Introduction Indications osteolysis loosening instability infection mal-alignment polyethylene wear fracture or implant failure Options include acetabular component revision most common reason for revision in the Charnley "low-friction" total hip arthroplasty femoral head and polyethylene exchange femoral component revisions conversion from a hip arthrodesis Complications significantly higher than primary hip reconstruction include dislocation (even in simple procedures) infection nerve palsy cortical perforation fractures abductor deficiency DVT limb length inequalities Classification of Bone Loss Acetabulum AAOS Classification of Acetabular Bone Loss Type I (segmental) Loss of part of the acetabular rim or medial wall Type II (cavitary) Volumetric loss in the bony substance of the acetabular cavity Type III (combined deficiency) Combination of segmental bone loss and cavitary deficiency Type IV (pelvic discontinuity) Complete separation between the superior and inferior acetabulum Type V (arthodesis) Arthrodesis Paprosky Classification of Acetabular Bone Loss Type I Minimal deformity, intact rim Type IIA Superior bone lysis with intact superior rim Type IIB Absent superior rim, superolateral migration Type IIC Localized destruction of medial wall Type IIIA Bone loss from 10am-2pm around rim, superolateral cup migration Type IIIB Bone loss from 9am-5pm around rim, superomedial cup migration Femur AAOS Classification of Femoral Bone Loss Type I (segmental) Loss of bone of the supporting shell of femur Type II (cavitary) Loss of endosteal bone with intact cortical shell Type III (combined) Combination of segmental bone loss and cavitary deficiency Type IV (malalignment) Loss of normal femoral geometry due to prior surgery, trauma, or disease Type V (stenosis) Obliteration of the canal due to trauma, fixation devices, or bony hypertrophy Type VI (femoral discontinuity) Loss of femoral integrity from fracture or nonunion Paprosky Classification of Femoral Bone Loss Type I Minimal metaphyseal bone loss Type II Extensive metaphyseal bone loss with intact diaphysis Type IIIa Extensive metadiaphyseal bone loss, minimum of 4 cm of intact cortical bone in the diaphysis Type IIIb Extensive metadiaphyseal bone loss, less than 4 cm of intact cortical bone in the diaphysis Type IV Extensive metadiaphyseal bone loss and a nonsupportive diaphysis Presentation Symptoms groin pain --> acetabulum thigh pain --> femoral stem start-up pain --> component loosening night pain --> infection Imaging Radiographs required views AP pelvis orthogonal views of involved hip full-length femur radiographs additional views pre-operative radiographs immediate post-operative radiographs Judet views useful for assessment of columns CT scan useful for determining extent of osteolysis radiographs frequently underestimate extent of osteolysis assessment of component position Evaluation Laboratory analysis infectious laboratories ESR CRP CBC Aspiration recommended if infectious laboratories are suggestive of infection Treatment Femoral revision primary total hip arthroplasty components indications minimal metaphyseal bone loss, Paprosky I uncemented extensively porous-coated long stem prosthesis (or porous-coated/grit blasted combination) or modular tapered stems indications most Paprosky II and IIIa defects; Paprosky IIIb (modular fluted tapered stem) outcomes 95% survival rate at 10-years impaction bone grafting indications large ectactic canal and thin cortices Paprosky IIIb and IV defects outcomes most common complication is stem subsidence allograft prosthetic composite indications Paprosky IIIb and IV defects modular oncology components indications massive bone loss with a non-supportive diaphysis Paprosky IIIB and IV defects cemented stems indications irradiated bone elderly low-demand patients outcomes high failure rate Acetabular revision porous-coated hemisphere cup secured with screws indications rim is competent (> 2/3 of rim remaining) reconstruction cage with structural bone allograft indications rim is incompetent (<2/3 of rim remaining) outcomes allograft failure is the most common complication high failure rate (40-60%) without reconstruction cage due to component migration after graft resorption custom triflange cup indications pelvic discontuity Combined revision femoral head and polyethylene exchange indications eccentric wear of the polyethylene with stable acetabular and femoral components outcomes hip instability is the most common complication of isolated liner exchange conversion from a hip arthrodesis indications low back and knee pain as a result of arthrodesis outcomes implant survival greater than 95% at 10 years competence of gluteal musculature is predictive of ambulatory success Surgical Techniques Femoral revision with uncemented extensively porous-coated long stem prosthesis technique femoral stem must bypass most distal defect by 2 cortical diameters prevents bending moment through cortical hole cavitary lesions are grafted with particulate graft allograft cortical struts may be used to reinforce cortical defects Femoral impaction bone grafting technique morselized fresh frozen allograft packed into canal smooth tapered stem cemented into allograft Acetabular revision with porous-coated hemisphere cup with screws technique cavitary lesions are filled with particulate graft cup placement should be inferior and medial lowers joint reactive forces metallic wedge augmentation may be used if cup in good position and rigid internal fixation is achieved jumbo cups may be used when larger reamer is needed to make cortical contact structural allografts may be used to provide stability while bone grows into cementless cup Acetabular revision with reconstruction cage and structural bone allograft technique polyethylene cup is cemented into reconstruction cage bone graft placed behind cage Femoral head and polyethylene exchange technique exchange both head and liner osteolytic defects may be bone grafted through screw holes to fill bony defects Gluteus maximus transfer in setting of irreparable abductor deficiency technique along with the tensor fascia lata, the anterior aspect of the gluteus maximus is freed and transferred to the greater trochanter so that the fibers are similarly oriented to the native abductor musculature
QUESTIONS 1 of 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.272) A 72-year-old patient is scheduled to undergo revision total hip arthroplasty. A 3D-model of the patient's hemipelvis is constructed for pre-operative planning and is shown in Figure A. A custom-designed implant shown in Figure B is created. Which of the following is TRUE of the planned reconstruction? Review Topic QID: 4907 FIGURES: A B 1 The implant is a bilobed cup. 4% (147/3694) 2 The most common complication is dislocation. 54% (1999/3694) 3 The acetabular defect can be classified as AAOS Type V. 25% (911/3694) 4 Radiation-compromised bone stock is a contraindication. 10% (359/3694) 5 The winged profile of the implant facilitates insertion through both anterior and anterolateral approaches. 7% (259/3694) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 2 This is an AAOS Self assessment question. Orthobullets was not involved into the editorial process, and does not have the ability to alter. If you prefer to hide SAE questions on topics simply turn them off in your Content Settings (SAE10HK.15) A 71-year-old woman with coronary artery disease underwent an uncomplicated right total hip arthroplasty for osteoarthritis 12 years ago. Her hip has functioned well until approximately 18 months ago when she noted the spontaneous onset of groin, buttock, and proximal thigh pain that is present at rest and made worse with activity. A radiograph is shown in Figure 15. What is the recommended management at this point? Review Topic QID: 7003 FIGURES: A 1 Immediate admission to the hospital and emergent revision hip arthroplasty 4% (3/78) 2 Reassurance and follow-up if symptoms worsen 1% (1/78) 3 Repeat radiographs in 1 month 1% (1/78) 4 Protected weight bearing with urgent revision hip arthroplasty when the patient is medically cleared 92% (72/78) 5 A prescription for alendronate and reevaluation in 1 year 1% (1/78) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 This is an AAOS Self assessment question. Orthobullets was not involved into the editorial process, and does not have the ability to alter. If you prefer to hide SAE questions on topics simply turn them off in your Content Settings (SAE07HK.67) What are the optimal conditions for leaving the acetabular shell in place, replacing the acetabular liner, and grafting the osteolytic defect shown in Figure 39? Review Topic QID: 6027 FIGURES: A 1 Nonmodular implant 3% (3/117) 2 Instability 1% (1/117) 3 Well-designed, well-fixed modular implant 94% (110/117) 4 Complete radiolucency of the acetabular component 2% (2/117) 5 Migration of the acetabular component 1% (1/117) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 This is an AAOS Self assessment question. Orthobullets was not involved into the editorial process, and does not have the ability to alter. If you prefer to hide SAE questions on topics simply turn them off in your Content Settings (SAE07HK.74) Figure 44 shows the radiograph of a 65-year-old man who underwent a revision arthroplasty to remove a loose, cemented femoral stem. When planning the postoperative restrictions, the surgeon should be aware that Review Topic QID: 6034 FIGURES: A 1 the approach used reduces the torque-to-failure (fracture) of the construct to less than 50% of the intact femur. 38% (26/68) 2 the technique of repair can return the reconstructed prosthesis/bone composite to nearly the strength of the intact femur. 24% (16/68) 3 there is no relationship between the density of the native bone and the strength of the prosthesis/bone composite. 3% (2/68) 4 the addition of bone graft substitute or autograft has been shown to lessen the time to complete healing. 4% (3/68) 5 there is a one in five chance of fracture with this technique; therefore, the surgeon must carefully weigh the potential benefits versus this risk. 29% (20/68) N/A Select Answer to see Preferred Response PREFERRED RESPONSE 1 This is an AAOS Self assessment question. Orthobullets was not involved into the editorial process, and does not have the ability to alter. If you prefer to hide SAE questions on topics simply turn them off in your Content Settings (SAE07HK.21) A 72-year-old woman who underwent right total hip arthroplasty 7 years ago now reports right hip pain and limb shortening. Studies for infection are negative. AP and lateral radiographs are shown in Figures 13a and 13b. What is the most appropriate management? Review Topic QID: 5981 FIGURES: A B 1 Observation only 0% (0/101) 2 Nonsteroidal anti-inflammatory drugs and protected weight bearing 0% (0/101) 3 Revision of the acetabular component with a jumbo cup with screws 13% (13/101) 4 Revision of the acetabular component with a reinforcement cage and bone grafting 87% (88/101) 5 Resection arthroplasty 0% (0/101) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.148) A 85-year-old man who underwent hemiarthroplasty 5 years ago now complains of thigh pain for the past four months. Laboratory studies show a normal white blood cell count (WBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). An aspiration of the hip is performed and is negative for infection. A radiograph is shown in Figure A. Which of the following is the best management option for the femoral implant? Review Topic QID: 534 FIGURES: A 1 Bone scan to look for loosening 16% (211/1346) 2 Touch down weight bearing and physical therapy 1% (16/1346) 3 Revision with a tumor prosthesis 3% (43/1346) 4 Revision of femoral component with metaphyseal cement fixation of the stem 13% (173/1346) 5 Revision to a cementless femoral component with diaphyseal press-fit fixation of the stem 67% (897/1346) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ06.174) Figure A shows an AP hip radiograph of a 72-year-old woman who had had a right total hip arthroplasty fifteen years previously. CT imaging of the affected hip shows non-contained defects in both the anterior and posterior columns of the peri-acetabular region affecting greater than 50% of the weight bearing surface. Which of the following revision procedures would restore the most acetabular bone stock and be most appropriate for this patient? Review Topic QID: 360 FIGURES: A 1 Morselized allograft and/or autograft bone, combined with a cemented acetabular component 4% (92/2566) 2 Acetabular revision with use of a bilobed cementless component and morselized allograft 7% (176/2566) 3 Morselized allograft and/or autograft bone, combined with a cementless acetabular component 7% (167/2566) 4 Revision using an ilioischial reconstruction ring acetabular component and structural corticocancellous graft 71% (1827/2566) 5 Revision using a roof ring acetabular component and structural corticocancellous graft 11% (294/2566) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ10.187) Which of the following is true regarding the conversion of hip arthrodesis to total hip arthroplasty? Review Topic QID: 3280 1 Implant survivorship is greater than 95% at 20 years following conversion to arthroplasty 5% (132/2865) 2 Conversion to arthroplasty should not be performed if arthrodesis is more than 15 years old 6% (170/2865) 3 Function of gluteus medius is predictive of ambulatory status 86% (2456/2865) 4 Rate of complication is equivalent to primary total hip arthroplasty 2% (51/2865) 5 Incidence of nerve palsy is comparable to primary total hip arthroplasty 1% (40/2865) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.17) A 71 year old gentleman underwent left total hip arthroplasty 10 years ago. Eighteen months ago he began having hip and thigh pain. Over the past 6 weeks, the pain has become excruciating and he has been unable to ambulate, even with the aid of a walker. He has mild pain with passive internal and external rotation of the hip. He is unable to ambulate in the office. Laboratory values are notable for a WBC of 10,300, CRP of 0.2, and ESR of 13. A radiograph is provided in figure A. Which of the following is the best treatment option? Review Topic QID: 4377 FIGURES: A 1 Radionuclide bone scan and MRI 3% (142/5174) 2 Open reduction internal fixation with a cable plate and allograft strut 5% (246/5174) 3 Revision arthroplasty with a fully coated cementless stem, cable wiring, and bone graft 63% (3278/5174) 4 Revision arthroplasty with a modular, tapered stem and bone grafting of the diaphyseal fixation 21% (1087/5174) 5 Revision arthroplasty with a total femur prosthesis 7% (388/5174) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ12.16) Which of the following statements is true regarding the thirty-year follow-up data obtained from the Charnley "low-friction" total hip arthroplasty? Review Topic QID: 4376 1 Acetabular component failure was the least common reason for revision surgery 5% (227/4697) 2 The number of revisions required for periprosthetic fractures was higher than that for deep infections 5% (234/4697) 3 Acetabular component failure was a more common reason for revision than deep infection 63% (2960/4697) 4 Femoral component failure was a more common reason for revision than acetabular component failure 16% (764/4697) 5 Deep infection was the most common reason for revision 10% (463/4697) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ08.217) A 67-year-old female with history rheumatoid arthritis presents with acute onset severe left hip pain eight years status-post total hip arthroplasty. She is unable to weight bear on the left leg, but denies any other pain or systemic symptoms. A current radiograph of the pelvis is shown in Figure A. What is the most likely cause of the patient's current hip pain symptoms? Review Topic QID: 603 FIGURES: A 1 Poor surgical technique 1% (36/2507) 2 Rheumatoid arthritis flare 2% (43/2507) 3 Catastrophic implant failure 16% (394/2507) 4 Development of pelvic discontinuity 80% (2006/2507) 5 Acute sepsis 1% (22/2507) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ12.149) A 91-year-old male with a history of chronic leukemia and dementia falls and sustains the hip fracture shown in Figure A. He undergoes a hemiarthroplasty through a posterior approach. A post-operative radiograph is shown in Figure B. Three weeks later he dislocates the hip arising from the toilet seat. A radiograph is shown in Figure C. The patient undergoes a closed reduction and is placed in a hip abduction brace. Post reduction radiograph is shown in Figure D. One month later he returns to clinic complaining of pain and inability to bear weight through the leg. A radiograph of the hip is included in Figure E. Which of the following factors has MOST likely contributed to the instability of the hip hemiarthroplasty? Review Topic QID: 4509 FIGURES: A B C D E 1 Femoral stem subsidence 1% (59/3995) 2 Increased offset 13% (536/3995) 3 Inadequate femoral stem neck length 13% (526/3995) 4 Patient's dementia status 70% (2803/3995) 5 Patient's gender 1% (36/3995) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ12.67) A 72-year old female who underwent an uncemented right total hip arthroplasty 2 years ago complains of right hip pain after a fall. Figure A shows her current radiograph. Which acetabular bone defect classification and treatment option best describes this scenario? Review Topic QID: 4427 FIGURES: A 1 AAOS Type III - anti-protrusio cage with augmentation and a posterior column plate 24% (941/3927) 2 AAOS Type IV - anti-protrusio cage with screw fixation and a posterior column plate 62% (2426/3927) 3 AAOS Type II - jumbo cup with augmentation and a posterior column plate 8% (311/3927) 4 AAOS Type I - total acetabular allograft with a cemented cup 1% (46/3927) 5 AAOS Type II - custom triflange acetabular component 4% (168/3927) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ12.50) A 74-year-old man presents with start-up thigh pain following a total hip replacement 10 years ago. Immediate post-operative radiograph is shown in Figure A. A current radiograph is shown in Figure B. Aspiration of the hip yields 1,005 white blood cells/ml. ESR is 12 (normal <40) and CRP is 0.4 (normal <1.2). Which of the following is the most appropriate management at this time? Review Topic QID: 4410 FIGURES: A B 1 Revision of the femoral component to an uncemented, long, fully porous-coated stem 78% (3379/4313) 2 Revision of the femoral component to a cemented stem 16% (696/4313) 3 Revision of the femoral component to an allograft prosthetic composite 2% (73/4313) 4 Revision of the femoral component to a proximal femoral replacement 1% (62/4313) 5 Removal of prosthesis with insertion of antibiotic spacer 2% (75/4313) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ10.7) A 72-year-old female returns to clinic for 15 year follow up of left total hip arthroplasty. She ambulates without any assistive devices, has no pain, and denies any recent fevers or systemic illness. A radiograph is provided in figure A. Which of the following is the best treatment option? Review Topic QID: 3095 FIGURES: A 1 Follow up radiographs in 3 years 21% (717/3391) 2 Follow up radiographs in 5 years 2% (65/3391) 3 Revision surgery with femoral head and polyethylene exchange and retroacetabular bone grafting 64% (2163/3391) 4 Revision of acetabular component with jumbo cup and femoral head exchange 10% (338/3391) 5 Revision of acetabular component with jumbo cup and femoral stem revision 3% (102/3391) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
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