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MONDAY, 2 SEPTEMBER, 2002

ALL questions must be answered - Question 3 (50%) & Questions 4 & 5 (25% each)

Question I (One Hour)
A 64-year-old semi-retired accountant presents 6 weeks following a cemented total hip arthroplasty with an acute posterior dislocation of the joint. The dislocation occurred while he was trying to do up his shoelace.
Clinical examination reveals a shortened and internally rotated lower limb with disturbed sensation in the leg and foot and MRC Grade IV weakness of ankle dorsiflexion.
He is otherwise in good health apart from mild, treated essential hypertension and mild symptoms of benign prostatic hypertrophy.

1. List the possible factors that may have contributed to his dislocation. (10 marks)
2. Create a set of instructions to give to your hip arthroplasty patients outlining the precautions for preventing post-operative hip instability. (20marks)
   
3. Outline your plan for management of the acute dislocation. (20marks)
   
4. Discuss your possible management options if dislocation becomes a recurrent problem. (50marks)

Question 2 (30 Minutes)
Blood transfusions are frequently part of the perioperative management of orthopaedic patients.
Outline:

1. The early and late complications of blood transfusions. (15 marks)
   
2. Methods that can be used to avoid homologous blood transfusions; include the advantages and disadvantages of each. (20 marks)
   
3. The relative risks of homologous transfusion. (10 marks)
   
4. Your haemoglobin threshold for prescribing a post operative blood transfusion after total hip arthroplasty, and why. (5 marks)

Question 3 (30 Minutes)
A thirty year old renal transplant recipient suffered a closed short oblique fracture of the right tibia at the junction of the middle and distal thirds in a motor vehicle accident eighteen months ago.
Closed intramedullary nailing with locking screws was undertaken within twenty four hours, and the patient discharged within one week, partial weight bearing. He failed to attend for follow up.
He complains of pain at the fracture site. Examination produces pain when the fracture site is stressed, and x-ray reveals an established non-union

1. List and briefly discuss the possible inhibitors of osteogenesis in this man. (15 marks)
   
2. Discuss the principles of management of this patient. (30 marks)
   Despite appropriate treatment, his fracture remains un-united at 30 months.
   
3. What recent advances in fracture management might be considered in this situation? (5 marks)

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