1.

A 45-year-old woman with a cementless total hip replacement prosthesis and a history of metal allergy to inexpensive jewelry complains of general discomfort associated with her implant. Metal hypersensitivity should be considered: A. when 3 months postoperatively the patient demonstrates dermatitis and swelling near the implant site B. when 6 months postoperatively the patient complains of pain and joint swelling, and radiographs show periprosthetic osteolysis C. when 6 months postoperatively the patient brings positive results of a metal allergy patch test conducted by an allergist D. when 3 years postoperatively the patient has dermatitis, urticaria, and vasculitis 2. In primary total hip arthroplasty for dysplasiam with arthritis, a bone graft to improve coverage of the cup is not required if the cup is covered by the host acetabulum by:

A. 40% B. 50% C. 60% D. 70% E. 80% 3. Normal bone turnover in the presence of particulate wear debris can be adversely affected by many mechanisms including the activation of osteoblasts (by ingestion of particles), which can induce: A. production of IL-6 and PGE-2, and decreased synthesis of type-I collagen B. increased elaboration of IL-1 and TNF-, which suppresses osteoclast function C.prostaglandin-mediated early apoptosis of chondroblasts and osteoblasts D. degradation of the type-I collagen in bone matrix E. conversion of undifferentiated mesenchymal cells from an osteoblast lineage to afibroblast lineage 4. During primary total hip arthroplasty for the dysplastic hip with arthritis, what is the maximum

lengthening possible if the sciatic nerve is monitored by visualization and palpation and, if necessary, a wake-up test: A. 2 centimeters B. 4 centimeters C. 6 centimeters D. 8 centimeters E. none at all

5. In the treatment of severe congenital femoral deficiency, the results of a rotationplasty of the affected limb can be enhanced by: A. addition of a Syme amputation B. fusing the residual femur to the ilium C. doing the procedure before the age of 2 years D. amputating the toes E. shortening the opposite limb

6. Revision of a loose femoral component associated with severe bone loss can be accomplished with good long-term (9-15-year) results in over three-quarters of patients using: A. any femoral prosthesis combined with oral biphosphonates B. any femoral prosthesis combined with ultrasound stimulation

C. a long-stem femoral prosthesis without cement or bone graft D. a long-stem femoral prosthesis cemented proximal femoral allograft but not to host bone E. a long-stem femoral prosthesis/allograft composite cemented to host bone over its distal half only

to

7. Administration of enoxaparin for 4 weeks following major lower extremity joint replacement surgery:

A. reduces the incidence of thromboembolism following total hip replacement B. provides no therapeutic benefit in total joint surgery C. was equally effective as a placebo in reducing the incidence of symptomatic pulmonary embolism in total joint replacement D. had an unacceptably high rate of neurologic complications E. was associated with worrisome changes in liver function tests 8. In patients undergoing total hip arthroplasty, epoetin alfa: A. has no measurable benefit in reducing the need for transfusion B. increases the risk of developing congestive heart failure postoperatively C. reduces the need for blood transfusions when given preoperatively D. has no role in autologous blood donation programs E. causes dangerous postoperative bleeding problems

9. Osteolysis induced by wear particles is a serious problem in joint arthroplasty. Particle induced bone loss is due to an imbalance between bone resorption by osteoclasts and bone formation by osteoblasts. Which of the following is most affected by wear particles? A. osteoblast activity B. osteoblast differentiation C. osteoclast activity D. osteoclast differentiation E. osteoclast survival 10. Following unilateral total hip arthroplasty with a press-fit acetabular component, retroacetabular pelvic bone-mineral density: A. increases significantly in the ipsilateral hemipelvis B. decreases significantly in the contralateral hemipelvis C does not change significantly in the ipsilateralhemipelvis

D. increases significantly in the contralateral hemipelvis E. decreases significantly in the ipsilateral hemipelvis 11. Which of the following can you anticipate within the first five years after having performed a total hip replacement with a cementless acetabular component in a patient with post-traumatic osteoarthritis: A. a prohibitively high incidence of clinically significant (Brooker class-III or IV) heterotopic ossification in patients in whom no postoperative prophylaxis was used B. a deep-infection rate that is significantly higher than that in patients having a total hip replacement for nontraumatic osteoarthritis C. similar radiographic stability but more periacetabular radiolucencies than in patients having a total hip replacement for nontraumatic osteoarthritis D. a dislocation rate that is significantly higher than that in patients having a total hip replacement for nontraumatic osteoarthritis

E. an aseptic loosening rate that is significantly higher than that in patients having a total hip replacement for nontraumatic osteoarthritis

6. Gaucher disease is an autosomal recessive genetic disorder in which the defect causes: A. a marked decrease in the lysosomal enzymes of the cellular elements in connective tissue B. an accumulation of fat in various organs as well as in the subcutaneous tissues C. an increased production of neurolemmal tissue surrounding major nerves D. an accumulation of glucosylceramide in the reticuloendothelial cells E. premature aging of connective tissue and collagen damage 14-When do most dislocations, deep wound infections, and pulmonary emboli occur in patients treated with primary or revision total hip replacement?

A. During the index hospitalization for the hireplacement B.between discharge from the acute care hospital and four weeks postoperatively C.from five to thirteen weeks postoperatively D.from fourteen to twenty-five weeks postoperatively E.the risk of these complications is essentially the same

16. The addition of osteogenic protein-1 (OP-1) to autograft and allograft bone results in a composite graft with osteoinductive properties that are: A. superior to autograft or allograft bone B. inferior to autograft or allograft bone C. inferior to autograft bone and equivalent to allograft bone D. superior to allograft bone but equivalent to autograft bone E. severely detrimental to local bone conduction 17. All of the following are indications for a singlestage total hip replacement in a patient with a history of septic arthritis except: A. a negative bone biopsy culture B. adequate treatment of the infection in the past C. infection with Staphylococcus aureus D. continued elevation of the erythrocyte sedimentation rate and C-reactive protein level

15.Which of the following factors is the most important in the loss of the plasma-sprayed hydroxyapatite coating on acetabular cups over time? A. direct dissolution B. delamination C. osteoclastic degradation D. substrate surface texture E. prosthetic design

E. infection with an antibiotic-sensitive streptococcus 18. The Dega osteotomy technique can be varied selectively to address different types of acetabular dysplasia by: A. using fibular strut allografts B. varying the extent of the inner pelvic cortex that is cut C. using osteotomes of different sizes D. changing the angle of the osteotomy referable to the medial-lateral plane E. always including a femoral osteotomy 19. The presence of osteolysis in the bone around the load-bearing junction of a modular femoral nail is most likely the result of: A. stress concentration resulting in excessive nail-bone interface motion B. fretting corrosion between the components C. undetected fatigue fracture of the nail D. stress protection due to the large size of the nail

E. a biologic response to excessive reaming when the nail was inserted 20. The most common mechanism of liner dislodgment in Harris-Galante acetabular components in total hip arthroplasty is: A. violent trauma, imposing sheer stress on the liner B. repetitive impacts, such as those imposed during running and during sports such as basketball C. progressive motion, wear, and deformation of the liner D. loosening of the metal shell and osteolysis E. varus and retroversion of a loose femoral component 21.More than a screening physical examination (such as hip radiographs or hip ultrasound) is indicated for assessment of a healthy newborn for developmental dysplasia of the hip in which of the following situations? A. male child with a history of breech presentation B. female child with a history of breech presentation C. male child with a family history of developmental dysplasia of the hip

D. female child with a family history of developmental dysplasia of the hip E. female child with no history of developmental dysplasia of the hip 22. Preoperative planning (approach, length of the prosthesis, thickness of the prosthesis, and extent of a femoral osteotomy) is most important for successful femoral revision with a revision stem with diaphyseal fixation. What is the most important information necessary for preoperative planning of a femoral revision without cement? A. the amount of shortening of the affected lower extremity compared with that of the contralateral limb B. the preoperative stability of the greater trochanter C. whether the loosened stem had cemented or cementless fixation D. the most proximal part of the femur at which stable fixation of the prosthesis is possible E. the amount of anterior bow of the femur 23. In long-term (more than ten-year) follow-up

studies of Porous Coated Anatomic (PCA) total hip replacements, the most important variable influencing the need for revision surgery was: A. size of the prosthetic femoral head B. gender of the patient C. thickness of the polyethylene liner D. age of the patient at the time of the initial surgery E. cause of the arthritis that led to the initial arthroplasty

24.Which of the following proteins is a target for therapies designed to inhibit loosening of total joint components? A. transforming growth factor-beta (TGF-) B. tumor necrosis factor-alpha (TNF-) C. insulin-like growth factor-1 (IGF-1) D. vascular endothelial growth factor (VEGF) E. fibroblast growth factor (FGF) .25.Which of the following factors is predictive of

the final functional result of a total hip arthroplasty performed for the treatment of an ankylosed hip? A. duration of fusion B. type of fusion C. initial diagnosis D. number of previous operations E. status of the gluteal muscles 26. Which of the following statementsconcerning osteonecrosis of the femoral head is most true? A. it is a disease state that is easy to model B.osteogenic protein-1 is definitely useful for patients with osteonecrosis C. free iliac crest bone graft is the most reliable graft for treatment of femoral head defects D. the dog is not a suitable model for studying femoral head defects E. the healing response of femoral head defects can be mimicked in a canine model

27. Bulk autologous femoral head bone grafts used in association with uncemented sockets for reconstruction in patients with developmental hip dysplasia were associated with: A. a high rate of infection at the site of the prosthetic hip B. good acetabular component fixation and good clinical results in the majority of patients C. complete bone graft resorption in most cases D. a high rate of dislocation of the prosthetic hip E. difficulty in obtaining good acute fixation of the acetabular component but good outcomes in patients in whom good fixation was obtained 28. The volume of total hip replacements per formed annually by the hospital and by the surgeon may influence the outcome of total hip replacement surgery. Which of the following statements correctly describes the association between hospital and surgeon volume and dislocation within ninety days after elective

primary total population?

hip

replacement

in

the

Medicare

A. hospitals and surgeons who perform a LOWER volume of total hip replacements each year have LOWER dislocation rates B. hospitals and surgeons who perform a HIGHER volume of total hip replacements each year have LOWER dislocation rates C. hospitals that perform a HIGHER volume of total hip replacements each year have LOWER dislocation rates; surgeon volume does not influence dislocation following primary elective total hip replacement D. Surgeons who perform a HIGHER volume of total hip replacements each year have LOWER dislocation rates; hospital volume does not influence dislocation following primary elective total hip replacement E. whether the surgeon is fellowship-trained is the most important variable in determining the complication rate following total hip replacement

29. Bone osteolysis about the prosthetic components is the primary process leading to premature failure of total hip arthroplasty. Second-generation cementless arthroplasty has minimized this problem by: A. redesign of the acetabular component to incorporate a collar that limits migration of small particles B. use of new high-density polyethylenes for the acetabular bearing C. use of circumferential ingrowth surfaces on the proximal portion of the femoral prosthesis D. redesign of the distal part of the femoral stem E. use of more precise broaches to produce a precision fit of the components 30. Comparison of the long-term results of ceramicon-polyethylene bearing surfaces with those of metalon-polyethylene bearing surfaces in total hip arthroplasty has shown that ceramic-on-polyethylene has: A. increased loosening rates B. increased osteolysis rates C. increased revision rates

D. decreased wear rates E. decreased survival rates 31. Following revision total hip arthroplasty, which acetabular construct is the most durable after ten years of follow-up? A. cemented all-polyethylene component B. cemented metal-backed component C. acetabular cage reconstruction D. cementless component E. cemented constrained component 32 .In a prospective randomized trial comparing postoperative radiation with a six-week course of indomethacin to prevent heterotopic ossification following surgical treatment of acetabular fractures, indomethacin was found to be: A. equally effective but it had a much higher incidence of complications B. less effective C. more effective D. equally effective with no complications

E. more effective and much less expensive 33.Which of the following factors is associated with an increased risk of mortality within thirty days after elective total hip arthroplasty? \ A. osteoarthritis as the reason for the arthroplasty B. revision surgery C. male gender D. female gender E. cemented acetabular component 34. Compared with a control patient, a patient who has had a successful pregnancy after a total hip arthroplasty will likely have which of the following? A. greater risk of infection B. greater risk of loosening C. greater risk of dislocation D. greater range of motion of the hip E. greater risk of thromboembolism

35.Compared with hand-packing techniques, contemporary cementing techniques for implantation of the femoral component in a total hip arthroplasty should provide: A. more predictable filling of the femoral canal with cement B. fewer air bubbles in cement C. better centralization of the prosthesis D. fewer femoral component fractures 36 .Recurrent dislocation following total hip arthroplasty can be difficult to manage. Some authors have advocated revision to a bipolar prosthesis to address this complication. The most frequent problem with this technique has been reported to be: A. recurrent dislocation B. infection C. protrusio acetabuli D. poor clinical hip rating and pain E. excessive wear of the bipolar component

37.What is the greatest limitation of the use of recombinant adenovirus-mediated gene therapy for the treatment of osteolysis? A. wild-type adenovirus can be generated and causes infectious disease B. liver toxicity C. a dominant host immune response to the vector exacerbates osteolysis and eliminates target gene expression in two weeks D. a young healthy volunteer was killed by recombinant adenovirus in a clinical trial E. recombinant adenoviruses infect osteoblasts and inhibit osteogenesis 38 An eighty-one-year-old man with Paget disease of the pelvis and precarious health undergoes total hip arthroplasty. During removal of the trial femoral head, it becomes dislodged and shifts into a retroperitoneal position that is inaccessible through the hip wound. There is no evidence of neurovascular, gastrointestinal, or

genitourinary action is to:

compromise.The

most

appropriate

A. call for a general surgeon to perform an immediate laparotomy to remove the trial head B. close the hip and postoperatively notify your liability insurance carrier C. plan to leave the component in place but later discuss its removal with the patient D. obtain a surgery consultation postoperatively in order to schedule a delayed endoscopic removal E. consult with the manufacturer to determine the material composition of the component and then test for allergies to its composite materials. Plan to remove it if the patient is allergi to it 39. Loosening of the acetabular component of a total hip replacement can be diagnosed on the basis of radiolucent lines. The minimal thickness for diagnosis is: A. 2-mm postoperative gap B. 1-mm postoperative gap

C. 1-mm progressive radiolucent line in any zone more than two years postoperatively D. 1-mm radiolucent lines in two zones at one year postoperatively E. 2-mm radiolucent lines in three zonesimmediately Postoperatively 40. Developmental dysplasia of the hip is one of the most common causes of secondary osteoarthritis. To prevent osteoarthritis, eccentric rotational acetabular osteotomy should be considered for young patients. Which of the following factors is not prerequisite for this operation?

A. center-edge angle of less than 15 and discontinuity of Shentons line B. terminal stage of osteoarthritis C. age between fifteen and sixty years D. joint congruity and femoral head coverage in maximum abduction E. unsuccessful nonoperative treatment for at least six months

41. When using a jumbo femoral head to treat recurrent dislocation following total hip replacement, what minimum ratio of the femoral head diameter to the acetabular shell diameter appears critical to optimize hip stability? A. less than 0.2 B. less than 0.5 C. greater than 0.5 D. greatr than 1 E. greater than 2

than 40% of the articular surface D. full-thickness abrasive loss of more than 40% of the articular surface of the femoral head E. acetabular fracture with articular comminution producing more than ten fragments 43 .The most common reason for failure of the acetabular and femoral components of cemented Charnley total hip replacements after twenty-five years of follow-up is: A. component fracture B. infection C. dislocation D. aseptic component loosening E. polyethylene wear 44.Which of the following bone-grafting materials is osteoconductive, osteoinductive, and osteogenic: A. demineralized bone matrix

42. All of the following are relative indications for treatment of a displaced acetabular fracture with an acute total hip arthroplasty EXCEPT: A. displaced comminuted fracture involving more than 40% of the femoral head B. T-type acetabular fracture with acetabular protrusion C. impaction of the acetabulum involving more

B. coralline hydroxyapatite C. calcium sulfate D. autologous cancellous bone E. autologous bone marrow

B. short stride length, reduced arc, plateau C. long stride length, reduced arc, two peaks D. short stride length, increased arc, plateau E. short stride length, increased arc, triple sinusoidal curves

45. Fractional lengthening of the iliopsoas tendon for iliopsoas snapping hip has what potential advantage over a complete surgical release? A. lower recurrence of snapping B. preservation of hip flexion strength C. less extensive surgical dissection D. earlier return to activity E. preservation of hip external rotation strength 46. Which of the following best represents the pattern of gait, in terms of stride length, arc of pelvic rotation, and shape of the ground-reaction force curve, of a patient who has had resection of the sciatic nerve of one lower extremity? A. long stride length, increased arc, two peaks

47. Venous thromboembolic disease is a major complication of total hip arthroplasty. Which of the following factors has been shown to decrease the incidence of this complication? A. institution of immediate partial weight-bearing after the operation B. keeping the operative time as short as possible C. vacuum-suction prophylaxis against fat and bone marrow embolism during the operation D. administration of aspirin before the operation E. avoiding the use of cell-saver blood recovery during surgery 48.Which of the following preoperative factors is the most important in the prediction of the

need for blood transfusion after prosthetic hip and knee surgery? A. weight of the patient B. results of a preoperative coagulopathy panel C. sex of the patient D. preoperative hemoglobin level E. age of the patient 49. In a healthy, active sixty-eight-year-old man who has symptomatic isolated loosening of the acetabular component and a well-fixed femoral stem following unilateral total hip arthroplasty,management should consist of: A. conservative treatment with anti-inflammatories and use of a cane B. nonoperative treatment until the femoral component loosens, and then revision of both components C. administration of alendronate and limitation of activities to encourage restabilization of th loose component D.revisionwithretentionofthefemoral,component and revision of the acetabular component E. revision of both the femoral and the acetabular

component to facilitate exposure and to improve the outcome for the acetabulum 50.What is the most common adverse outcome following arthroscopic dbridement of the osteoarthritic knee in patients fifty years of age or older? A. deep-vein thrombosis B. infection C. early failure of the procedure requiring repeat arthroscopic dbridement D. early failure of the procedure requiring high tibial osteotomy E. early failure of the procedure requiring total knee arthroplasty 51. The structure that is most often confused with the iliopsoas tendon during a standard iliofemoral approach is: A. femoral nerve B. femoral vein C. lateral femoral cutaneous nerve

D. medial femoral circumflex artery E. spermatic cord in males 52.Which of the following factors does not contribute to the differences in the liner wear rate and the rate of osteolysis between nonmodular acetabular components and modular acetabular components in total hip arthroplasty? A. liner-shell conformity B. polyethylene liner thickness C. liner-shell micromotion D. liner shelf life E. sterilization process 53. The long-term clinical outcomes after Salter innominate osteotomy for the treatment of developmental dysplasia of the hip in children is significantly influenced by: A. the age of the patient at the time of the operation B. the addition of an intertrochanteric osteotomy C. the severity of any postoperative avascular

necrosis of the femoral head D. the sex of the patient E. the type of fixation used to stabilize theosteotomy 54. The main reason for revision of an alumina-on alumina total hip arthroplasty in the long term is: A. fracture of the alumina femoral head B. fracture of the alumina acetabular component C. periprosthetic osteolysis D. loosening of the femoral component E. loosening of the acetabular component 55. At the time of total hip arthroplasty in adults with congenital dislocation and severe dysplasia of the hip, the most common anatomical abnormalities observed are: A. excessive retroversion of the femoral neck and deficiency of the superoposterior portion of acetabulum B. anterior position of the greater trochanter with acetabular protrusion C. excessive anteversion of the femoral neck

the

with a superolaterally deficient acetabulum D. severe coxa vara with anterior erosion of the acetabulum E. severe coxa valga with superior deficiency of the acetabulum 56.Which of the following cells are particularly sensitive to treatment with ultra-high molecular weight polyethylene particles in vitro, producing nitrous oxide and prostaglandin E2, potent mediators known to be involved in transducing signals between neighboring cells? A. mature osteoblasts B. fibroblasts C. chondrocytes D. mesenchymal stem cells E. perimyocytes 57.Particle-induced osteolysis is the most common cause of implant loosening after joint replacement. Alendronate, a bisphosphonate, may slow or reverse the osteolysis. Which of the following statements best describes the mechanism of action of alendronate?

A. increases the catabolism of microparticles B. prevents formation of Howship lacunae C. blocks osteoclastic resorption D. increases osteoblast recruitment E. increases bone turnover 58 Activity-related pain and a joint effusion are clinical findings associated with accelerated polyethylene wear of implants sterilized by gamma irradiation in air. Which practice best alerts the surgeon to the likelihood of accelerated polyethylene wear? A. comparison of serial plain radiographs B. serial fluoroscopically controlled radiographs C. determination, by contacting the implant manufacturer, of the duration of shelf storage prior to the arthroplasty D. joint aspiration and analysis of the joint fluid E. arthroscopy 59.When harvesting anterior iliac-crest bone

grafts, the most important contributing factor associated with injury of the lateral femoral cutaneous nerve is: A. patient obesity B. subperiosteal dissection of the iliac crest C. postoperative hematoma D. anatomic variation in the position lateral femoral cutaneous nerve E. constricting postoperative dressing

C. the amount of contact of the collar of the prosthesis with the calcar of the femur D. the degree of valgus or varus in which the femoral prosthesis is set E. the patients weight 61. A forty-year-old man was involved in a motorvehicle accident in which he sustained a fracture of the posterior wall of the acetabulum and a posterior dislocation of the hip, which was reduced fourteen hours after injury. The most important risk factor associated with an unsatisfactory clinical outcome is: A. the patients age B. a twenty-five-year history of smoking C. the duration of unreduced hip dislocation D. the size of the posterior wall fracture fragment E. an associated head injury 62.When treating a periprosthetic femoral fracture around a well-fixed prosthesis:

of

the

60 The cement strains in a cemented femoral component of a total hip replacement during simulated stair-climbing are higher for smaller stems assuming that all other conditions are the same. What factor is more important in generating the highest peak strains in the cement? A. the length of the neck of the femoral component B. the amount of offset of the neck of the femoral component

A. revision of the prosthesis is necessary in order to obtain stable fixation B. cortical onlay allograft struts alone provide mechanical stability and improve bone stock C. use of a cortical strut and a plate is superior to use of two cortical allografts alone D. union of allograft to host bone is usually seen by two years postoperatively E. late femoral component loosening is a frequent Complication 63. At ten years postoperatively, radiographic evaluation of uncemented acetabular components in patients younger than fifty years old is most likely to demonstrate a high prevalence of: A. complete radiolucent lines B. component migration C. pelvic osteolysis D. liner dissociation E. screw breakage

64. The presence and extent of periacetabular osseous lysis secondary to polyethylene wear often must be determined in patients with total hip implants. Which method provides the most information on the extent and location of these lesions? A. four-view plain radiographs B. magnetic resonance imaging C. helical computed tomography D. ultrasound E.scintigraphywithtechnetium-methylene diphosphonate 65. Aseptic loosening of cemented femoral components and subsequent bone lysis is a major cause of revision of total hip replacements. The surface finish of the femoral stem is thought to be a possible contributing factor. Which of the following statements is true? A. polished and rough-surfaced stems have a similar incidence of loosening and need for revision

B. stems with polished surfaces loosen and require revision more frequently than do roughsurfaced stems C. surface finish of cemented stems is not related to the incidence of stem loosening D. polished stems, when loose, cause less lysis of bone than do rough stems E. polished stems loosen less often than do rough stems but have a much higher incidence of fracture 66. A fifty-year-old man presents with right groin pain and is suspected of having early-stage osteonecrosis of the hip. Which entity presents with radiographic and magnetic resonance imaging findings most similar to osteonecrosis: A. osteoarthritis B. pigmented villonodular synovitis C. transient osteoporosis D. Lyme arthritis E. sickle cell disease

67. An improved prognosis following core decompression is most likely to be associated with: A. steroid use B. idiopathic osteonecrosis C. a sclerotic rim around a necrotic lesion D. a younger patient E. a female patient

68.Which of the following is true concerning the potential change in pelvic dimensions, documented by magnetic resonance pelvimetry, in young women who have had a reconstructive periacetabular osteotomy? A. the bispinous diameter will be significantly decreased B. the bispinous diameter will be significantly increased C. the bispinous diameter will not be significantly altered D. the anterior-posterior inlet measurement will

be significantly decreased E. both the bispinous diameter anteriorposterior inlet measurement significantly decreased

and will

the be

69 In an evaluation of the ten-year results of total hip arthroplasty in patients younger than fifty years old, which of the following is least likely to be associated with aseptic loosening: A. a history of osteonecrosis B. a 32-mm femoral head C. a femoral component with a surface RA of 90 D.a cementless porous-coated acetabular component E. polyethylene gamma irradiation in air

junction D. use of plate and screw fixation instead of an intramedullary nail E. use of unicondylar rather than full articular allografts 71.The main beneficial effect of antibiotic impregnated cement in total knee arthroplasty is: A. faster polymerization of polymethylmethacrylate B. improved mechanical strength of cement C. local elution of antibiotic into the joint fluid D. ability to avoid systemic antibiotic prophylaxis E. hemostatic effect 72 .In revision total hip arthroplasty, segmental bone loss of <5 cm in length on the femoral side is best managed by: A. a proximal femoral allograft B. a calcar-replacing implant C. a standard-length uncemented implant D. a proximally porous-coated implant

70.Which of the following factors is most responsible for a nonunion after reconstruction with an allograft? A. use of chemotherapy B. use of fixation that is not sufficiently rigid C. not applying autograft at the host bone allograft

E. the body-mass index of the patient 73.In revision total hip arthroplasty, contained bone loss on the acetabular side can be managed by an uncemented cup: A. if contact of the cup can be made with 50% of the area of the host bone B. if a large structural graft involving >50% of the acetabulum is used C. if >50% of the acetabulum is filled with morselized allograft bone D. if the cup is placed in a protruded position 74. In total hip replacement surgery, the most important factor predicting the likelihood of autologous or allogeneic transfusion is: A. the availability of predonated autologous units B. the severity of baseline anemia C. the amount of operative blood loss D. the amount of blood loss estimated for the entire hospital duration 75.Which of the following factors is NOT associated with an increased risk of a contralateral slipped capital femoral epiphysis? A. African-American ethnicity B. advanced bone age C. endocrinopathy D. premenarchal status E. obesity 76. In addition to surgically treating a patient with a low-energy hip fracture, the orthopaedist should: A. obtain a dual-energy x-ray absorptiometry scan prior to discharge B. begin treatment with calcium, a bisphosphonate, and estrogen C. begin treatment with vitamin D, calcium, and a bisphosphonate D. prescribe a commercial hip protector E. consult an endocrinologist or metabolic bone specialist

77. Cementation of a polyethylene liner into a well-fixed metal shell has become an increasingly popular technique in revision total hip arthroplasty. Which of the following factors would most likely lead to catastrophic failure of this construct? A. an undersized liner with a smooth surface B. an undersized liner with a circumferentially grooved surface C. an undersized liner placed into a metal shell with no holes D. an oversized liner E. an undersized liner placed into a cluster-holed metal shell 78. A six-year-old girl with a history of developmental dysplasia of the hip that was treated in infancy is seen during routine follow-up. She has no pain or limp but has radiographic evidence of residual acetabular dysplasia. The recommended treatment is: A. observation; tell the parents that the child

will do well B. abduction bracing C. no treatment now; tell the parents that a pelvic osteotomy may be needed as a teenager D. femoral osteotomy only E. pelvic osteotomy with or without femoral Osteotomy 79. Ischemic necrosis of the immature femoral head has been shown to produce femoral head flattening. Which of the following processes plays a role in the development of femoral head flattening? A. appositional bone formation B. osteoclastic bone resorption C. mechanical fragmentation D. subchondral bone fracture E. chondrolysis 80. The fifteen-year survivorship free of revision for aseptic loosening of a collared matte finished femoral component inserted with second-generation cement techniques is:

A. the same for patients regardless of age B. worse for patients under fifty years of age at the time of the operation C. better for patients under fifty years of age at the time of the operation D. worse for patients of high weight E. worse in males than in females 81.Which of the following factors has been shown to increase the risk of pulmonary fat embolism following total hip arthroplasty? A. bilateral simultaneous total hip arthroplasty B. operative time of less than two hours C. total hip arthroplasty with cement D. regional rather than general anesthesia E. preoperative elevated triglyceride level 82. A ten-year follow-up study of cementless porouscoated sockets implanted without screw fixation revealed that the most likely cause for revision of the socket was: A. change of cup position

B. recurrent dislocation C. aseptic loosening of the socket D. polyethylene wear E. liner dissociation 83.What is the most common early complication after hip revision with impacted morselized allograft bone and cement? A. femoral head dislocation B. aseptic loosening C. infection D. femoral fracture E. pulmonary embolism 84.Which of the following is the most important factor influencing the longevity of the acetabular component following the conversion of a fused hip to a total hip arthroplasty? A. diagnosis at the time of fusion B. gender of the patient C. age at which the fusion was performed D. age at which the total hip arthroplasty was performed

E. type/nature of the fusion technique 85. In a study of patients younger than sixty who had sustained a displaced subcapital fracture of the hip, the results of reduction and internal fixation performed within the first twelve hours after injury were compared with those of operations done more than twelve hours after injury. It was found that patients who were operated on more than twelve hours after injury had: A. a poorer functional outcome B. a higher prevalence of osteonecrosis C. a higher prevalence of delayed union D. a higher prevalence of deep venous thrombosis E. a higher prevalence of urinary tract infection 86. Of the following factors, which is associated with the highest risk of later fracture of the femoral shaft (excluding intraoperative fractures) following surgery for a hip fracture?

A. low mental test score of the patient at the time of the original hip fracture B. male gender of the patient C. a hip fracture pattern graded as severe with use of the Garden and Evans classification D. poor walking ability of the patient prior to the hip fracture E. use of an implant with a proximal diaphyseal intramedullary stress riser 87. During the first year after a solid organ transplantation, osteonecrosis of the femoral head will develop in what percentage of patients? A. 0% to 5% B. 6% to 25% C. 26% to 50% D. 51% to 75% E. 76% to 100% 88.When the most disabled patients who undergo total hip arthroplasty are compared with less disabled patients, which statement is correct?

A. the most disabled patients improve the same amount but their final status is worse B. the most disabled patients improve more but their final status is worse C. the most disabled patients improve more and their final status is equal D. the most disabled patients do not improve as much but derive more benefit from surgery E. there is no relationship between preoperative disability and outcome 89. Some patients have a dislocation for the first time many years after a total hip arthroplasty. These late dislocations occur: A. less commonly than was previously thought B. more frequently in men than in women C. after a median time of less than ten years D. more frequently than early dislocations E. in association with multiple different predisposing factors

90.Which of the following is most likely to be associated with increased stability of the hip following revision total hip arthroplasty? A. trochanteric nonunion B. use of an elevated-rim liner C. use of 22-mm femoral head D. male gender E. anterolateral surgical approach

91. The risk of dislocation following primary total hip replacement is increased after a posterior approach when no attempt is made to repair the capsule and tendons. Biomechanically, transosseous repair of the hip capsule and short external rotators will: A. increase torque resistance prior to dislocation but decrease rotational stability B. increase stability, whatever the position or orientation of the implant C. have no significant advantage over a softtissue repair that is not transosseous D. increase stability but limit hip flexion to <90

E. increase stability only when there is malposition of one of the components 92. Compared with physician-adjusted dosage of warfarin following total joint arthroplasty, the use of a nomogram to direct dosage adjustment resulted in similar findings regarding: A. mean international normalized ratio achieved B. average number of days to achieve an international normalized ratio of >1.7 C. duration of maintenance of the desired international normalized ratio D. prevalence of deep vein thrombosis or pulmonary embolism E. all of the above 93. In comparison with patients who undergo primary total hip arthroplasty for a displaced intracapsular hip fracture, patients who undergo total hip arthroplasty after failed internal fixation are at greater risk of:

A. requiring another revision in the first year B. dying in the first year C. having a more painful hip D. sustaining a hip dislocation in the first year E. having a deep wound infection in the first year 94. Treatment of periprosthetic femoral fractures with a Mennen plate has a high rate of failure. Which of the following factors might explain the disappointing results? A. gender and weight of the patient B. previous operations to treat the fracture C. use of the Mennen plate for periprosthetic fractures proximal to the tip of the prosthesis D. use of the Mennen plate for periprosthetic fractures distal to the tip of the prosthesis E. unsupervised postoperative activity

95 The osteoseptocutaneous fibular transplant includes skin with the vascularized fibula to serve as soft-tissue supplementation as well as a means with

which to monitor the vascularity of the transplant. The skin paddle is nourished by: A. perforators from the anterior crural septum of the lateral compartment B. perforators from the posterior crural septum of the lateral compartment C. perforators from the anterior compartment D. direct perforators from the posterior tibial artery E. musculocutaneous perforators from the extensor digitorum muscle 96 Theoretical complications of a metallic femoral head-polyethylene articulation with sliding include: A. premature polyethylene wear B. prosthetic loosening C. an increase in hip forces at heel strike D. eventual instability E. all of the above 97. What is the most important effect of preheating a femoral stem used for a total hip arthroplasty with cement?

A. time of cement polymerization is increased B. temperature of cement polymerization is increased C. porosity at the stem-cement interface is decreased D.fatigue strength ofthecement-bone interface is increased E. porosity at the cement-bone interface is decreased 98. Recovery from injury of the femoral nerve associated with a displaced acetabular fracture is most dependent on which of the following factors? A. acetabular fracture type B. timing of surgical nerve exploration C. type of nerve injury (traumatic or iatrogenic) D. time from nerve injury E. timing of electrodiagnostic studie 99. Following primary total hip arthroplasty, the risk of which of the following postoperative complications does NOT increase with age? A. death B. infection

C. pulmonary embolus D. hip dislocation E. readmission to the hospital because of a musculoskeletal complication 100 The mortality rate within ninety days following primary total knee arthroplasty is: A. 0% to 0.5% B. 0.6% to 0.9% C. 1% to 2% D. 2.1% to 2.9% E. 3.0% to 3.9% 101.Which of the following factors is associated with a decreased likelihood of recurrence of infection after total hip arthroplasty in adult patients who had childhood infection of the hip? A. normal erythrocyte sedimentation rate and elevated C-reactive protein level B. positive intraoperative bacterial culture C. more than ten white blood cells per high-power

field on histological section D. quiescent period of more than ten years between the infection and total hip arthroplasty E. diabetes mellitus 102.Which of the following additional procedures is most commonly needed to perform total hip arthroplasty successfully in patients with diastrophic dysplasia? A. shortening osteotomy of the femur B. adduction tenotomy C. flexor tenotomy D. autologous bone-grafting to the roof of the acetabulum E. autologous bone-grafting to the medial wall of the acetabulum 103. Compared with non-cross-linked acetabular liners sterilized with gas plasma, liners subjected to terminal sterilization with gamma radiation in air were found to have a reduction in the average in vivo wear rate at 5.2 years postoperatively of:

A. 0 B. 1/5 C. 1/3 D. 1/2 E. 3/4 104.Which of the following factors is the most important in assessing the risk of secondary reconstructive surgery for the management of residual hip dysplasia after reduction of a dislocated hip? A. previous use of a Pavlik harness B. side of dislocation C. use of prereduction traction D. age of the patient at reduction E. use of adductor tenotomy at reduction 105.Which of the following surgical approaches for performance of periacetabular osteotomy has been shown to increase the risk of prolonged abductor weakness? A. transtrochanteric exposure

B. classic Smith-Petersen exposure C. modified Smith-Petersen exposure D. ilioinguinal exposure E. direct anterior exposure 106.A prospective study that assesses the cost per quality-adjusted life year gained from total hip replacement would be best categorized as what type of economic analysis? A. case-control study B. cost-minimization (identification) analysis C. cost-effectiveness analysis D. cost-utility analysis E. cost-benefit analysis 107.Which of the following postoperative radiographic factors is the most important in determining the result following periacetabular osteotomy for a dysplastic hip? A. center-edge angle B. acetabular roof angle

C. head lateralization index D. joint congruency E. false-profile index 108.Which of the following factors is the most important for providing accurate estimates of polyethylene wear following total hip replacement? A. comparison of supine and standing radiographs B. single-limb-stance radiographs C. good-quality anteroposterior pelvic radiographs D. oblique (Judet) radiographs of the hip E. good-quality anteroposterior and lateral radiographs of the hip 109. Extended trochanteric osteotomy provides wide exposure of the femoral canal during revision total hip arthroplasty. Which of the following factors is associated with an improved rate of healing of the osteotomized bone fragment? A. dissection of the vastus lateralis to visualize anatomic reduction of the osteotomy

B. combined trochanteric and diaphyseal cable fixation C. male gender D. use of an abduction orthosis E. fewer prior revisions 110 Femoral notching has been shown to decrease distal femoral torsional load to failure. Which of the following variables, when examined together, most closely predict the torsional load to failure of notched femora? A. anterior cortical thickness and distal femoral bone mineral density B. posterior polar moment of inertia and Singh index C. posterior polar moment of inertia and distal femoral bone mineral density D. anterior cortical thickness and Singh index E. distal femoral bone mineral density and Singh index 111.What is the main cause of failure of bipolar arthroplasty? A. osteolysis

B. dissociation C. dislocation D. acetabular cartilage deterioration E. femoral subsidence 112. A ten-year follow-up study of the cementless Zweymller Alloclassic system revealed that the most likely cause for cup loosening was: A. vertical cup position and acetabular wear of 1 mm B. deficient acetabular bone stock C. activity level D. small cup diameter E. uncontained threads

B. concomitant arthrotomy C. size of the femoral head D. satisfactory joint congruency after surgical correction E. concomitant proximal femoral osteotomy 114. To produce the strongest (most resistant to shear) bone graft for use in impaction bonegrafting: A. cancellous allograft should be passed once through a large-aperture bone mill B. a large amount of compactive force should be applied to the graft C. whichever mill is used, the graft should be washed free of fat and marrow D. cartilage, cystic material, and cortical bone need not be removed E. graft particles should be homogeneous in size 115. Of the following factors, which one decreases the quality of the survivorship of revision total hip arthroplasty after fracture of a ceramic femoral head?

113. Reorientation of the acetabulum is frequently used to correct acetabular dysplasia. Which of the following factors has been shown to be important for the achievement of a good long-term clinical outcome? A. gender and weight of the patient

A. exchange of the cup B. a posterolateral surgical approach C. use of a new femoral head made of stainless steel D. performance of a synovectomy that is as extensive as possible E. a long delay between the femoral head fracture and the revision procedure

A. texturing the acetabular shell B. texturing the liner vertically C. texturing the liner vertically and circumferentially D. maximizing cement thickness (using a smaller liner) E. minimizing cement thickness (using a larger liner) 118. Osteonecrosis is a significant complication for some patients with slipped capital femoral epiphysis. Which of the following patient factors is most closely related to the development of osteonecrosis? A. patient weight B. patient race C. classification of the slip as acute D. classification of the slip as unstable E. patient gender 119. Placement of an antegrade intramedullary nail through the tip of the greater trochanter in children has been associated with which of the following complications?

116 Long-term follow-up of cementless total hip replacements has demonstrated that major reason for reoperation is related to: A. dislocation B. infection C. fracture D. femoral loosening and osteolysis E. acetabular loosening and osteolysis

the

117. When cementing a smooth polyethylene liner into an acetabular shell, which of the following will most improve the mechanical strength of the construct?

A. coxa vara with femoral neck narrowing B. coxa valga with femoral neck narrowing C. osteonecrosis of the femoral head D. limb-length discrepancy due to physeal arrest E. avulsion of the abductor with persistent limp 120. What features make up the pathognomonic radiographic and magnetic resonance imaging triad of traumatic posterior hip subluxation? A. hemarthrosis B. iliofemoral ligament disruption C. acetabular lip fracture D. all of the above E. none of the above 121 Which radiographic acetabular fracture pattern demonstrated the lowest level of agreement with the intraoperative diagnosis? A. t-shaped

B. both-column C. anterior wall D. transverse plus posterior wall E. posterior column 122.What added value to conventional radiographs is offered by computed tomography in the assessment of acetabular fractures? A. distinguishing between elementary and associated fracture patterns B. identifying loose bodies and femoral head damage C. improving the reliability of Letournels acetabular fracture classification D. dictating the surgical approach to be used for the treatment of acetabular fractures E. eliminating the need for the standard three plain radiographs of the pelvis (anteroposterior and 45 Judet oblique radiographs).

123. The indication for treatment of nonunion of the greater trochanter following total hip arthroplasty should be primarily based on: A. hip mobility B. limp (Trendelenburg sign) C. risk of loosening D. risk of osteolysis E. previous hip surgery 124. Recovery of femoral nerve function in hemophilic patients after iliopsoas hemorrhage will most likely be: A. complete for the sensory and motor components B. complete for the sensory component and incomplete for the motor component C. incomplete for the sensory component and complete for the motor component D. incomplete for the sensory and motor components E. no functional recovery expected 125. Compared with conventional polyethylene, which of the following is a characteristic of

crosslinked polyethylene: A. higher wear rate B. higher melting temperature C. lower elongation to break D. lower fatigue resistance E. darker color 126 Regarding hips with a metal-on-metal bearing, which of the following statements is true? A. the risk of hypersensitivity is reduced B. there is no difference in overall cancer risk C. the fracture risk is increased D. volumetric wear increases with increasing head size E. lower serum chromium levels 127.When assessing radiographs for the presence of periacetabular osteolysis following total hip replacement, orthopaedists need to be aware of the merits and limitations of radiographs. Which of the following statements is correct?

A. radiographs have a high sensitivity and low specificity for the detection of periacetabular osteolysis B. once an osteolytic lesion is detected on a radiograph, the likelihood that it truly exists is high C. the two-dimensionally measured size of an osteolytic lesion represents the true volume of the defect D. radiographs have a low sensitivity and specificity for the detection of periacetabular osteolysis E. assessing multiple views does not improve the detection rate for periacetabular osteolysis 128. Which of the following factors is the most important for achieving stability of a revision proximal ingrowth femoral stem? A. age of the patient B. bone quality C. fill of the isthmus D. gender of the patient

E. titanium-metal substrate 129. Which of the following methods of femoral revision for periprosthetic fracture resulted in the lowest combined rate of subsequent femoral loosening and fracture nonunion? A. a cemented short-stem femoral component B. a cemented long-stem femoral component C. an uncemented proximally porous-coated monoblock component D. an uncemented extensively porous-coated femoral component E. an allograft-prosthesis composite or tumor prosthesis 130. Benefits of the extended trochanteric osteotomy in complex primary total hip arthroplasty include all of the following EXCEPT: A. improved acetabular exposure B. easier hardware removal C. decreased prevalence of dislocation D. correction of femoral deformity

E. ease of femoral canal preparation 131. Among individuals who are at least fifty years old, which of the following fractures has been shown to increase the relative risk of hip fracture significantly more in men than in women? A. spine (vertebral body) fracture B. elbow (olecranon) fracture C. wrist (distal radial [Colles]) fracture D. ankle (distal tibial and fibular) fracture E. calcaneal (os calcis) fracture 132. Serum cobalt concentrations during the first five years after metal-on-metal total hip arthroplasty: A. show a gradual increase over time B. are high initially and then gradually decrease (the so-called run-in wear phenomenon) C. remain in a constant range slightly above the detection limit D. remain at >10 g/L at all measured time-points

E. are five times higher than the concentrations in patients treated with ceramic-onpolyethylene total hip arthroplasty 133. An example of an indirect cause of iatrogenic limb lengthening with total hip arthroplasty is: A. inferior positioning of the acetabular component B. superior positioning of the femoral component C. use of an excessively long femoral neck D. use of an excessively large femoral head E. retroversion of the acetabular component 134. During revision total hip replacement of both the femoral and the acetabular component in a patient with no autologous blood available, use of an intraoperative blood collection and reinfusion device such as the Cell Saver: A. is contraindicated B. is not a useful adjunct for blood conservation C. will decrease net blood loss by about 100 mL D. will decrease net blood loss by about 500 mL

E. will decrease net blood loss by >1500 mL 135. Which of the following is the most important factor in maximizing the accuracy of computerassisted radiographic wear measurements following total hip arthroplasty? A. abduction angle of the acetabular component B. exposure settings of the radiograph C. magnification of the radiograph D. centering of the radiograph relative to the pelvis E. resolution at which the radiograph is scanned 136. Which of the following contributes most to reduction in wear rates of polyethylene acetabular liners? A. smaller femoral head size B. larger femoral head size C. increased cross-linking of polyethylene D. duration o f wear testing E. fluid absorption during wear testing

137. The mechanical strength of the bone-cement interface is increased most by: A. lower pressurization of cement B. greater bone porosity C. decreased cement penetration distance D. trabecular orientation parallel to the implant surface E. trabecular orientation perpendicular to the implant surface 138. An indication to revise a well-fixed modular cementless acetabular component at the time of revision hip surgery is: A. presence of pelvic osteolysis B. intraoperative hip instability at the time of trial reduction C. excessive wear of the bearing surface D. the acetabular component in vivo for more than ten years E. a deficient locking mechanism of the acetabular component

139. Which of the following clinical parameters is NOT associated with the likelihood that a nonanemic patient undergoing total hip arthroplasty will require a perioperative transfusion? A. preoperative hemoglobin level of >110 g/L B. patient older than seventy-five years C. male gender D. hypertension E. body mass index of <27 140. When a previously asymptomatic patient presents with lower-extremity swelling four years following total hip arthroplasty, the differential diagnosis should include all but which of the following: A. deep-vein thrombosis B. infection C. compression of iliac vessels secondary to an intrapelvic cyst D. osteolysis E. occult lymphedema

141. Which of the following factors was found to be the most important in decreasing the rate of loosening and polyethylene wear in patients undergoing total hip arthroplasty for developmental dysplasia? A. lateralization of the hip center B. use of an acetabular allograft C. medialization of the hip center D. use of a cemented cup and stem E. cup inclination angle of >45 142. In a long-term follow-up study that compared the durabilities of cementless and cemented acetabular components, which of the following was more prevalent when a cementless component had been used? A. acetabular component loosening B. acetabular component polyethylene wear C. dislocation D. infection E. femoral component loosening

143. When the ceramic head of a total hip prosthesis is scratched on a metal surface, the scratched area of the head may become black. What is the source of the black discoloration? A. damage to the surface polishing of the ceramic head B. bloody joint fluid coating the ceramic head C. phase transformation of the ceramic D. metallic debris transfer from the metal surface E. fissuring of the ceramic 144. When a diaphyseal fitting stem is used in revision total hip arthroplasty, which of the following factors is most highly associated with the likelihood of an intraoperative femoral fracture? A. surgical approach B. preoperative bone loss C. previously cemented femoral stem D. use of a bowed stem E. female gender 145 The benefits of increased femoral offset include all of the following EXCEPT:

A. improved abductor muscle function B. lower joint reaction forces C. adequate soft-tissue tension without limblengthening D. reduced polyethylene wear E. lower femoral loosening rates 146. The most important variable affecting the initial stability of a cemented femoral stem that is tapered in the coronal plane was found to be: A. thickness of the cement mantle B. presence of a collar C. presence of a distal centralizer D. stem size E. stem surface finish 147. What may be the clinical relevance of metaphyseal radiolucent changes observed in patients with Legg-Calv-Perthes disease? A. no relevance B. the end of the fragmentation stage C. associated with a growth disturbance of the

proximal femoral physis D. associated with a prolonged disease course E. signifies a need for a pelvic or femoral osteotomy 148. When compared with patients of normal stature who undergo total hip arthroplasty, patients of small stature were more likely to sustain which of the following complications? A. postoperative infection B. deep-vein thrombosis C. dislocation D. periprosthetic fracture E. wound hematoma 149. In a recent study, the most frequent longterm complication of acetabular revision with a porous-coated component and multiple screw fixation was: A. polyethylene wear B. infection C. limb-length discrepancy

D. dislocation E. component loosening 150. A meta-analysis of randomized trials evaluating the use of closed suction drains following elective hip and knee arthroplasty indicated that, in comparison with patients in whom no drains were used, patients in whom drains were used had a significant difference with regard to which of the following outcomes? A. increased need for blood transfusion B. reduced occurrence of wound hematoma C. increased reoperation rate for wound-healing complications D. reduced occurrence of wound infection E. reduced prevalence of venous thrombosis 151. A three-year-old boy presents to the emergency room with a twelve-hour history of worsening hip pain and fever and is unwilling to bear weight. The erythrocyte sedimentation rate is 42 mm/hr, and the

white blood-cell count is 13 109/L. The most appropriate next step is to: A. begin antibiotic therapy immediately B. admit the patient for close follow-up C. perform a bone scan immediately D. perform a needle aspiration of the hip E. perform a surgical dbridement of the hip immediately 152. Which of the following is the most crucial in determining the diagnosis of septic arthritis in children and the need for surgical irrigation and dbridement? A. history of fever B. non-weight-bearing on the painful hip C. erythrocyte sedimentation rate of 40 mm/hr D. hip arthrocentesis analysis (white blood-cell count, Gram stain) E. serum white blood-cell count of >12.0 109/L 153. Which statement is correct regarding developmental dysplasia of the hip:

A. selective ultrasonographic screening of infants with risk factors for hip dysplasia detects the majority of infants with persistent dysplasia B. selective ultrasonographic screening of infants with risk factors for hip dysplasia reduces rates of subsequent surgery C. delaying closed reduction of a dislocated hip until development of the ossific nucleus as seen on radiographs likely reduces the risk of postreduction osteonecrosis, but it may increase the necessity of secondary reconstructive procedures D. long-term results of the Salter innominate osteotomy for hip dysplasia generally show excellent functional and radiographic results E. periacetabular osteotomy for hip dysplasia increases the radiographic anterior center-edge angle but does not increase the lateral centeredge angle 154. The components of linear wear penetration, which are commonly used to assess polyethylene wear, include all of the following EXCEPT: A. creep

B. bedding-in of the liner into the modular acetabular shell C. removal of material (true wear) D. loading of the articulation E. method of component fixation 155. In comparison with patients who report high health-related quality-of-life scores prior to total hip or knee arthroplasty, patients with low preoperative scores can expect: A. less improvement B. greater improvement and greater final function C. greater improvement but a lower level of final function D. more difficult rehabilitation E. higher satisfaction 156. During total hip replacement, failure to restore femoral head offset is common. The consequences are: A. higher joint reactive force B. decreased abductor strength

C. greater risk of dislocation D. increased polyethylene wear rate E. all of the above 157. After a mean duration of follow-up of ten years, successful revision with use of a cemented femoral component was found to be associated with all of the following EXCEPT: A. host bone quality B. third-generation cementation techniques C. younger patient age D. grade of the postoperative cement mantle E. gender 158. In a comparison of the use of titanium elastic nails, traction, and immobilization in a spica cast for the treatment of femoral neck fractures in children, the use of titanium elastic nails was found to be associated with: A. a higher rate of complications B. a longer initial hospital stay

C. a significantly more rapid achievement of recovery milestones D. a better outcome at one year E. substantially higher hospital charges 159. In a series of patients with stage-I or II osteonecrosis of the femoral head, those who underwent core decompression and implantation of autologousbone marrow cells were compared with those who underwent core decompression alone. The former treatment group had: A. no difference in pain relief B. no difference in joint symptoms C. better bone stock for subsequent total hip arthroplasty D. less progression to stage-III changes E. no change in the volume of the necrotic lesion 160. Clinically retrieved highly cross-linked polyethylene acetabular liners have demonstrated: A. surface wear patterns similar to those seen in hip simulator studies

B. surface defects not typically hipsimulator studies C. high volumetric wear rates D. fatigue failure mechanisms E. liner-locking mechanism dissociation

observed

in

161. The addition of a hydroxyapatite coating to a proximally porous-coated tapered femoral stem: A. prevents subsidence of the stem B. reduces aseptic loosening C. decreases distal osteolysis D. improves osseointegration of the femoral stem E. has no influence on the outcome of total hip arthroplasty at a mean of ten years postoperatively 162. In a recent study, the clinical wear performance of conventional polyethylene sterilized with gamma irradiation (either in vacuum-barrier packaging or in air) was superior to the performance of nonirradiated gas-plasma-sterilized components. This result supports the hypothesis that:

A. oxidation increases polyethylene wear B. increased cross-linking decreases polyethylene wear C. shelf life affects polyethylene wear D. gas-plasma sterilization increases polyethylene wear E. differences in structure affect polyethylene wear 163. The presence of a dorsal flange on a cemented femoral stem results in: A. decreased stem-cement interlock and decreased bone-cement micromotion B. decreased stem-cement interlock and increased bone-cement micromotion C. increased stem-cement interlock and decreased bone-cement micromotion D. increased stem-cement interlock and increased bone-cement micromotion E. reduced strains of the medial femoral surface and increased stress-shielding

164. Which of the following statements is correct concerning a clinical prediction rule that was developed to differentiate between septic arthritis and transient synovitis of the hip in children? A. clinical prediction rules usually demonstrate identical diagnostic performance in a new patient group compared with the original group from which the rule was derived B. clinical prediction rules are meant as rigid guidelines to replace clinical judgment C. clinical prediction rules can be validated within the original patient group through sampling methods such as boot-strapping but are best validated in a new patient group D. clinical prediction rules should be modified by anecdotal experience E. treatment should be strictly based on the clinical prediction rule without regard to atypical patients or unusual presentations

165. The risk of death during the first thirty days following a hip arthroplasty performed for fracture is higher in: A. patients with intertrochanteric fracture B. patients over seventy years of age C. patients with prior cardiorespiratory illnesses D. arthroplasty performed with cement E. all of the above 166 .When impaction bone-grafting is used in revision total joint arthroplasty, which of the following was found to be most important in optimizing the mechanical performance of morselized bone graft? A. the addition of biological induction agents (e.g., OP-1) B. increasing the porosity of the compacted graft C. avoiding the use of frozen bone graft D. the degree of graft compaction achieved E. the use of commercially available bone mills

167.Increased levels of molecular crosslinking of polyethylene are associated with: A. increased wear rates B. increased fracture toughness C. increased tensile strength D. increased oxidative resistance E. decreased resistance to crack propagation 168.In a comparison of the short-term results of patients who underwent a mini-incision total hip arthroplasty (incision length 10cm) and those who underwent a total hip arthroplasty with a standard incision, the mini-incision technique was found to: A. be less invasive B. result in more frequent discharge to the patients home rather than transfer to a rehabilitation center or skilled nursing facility C. result in a smaller scar D. be associated with a shorter hospital stay E. be associated with the need for less postoperative pain medication

169. Which of the following is the earliest abnormal magnetic resonance imaging finding of osteonecrosis of the femoral head? A. bone-marrow-edema pattern B. abnormal signal-intensity band C. magnetic resonance crescent sign D. joint effusion E. signal change on the acetabular side 170. In patients who underwent hip arthroplasty for metastatic disease of the hip, improved patient survival was most closely associated with which of the following? A. male gender B. a lack of postoperative complications C. a diagnosis of metastatic cancer of the lung D. a metastasis confined to the acetabulum E. a short time-interval between the diagnosis of the primary tumor and impending prosthetic fracture

171. Magnetic resonance imaging after total hip arthroplasty: A. is of limited value because of metal-induced artifact B. can be used to assess intraosseous osteolysis but not soft-tissue extension C. has no advantages over computerized tomography in the evaluation of periprosthetic osteolysis D. can be used to assess soft-tissue extension of osteolysis but not intraosseous destruction E. can be used to assess osteolysis associated with both cobalt-chromium and titanium metal implants, with less artifact about titanium implants 172. Postoperative dislocation is one of the most common complications following a two-stage revision hip arthroplasty for infection. Which of the following factors has been shown to decrease the risk of this complication? A. use of a transtrochanteric approach B. use of a temporary prosthesis in the interim period

C. use of skeletal traction in the interim period D. use of a cemented acetabular socket E. use of a hip brace 173. When performing a surface arthroplasty of the hip, which aspect of surgical technique has been shown to be associated with a successful clinical outcome: A. decreased femoral offset B. valgus positioning of the femoral component C. shortening of the femoral neck D. low femoral neck ratio E. notching of the lateral cortex of the femoral neck 174. Which of the following statements is most correct regarding the results of operative treatment of femoral neck fractures in young patients between the ages of fifteen and fifty years old? A. nonunion is the main reason for a reoperation B. osteonecrosis rates of <5% can be expected if excellent reduction is achieved in a timely fashion

C. the femoral neck fracture is rarely associated with other orthopaedic and visceral injuries D. osteonecrosis is the main reason for conversion to total hip arthroplasty E. the ten-year survivorship of the native femoral head without conversion to total hip arthroplasty is <60% 175. The two most important factors in predicting outcome in patients with Legg-Calv-Perthes disease were found to be: A. the type of treatment and age of the patient B. the type of treatment and gender of the patient C. the age of the patient and the lateral pillar classification D. the lateral pillar classification and the Stulberg classification E. the age and gender of the patient 176. Which cost-containment measure did United States hospitals implement in the 1980s to drive down the cost of primary hip replacement and was it successful?

A. implant cost reduction, and it was not succme cessful in reducing cost B. hospital stay reduction, and it was successful in reducing cost C. implant cost reduction, and it was successful in reducing cost D. hospital stay reduction, and it was not successful in reducing cost E. none of the above 177. Of the following imaging modalities, which was shown to have the best diagnostic accuracy for detection of a loose acetabular component? A. plain radiography B. subtraction arthrography C. nuclear arthrography D. bone scintigraphy E. magnetic resonance imaging 178. There have been several clinical studies on proximally hydroxyapatite-coated femoral stems with follow-up exceeding ten years. These studies indicate that the bone changes:

A. consist of proximal bone densification with loss of bone density at the middle and distal levels around the stem B. demonstrate progressive distal osteolysis after longer periods of follow-up C. consist of bone densification at the middle and distal levels of the bone surrounding the stem D. consist of bone densification at the middle level around the stem with loss of bone proximally and distally E. are complete at two years after implantation 179. Which of the following answers is correct concerning very small asymptomatic stage-I osteonecrotic lesions of the hip? A. they never collapse B. pain always proceeds progression to stage II C. most of the lesions collapse after five years of follow-up D. collapse occurs before symptoms E. small lesions never require surgery for pain

180. In a severely affected patient with cerebral palsy, which of the following interventions is least associated with a decrease in hip pain? A. improving general hip motion B. preventing hip joint flexion contractures C. maintaining a neutral sitting position D. decreasing the amount of time spent sitting in a chair E. decreasing the amount of spasticity 181. When compared with a porous-coated surface, the use of a hydroxyapatite coating on a proximally modular revision hip stem was found to: A. improve the postoperative Harris hip score B. increase the chance for bone ingrowth in Paprosky type-I and II bone defects C. decrease the risk of periprosthetic fracture D. decrease the prevalence of distal osteolysis E. increase the chance for bone ingrowth in Paprosky type-III bone defects

182. A comparison of arthroplasty and internal fixation for the treatment of displaced femoral neck fractures in elderly patients showed which of the following to be true: A. compared with internal fixation, arthroplasty reduces the risk of revision surgery by 77% B. compared with arthroplasty, internal fixation significantly reduces the risk of mortality C. arthroplasty is best performed as a unipolar hemiarthroplasty without cement D. infection rates after arthroplasty are significantly reduced compared with those after internal fixation E. the prevalence of pulmonary embolism is higher after arthroplasty 183. The performance of hydroxyapatite-coated acetabular components has generally not been as satisfactory as that of hydroxyapatitecoated femoral components. Which of the following factors has been shown to improve cup performance? A. use of thick hydroxyapatite coatings

B. use of coatings that rapidly dissolve in the body C. line-to-line reaming of the acetabulum D. restriction of hydroxyapatite fixation to DeLeeCharnley Zones I and II E. a cup surface that provides mechanical interlock 184. Spontaneous resolution of asymptomatic osteonecrosis of the femoral head was found to be associated with: A. younger age of the patient B. a small lesion C. low steroid dosage D. absence of tobacco usage E. female gender 185. All of the following patients might be reasonable candidates for a proximal femoral valgus-producing intertrochanteric osteotomy, EXCEPT: A. an active fifty-year-old woman with a nonunion of a Pauwels type-III femoral neck fracture B. a twenty-eight-year-old man with mild osteoarthritis

of the hip who is more comfortable with the hip in abduction than in adduction on examination C. a fifty-five-year-old man with osteoarthritis and joint-space loss at the superolateral edge of the hip joint D. a forty-five-year-old man with 2 cm of posttraumatic shortening of the ipsilateral lower limb who is otherwise asymptomatic E. a thirty-year-old woman with osteonecrosis affecting the superolateral aspect of the femoral head, with a Kerboul necrotic angle of 120 186 The optimal method for diagnosing osteonecrosis in asymptomatic patients is: A. taking the patients history B. technetium bone-scanning C. radiography D. computerized tomography E. magnetic resonance imaging 187. Expected-value decision analysis of prophylactic

pinning as compared with observation of the contralateral hip after unilateral slipped capital femoral epiphysis led to which of the following conclusions? A. observation is favored in all cases B. prophylactic pinning is favored in all cases C. observation is generally favored; however, prophylactic pinning is favored when the probability of a contralateral slip is >27% D. prophylactic pinning is generally favored; however, observation is favored when the probability of a contralateral slip is >27% E. prophylactic pinning is generally favored; however observation is favored when the utility of uncomplicated prophylactic pinning is >9.8 188. Which of the following statements about advancement and separation of apical hole eliminators from the acetabular shell is least true: A. the diagnosis of advancement is best made with an iliac oblique radiograph

B. separation of the hole eliminator is associated with pelvic osteolysis C. advancement or separation of the hole eliminator does not affect patient function and satisfaction D. separation of the hole eliminator is an indication for revision E. advancement or separation of the hole eliminator can occur with linear wear rates of <0.1 mm per year 189. A seventy-two-year-old woman slips and falls in her kitchen and sustains a hip fracture. The best strategy for maximizing the likelihood that this patient will receive appropriate osteoporosis treatment includes: A. directly involving the patient in her own health care through education and self-advocacy B. mailing guidelines to local primary care physicians C. obtaining a DEXA scan on an in-patient basis D. immediately initiating bisphosphonate therapy E. scheduling an appointment at the fracture clinic within one week postoperatively

190. In the periarticular soft tissues retrieved during revision of failed metal-on-metal total hip prostheses: A. plasma cells were seen in all tissues from metal-on-metal prostheses B. plasma cells were seen only in association with perivascular lymphocytic cuffs C. plasma cells were seen only in association with macrophages laden with metallic debris from metal-on-metal prostheses D. plasma cells were found in tissues from cobalt chromium-on-polyethylene prostheses E. the condition of the tissue surface was closely related to the extent of the plasma cell infiltrate 191.Which of the following restrictions was found to be the most important in preventing early dislocation following total hip arthroplasty? A. abduction pillow B. no side-sleeping C. no driving

D. limitation of hip flexion E. use of elevated chairs/toilet seats

.192.When the twenty-year results of total hip

arthroplasty performed with filling of the superolateral defect of the acetabulum with cement in patients with congenital hip dislocation were compared with the twenty year results of total hip arthroplasty performed for hip arthritis with other causes,it was found that: A. the results were comparable B. the results were better in the former group C. the results depended on the amount of cement coverage D. the results depended on the femoral deformity E. the results were markedly worse in the former group 193. Patients who sustain a fracture of the femoral neck and have a correctable acute medical comorbidity: A. should nevertheless undergo immediate operative intervention

B. should undergo surgery within twenty-four hours to prevent progression of the acute medical condition C. should be maximally optimized before being operated on D. should have surgery within four days after the fracture because mortality rates rise after the fifth day E. should have surgery within four days after optimization of the medical condition 194. On the average, an extended trochanteric osteotomy decreases the torsional strength of a femur by about: A. 10% B. 20% C. 50% D. 70% E. 90% 195. A thirteen-year-old Amish boy presents with a five-month history of groin pain. A diagnosis

of slipped capital femoral epiphysis is made. You inform the parents that, compared with non-Amish white children with slipped capital femoral epiphysis, Amish children with the disorder have: A. a higher prevalence of bilaterality and a higher prevalence of positive family history B. a higher prevalence of bilaterality and a lower prevalence of positive family history C. a lower prevalence of bilaterality and a higher prevalence of positive family history D. a lower prevalence of bilaterality and a lower prevalence of positive family history E. the same prevalence of bilaterality and the same prevalence of positive family history 196. Which of the following factors may decrease the risk of thermal injury during ultrasonic cement removal? A. use of short bursts of energy B. constant motion of the ultrasonic device within the cement mantle

C. frequent irrigation between passes of the ultrasonic probe D. deflation of the tourniquet E. all of the above 197. Following total hip arthroplasty with a metal onmetal articulation, hypersensitivity reactions to wear and repassivation products may develop in some patients. If hypersensitivity is established as the cause of bursa formation, pain, or bone resorption, a surgeon should consider: A. reassuring the patient and waiting for relief ofsymptoms B. suppressing the reactions with drug therapy C. replacing the articulation with a different articulation device that does not liberate nickel, cobalt, or chromium ions D. advising the patient to limit activity in order to reduce the rate of wear E. treating the osteolytic lesions (resecting the granuloma, refreshing the bone surfaces until bleeding occurs, bone-grafting, and using cementing techniques) so that implant stability is not jeopardized

198 .When liquid gentamicin is added to cement, all but one of the following statements are true: A. it maintains bacteriocidal activity B. it is eluted effectively from cement C. it can be used in cement spacers D. it is cost-effective when compared with tobramycin E. it can be used to reimplant prosthetic components 199.The effect of bisphosphonates in patients undergoing total hip and knee arthroplasty is best described as follows: A. bisphosphonates lead to significant decreases in bone mineral density when compared with control values B. bisphosphonates have no effect on bone mineral density in patients undergoing hip and knee arthroplasty C. patients taking bisphosphonates will have sig nificantly greater bone mineral density values at one year after surgery compared with the bone mineral density at the time of surgery D. bisphosphonates lead to significantly less

periprosthetic bone loss (bone mineral density) than that in controls E. bisphosphonates are contraindicated in any patient undergoing joint arthroplasty 200. Bisphosphonates may prevent femoral head deformity following ischemic necrosis in pigs through which mechanism? A. stimulating revascularization and appositional new bone formation B. decreasing pain and mechanical fragmentation of the femoral head C. strengthening necrotic bone through a physiochemical mechanism D. preserving the trabecular framework of the femoral head by inhibiting bone resorption E. stimulating recruitment of osteoblast precursors to the site of repair 201. Of the following hospital cost centers, which one is associated with the highest amount of resource utilization for primary and revision

total hip arthroplasty? A. blood bank B. rehabilitative services C. radiology D. operating room equipment and implants E. operating room time and staff 202. When a young patient with cam-type femoroacetabular impingement is treated with surgical resection of the head-neck junction, how much bone can be safely resected without significantly weakening the femoral neck? A. 5% of the neck diameter B. 10% of the neck diameter C. 30% of the neck diameter D. 50% of the neck diameter E. 75% of the neck diameter 203. In a rabbit model, the greatest reduction in both the prevalence and the severity of heterotopic ossification was observed

when preoperative irradiation of the hip was performed: A. three weeks before the operation B. within forty-eight hours before the operation C. twenty-four hours before the operation D. seventy-two hours before the operation E. at any time before the operation; the specific timing of the irradiation was not important 204. In a comparison of computed tomography and plain radiography for the assessment ofperiacetabular osteolysis following total hip arthroplasty, it wasfound that computed tomography has: A. an average relative error of volume measurements of 63.4% B. a detection rate that is the same as that of plain radiography C. a 100% detection rate D. a better detection rate than plain radiography E. a worse detection rate than multiple plain radiographic Views

205. All of the following statements are true except: A. generation of particulate wear debris is inevitable during the normal use of a prosthetic joint B. periprosthetic pseudomembranes usually contain macrophages, fibroblasts, foreignbody giant cells, and numerous wear debris particles C. debris-associated inflammation and bone resorption contribute to the loosening process of a prosthetic joint D. therapy targeted to periprosthetic pseudomembranes could be a potential approach to halting the loosening process E. gene therapy is readily available to treat patients with signs of aseptic loosening 206. In the treatment of a pertrochanteric typeA1.1 or A2.1 fracture in an osteoporotic patient, which of the following procedures was shown to provide good fixation with minimal blood loss and no need for blood transfusion?

A. intramedullary rod B. dynamic hip screw C. external fixation with titanium-coated pins D. external fixation with hydroxyapatite-coated pins E. blade-plate 207. Hip arthroscopy can be performed with the patient in either the supine or the lateral decubitus position. An advantage of the lateral position is that: A. fluoroscopy is seldom needed B. the femoral head requires no distraction C. most aspects of the joint can be visualized through the anterior and superior paratrochanteric portals D. no special distraction equipment is needed E. muscle relaxation is not required 208. In a study of patients with articular cartilage degeneration associated with post collapse osteonecrosis in the femoral head, which of the following statements was found to be most correct?

A. the mechanical properties of articular cartilage are degraded in advanced radiographic stages of the disease B. cartilage in the late stages of osteonecrosis may maintain mechanical properties even after collapse of the articular surface C. the gross appearance of the articular surface is a poor indicator of the mechanical properties of the cartilage D. the success of head-sparing procedures in patients with osteonecrosis is unrelated to the radiographic stage of the disease E. cartilage in the late stages of osteonecrosis rarely shows signs of degeneration 209. In patients with metal-on-metal bearing hip prostheses: A. serum cobalt and chromium ion levels are unaffected by patient activity B. the majority of cobalt and chromium is excretedin sweat C. the majority of cobalt and chromium is excreted in stool D. serum cobalt and chromium levels tend torise over time

E. serum cobalt and chromium levels are independent of renal function 210. Following the diagnosis of deep periprosthetic infection in a patient who was treated for an orthopaedic oncological condition, which treatment yields the best functional outcome and probability of eradicating the infection? A. one-stage revision B. antibiotics alone C. Girdlestone excision arthroplasty D. two-stage revision E. surgical dbridement and insertion of gentamicin beads 211. A diagnosis of pigmented villonodular synovitis of the hip can be made with magnetic resonance imaging. Which of the following findings is least consistent with this diagnosis? A. intra-articular effusion B. low signal intensity on both T1 and T2-weighted images C. synovial hyperplasia D. bone erosions E. a diminished width of the joint space

212. Acetabular chondral injuries are graded according to severity, and they influence surgical outcome. These lesions most often: A. occur in the posterior aspect of the acetabulum as a result of posterior dislocation B. are symptomatic C. occur only in patients with moderated dysplasia D. occur in the anterior aspect of the joint in association with a labral tear E. are easily detected by magnetic resonance imaging 213 Which of the following five locations in a modular acetabular liner that has been gammasterilized in air is the most susceptible to in vivo oxidation? A. worn bearing surface B. worn backside surface C. unworn backside surface D. rim E. locking mechanism 214. The goal of a valgus, extension proximal femoral osteotomy in the Ilizarov hip reconstruction

for treatment of the sequelae of infantile hip infection is to: A. lengthen the leg B. improve hip biomechanics C. increase the range of motion of the hip D. decrease hip pain E. achieve a hip arthrodesis 215 Which of the following factors has been suggestedto explain the substantially greater revision burden for hip arthroplasty in the United States compared with that in Sweden? A. difference in hip implant designs B. difference in implant survivorship in the elderly population C. increased rate of implantation in younger patients in the United States D. difference in gender breakdown in the installed base (patient population) E. increasing obesity rate in the United States

216. When a group of patients who underwent revision total hip arthroplasty because of infection was compared with patients who underwent revision total hip arthroplasty because of aseptic loosening, the only significant difference between the groups was: A. body mass index B. APR-DRG SOI (severity-of-illness score) C. estimated blood loss D. acetabular and femoral bone loss E. operative time 217. A fourteen-year-old boy presents with a sixmonth history of left hip pain and limp. The findings of the radiographic evaluation are consistent with a diagnosis of monostotic fibrous dysplasia involving the femoral neckwith evidence of a fatigue fracture. Which of the following bone-graft options would be the most appropriate for improving the mechanical strength of the femoral neck? A. demineralized bone matrix B. cortical allograft

C. cancellous allograft D. cortical autograft E. cancellous autograft 218. Metal-on-metal articulation has been used as a bearing surface in total hip arthroplasty. Which of the following statements is correct? A. a metal-on-metal articulation generates no wear particles B. implant fixation is more durable with a metalonmetal articulation than with a metal-onpolyethylene coupling C. serum ion levels increase with increased patient activity D. histological evidence of hypersensitivity reaction has been observed in tissues retrieved from hips with a metal-on-metal articulation E. there is an increase in neoplasia in patients with a metal-on-metal articulation 219. Which of the following is the most important factor in predicting the future extent of pelvic

osteolysis adjacent to a cementless acetabular cup? A. type of communication pathway between the lesion and the joint space B. usage of screws C. number of screw holes D. location of the lesion E. presence of cortical erosion 220. A seventy-four-year-old woman who independently sustained a displaced femoral neck fracture after a simple fall at the golf course. She has mild hypertension but is otherwise healthy. If you perform internal fixation rather than a total hip replacement, which of the following outcome measures would be most likely? A. a better possibility of independent living B. better hip function C. a reduced risk of hip complications D. an increased risk of revision surgery E. a better quality of life lives

221. When patients who underwent hip hemiarthroplasty because of a neoplasm of the proximal part of the femur were compared with patients who underwent the same procedure for any other diagnosis, the dislocation rate at ten years postoperatively was found to be: A. ten times higher in the neoplasm group B. five times higher in the neoplasm group C. two times higher in the non-neoplasm group D. five times higher in the non-neoplasm group E. equal between the two groups 222. A sixty-three-year-old man who underwent a second-generation metal-on-metal total hip replacement eighteen months ago complains of pain in the right hip. Radiographs show a large femoral osteolytic lesion with a risk of fracture through the greater trochanter. The retrieved periprosthetic tissues from a revision operation show a perivascular accumulation of T-lymphocytes and macrophages and an absence of both particle-laden macrophages

and polymorphonuclear cells. Which of the following is the most plausible mechanism responsible for the periprosthetic bone loss? A. periprosthetic infection B. metal-particle-induced osteolysis C. osteolysis secondary to joint fluid pressure D. stress-shielding in the proximal part of the femur E. hypersensitivity reaction to metal 223 It has been claimed that zirconia ceramics have better mechanical strength and wear performance than alumina ceramics. Which of the following factors may limit the clinical usefulness of zirconia ceramics? A. surface roughness B. phase transformation C. poor fracture toughness D. poor lubrication E. poor thermoconductivity

224 After penetration into Durasul highly crosslinked polyethylene had reached a steady rate, the annual penetration rate was foundto be what percentage of the penetration rate of conventional ultra-high molecular weight polyethylene? A. 10% B. 25% to 40% C. 55% D. 80% E. 100% 225 A seventy-year-old patient who is generally healthy is scheduled to have a total hip replacement next week. The patient and his family want to know what to expect in terms of short-term and longer-term mortality. You should tell them that, compared with patients of the same age who do not have hip replacement, patients who have hip replacement have: A. essentially the same survival at one month, one year, and five years after surgery

B. better survival at one month, one year, and five years after surgery C. worse survival at one month, one year, and five years after surgery D. worse survival at one month but better survival at one year and five years after surgery E. better survival at one month but worse survival at one year and five years after surgery 226. In a prospective study that compared the results of vascularized fibular grafting with those of nonvascularized fibular grafting for the treatment of osteonecrotic lesions of the femoral head, the authors found that vascularized fibular grafting provided: A. better results for patients with steroid-associated osteonecrosis, regardless of stage B. better results for younger patients C. better results for patients with a Stage-IIC lesion D. better results for patients with a Stage-IIIC or Stage-IVC lesion E. no difference compared with nonvascularized fibular grafting

227. Which of the following factors is the most closely correlated with rapid collapse of an osteonecrotic femoral head? A. age and activity of the patient B. hyperlipidemia C. alcohol abuse D. large necrotic area (>30% of the femoral head) E. a history of steroid medication 228. Which of the following factors was found to be the most important determinant of restoration of a negative Trendelenburg test following pelvic support osteotomy for congenital dislocation of the hip? A. younger age at the time of the operation B. advancing the insertion of the gluteus maximus C. male gender D. valgus angulation of the proximal part of the femur E. distal transfer of the greater trochanter 229. The femoral heads of patients with stage-I or II

osteonecrosis were treated either with shock waves or with core decompression and bonegrafting. At an average of twenty-five months after the procedure, the shock-wave group: A. required fewer conversions to total hip arthroplasty B. had worse pain scores C. had worse Harris hip scores D. had more complications E. had greater progression of the lesions 230. A retrospective study of patients who sustained motor nerve palsy following total hip arthroplasty demonstrated a higher prevalence of this complication in all of the following except: A. patients with a diagnosis of developmental dysplasia B. hips with cemented fixation C. patients seen after 1989 D. patients with posttraumatic arthritis E. patients treated with a posterior surgical Approach

231. When cementless calcar-replacement hemiarthroplasty was compared with intramedullary fixation for the treatment of unstable intertrochanteric fractures in elderly patients, hemiarthroplasty: A. resulted in better function at two years postoperatively B. was less expensive C. required a shorter operating time D. was associated with more blood loss E. was associated with a lower mortality rate 232. During preoperative templating for a revision total hip arthroplasty, the surgeon notes extensive bone loss in the femoral neck and calcar region, as far distally as the entire lesser trochanter. The optimal management of this form of bone loss is: A. placement of the collar of a standard femoral component at the lower level of host bone and use of a long skirted femoral head to reestablish the hip center B. use of a proximal femoral allograft to reconstruct

the defect C. use of cement to fill the defect D. use of cancellous bone graft to fill the defect E. use of a 30-mm calcar replacement in order to restore the hip center and avoid the use of a long skirted ball 233. A higher cumulative rate of first-time dislocations following primary total hip arthroplasty was associated with: A. a 32-mm-diameter prosthetic femoral head B. an anterolateral approach C. a transtrochanteric approach D. a 22-mm-diameter prosthetic femoral head E. a 28-mm-diameter prosthetic femoral head 234.During revision surgery for a total hip arthroplasty, the accepted standard for the presence of an infection on frozen tissue histological analysis is: (A) Five mononuclear cells per high-powered field

(B) Ten mononuclear cells per high-powered field (C) Five polymorphonuclear cells per high-powered field (D) Ten polymorphonuclear cells per high-powered field (E) One bacterium per high-powered field Explanation: Frozen section analysis is important in revision surgery to determine why a component has become loose. Ten polymorphonuclear cells (PMNs) per highpowered field lowers the sensitivity for infection but does not reduce the specificity to diagnose an infection. Five PMNs per highpowered field is the current standard that is accepted as diagnostic for an infection. Mononuclear cells can be present in the face of aseptic loosening or polywear disease. PMNs are diagnostic of a biologic infectious response.