening is this
most likely to represent?
A. Bending cantilever (fatigue)
B. Calcar pivot
C. Medial midstem pivot
D. Pistoning: Stem within bone
E. Pistoning: Stem within cement
47. Which of the following factors is not associated
with increased risk of cemented stem fracture?
A. Elongated femoral head
B. Increased body mass
C. Low neck cut
D. Poor distal cement fixation
E. Smaller stem size
48. Which factor does not predispose to an
increased risk of hip dislocation?
A. Direct anterior approach
B. Elevated BMI
C. Parkinson
D. Previous lumbar fusion
E. Total hip arthroplasty for hip fracture
49. A 75-year-old patient develops degenerative hip
arthritis 8 years following an intertrochanteric
fracture treated with a dynamic hip screw.
What is the correct surgical management plan?
A. Removal of all metalwork and cemented total
hip arthroplasty bypassing the most distal
crew hole by at least 1.5 femoral diameters
B. Removal of all metalwork and cemented total
hip arthroplasty bypassing the most distal
crew hole by at least 2.5 femoral diameters
C. Removal of all metalwork and cemented total
hip arthroplasty bypassing the most distal
crew hole by at least 3.5 femoral diameters
D. Removal of all metalwork and cemented total
hip arthroplasty bypassing the most distal
crew hole by at least 4.5 femoral diameters
E. Removal of all metalwork and cemented total
hip arthroplasty bypassing the most distal
crew hole by at least 5.5 femoral diameters
’s disease
46. You are reviewing the AP radiograph of patient
who has been referred with thigh pain 5 years
following cemented total hip arthroplasty.
48
50. Which of the following mechanical properties
is not associated with the high cross-linking of
polyethylene?
Hip II Structured SBA
A. Increased fracture toughness
B. Increased Young’s modulus
C. Reduced ductility
D. Reduced linear wear
E. Smaller wear particles
51. Total hip arthroplasty is planned for a 40-year-
old male with high developmental hip dysplasia
(Crowe type IV).
What is the maximum amount of leg length
correction that could be considered before
proximal femoral osteotomy should be planned
to reduce the risk of sciatic nerve palsy?
A. 3cm
B. 4cm
C. 5cm
D. 6cm
E. 7cm
52. When assessing a patient 1 day following total
hip arthroplasty, there is absence of sensation
over the dorsum of the foot and an MRC grade
0 power of ankle dorsiflexion. Total hip arthroplasty was performed under spinal anaesthetic
via a posterior approach and the nerve was not
encountered at any stage during the operation.
What is the most appropriate immediate
management?
A. Computed tomography to assess for haem-
atoma or cement
B. Foot drop splint and nerve conduction stud-
ies at 12 weeks if no clinical improvement
C. Magnetic resonance imaging to assess for
tethering of the nerve
D. Plain film imaging
E. Surgical exploration of the sciatic nerve
53. Which of the following factors increases pri-
mary arc range in total hip arthroplasty?
A. Constrained liner
B. Extended lipped liner
C. Increased femoral neck length
D. Increased offset
E. Larger femoral head
54. Submicron particles generation results in osteo-
lysis via the RANK ligand pathway.
What type of wear is the most important process that generates submicron-sized particles in
a metal-on-polyethylene THA?
A. Abrasive wear
B. Adhesive wear
C. Corrosive wear
D. Mode 2 wear
E. Mode 3 wear
55. You are performing a hybrid THA for a 76-year-
old female patient, when inserting the uncemented cup you notice a crack in the bone extending
superiorly from the interface between the cup
and bone. The fracture line extends 3cm superiorly. The cup is stable.
What is the most appropriate thing to do?
A. Continue with THA as planned
B. Fix the fracture with a compression plate
C. Insert screws into cup
D. Remove uncemented cup and insert
cemented cup
E. Remove uncemented cup and insert triflange
cage spanning fracture
56. Which of the following patients would it
be most appropriate to treat with THA for
fractured intra-capsular neck of
femur?
A. A 55-year-old lady with multiple sclerosis
who mobilises with a frame
B. A 65-year-old male who mobilises with a
single walking stick
C. A 65-year-old smoker with lung cancer with a
possible pathological fracture
D.
A 65-year-old with Parkinson’s disease
E. A 74-year-old lady with past medical history
of rheumatoid arthritis
57. A patient reports a feeling like their native hip is
dislocating.
What is the most likely diagnosis?
A. Hip micro instability
B. Iliopsoas impingement
C. Labral tear
D. Snapping iliotibial band
E. Torn ligamentum teres
58. Osteonecrosis of the femoral head can result in
subchondral collapse.
What is the pathophysiological cause of the loss
of trabecular structural integrity?
A. Decreased blood flow
B. Fat cell hypertrophy
49
James Gill and Majeed Shakokani
C. Osteocyte necrosis
D. Reactive hyperaemia
E. Resorption of bone
59. Which of the following pairings of causative
factor and pathophysiological mechanism for
femoral head osteonecrosis is incorrect?
A. Corticosteroids – fat cell hypertrophy
B. Gaucher’s disease – intravascular coagulation
C. Protein S deficiency – intravascular occlusion
D. Sickle cell disease – intravascular coagulation
E. Subcapital femur fracture – mechanical vas-
cular interruption
60. Which of the following mechanisms occurs in
the reparative stage of osteonecrosis?
A. Creeping substitution
B. Enchondral ossification
C. Intramembranous ossification
D. Primary bone healing
E. Secondary bone healing
61. A 70-year-old male patient wakes with severe
groin pain the day after hip resurfacing surgery.
Which of the following complications is most
likely?
A. Femoral neck fracture
B. Femoral nerve injury
C. Haematoma
D. Iliopsoas impingement
E. Sciatic nerve injury
62. A 45-year-old male reports severe pain around
the hip and buttock area following a fall while
water skiing.
Which of the following structures are you concerned might have been injured?
A. Gluteus maximus insertion avulsion
B. Greater trochanter fracture
C. Proximal hamstring avulsion
D. Rectus femoris avulsion
E. Transverse process fractures
63. During clinical examination you note a patient
has a leg length discrepancy.
Which of the following is an apparent leg
length discrepancy with the correct clinical
findings?
A. Crowe IV dysplastic hip (superior sublux-
ation) – positive Galeazzi test, asymmetrical
Bryant’s triangle, Thomas test negative
B. Hip arthrodesis – negative Galeazzi test, sym-
metrical Bryant’s triangle, Thomas test negative
C. Hip fixed flexion deformity – Galeazzi test
negative, asymmetrical Bryant’s triangle,
Thomas test negative
D. Previous distal femoral physeal injury – nega-
tive Galeazzi test, symmetri cal Bryant’s triangle, Thomas test negative
E. Previous tibia fracture malunion – positive
Galeazzi test, asymmetrical Bryant’s triangle,
Thomas test negative
64. Which is not a cause of a positive Trendelenburg
sign?
A. Hip abductor tendinopathy
B. Hip arthritis
C. L2 root lesion
D. Total hip arthroplasty with reduced offset
E. Post-operative superior gluteal nerve palsy
50
HIP II STRUCTURED SBA ANSWERS
1. Answer D. Type IV
Type IV hypersens itivity is responsible for the hyper sensitivity response to metallic orthopaedic implants.
Type IV sensitivity is cell mediated opposed to antibody mediated, helper T cells activate cytotoxic cells
and macrophages. Types I, II, III and V hypersensitivity are all antibody mediated. Currently, there are
no guidelines for addressing suspected or known
metal allergy preoperatively and there is no
evidence-based support for either preoperative
testing or routine use of hypoallergenic implants.
Eftekhary N et al. Metal hypersensitivity in
total joint arthroplasty. JBJS Rev. 2018;6:e1.
2. Answer C. Neurofibromatosis
Protrusio is not commonly associated with neurofibromatosis. Focal skeletal abnormalities associated with neurofibromatosis include scoliosis,
congenital bowing of the tibia (anterior lateral)
and forearm, pseudoarthrosis and limb hypertrophy. The other four systemic conditions are
all associated with protrusio acetabuli.
3. Answer E. Simvastatin
The radiograph demonstrates osteonecrosis (see
Figure 4.1 in the Questions section). Simvastatin
is not a cause of osteonecrosis and has been
postulated to be protective against osteonecrosis.
Glucocerebrosidase is the gene underlying
Gaucher’s disease, which is a recognised cause of
osteonecrosis. HbSS is the genotype of sickle cell
disease, a recognised cause of osteonecrosis, and
protein S deficiency is a clotting abnormality
resulting in a hypercoagulable state. Immunological
conditions such as SLE, Sjogren’s syndrome, dermatomyositis, rheumatoid arthritis and scleroderma
have been associated with increased risk of osteonecrosis. These associations may be mediated by use of
corticosteroids or other immunosuppressive drugs
or may be related to the specific disease activity itself.
Yang Z et al. The efficacy of statins in preventing
glucocorticoid-related osteonecrosis in animal
models: a meta-analysis. Bone Joint Res.
2016;5:393–402.
4. Answer D. 25° flexion, 5° adduction, 5° external
rotation
Hip II Structured SBA
Optimal position of flexion is a compromise
between ease of standing and sitting. Any abduction of the hip results in coronal imbalance when
standing, and therefore a few degrees of adduction
is preferred to position the ankle joint beneath the
centre of mass of the torso. External rotation is
generally matched to the contralateral side. In a
review article, Beaulé et al. (2002) recommended
flexion of 20–30°, adduction 5° and external rotation 5–10°.
Beaulé PE, Matta JM, Mast JW. Hip
arthrodesis: current indications and techniques.
J Am Acad Orth Surg. 2002;10:249–258.
5. Answer C. Reducing offset
Reducing hip offset increases the force required by
the abductors muscles to maintain a single leg
stance. Medialisation of the cup reduces the
moment arm of the body mass and therefore
reduces the force required by the abductors to
maintain a single leg stance. Walking with a stick
in the contralateral hand reduces the abductor
force. Trunk leaning to the ipsilateral side shifts
the centre of mass over the hip joint which
reduces the force required by the abductors to
maintain single leg stance. Carrying a bag of
shopping in the ipsilateral arm helps to balance
the centre of mass and therefore reduces the force
required by the abductors to maintain a single leg
stance.
6. Answer B. 1, 2, 6 and 7
In a seminal orthopaedic paper, Gruen et al.
(1979) described both zones of failure of a
cemented femoral total hip arthroplasty stem
and five different modes of failure. Zone 1
describes the proximal lateral bone–cement–
implant interface, zone 4 the tip and zone 7 the
proximal medial aspect of the femur. The classical mechanism by which femoral stems fracture
is due to loss of proximal support with a stem
that is well fixed distally. The proximal medial
and lateral cement breaks up, resulting in lucency
in Gruen zones 1, 2, 6 and 7. This mode of failure
is termed cantilever bending.
Gruen TA, McNeice GM, Amstutz HC.
‘Modes of failure ’ of cemented stem-type
femoral components: a radiographic analysis
of loosening. Clin Orth Rel Res. 1979;141:17–27.
51
James Gill and Majeed Shakokani
7. Answer B. MARS MRI
Metal artefact reduction sequence MRI or ultrasound are recommended by the Medicines and
Healthcare products Regulatory Agency (MHRA)
for imaging of metal-on-metal hip replacements.
Ultrasonography is a good screening tool, is cheap
and has no radiation hazard; however, the detection of small or deep lesions with ultrasound is
difficult. Soft tissue inflammatory reactions to
metal debris are a recognised complication of
metal-on-metal resurfacing. These reactions are
grouped under the umbrella term ‘adverse reactions to metal debris’ (ARMD). The spectrum of
ARMD is extensive and ranges from small asymptomatic cysts to large soft tissue masses (pseudotumours). Inflammatory pseudotumour is the
clinical term given to an aseptic mass in the periprosthetic tissues that is either solid or cystic and is
associated with clinical, radiological or histopathological signs of inflammation. An asepticlymphocytic vasculitis-associated lesion (ALVAL)
is a histological diagnosis that describes the unique
cellular changes that occur periprosthetically in
response to metal particles.
Drummond J, Tran P, Fary C. Metal-on-
metal hip arthroplasty: a review of adverse reactions and patient management. JFunct
Biomaterials 2015;6:486–499.
8. Answer C. Revise to a metal-lined ceramic head
with change of polyethylene liner
Ceramic head fracture is rare, especially with
modern ceramics. The safest of the given options
is to revise to a metal-lined ceramic head with a
change of polyethylene. Metal-bearing surfaces
should be avoided due to their reduced scratch
resistance (hardness) compared with ceramicbearing surfaces. Revision of all implants is
unnecessary, provided all implants are in a satisfactory position and there has not been significant damage to the acetabular shell liner locking
mechanism and the stem trunnion. Completed
synovectomy is recommended during revision to
remove as much of the ceramic debris as possible
which can lead to accelerated third body wear.
9. Answer B. Boundary
Boundary lubrication is the predominant mechanism by which lubrication occurs in prosthetic
joints. Elastohydrodynamic, squeeze film,
weeping and boosted lubrication occur in native
synovial cartilaginous joints but not prosthetic
joints. Boundary lubrication also occurs in native
synovial cartilaginous joints.
10. Answer C. Failure of the repair of the short
external rotators
The short external rotators consist of piriformis,
superior gemellus, obturator internus, inferior
gemellus and quadratus femoris. The short external rotators are divided during the posterior
approach to the hip. Repair of the short external
rotators has been shown to reduce the risk of
dislocation and so has become common practice.
Failure of repair of the short external rotators
can result in the foot turning inwards with
walking. Excessive retroversion of the femoral
stem may result in hip instability or an externally
rotated lower leg. Weakness of the gluteus maximus results in weakness of hip extension.
Excessive cup anteversion is most likely to result
in anterior hip instability. Palsy of gluteus medius and minimus would result in weakness of hip
abduction and a Trendelenburg gait.
11. Answer A. External iliac
With profuse bleeding, it is likely that a major
vessel has been injured. Of the major vessels (femoral, internal and external iliac), the most commonly injured is the external iliac artery. The
anterior superior quadrant of the acetabulum is
known as the ‘zone of death’, as a screw or a drill
that penetrates too far risks laceration of the external artery or vein. If a major vessel is injured
during screw placement, the hip wound should
be packed tightly. An anterior incision should be
performed before closing the hip wound in order
to gain proximal control of the bleeding artery
(Figure 4.2).
Shoenfeld NA, Stuchin SA, Pearl R, Haveson
S. The management of vascular injuries associated
with total hip arthroplasty. JVascSurg.
1990;11:549–555.
12. Answer D. Hypotensive anaesthesia
Hypotensive anaesthesia has been shown to
reduce blood loss in primary and revision THA.
In a case series of 100 patients who were Jehovah’s
Witnesses undergoing THA, hypotensive anaesthesia was performed in 89 of them. Sixty-five
52
Common iliac artery
Internal iliac artery
External iliac vein
External iliac artery
Deep circumex iliac artery
Supercial circumex art.
Obturator artery
S9
S8
S6
S5
S1
S3
S10
S0
Hip II Structured SBA
Figure 4.2 Acetabular screw position
and risk of vascular injury
Superior gluteal artery
S4
Inferior gluteal artery
S2
S12
S7
patients underwent primary THA with an average
of 450ml of blood loss; this was 43% less than a
control group. Twenty-four patients who had had
previous ipsilateral hip surgery underwent revision hip arthroplasty under hypotensive analgesia
and sustained an average intraoperative blood loss
of 680ml, which was 30% less than that of similar
matched controls. The final 11 Jehovah’s
Witnesses undergoing hip arthroplasty were not
candidates for hypotensive anaesthesia. Other
blood management techniques in patients who
are Jehovah’s Witnesses include erythropoietin
therapy, meticulous haemostasis, haemodilution
and intraoperative blood salvage.
Nelson CL, Bowen WS. Total hip arthroplasty
in Jehovah’s Witnesses without blood transfusion.
J Bone Joint Surg Am.1986;68:350–353.
Nelson CL, Stewart JG. Primary and revision
total hip replacement in patients who are Jehovah’s
Witnesses. Clin. Ortho Rel Res. 1999;369:251–261.
13. Answer A. Antibiotic loaded bone cement
The Medical Research Council (MRC) trial published by Lidwell et al. (1982) showed that antibiotic loaded cemented was the greatest factor in
reducing prosthetic joint infection. In decreasing
Pudendal artery
order of effect, the other factors assessed were
systemic antibiotics, ultraclean air, plastic isolators and body exhaust suits.
Lidwell OM et al. Effect of ultraclean air in
operating rooms on deep sepsis in the joint after
total hip or knee replacement: a randomised
study. BMJ (Clinical Res Ed.) 1982;285:10–14.
14. Answer B. Nerve to obturator internus
From superior to inferior, the short external rotators consist of piriformis supplied by the nerve to
piriformis, superior gemellus and obturator internus, which are both supplied bythe nerve toobturator internus, inferior gemellus and quadratus
femoris, which are both supplied by the nerve to
quadratus femoris and obturator externus, which
is supplied by the posteriorbranch of theobturator
nerve (Figure 4.3). Particular attention should be
paid to the nerve supply of the gemelli, as they are
innervated by two different nerves, which are
named after and also innervate the short external
rotators immediately inferior to them.
15. Answer B. Nerve to quadratus femoris
The nerve to quadratus femoris exits the greater
sciatic foramen but does not re-enter the lesser
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