ARTHROPLASTY AND ARTHRODESIS & PHYSIOTHERAPY MANAGEMENT

1. CCHHOOIITTHHRRAAMM IINNSSTTIITTUUTTEE
OOFF HHEEAALLTTHH SSCCIIEENNCCEESS
ARTHROPLASTY AND ARTHRODESIS
&
PHYSIOTHERAPY MANAGEMENT
PRESENTED TO- presented by-
DR.KIRAN SIR Priyanka Das
BPT

2. CCOONNTTEENNTTSS--
1. ARTHROPLASTY
 INTRODUCTION
 INDICATION
 CONTRAINDICATION
 TYPES OF ARTHROPLASTY
 PROSTHESIS
 BONE CEMENT IN ARTHROPLASTY
 OPERATED APPROACHES
 COMPLICATION
 PHYSIOTHERAPY MANAGEMENT
 PREVENTION

3. IINNTTRROODDUUCCTTIIOONN
Arthroplasty is a
operative
treatment of
orthropaedic
disorder .
Arthroplasty is the
operation for
reconstruction of a
new movable joint .

4. IINNDDIICCAATTIIOONN
Severe osteoarthritis of the hip and knee
joint.
Advance rheumatoid arthritis with disabling
pain.
Quiescent destructive tuberculous arthritis.
Un united femoral neck fracture.
Correction of certain type of deformity,
especially hallux valgus.
Avascular necrosis.

6. CCoonntt..--
Hip displasia.
Bone tumors.
Instability of hip joint.
Joint stiffness.
Acetabular dispasia.
Frozen shoulder and loose shoulder.
Failure of conservative management or
joint reconstruction procedure.

7. CCOONNTTRRAAIINNDDIICCAATTIIOONN
ABSOLUTE contra indication
1.Active joint infection.
2. Systemic infection or sepsis.
3.Chronic osteomyelitis.
4.Neuropathic of hip joint.
5. Severe paralysis of the muscles
surrounding the joint.

8. RREELLAATTIIVVEE ccoonnttrraaiinnddiiccaattiioonn

1.Localized infection such as bladder or
skin.
2. Insufficient function of the gluteus medius
muscles.
3.Progressive neurological disorder.
4. Insufficient femoral or acetabular bone
stock associated with progressive bone
disease.

9. TTYYPPEESS OOFF AARRTTHHRROOPPLLAASSTTYY
It may two types-
1.Replament arthroplasty- it is
reconstruction of the joint by replacing the
joint partially or totally.
It can be-
HEMI REPLACEMENT-in this type, only one
of the articulating surfaces is remove and is
replaced by a prosthesis of a similar type.
TOTAL JOINT REPLACEMENT-in this type,
both of the opposed articulating surfaces are
removed. and replaced by prosthetic
compounds.

11. 1. EXCISION ARTHROPLASTY-in this type,
one or both of the articular ends are
excised so that a gap is created between
them.
 This gap fills with fibrous tissue.

12. PPRROOSSTTHHEESSIISS IINN AARRTTHHRROOPPLLAASSTTYY
Joint replacement is a procedure where by
one or both the component forming a joint
are replaced with artificial component is
called as prosthesis.
Prosthesis are made up of special metal alloy
and special high density polyethylene.
Two types prosthesis are use-
1.Austin moore prosthesis.
2.Thomson prosthesis.
These are commonly use in hip joint.

13. BBOONNEE CCEEMMEENNTT
Bone cement is a methyl-methacrylate
compound.
Cement can be used with or without in
hip joint.
It can be two types-
1.CEMENTED HIP-in the cemented hip the
acetabular as well as femoral component
are fixed with the help of bone cement.

15. Cemented hip arthroplasty use in elderly
patient with expected life of 10-15 years.
As the stability of the prosthesis is
achieved within 15 minutes of surgery.
2.NON-CEMENTED HIP-is a recent
development in which bone cement is not
used to fixed the components of the hip
joint.
Non-cement hip is use In younger
people.

17. OOPPEERRAATTIIVVEE AAPPPPRROOAACCHHEESS
It can be divided into two broad
categories-
1. Standard surgical approaches.
2.Minimally invasive approaches.
1.STANDARD SURGICAL APPROACHES-it
can be three types-a.
postero-lateral approach.
b.Direct-lateral approach.
c.antero-lateral approach.

19. 22..MMIINNIIMMAALLLLYY IINNVVAASSIIVVEE
AAPPPPRROOAACCHHEESS--
it can be two types-a.
Single-incision approach.
b. Two-incision approach.
In this approach the length of incision is
less than 10cm,depending on the location
of the approach and the of the patient .

20. A. Postero -lateral approach -this is the
most frequently used approach for total
hip arthroplasty.
 In this approach the gluteus maximus is
split in line with the muscle fibers.
 In this approach the gluteus medius and
vastus lateralis muscles is not splited.

21. In this approach after total hip arthroplasty early
postoperative motion of hip joint is hip
FLEXION,ADDUCTION, and INTERNAL
ROTATION of hip joint movement is AVOID.
2.DIRECT LATERAL APPROACH-in this
approach requires longitudinal division of the tensor
fasciae latae,one-half of the gluteus medius and
longitudinal splitting of the vastus minimus.


22. In this approach disruption of the abductor
mechanism is associated with post operative
weakness and gait abnormalities.
In direct lateral approach the positive
Trendelenburg sign is present.
3.ANTERO-LATERAL APPROACH-in
addition to the gluteus medius, soft tissues
disturbed include gluteus minimus, tensor
fascie latae,iliopsoas,rectus femoris,and
vastus lateralis muscles as well as the
anterior capsul is disturbed.

24. CCOOMMPPLLIICCAATTOONN
1. DEEP VEIN THROMBOSIS-this occurs due
to inadvertent manipulation of the thigh
during surgery, venous stasis in the limb
due to immobility.
2. INFECTION-this is the most serious of all
complication.
3. NERVE PALSIES-the sciatic nerve is most
commonly affected.
4. VASCULAR INJURY- this is uncommon,
but can occur mainly due to technical
reasons.

25. 6.FRACTURE-these may occur during the
process of implantation of the prosthesis.
7.DISLOCATION-it is primarily due to
malpositioning of limb during early post
operative period.
8.HETEROTROPIC BONE FORMATION-new
bone formation around the
components occurs in some cases such as
ankylosing spondilitis,and results in
decreased range of joint movements.

26. PPHHYYSSIIOOTTHHEERRAAPPYY MMAANNAAGGEEMMEENNTT
TOTAL HIP ARTHROPLASTY
MANAGEMENT-
Goal`s-
1.A pain free hip joint.
2.A Stable joint for lower extremity weight
bearing and function ambulation.
3.Adequate range of motion for functional
activities.
4. Strength of lower extremity for functional
activity.

27. PPHHYYSSIIOOTTHHEERRAAPPYY MMAANNAAGGEEMMEENNTT
1. PREOPERATIVE -
a) Evaluation:- Pain
Deformity
ROM
Ms power
Ms atrophy
Ambulation & Gait

28. 2. Preoperative patient education:-
It should be taught on the sound limb
for easy grasp.

29. PPRREEOOPPEERRAATTIIVVEE PPHHYYSSIIOOTTHHEERRAAPPYY
1.Deep breathing & coughing.
2.Strong & sustained isometric contraction.
3.Guidance of ROM & Strengthening
exercises.
4.Resisted exercises .
5.To teach proper limb positioning.
6.To teach appropriate technique of transfer.
7.To mentally prepare the patient for the
painful active stage ahead.

30. PPoosstt ooppeerraatteedd mmaannaaggeemmeenntt--
Day ;-1 =
1.Chest pt
2.Vigorous toe and ankle movements
3. Isometrics to quadriceps.
Day ;-2=
1. Sitting up by gradually raising the back rest.
2.Bed transfer
3. Standing, walking with partial weight bearing or
toe down weight bearing with a walker.

31. Day;- 3-7 =
1. Isomatric to gluteus maximus, medius and
minimus.
2.Assisted hip flexion [heel drag] and hip
abduction.
3. Initiate prone lying.
4.Thomas stretch.
5.Relaxed passive hip movement.
Week 2=
1.Active hip flexion, knee extension [bed side
sitting or chair sitting with back rest].

32. Week 3 =
1. Partial weight bearing walking on crutches with
free swinging of the operated leg.
Week 4=
1. Ped-o-cycle or static bicycle [possible free ROM].
2. Stair climbing going up with the GOOD LEG first.
Coming down with the OPERATED LEG first.
3. Initiate leg rotation in supine and progress to
against gravity and against resistence.
Week 5-6=
1. Gradually increase hip abduction and rotation in
supine and bed side sitting.

33. PPRREECCAAUUTTIIOONN
Avoid early initiation of hip abduction and
rotation.
Transfer to the sound side from bed to chair
or chair to bed.
Do not cross the legs.
Keep the knees slightly lower than hips when
sitting.
Avoid sitting in low, soft chairs.
If the bed at the home is low, raise it on
blocks.

34. Use a raised toilet seat.
Avoid bending the trunk over the legs when
rising from or sitting down in a chair or
dressing or undressing.
Avoid standing activities that involve
rotating the body toward the operated
extremity.
Always use pillow between the legs in
resting, sitting, while turning in bed or
during transfers.
Avoid SLR or hip abduction against gravity.

35. TTOOTTAALL KKNNEEEE RREEPPLLAACCEEMMEENNTT
AARRTTHHRROOPPLLAASSTTYY
Total knee arthroplasty , also called as total
knee replacement
It is a widely performed procedure for
advanced arthritis of the knee, primarily in
older patients (more than 70 years of age)
with osteoarthritis.
The primary goals of TKA are to relieve pain
and improve a patient’s physical function and
quality of life.

37. IINNDDIICCAATTIIOONN OOFF TTKKAA
Severe joint pain with weight bearing or
motion.
Extensive destruction of articular
cartilage of the knee joint.
Marked deformity of the knee such as
genu varum or genu valgum.
Gross instability or limitation of motion.
Failure of non-operative management.
Failure of a previous surgical procedure.

39. NNUUMMBBEERR OOFF CCOOMMPPAARRTTMMEENNTTSS
RREEPPLLAACCEEDD
It can be three compartment replaced-
1.UNI-COMPARTMENT:- only medial or
lateral joint surfaces replace.
2. BI-COMPARTMENT:-entire femoral and
tibial surfaces replaced.
3.TRI-COMPARTMENT:-femoral,tibial,and
patellar surfaces replaced.

42. SSUURRGGIICCAALL AAPPPPRROOAACCHH
1. Standard/tradition or minimal invasive.
2. Quadriceps-splitting or quadriceps-sparing.

44. 1. STANDARD APPROCH- antero-medial
parapatellar vertical or curved
incision from the distal aspect of the
femoral shaft, running medial of the patella
to just medial of the tibial tubercle, ranging
from 8 to 12cm or 13 to 15 cm in length.
2. MINIMALLY INVASIVE
APPROACH-reduced length of antero-medial
skin incision 6-9cm in length.
 Anterior capsule release.

46. IIMMPPLLAANNTT FFIIXXAATTIIOONN
 cemented.
 un-cemented.
 hybrid.

47. PPHHYYSSIIOOTTHHEERRAAPPYY MMAANNAAGGEEMMEENNTT
IINN TTKKRR
The principal aim of the physiotherapy is
to offer maximum static as well as
dynamic stability to the knee.
GOALS-
1)Control post operative swelling.
2)Minimize pain.

48. PPRREE OOPPEERRAATTIIVVEE AASSSSEESSSSMMEENNTT
A thorough assessment is done prior to the
surgery, and the postoperative regime of
physiotherapy is explained to the patient.
a) Pain.
b)Deformity.
c)Rom.
d)Strength and endurance.
e) Effusion and atrophy.
f) Complete gait analysis.

49. PPRREE--OOPPEERRAATTIIVVEE TTRRAANNIINNGG
It includes the following-
1)Explain to the patient the total post
operative regime and his responsibility.
2)Educate the patient on the measures taken
in prevention of edema, deep venous
thromosis,chest complication.
3)Training of isometrics to
quagriceps,hamstings,and glutei.
4)Self-assisted passive mobilisation.
5)Relaxed free movement.
6) techniques of self-assisted mobilisation.

50. PPOOSSTT--OOPPEERRAATTIIVVEE
MMAANNAAGGEEMMEENNTT
DAY-1
1.Chest physiotherapy.
2.Vigorous toe and ankle movements.
3.Maintain the limb with [with pop on with
heel or lower leg resting on a pillow].
4. Static glutei by pressing the pillow the
heel.
5.Gentle isometrics to quadriceps.

51. DAY 2-3;-
1.Transfer in bed.
2.Gentle patellar mobilisation.
3.Rapid isometrics to quadriceps[speedy
and with 10sec. Hold].
4.Assisted SLR.
5. Stand and ambulate with pop on and
walker.

52. DDaayy 44--55--66;;--
1.Transfer in chair.
2. Self-assisted passive knee flexion;-
a) Heel drag in supine.
b) Bed side, relaxed knee movements with
the help of sound leg[in unilateral TKA].
c) Sitting with feet plated on the ground,
and push forward by raising trunk on
arms.

53. 3.- CPM 5-10 degree daily. Range of knee
flexion must not exceed 40˚ because
transcutaneous O2 tension of the skin near
the incision decreases significantly after 40˚
of flexion.
4.-begin active or active assisted exercise, if
the wound is clear and dry.
5.-bed side active knee flexion-extension[
self-assisted, if necessary.
6.-ambulation without pop[can do three
SLR without pop].

54. DDAAYY 77--1100;;--
1. Work up toward 90 degree flexion by
10-14 days.
2. Hamstring strengthening.
3. Assisted step and stairs.
 DAY 11-3 WEEKS- progress all
exercise.
 WEEKS 4-6;-
1. Work up toward knee flexion 110-115
degree.

55. 2.-quadriceps dips and steps up.
3.stastionary bicycle.
4.total weight bearing with can.

56. RREECCOOMMMMEENNDDAATTIIOONN FFOORR
PPAARRTTIICCIIPPAATTIIOONN IINN TTKKAA
HIGHLY RECOMMENDED-
1. Stationary cycling.
2. Swimming, water aerobics.
3.Walking
4. golf [preferably with golf cart].
5.Ballroom or square dancing.
6.Table tennis.

57. RREECCOOMMMMEENNDDEEDD IIFF EEXXPPEERRIIEENNCCEEDD
BBEEFFOORREE TTKKAA--
1.Road cycling.
2. Speed/ power walking.
3.Doubles tennis.
4.Rowing.
5.Bowling.
6.Cross-country skiing [machine or
outdoor].

58. NNOOTT RREECCOOMMMMEENNDDEEDD;;--
1. Jogging, running.
2. Basketball.
3. Volleyball.
4. Baseball.
5. Football.
6. Gymnastics.
7. Squash.

59. AARRTTHHRROODDEESSIISS
CONTENTS-
1.Definition.
2. Indication.
3.Goals.
4. types of arthrodesis.
5.Position of arthrodesis.
6. complication.
7.Physiotherapy management.

60. DDEEFFIINNIITTIIOONN
Arthrodesis also known as called as
fusion of joint.
In this operation , fusion is achieved
between the bones forming a joint so as
to eliminate any motion at the joint.
arthrodesis is mostly performed on ankle
& wrist joint but it can be performed on
other joint.

62. IINNDDIICCAATTIIOONN OOFF AARRHHTTRROODDEESSIISS
1. Advanced osteoarthritis and rheumatoid
arthritis with disabling pain.
2. Quiescent tubercular arthritis with
destruction of the joint surfaces.
3. Instability from muscle paralysis, as after
poliomyelitis.
4. For permanent correction of deformity
as in hammer toe.

63. GGOOAALLSS
1. To provide pain relief.
2. To restore skeletal stability.
3. Improve alignment in people with
advanced arthritis.

64. TTYYPPEESS OOFF AARRTTHHRROODDEESSIISS
In arthrodesis may be –
1. Intra-articular type.
2. Extra-articular type.
3. Combined type.
INTRA- ARTICULAR TYPE-in intra- articular
arthrodesis the articulating surfaces are raw and
the joint immobilised in the position of optimum
function until there is a bony between the bones.
EXTRA-ARTICULAR TYPE-in an extra
articular arthrodesis ,an extra-capsular bridge of
bone is created between the articulating bones.
COMBINED TYPE- in this type both intra and
extra articular fused joint.

65. PPOOSSIITTIIOONN OOFF AARRTTHHRROODDEESSIISS
The best position of arthrodesis of a
joint the one which conforms to the
requirements of the patients work.

66. PPOOSSIITTIIOONN OOFF AARRTTHHRROODDEESSIISS OOFF
DDIIFFFFEERREENNTT JJOOIINNTT
1. SHOULDER JOINT= flexion-25 degree,
= abduction-30 degree,
= int.rota.- 45 degree.
2.ELBOW JOINT=
A. Single joint- flexion=75 degree
B. Both- one in flex.70 degree,
other in flex.130 degree.
3.WRIST JOINT= dorsi flexion-20 degree.

67. 1. HIP JOINT = flexion-15 degree
= no adduction
= no abduction[neutral position]
2. KNEE JOINT = flexion= 5 to 10 degree.
3. ANKLE JOINT =
male= neutral position,
female=planter-flexion for high
heels.

68. CCOOMMPPLLIICCAATTIIOONN
1. Bleeding.
2. Infection.
3. Blood clots In the legs.
4. Loosening of prosthetic part.

69. PPHHYYSSIIOOTTHHEERRAAPPYY MMAANNAAGGEEMMEENNTT
IINNAARRTTHHRROODDEESSIISS
In two phases-
1.During immobilisation phase.
2.During mobilisation phase.

70. DDUURRIINNGG IIMMMMOOBBIILLIISSAATTIIOONN
PPHHAASSEE;;--
1. To prevent and manage the possible post
operative complications.
2. Maintenance of the proper position of the
operated joint.
3. Strengthening and ROM exercise for the
joints free from immobilisation.
4. Initiating early non weight bearing
ambulation in case of hip, knee, and ankle
arthrodesis.

71. DDUURRIINNGG MMOOBBIILLIISSAATTIIOONN PPHHAASSEE;;--
1. In lower extremity gradual and correct
weight bearing, weight transfer and
balancing should be initiated with
adequate aid.
2. Guidance and assistance with several
sessions a day are needed to achieve
functional proficiency.

72. MMUULLTTIIPPLLEE CCHHIIOOCCEE QQUUEESSTTIIOONN
OOFF aarrtthhrrooppllaassttyy aanndd aarrtthhrrooddeessiiss
Q.-1 which operation is called as reconstruction
of a new mobile joint-
A.Arthrodesis.
B. Arthroplasty.
C.Arthroscopy.
D.Osteotomy.
Q.-2 which technique is known as fusion of a
joint-
A.Arthroplasty.
B. Arthrectomy.
C.Arthroscopy.
D.Arthrodesis.

73. Q.-3 which operation is called cutting of bone-
A.Osteotomy.
B.Arthrodesis.
C.Arthroplasty.
D.Arthroscopy.
Q.-4 which method is called as operative method
of treatment-
A.Arthroplasty.
B.Arthrodesis.
C.Arthroscopy.
D.All the above.

74. Q.-5 which compound form BONE CEMENT use
in arthroplasty-
A.Methyl-ethacrylate.
B.Ethyl-methacrylate.
C.Ethyl-ethacrylate.
D.Methyl-methacrylate.
Q.6-in exicisional arthroplasty form a gap which
fills by-
A.Adipose tissue.
B.Aerolar tissue.
C.Fibrous tissue.
D.Elastic tissue.

75. Q.7- stability of prosthesis is achieve within minutes
of surgery in total hip arthroplasty-
A.15 minutes.
B. 20 minutes.
C.25 minutes.
D.30 minutes.
Q.8- in stair climbing going up and coming down
which leg first respectively in total hip
replacement-
A.Good leg and operated leg.
B.Operated leg and good leg.
C.Alternate good and operated.
D.All the above.

76. Q.-9 which are type of total hip implants use in
arthroplasty-
A.Cemented hip.
B.Non-cemented hip.
C.Both a and b.
D.None.
Q.-10 why joint replacement occur in
human, why not occur in animals-
A.Because human is bi-pedal locomotion.
B.Because animal is Quadra-pod locomotion.
C.Both a and b.
D.None.

77. Q.-11 in joint replacement surgery which types
complication occur—
A.Deep venous thrombosis.
B. Infection.
C.Nerve palsy.
D.All the above.
Q.-12 in which range of motion knee flexion must
not exceed within the first three post operative
day-
A.Must not exceed 40 degree.
B.Must not exceed 50 degree.
C.Must not exceed 30 degree.
D.Must not exceed 20 degree.

78. Q.-13 in which types of arthrodesis only
articulating surface is fused-
A.Extra-articular type.
B.Intra-articular type.
C.Combined type.
D.All the above.
Q.14 in joint replacement surgery which type of
artificial components is use-
A.Orthosis.
B.Prosthesis.
C.Both a and b.
D.None.

79. Q.-15 in the isometric quadriceps exercises how
many second hold in total hip arthroplasty-
A.25 sec.
B.2o sec.
C.15 sec.
D.10 sec.
Q.-16 which day patient walk after surgery of
total hip replacement-
A.2-3 day after surgery P.W.B. with walker.
B.4-5 day after surgery F.W.B. with cane.
C.7-9 day after surgery N.W.B. with crutch.
D.11-12 day after surgery P.W.B. with stick.

80. Q.-17 in which position of arthrodesis is done in
shoulder joint joint-
A.Extension 25degree,adduction
30degree,external rotation 45 degree.
B.Flexion 30 degree, adduction 25degree,exernal
rotation 50degree.
C.Extension 30 degree, abduction 25degree,
internal rotation 50.
D.Flexion 25 degree, abduction 30 degree, internal
rotation 45degree.

81. Q.-18 the prosthesis is made up of –
A.Special metal alloy.
B.Special high density poly ethylene.
C.Both a and b.
D.Special low density poly ethylene.
Q.-19 In which operative approach the positive
Trendelenburg sign is present in total hip
replacement-
A.Postero-lateral approach.
B.Direct-lateral approach.
C.Antero-lateral approach.
D.All the above.

82. Q.-2O in Postero-lateral approach is use in total hip
replacement which movement is initially AVOID
after post operative period-
A.Hip extension,abduction,and external rotation.
B.Hip flexion,adduction,and internal rotation.
C.Hip exension,adduction,and internal rotation.
D.Hip flexion,abduction,and exernal rotation.
Q.-21 in which approach the HIP
EXTENSION,ABDUCTION,and EXTERNAL
ROTATION is AVOID in after total hip
replacement-
A.Direct-lateral approach.
B.Antero-lateral approach.
C.Postero-lateral approach.
D.Both A.and B.

83. Q.-22 in direct-lateral approach of operative
procedure in total hip replacement which type of
sign is present-
A.Galleazzi sign.
B.Gower`s sign.
C.Tinel`s sign.
D.Trendelenberg sign.
Q.-22 chronic osteomyelitis,nearopathic hip joint,
active joint infection these are in arthroplasty is-
A.Indication.
B.Contra-indication.
C.Both A and B.
D.None.

84. Q.-24 in which type of joint replacement surgery
only one part of articulating surface is remove-
A.Excision arthroplasty.
B.Hemi-replacement arthroplasty.
C.Total replacement arthroplasty.
D.Both A and B.
Q.-25 after total hip arthroplasty which activities are
AVOID-A.
Avoid cross the leg.
B.Avoid Indian toilet seat.
C.Avoid transfer to the affected side from bed to
chair or chair to bed.
D.All the above.

85. Q.-26 in which type one both of the articular ends of
the bone is excised-
A.Total replacement arthroplasty.
B.Excision arthroplasty.
C.Both A and B .
D.Hemi-replacement arthroplasty.
Q.27 which hip flexion range of motion to be contra-indicated
in total-replacement arthroplasty-
A.Beyond 30 degree.
B.Beyond 45 degree.
C.Beyond 60 degree
D.Beyond 90 degree.

86. Q.-28 in which condition arthrodesis is
used most commonly-
A.Painless, and stiff joint.
B.Painful, and stiff joint.
C.Both A and B.
D.None.

87. Q.29- which prosthesis used only without cemented in hip
replacement arthroplasty is-
A.Thompson prosthesis.
B. Charnley`s prosthesis.
C.Muller`s prosthesis.
D.Austin -moore prosthesis.
Q.30- which physical activities following total knee
arthroplasty is highly recommended –
A.Low impact aerobics.
B. Middle impact aerobics.
C.High impact aerobics.
D. Water aerobics.

88. Q.31- which games after total knee arthroplasty is not recommended-
A. Table tennis.
B. Doubles tennis.
C. Single tennis.
D. Golf.
Q.32- in standard or minimally invasive approach which incision is
used in total knee arthroplasty-
A. Postero-medial-parapatellar incision.
B. Antero-lateral –parapatellar incision.
C. Postero-lateral- paratellar incision.
D. Antero-medial-parapatellar incision.

89. Q.33- which type bone cement is used in
total knee arthroplasty-
A. D-crylic cement
B. B-crylic cement.
C. A-crylic cement.
D. C-crylic cement.

90. Q.33- in minimally invasive approach the incision
is made in centimeter of length in THR-A.
Less than 25cm in length.
B.More than 15cm in length.
C.Less than 10cm in length.
D.More than 20cm in length.
Q.34- in postero -lateral approach which muscle
is split in line of muscle fibers-
A.Gluteus medius.
B.Gluteus minimus.
C.Gluteus maximus.
D.All the above.

91. Q.35- in cemented arthroplasty is generally
used in-
A.Elderly people.
B.Old people.
C.Both a and b.
D.None.
Q.36- in nerve palsy complication of joint
replacement arthroplasty which nerve
commonly affected-
A.Femoral nerve.
B.Popliteal nerve.
C.Gluteal nerve.
D.Sciatic nerve.

92. Q.36- the implant of femoral component of
total knee arthroplasty shape is –
A.`T`- shape.
B.`C`- shape.
C.`D`- shape.
D.`U`-shape.
Q.37- in which of the following is relative
contra-indication in THR-A.
Active joint infection.
B.Systemic infection.
C.Neuropathic hip joint.
D.Progressive neurological disorder.

93. Q.38- which surgical approach is most
recent is use in knee arthroplasty-
A.Minimally invasive approach.
B.Standard approach.
C.Traditional approach.
D.All the above.sssss