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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 d4
A dpatient dwith da dhistory dof drheumatoid darthritis dreports da dpainful dtotal dhip darthroplasty d3
dyears dafter dthe dindex dprocedure. d Radiographs dreveal dloosening dof dthe dfemoral
dcomponent. d Preoperative dblood dwork dshows dan derythrocyte dsedimentation drate d(ESR) dof
d38 dmmlh d(nOlmal d0-29 dmmlh) dand da dC-reactive dprotein d(CRP) dof d8.9 d(0.2-8.0). d W dhat
dis dthe dmost dappropriate daction dat dthis dtime?
1. Technetium dbone d scan
2. Hip d aspiration d for d culture
3. FDG-PET d scan
4. Surgery d with dno dfurther d investigations
5. Revision dsurgery dand dobtain dan dintraoperative dfrozen
dsection dPREFERRED dRESPONSE: d2
DISCUSSION: d The dquestion dcenters don dthe dappropriate dwork-up dfor da dfailed dtotal dhip
darthroplasty dprior dto drevision dsurgery. d The dpreoperative dESR dis delevated dand dthe dCRP
dis dat dthe dupper dend dof dnormal. d If d either dthe dESR dor dCRP dis delevated, dfurther
dinvestigations dare drequired dto dexclude dinfection das da dcause dof d loosening, dparticularly din
da dpatient donly d3 dyears dafter dthe dindex dprocedure. d A dtechnetium dscan dalone dis
d nonspecific dand dwill dshow dincreased duptake dbecause dof dthe dloose dfemoral dcomponent. d An
dintraoperative
frozen dsection dis da dhelpful dconfirmatory dinvestigation, dbut dwhenever dpossible dthe ddiagnosis
dshould dbe dmade dpreoperatively dto dallow dfor dappropriate dsurgical dplanning. d Recently,
d investigators dhave dshown dthe dvalue dof dFDG-PET d scanning das d a d useful dinvestigation d for
ddiagnosing d infection; d however, d it dis dno d more daccurate d than dthe d combined d use d of dan
d ESR d and d CRP, d and d does d not d allow d for d identification d of dan d infecting d organism. d At
dthis dpoint, da dhip daspiration dfor dculture dis dthe dmost dappropriate dinvestigation.
REFERENCES: dBauer dTW, dParvizi dJ, dKobayashi dN, det dal: dDiagnosis dof dperiprosthetic
dinfection. d J dBone dJoint dSurg dAm d2006;88:869-882.
Pill dSG, dParvizi dJ, dTang dPH, det dal: d Comparison doffiuorodeoxyglucose dpositron demission
dtomography dand d(d11 d1)indium-white dblood dcell dimaging din dthe ddiagnosis dof
dperiprosthetic dinfection dof dthe dhip. d J dArthroplasty d2006;21:91-97.
Spangehl dMJ, dMasri dBA, dO'Connell dJX, det dal: d Prospective danalysis dof dpreoperative dand
dintraoperative dinvestigations dfor dthe ddiagnosis dof dinfection dat dthe dsites dof dtwo dhundred
dand dtwo drevision dtotal dhip darthroplasties. d J dBone dJoint dSurg dAm d 1999;8 d1:672-683.
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 d4
A dpatient dwith da dhistory dof drheumatoid darthritis dreports da dpainful dtotal dhip darthroplasty d3
dyears dafter dthe dindex dprocedure. d Radiographs dreveal dloosening dof dthe dfemoral
dcomponent. d Preoperative dblood dwork dshows dan derythrocyte dsedimentation drate d(ESR) dof
d38 dmmlh d(nOlmal d0-29 dmmlh) dand da dC-reactive dprotein d(CRP) dof d8.9 d(0.2-8.0). d W dhat
dis dthe dmost dappropriate daction dat dthis dtime?
1. Technetium dbone d scan
2. Hip d aspiration d for d culture
3. FDG-PET d scan
4. Surgery d with dno dfurther d investigations
5. Revision dsurgery dand dobtain dan dintraoperative dfrozen
dsection dPREFERRED dRESPONSE: d2
DISCUSSION: d The dquestion dcenters don dthe dappropriate dwork-up dfor da dfailed dtotal dhip
darthroplasty dprior dto drevision dsurgery. d The dpreoperative dESR dis delevated dand dthe dCRP
dis dat dthe dupper dend dof dnormal. d If d either dthe dESR dor dCRP dis delevated, dfurther
dinvestigations dare drequired dto dexclude dinfection das da dcause dof d loosening, dparticularly din
da dpatient donly d3 dyears dafter dthe dindex dprocedure. d A dtechnetium dscan dalone dis
d nonspecific dand dwill dshow dincreased duptake dbecause dof dthe dloose dfemoral dcomponent. d An
dintraoperative
frozen dsection dis da dhelpful dconfirmatory dinvestigation, dbut dwhenever dpossible dthe ddiagnosis
dshould dbe dmade dpreoperatively dto dallow dfor dappropriate dsurgical dplanning. d Recently,
d investigators dhave dshown dthe dvalue dof dFDG-PET d scanning das d a d useful dinvestigation d for
ddiagnosing d infection; d however, d it dis dno d more daccurate d than dthe d combined d use d of dan
d ESR d and d CRP, d and d does d not d allow d for d identification d of dan d infecting d organism. d At
dthis dpoint, da dhip daspiration dfor dculture dis dthe dmost dappropriate dinvestigation.
REFERENCES: dBauer dTW, dParvizi dJ, dKobayashi dN, det dal: dDiagnosis dof dperiprosthetic
dinfection. d J dBone dJoint dSurg dAm d2006;88:869-882.
Pill dSG, dParvizi dJ, dTang dPH, det dal: d Comparison doffiuorodeoxyglucose dpositron demission
dtomography dand d(d11 d1)indium-white dblood dcell dimaging din dthe ddiagnosis dof
dperiprosthetic dinfection dof dthe dhip. d J dArthroplasty d2006;21:91-97.
Spangehl dMJ, dMasri dBA, dO'Connell dJX, det dal: d Prospective danalysis dof dpreoperative dand
dintraoperative dinvestigations dfor dthe ddiagnosis dof dinfection dat dthe dsites dof dtwo dhundred
dand dtwo drevision dtotal dhip darthroplasties. d J dBone dJoint dSurg dAm d 1999;8 d1:672-683.
