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AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
Your Source for Lifelong Orthopaedic Learning
Adult Reconstructive
Surgery of the
Hip and Knee I
I
[
I
Answer Book
, 2025 Adult Reconstructive Surgery of the Hip and Knee Examination Answer Book · 7
Question T T 1
During T the T course T of Ta T revision T total T knee T arthroplasty T via T a T medial T parapatellar T exposure, T the
T surgeon Tdoes T a T complete T intra-articular T release T and T synovectomy T but T exposure T is T still
T inadequate. T A T quadriceps Tsnip T is T performed T and, T at T the T end T ofthe T procedure, T the T knee T is
T stable T throughout T a T range T of Tmotion T and Tthe T postoperative T radiographs T show T acceptable
T alignment T of Tthe T components. T The Tpatient's T postoperative Tphysical T therapy T regimen T should
T include T which T of Tthe T following?
1. No Trestriction T in Trange T of Tmotion Tor T weight Tbearing Tafter T surgery.
2. Limit T flexion T to T 30 T degrees T postoperatively, T progressing T 1 0 T degrees T per T week
3. Limit Tflexion Tto T 90 T degrees T for T the T first T6 T weeks T postoperatively
4. Limit Tto T active T flexion T only T with Tno Tpassive T flexion T or Tactive T extension T for T6 T weeks
5. Use Tof Ta Thinged Tknee Tbrace Tfor T6 Tweeks
T postoperatively TPREFERRED T RESPONSE: T 1
DISCUSSION: TA Tquadriceps Tsnip Tis Tperformed Tby Textending Ta Tmedial Tparapatellar Tapproach
T superiorly Tand Tlaterally Tacross Tthe Tquadriceps Ttendon. T It Tis Tthen Trepaired Tprimarily Tat Tthe Tend TofTthe
T procedure. T The Tprimary Tadvantage TofTthis Ttechnique Tover Tother Tsurgical Tmaneuvers Tthat Timprove
T exposure Tat Tthe Ttime Tof Trevision Ttotal Tknee Tarthroplasty Tis Tthat Tthe Tpostoperative Tregimen Tfor Tphysical
T therapy Tdoes Tnot Tneed Tto Tbe Taltered.
REFERENCES: T Younger TAS, T Duncan TCP, TMasri T BA: T Surgical Texposures Tin Trevision Ttotal Tknee
T arthroplas- Tty. T J TAm TAcad TOrthop TSurg T 1 T998;6:55 T-64.
Della T Valle T CJ, T Berger TRA, T Rosenberg T AG: T Surgical T exposures T in T revision T total T knee T arthroplasty.
T T Clin TOrthop TRelat TRes T2006;446 T: T59-68. T
Barrack T RLT, T Smith T P, T Munn TB, T et T al: T The T Ranawat TAward. T Comparison T of Tsurgical T approaches T in
T total Tknee TarthroplTasty. T Clin TOrthop TRelat TRes T 1 998;3 56: T16-2 1 . T
Question T 2
A Thealthy T72-year-old Twoman Tis T seen T 14 T days Tafter Tcemented Ttotal Tknee Tarthroplasty. T She Treports
T increasing Tpain Tand Tswelling Tfor Tthe Tlast T4 Tdays Taccompanied Tby T4 Tdays Tof Twound Tdrainage.
T Examination Treveals Tthat Tshe Tis Tafebrile, Tand Thas Terythema Tand Tmoderate Tserosanguinous Tdrainage Tfrom
the Twound.
T T The Tknee T is T moderately Tswollen. T Aspiration TofTthe Tknee T reveals T no T organisms Ton TGram
T stain. T Culture Tresults Tare Texpected Tback Tin T48 Thours. T Optimal Tmanagement Tshould Tconsist Tof
1. initiation T of Ta T first-generation T cephalosporin T while T awaiting T culture T results.
2. initiation T of Tbroad-spectrum T antibiotics T while T awaiting T culture T results.
3. ultrasound Tto T evaluate Tfor Tfluid Tcollection T around Tthe Tknee.
4. surgical T debridement T ofTthe T knee Tbefore Tculture T results Tare T available.
5. inpatient T observation T and T no T antibiotics T until T culture T results T are T available.
PREFERRED T RESPONSE: T 4
,8 • American Academy of Orthopaedic Surgeons
DISCUSSION: T Increased Tpain, T swelling, T erythema, Tand Tdrainage T2 T weeks T removed T from Tthe Tprimary
T arthroplasty T are T all T signs T of Ta T probable T infection. T Erythrocyte T sedimentation T rate T and T C-reactive
T protein Tmay T not T be T helpful T as T they T are T elevated Tpostoperatively T even T in T the T absence T of Tinfection.
T Even T in Tthe Tabsence T of Tinfection, Tpersistent Twound Tdrainage Tis T an Tindication Tfor Tsurgical Tdebridement
T to Tprevent Tsubsequent Tinfection. T When T a Tpostoperative T infection Tis T easily T recognized Tby T clinical
T examination, T there Tis T no Tneed Tto Twait Tfor Ta Tpositive T culture Tbefore Tproceeding Twith Tdebridement.
REFERENCES: T Weiss T AP, T Krackow T KA: T Persistent T wound T drainage T after Tprimary T total T knee
T arthroplasty. TJ TArthroplasty T 1 T993;8 T:285-289T.
laberi T FM, T Parvizi T J, T Haytmanek TCT, T et T al: T Procrastination T ofTwound Tdrainage Tand Tmalnutrition Taffect
T the Toutcome TofTjoint Tarthroplasty. T Clin TOrthop TRelat TRes T20 08 ;4 66 :13 68 -1 3 7 1 . T
Insall T IN, T Windsor T RE, T Scott, T WN: T Surgery T ofthe T Knee, T ed T2 . T New T York, T NY, T Churchill
T Livingstone, T1 T993, T pp T959-964.
Figure T 3a Figure T 3b T
Question T 3
A T72-year-old Twoman Tunderwent Ta Tprimary Ttotal Thip Tarthroplasty T 14 T months T ago. T She Tstates Tthat
T the Thip Thas Tnow Tdislocated Tfour Ttimes Twhen Trising Tfrom Ta Tlow Tchair, Trequiring Tclosed Treduction. T A
radiograph Tis T shown Tin TFigure T 3a T and Ta T CT T scan T of Ther Tpelvis T is T shown Tin TFigure T3b.
T T What Tis
T the Tmost Tre1iable Tmethod Tfor Trectifying Ther Tinstability?
1. Use Tof Tan Tabduction Torthosis Tfor T6 Tweeks
2. Modular T exchange T ofTthe T femoral T head Tto T a T 36-mm T head T and T a T longer Tneck
3. Modular T exchange T ofthe T polyethylene T liner T to T a T constrained T acetabular T insert
4. Revision T and T repositioning T of Tthe T acetabular T component T and T use T of Ta T 36-mm
T femoral Thead
5. A Tphysical Ttherapy Tprogram Tstressing Tabductor
T strengthening TPREFERRED TRESPONSE: T4
DISCUSSION: TThe Tradiograph Tshows Twell-fixed Tcomponents Twithout Tevidence Tof Tloosening. T The TCT
T scan Tshows T severe Tretroversion Tof Tthe Tacetabu1ar T component. T Revision T of Tthe T component Tinto Tthe
T correct T amount Tof Tanteversion T will Tmost Treliably T rectify Tthe Tinstability T in Tthe Tface Tof Tsevere
T component Tmalposition.
, 2010 Adult Reconstmctive Surgery ofthe Hip and Knee Examination Answer Book· 9
REFERENCES: TParvizi TJ, TPidnic TE, TSharkey TPF: TRevision Ttotal Thip Tarthroplasty Tfor Tinstability:
T Surgical Ttechniques Tand Tprinciples. T J TBone TJoint TSurg TAm T2008;90: T1134-T1T142.
DeWal TH, TSu TE, TDiCesare TPE: TInstability Tfollowing Ttotal Thip Tarthroplasty. T Am TJ TOrthop T2003;32:
377-382. TBarrack TRL, TBooth TRE TJr, TLonner TlH, Tet Tal T(eds)T: T Orthopaedic TKnowledge TUpdate: T Hip
T
T and TKnee TReconstruction T3. T Rosemont, T IL, TAmelican TAcademy Tof TOrthopaedic TSurgeons, T2006, Tpp
T 475-503.
Question T4
A Tpatient Twith Ta Thistory TofTrheumatoid Tarthritis Treports Ta Tpainful Ttotal Thip Tarthroplasty T3 Tyears Tafter
T the Tindex Tprocedure. T Radiographs Treveal Tloosening TofTthe Tfemoral Tcomponent. T Preoperative Tblood
T work Tshows Tan Terythrocyte Tsedimentation Trate T(ESR) TofT38 Tmmlh T(nOlmal T0-29 Tmmlh) Tand Ta TC-
reactive Tprotein T(CRP) Tof T8.9 T(0.2-8.0). T WThat Tis Tthe Tmost Tappropriate Taction Tat Tthis Ttime?
1. Technetium T bone T scan
2. Hip T aspiration T for T culture
3. FDG-PET T scan
4. Surgery T with Tno Tfurther T investigations
5. Revision Tsurgery Tand Tobtain Tan Tintraoperative Tfrozen
T section TPREFERRED TRESPONSE: T2
DISCUSSION: T The Tquestion Tcenters Ton Tthe Tappropriate Twork-up Tfor Ta Tfailed Ttotal Thip Tarthroplasty
prior Tto Trevision Tsurgery. T The Tpreoperative TESR Tis Televated Tand Tthe TCRP Tis Tat Tthe Tupper Tend Tof
T
normal. T If T either Tthe TESR Tor TCRP Tis Televated, Tfurther Tinvestigations Tare Trequired Tto Texclude
T
T infection Tas Ta Tcause Tof T loosening, Tparticularly Tin Ta Tpatient Tonly T3 Tyears Tafter Tthe Tindex Tprocedure.
T A Ttechnetium Tscan Talone Tis T nonspecific Tand Twill Tshow Tincreased Tuptake Tbecause TofTthe Tloose
femoral Tcomponent. T An Tintraoperative
T
frozen Tsection Tis Ta Thelpful Tconfirmatory Tinvestigation, Tbut Twhenever Tpossible Tthe Tdiagnosis Tshould Tbe
T made Tpreoperatively Tto Tallow Tfor Tappropriate Tsurgical Tplanning. T Recently, T investigators Thave Tshown
T the Tvalue Tof TFDG-PET T scanning Tas T a T useful Tinvestigation T for Tdiagnosing T infection; T however, T it Tis Tno
T more Taccurate T than Tthe T combined T use T of Tan T ESR T and T CRP, T and T does T not T allow T for T identification
T of Tan T infecting T organism. T At Tthis Tpoint, Ta Thip Taspiration Tfor Tculture Tis Tthe Tmost Tappropriate
T investigation.
REFERENCES: TBauer TTW, TParvizi TJ, TKobayashi TN, Tet Tal: TDiagnosis TofTperiprosthetic Tinfection. T J
Bone TJoint TSurg TAm T2006;88:869-882.
T
Pill TSG, TParvizi TJ, TTang TPH, Tet Tal: T Comparison Toffiuorodeoxyglucose Tpositron Temission
tomography Tand T(T11 T1)indium-white Tblood Tcell Timaging Tin Tthe Tdiagnosis Tof Tperiprosthetic
T
T infection Tof Tthe Thip. T J TArthroplasty T2006;21:91-97.
Spangehl TMJ, TMasri TBA, TO'Connell TJX, Tet Tal: T Prospective Tanalysis TofTpreoperative Tand Tintraoperative
T investigations Tfor Tthe Tdiagnosis TofTinfection Tat Tthe Tsites Tof Ttwo Thundred Tand Ttwo Trevision Ttotal Thip
T arthroplasties. T J TBone TJoint TSurg TAm T 1999;8T1:672-683.
AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
Your Source for Lifelong Orthopaedic Learning
Adult Reconstructive
Surgery of the
Hip and Knee I
I
[
I
Answer Book
, 2025 Adult Reconstructive Surgery of the Hip and Knee Examination Answer Book · 7
Question T T 1
During T the T course T of Ta T revision T total T knee T arthroplasty T via T a T medial T parapatellar T exposure, T the
T surgeon Tdoes T a T complete T intra-articular T release T and T synovectomy T but T exposure T is T still
T inadequate. T A T quadriceps Tsnip T is T performed T and, T at T the T end T ofthe T procedure, T the T knee T is
T stable T throughout T a T range T of Tmotion T and Tthe T postoperative T radiographs T show T acceptable
T alignment T of Tthe T components. T The Tpatient's T postoperative Tphysical T therapy T regimen T should
T include T which T of Tthe T following?
1. No Trestriction T in Trange T of Tmotion Tor T weight Tbearing Tafter T surgery.
2. Limit T flexion T to T 30 T degrees T postoperatively, T progressing T 1 0 T degrees T per T week
3. Limit Tflexion Tto T 90 T degrees T for T the T first T6 T weeks T postoperatively
4. Limit Tto T active T flexion T only T with Tno Tpassive T flexion T or Tactive T extension T for T6 T weeks
5. Use Tof Ta Thinged Tknee Tbrace Tfor T6 Tweeks
T postoperatively TPREFERRED T RESPONSE: T 1
DISCUSSION: TA Tquadriceps Tsnip Tis Tperformed Tby Textending Ta Tmedial Tparapatellar Tapproach
T superiorly Tand Tlaterally Tacross Tthe Tquadriceps Ttendon. T It Tis Tthen Trepaired Tprimarily Tat Tthe Tend TofTthe
T procedure. T The Tprimary Tadvantage TofTthis Ttechnique Tover Tother Tsurgical Tmaneuvers Tthat Timprove
T exposure Tat Tthe Ttime Tof Trevision Ttotal Tknee Tarthroplasty Tis Tthat Tthe Tpostoperative Tregimen Tfor Tphysical
T therapy Tdoes Tnot Tneed Tto Tbe Taltered.
REFERENCES: T Younger TAS, T Duncan TCP, TMasri T BA: T Surgical Texposures Tin Trevision Ttotal Tknee
T arthroplas- Tty. T J TAm TAcad TOrthop TSurg T 1 T998;6:55 T-64.
Della T Valle T CJ, T Berger TRA, T Rosenberg T AG: T Surgical T exposures T in T revision T total T knee T arthroplasty.
T T Clin TOrthop TRelat TRes T2006;446 T: T59-68. T
Barrack T RLT, T Smith T P, T Munn TB, T et T al: T The T Ranawat TAward. T Comparison T of Tsurgical T approaches T in
T total Tknee TarthroplTasty. T Clin TOrthop TRelat TRes T 1 998;3 56: T16-2 1 . T
Question T 2
A Thealthy T72-year-old Twoman Tis T seen T 14 T days Tafter Tcemented Ttotal Tknee Tarthroplasty. T She Treports
T increasing Tpain Tand Tswelling Tfor Tthe Tlast T4 Tdays Taccompanied Tby T4 Tdays Tof Twound Tdrainage.
T Examination Treveals Tthat Tshe Tis Tafebrile, Tand Thas Terythema Tand Tmoderate Tserosanguinous Tdrainage Tfrom
the Twound.
T T The Tknee T is T moderately Tswollen. T Aspiration TofTthe Tknee T reveals T no T organisms Ton TGram
T stain. T Culture Tresults Tare Texpected Tback Tin T48 Thours. T Optimal Tmanagement Tshould Tconsist Tof
1. initiation T of Ta T first-generation T cephalosporin T while T awaiting T culture T results.
2. initiation T of Tbroad-spectrum T antibiotics T while T awaiting T culture T results.
3. ultrasound Tto T evaluate Tfor Tfluid Tcollection T around Tthe Tknee.
4. surgical T debridement T ofTthe T knee Tbefore Tculture T results Tare T available.
5. inpatient T observation T and T no T antibiotics T until T culture T results T are T available.
PREFERRED T RESPONSE: T 4
,8 • American Academy of Orthopaedic Surgeons
DISCUSSION: T Increased Tpain, T swelling, T erythema, Tand Tdrainage T2 T weeks T removed T from Tthe Tprimary
T arthroplasty T are T all T signs T of Ta T probable T infection. T Erythrocyte T sedimentation T rate T and T C-reactive
T protein Tmay T not T be T helpful T as T they T are T elevated Tpostoperatively T even T in T the T absence T of Tinfection.
T Even T in Tthe Tabsence T of Tinfection, Tpersistent Twound Tdrainage Tis T an Tindication Tfor Tsurgical Tdebridement
T to Tprevent Tsubsequent Tinfection. T When T a Tpostoperative T infection Tis T easily T recognized Tby T clinical
T examination, T there Tis T no Tneed Tto Twait Tfor Ta Tpositive T culture Tbefore Tproceeding Twith Tdebridement.
REFERENCES: T Weiss T AP, T Krackow T KA: T Persistent T wound T drainage T after Tprimary T total T knee
T arthroplasty. TJ TArthroplasty T 1 T993;8 T:285-289T.
laberi T FM, T Parvizi T J, T Haytmanek TCT, T et T al: T Procrastination T ofTwound Tdrainage Tand Tmalnutrition Taffect
T the Toutcome TofTjoint Tarthroplasty. T Clin TOrthop TRelat TRes T20 08 ;4 66 :13 68 -1 3 7 1 . T
Insall T IN, T Windsor T RE, T Scott, T WN: T Surgery T ofthe T Knee, T ed T2 . T New T York, T NY, T Churchill
T Livingstone, T1 T993, T pp T959-964.
Figure T 3a Figure T 3b T
Question T 3
A T72-year-old Twoman Tunderwent Ta Tprimary Ttotal Thip Tarthroplasty T 14 T months T ago. T She Tstates Tthat
T the Thip Thas Tnow Tdislocated Tfour Ttimes Twhen Trising Tfrom Ta Tlow Tchair, Trequiring Tclosed Treduction. T A
radiograph Tis T shown Tin TFigure T 3a T and Ta T CT T scan T of Ther Tpelvis T is T shown Tin TFigure T3b.
T T What Tis
T the Tmost Tre1iable Tmethod Tfor Trectifying Ther Tinstability?
1. Use Tof Tan Tabduction Torthosis Tfor T6 Tweeks
2. Modular T exchange T ofTthe T femoral T head Tto T a T 36-mm T head T and T a T longer Tneck
3. Modular T exchange T ofthe T polyethylene T liner T to T a T constrained T acetabular T insert
4. Revision T and T repositioning T of Tthe T acetabular T component T and T use T of Ta T 36-mm
T femoral Thead
5. A Tphysical Ttherapy Tprogram Tstressing Tabductor
T strengthening TPREFERRED TRESPONSE: T4
DISCUSSION: TThe Tradiograph Tshows Twell-fixed Tcomponents Twithout Tevidence Tof Tloosening. T The TCT
T scan Tshows T severe Tretroversion Tof Tthe Tacetabu1ar T component. T Revision T of Tthe T component Tinto Tthe
T correct T amount Tof Tanteversion T will Tmost Treliably T rectify Tthe Tinstability T in Tthe Tface Tof Tsevere
T component Tmalposition.
, 2010 Adult Reconstmctive Surgery ofthe Hip and Knee Examination Answer Book· 9
REFERENCES: TParvizi TJ, TPidnic TE, TSharkey TPF: TRevision Ttotal Thip Tarthroplasty Tfor Tinstability:
T Surgical Ttechniques Tand Tprinciples. T J TBone TJoint TSurg TAm T2008;90: T1134-T1T142.
DeWal TH, TSu TE, TDiCesare TPE: TInstability Tfollowing Ttotal Thip Tarthroplasty. T Am TJ TOrthop T2003;32:
377-382. TBarrack TRL, TBooth TRE TJr, TLonner TlH, Tet Tal T(eds)T: T Orthopaedic TKnowledge TUpdate: T Hip
T
T and TKnee TReconstruction T3. T Rosemont, T IL, TAmelican TAcademy Tof TOrthopaedic TSurgeons, T2006, Tpp
T 475-503.
Question T4
A Tpatient Twith Ta Thistory TofTrheumatoid Tarthritis Treports Ta Tpainful Ttotal Thip Tarthroplasty T3 Tyears Tafter
T the Tindex Tprocedure. T Radiographs Treveal Tloosening TofTthe Tfemoral Tcomponent. T Preoperative Tblood
T work Tshows Tan Terythrocyte Tsedimentation Trate T(ESR) TofT38 Tmmlh T(nOlmal T0-29 Tmmlh) Tand Ta TC-
reactive Tprotein T(CRP) Tof T8.9 T(0.2-8.0). T WThat Tis Tthe Tmost Tappropriate Taction Tat Tthis Ttime?
1. Technetium T bone T scan
2. Hip T aspiration T for T culture
3. FDG-PET T scan
4. Surgery T with Tno Tfurther T investigations
5. Revision Tsurgery Tand Tobtain Tan Tintraoperative Tfrozen
T section TPREFERRED TRESPONSE: T2
DISCUSSION: T The Tquestion Tcenters Ton Tthe Tappropriate Twork-up Tfor Ta Tfailed Ttotal Thip Tarthroplasty
prior Tto Trevision Tsurgery. T The Tpreoperative TESR Tis Televated Tand Tthe TCRP Tis Tat Tthe Tupper Tend Tof
T
normal. T If T either Tthe TESR Tor TCRP Tis Televated, Tfurther Tinvestigations Tare Trequired Tto Texclude
T
T infection Tas Ta Tcause Tof T loosening, Tparticularly Tin Ta Tpatient Tonly T3 Tyears Tafter Tthe Tindex Tprocedure.
T A Ttechnetium Tscan Talone Tis T nonspecific Tand Twill Tshow Tincreased Tuptake Tbecause TofTthe Tloose
femoral Tcomponent. T An Tintraoperative
T
frozen Tsection Tis Ta Thelpful Tconfirmatory Tinvestigation, Tbut Twhenever Tpossible Tthe Tdiagnosis Tshould Tbe
T made Tpreoperatively Tto Tallow Tfor Tappropriate Tsurgical Tplanning. T Recently, T investigators Thave Tshown
T the Tvalue Tof TFDG-PET T scanning Tas T a T useful Tinvestigation T for Tdiagnosing T infection; T however, T it Tis Tno
T more Taccurate T than Tthe T combined T use T of Tan T ESR T and T CRP, T and T does T not T allow T for T identification
T of Tan T infecting T organism. T At Tthis Tpoint, Ta Thip Taspiration Tfor Tculture Tis Tthe Tmost Tappropriate
T investigation.
REFERENCES: TBauer TTW, TParvizi TJ, TKobayashi TN, Tet Tal: TDiagnosis TofTperiprosthetic Tinfection. T J
Bone TJoint TSurg TAm T2006;88:869-882.
T
Pill TSG, TParvizi TJ, TTang TPH, Tet Tal: T Comparison Toffiuorodeoxyglucose Tpositron Temission
tomography Tand T(T11 T1)indium-white Tblood Tcell Timaging Tin Tthe Tdiagnosis Tof Tperiprosthetic
T
T infection Tof Tthe Thip. T J TArthroplasty T2006;21:91-97.
Spangehl TMJ, TMasri TBA, TO'Connell TJX, Tet Tal: T Prospective Tanalysis TofTpreoperative Tand Tintraoperative
T investigations Tfor Tthe Tdiagnosis TofTinfection Tat Tthe Tsites Tof Ttwo Thundred Tand Ttwo Trevision Ttotal Thip
T arthroplasties. T J TBone TJoint TSurg TAm T 1999;8T1:672-683.
