501. (3903) Q1-7783:

What is the reported incidence in the literature for a satisfactory outcome following open rotator cuff repair:

1) Less than 60%

3) Between 70% and 80%

2) Between 60% and 70%

5) Greater than 90%

4) Between 80% and 90%

Neer and researchers reviewed the results of 245 shoulders that underwent rotator cuff repair. In this patient series, an acromioplasty was also performed in 243/245 of the shoulders. In this large series, the authors reported an excellent or satisfactory result in 92% of the shoulders.

Correct Answer: Greater than 90%

502. (3904) Q1-7784:

What tool has been recently shown to improve the accuracy of shoulder injections and has become increasingly popular in clinical application:

1) Ultrasound

3) Computed tomography scans

2) Bi-plane fluoroscopy

5) Fluoroscopy

4) MagnetiCresonance imaging

A new treatment modality that has made a large impact on the treatment of patients with shoulder pain is ultrasound-guided injections. Ultrasound guidance allows the health care provider to more accurately place the injection. This has important therapeutiCas well as diagnostiCimplications.

Correct Answer: Ultrasound

503. (3905) Q1-7785:

What is the reported re-tear rate of massive rotator cuff tears at the near 10-year mark:

1) Less than 20%

3) Between 30% and 40%

2) Between 20% and 30%

5) Greater than 50%

4) Between 40% and 50%

Recently, Zumstein and researchers reviewed the outcome of twenty-seven consecutive open repairs of massive rotator cuff tears. At a mean follow-up of 3.1 years, the re-tear rate was 37%. At a mean follow-up of 9.9 years, among 23 patients who returned for evaluation, the re-tear rate had increased to 57%. Patients with an intact rotator cuff repair had a substantially better outcome according to Constant scores as well as abduction strength. The authors noted that the preoperative integrity of the tendon appeared to be protective against future muscle deterioration and risk of developing a re-tear. Additionally, the authors noted that a wide lateral extension of the acromion was identified as a previously unknown risk factor for re-tearing.

Correct Answer: Greater than 50%

504. (3906) Q1-7786:

What pathologiCfinding is consistently observed with anterior instability following shoulder arthroplasty:

1) Anterior glenoid bone loss

3) Disruption of the infraspinatus/teres minor

2) Atrophy of the anterior deltoid

5) Disruption of the long head of the biceps

4) Disruption of the subscapularis

Tearing of the subscapularis is a common finding associated with anterior instability following shoulder arthroplasty. Correct Answer: Disruption of the subscapularis

505. (3907) Q1-7787:

What soft tissue augmentation is used in the reconstruction of the subscapularis when associated with anterior instability following shoulder arthroplasty:

1) Tendo Achilles allograft

3) Middle-third patellar tendon autograft

2) Hamstring tendons

5) Fascia lata

4) Triceps autograft

Moeckel and colleagues reported the use of tendo Achilles allograft for the treatment of anterior instability following shoulder arthroplasty in combination with attempted subscapularis repair.

Correct Answer: Tendo Achilles allograft

506. (3908) Q1-7788:

Which of the following factors is associated with posterior instability following shoulder arthroplasty:

1) Retroverted humeral component

3) Retroverted glenoid component

2) Posterior capsular laxity

5) All of the above

4) Disruption of the posterior capsule

All of the above factors may contribute to posterior instability following shoulder arthroplasty. Correct Answer: All of the above

507. (3909) Q1-7789:

Which of the following strategies are used to treat posterior instability following shoulder arthroplasty:

1) Increasing the anteversion of the humeral component

3) Creating a neutral orientation for the glenoid

2) Using posterior capsular plication

5) All of the above

4) Delaying postoperative rehabilitation program

All of the above are potential treatment strategies for treating posterior instability following shoulder arthroplasty. Correct Answer: All of the above

508. (3910) Q1-7790:

What is the rate of recurrent instability following revision surgery for an unstable shoulder prosthesis:

1) Less than 5%

3) Between 10% and 20%

2) Between 5% and 10%

5) Greater than 30%

4) Between 20% and 30%

In the study by Sanchez and colleagues, more than 50% of the shoulders in the study remained unstable despite attempts at revision.

Correct Answer: Greater than 30%

509. (3933) Q1-8118:

Labral and soft tissue pathology are best visualized using:

1) Standard pelvis magnetiCresonance image (MRI)

3) 3D computed tomography (CT) scan

2) Plain film radiograph

5) MR arthrogram

4) Hip arthrogram

Although standard pelvis MRI has a role in visualizing soft tissues and bone, MR arthrogram best images the intra-articular structures of the hip. Hip arthrogram alone, CT, and plain film do not provide adequate soft tissue resolution.

Correct Answer: MR arthrogram

510. (3934) Q1-8119:

Advantages of plain film radiograph in diagnosis and treatment of femoral acetabular impingement do NOT include:

1) Visualization of cam impingement lesion

3) Observation of joint space narrowing

2) Detection of labral injury

5) Assessment for pincer impingement

4) Detection of developmental dysplasia of the hip (DDH)

Plain film radiographs can successfully detect cam and pincer impingement and cartilage space narrowing, as well as allow quantified measurement of femoral head coverage. A magnetiCresonance arthrogram is necessary, however, to successfully visualize labral pathology.

Correct Answer: Detection of labral injury

511. (3935) Q1-8121:

Upon review of a plain film series for developmental dysplasia of the hip (DDH), contraindication to periacetabular osteotomy is suggested by:

1) Cup medialization

3) Center edge angle of 5°

2) Excessive acetabular index

5) No cartilage space maintained on abduction view

4) Anterior coverage of less than 5° on false profile

None of the options necessarily preclude periacetabular osteotomy as a treatment option for DDH provided that the patient wishes to proceed; however, little or no cartilage space, or poor concentriCreduction of hip joint would suggest poor outcome with this procedure.

Correct Answer: No cartilage space maintained on abduction view

512. (3936) Q1-8122:

The most valuable imaging study for assessment of radiographiCleg length in patients preparing to undergo total hip arthroplasty is:

1) Anteroposterior (AP) of the hip

3) MagnetiCresonance image of the pelvis

2) 3D computed tomography

5) Lauenstein lateral hip

4) AP of the pelvis

Of all the study techniques listed, only the AP of the pelvis allows radiographiCcomparison of hips. This imaging may prove helpful in assessment of leg-length disparity due to lower extremity inequity or pelviCobliquity.

Correct Answer: AP of the pelvis

513. (3937) Q1-8125:

In the presence of osteolysis around the acetabular component, the most thorough means of visualizing bone loss is via:

1) PelviCJudet views

3) Standard magnetiCresonance imaging (MRI) of the pelvis

2) Cross-table lateral radiograph

5) Computed tomography (CT) of the hip

4) Bone scan

Computed tomography scan remains the most thorough means of assessing bone loss in the pelvis. MRI is relatively ineffective due to artifact scatter; cross-table lateral radiographs and bone scan are of little use; and pelviCJudet views, although helpful, are not as thorough as CT.

Correct Answer: Computed tomography (CT) of the hip

514. (3976) Q1-8228:

Advances in cement technique include all of the following EXCEPT:

1) Retrograde canal filling

3) Canal plugging

2) Pressurization

5) Pressurized mixing

4) Canal lavage

Retrograde canal filling, canal pressurization and plugging, and lavage are all developments in cement technique. The mixing process has been enhanced by mixing under vacuum conditions, however, rather than pressure.

Correct Answer: Pressurized mixing

515. (3977) Q1-8229:

In the Gruen classification of cement mantle, zone 4 is located:

1) Superior lateral

3) Mid lateral

2) Superior medial

5) Tip of the stem

4) Distal medial

In the classification described by Gruen, zone 4 is located at the tip of the stem; zone 1 is proximal lateral, and zone 7 proximal medial.

Correct Answer: Tip of the stem

516. (3978) Q1-8230:

Cemented stem failure is most likely to result from:

1) Varus stem

3) Stem contact with endosteal cortex

2) Thin medial cement mantle

5) Valgus stem placement

4) Excessive mantle laterally

All of the above variables do not elevate the risk of stem failure with the exception of stem-cortical contact. This avoidable circumstance is thought to result in an excessively thin mantle and risk for cement fracture and subsequent loosening.

Correct Answer: Stem contact with endosteal cortex

517. (3979) Q1-8231:

Initial enthusiasm of cemented femoral stems in total hip arthroplasty was tempered by:

1) Stem fracture

3) Recurrent dislocation

2) Poor survivorship in patients younger than 50 years of age

5) Fracture

4) Infection

Early outcomes were characterized by poor survivorship in the young population, a situation that corrected with subsequent polyethylene improvements and cement techniques.

Correct Answer: Poor survivorship in patients younger than 50 years of age

518. (3980) Q1-8232:

Variables that affect the rate at which cement polymerizes include the following EXCEPT:

1) Room temperature

3) Rate of mixing

2) Humidity

5) Inclusive agents, such as antibiotics

4) Material makeup of the mixing bowl

Temperature, humidity, mixing rate, and added agents affect the rate of polymerization. The materials with which the polymer and powder contact are not known to affect this rate.

Correct Answer: Material makeup of the mixing bowl

519. (3997) Q1-8249:

Which is the preferred imaging modality to determine the fracture pattern in a patient with a proximal humerus nonunion:

1) Plain radiographs

3) MagnetiCresonance image

2) Fluoroscopically-positioned  plain radiographs

5) Computed tomography (CT) scan

4) Tomograms

A CT scan provides important information in regard to the fracture pattern, the amount of bone remaining in the humeral head, as well as information about the possibility of performing an ORIF with bone graft compared to proceeding with an arthroplasty procedure.

Correct Answer: Computed tomography (CT) scan

520. (3998) Q1-8250:

Which is the most common complication among patients who undergo shoulder arthroplasty for proximal humerus nonunion:

1) Infection

3) Humeral component loosening

2) Instability

5) Greater tuberosity nonunion

4) Glenoid component loosening

The most common reason for an unsatisfactory outcome after shoulder arthroplasty for a proximal humerus nonunion is a greater tuberosity nonunion.

Correct Answer: Greater tuberosity nonunion

521. (3999) Q1-8251:

Which organism is most frequently found in patients with an infected humeral nonunion:

1) Escherichia coli

3) Propionibacterium acnes

2) Streptococcus

5) None of the above

4) Brucella

One of the most common organisms found in an infected proximal humerus nonunion is Propionibacterium acnes. Staphylococcus aureus is another organism that is frequently found in patients with an infected humeral nonunion.

Correct Answer: Propionibacterium acnes

522. (4000) Q1-8252:

Who would be a good candidate for shoulder arthroplasty for a proximal humerus nonunion:

1) An elderly patient

3) A patient with poor quality bone in the humeral head

2) A patient with a high fracture pattern

5) All of the above

4) A patient with glenohumeral arthritis

The ideal candidate for shoulder arthroplasty for a proximal humerus nonunion is an elderly patient with a small humeral head fragment of poor bone quality with associated glenohumeral arthritis.

Correct Answer: All of the above

523. (4001) Q1-8253:

Who would be an ideal candidate for internal fixation and bone grafting in the setting of a proximal humerus nonunion:

1) A patient with a low fracture pattern

3) A young patient

2) A patient with minimal to no glenohumeral arthritis

5) All of the above

4) A patient with an intact rotator cuff

The ideal patient for an attempt at open reduction internal fixation is a young patient with a low fracture pattern, an intact rotator cuff, and minimal to no glenohumeral arthritis.

Correct Answer: All of the above

524. (1) Q2-28:

Which of the following bone tumors commonly occurs in patients with closed physes between 20 and 50 years of age:

1) Osteoid osteoma

3) Solitary bone cyst

2) Chondromyxoid fibroma

5) Non-ossifying fibroma

4) Giant cell tumor

Certain bone tumors have a predilection to occur in certain age groups. Non-ossifying fibroma, chondromyxoid fibroma, solitary bone cyst, and osteoid osteoma tend to occur in young patients with open physes. In contrast, giant cell tumor of bone rarely occurs in patients with open physes. When giant cell tumor occurs in children with open physes, it tends to involve only the metaphysis.

The common tumors in children with open physes are:

Benign

Osteoid osteoma Osteochondroma Chondroblastoma Solitary bone cyst

Malignant Osteosarcoma Ewingâs tumor Leukemia

In adults with closed physes, the common tumors are

Benign

Giant cell tumor

Pagetâs disease

Correct Answer: Giant cell tumor

Malignant

MetastatiCbone disease Multiple myeloma Lymphoma

Primary mesenchymal tumors: Â Â Chondrosarcoma

  Malignant fibrous histiocytoma Osteosarcoma occurring in Pagetâs disease   Postirradiation sarcoma

525. (2) Q2-29:

Which of the following bone tumors arises exclusively in the epiphysis:

1) Osteoid osteoma

3) Giant cell tumor

2) Chondromyxoid fibroma

5) Non-ossifying fibroma

4) Chondroblastoma

Bone tumors tend to occur in certain locations within a bone. Knowing the specifiClocation in the bone where a tumor arises is a good clue in determining the nature of a lesion. Chondroblastomas uniquely arise in the epiphysis or the apophysis of long bones. Common locations that one should remember include:

Epiphysis

Chondroblastoma

Clear cell chondrosarcoma

Metaphysis

Osteoid osteoma Osteoblastoma Osteosarcoma Giant cell tumor

Non-ossifying fibroma Chondromyxoid fibroma Ewingâs tumor Chondrosarcoma

Diaphysis

Ewingâs tumor

Adamantinoma

Osteosarcoma (7% of cases occurring in long bones)

Correct Answer: Chondroblastoma

526. (4036) Q2-30:

Which of the following bone tumors commonly arises from the surface of the posterior cortex of the distal femur:

1) Ewingâs tumor

3) Parosteal osteosarcoma

2) Periosteal osteosarcoma

5) Periosteal chondroma

4) Giant cell tumor

Parosteal osteosarcomas usually have a distinctive radiographiCappearance:

Heavily mineralized nodular lesion on the surface of the bone

Broad attachment to the cortex

Lucent areas at the periphery of the lesion

Large lesions encircling the bone

The most common location of parosteal osteosarcomas is the posterior cortex of the distal femur. When this lesion occurs in young patients, it is virtually diagnostiCof parosteal osteosarcoma.

Correct Answer: Parosteal osteosarcoma

527. (3) Q2-31:

Which of the following patterns of bone destruction suggests a benign process:

1) Permeative

3) GeographiCwith a sclerotiCrim

2) Moth-eaten

5) Large lytiCfocus with ill-defined margin

4) Cortical erosion with cortical thickening

Active lesions in the intramedullary cavity of a bone tend to destroy the trabecular bone and will eventually remove the cortex and extend into the soft tissues. In contrast, non-aggressive lesions will generally remain in the intramedullary cavity and the host

bone will contain the lesion by developing a rim of bone around the lesion. Lodwick described three patterns of bone destruction:

Geographic: The clinician can easily see where the lesion starts and ends due to a well-circumscribed area of bone destruction. There may be a rim of reactive bone that surrounds the lesion.

Moth-eaten: Multiple holes in the bone with some of the holes appearing to coalesce into a larger hole. This pattern of destruction is similar to how a group of moths destroy a piece of cloth.

Permeative: This pattern consists of multiple, small lytiClesions in the bone that are poorly marginated.

Moth-eaten and permeative patterns suggest a malignant lesion. Correct Answer: GeographiCwith a sclerotiCrim

528. (11) Q2-39:

The most common location of adamantinoma of bone is the:

1) Radius

3) Femur

2) Ulna

5) Fibula

4) Tibia

Adamantinomas almost exclusively occur in the tibia alone or in the tibia and fibula. Occasionally, this rare tumor occurs in the femur, radius, or ulna (very rare).

Radiographically, this lesion is based in the diaphysis; there is usually one dominant lesion with surrounding sclerosis and other smaller lesions, again with areas of sclerosis.

Correct Answer: Tibia

529. (12) Q2-40:

The most common location of osteofibrous dysplasia is the:

1) Femur

3) Fibula

2) Tibia

5) Ulna

4) Radius

Osteofibrous dysplasia occurs exclusively in the tibia. This non-neoplastiCcondition may be related to adamantinoma. The lesion is usually located in the anterior cortex and there is often bowing of the tibia.

Correct Answer: Tibia

530. (13) Q2-41:

The most common soft tissue sarcoma of the foot and ankle is:

1) Primitive neuroectodermal tumor

3) Liposarcoma

2) Malignant fibrous histiocytoma

5) Synovial sarcoma

4) Epithelioid sarcoma

Malignant melanoma is the most common soft tissue malignancy of the foot; however, synovial sarcoma is the most common soft tissue sarcoma. There may be a long duration of presence of the mass, with or without growth of the lesion. When one evaluates a patient with a small or large soft tissue mass on the foot, synovial sarcoma should be considered in the differential diagnosis.

Correct Answer: Synovial sarcoma

531. (14) Q2-42:

The most common soft tissue sarcoma of the upper extremity is:

1) Primitive neuroectodermal tumor

3) Liposarcoma

2) Malignant fibrous histiocytoma

5) Synovial sarcoma

4) Epithelioid sarcoma

Epithelioid sarcoma is the most common soft tissue sarcoma of the upper extremity. This soft tissue sarcoma may have a deceptive presentation. The tumor occurs in young patients and often presents itself as a small, superficial mass or a deep tumor. When located in a superficial location, the lesion will also ulcerate. Even with biopsy, this lesion is confused with other processes such as rheumatoid nodules, granulomas, granuloma annulare, and others.

Correct Answer: Epithelioid sarcoma

532. (15) Q2-44:

Which of the following describes the signal sequences on T1 and T2 weighted imaging of a soft tissue sarcoma:

1) Moderate(T1) / Low(T2)

3) High(T1) / High(T2)

2) Low(T1) / Low(T2)

5) High(T1) / Moderate(T2)

4) Low(T1) / High(T2)

Soft tissue sarcomas have a characteristiCMRI appearance: Low signal on T1 weighted images and high signal on T2 weighted images.

It is important to remember the characteristiCsignal sequences of both normal tissues and abnormal ones:

â Signal drop out (very low signal on gradient echo sequences) Correct Answer: Low(T1) / High(T2)

533. (16) Q2-46:

Which of the following describes the signal sequences on T1 and T2 weighted images of a ganglion cyst:

1) Moderate(T1) / Low(T2)

3) High(T1) / High(T2)

2) Low(T1) / Low(T2)

5) High(T1) / Moderate(T2)

4) Low(T1) / High(T2)

Ganglion cysts are composed of fluid under pressure, with a thin lining of cells. This fluid gives a uniformly low signal (very homogeneous) on T1 weighted images and a bright (hyperintense) signal on T2 weighted images. If the patient is given a contrast agent, such as gadolinium, the cyst fluid will not enhance, but the wall often will.

It is important to remember the appearances of common tissues on both T1 and T2 weighted images:

â Signal drop out (very low signal on gradient echo sequences) Correct Answer: Low(T1) / High(T2)

534. (22) Q2-58:

Pigmented villonodular synovitis occurs most commonly in which of the following joints:

1) Hip

3) Shoulder

2) Knee

5) Ankle

4) Elbow

Pigmented villonodular synovitis occurs mainly in the large joints of the lower extremity. The knee is the most common location, followed by the hip and shoulder. This lesion may also occur in the ankle and other smaller joints.

Correct Answer: Knee

535. (25) Q2-61:

To which of the following organs do soft tissue sarcomas most commonly metastasize:

1) Brain

3) Adrenals

2) Lungs

5) Kidneys

4) Other bones

Soft tissue sarcomas most commonly metastasize to the lungs. Plain chest radiographs may not reveal small lesions. Computerized tomography of the chest is the most sensitive method to detect small nodules that are 3 mm to 15 mm in diameter. Other sites of metastases include other bones and visceral organs, such as the liver, spleen, and kidneys.

Correct Answer: Lungs

536. (26) Q2-62:

A 15-year-old boy has a destructive lesion in the distal femur with soft tissue extension. Needle biopsy shows a high-grade osteosarcoma. CT scan of the chest is normal and the technetium bone scan shows involvement of only the distal femur. What is the surgical stage according to the system of the Musculoskeletal Tumor Society:

1) Stage 1

3) Stage IIA

2) Stage 2

5) Stage III

4) Stage IIB

 

From the data provided in the question, this lesion has the following features:

High-grade: Stage II

Extra-compartmental: Add suffix B

No evidence of metastases: Patient is not Stage III

The Surgical Staging System of the Musculoskeletal Tumor Society is a useful system to both predict prognosis and plan treatment. The system for malignant lesions has three different stages:

                      Stage                                                        Description

 

Stage IA                             Low-grade intracompartmental lesions (the tumor remains

confined to the medullary cavity)

Stage IB                             Low-grade extra compartmental (the tumor has penetrated

the cortex and entered the soft tissues)

Stage IIA                            High-grade intracompartmental (the tumor remains confined

to the medullary cavity)

Stage IIB                            High-grade extra compartmental (the tumor has penetrated

the cortex and entered the soft tissues)

Stage III The presence of metastases in addition to the primary lesion, such as pulmonary metastases or other bone lesions

In order to use this system, one must know the grade of the tumor:

537. (27) Q2-63:

A 16-year-old boy has a destructive lesion in the proximal humerus. There is soft tissue extension and the CT scan of the chest shows three 1-cm nodules in the left thorax and four 1-cm nodules in the right thorax. Needle biopsy shows high-grade intramedullary osteosarcoma. The surgical stage according to the system of the Musculoskeletal Tumor Society is:

1) Stage 1

3) Stage 3

2) Stage 2

5) Stage III

4) Stage II

 

From the data provided in the question, this lesion has the following features:

High-grade lesion: Stage II

Extra compartmental extension: Add suffix B

Positive nodules on the CT scan denoting pulmonary metastases: Upgrade to Stage III with the systemic metastases

The Surgical Staging System of the Musculoskeletal Tumor Society is a useful system to both predict prognosis and plan treatment. The system for malignant lesions has three different stages:

                      Stage                                                        Description

 

Stage IA                             Low-grade intracompartmental lesions (the tumor remains

confined to the medullary cavity)

Stage IB                             Low-grade extra compartmental (the tumor has penetrated

the cortex and entered the soft tissues)

Stage IIA                            High-grade intracompartmental (the tumor remains confined

to the medullary cavity)

Stage IIB                            High-grade extra compartmental (the tumor has penetrated

the cortex and entered the soft tissues)

Stage III The presence of metastases in addition to the primary lesion, such as pulmonary or other bone lesions

538. (28) Q2-64:

A 15-year-old boy has a non-ossifying fibroma of the distal femur discovered incidentally following a soccer injury. He currently has no pain. The width of the lesion is 1/3 of the width of the medullary cavity. What is the surgical stage according to the system of the Musculoskeletal Tumor Society:

1) Stage 1

3) Stage 3

2) Stage 2

5) Stage II

4) Stage I

 

From the data provided in the question, this lesion has the following feature:

The lesion is asymptomatic with no evidence of active growth

The Surgical Staging System of the Musculoskeletal Tumor Society is a useful system to both predict prognosis and plan treatment. The system for benign lesions is divided into three groups - inactive (latent), active, and aggressive:

539. (29) Q2-65:

A 12-year-old boy has a solitary osteochondroma arising from the medial cortex of the distal femur. The lesion is not painful, nor is it causing any disability. What surgical stage would be assigned according to the system of the Musculoskeletal Tumor Society:

1) Stage 1

3) Stage 3

2) Stage 2

5) Stage II

4) Stage I

From the data provided in the question, this lesion has the following feature:

This lesion is not causing any pain or disability. There is no risk of fracture or other major problem. Accordingly, the lesion is not active and would be a Stage 1 lesion.

The Surgical Staging System of the Musculoskeletal Tumor Society is a useful system to both predict prognosis and plan treatment. The system for benign lesions is divided into three groups - inactive (latent), active, and aggressive:

540. (30) Q2-66:

A 25-year-old man has a destructive lesion in the medial femoral condyle that extends to the articular surface. Open biopsy shows a giant cell tumor. There is no evidence of pathologic fracture or major soft tissue extension. What surgical stage would be assigned according to the system of the Musculoskeletal Tumor Society:

1) Stage 1

3) Stage 3

2) Stage 2

5) Stage II

4) Stage I

The data in the question's stem provides the following information:

The lesion is a giant cell tumor. These lesions behave very aggressively and grow to a large size. They can cause pathologic fracture and are prone to local recurrence. This would be a Stage 2 lesion because there is no soft tissue extension, fracture of the joint, etc.

The Surgical Staging System of the Musculoskeletal Tumor Society