Introduction Fractures around a total hip prosthesis increasing in incidence as a result of increased arthroplasty procedures and high-demands of elderly patients Classification intraoperative fractures femur acetabulum postoperative fractures femur acetabulum Epidemiology incidence intraoperative fractures 3.5% of primary uncemented hip replacements 0.4% of cemented arthroplasties postoperative fractures 0.1% most common at stem tip Prevention preoperative templating reduces risk of intraoperative fractures adequate surgical exposure special care when using cementless prosthesis in poor bone (RA, osteoporosis) Intraoperative Acetabular Fractures Introduction incidence cemented acetabular components 0.2% cementless acetabular components 0.4% mechanism typically occurs during acetabular component impaction risk factors underreaming >2mm elliptical modular cups osteoporosis cementless acetabular components dysplasia radiation Evaluation must determine stability of implant Treatment observation alone indications if evaluated intraoperatively and found to be stable postoperative care consider protected weight-bearing for 8-12 weeks acetabular revision with screws vs. ORIF indications if evaluated intraoperatively and found to be unstable technique addition of acetabular screws may consider upgrading to "jumbo" cup ORIF of acetabular fracture with revision of acetabular component if posterior column is compromised, ORIF + revision is most stable construct may add bone graft from reamings if patient has poor bone stock postoperative care consider protected weight-bearing for 8-12 weeks Intraoperative Femur Fractures Introduction incidence primary THA 0.1-5% revision THA 3-21% mechanism proximal fractures usually occur with bone preparation (ie aggressive rasping) and prosthetic insertion may occur during implant insertion from dimension mismatch middle-region fractures usually occur when excessive force is used during surgical exposure or bone preparation distal fractures usually occur when tip of a straight-stem prosthesis impacting at femoral bow risk factors impaction bone grafting female gender technical errors cementless implants osteoporosis revision minimally invasive techniques (controversial) Presentation change in resistance while inserting stem should raise suspicion for fracture Classification Vancouver classification (intraoperative) considerations location pattern stability of fracture types A - proximal metaphysis B - diaphyseal C - distal to stem tip (not amenable to insertion of longest revision stem) subtypes 1 - cortical perforation 2 - nondisplaced crack 3 - displaced unstable fracture pattern Imaging intraoperative radiographs are required when there is a concern for fracture Treatment stem removal, cabling, and reinsertion indications intraoperative longitudinal calcar split trochanteric fixation with wires, cables, or claw-plate indications intraoperative, proximal femur fractures removal of implant, insertion of longer stem prosthesis indications complete (two-part) fractures of middle region technique distal tip of stem must bypass distal extent of fracture by 2 cortical diameters may use cortical allograft struts for added stability removal of implant, internal fixation with plate, reinsertion of prosthesis indications distal fractures that cannot be bypassed with a long-stemmed prosthesis Vancouver Classification & Treatment - Intraoperative Periprosthetic Fracture Type Description Treatment Image A1 Proximal metaphysis, cortical perforation bone graft alone (e.g. from acetabular reaming) A2 Proximal metaphysis, nondisplaced crack cerclage wire before inserting stem(to prevent crack propagation) ignore the fracture if fully porous coated stem is used (provided there is no distal propagation) A3 Proximal metaphysis, displaced unstable fracture fully porous coated stem, or tapered fluted stem provided wires/cables/claw plate for isolated GT fractures B1 Diaphyseal, cortical perforation (usually during cement removal) fully porous coated stem (bypass by 2 cortical diameters) ± strut allograft B2 Diaphyseal, nondisplaced crack (from increased hoop stress during broaching or implant placement) cerclage wire (if implant stable) fully porous coated stem to bypass defect (if implant unstable) ± strut allograft PWB and observation (if detected postop) B3 Diaphyseal, displaced unstable fracture (usually during hip dislocation, cement removal, stem insertion) fully porous coated stem to bypass defect ± strut allograft C1 Distal to stem tip, cortical perforation (during cement removal) morcellized bone graft, fully porous coated stem to bypass defect, strut allograft C2 Distal to stem tip, nondisplaced fracture cerclage wire, strut allograft C3 Distal to stem tip, displaced unstable fracture ORIF Postoperative Femur fracture Introduction incidence 0.1-3% for primary cementless total hip arthroplasties etiology early postoperative fractures cementless prosthesis tend to fracture in the first six months likely caused by stress risers during reaming and broaching wedge-fit tapered designs cause proximal fractures cylindrical fully porous-coated stems tend to cause a distal split in the femoral shaft late postoperative fractures cemented prosthesis tend to fracture later (5 years out) tend to fracture around the tip of the prosthesis or distal to it risk factors poor bone quality cementless prostheses compromised bone stock revision procedures Classification Vancouver classification (postoperative) considerations stability of prosthesis location of fracture quality of surrounding bone pros simple validated cons often difficult to differentiate between B1 and B2 fractures based on radiographs alone Vancouver Classification & Treatment - Postoperative Periprosthetic Fracture Type Description Treatment Image A Fracture in trochanteric region. Commonly associated with osteolysis. AG (greater trochanter) fractures caused by retraction, broaching, actual implant insertion, previous hip screws. Often requires treatment that addresses the osteolysis. AG fractures with <2cm displacement, treat nonoperatively with partial WB and allow fibrous union. AG fractures >2cm needs ORIF (loss of abductor function leads to instability) with trochanteric claw/cables. B1 Fracture around stem or just below it, with a well fixed stem ORIF using cerclage cables and locking plates B2 Fracture around stem or just below it, with a loose stem but good proximal bone stock Revision of the femoral component to a long porous-coated cementless stems and fixation of the fracture fragment. Revision of the acetabular component if indicated B3 Fracture around stem or just below it, with proximal bone that is poor quality or severely comminuted Femoral component revision with proximal femoral allograft or proximal femoral replacement C Fracture occurs well below the prosthesis ORIF with plate- leave the hip and acetabular prosthesis alone Presentation often result after low-energy trauma Treatment nonoperative treatment with protected weight-bearing indications non-displaced periprosthetic fractures of greater trochanter non-displaced fractures of lesser trochanter technique limiting abduction may decrease chances of displacement with greater trochanter fractures ORIF greater trochanter with wires, cables, or claw-plate indications displaced periprosthetic fractures of the greater trochanter technique if osteolysis is present, use cancellous allograft to fill defects ORIF femoral shaft with locking plate and cerclage wires indications Vancouver B1 fractures Vancouver C fractures technique typically place cerclage wires/cables proximally and bicortical screws distal to stem may use unicortical locking screws proximally may add cortical strut allografts femoral component revision with long-stem prosthesis indications Vancouver B2 fractures some Vancouver B3 fractures femoral component revision with proximal femoral allograft indications Vancouver B3 fractures in young patients femoral component revision with proximal femoral replacement indications Vancouver B3 fractures in elderly, low-demand patients
QUESTIONS 1 of 44 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 32 33 34 35 36 37 38 39 40 41 42 43 44 Previous Next 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 (OBQ13.214) Which of the following fractures would most likely require revision arthroplasty with a long-stemmed, uncemented prosthesis? Review Topic QID: 4849 FIGURES: A B C D E 1 Figure A 1% (22/3617) 2 Figure B 86% (3114/3617) 3 Figure C 2% (70/3617) 4 Figure D 4% (132/3617) 5 Figure E 7% (252/3617) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ13.136) Figure A shows the image of a 72-year-old male who sustained a fall from standing. Past medical history is significant for hypertension. He was a community ambulator without the use of a cane or walker prior to the fall. During the operation, he is noted to have a well-fixed acetabular component without significant wear of his polyethylene liner, but his femoral component is easily extractable. Which of the following correctly pairs his Vancouver classification and appropriate surgical intervention? Review Topic QID: 4771 FIGURES: A 1 Vancouver A, Revision of femoral component to cemented stem with fixation of the fracture 1% (35/4475) 2 Vancouver B1, Revision of femoral component to cemented stem with fixation of the fracture 2% (81/4475) 3 Vanvouver B1, Revision of femoral component to a long, porous-coated, cementless stem with fixation of the fracture 9% (406/4475) 4 Vancouver B2, Fixation of the fracture with a plate and cerclage wires 2% (109/4475) 5 Vancouver B2, Revision of femoral component to a long, porous-coated, cementless stem with fixation of the fracture 85% (3819/4475) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 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 (SAE13HK.10) A healthy, active 72-year-old man tripped and fell, landing on his left hip 10 weeks after an uncomplicated left primary uncemented total hip replacement. A radiograph taken 6 weeks after surgery and before the fall is shown in Figure 10a. A radiograph taken after the fall is shown in Figure 10b. He was unable to bear weight and was brought to the emergency department. Examination revealed a slightly shortened left lower extremity and some mild ecchymosis just distal to the left greater trochanteric region, but his skin was intact without abrasions or lacerations. What is the most appropriate treatment? Review Topic QID: 8342 FIGURES: A B 1 Open reduction and cerclage fixation of the fracture 13% (161/1234) 2 Open reduction and revision of the femoral implant to a long cemented stem 12% (152/1234) 3 Open reduction and revision of the femoral implant to a long fluted and tapered uncemented stem 74% (908/1234) 4 Application of balanced traction and surgery after the ecchymosis has resolved 0% (3/1234) 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 (OBQ12.217) An 82-year-old male sustains a ground level fall and sustains the injury shown in Figure A. Which of the following treatment methods is most appropriate for treating this injury? Review Topic QID: 4577 FIGURES: A 1 Closed reduction and functional bracing 0% (6/3310) 2 Open reduction and fixation with a plate with screws and cerclage cables 86% (2837/3310) 3 Open reduction and fixation with a cortical allograft strut and cerclage cables 11% (369/3310) 4 Revision hip arthroplasty with bridging of the fracture with a plate with screws and cerclage cables 1% (45/3310) 5 Total femoral replacement 1% (36/3310) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ12.78) A 78-year-old female undergoes total hip arthroplasty through a minimally invasive surgical approach. During insertion of a metaphyseal fixation stem with a cementless press-fit technique, a crack in the calcar is identified. The stem is removed, two cable wires are passed around the calcar, and the same stem is reinserted. Which of the following statements is true? Review Topic QID: 4438 1 The patient should be advised she is at greater risk of stem subsidence and early revision 19% (815/4304) 2 Female sex is a risk factor for intraoperative calcar fracture 59% (2527/4304) 3 A better outcome would be expected if a long-stem diaphyseal fixation stem had been inserted after recognition of the calcar fracture 14% (621/4304) 4 Cementless press-fit technique is not a risk factor for intraoperative fracture 1% (63/4304) 5 Minimally invasive surgical approach is not a risk factor for intraoperative fracture 6% (255/4304) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 2 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 (OBQ10.26) In his first day home after undergoing a total hip arthroplasty a 65-year-old male falls down the stairs and sustains the fracture seen in Figure A and B. Intra-operative examination reveals the stem to be loose. What is the preferred treatment for this injury? Review Topic QID: 3114 FIGURES: A B 1 Open reduction internal fixation with cables and proximal femoral locking plate 13% (449/3519) 2 Open reduction internal fixation with allograft strut and multiple cables 5% (162/3519) 3 Revision femoral component with proximal femoral replacement 1% (31/3519) 4 Revision femoral component with long stem diaphyseal press-fit stem 80% (2805/3519) 5 Revision femoral component with cemented stem 2% (54/3519) ML 3 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 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ10.108) A 67-year-old man 6 years status post right total hip arthroplasty falls while walking his dog. He complains of pain and is unable to bear weight through the right leg. He denies any hip or thigh pain prior to this fall. A radiograph is provided in figure A. Which of the following is the most appropriate management? Review Topic QID: 3202 FIGURES: A 1 Traction for 3 weeks followed by 2 months of non-weight bearing mobilization 0% (2/2492) 2 Open reduction and plate fixation with cable augmentation proximally 62% (1545/2492) 3 Revision arthroplasty with a cementless long stem bypassing the fracture site by two cortical diameters 27% (679/2492) 4 Revision arthroplasty with cemented femoral stem bypassing the fracture site by two cortical diameters 2% (51/2492) 5 Revision arthroplasty with cementless long stem bypassing the fracture site by two cortical diameters and allograft strut augmentation 8% (209/2492) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 2 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 (OBQ09.140) A previously healthy 68-year-old woman falls and sustains the fracture seen in Figure A. Her index procedure was approximately 10 years ago. The patient is taken to surgery, and the femoral stem is found to be loose. The acetabular component is found to be well fixed in good position. In addition to using a new poly liner, what other procedure(s) is now indicated in this patient? Review Topic QID: 2953 FIGURES: A 1 Cemented femoral revision 7% (134/2058) 2 Retention of current hardware and fixation using cerclage wires 1% (17/2058) 3 Open reduction and internal fixation with a locking plate 2% (47/2058) 4 Both uncemented femoral revision and revision of the acetabular shell 2% (47/2058) 5 Uncemented femoral revision bypassing the distal deficiency by two cortices. 88% (1802/2058) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ08.125) A 65-year-old healthy patient fell 18 years after a total hip arthroplasty and sustained the fracture shown in Figure A. What is the most appropriate treatment? Review Topic QID: 511 FIGURES: A 1 Percutaneous locked plating 1% (11/1727) 2 Open reduction internal fixation with a cable plate and allograft strut 4% (72/1727) 3 Revision to a long, porous coated femoral stem with biplanar allograft struts 84% (1454/1727) 4 Revision to a cemented revision femoral stem that bypasses the fracture site by 5 cm 10% (166/1727) 5 Three months of non-weight bearing 1% (12/1727) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ08.268) A nondisplaced periprosthetic small posterior wall acetabular fracture is noted intra-operatively during total hip arthroplasty. The acetabular component is stable and well-fixed after implantation of an ingrowth acetabular shell during intraoperative examination. Which of the following treatment options will best maintain motion and clinical function? Review Topic QID: 654 1 ORIF of the posterior column and THA revision 3% (65/2340) 2 Cage reconstruction of acetabular component 1% (33/2340) 3 THA revision using a cemented acetabular component 1% (20/2340) 4 Placement of a hip abductor brace and non-weight bearing in the affected limb 14% (320/2340) 5 No change in treatment 81% (1897/2340) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 5 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.88) During impaction of a cementless acetabular component, the posterior column was fractured and found to be displaced. Which of the following is considered the most appropriate surgical option? Review Topic QID: 6048 1 Exchange of the cementless cup to a larger component 6% (3/52) 2 Retention of the component and bone grafting of the fracture 0% (0/52) 3 Retention of the component and postoperative weight protection until the posterior column heals 12% (6/52) 4 Removal of the cup, fixation of the posterior column, and application of an antiprotrusio cage 81% (42/52) 5 Removal of the cup and cementing of an all-polyethylene liner 2% (1/52) 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.72) In the radiograph shown in Figure 42, the fracture pattern around this well-fixed stem is classified as Vancouver type Review Topic QID: 6032 FIGURES: A 1 A. 1% (1/107) 2 B1. 58% (62/107) 3 B2. 15% (16/107) 4 B3. 15% (16/107) 5 C. 8% (9/107) ML 3 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 (SAE07HK.69) A 67-year-old patient seen in the emergency department reports the acute onset of pain and is unable to ambulate. History reveals that the patient underwent surgical treatment for a periprosthetic femoral fracture 6 months ago. A radiograph is shown in Figure 41. What is the best treatment option at this time? Review Topic QID: 6029 FIGURES: A 1 Open reduction and internal fixation with cortical onlay strut grafts and bone morphogenic protein 31% (32/102) 2 Resection arthroplasty 5% (5/102) 3 Revision hip arthroplasty with an allograft prosthetic composite 5% (5/102) 4 Revision hip surgery with distal stem fixation using a long stem implant with strut grafts 57% (58/102) 5 Revision hip arthroplasty with a proximally coated implant 0% (0/102) ML 4 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.68) A 53-year-old patient is seen in the emergency department after sustaining a fall onto her left hip. A current radiograph is shown in Figure 40. What is the best treatment option? Review Topic QID: 6028 FIGURES: A 1 Bed rest and non-weight-bearing for 6 to 8 weeks 0% (0/118) 2 Component retention and open reduction and internal fixation 16% (19/118) 3 Proximal femoral replacement prosthesis 3% (3/118) 4 Revision arthroplasty with a long cemented stem 7% (8/118) 5 Revision arthroplasty with a long porous-coated cylindrical stem 69% (82/118) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 5 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.62) Figure 37 reveals a periprosthetic fracture around a cemented femoral stem in an 81-year-old patient with Paget’s disease and mild coagulopathy. What is the most appropriate reconstructive management on the femoral side? Review Topic QID: 6022 FIGURES: A 1 Open reduction and internal fixation 5% (8/153) 2 Impaction allografting 0% (0/153) 3 Proximally coated femoral stem 2% (3/153) 4 Allograft prosthetic composite (APC) 4% (6/153) 5 Proximal femoral replacement (PFR) 89% (136/153) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 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.59) Figure 36 shows the radiograph of a patient who has hip pain and is unable to ambulate. What is the most appropriate management for this patient? Review Topic QID: 6019 FIGURES: A 1 Bisphosphonates 0% (0/140) 2 Protected weight bearing 14% (20/140) 3 Open reduction and internal fixation 19% (27/140) 4 Revision total hip arthroplasty 66% (92/140) 5 Resection arthroplasty 1% (1/140) ML 3 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.49) Figure 28 shows the postoperative radiograph of a 36-year-old patient. The cerclage cable was placed for a minimal medial calcar fracture seen during femoral preparation. In the immediate postoperative period, what is the highest level of activity that would be safely permitted? Review Topic QID: 6009 FIGURES: A 1 Immediate full weight bearing 53% (49/93) 2 Protected weight bearing 15% (14/93) 3 Toe touch weight bearing 25% (23/93) 4 Non-weight-bearing 3% (3/93) 5 50% weight bearing 4% (4/93) ML 3 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.31) A 75-year-old woman undergoes hybrid total hip arthroplasty for osteoarthritis. A postoperative radiograph obtained in the recovery room is shown in Figure 18. Treatment should now consist of Review Topic QID: 5991 FIGURES: A 1 open reduction and internal fixation with strut graft and cerclage wire. 16% (20/124) 2 open reduction and internal fixation with a plate, screws, and bone graft. 17% (21/124) 3 exchange of the femoral components with insertion of a long stem cementless implant. 19% (24/124) 4 cast immobilization. 0% (0/124) 5 minimal weight bearing and observation. 43% (53/124) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 5 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.16) Figure 10 shows the AP radiograph of an ambulatory 76-year-old patient. What is the most appropriate surgical treatment option for this patient? Review Topic QID: 5976 FIGURES: A 1 Revision arthroplasty using a cemented femoral component 10% (9/89) 2 Impaction allografting of the femoral component 4% (4/89) 3 Proximal femoral replacement arthroplasty 74% (66/89) 4 Resection arthroplasty 4% (4/89) 5 Hip arthrodesis 0% (0/89) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (SBQ07HK.62) A 88-year-old female fell onto her right hip sustaining the fracture shown in Figure A. Past medical history is significant for mild dementia and moderate coronary artery disease. At baseline, she ambulates with a walker. There are concerns about her ability to maintain weight-bearing precautions following surgery. Which of the following is most appropriate for management of the femoral side? Review Topic QID: 1647 FIGURES: A 1 Revision total hip replacement with a proximally coated femoral stem 4% (88/2008) 2 Open reduction, internal fixation with plate and cerclage wires 8% (155/2008) 3 Proximal femoral replacement with megaprosthesis 84% (1689/2008) 4 Impaction bone grafting 0% (7/2008) 5 Cortical strut allograft with cerclage wiring 3% (63/2008) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ06.180) A 78-year-old male falls at home four months following a right total hip arthroplasty. Right leg deformity, pain, and inability to bear weight are present on physical exam. An injury radiograph is provided in Figure A, while radiographs taken immediately following the initial total hip arthroplasty are provided in Figures B and C. The patient denies any prodromal groin pain prior to his fall. Which of the following is the best treatment option? Review Topic QID: 366 FIGURES: A B C 1 Traction for 6 weeks followed by slow return to weight bearing 0% (1/1072) 2 Open reduction and internal fixation 81% (867/1072) 3 Revision to a long, cementless femoral stem 13% (135/1072) 4 Revision to a long, cementless stem with strut allograft 3% (36/1072) 5 Revision to a long, cemented stem 2% (24/1072) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ05.173) During insertion of a cementless femoral stem, a nondisplaced fracture is noticed along the femoral calcar. Which of the following is the most appropriate next step in surgical management? Review Topic QID: 1059 1 Continued insertion of the stem, cerclage wiring around the fracture site, and non-weight bearing x6 weeks 8% (76/1001) 2 Continued insertion of the stem, reduction of the hip, and non-weight bearing activity restrictions following surgery 2% (22/1001) 3 Removal of the stem, cerclage wiring around the fracture site, and re-insertion of a stem 87% (871/1001) 4 Removal of the stem and conversion to a cemented femoral stem 2% (17/1001) 5 Removal of the stem, open reduction internal fixation of the femur with planned delayed femoral stem insertion following fracture healing 1% (8/1001) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ05.124) An 82-year-old woman falls and sustains the fracture shown in figure A. She denies any history of dislocation or prodromal pain prior to her fall. What is the most appropriate treatment? Review Topic QID: 1010 FIGURES: A 1 Toe-touch weightbearing 0% (1/999) 2 Open reduction internal fixation with a cable plate 9% (85/999) 3 Revision of the femur with a long, cementless stem 83% (829/999) 4 Revision of the femur with a long, cemented stem 8% (76/999) 5 Girdlestone resection arthroplasty 0% (2/999) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ04.244) While performing a cementless total hip arthroplasty in a healthy 68-year-old female, the surgeon notes an audible change while impacting the final broach. The broach is removed and a 1cm longitudinal crack originating at the calcar is visualized. Bone stock is otherwise preserved. What is the next best step in management? Review Topic QID: 1349 1 Insert standard press-fit stem, weight bearing as tolerated postoperatively 5% (101/2043) 2 Apply cerclage wire, insert standard press-fit stem, weight bearing as tolerated postoperatively 74% (1510/2043) 3 Insert long porous-coated stem, touch down weight bearing postoperatively 7% (141/2043) 4 Insert long cemented stem, weight bearing as tolerated postoperatively 2% (46/2043) 5 Insert long porous-coated stem, augment with cortical allograft and cerclage wires, touch down weight bearing postoperatively. 12% (236/2043) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ04.232) A 67-year-old man who underwent total hip arthroplasty (THA) 4 years ago fell on to his right hip. His pre-injury right hip film is seen in Figure A while films of his current injury are seen in Figures B and C. Prior to the fall he had no thigh or hip pain. His ESR and CRP are within normal limits. During intraoperative assessment, the acetabular and femoral stems are found to be well fixed. What is the next best course of action? Review Topic QID: 1337 FIGURES: A B C 1 Revision of the acetabular component and ORIF of the femur with locking plates and cerclage wires 0% (7/1692) 2 Revison of the femoral component, bypassing the fracture by two cortical diameters 8% (138/1692) 3 Revision of the femoral component with impaction grafting and cerclage wires 2% (31/1692) 4 Revision to a cemented component, bypassing the fracture by two cortical diameters 1% (20/1692) 5 ORIF of the femur with locking plates and cerclage wires 88% (1484/1692) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 5
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