Complications of Arthroplasty — MCQs
Complications of sling procedures (TVT) for USI are all except:
What is the condition commonly known as jumper's knee?
Tom-smith arthritis results from
Most common cause of death after Total Hip Replacement is-
Most specific for diagnosing Ankylosing spondylitis?
Most common complication of intertrochanteric fracture femur is:
The Henderson-Jones classification is used for:
The commonest complication of fracture of clavicle is :
Which of the following is considered a fenestrated hip prosthesis?
A patient with an orthopaedic hip implant is to undergo dental extraction. What antibiotic prophylaxis is recommended?
Complications of Arthroplasty Indian Medical PG Practice Questions and MCQs
Question 1: Complications of sling procedures (TVT) for USI are all except:
- A. Obturator nerve injury is about 10% (Correct Answer)
- B. Overactive bladder in about 7% cases
- C. Injury to bladder and wound haematoma
- D. Sling erosion particularly with polytetrafluoroethylene (Goretex)
Explanation: ***Obturator nerve injury is about 10%*** ✓ **CORRECT ANSWER (NOT a complication of TVT)** - **Obturator nerve injury** is exceedingly rare during **TVT (Tension-free Vaginal Tape)** procedures, which use a retropubic approach through the space of Retzius. - This complication is primarily associated with **TOT (Trans-Obturator Tape)** procedures where the tape passes near the obturator foramen, not with standard retropubic TVT. - The incidence of obturator nerve injury in TVT is essentially negligible (<0.1%), nowhere near 10%. *Overactive bladder in about 7% cases* - **De novo overactive bladder (OAB)** symptoms or worsening of pre-existing OAB can occur in 3-15% of patients after TVT procedures, with 7% being a commonly cited figure. - This occurs due to changes in bladder neck support, urethral kinking, or irritation from the sling material. *Injury to bladder and wound haematoma* - **Bladder injury/perforation** occurs in 2-5% of TVT cases due to the retropubic passage of needles close to the bladder, which is why intraoperative cystoscopy is routinely performed. - **Wound hematoma** can occur at the vaginal or suprapubic incision sites as a common surgical complication from tissue dissection and bleeding. *Sling erosion particularly with polytetrafluoroethylene (Goretex)* - **Sling erosion** into the vagina or urethra is a documented complication of synthetic slings, with rates of 0.5-3% for modern materials. - **Polytetrafluoroethylene (Goretex)**, an older first-generation mesh material, was associated with significantly higher rates of erosion (up to 10%) and infection compared to modern monofilament polypropylene meshes, which is why it has been largely discontinued for sling procedures.
Question 2: What is the condition commonly known as jumper's knee?
- A. Inflammation of the patellar tendon at its insertion on the patella.
- B. Tendinopathy of the quadriceps tendon.
- C. Injury to the hamstring tendon.
- D. Patellar tendonitis due to overuse of the patellar tendon. (Correct Answer)
Explanation: ***Patellar tendonitis due to overuse of the patellar tendon.*** - **Jumper's knee** is the common term for **patellar tendonitis**, which specifically refers to inflammation of the patellar tendon. - This condition is frequently caused by **overuse**, especially in activities involving repetitive jumping and landing. *Inflammation of the patellar tendon at its insertion on the patella.* - While jumper's knee does involve inflammation of the patellar tendon, it is more commonly at its insertion on the **tibial tubercle** or specifically its origin at the **inferior pole of the patella**, not necessarily at the patella itself. - This option is less precise as it describes only one aspect of the condition without mentioning the critical role of overuse. *Tendinopathy of the quadriceps tendon.* - **Tendinopathy of the quadriceps tendon** is a distinct condition affecting the tendon above the patella, known as **quadriceps tendinopathy**. - It presents with pain proximal to the patella, differentiating it from jumper's knee, which involves the tendon distal to the patella. *Injury to the hamstring tendon.* - An **injury to the hamstring tendon** would cause pain and symptoms on the posterior aspect of the knee or thigh. - This is completely unrelated to jumper's knee, which is characterized by anterior knee pain.
Question 3: Tom-smith arthritis results from
- A. Staphylococcus aureus infection (Correct Answer)
- B. Streptococcus pyogenes infection
- C. Haemophilus influenzae infection
- D. Escherichia coli infection
Explanation: ***Staphylococcus aureus infection*** - **Tom-smith arthritis** (more commonly known as **septic arthritis** or infectious arthritis) is most frequently caused by **Staphylococcus aureus**, especially in adults and older children [1]. - The bacteria can enter the joint directly via trauma, surgery, or spread hematogenously from a distant infection, leading to rapid joint destruction if untreated [1]. *Streptococcus pyogenes infection* - While **Streptococcus pyogenes** can cause infectious arthritis, it is a less common cause than **Staphylococcus aureus** [1]. - It is more classically associated with **rheumatic fever** following pharyngitis, which involves migratory polyarthritis but is an immunologically mediated process, not direct bacterial infection of the joint in the same way. *Haemophilus influenzae infection* - **Haemophilus influenzae type b (Hib)** was once a common cause of septic arthritis in unvaccinated children but is now rare due to widespread vaccination. - In adults, other bacterial causes are more prevalent for septic arthritis. *Escherichia coli infection* - **Escherichia coli** can cause septic arthritis, particularly in neonates, immunocompromised individuals, or following genitourinary tract infections or intra-abdominal sepsis. - However, it is less common than **Staphylococcus aureus** as the primary cause of acute septic arthritis in otherwise healthy adults.
Question 4: Most common cause of death after Total Hip Replacement is-
- A. Thromboembolism (Correct Answer)
- B. Pneumonia
- C. Anemia
- D. Infection
Explanation: ***Thromboembolism*** - **Venous thromboembolism (VTE)**, which includes **deep vein thrombosis (DVT)** and **pulmonary embolism (PE)**, is a significant and common complication after total hip replacement. - **Pulmonary embolism (PE)**, a severe manifestation of VTE, is the leading cause of early postoperative death following total hip arthroplasty due to embolization of a DVT. *Pneumonia* - While **postoperative pneumonia** can occur due to immobility and anesthesia, it is generally less common as a cause of death compared to VTE in the early postoperative period after THR. - Effective respiratory physiotherapy and mobility protocols aim to reduce its incidence. *Anemia* - **Postoperative anemia** is common after THR due to blood loss during surgery, but it is rarely a direct cause of death. - It is typically managed with blood transfusions or iron supplementation, and while it can contribute to weakness or other complications, it's not the primary cause of mortality. *Infection* - **Periprosthetic joint infection (PJI)** is a serious complication that can occur early or late after THR, potentially leading to significant morbidity. - While it can be life-threatening if severe or unmanaged, **sepsis** due to PJI is a less common cause of immediate postoperative death compared to the acute cardiovascular events associated with VTE.
Question 5: Most specific for diagnosing Ankylosing spondylitis?
- A. HLA B27
- B. ESR
- C. B/l sacroilitis (Correct Answer)
- D. Lumbar movement
Explanation: ***B/l sacroiliitis*** - **Bilateral sacroiliitis** on imaging (X-ray or MRI) is the **hallmark** and most specific diagnostic criterion for ankylosing spondylitis, as it represents the primary pathology [1]. - While other features may suggest AS, definitive imaging evidence of inflammation and structural changes in the **sacroiliic joints** confirms the diagnosis [1]. *HLA B27* - **HLA-B27** is present in a high percentage of patients with ankylosing spondylitis but is not *specific*; it can be found in healthy individuals and other spondyloarthropathies [1]. - Its presence increases the *susceptibility* but does not confirm the diagnosis on its own [1]. *ESR* - **Erythrocyte sedimentation rate (ESR)** is a general marker of **inflammation** and can be elevated in many conditions, including ankylosing spondylitis. - However, it is **non-specific** and not diagnostic for AS; some patients with active disease may even have normal ESR levels. *Lumbar movement* - **Reduced lumbar movement** (e.g., restricted lumbar flexion and extension, positive **Schober's test**) is a *clinical feature* commonly found in ankylosing spondylitis due to spinal involvement. - While important for assessing disease progression and functional impairment, it is not as **specific** as radiological evidence of sacroiliitis, as other conditions can also limit lumbar mobility [1].
Question 6: Most common complication of intertrochanteric fracture femur is:
- A. Malunion (Correct Answer)
- B. Nerve injury
- C. Osteoarthritis
- D. Non-union
Explanation: ***Malunion*** - **Malunion** is the most common complication of intertrochanteric fractures, particularly with unstable fracture patterns or inadequate reduction and fixation. - This typically results in leg length discrepancy, gait disturbance, and persistent pain due to abnormal alignment. *Nerve injury* - **Nerve injury** is a rare complication of intertrochanteric fractures, as the major nerves (e.g., sciatic, femoral) are not in close proximity to the fracture site. - While possible with severe trauma or surgical errors, it is not considered the most common complication. *Osteoarthritis* - **Osteoarthritis** can develop years after an intertrochanteric fracture due to altered biomechanics, but it is a long-term sequela, not an immediate or most common post-fracture complication. - Early complications like malunion or infection are more prevalent. *Non-union* - **Non-union** is relatively uncommon in intertrochanteric fractures because this area of the femur has an excellent blood supply, which promotes healing. - This complication is more frequently seen in femoral neck fractures due to their tenuous blood supply.
Question 7: The Henderson-Jones classification is used for:
- A. Diabetic foot
- B. Prosthetic joint infection (Correct Answer)
- C. Pressure ulcers
- D. Burns
Explanation: ***Prosthetic joint infection*** - The **Henderson-Jones classification** is a system used to categorize **prosthetic joint infections (PJI)** based on their **timing** of onset, distinguishing between early, delayed, and late infections. - This classification aids in guiding **treatment strategies**, as the approach for PJI varies depending on when the infection develops after surgery. *Diabetic foot* - **Diabetic foot ulcers** are typically classified using systems like the **Wagner classification** or the **University of Texas Wound Classification System**, which focus on wound depth, presence of infection, and ischemia. - These classifications specifically address the unique pathology and progression of **foot complications** in diabetic patients. *Pressure ulcers* - **Pressure ulcers (bedsores)** are commonly classified using the **National Pressure Ulcer Advisory Panel (NPUAP)** staging system or the **International Pressure Ulcer Classification System**, which categorize ulcers by depth of tissue damage. - These systems are crucial for assessing severity, guiding treatment, and predicting outcomes for **skin and underlying tissue injury** caused by sustained pressure. *Burns* - **Burns** are traditionally classified by **depth** (e.g., first, second, third, and fourth-degree burns) and **total body surface area (TBSA)** affected, using tools like the Rule of Nines. - This classification helps determine the **severity** of the burn and guides initial management, fluid resuscitation, and surgical intervention.
Question 8: The commonest complication of fracture of clavicle is :
- A. non union
- B. avascular necrosis
- C. Neurovascular injury
- D. malunion (Correct Answer)
Explanation: ***malunion*** - **Malunion** is the most frequent complication following a clavicle fracture, meaning the bone heals in an anatomically incorrect or deformed position. - This often results in a palpable bump or cosmetic deformity, and can occasionally cause functional impairment. *non union* - **Non-union** occurs when the fracture fails to heal completely, leaving a persistent gap between the bone fragments. - While possible, it is less common than malunion in clavicle fractures, especially with appropriate management. *avascular necrosis* - **Avascular necrosis** is rare in clavicle fractures because the clavicle has a rich blood supply. - It typically affects bones with precarious blood supply, such as the femoral head or scaphoid. *Neurovascular injury* - **Neurovascular injury** involving the subclavian vessels or brachial plexus is a serious but relatively rare complication of clavicle fractures. - While possible, especially with displaced fractures, it is not the most common adverse outcome.
Question 9: Which of the following is considered a fenestrated hip prosthesis?
- A. Bipolar prosthesis
- B. Austin Moore prosthesis (Correct Answer)
- C. Thompson prosthesis
- D. All of the above
Explanation: **Explanation:** The correct answer is **Austin Moore prosthesis**. In orthopaedic surgery, a **fenestrated prosthesis** refers to an implant with "windows" or openings in its stem. These holes allow for bone to grow through the prosthesis (biological fixation), providing long-term stability. **1. Why Austin Moore is correct:** The Austin Moore prosthesis is a unipolar hemiarthroplasty implant used for femoral neck fractures. Its defining feature is a **fenestrated stem**. During surgery, bone chips are often packed into these fenestrations; over time, bone grows through these holes (osseointegration), anchoring the prosthesis to the femoral shaft without the need for bone cement. **2. Why the other options are incorrect:** * **Thompson prosthesis:** This is also a unipolar prosthesis, but it has a **solid (non-fenestrated) stem**. It is designed to be used with bone cement (Polymethylmethacrylate - PMMA) for fixation. * **Bipolar prosthesis:** This refers to an implant with two points of articulation (one at the acetabulum and one within the prosthetic head). While the stem design can vary, the term "bipolar" describes the head mechanism, not the presence of fenestrations. **High-Yield Clinical Pearls for NEET-PG:** * **Fixation:** Austin Moore = **Uncemented** (Press-fit/Biological); Thompson = **Cemented**. * **Indications:** Austin Moore is preferred in patients with good bone quality; Thompson is preferred in osteoporotic patients where cement provides immediate stability. * **Calcar:** The Austin Moore prosthesis has a collar that rests on the calcar femorale to prevent subsidence. * **Complication:** A common complication of unipolar prostheses (Moore/Thompson) is **acetabular erosion** (protrusio acetabuli) because the metal head rubs directly against the native cartilage.
Question 10: A patient with an orthopaedic hip implant is to undergo dental extraction. What antibiotic prophylaxis is recommended?
- A. Amoxicillin 3 times a day for 3 days before the procedure
- B. Amoxicillin 3 times a day for 1 day before the procedure
- C. Amoxicillin intravenously 1 hour before the procedure
- D. Antibiotic prophylaxis is not required (Correct Answer)
Explanation: **Explanation:** The correct answer is **D. Antibiotic prophylaxis is not required.** **1. Underlying Medical Concept:** Historically, it was believed that dental procedures could cause transient bacteremia leading to Late Prosthetic Joint Infection (PJI). However, current evidence-based guidelines from the **American Academy of Orthopaedic Surgeons (AAOS)** and the **American Dental Association (ADA)** state that there is no direct link between dental procedures and PJI. Routine antibiotic prophylaxis is **not recommended** for patients with prosthetic joint replacements undergoing dental procedures. The risks of antibiotic use (allergic reactions, *C. difficile* infection, and antimicrobial resistance) outweigh the unproven benefits of preventing joint infection. **2. Why Incorrect Options are Wrong:** * **Options A and B:** Prophylaxis is never administered for multiple days or a full day before a procedure. If prophylaxis were indicated (e.g., for infective endocarditis), it would be a single pre-operative dose. * **Option C:** While IV antibiotics are used for surgical prophylaxis (like during the arthroplasty itself), they are not indicated for dental work in patients with joint implants. **3. Clinical Pearls for NEET-PG:** * **Exception:** Prophylaxis may be considered only in **severely immunocompromised** patients (e.g., stage 3 AIDS, chemotherapy, or recent organ transplant) with poorly controlled oral infections, and even then, only after consultation between the dentist and the orthopedic surgeon. * **Timing:** If prophylaxis is deemed necessary for other reasons (like high-risk cardiac conditions), the standard dose is **2g Amoxicillin orally 30-60 minutes before** the procedure. * **High-Yield Fact:** The most common cause of Late PJI is hematogenous spread, but the source is usually skin or urinary tract infections, not dental flora.
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