Journal of Bone and Joint Surgery (British Volume)

CME questions April 2009

Refresh your memory with the April 2009 CME questions and then click on the link at the bottom of the page to find out the answers.

1. 1. On a radiograph in diabetics with vasculopathy at the level of the ankle joint, in what layer of the artery is the circumferential calcification found?
1. a. Endothelium
2. b. Basement membrane
3. c. Plaques lining the interior of the vessel
4. d. Tunica media
5. e. Tunica adventitia
2. 2. Which of the following methods of measurement gives the best prediction of adequacy of blood supply in the diabetic foot?
1. a. Ankle/Brachial pressure index
2. b. Presence of dorsalis pedis pulse
3. c. Toe pressures
4. d. Transcutaneous oxygen tension
5. e. Semmes Weinstein monofilament
3. 3. Concerning imaging of the diabetic foot prior to surgical treatment, which of the following contributes most to management decisions?
1. a. Plain radiographs
2. b. Technetium bone scan
3. c. Indium scan
4. d. Combined Indium and Technetium scanning
5. e. MRI scan
4. 4. According to Brodsky’s modification of the Wagner classification of diabetic foot ulcers, how would you grade the following lesion? A deep ulcer that extends to the 5th metatarsophalangeal joint and with no palpable foot pulses, though there is no gangrene.
1. a. 1C
2. b. 2B
3. c. 2C
4. d. 3B
5. e. 3C
5. 5. Which of the following is the most appropriate treatment for a deep diabetic ulcer, exposing tendon, that is ischaemic but without evidence of gangrene?
1. a. Total contact footwear and absorbent dressings
2. b. Total contact cast and absorbent dressings
3. c. Surgical debridement followed by total contact casting when soft tissues settled
4. d. Surgical debridement including drilling of bone or excision of bone followed by total contact casting
5. e. Ray amputation and primary closure of wound
6. 6. If a grade 1 diabetic foot ulcer fails to heal with total contact cast treatment which has been continued for adequate time, what is the most common underlying reason for failure?
1. a. Failure to avoid weight bearing
2. b. Infection
3. c. Poor cast technique
4. d. Underlying bony prominence
5. e. Vascular insufficiency
7. 7. Which of the following would be the most appropriate management plan for a diabetic without peripheral vascular disease who sustains an unstable ankle fracture?
1. a. Plaster cast treatment only, with three months of cast immobilisation
2. b. Transcutaneous pinning, with transarticular pins if necessary, followed by six weeks in plaster cast
3. c. Plate and screw fixation with routine immobilisation after operation as there is no increased risk in this group
4. d. Plate and screw fixation with three months of cast or splint immobilisation afterwards
5. e. External fixation to allow skin care, changing to cast after six weeks, for a further six week period
8. 8. What is the source of the blood supply to the Ligamentum Teres of the hip?
1. a. Anterior circumflex femoral artery
2. b. Anterior division of the obturator artery
3. c. Inferior gluteal artery
4. d. Posterior circumflex femoral vessel
5. e. Posterior division of the obturator artery
9. 9. In which position of the hip is the Ligamentum Teres under greatest tension?
1. a. Abduction, flexion and external rotation
2. b. Abduction of the extended hip
3. c. Adduction, flexion and external rotation
4. d. Adduction, flexion and internal rotation
5. e. Extension and internal rotation
10. 10. At which stage in development is the hip least stable?
1. a. Before the Ligamentum Teres appears at eight weeks
2. b. Prior to vascularisation of the Ligamentum Teres at 22 weeks
3. c. In the third trimester of pregnancy
4. d. At birth
5. e. From 12 to 36 months of age
11. 11. What does animal research indicate may be a unique feature of the insertion of the Ligamentum Teres of the hip?
1. a. It has type V collagen at one end only
2. b. It is composed primarily of type I collagen
3. c. It lacks fibrocartilage
4. d. It lacks Sharpey’s fibres
5. e. There is no tidemark
12. 12. Which of the following describes McCarthy’s test for intra-articular pathology of the hip?
1. a. Flexed hip is brought passively down into the extended position, alternately in internal and external rotation
2. b. Fully flexed hip is adducted then axially loaded
3. c. Hip is flexed, abducted then turned passively into full external rotation
4. d. Internally rotated, extended hip is gradually flexed
5. e. Patient prone, the hip is fully extended with the knee flexed and then turned alternately into internal and external rotation
13. 13. Which of the following best predicts that surgical resection will cure the symptoms of a problematic neuroma following total knee replacement?
1. a.Palpable tender nodule
2. b. Positive response to local anaesthetic block
3. c. Presence of pain with no distal anaesthesia
4. d. Slow onset of symptoms over a 3 month period
5. e. Strong paraesthesia on percussion
14. 14. What term relates to the perception of pain on the application of a stimulus that is normally non-noxious?
1. a. Allodynia
2. b. Dolorophobia
3. c. Dysaesthesia
4. d. Hyperaesthesia
5. e. Hypoaesthesia
15. 15. Which of the following is statistically most likely to complicate total knee replacement?
1. a. Patellar clunk syndrome
2. b. Patellar tendon rupture
3. c. Periprosthetic patellar fracture
4. d. Quadriceps tendon rupture
5. e. Recurrent haemarthrosis
16. 16. A knee is stiff and painful six months after knee replacement. A cruciate retaining implant has been used and there is no evidence of infection. Which of the following manoeuvres, carried out arthroscopically, can be particularly helpful in relieving pain?
1. a. Lateral release
2. b. Medial ligament release from the tibia
3. c. Popliteus tendon release
4. d. Release of the posterior cruciate ligament
5. e. Thermal shrinkage of the capsule
17. 17. According to the UK National Joint Registry, what proportion of patients are not satisfied with the outcome of total knee replacement one year after surgery, usually because of unexplained and continuing pain?
1. a. Less than 1%
2. b. 2% to 5%
3. c. 5% to 10%
4. d. 15% to 20%
5. e. 25% to 30%
18. 18. Which of the following factors is least indicative of the need for limited femoral resurfacing arthroplasty in a young person with an osteonecrotic lesion of the femoral head?
1. a. 35% involvement of femoral head
2. b. Change in femoral head contour of 2.5mm
3. c. Combined necrotic angle of 1500
4. d. Ficat stage III disease
5. e. Normal acetabular cartilage
19. 19. What is the optimal position for a free, vascularised fibular graft when used in the treatment of osteonecrosis of the femoral head?
1. a. Directed along the posterior neck and into the femoral head in that alignment, ending 5 mm from the subchondral plate
2. b. Directed from the anterior neck to the posterior head, ending 1 cm from the subchondral plate
3. c. From lateral cortex to inferior part of the neck and head, ending 1 cm from subchondral plate
4. d. In the centre of the femoral head and neck, ending 2 cm from the subchondral plate
5. e. Into the centre of the lesion and ending 5 mm from the subchondral plate
20. 20. In what circumstances is the insertion of a free, vascularised fibular graft most likely to arrest the progress of avascular necrosis of the hip?
1. a. Progress is almost always arrested after this procedure
2. b. When inserted before collapse of 2 mm to 3 mm has occurred
3. c. When inserted prior to the development of a subchondral fracture
4. d. When it is carried out in a non-smoker
5. e. When the nutrient vessel is > 2 mm diameter
21. 21. When osteonecrosis occurs secondary to the following conditions, which carries the worst prognosis?
1. a. Alcoholism
2. b. Infection
3. c. Perthes disease
4. d. Pregnancy
5. e. Slipped upper femoral epiphysis
22. 22. If free vascularised grafting is carried out in patients with osteonecrosis of the hip who also have the following medical problems, which is least likely to succeed?
1. a. Healed Perthes disease
2. b. Pregnant patients
3. c. Previous slipped upper femoral epiphysis
4. d. Renal transplant recipients
5. e. Those with thyrotoxicosis
23. 23. Which of the following is the least likely complication of harvesting the fibula?
1. a. Difficulty walking on uneven surfaces
2. b. Dysaesthesia
3. c. Feeling of ankle instability
4. d. Flexion contracture of the flexor hallucis longus
5. e. Restriction of ankle flexion
24. 24. Which of the following materials has been discredited experimentally as a material for augmenting fixation in osteoporotic bone?
1. a. Allograft bone
2. b. Bis – GMA
3. c. Calcium Phosphate degradable cement
4. d. Coral
5. e. Polymethyl methacrylate
25. 25. Which of the following best summarises the two year results of experimental study of the use of Calcium Phosphate bone cement when used to augment the fixation of implants in osteoporotic bone of the fractured hip?
1. a. Although initial stability is improved, there is subsequent migration and the end results are only marginally better
2. b. Augmentation has no effect on the results at two years
3. c. There is a higher risk of non-union and avascular necrosis
4. d. There is less loss of position and significantly better results are seen
5. e. There is less migration of implants or loss of position until three months, but by six months augmented fixations are significantly worse

Find the answers to the April CME here.
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