Sports

Question 1

Dial test?

Answer 1

> 10 deg ER at 30 deg –> PLC injury<div>>10 deg ER at 30 + 90 deg –> PLC and PCL injury</div>

Question 2

Exam maneuvers for PCL? Not a RC Q

Answer 2

Posterior drawer - most accurate<div>Quads active - knee flexed, activation of quads reduces subluxed tibia</div><div>Reverse pivot shift (ER foot, bring knee into ext with valgus force)</div><div>Dial test (>10 deg ER in 30 deg and 90 deg : PLC and PCL; >10 deg ER in 30 deg: PLC)</div><div>Posterolateral drawer (knee 90 deg, ER 15-> tibia rotates posterior and laterally off LFC)</div>

Question 3

Indications for TTO in PF instability?

Answer 3

“TT-TG>20mm, high TT-PCL<div>Patella alta (CD>1.3)</div><div>Lateral PF chondral lesion (relative)</div><div><img></img><br></br></div><div>Note: leave distal periosteum intact (Decreases nonunion, stress #, CS)</div>”

Question 4

MPFL: effect of femoral tunnel on graft tension?

Answer 4

“Schottle’s point - isometric<div>1cm distal - tight in ext, loose in flex</div><div>1cm prox - loose in flex, tight in ext</div><div>1cm ant - loose in ext, tight in flex</div>”

Question 5

MOI for prox tib/fib dislocation? reduction technique?

Answer 5

MOI: knee hyperflexed with foot inverted and PF - leads to anterolateral dislocation (most common)<div><br></br><div>Reduction:</div><div>-knee flexed to 80-110 deg (relaxes BF)</div><div>-Ankle DF, foot everted and ER</div><div>-pressure to fibular head</div><div><br></br></div></div>

Question 6

Definitive Mx Principles for Knee Dislocation? not a rc q.

Answer 6

-Timing: 2-3 weeks<div>-Order:</div><div> 1- tension PCL (achilles allograft) at 90 deg</div><div> 2- tension ACL (hamstring auto) at full ext</div><div> 3- tension PLC with valgus load</div><div> 4- MCL/PMC last (open)</div><div>-Post-op: NWB- hinged ROM brace</div>

Question 7

KD classification for Knee Dislocations?

Answer 7

KD1 - ACL injured, PCL intact<div>KD2 - ACL, PCL injured</div><div>KD3 - ACL, PCL, 1 collateral</div><div>KD4 - ACL, PCL, 2 collaterals</div><div>KD5 - # dislocation</div>

Question 8

Laprade Windows/Surgical Approach? Not a RC Q.

Answer 8

“1- anterior to ITB: femoral insertions of PLC<div>2 - ITB/BF: fibular insertions of PLC</div><div>3 - prox and posterior to BF –> carry distally to decompress CPN</div><div><br></br></div><div><img></img><br></br></div>”

Question 9

Causes of ACLr failure? Not a RC Q

Answer 9

Patient: over aggressive rehab<div>Surgical: tunnel malposition, inadequate graft fixation (graft-screw divergence>30 deg)</div><div>Others: missed dx (PLC, PCL, meniscus), malalignment, infection</div>

Question 10

Complications of Hip Scope?

Answer 10

Neuropraxia (1.4%; 99% are temporary)<div>- pudendal (40%) - post</div><div>- LFCN 21% - anterolat portal</div><div>- sciatic 17% - posterior portal</div><div>- common peroneal 17% - posterior</div><div>Others: skin damage (traction), dislocation, AVN, fracture</div>

Question 11

Poor Prognosis for Knee OCD

Answer 11

Pt factors: Older AGE (ie skeletally mature)<div>Lesion factors: large lesion (>2cmX2cm), location (LFC, patella worse than MFC), unstable (cyst/fluid), sclerosis</div>

Question 12

Treatment algorithm for knee OCD

Answer 12

NON-OP<div>Operative</div><div>-intact cartilage + stable lesion = drilling</div><div>-intact cartilage + unstable = fixation +/- grafting</div><div>-full thickness defect = Autograft (ACI, OAT, mosaicplasty), Allograft (osteochondral allograft)</div><div>-malalign: osteotomy</div>

Question 13

Microfracture/Drilling leads to?

Answer 13

Fibrocartilage (Type I collagen)<div>(cf hyaline which is mostly Type II)</div>

Question 14

Surgical goal for HTO for varus knee?

Answer 14

Slight overcorrection (valgus 3-6 deg)<div>Mechanical axis to fall 62% from medial to lateral (ie just lateral to tibial spine)</div>

Question 15

Methods to address patella baja in TKA

Answer 15

-Place patella component superiorly<div>-Lower joint line (more tibial cut, need to add distal femur augment)</div><div>-TT transfer proximally</div><div>-Patellectomy<br></br></div>

Question 16

Meniscal Repair Indications? outcomes? not rc q.

Answer 16

Patient: Age<40, no mechanical malalignment, acute tears (<6weeks)<div><br></br></div><div>Tear Characteristics:</div><div>-1-4cm</div><div>-red zone tear</div><div>-vertical tear</div><div>-concurrent ACL reconstruction</div><div>-posterior root tears</div><div><br></br></div><div>Outcomes:</div><div><ul> <li>Stein T (AJSM 2010) Long term outcome after arthroscopic repair vs arthroscopic partial menisectomy for traumatic meniscal tears</li> <ul> <li>Matched cohort study</li> <ul> <li>Primarily longitudinal tears in most groups, only a few buckets (2 and 4)</li> </ul> <li>No differences at 3 years</li> <li>At 8 years:</li> <ul> <li>No OA progression in 83% repaired menisci vs 40% menisectomy</li> <li>Pre-injury activity level in 96.2% in repair vs 50% menisectomy</li> <li>BUT functional scores not different</li> </ul> </ul></ul></div>

Question 17

JAAOS 2018 Effect of Age on ACL Biology?

Answer 17

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Question 18

MOI for PCL rupture? Not a RC Q

Answer 18

<ul> <li>Directed posterior force to the proximal tibia with a flexed knee</li> <li>Addition of a varus or rotational force may lead to an LCL or PLC injury</li> <li>Fall onto flexed knee with plantar flexed foot</li> <li>Cutting, twisting, hyperextension --> more commonly have multi-ligamentous injuries</li></ul>

Question 19

Laprade Reconstruction? not a RC Q

Answer 19

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Question 20

Inside Out technique for meniscal repair - method and approaches? not a rc q

Answer 20

“<ul> <li>Incision on the skin –> tied down to capsule</li> <ul> <li>Surgical Approaches</li> <ul> <li>Knee flexion to relax NV structures</li> <li>Use protective spoons</li> </ul> <li>Anterior to head of gastrocs on either side</li> <ul> <li>Medial - between MCL and sartorius</li> <ul> <li>Risk: saphenous nerve</li> </ul> <li>Lateral - between LCL/IT Band and Biceps femoris tendon </li> <ul> <li>Risk: cpn</li> </ul> </ul> </ul> <li>Tie in relative extension to prevent capture of the capsule when it folds with flexion</li></ul><div><div> <div> <div><img></img></div><div><br></br></div><div><div> <div> <div><img></img></div> </div></div></div><div><br></br></div><div><br></br></div> </div></div></div>”

Question 21

functions of the meniscus? not a rc q.

Answer 21

<div> <div> <div> <div>load transmission</div><div>joint stability (secondary)</div><div>shock absorption</div><div>lubrication</div><div>proprioception</div> </div> </div></div>

Question 22

posterior horn of mm tear imaging and tx? not a rc q

Answer 22

“<ul> <li>Meniscal extrusion > 3mm outside the peripheral margin of the joint (CORR Recon)</li> <ul> <li>Consider extrusion vs discoid meniscus</li> </ul> <li>Ghost sign</li> <ul> <li>Sagittal cut -> absence of posterior meniscus in expected spot</li> <li>Increased signal within the meniscal root</li></ul><li>Tx: Meniscal repair</li> <ul> <li>Multiple techniques described</li> <ul> <li>Posteromedial portal use (between MCL and sartorius/semimem)</li> <li>Suture tunnels over a bone bridge</li> </ul> <li><img></img></li> </ul></ul>”

Question 23

Medial layers of the knee? not a rc q

Answer 23

“<div>1 - Sartorius fascia</div> <ul> <li>Blends with tibial periosteum distally</li> </ul> <div>2 - superficial MCL, POL, MPFL, medial patellar retinaculum, semimembranosus, posteromedial corner ligaments</div><div><br></br></div> <div>3 - deep MCL, true capsule of the knee</div> <ul> <li>Joins with layer II posteromedially to form posteromedial capsule</li> <ul> <li>Joins with semi-membranosus</li> </ul> <li>Capsule has no anterior stabilizing effects</li></ul><div><img></img><br></br></div>”

Question 24

Physical Exam for Posterolateral corner? Not a RC Q

Answer 24

-gait: varus or extension thrust, may walk with knee flexed to avoid extension instability<div>-align: varus</div><div>-inspection: effusion, ecchymosis</div><div>-palp: tender over posterolateral knee</div><div>-special tests: varus stress, dial test, posterolateral drawer test (hip 45, knee 80, er 15 - apply posterior and ER force), reverse pivot shift (knee 90 deg, ER and valgus)</div>

Question 25

JAAOS 2018 - concussion symptoms (4)

Answer 25

<ul> <li>Somatic symptoms</li> <ul> <li>Headaches most common (migraine or tension type)</li> <ul> <li>Treated with NSAIDS, amitriptyline, CCB, beta blockers, gabapentin, trigger point injections, PT</li> </ul> <li>Vision complaints (diplopia, blurriness)</li> <ul> <li>Ocular vision therapy</li> </ul> <li>Vestibular (nausea, balance, dizziness)</li> <ul> <li>Vestibular PT, neuromotor retraining</li></ul></ul></ul>

<div><br></br></div>

<ul> <li>Cognitive symptoms</li> <ul> <li>Slow reaction time, decreased concentration, poor attention, school difficulties</li> <li>Most resolve 2-3 weeks</li> <li>Persistent symptoms may require stimulant meds</li> </ul></ul>

<div><br></br></div>

<ul> <li>Emotional disturbances</li> <ul> <li>Depression and anxiety common (50%)</li> <li>CBT, SSRI, TCA</li> </ul></ul>

<div><br></br></div>

<ul> <li>Sleep disturbances</li> <ul> <li>Sleep hygiene, melatonin, trazadone</li> </ul></ul>

Question 26

Concussion RTP protocol?

Answer 26

“<div> <div> <div>begin when symptoms resolve</div><div><div> <div> <div><img></img></div> </div></div></div><div><img></img></div> </div></div>”

Question 27

indications for acute mri knee?

Answer 27

<ul> <li>Extensor mechanism disruption</li> <li>Acute meniscal pathology</li> <li>Chondral defects</li> <li>Ligament avulsions</li> <li>Tendon avulsions</li></ul>

Question 28

tibial plateau / meniscal anatomy (med vs lat)

Answer 28

“<ul> <li>Medial Plateau:</li> <ul> <li>Concave, Posteriorly sloped ~10o</li> <li>Larger</li> <li>Cartilage thick ~3mm</li> <li>Meniscus:</li> <ul> <li>C-shaped</li> <li>Intimately attached to MCL</li> <li>Secondary stabilizer to anterior translation (hence frequently injured in ACL deficient patient)</li> </ul> </ul> </ul> <div></div> <ul> <li>Lateral Plateau:</li> <ul> <li>Convex, posterior slop 7o</li> <li>Higher on the lateral view</li> <ul> <li>Think of the fibula ‘pushing up the lateral plateau’</li> </ul> <li>Larger meniscus</li> <li>Meniscus:</li> <ul> <li>More circular than medial</li> <li>Covers more of articular surface than medial one</li> <li>Attached to PCL via Humphry (Anterior)/Wrisberg(Posterior) Ligaments NOT to LCL</li> </ul> </ul></ul>”