Principles of Joint Replacement — MCQs
Fracture neck of femur in 80-year-old male sustained 1 week ago. The treatment of choice is -
Contraindications for skin traction: a) Dermatitis b) Vascularly compromised status of limb c) Abrasions d) Hypopigmentation (vitiligo) e) Bony deformity
All of the following factors affect osseointegration EXCEPT:
Why is early mobilization important after hip arthroplasty?
What is the most common complication after total hip replacement?
A 70-year-old woman with chronic osteoarthritis of the hip presents with worsening pain and limited mobility despite conservative management. What is the next appropriate step?
In hand injury, the first structure to be repaired should be?
A 65-year-old presents with chronic knee pain, varus deformity, and medial joint space narrowing. BMI is 32. Best treatment option?
A 75-year-old man presents with a fracture of the intracapsular neck of the femur. What is the most common management option for this patient?
Treatment of choice for displaced fracture neck femur in a 40 years old female
Principles of Joint Replacement Indian Medical PG Practice Questions and MCQs
Question 1: Fracture neck of femur in 80-year-old male sustained 1 week ago. The treatment of choice is -
- A. Hemiarthroplasty (Correct Answer)
- B. Closed reduction and fixation with three cancellous screws
- C. Longitudinal skin traction for 6 weeks
- D. Excision arthroplasty
Explanation: ***Hemiarthroplasty*** - For an 80-year-old with a **fracture of the femoral neck**, especially if sustained a week ago, **hemiarthroplasty** is the preferred treatment to allow early mobilization and prevent complications of prolonged recumbency. - This procedure replaces the **femoral head** and neck, minimizing the risk of **avascular necrosis** and **non-union** which are common complications in older patients with displaced femoral neck fractures. *Excision arthroplasty* - **Excision arthroplasty**, also known as **Girdlestone arthroplasty**, is a salvage procedure typically reserved for cases of severe infection, failed prosthetic implants, or when other options are not viable. - It involves removing the femoral head, creating a **pseudarthrosis**, and results in a shortened, unstable limb, making it unsuitable as a primary treatment. *Closed reduction and fixation with three cancellous screws* - This option is generally considered for **younger patients** with undisplaced or minimally displaced **femoral neck fractures** due to better bone quality and lower risk of avascular necrosis. - In an 80-year-old, the risks of **non-union** and **avascular necrosis** are significantly higher, and the prolonged weight-bearing restrictions associated with this method are detrimental. *Longitudinal skin traction for 6 weeks* - Prolonged **skin traction** is rarely used for femoral neck fractures, especially in the elderly, due to the high risk of complications such as **skin breakdown**, **deep vein thrombosis**, **pneumonia**, and **muscle atrophy**. - It does not provide definitive fixation and is not a definitive treatment for a bony fracture.
Question 2: Contraindications for skin traction: a) Dermatitis b) Vascularly compromised status of limb c) Abrasions d) Hypopigmentation (vitiligo) e) Bony deformity
- A. ab
- B. abc (Correct Answer)
- C. acd
- D. bcd
Explanation: ***ab*** - All conditions listed under 'a' and 'b' (Dermatitis, Vascularly compromised status of limb, Abrasions) are **absolute contraindications** for skin traction as they directly compromise skin integrity or circulation. - Applying skin traction in these situations can lead to **skin breakdown**, infection, or further **ischemic damage**, worsening the patient's condition. *ab* - While **dermatitis**, **vascular compromise**, and **abrasions** are indeed contraindications, the option for 'abc' implies there might be other correct choices included, which is not the case for this option. - This option is incomplete as it misses 'c' (Abrasions) which is also a significant contraindication. *acd* - This option incorrectly includes **hypopigmentation (vitiligo)** as a contraindication, which does not inherently prevent skin traction. - It also omits **vascularly compromised status of limb**, a critical contraindication, while including 'a', 'c', and 'd'. *bcd* - This option incorrectly includes **hypopigmentation (vitiligo)** as a contraindication for skin traction. - It also omits **dermatitis**, a key contraindication, while including 'b', 'c', and 'd'.
Question 3: All of the following factors affect osseointegration EXCEPT:
- A. Biocompatibility of implant material.
- B. Implant design.
- C. Patient's blood type (Correct Answer)
- D. Status of the host bed.
Explanation: ***Patient's blood type*** - A patient's **blood type** (e.g., A, B, AB, O) is determined by antigens present on red blood cells and plays no direct role in the biological processes of bone healing or the integration of a dental implant with bone. - While systemic factors can influence osseointegration, blood type itself does not affect the cellular and molecular mechanisms required for direct bone-to-implant contact. *Biocompatibility of implant material* - The **biocompatibility** of the implant material (e.g., **titanium**) is crucial for osseointegration, as it must not elicit adverse reactions and must permit host bone growth on its surface. - Materials that are cytotoxic or inflammatory will prevent bone apposition and lead to fibrous encapsulation rather than direct bone contact. *Implant design* - **Implant design**, including features like **surface roughness**, thread pitch, and macro-geometry, significantly influences the initial stability and long-term success of osseointegration. - A greater surface area and appropriate surface treatments can enhance bone cell attachment and differentiation, promoting faster and stronger bone integration. *Status of the host bed* - The **status of the host bone bed** refers to its quality and quantity (e.g., bone density, vascularity), which are critical for the biological processes of osseointegration. - Adequate bone volume and good bone quality provide a stable foundation and sufficient blood supply for bone regeneration around the implant.
Question 4: Why is early mobilization important after hip arthroplasty?
- A. Prevents joint stiffness
- B. Prevents DVT
- C. Reduces hospital stay
- D. All of the options (Correct Answer)
Explanation: ***All of the options*** - Early mobilization is crucial following hip arthroplasty as it offers a multifaceted approach to recovery, addressing **joint stiffness**, the risk of **DVT**, and the duration of **hospital stay**. - This comprehensive benefit highlights the importance of an integrated approach to postoperative care. *Prevents joint stiffness* - While early mobilization helps prevent joint stiffness, it is not the sole benefit, as it also addresses other critical postoperative complications. - Restricted movement in the initial postoperative period can lead to adhesions and **contractures**, limiting the long-term range of motion. *Prevents DVT* - Preventing **deep vein thrombosis (DVT)** is a significant benefit of early mobilization, but it represents only one aspect of its overall importance. - Immobility post-surgery increases the risk of blood clot formation due to venous stasis, making active movement essential. *Reduces hospital stay* - Reducing the length of hospital stay is a key advantage of early mobilization, but it's part of a broader set of benefits that contribute to faster recovery and better outcomes. - Expedited discharge is often a direct result of improved patient mobility, reduced complication rates, and enhanced surgical recovery.
Question 5: What is the most common complication after total hip replacement?
- A. Dislocation
- B. DVT (Correct Answer)
- C. Infection
- D. Aseptic Loosening
Explanation: ***DVT*** - Deep vein thrombosis (DVT) is the **most common overall complication** following total hip replacement, with reported incidences as high as 40-60% without prophylaxis. - The risk of DVT is significant due to **venous stasis during surgery**, immobilization, and the inflammatory response to tissue injury. *Dislocation* - While a serious complication, **dislocation** of the prosthetic hip joint is less common than DVT, occurring in about 1-5% of primary total hip replacements. - It typically results from **improper joint positioning** or patient activities that push the hip beyond its normal range of motion. *Infection* - **Infection** is a severe but relatively rare complication, with rates for periprosthetic joint infection in total hip replacement typically ranging from 0.5% to 2%. - It can lead to significant morbidity and usually requires **further surgical intervention** for eradication. *Aseptic Loosening* - **Aseptic loosening** is a long-term complication, occurring years after the surgery, rather than an immediate post-operative complication. - This complication involves the **failure of the implant-bone interface** without evidence of infection, often due to particle disease or mechanical stress.
Question 6: A 70-year-old woman with chronic osteoarthritis of the hip presents with worsening pain and limited mobility despite conservative management. What is the next appropriate step?
- A. NSAIDs
- B. Physical therapy
- C. Intra-articular corticosteroid injections
- D. Total hip replacement (Correct Answer)
Explanation: ***Total hip replacement*** - For **severe osteoarthritis (OA)** causing significant pain and **functional impairment** despite failed conservative management, **total hip replacement** is the most definitive and effective treatment. - This procedure alleviates pain and restores **mobility**, dramatically improving the patient's quality of life. *NSAIDs* - **NSAIDs** are typically part of **initial conservative management** for symptomatic relief in mild to moderate OA, but they have already failed in this patient. - Continued use in elderly patients carries risks of **gastrointestinal, renal, and cardiovascular side effects**, making it a less desirable long-term solution. *Physical therapy* - **Physical therapy** is a crucial component of conservative management to improve **strength, flexibility, and function**, but it often becomes insufficient in advanced OA. - Since this patient has worsening symptoms despite conservative measures, physical therapy alone is unlikely to provide adequate relief. *Intra-articular corticosteroid injections* - **Corticosteroid injections** can provide temporary pain relief by reducing inflammation but do not address the underlying **structural damage** of severe OA. - Their effectiveness diminishes over time, and repeated injections are discouraged due to potential cartilage damage.
Question 7: In hand injury, the first structure to be repaired should be?
- A. Skin
- B. Muscle
- C. Nerve
- D. Bone (Correct Answer)
Explanation: ***Bone*** - In hand injury, **skeletal stability** is paramount and is typically the first structure to be addressed to provide a stable foundation. - Repairing bone first allows for proper alignment and length restoration, which is crucial for the subsequent repair of soft tissues like tendons, nerves, and vessels. *Skin* - While skin closure is the final step in wound management, it should only be performed after deeper structures like bone, tendons, and nerves have been repaired. - Repairing the skin first would prevent access to underlying damaged structures and could lead to functional impairment. *Muscle* - Muscle repair is important for restoring function but should follow bone stabilization to ensure proper length and tension. - Unstable bone fragments can impede effective muscle repair and healing. *Nerve* - Nerve repair is critical for restoring sensation and motor function and should be done with meticulous attention to detail. - However, nerve repair typically follows bone stabilization and sometimes tendon repair, as a stable environment is necessary for successful nerve coaptation and healing.
Question 8: A 65-year-old presents with chronic knee pain, varus deformity, and medial joint space narrowing. BMI is 32. Best treatment option?
- A. Arthroscopic Debridement
- B. Unicompartmental Knee Replacement
- C. High Tibial Osteotomy
- D. Total Knee Replacement (Correct Answer)
Explanation: ***Total Knee Replacement*** - This is the most appropriate treatment for a 65-year-old with chronic knee pain, significant **varus deformity**, and **medial joint space narrowing**, indicative of advanced **osteoarthritis**. - A **high BMI (32)** is also a factor that often points towards the need for total joint replacement when conservative measures have failed, as it contributes to increased stress on the knee. *Arthroscopic Debridement* - This procedure is generally reserved for less severe osteoarthritis symptoms or mechanical symptoms like locking, and it is **not effective** for advanced joint degeneration with significant deformity. - It would provide little to no long-term benefit for the presented severe changes and chronic pain. *Unicompartmental Knee Replacement* - While suitable for isolated medial compartment osteoarthritis, a **varus deformity** indicates damage beyond a single compartment or significant malalignment that might not be fully corrected by a unicompartmental approach. - The chronicity, age, and likely degree of degeneration suggest a more comprehensive solution is needed. *High Tibial Osteotomy* - This procedure is typically performed in younger, more active patients with **varus malalignment** and early to moderate osteoarthritis to shift weight to a healthier compartment. - At 65 years old with chronic pain and advanced joint space narrowing, a **corrective osteotomy** is less likely to provide long-term relief and may delay a more definitive solution.
Question 9: A 75-year-old man presents with a fracture of the intracapsular neck of the femur. What is the most common management option for this patient?
- A. Hemiarthroplasty (Correct Answer)
- B. Total Hip Replacement
- C. Dynamic Hip Screw
- D. Conservative Management
Explanation: **Hemiarthroplasty** - **Hemiarthroplasty** is the most common management for **intracapsular neck of femur fractures** in elderly patients, especially those who are frail or have substantial comorbidities. - This procedure replaces the **femoral head** with a prosthesis, preserving the native acetabulum, which is sufficient given the higher risk of complications with a full replacement in this age group. *Total Hip Replacement* - **Total hip replacement (THR)** is typically reserved for more active elderly patients with **pre-existing osteoarthritis** or for those requiring revision surgery, due to better functional outcomes but higher surgical risks. - It involves replacing both the **femoral head** and the **acetabulum**, *Dynamic Hip Screw* - A **dynamic hip screw (DHS)** is primarily used for **extracapsular femur fractures** (e.g., trochanteric fractures), where the blood supply to the femoral head is largely preserved. - It involves fixation, which is not suitable for most **intracapsular fractures** due to the disruption of blood supply, increasing the risk of **avascular necrosis** and non-union. *Conservative Management* - **Conservative management** (e.g., bed rest, pain control) is generally not recommended for **intracapsular neck of femur fractures** in mobile elderly patients due to high rates of complications such as **deep vein thrombosis**, **pressure ulcers**, and **avascular necrosis**. - It may be considered only in patients who are **non-ambulatory** or have severe contraindications to surgery.
Question 10: Treatment of choice for displaced fracture neck femur in a 40 years old female
- A. None of the options
- B. Bipolar hemiarthroplasty
- C. Multiple screw fixation (Correct Answer)
- D. THR
Explanation: ***Multiple screw fixation*** - For a **displaced femoral neck fracture** in a younger patient (40 years old), **internal fixation** with multiple screws is generally the preferred treatment to preserve the native **femoral head**. - This approach aims to achieve **anatomical reduction** and stable fixation, allowing for bone healing and a better long-term functional outcome in active individuals. *Bipolar hemiarthroplasty* - This procedure is typically reserved for older, less active patients with **displaced femoral neck fractures**, particularly those with pre-existing conditions that might limit their longevity or activity level. - While it replaces the femoral head, it does not preserve the native joint, which is a less desirable outcome in a 40-year-old. *THR* - **Total hip replacement** is usually considered for older patients, or younger patients with **pre-existing arthritis** or failed internal fixation, due to concerns about the prosthesis's longevity and potential future revisions. - In a 40-year-old, the goal is typically to preserve the native joint if possible, unless there are other complicating factors. *None of the options* - Internal fixation with multiple screws is a well-established and appropriate treatment for a displaced femoral neck fracture in a 40-year-old patient. - Therefore, one of the provided options is indeed the correct treatment choice for this specific scenario.
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