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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 1
During the course of a revision total knee arthroplasty via a medial parapatellar exposure, the surgeon
does a complete intra-articular release and synovectomy but exposure is still inadequate. A quadriceps
snip is performed and, at the end ofthe procedure, the knee is stable throughout a range of motion and
the postoperative radiographs show acceptable alignment of the components. The patient's postoperative
physical therapy regimen should include which of the following?
1. No restriction in range of motion or weight bearing after surgery.
2. Limit flexion to 30 degrees postoperatively, progressing 1 0 degrees per week
3. Limit flexion to 90 degrees for the first 6 weeks postoperatively
4. Limit to active flexion only with no passive flexion or active extension for 6 weeks
5. Use of a hinged knee brace for 6 weeks postoperatively
PREFERRED RESPONSE: 1
DISCUSSION: A quadriceps snip is performed by extending a medial parapatellar approach superiorly
and laterally across the quadriceps tendon. It is then repaired primarily at the end of the procedure. The
primary advantage of this technique over other surgical maneuvers that improve exposure at the time of
revision total knee arthroplasty is that the postoperative regimen for physical therapy does not need to be
altered.
REFERENCES: Younger AS, Duncan CP, Masri BA: Surgical exposures in revision total knee arthroplas-
ty. J Am Acad Orthop Surg 1 998;6:55 -64.
Della Valle CJ, Berger RA, Rosenberg AG: Surgical exposures in revision total knee arthroplasty. Clin
Orthop Relat Res 2006;446 : 59-68.
Barrack RL , Smith P, Munn B, et al: The Ranawat Award. Comparison of surgical approaches in total
knee arthropl asty. Clin Orthop Relat Res 19 98;3 56: 16-2 1 .
Question 2
A healthy 72-year-old woman is seen 14 days after cemented total knee arthroplasty. She reports
increasing pain and swelling for the last 4 days accompanied by 4 days of wound drainage. Examination
reveals that she is afebrile, and has erythema and moderate serosanguinous drainage from the wound. The
knee is moderately swollen. Aspiration of the knee reveals no organisms on Gram stain. Culture results
are expected back in 48 hours. Optimal management should consist of
1. initiation of a first-generation cephalosporin while awaiting culture results.
2. initiation of broad-spectrum antibiotics while awaiting culture results.
3. ultrasound to evaluate for fluid collection around the knee.
4. surgical debridement of the knee before culture results are available.
5. inpatient observation and no antibiotics until culture results are available.
PREFERRED RESPONSE: 4
,8 • American Academy of Orthopaedic Surgeons
DISCUSSION: Increased pain, swelling, erythema, and drainage 2 weeks removed from the primary
arthroplasty are all signs of a probable infection. Erythrocyte sedimentation rate and C-reactive protein
may not be helpful as they are elevated postoperatively even in the absence of infection. Even in the
absence of infection, persistent wound drainage is an indication for surgical debridement to prevent
subsequent infection. When a postoperative infection is easily recognized by clinical examination, there is
no need to wait for a positive culture before proceeding with debridement.
REFERENCES: Weiss AP, Krackow KA: Persistent wound drainage after primary total knee arthroplasty.
J Arthroplasty 1 993;8 :285-289 .
laberi FM, Parvizi J, Haytmanek CT, et al: Procrastination of wound drainage and malnutrition affect the
outcome of joint arthroplasty. Clin Orthop Relat Res 20 08 ;466 :13 68 -1 3 7 1 .
Insall IN, Windsor RE, Scott, WN: Surgery ofthe Knee, ed 2 . New York, NY, Churchill Livingstone,
1 993, pp 959-964.
Figure 3a Figure 3b
Question 3
A 72-year-old woman underwent a primary total hip arthroplasty 14 months ago. She states that the hip
has now dislocated four times when rising from a low chair, requiring closed reduction. A radiograph is
shown in Figure 3a and a CT scan of her pelvis is shown in Figure 3b. What is the most re1iable method
for rectifying her instability?
1. Use of an abduction orthosis for 6 weeks
2. Modular exchange of the femoral head to a 36-mm head and a longer neck
3. Modular exchange ofthe polyethylene liner to a constrained acetabular insert
4. Revision and repositioning of the acetabular component and use of a 36-mm femoral
head
5. A physical therapy program stressing abductor strengthening
PREFERRED RESPONSE: 4
DISCUSSION: The radiograph shows well-fixed components without evidence of loosening. The CT scan
shows severe retroversion of the acetabu1ar component. Revision of the component into the correct amount
of anteversion will most reliably rectify the instability in the face of severe component malposition.
, 2010 Adult Reconstmctive Surgery ofthe Hip and Knee Examination Answer Book· 9
REFERENCES: Parvizi J, Pidnic E, Sharkey PF: Revision total hip arthroplasty for instability: Surgical
techniques and principles. J Bone Joint Surg Am 2008;90: 1134- 1 142.
DeWal H, Su E, DiCesare PE: Instability following total hip arthroplasty. Am J Orthop 2003;32: 377-382.
Barrack RL, Booth RE Jr, Lonner lH, et al (eds) : Orthopaedic Knowledge Update: Hip and Knee
Reconstruction 3. Rosemont, IL, Amelican Academy of Orthopaedic Surgeons, 2006, pp 475-503.
Question f4
A fpatient fwith fa fhistory fof frheumatoid farthritis freports fa fpainful ftotal fhip farthroplasty f3 fyears
fafter fthe findex fprocedure. f Radiographs freveal floosening fof fthe ffemoral fcomponent.
f Preoperative fblood fwork fshows fan ferythrocyte fsedimentation frate f(ESR) fof f38 fmmlh f(nOlmal
f0-29 fmmlh) fand fa fC-reactive fprotein f(CRP) fof f8.9 f(0.2-8.0). f W fhat fis fthe fmost fappropriate
faction fat fthis ftime?
1. Technetium fbone f scan
2. Hip f aspiration f for f culture
3. FDG-PET f scan
4. Surgery f with fno ffurther f investigations
5. Revision fsurgery fand fobtain fan fintraoperative ffrozen
fsection fPREFERRED fRESPONSE: f2
DISCUSSION: f The fquestion fcenters fon fthe fappropriate fwork-up ffor fa ffailed ftotal fhip
farthroplasty fprior fto frevision fsurgery. f The fpreoperative fESR fis felevated fand fthe fCRP fis fat
fthe fupper fend fof fnormal. f If f either fthe fESR for fCRP fis felevated, ffurther finvestigations fare
frequired fto fexclude finfection fas fa fcause fof f loosening, fparticularly fin fa fpatient fonly f3 fyears
fafter fthe findex fprocedure. f A ftechnetium fscan falone fis f nonspecific fand fwill fshow fincreased
fuptake fbecause fof fthe floose ffemoral fcomponent. f An fintraoperative
frozen fsection fis fa fhelpful fconfirmatory finvestigation, fbut fwhenever fpossible fthe fdiagnosis fshould fbe
fmade fpreoperatively fto fallow ffor fappropriate fsurgical fplanning. f Recently, f investigators fhave
fshown fthe fvalue fof fFDG-PET f scanning fas f a f useful finvestigation f for fdiagnosing f infection;
f however, f it fis fno f more faccurate f than fthe f combined f use f of fan f ESR f and f CRP, f and f does f not
f allow f for f identification f of fan f infecting f organism. f At fthis fpoint, fa fhip faspiration ffor fculture fis
fthe fmost fappropriate finvestigation.
REFERENCES: fBauer fTW, fParvizi fJ, fKobayashi fN, fet fal: fDiagnosis fof fperiprosthetic finfection.
f J fBone fJoint fSurg fAm f2006;88:869-882.
Pill fSG, fParvizi fJ, fTang fPH, fet fal: f Comparison foffiuorodeoxyglucose fpositron femission
ftomography fand f(f11 f1)indium-white fblood fcell fimaging fin fthe fdiagnosis fof fperiprosthetic
finfection fof fthe fhip. f J fArthroplasty f2006;21:91-97.
Spangehl fMJ, fMasri fBA, fO'Connell fJX, fet fal: f Prospective fanalysis fof fpreoperative fand
fintraoperative finvestigations ffor fthe fdiagnosis fof finfection fat fthe fsites fof ftwo fhundred fand ftwo
frevision ftotal fhip farthroplasties. f J fBone fJoint fSurg fAm f 1999;8 f1:672-683.
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 1
During the course of a revision total knee arthroplasty via a medial parapatellar exposure, the surgeon
does a complete intra-articular release and synovectomy but exposure is still inadequate. A quadriceps
snip is performed and, at the end ofthe procedure, the knee is stable throughout a range of motion and
the postoperative radiographs show acceptable alignment of the components. The patient's postoperative
physical therapy regimen should include which of the following?
1. No restriction in range of motion or weight bearing after surgery.
2. Limit flexion to 30 degrees postoperatively, progressing 1 0 degrees per week
3. Limit flexion to 90 degrees for the first 6 weeks postoperatively
4. Limit to active flexion only with no passive flexion or active extension for 6 weeks
5. Use of a hinged knee brace for 6 weeks postoperatively
PREFERRED RESPONSE: 1
DISCUSSION: A quadriceps snip is performed by extending a medial parapatellar approach superiorly
and laterally across the quadriceps tendon. It is then repaired primarily at the end of the procedure. The
primary advantage of this technique over other surgical maneuvers that improve exposure at the time of
revision total knee arthroplasty is that the postoperative regimen for physical therapy does not need to be
altered.
REFERENCES: Younger AS, Duncan CP, Masri BA: Surgical exposures in revision total knee arthroplas-
ty. J Am Acad Orthop Surg 1 998;6:55 -64.
Della Valle CJ, Berger RA, Rosenberg AG: Surgical exposures in revision total knee arthroplasty. Clin
Orthop Relat Res 2006;446 : 59-68.
Barrack RL , Smith P, Munn B, et al: The Ranawat Award. Comparison of surgical approaches in total
knee arthropl asty. Clin Orthop Relat Res 19 98;3 56: 16-2 1 .
Question 2
A healthy 72-year-old woman is seen 14 days after cemented total knee arthroplasty. She reports
increasing pain and swelling for the last 4 days accompanied by 4 days of wound drainage. Examination
reveals that she is afebrile, and has erythema and moderate serosanguinous drainage from the wound. The
knee is moderately swollen. Aspiration of the knee reveals no organisms on Gram stain. Culture results
are expected back in 48 hours. Optimal management should consist of
1. initiation of a first-generation cephalosporin while awaiting culture results.
2. initiation of broad-spectrum antibiotics while awaiting culture results.
3. ultrasound to evaluate for fluid collection around the knee.
4. surgical debridement of the knee before culture results are available.
5. inpatient observation and no antibiotics until culture results are available.
PREFERRED RESPONSE: 4
,8 • American Academy of Orthopaedic Surgeons
DISCUSSION: Increased pain, swelling, erythema, and drainage 2 weeks removed from the primary
arthroplasty are all signs of a probable infection. Erythrocyte sedimentation rate and C-reactive protein
may not be helpful as they are elevated postoperatively even in the absence of infection. Even in the
absence of infection, persistent wound drainage is an indication for surgical debridement to prevent
subsequent infection. When a postoperative infection is easily recognized by clinical examination, there is
no need to wait for a positive culture before proceeding with debridement.
REFERENCES: Weiss AP, Krackow KA: Persistent wound drainage after primary total knee arthroplasty.
J Arthroplasty 1 993;8 :285-289 .
laberi FM, Parvizi J, Haytmanek CT, et al: Procrastination of wound drainage and malnutrition affect the
outcome of joint arthroplasty. Clin Orthop Relat Res 20 08 ;466 :13 68 -1 3 7 1 .
Insall IN, Windsor RE, Scott, WN: Surgery ofthe Knee, ed 2 . New York, NY, Churchill Livingstone,
1 993, pp 959-964.
Figure 3a Figure 3b
Question 3
A 72-year-old woman underwent a primary total hip arthroplasty 14 months ago. She states that the hip
has now dislocated four times when rising from a low chair, requiring closed reduction. A radiograph is
shown in Figure 3a and a CT scan of her pelvis is shown in Figure 3b. What is the most re1iable method
for rectifying her instability?
1. Use of an abduction orthosis for 6 weeks
2. Modular exchange of the femoral head to a 36-mm head and a longer neck
3. Modular exchange ofthe polyethylene liner to a constrained acetabular insert
4. Revision and repositioning of the acetabular component and use of a 36-mm femoral
head
5. A physical therapy program stressing abductor strengthening
PREFERRED RESPONSE: 4
DISCUSSION: The radiograph shows well-fixed components without evidence of loosening. The CT scan
shows severe retroversion of the acetabu1ar component. Revision of the component into the correct amount
of anteversion will most reliably rectify the instability in the face of severe component malposition.
, 2010 Adult Reconstmctive Surgery ofthe Hip and Knee Examination Answer Book· 9
REFERENCES: Parvizi J, Pidnic E, Sharkey PF: Revision total hip arthroplasty for instability: Surgical
techniques and principles. J Bone Joint Surg Am 2008;90: 1134- 1 142.
DeWal H, Su E, DiCesare PE: Instability following total hip arthroplasty. Am J Orthop 2003;32: 377-382.
Barrack RL, Booth RE Jr, Lonner lH, et al (eds) : Orthopaedic Knowledge Update: Hip and Knee
Reconstruction 3. Rosemont, IL, Amelican Academy of Orthopaedic Surgeons, 2006, pp 475-503.
Question f4
A fpatient fwith fa fhistory fof frheumatoid farthritis freports fa fpainful ftotal fhip farthroplasty f3 fyears
fafter fthe findex fprocedure. f Radiographs freveal floosening fof fthe ffemoral fcomponent.
f Preoperative fblood fwork fshows fan ferythrocyte fsedimentation frate f(ESR) fof f38 fmmlh f(nOlmal
f0-29 fmmlh) fand fa fC-reactive fprotein f(CRP) fof f8.9 f(0.2-8.0). f W fhat fis fthe fmost fappropriate
faction fat fthis ftime?
1. Technetium fbone f scan
2. Hip f aspiration f for f culture
3. FDG-PET f scan
4. Surgery f with fno ffurther f investigations
5. Revision fsurgery fand fobtain fan fintraoperative ffrozen
fsection fPREFERRED fRESPONSE: f2
DISCUSSION: f The fquestion fcenters fon fthe fappropriate fwork-up ffor fa ffailed ftotal fhip
farthroplasty fprior fto frevision fsurgery. f The fpreoperative fESR fis felevated fand fthe fCRP fis fat
fthe fupper fend fof fnormal. f If f either fthe fESR for fCRP fis felevated, ffurther finvestigations fare
frequired fto fexclude finfection fas fa fcause fof f loosening, fparticularly fin fa fpatient fonly f3 fyears
fafter fthe findex fprocedure. f A ftechnetium fscan falone fis f nonspecific fand fwill fshow fincreased
fuptake fbecause fof fthe floose ffemoral fcomponent. f An fintraoperative
frozen fsection fis fa fhelpful fconfirmatory finvestigation, fbut fwhenever fpossible fthe fdiagnosis fshould fbe
fmade fpreoperatively fto fallow ffor fappropriate fsurgical fplanning. f Recently, f investigators fhave
fshown fthe fvalue fof fFDG-PET f scanning fas f a f useful finvestigation f for fdiagnosing f infection;
f however, f it fis fno f more faccurate f than fthe f combined f use f of fan f ESR f and f CRP, f and f does f not
f allow f for f identification f of fan f infecting f organism. f At fthis fpoint, fa fhip faspiration ffor fculture fis
fthe fmost fappropriate finvestigation.
REFERENCES: fBauer fTW, fParvizi fJ, fKobayashi fN, fet fal: fDiagnosis fof fperiprosthetic finfection.
f J fBone fJoint fSurg fAm f2006;88:869-882.
Pill fSG, fParvizi fJ, fTang fPH, fet fal: f Comparison foffiuorodeoxyglucose fpositron femission
ftomography fand f(f11 f1)indium-white fblood fcell fimaging fin fthe fdiagnosis fof fperiprosthetic
finfection fof fthe fhip. f J fArthroplasty f2006;21:91-97.
Spangehl fMJ, fMasri fBA, fO'Connell fJX, fet fal: f Prospective fanalysis fof fpreoperative fand
fintraoperative finvestigations ffor fthe fdiagnosis fof finfection fat fthe fsites fof ftwo fhundred fand ftwo
frevision ftotal fhip farthroplasties. f J fBone fJoint fSurg fAm f 1999;8 f1:672-683.
