Inflammatory and Metabolic Arthropathy — Orthopedic Management MCQs

Orthopedics · 41 free questions with answers & explanations.

1. A 55-year-old woman with long-standing rheumatoid arthritis (RA) presents with bilateral knee pain, valgus deformity, and destroyed joint surfaces on X-ray. She failed DMARDs and biologics. Which surgical intervention has the most durable outcomes for end-stage RA knee disease?
2. A 50-year-old man with a 10-year history of gout presents with a large, firm, painless tophi over the olecranon and first MTP joint with destruction of the joint surface on X-ray. His serum uric acid is 11 mg/dL. Which statement about orthopedic management is CORRECT?
3. In ankylosing spondylitis (AS) with a severe fixed thoracolumbar kyphotic deformity causing the patient to be unable to look ahead while walking (chin-on-chest deformity), the definitive surgical treatment is:
4. A 45-year-old woman with primary hyperparathyroidism undergoes a DEXA scan. T-score at lumbar spine is −3.2 and at femoral neck −2.8. She sustains a low-energy distal radius fracture. What is the orthopedic implication regarding fracture healing in the setting of primary hyperparathyroidism?
5. A 52-year-old woman with long-standing seropositive RA presents with severe valgus knee deformity (25°) and severe tricompartmental destruction on radiograph. She has failed medical management. She has marked quadriceps weakness (Grade 3/5) and significant osteoporosis (T-score −3.2). Which additional surgical planning consideration is MOST important for her TKR?
6. A 60-year-old man with tophaceous gout has a tophus eroding into the first MTP joint with avascular necrosis of the metatarsal head and chronic pain unresponsive to urate-lowering therapy. Serum uric acid is 12 mg/dL despite allopurinol. The orthopedic surgical option most appropriate for definitive pain relief is:
7. A 48-year-old woman with psoriatic arthritis develops rapidly destructive arthritis of the knee with radiological appearance of near-complete articular cartilage loss, subchondral collapse, and large osteophytes in a pattern sometimes described as 'pencil-in-cup' deformity. She requires TKR. What is the MOST important intraoperative challenge anticipated compared to a standard osteoarthritis TKR?
8. A 55-year-old woman with long-standing rheumatoid arthritis presents with severe wrist pain, dorsal wrist synovitis, and extensor tendon rupture affecting ring and little fingers sequentially (Vaughan-Jackson syndrome). The primary pathological process causing the tendon ruptures is:
9. Charcot (neuropathic) arthropathy at the tarsometatarsal (Lisfranc) joint level in a patient with longstanding diabetes mellitus is best classified using:
10. A patient with ankylosing spondylitis (AS) develops a fracture through a rigid ankylosed cervical spine after a trivial fall. Which description best characterises the biomechanical risk of this fracture pattern?
11. A 65-year-old man with severe bilateral knee osteoarthritis and a valgus deformity of 18° undergoes total knee replacement. Intraoperatively, the lateral structures are found to be tight even after soft tissue release. The most appropriate technique to balance the knee and correct the residual valgus is:
12. A 55-year-old woman with longstanding rheumatoid arthritis undergoes total wrist arthrodesis. The preferred position of arthrodesis for maximum functional benefit (balance of power grasp and ADL performance) is:
13. A patient with psoriatic arthritis develops a 'sausage digit' (dactylitis) of the index finger. In addition to DMARDs/biologics, the deformity of the DIP joint that is characteristic of psoriatic arthritis (and NOT seen in RA) and that may require surgical intervention is:
14. A 60-year-old man with tophaceous gout has a chronic gouty tophus over the first MTP joint causing skin breakdown and secondary infection. His serum urate is 9.2 mg/dL despite allopurinol 300 mg/day. The orthopedic intervention most appropriate for the infected tophus with impending skin loss is:
15. In ankylosing spondylitis with severe hip flexion deformity (30° fixed flexion deformity) and ankylosis of the hip joint, total hip arthroplasty is the definitive treatment. The specific technical challenge unique to AS patients undergoing THR compared to osteoarthritis patients is:
16. A patient with longstanding rheumatoid arthritis develops atlantoaxial instability with an atlantodental interval (ADI) of 8 mm on flexion radiograph. The threshold ADI at which posterior atlantoaxial fusion is indicated to prevent cord compression is:
17. A patient with tophaceous gout has a large tophus eroding into the first MTP joint with joint space destruction and chronic pain unresponsive to medical therapy. The preferred surgical intervention is:
18. Calcium pyrophosphate deposition disease (pseudogout) most commonly affects which joint, and the characteristic radiological finding is:
19. A 58-year-old man with long-standing rheumatoid arthritis presents with C1–C2 instability (atlantoaxial subluxation) confirmed on MRI showing >3.5 mm anterior atlanto-dens interval and spinal cord compression. He has neck pain with myelopathic signs. The definitive surgical treatment is:
20. A 70-year-old woman with end-stage knee OA (Kellgren-Lawrence Grade 4) has a fixed varus deformity of 18° on clinical examination with medial joint line obliteration. On weight-bearing knee X-ray, the mechanical axis passes through the medial compartment. The most appropriate surgical option is:
21. A 40-year-old man with ankylosing spondylitis develops severe fixed thoracolumbar kyphosis with chin-on-chest deformity. Sagittal correction surgery is planned. The osteotomy that provides maximum correction per level (30–40°) and is indicated for severe deformity requiring correction >30° at a single level is:
22. A 45-year-old woman with gout presents to the orthopedic clinic with a chronic tophaceous deposit eroding through the skin overlying the first MTP joint with secondary infection. Her serum uric acid is 11.2 mg/dL. What is the orthopedic indication for surgical debridement/tophus excision in gout?
23. A 55-year-old with end-stage rheumatoid arthritis of the knee undergoes total knee arthroplasty. Intraoperatively, the flexion and extension gaps are found to be unequal, with the flexion gap larger than the extension gap. What is the best intraoperative solution?
24. Tophaceous gout deposits in the first MTP joint cause destruction leading to hallux rigidus. The definitive indicator for surgical intervention (first MTP fusion) in chronic tophaceous gout versus conservative management is:
25. A 55-year-old man with long-standing rheumatoid arthritis has swan neck deformity of his right ring finger. The swan neck deformity is characterised by:
26. A 63-year-old man with gout presents acutely with a hot, swollen first MTP joint (podagra). Serum urate is 10.2 mg/dL. Joint aspiration shows negatively birefringent needle-shaped crystals. Long-term urate-lowering therapy (ULT) should be commenced:
27. Calcium pyrophosphate crystal deposition disease (pseudogout) most commonly affects which joint?
28. A 48-year-old woman with seronegative spondyloarthropathy (psoriatic arthritis) involving her hands shows a 'pencil-in-cup' deformity on X-ray. This deformity indicates:
29. A 50-year-old man with ankylosing spondylitis presents with acute severe back pain after a minor fall. Radiograph shows diffuse ossification of the spine ('bamboo spine'). The fracture most feared in this setting occurs at:
30. A 42-year-old woman with 15-year history of rheumatoid arthritis has C1-C2 subluxation of 10 mm on lateral cervical spine flexion view. She has myelopathic signs. The surgical procedure of choice is:
31. In pseudogout (calcium pyrophosphate deposition disease), which radiological finding distinguishes it from osteoarthritis?
32. A 68-year-old patient with end-stage rheumatoid arthritis of the knee requires total knee replacement. Intraoperatively, a flexion contracture of 25° is noted. The most appropriate intraoperative technique to achieve full extension is:
33. Biologic DMARD therapy with TNF-alpha inhibitors (e.g., etanercept) in rheumatoid arthritis patients undergoing elective total joint replacement should be:
34. A patient with long-standing rheumatoid arthritis (RA) develops severe atlantoaxial instability on dynamic radiographs with anterior atlantodental interval (ADI) of 9 mm and posterior atlantodental interval (PADI) of 12 mm. The surgical threshold for posterior cervical fusion in RA-related AAI is determined by PADI less than:
35. In the surgical management of hallux valgus with a hallux valgus angle (HVA) of 38° and intermetatarsal angle (IMA) of 18°, the appropriate osteotomy for correction is:
36. Gouty arthropathy affecting the first metatarsophalangeal joint causes characteristic X-ray changes. The EARLIEST radiographic finding in tophaceous gout is:
37. A patient with ankylosing spondylitis develops severe hip flexion contracture of 40° bilaterally. Total hip replacement in ankylosing spondylitis has a unique concern about the position of acetabular component. The risk is:
38. A 60-year-old woman with severe end-stage rheumatoid arthritis of the knee (Larsen Grade V) continues to have pain and instability despite maximum medical therapy including biologic DMARDs. The most appropriate surgical option is:
39. A patient with psoriatic arthritis has developed a 'pencil-in-cup' deformity of the distal interphalangeal joint on radiograph. Which histopathological process is responsible?
40. Charcot's neuroarthropathy of the foot in a diabetic patient is best described radiographically in the active (acute inflammatory) phase by which finding?
41. A patient with ankylosing spondylitis (AS) suffers a minor fall and complains of severe neck pain. A CT scan shows a fracture through the C6–C7 disc space traversing both cortices of the ankylosed spine. The mechanism and management concern is: