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Journal of Bone and Joint Surgery (British Volume)

CME questions January 2007

These papers have been set on the review articles and aspects of current management papers from the 2006 October, November and December issues of the JBJS-Br.

  1. Which of the following sites is least frequently affected by osteoporotic fractures in women?
    1. Distal radius
    2. Humerus
    3. Pelvis
    4. Proximal femur
    5. Ribs
  2. 2. How is osteoporosis defined in the clinical setting?
    1. Bone mass > 1 SD below the mean for an age matched individual
    2. Bone mass > 2.5 SDS. below the mean for an age matched individual
    3. Bone mass > 1 SD below the mean for a young adult
    4. Bone mass > 2.5 SDS below the mean for a young adult
    5. Bone mass > 1 SD below the mean for an age matched individual in association with fragility fracture
  3. 3. Which of the following is not characteristic of osteoporotic bone:
    1. increased cortical porosity
    2. increased cross sectional area of callus during healing
    3. medullary expansion
    4. some prolongation of the fracture healing process
    5. thinner cross linking trabecular connections
  4. In the loaded taper model of femoral stem design, which of the following statements does not reflect the design philosophy:
    1. Centralisers are used to facilitate subsidence of the stem into a stable position that protects the cement mantle in Gruen zone 4 from fracture
    2. Peak stresses are particularly reduced in Gruen zones 2 and 6 of the cement mantle
    3. Radial compressive forces are created in the cement and transmitted to the bone as hoop stress
    4. The stem lodges as a wedge in the cement mantle during axial loading
    5. The stem is tapered in 2 or more planes
  5. Which of the following is a consequence of selecting a highly polished stem rather than a roughened stem?
    1. Compression stresses at the stem/cement interface are reduced
    2. Higher shear stresses occur at the cement/bone interface
    3. Little effect is noted on proximal cement stresses but there is a significant increase distally
    4. No effect is noted on the capacity of the stem/cement interface to transmit compressive stress
    5. Stem subsidence in the first year will be less
  6. What is the main factor that makes movement between the stem and cement mantle inevitable?
    1. Differences in elasticity comparing the stem material, cement and bone
    2. Discrepancy between the loads applied in axial and radial directions
    3. Insinuation of polyethylene debris into the interface as time passes
    4. Release of cytokines into joint space fluid by activated macrophages
    5. Variations in loading during various stages of the gait cycle
  7. Which of the following is an effect of adding a dorsal flange to a femoral stem design?
    1. Increased incidence of distal cement mantle fractures
    2. Increased subsidence of the stem
    3. More cement-bone micromovement
    4. Reduced incidence of cement-bone lucencies in vivo
    5. Reduced mechanical stability of the stem
  8. Which of the following is not an effect of the collar, at least theoretically, when added to the design of a cemented femoral stem?
    1. Controls insertion and ensures the implant is seated at the same level as the broach
    2. Prevents early resorbtion of the femoral neck
    3. Promotes transfer of load from the implant to the medial cement mantle and bone of the femoral neck
    4. Reduces overall migration
    5. Unloads the proximal cement mantle
  9. In which of the following situations is a collar a reasonable addition to the design of an implant ?
    1. Composite beam stem identical in size to the final broach
    2. Composite beam stem undersized when compared to final broach
    3. Loaded taper stem identical in size to final broach
    4. Loaded taper stem undersized when compared to final broach
    5. Stem with an oval cross section
  10. Which of the following statements concerning cement mantles around the femoral stem is correct?
    1. Cement mantles less than 1mm thick where the implant contacts cortical bone promote earlier osteolysis.
    2. Strength of fixation is greatest if a layer of cancellous bone can be left between the implant and cortex
    3. The best interdigitation is achieved by using an undersized stem compared to the final broach
    4. The cement mantle should be as thick as possible
    5. With line-to-line cementation, defects in the mantle are most likely to occur in the proximal 1/3 of the stem.
  11. Which of the following is more common in obese than in non-obese patients undergoing hip replacement?
    1. Bleeding problems in peri-operative period
    2. Dislocation
    3. Early penetrative wear
    4. Low patient satisfaction scores
    5. Poor outcome scores
  12. Which of the following structures can be disrupted but will not defunction the superior shoulder suspensory complex, even in combination with a second injury of the complex?
    1. Acromial process
    2. Clavicle
    3. Coracoacromial ligament
    4. Coracoclavicular ligaments
    5. Coracoid process
  13. Which of the following is the most significant risk factor for nonunion of fractures of the middle third of the clavicle?
    1. Comminution of the fracture site
    2. Inadequate immobilisation
    3. Obesity
    4. Shortening of > 2 cm
    5. Smoking status
  14. In which position of the hip is impingement pain most apparent on clinical examination?
    1. Extension
    2. Flexion, abduction and external rotation
    3. Flexion, abduction and internal rotation
    4. Flexion, adduction and external rotation
    5. Flexion, adduction and internal rotation
  15. Which of the following statements concerning labral tears in the hip is incorrect?
    1. They can be associated with Perthés disease and developmental dysplasia
    2. They cause catching, clicking and locking
    3. They most often involve detachment of the labrum from the bony rim of the acetabulum
    4. They are most common in relation to the posterior rim
    5. The usual cause is a twisting or pivoting mechanism
  16. What results does the current literature on the management of labral tears reveal?
    1. After tear resection 50% of those with no arthritic change on X ray had a good result but none of those with arthritic changes present had a good result
    2. After tear resection 80% of those with no arthritic change on X ray had a good result but none of those with arthritic changes present had a good result
    3. After tear resection 80% of those with no arthritic change on X ray had a good result compared with 50% of those with arthritic changes present
    4. After tear resection 100% of those with no arthritic change on X ray had a good result but only 50% of those with arthritic changes present
    5. After tear resection 100% of those with no arthritic change on X ray had a good result compared to 80% of those with arthritic changes present
  17. What is the most common complication of labral repair, as described in the largest published series to date?
    1. Capsule-labral adhesions
    2. Chondral injury
    3. Compartment syndrome of the buttock
    4. Femoral nerve injury
    5. Instrument breakage in joint
  18. Approximately what proportion of patients undergoing arthroscopic removal of loose bodies from the hip develop recurrent symptoms sufficiently severe to warrant a further arthroscopy?
    1. One in a hundred
    2. One in fifty
    3. One in ten
    4. One in five
    5. One in three
  19. In which of the following pathological conditions of the hip is there the weakest consensus of opinion favouring arthroscopic management?
    1. Labral tears
    2. Loose bodies
    3. Osteonecrosis
    4. Ruptures ligamentum Teres
    5. Septic arthritis
  20. In which position of the hip does cam type impingement occur?
    1. Abduction and external rotation
    2. Abduction and internal rotation
    3. Deep flexion alone
    4. Deep flexion and internal rotation
    5. Forced extension
  21. Which of the following is not an absolute contra-indication to hip arthroscopy?
    1. Acute inflammation in the vicinity of portals
    2. Acute osteomyelitis of the femur or acetabulum
    3. Heterotopic ossification
    4. Morbid obesity
    5. l Skin ulceration in the vicinity of portals
  22. Which of the following complications is least frequent after hip arthroscopy?
    1. Chondral damage
    2. Fluid extravasation
    3. Infection
    4. Labral damage
    5. Transient sciatic nerve palsy
  23. Which of the following is not part of the minimum dataset to be collected by a joint replacement register, as recommended by the International Society of Arthroplasty registries?
    1. Gender of patient
    2. Lot number of prosthesis
    3. Side operated upon
    4. Surgeon identifier
    5. Whether or not cement is used
  24. If 4000 patients are admitted to a randomised controlled trial comparing two knee replacements, what is the chance that a 30% difference in revision rate at 10 years (true difference 6.6% vs 5%) will be missed even if all patients are followed up for the full 10 year period?
    1. 5%
    2. 10%
    3. 20%
    4. 40%
    5. 75%
  25. Which of the following is not a benefit of a national arthroplasty register?
    1. Deterrance from introduction of poorly tested implants onto market
    2. Epidemiology can be studied, as well as outcome
    3. Promotes evolution of surgical technique
    4. Quality yardsticks are produced, enabling hospitals to compare their own results
    5. Warning of underperforming implants

Here are the answers to the January 2007 CME test paper.
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Hip, Knee, Trauma, Upper limb, Foot & Ankle, Paediatrics, Oncology, Spine, Arthroplasty, General