Sports (2008-2019)

Question 1

1. 4 contraindications to an HTO (2012)

Answer 1

• JAAOS 2005 - High Tibial Osteotomy
  
  • Disease of the contra-lateral compartment
  • Absent contra-lateral meniscus
  • Symptomatic patellofemoral disease
  • Inflammatory arthritis
  • Severe angular malalignment
  • Non-concordant pain pattern
  • Older physiologic age (better suited to TKA)

Question 2

2. List 4 advantages of doing a medial opening wedge HTO over a lateral closing wedge. (2016)

Answer 2

JAAOS 2005 - HTO/JAAOS 2011

• Easy to control correction (can dial it in)
• Less extensive surgical dissection/no disruption to proximal tib/fib joint
• Less proximity to peroneal nerve
• Can be combined with PF procedures
• No loss of lateral bone stock

Question 3

3. List 5 features of traumatic proximal tibia fibula dislocation. (2013)

Answer 3

JAAOS 2003 - Instability of the Proximal Tibiofibular Joint

• Pain over lateral knee, radiates up biceps femoris
• Prominence of fibular head
• Pain aggravated by ankle ROM
• Instability to weightbear
• Peroneal nerve symptoms
• Posterolateral corner instability
• LCL instability
• Pain and loss of knee ROM

Question 4

4. In regards to an acute, traumatic proximal tibia fibula dislocation (2013):

• Explain the mechanism of injury, including position of limb and knee position. (2 marks)
• Two features seen on examination
• Explain your reduction technique (2 marks)

Answer 4

• Explain the mechanism of injury, including position of limb and knee position. (2 marks)
  
  • Hyperflexed knee, plantarflexed and internally rotated foot
• Two features seen on examination
  
  • Prominence of fibular head and lateral knee
  • Instability of posterolateral corner
• Explain your reduction technique (2 marks)
  
  • Knee at 80-110o of flexion (relax biceps femoris)
  • Ankle dorsiflexed, foot everted and externally rotated (relax peroneals)
  • Pressure to fibular head in appropriate direction

Question 5

5. List 4 things that can cause loss of extension after ACL reconstruction? (2012, 2016)

Answer 5

JAAOS 1999 - Loss of Extension after Reconstruction of the ACL

• Cyclops lesion
• Capsulitis leading to arthrofibrosis
• Post-operative immobilization
• Lack of post-operative rehabilitation
• Non-anatomic graft placement
• Infection
• Trauma - bucket handle of meniscal tear

Question 6

6. What are 4 surgical techniques for ACL reconstruction in an 11 year old female athlete? (2012, 2013)

Answer 6

• Iliotibial band extra-physeal reconstruction (modified McIntosh)
  
  • IT band remains attached to Gerdy’s tubercle, passes over femoral condyle and under intermeniscal ligament to suture under flaps of anterior tibial periosteum
• All Epiphyseal Reconstruction
  
  • Anderson technique: 4 strand hamstring all epiphyseal suspensory technique on femur, epiphyseal tibial tunnel exiting above physis but interference screw inserted below physis to tether graft
  • Ganley technique - 4 string hamstring graft with epiphyseal femoral interference screw and epiphyseal vertical tibial interference screw
  • Cordasco-Green - epiphyseal tunnels in femur and tibia; suspensory fixation for both
• Partial trans-physeal
  
  • Epiphyseal femoral tunnel and trans-physeal tibial tunnel
• Trans-physeal reconstruction
  
  • I would not answer this on an exam for an 11yo if I could avoid it; if I use it I would specify partial transphyseal with an epiphyseal femoral tunnel and a vertical, central, small diameter tibial tunnel

Question 7

7. When performing the Thesally physical exam on the knee, what are 3 conditions that can give you a false positive. (2011, 2013)

Answer 7

• OA
• Osteochondral Injury
• Collateral Ligament Injury
• Posterolateral Corner Injury
• Associated ACL Injury
• Tibial Plateau #
• Loose body

Question 8

8. What are 6 risk factors for recurrent patellar dislocation? (2014, 2015)

Answer 8

JAAOS 1997 - PF Instability

• Previous patellar instability
• Increased ligamentous laxity
• Patella alta
• Trochlear dysplasia/Hypoplastic lateral condyle
• Patellar dysplasia
• Malalignment (increased femoral anteversion, genu valgum, increase ER of tibia)
• Increased Q Angle
• VMO Atrophy
• Female gender (AAOS COR)
  
  • Not a risk factor for initial dislocation, but risk factor for recurrence

Question 9

9. List 3 prognostic factors for healing of OCD of the knee. (2015)

Answer 9

• Status of physis
• Size of lesion (>15mm)
• Chronicity of lesion
• Integrity of cartilage
• Mechanical symptoms/loose fragment
• Atypical location (patella, lateral femoral condyle)

Question 10

10. Patient with a PCL and Posterolateral corner injury:
11. Increased external rotation of tibia with knee at 30 degrees but not at 90 degrees
12. Increased external rotation of tibia with knee at 30 degrees and at 90 degrees
13. Increased laxity with varus stress
14. Pivot shift positive

Answer 10

ANSWER: B (increase ER or Dial test at 30 AND 90 degrees)

2013, 2015

• JAAOS 2016 - Management of Posterior Cruciate Ligament Injuries
  
  • A positive result occurring only at 30o of knee flexion indicates a PLC injury, and 90o of knee flexion indicates a combined PCL and PLC injury. 

Question 11

11. Which of the following are not part of the posterolateral corner
12. LCL
13. PCL
14. Popliteofibular ligament
15. Popliteus

Answer 11

ANSWER: B (not PCL)

2013, 2014

Covey (JBJS 2001) Injuries of the posterolateral corner of the knee

• Static:
  
  • LCL
  • Popliteus Tendon
  • Popliteofibular ligament
  • Lateral Capsule
  • Variable –> arcuate ligament, fabellofibular ligament
• Dynamic Structures:
  
  • Biceps femoris
  • Popliteus muscles
  • IT band
  • Lateral head of gastrocs

Question 12

12. What vessel provides blood supply to the PCL?
13. Inferior geniculate
14. Superior geniculate
15. Middle geniculate

Answer 12

ANSWER: C (middle geniculate)

2011,2016

COR2

Question 13

13. Late complaint after PCL insufficient Knee?
14. Medial compartment OA
15. Instability
16. Lateral Compartment OA

Answer 13

ANSWER: A (AnteroMEDIAL)

• 2009
• Old Evidence:
  
  • “The natural history of the PCL-deficient knee leads to increased contact pressures in both the medial and PF compartments”
• ACL - posteromedial
• PCL – anteromedial
• Both medial compartment

Question 14

14.All of the following are risk factors for ACL tear except:

1. Female
2. Cavovarus
3. Increased Q-angle
4. Increased BMI

Answer 14

ANSWER: B (Not cavovarus)

• 2016
• Really not the greatest evidence for BMI available
• JAAOS 2000 - Noncontact ACL Injuries: Risk Factors and Prevention Strategies
  
  • Environmental:
    
    • Equipment
    • Shoe-surface interaction
  • Anatomic:
    
    • Knee angle
    • Hip angle
    • Laxity
    • Notch size
    • Hormonal
  • Biomechanical:
    
    • Muscular strength
    • Skill level
    • Neuromuscular control
    • Body movement

Question 15

15. When treating an infection post-ACL reconstruction, all are true EXCEPT: 
16. Blood cultures are usually not positive
17. Every reasonable effort should be made to retain the graft and hardware
18. Acute infections have the same prevalence as delayed infections
19. Arthrocentesis is the diagnostic modality of choice

Answer 15

ANSWER: C

2016

• JAAOS 2013 - Management of Septic Arthritis Following ACL Reconstruction
  
  • “Blood cultures, which are often ordered at presentation, are not reliable markers of infection because they are often negative or prone to contamination from skin flora”
  • “All reasonable attempts are initially made to preserve the reconstructed graft and associated hardware”
  • “Typically presents either acutely (<2 weeks from surgery) or subacutely (2 weeks to 2 months). Late presentation is relatively infrequent”
  • “Arthrocentesis remains the standard of care for diagnosis of septic arthritis following ACL reconstruction”

Question 16

16. Where is the posterolateral bundle of the ACL tightest?
17. Extension
18. 30 degrees flexion
19. 90 degrees flexion
20. Same in all degrees flexion/extension

Answer 16

ANSWER: A

• 2014
• Amis (JBJS Br 1991) Functional anatomy of the ACL 
• Anterior bundles tight in FLEXION
• Posterior bundles tight in EXTENSION
  *

Question 17

17. What is true regarding ACL tunnel Placement
18. Tibial tunnel is most important
19. If femoral tunnel is too posterior, graft lengthens in flexion
20. If femoral tunnel too anterior, graft lengthens in flexion
21. Over the top femoral placement of graft does not change in extension

Answer 17

ANSWER: C

• 2008, 2012
• Depends on whether tunnel is anterior in femur or tibia
• Etiologic Factors That Lead to Failure After Primary Anterior Cruciate Ligament Surgery. Jan 2017 Clin Sports Med
• TRICK: femur rotates during flexion, what is posterior becomes anterior and vis versa

Question 18

18. Chronic ACL all associated except:
19. Increased risk of OA
20. ACL recon has not been shown to decrease OA
21. More chance of damaging cartilage and meniscus
22. More likely to damage lateral as opposed to medial meniscus

Answer 18

ANSWER: D (chronic ACL = posteroMEDIAL OA)

• 2013 (two variants)
• Cipolla M (KSSTA 1995) Different patterns of meniscal tears in acute Acl ruptures and in chronic ACL deficient knees
  
  • Retrospective study of 1103 reconstructions
  • “Acute injuries show a higher rate of lateral meniscus tears, chronic laxities are very frequently associated with severe medial meniscal lesions”
• Gillquist J (Sports Med 1999) ACL reconstruction and the long-term incidence of gonarthrosis
  
  • 10-20% incidence of arthrosis
  • 10x higher than age matched controls
  • Menisectomy doubles risk (50-70% incidence at 15-20 years)
  • Not necessarily symptomatic
• Lohmander LS (AJSM 2007) The long-term consequence of ACL and meniscus injuries: osteoarthritis
  
  • “there is lack of evidence to support a protective role of repair or reconstructive surgery of the ACL or meniscus against osteoarthritis development”
  • 50% of patients with ACL/meniscus injuries have OA at 10-20 years
• Oiestad BE (AJSM 2009) Knee OA after ACL injury: a systematic review
  
  • Review of 7 prospective and 24 retrospective
  • 0-13% incidence of OA for ISOLATED ACL injury at at least 10 years
  • Combined injury 21-48%

Question 19

19. What is not associated with a poor prognosis after ACL injury?
20. Hearing a pop at time of injury
21. Smoking
22. Gain 15lbs in first year
23. Wearing a brace for 1 year post-op

Answer 19

ANSWER: D

• 2010
• OKU 9:
  
  • Independent poor predictors after ACL reconstruction:
    
    • Smoking
    • Recollection of hearing a pop at injury
    • Weight gain of 15lbs
    • No change in educational level since injury
• Spindler K (JBJS 2005) Clinical outcome at a minimum of five years after reconstruction of the ACL
  
  • Independent predictors of a worse outcome…..included the patient’s recollection of hearing or feeling a pop, a weight gain of >15lbs, and no change in educational level since surgery

Question 20

20. What is true regarding pediatric ACL reconstruction:
21. Transphyseal tibial tunnel is an option
22. Bone-patellar-tendon-bone graft is a good option
23. Screw placement across the physis is acceptable
24. Non-operative treatment has good outcomes

Answer 20

ANSWER: A

2015 

JAAOS - ACL in the Skeletally Immature

• “Conservative management of skeletally immature patients with complete ACL injuries has been less successful. The high non-compliance rate is associated with secondary damage of the menisci and/or articular cartilage, and a large percentage of patients eventually require surgical reconstruction”

2018 IOC consensus on pediatric ACL:

• OK to go transphyseal BUT need to be central, vertical and no hardware crossing physis
• Non-operative
  
  • Kocher found that partial tears-1/3 of them required surgery for persistent instability
  • 50% will drop out of sports b/c of instability
  • Increased rate of meniscal and chondral damage

Question 21

21. Hamstrings tendon grafts in ACL reconstruction, all are true except:
22. Previous MCL injury is a contra-indication to using hamstring tendon
23. Ligamentous laxity is a contraindication to using hamstring tendon
24. Sprinter is a contraindication to using hamstring tendon
25. Previous hamstring injury is a contra-indication to using hamstring tendon

Answer 21

ANSWER: A

2008

JAAOS 2005 - Graft Selection in ACL Reconstruction

• Contra-indications to hamstring autograft:
• Generalized ligamentous laxity
• Competitive sprinters
• Previous hamstring injury
• Acute MCL

Question 22

22. In performing an opening wedge HTO, all of the following are true except:
23. In an ACL deficient knee, placing the bone wedge posteromedially will decrease the tibial slope and decrease anterior translation
24. In a PCL deficient knee, placing the bone wedge anteromedially will increase the tibial slope and increase posterior translation
25. Placing the bone wedge direct medial will not affect the slope
26. Smaller anterior gap with a larger posterior gap will preserve the native tibial slope

Answer 22

ANSWER: B (best answer) but C also not true

2015

Charles: C is also NOT true

• JAAOS 2011 – Role of the HTO in the varus knee
  
  • “The tibia has a triangular shape and to preserve the anatomic slope, the anterior opening shoulder be smaller than the posterior medial opening.
  • My understanding is that you are opening more lateral posteriorly (base of triangle) and therefore are opening LESS central posterior then central anterior.

Increased tibial slope will DECREASE posterior translation

JAAOS 2011 - Role of the HTO in the varus knee

• ACL deficiency –> decrease tibial slope
• PCL deficiency –> increase tibial slope

Question 23

23. When doing a proximal tibial osteotomy for a varus knee, what is the difference between doing a fibular osteotomy and a partial resection of the fibular head
24. Increased peroneal nerve injury with osteotomy
25. Increased non union
26. Difficult to do the tibial osteotomy
27. Increased risk of popiteal artery injury

Answer 23

ANSWER: A (old answer C)

2008

-less chance of damage to CPN: at tib/fib joint (zone 1) or at junction of middle and distal thirds of fibula (zone 4)

• JAAOS 2005 - HTO
  
  • Incidence of peroneal nerve palsy after lateral closing wedge 0-20%
  • Osteotomy in vicinity of the fibular head associated with higher incidence of peroneal nerve palsy than fibular osteotomy >15cm distal to head

Question 24

24. What is true regarding ACL graft choices:
25. Single bundle reconstruction restores normal knee kinematics
26. Posterolateral bundle is shorter
27. Double bundle reconstruction has better clinical outcomes
28. Can regain hamstring strength following hamstring graft harvest with appropriate PT

Answer 24

ANSWER: B

2015

• JAAOS 2008 - Controversies in Soft Tissue ACL Reconstruction
  
  • No difference in clinical outcomes between single and double bundle
• Fu F () Gross, arthroscopic and radiographic anatomies of the ACL: Foundations for ACL Surgery
  
  • AM bundle is 38mm in length, PL bundle is 17.8mm
• Tiamklang T (Cochrane 2012) Double-bundle versus single-bundle reconstruction for ACL rupture in adults
  
  • Comparison of 17 trials
  • No statistical or clinical difference between groups in IKDC, Tegner, Lysholm scores in immediate or long follow up
• Ardern CL (Arthroscopy 2010) Hamstring strength recovery after hamstring tendon harvest for ACL reconstruction
  
  • No differences between semi-T/gracilis and Semi-T alone)
  • All had 3-27% strength deficit compared to contra-lateral side
• Battaglia TC - Strength and regrowth of hamstring tendons after hamstring autograft ACL reconstruction

Question 25

25. Which of the following is true about cruciate synovial cysts?
26. Cause pain during deep squatting
27. Are very rare and have no classification system
28. Are impossible to distinguish from synovial sarcoma on MRI/”are confused with”
29. Have a high risk of recurrence following arthroscopic excision

Answer 25

ANSWER - A

2014

Cysts about the Knee: Evaluation and Management. JAAOS August 2013

• B - Untrue: Prevalence of 0.2 to 1.9%, and classification is anterior to ACL, between ACL and PCL and posterior to PCL
• A - True: Pain can be intermittent or constant, and often worse with exercise especially squatting (squeezing the cyst)
• D - Untrue: Arthroscopic excision is the treatment of choice with “no” symptomatic recurrences
• C - Untrue: Although the differential includes other ganglion cysts, hemangioma, synovial sarcoma and villonodular synovitis these pathologies should have unique MRI features that should lead to proper diagnosis

Question 26

26. Post ACL reconstruction. What will predict arthritis?
27. degree of pre-op AP laxity
28. intra-op findings of a chondral lesion
29. use of a hamstring graft
30. Wrestling with Brendan oneil early

Answer 26

ANSWER: B

2011

• Oiestad (AJSM 2009) Knee osteoarthritis after anterior cruciate ligament injury
• Predictors of OA:
  
  • Obesity
  • Chondrosis in medial compartment > grade 2
  • Prior medial menisectomy
  • Longer duration of follow up
  • Female
  • PF chondrosis
  • Prior lateral menisectomy

Question 27

27. Proper placement of ACL tibial tunnel to prevent graft impingement is achieved by?
28. Placement of tunnel in the center of the ACL footprint
29. Placement of tunnel posterior to the ACL footprint, 6mm anterior to PCL
30. Placement of tunnel in front of the ACL footprint
31. Placement of tunnel posterior to ACL foot print

Answer 27

ANSWER: A

2011

JAAOS 1999 - Loss of extension after reconstruction of the ACL

• Ideal place for the tunnel is 3mm posterior to the center of the origin of the ACL
• Orthobullets
• Tibial tunnel should be 10-11mm in front of the anterior border of PCL insertion

Question 28

28. What position do you tighten your ACL graft?
29. full extension
30. 30 degrees of flexion
31. 90 degrees of flexion
32. ryan martin is gay

Answer 28

ANSWER: B

2011

JAAOS 1999 - Loss of extension after reconstruction of the ACL

• Some biomechanical studies that there is a loss of extension with tightening in 30o
• Areneja (Arthroscopy 2009)
• No difference in a systematic review of papers tightening in full extension, 30o flexion, 10o flexion

JAAOS 2012 – Graft tensionin during knee ligament reconstruction:

• Some biomech studies say decrease extension if overtension at 30 degrees (most studies look at 30 degrees)
• Consensus is that you can tension at full extension or 30 degrees (more common at Western)
• Maximum tensioning at full extension OR submaximum loading/tensioning at 30 degrees (which is why we use the tensionometer)

Question 29

29. Which position of the knee places the ACL at its greatest strain ?
30. Hyperextension
31. 30 deg flexion
32. 90 deg flexion
33. hyperflexion

Answer 29

ANSWER: A

2008

• Wheeless:
  
  • Hyper-extension
    
    • At 5o of hyperextension the ACL ligament forces range between 50 and 240 Newtons
    • Hyperextension of the knee develops much higher forces in ACL than in the PCL
  • ACL strain at 30o of knee flexion are significant higher than at 90o where the ligament remains unstrained
• Frank (JBJS 1997) Current Concepts Review
  
  • Extensive in vitro and in vivo evidence has shown that the circumstances that cause the highest loads and strains on the ACL during daily function are quadriceps-powered extension of the knee, moving it from approximately 40o of flexion to full extension; hyperextension of the knee; excessive internal tibial rotation; or excessive varus or valgus stress on the tibia
• 2018 - A Review on Biomechanics of Anterior Cruciate Ligament and Materials for Reconstruction
  
  • the highest shear forces on the anterior cruciate ligament occur during hyperextension/low flexion angles of the knee joint

Question 30

30. Which of the following activities places the greatest peak strain on the ACL :
31. Ascending stairs
32. Ascending a ramp
33. Descending stairs
34. Descending a ramp

Answer 30

ANSWER: C

2008

Frank (JBJS 1997) Current Concepts Review

• ®Frank, JBJS, Current Concepts Review, 1997 - highest loads and strains during daily function on ACL are during quad powered extension from 40° to hyperextension
• PCL
  
  • • Level Walking = 352 N
  • • Ascending Stairs = 641 N
  • • Descending Stairs = 262 N
  • • Ascending Ramp = 1215 N
  • • Descending Ramp = 449 N
• ACL
  
  • • Level Walking = 169 N
  • • Ascending Stairs = 67 N
  • • Descending Stairs = 445 N
  • • Ascending Ramp = 27 N
  • • Descending Ramp = 93 N

Question 31

31. Which of these is true about ACL injuries?
32. MRI shows bruise on the Posterior Medial Femur
33. 40% of pts with ACL tear show bruising on MRI
34. Visible on scope
35. Full thickness injury to cartilage on histology

Answer 31

ANSWER: C (prob best answer)

or D (also say histologic evidence of chondrocyte damage in 35%)

• A: False Bone bruising on lateral side of femur and tibia. Middle 1/3 of lateral femoral condyle and posterior 1/3 of lateral tibial plateau. The plateau comes forward under the femur during injury and impact in the middle third of the femur.
• B: False M- ore than 80%
• Graf, Am J Sp Med, 1993 - middle third of the lateral femoral condyle and the posterior third of the lateral tibial plateau, no correlation with position or location of meniscus injury, 48% had bone bruising
• Treatment of ACL Injuries, Part I; Vol.33,No.10,2005; p.1583 “Several investigators reported 80% or more of ACL injuries were associated with bone bruises in the lateral compartment.”
• Mair, Am J Sp Med, 2004 – PCL injury with 83% isolated injury of PCL and at least one bruise
• Costa-paz, Arthroscopy, 2001 – f/u MRI with ACL and bone bruise after recon, 24 to 64 months post op, 71% gone, 29% retained suggesting OC injury
• Davies, Clinical Radiology, 2004 – bone bruises persist longer than 12 to 14 weeks, more than previously thought, 67% had ACL injuries, 23% collateral injuries, 10% no assoc lig injury, no correlation in bruise size or location with type of or lack of injury

Question 32

32. Grade III MCL & ACL rupture. What to do?
33. Rehab as per ACL
34. Brace in extension x 2-3wks
35. Reconstruct ACL, fix MCL, brace 30-90deg
36. Reconstruct ACL, brace 30-90deg

Answer 32

ANSWER: B

Grade 3 MCL gets residual laxity, not a functional problem. Controversial what to do for combined but some suggest trial nonop.

2008

• Combined anterior and posterior cruciate and medial collateral ligament injury: nonsurgical and delayed surgical treatment (ICL 2003)
• “anterior cruciate ligament injuries in combination with medial collateral ligament and/or PCL injury can initially be treated nonsurgically and reconstructed later as dictated by patient symptoms and activity level.”
• Medvecky M (Sports Med and Arthrosc Revew 2015) Management of Acute combined ACL-Medial and posteromedial instability of the knee
• There is fairly uniform consensus in the literature that non-operative management of first-degree and second-degree injuries is appropriate. With regard to acute third-degree medial-sided injuries, some controversy does exist regarding non-operative versus operative intervention. However, most studies advocate non-operative treatment of medial-sided injury
• Recommend short term immobilization in extension
• Previous answer (2008 toronto and 2008 UWO) is grade 3 MCL gets residual laxity. All agree that isolated grade 3 gets nonop initially but highly controversial if treat nonop or op for combined ACL and grade 3. Would try non-op and brace first.

Question 33

33. A 20yo male football player sustains an isolated, grade III MCL tear. Which of the following is true?
34. Operative repair leads to earlier healing and return to play
35. Non-operative treatment leads to return to play in 3 weeks
36. You should perform arthroscopy to detect any intra-articular pathology and to determine treatment plan
37. The MCL usually tears from the femoral side

Answer 33

ANSWER - D

• Treatment of Medial Collateral Ligament Injuries. JAAOS 2009
  
  • Most commonly a rupture at the femoral insertion, however an avulsion with bony fragment is an indication for acute fixation.
  • Pellegrini-Stieda Syndrome is recalcification at the femoral insertion
• Return to Sport:
• Serscheid and Garrick (AJSM 1981)
  
  • Grade II: In high school football series average return in 19.5 days
  • Grade I: In high school football average return in 10.6 days
• Jones (Clin Orthop 1986):
  
  • Grade III injuries in high school players average return in 34 days
• ACL tears comprise up to 95% of associated injuries; 20% are with grade I MCL injuries, 52% are with grade II MCL injuries, 78% are with grade III injuries
• Should be able to pick up on MR or clinical exam
• Kim C (Clin Sport Med 2016) Return to Play after MCL Injury
  
  • Not great evidence, review article
  • Conservative management - 5-7 weeks to return to play
  • Operative - 6-9 months
  • Definitely some injury severity bias
• JAAOS 2017 - Physical examination of knee ligament injuries
  
  • Agree MCL usually tears from femoral side - check for point tenderness at medial epicondyle
  • Valgus stress should be done at both 0deg and 30deg; 30deg helps isolate sMCL

Question 34

34. What type of fibres in the meniscus resist hoop stresses?
35. Circumferential
36. Crossing
37. Radial
38. Vertical

Answer 34

ANSWER - A

2011, 2014

• From: The knee meniscus: Structure-function, pathophysiology, current repair techniques, and prospects for regeneration. E.A. Makris et al. / Biomaterials 32 (2011) 7411-7431
• “The biomechanical properties of the knee meniscus are appropriately tuned to withstand the forces exerted on the tissue. Many studies have helped to quantify the properties of the tissue both in humans and in animal models. According to these studies, the meniscus resists axial compression with an aggregate modulus of 100-150 kPa. The tensile modulus of the tissue varies between the circumferential and radial directions; it is approximately 100-300 MPa circumferentially and 10-fold lower than this radially.”
• From The meniscus: Review of basic principles with application to surgery and rehabilition (J Athl Train 2001)
• Three collagen fiber layers are specifically arranged to convert compressive loads into circumferential or “hoop” stresses (Figure (Figure4).4). In the superficial layer, the fibers travel radially, serving as “ties” that resist shearing or splitting. In the middle layer, the fibers run parallel or circumferentially to resist hoop stress during weight bearing. Lastly, there is a deep layer of collagen bundles that are aligned parallel to the periphery
• 70% water, 30% organic; Type II collagen is main component, GAGs 1%

Question 35

35. Regarding cartilage repair techniques for a young patient, which is true?
36. No difference in techniques
37. Mosaicplasty is more effective
38. Allograft is more effective
39. Microfracture is more effective.

Answer 35

ANSWER: A

2013

JAAOS 2010 - The evidence for surgical repair of articular cartilage in the knee.

• Given the limitations of the available studies, no clear outcome benefit can be confirmed for either ACI or OAT
• The best level 1A evidence available could not demonstrate a difference in outcome between ACI and microfracture at 5 years
• Wasiak J (Cochrane 2006)
• No evidence to suggest a difference in outcome between ACI and other interventions
• A.H. Gomoll (JBJS 2010) Surgical Management of Articular Cartilage Defects of the Knee. Instructional Course Lecture.
• Magnussen (CORR 2008) Treatment of Focal Articular Cartilage Defects in the Knee: A Systematic Review
• COR2 - Ch 127 Surprisingly thoughtful overview of evidence
• “the use of microfracture, autologous osteochondral transplantation, and osteochondral allograft transplantation is supported by fair evidence based on Level II or III studies with consistent findings”
• “the use of autologous chondrocyte implantation is supported by poor quality evidence based on Level IV studies with consistent findings.” (I think they mean DeNovo)

Question 36

36. What is not a block to flexion following knee surgery:
37. Cyclops lesion
38. Quads adhesions
39. Adhesions in medial/lateral gutters
40. Patella baja

Answer 36

ANSWER: A

2015

Old Answer: JAAOS 2004 - Stiffness after TKA

• Cyclops lesions - anterior arthrofibrosis –> extension loss
• Quads adhesion –> tightening of extensor mechanism
• Patella baja –> shown to decrease flexion in TKA due to joint line elevation
• Arthrofibrosis –> causes decreased ROM in both directions

Question 37

37. Which of these is true about the MPFL?
38. Isometric throughout the ROM
39. You want it loose in extension and tight in flexion
40. If too proximal, loose in flexion
41. If too distal, creates extensor lag

Answer 37

ANSWER: D

2016

• Patella dislocates in relative extension, therefore being loose in extension wouldn’t make sense
• JAAOS 2014 - Guidelines for MPFL Reconstruction in Chronic Lateral Patellar Instability
• Thaunat and Erasmus suggested that a femoral tunnel that is too far proximal may lead to graft laxity in extension and graft tension in flexion, with a clinical presentation of anterior knee pain and loss of flexion
• “the objective should be to have an MPFL graft isometric from zero to 30o of knee flexion which duplicates the isometry of the native ligament. Therefore, a grafted ligament should tighten in extension and be lax in flexion, with a length change pattern of at least 5mm between complete extension and deep flexion.”
• Femoral tunnel too distal may head to graft tension in extension and laxity in flexion. Its clinical presentation would be extension lag
• Anterior positioning of femoral tunnel leads to overloading of the medial PF cartilage
• Steensen (AJSM 2008) –> 5.4mm length change throughout motion –> non-isometric
• Confirmed by Victor (AJSM 2009)
• Position of femoral attachment substantially changes isometry, patellar attachment not so much
• JBJS Reviews - MPFL Reconstruction in Children and Adolescents
• The MPFL remains isometric between 0o and 90o of knee flexion and becomes slack beyond 90o, there is variation in the length relationships between the different bundles of the MPFL throughout flexion and extension

Question 38

38. With lateral patellar dislocation, what describes the J sign?
39. lateral to medial with knee in full extension to flexion
40. medial to lateral with knee in full extension to flexion
41. goes lateral with knee held in 30° flexion

Answer 38

ANSWER: A

2011

J Sign is where the patella sits lateral when lax in extension, then snaps medial as it engages the trochlea at 30o flexion

Question 39

39. In regards to microfracture treatment (of OCD), all are true except?
40. Younger age have better outcome
41. Decreased BMI do better
42. No correlation between MRI findings and clinical outcome
43. Long term MRI findings show 50% of cases have evidence of fibrous filling of defect.

Answer 39

ANSWER: C

2011

• Mithoefer K (AJSM 2009) Clinical efficacy of the microfracture technique for articular cartilage repair in the knee
• “Defect fill on MRI was highly variable and correlated with functional outcome”
• Erggelet C (J Clin Orthop Trauma 2016) Microfracture for the treatment of cartilage defects in the knee joint
• Systematic review
• “There is evidence from the described studies that younger patients under 30-40 years might benefit more from microfracture technique”

Question 40

40. All are factors that contribute to increased chance of PF instability, EXCEPT
41. Internal tibial torsion
42. Increased femoral anteversion
43. Increased Q angle
44. Genu valgum

Answer 40

ANSWER: A

2013

External tibial torsion associated with PF instability

Question 41

41. Which of the following is true about athletic groin injuries?
42. Adductor magnus is the most common adductor strain
43. Chronic osteitis pubis can lead to narrowing of the pubic symphysis seen on XR
44. Moderate to severe sports hernia rarely improves with nonoperative management
45. Resisted abdominal flexion improves symptoms of sports hernia

Answer 41

ANSWER: C

2019

• ANSWER: Moderate to severe sports hernia rarely improves with nonoperative mgmt
• Most commonly adductor longus (eliminates a)
• Osteitis pubis = inflammation of the pubis symphysis from repetitive trauma
• Can sometimes see diastasis from bony erosion (eliminates b)
• Sports hernia
• Non-operative mgmt. 6-8 weeks (physio)
• Flexion worsens pain (eliminates d)
• JAAOS 2017 à Athletic hip injuries
• Moderate to severe symptoms of athletic pubalgia rarely improve with nonsurgical care and eventual surgical repair for symptom relief is typically required to allow the athlete to return to play

Question 42

42. 30Y patient. 3 months post injury. 6cm gap. What is the most appropriate treatment///Old Man running and suffers Achilles rupture. Unfortunately not smart enough to get checked out for a month. MRI shows there is a 6cm gap. What to do?
43. FHL reconstruction
44. V-Y advancement
45. Synthetic graft
46. Allograft

Answer 42

ANSWER: A

2019

• ANSWER: FHL reconstruction
• Chronic Achilles, 6 cm
• <3cm can try repair, >3cm need additional techniques
• techniques include local tissue transfer, tissue augmentation, synthetic biomaterials, and allograft
• <1cm direct repair as in acute cases.
• 1-2cm: Shorten and repair. May need to stretch tendon intra-operatively to gain length.
• 2-5cm V-Y advancement or turndown procedure
• >5cm FHL tendon transfer +/- VY or turndown.
• FHL brought through a drill hole in the calcaneus and then weaved through Achilles tendon ends
• Also, suture anchors with side-to-side Kessler to Achilles
• Make sure to tension in DF to prevent stiffness

Question 43

43. All of the following are true regarding Achilles management except:
44. Nonoperative treatment requires functional rehab
45. An Achilles tendon bony avulsion must be treated surgically
46. Nonoperative management with early rehab involves dorsiflexion past neutral within 6 weeks.
47. Nonoperative management has less complications

Answer 43

ANSWER: C

2019

ANSWER: Non-op involves DF past neutral within 6 weeks

• Non-op with accelerated functional rehab (eliminates a)
• Achilles bony avulsion
• Fixation of tendo Achilles avulsion fracture - 2009
• Avulsion of the bony insertion of the Achilles tendon at the calcaneus is infrequent and is diagnosed by radiography. Open reduction and internal fixation is indicated to achieve bone to bone healing and restoration of the function and continuity of the triceps surae mechanism
• Non-op management – DF to neutral only at 6 weeks
• Equinus BK cast – allows for consolidation of hematoma
• 0-2 weeks: Posterior slab/splint, NWB in 20 degrees of PF
• 2-4 weeks: Aircast with 2cm heel lift; PWB; active PF and DF to neutral
• 4-6 weeks: WBAT; continue 2-4 week protocol
• Non-op less complications
• To date, there have been two small randomized trials comparing the outcomes of patients with acute Achilles tendon rupture who were treated operatively with the outcomes of those treated non-operatively in which early weight-bearing and mobilization was the focus of rehabilitation in both groups
• In both studies, there was no significant difference between groups with regard to the re-rupture rate.
• There was also no significant difference between groups with regard to range of motion, strength, calf circumference, or functional assessment
• Surgical complications – wound issues, infection, sural nerve injury, DVT

Question 44

44. Very long stem. Essentially 18yo F with positive Lachman. Which of the following is true regarding this patient:
45. Posterolateral meniscocapsular detachment is more common than posteromedial meniscocapsular detachment
46. 5% risk of contralateral ACL rupture within 10 years
47. Within 10 years, there is a higher risk of rupturing the ACL graft of the ipsilateral ACL-reconstructed knee compared to the unoperated contralateral knee -
48. Females have a predictably different psychological response to their initial injury compared to males

Answer 44

ANSWER: D

2019

Females different response than males

• Posteromedial meniscocapsular separation is typically associated with ACL injuries.4 The incidence of such lesions has been reported from 16.6% to as high as 23.2%
• * If tear one ACL – 5-10% chance of rupturing other
• At 10 years, >10%
• the rate of contralateral ACL injury is higher than the ipsilateral graft rupture 
• Systematic review of prospective studies identified the ACL graft rupture risk to be 1.8–10.4% and risk of ACL injury in the contralateral knee to be 8.2–16.0%
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110421/
• DEPENDS ON GRAFT (*Getgood)
• BTB graft – higher rate CONTRALAT rupture
• Hamstring – higher rate ISPILATERAL rupture
• • Male patients who participated frequently in sport before ACL injury had higher psychological readiness. Conversely, female patients had a more negative outlook and may therefore benefit more from interventions designed to facilitate a smooth transition back to sport.

Question 45

45. 50yo has a hip labral tear. Which of the following is true:
46. 10% risk of pudendal nerve injury
47. >15% reoperation rate at 2 years
48. Increased risk of (wound?) complications with arthroscopic treatment versus open

Answer 45

ANSWER: B

2019

• Griffin et al 2016 – reoperation rate The 2-year rate of conversion to arthroplasty after hip arthroscopy has been found to increase significantly in patients aged 40 to 49 years (16%) compared with patients younger than 40 years (3%), and peaks at 35% in patients aged 60 to 69 years
• Pudendal nerve injury is not uncommon following hip arthroscopy, with a reported rate found in this review of 1.8%. Potential risk factors may include the use of a perineal post and long traction times. All reported cases resolved within 3 months. Patients should be informed of complications related to pudendal nerve injury, which include sexual and urinary dysfunction.

Question 46

46. What is the best prognostic factor for OCD (osteochondritis dissecans) lesions of the knee?
47. Status of the physis
48. Size of the lesion
49. Stability of the lesion
50. Location in the femoral condyle

Answer 46

ANSWER: A

2019

• OCD Prognosis:
• juvenile form
• prognosis correlates with  
• age 
• younger age correlates with better prognosis
• open distal femoral physes are the best predictor of successful non-operative management 
• location
• lesions in lateral femoral condyle and patella have poorer prognosis
• appearance  
• sclerosis on xrays correlates with poor prognosis 
• synovial fluid behind the lesion on MRI correlates with a worse prognosis
• adult form
• worse prognosis
• usually symptomatic and leads to DJD if untreated

Question 47

47. What of the following is not associated with increased patellar instability
48. Increased femoral anteversion
49. internal tibial torsion
50. Increased Q angle
51. Valgus knee

Answer 47

ANSWER: B

2019

Increased femoral anteversion – increases apparent valgus

internal tibial torsion

Increased Q angle - associated

Valgus knee – same thing as Q angle

Question 48

48. With respect to PCL injuries of the knee, all of the following true EXCEPT? 
49. The utility of MRI for chronic tears is less than in acute PCL tears 
50. The AL bundle is longer and stronger than the PM bundle 
51. The dial test with a PCL and concomitant PLC injury will show >10 deg ER asymmetry at 30 and 90deg flexion 
52. PCL deficiency leads to increased force in the patellofemoral and lateral compartments 

Answer 48

ANSWER: B and D

2019

• Deficiency of the PCL results in abnormal kinematics and contact pressures in the medial and patellofemoral
• compartments of the knee and may increase strain on the posterolateral knee structures, placing them at risk of subsequent injury. 
• • PCL has two bundles
• anterolateral bundle (shorter, bigger, stronger)
• tight in flexion
• strongest and most important for posterior stability at 90° of flexion
• mnemonic “PAL” - PCL has an AnteroLateral bundle
• posteromedial bundle (Longer, smaller, weaker)
• tight in extension
• reciprocal function to the anterolateral bundle
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6105479/pdf/12178_2018_Article_9492.pdf
• Osti et al. found that the average length and diameter of the ALB is 31.79 mm and 6.50 mm2 , respectively
• Osti et al. found that the average length and diameter of the PMB is 32.42 mm and 5.62 mm2 , respectively

NOTE: Both anterior bundles (of ACL and PCL) are more important.

AMB in ACL primary restraint to anterior translation in flexion (although longer and smaller)

ALB of PCL primary restraint ot posterior translation in flexion (shorter and bigger)

Question 49

49. Achilles tendon tear in a 40 yr old dude, how do you counsel?
50. Significantly decreased rerupture rates with surgery
51. Non-op includes an early mobilization protocol (they used these words and I’m assuming this means functional rehab?)
52. Larger calf circumference in those treated surgically
53. Increased dorsiflexion in those treated surgically

Answer 49

Answer: B (2017)

A - No

B - Yes

C - No

D – No

• Ten studies met the inclusion criteria. If functional rehabilitation with early range of motion was employed, rerupture rates were equal for surgical and nonsurgical patients (risk difference = 1.7%, p = 0.45). If such early range of motion was not employed, the absolute risk reduction achieved by surgery was 8.8% (p = 0.001 in favor of surgery). Surgery was associated with an absolute risk increase of 15.8% (p = 0.016 in favor of nonoperative management) for complications other than rerupture. Surgical patients returned to work 19.16 days sooner (p = 0.0014). There was no significant difference between the two treatments with regard to calf circumference (p = 0.357), strength (p = 0.806), or functional outcomes (p = 0.226).

Question 50

50. What is true regarding a 65yo female undergoing labral debridement via hip arthroscopy
51. The risk of pudendal nerve injury is 10%
52. She has a high chance of significant improvement in pain and function
53. Reoperation rate approaches 40% at 2 years post-operatively
54. There is no risk of iatrogenic chondral injury

Answer 50

Answer: C

A – false -2% at most.

B- – false

C – True. Reoperation rate 25% for THA at 2 years. Age 60 it’s 37%!!!

D – false

• Journal of arthroplasty - <40 yrs old repair is better than debridement.
• Purpose: The purpose of this study was to (1) evaluate the clinical outcomes of a series of patients aged 60 years or older who underwent hip arthroscopy for labral tears with minimum 2-year follow-up and (2) identify risk factors for conversion to total hip arthroplasty (THA). Methods: Outcome data were prospectively collected and retrospectively reviewed in patients aged 60 years or older who underwent hip arthroscopy between April 2008 and May 2012. Four patient-reported outcome (PRO) scores, pain scores, and satisfaction ratings were collected. Conversion to THA and revision surgery rates were recorded. A subgroup analysis compared survivors with patients requiring THA. Results: Minimum 2-year follow-up was available for 30 patients with a mean age of 63.9 years. The 2-year survivorship rate was 70%, with 9 patients undergoing conversion to THA at a mean of 1.1 years after hip arthroscopy. Two patients required additional surgery during the study period, for a reoperation rate of 37% (11 of 30 patients).
• • The 19 surgeons who chose age as an important factor selected a mean patient age of 52 ± 9.08 years (range, 30-60 years) as the age below which they favored repair over debridement and a mean age of 54 ± 6.41 years (range, 40-60 years) as the age above which they favored debridement over repair of labral tears

Question 51

51. What is true regarding open vs arthroscopic hip intervention for femoroacetabular impingement.
52. The risk of complications is the same
53. There is higher HRQOL measurements post hip arthroscopy
54. The chance of requiring subsequent procedure is 20%
55. Patients will have similar pain scores after 2 weeks with either treatment

Answer 51

Answer: B (2017)

• Scores (NAHS) at 3- and 12-month follow-ups, a significant improvement in NAHS from preoperation to 3 months postoperation, and a significantly lower reoperation rate. Open surgical dislocation resulted in a significantly improved alpha angle by the Dunn view in patients with cam osteoplasty from preoperation to postoperation, compared with hip arthroscopy. This meta-analysis demonstrated no significant differences in the modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living, or Hip Outcome Score-Sport Specific Subscale at 12 months of follow-up, or in complications (including nerve damage, wound infection, and wound dehiscence).
• • However, hip arthroscopy was shown to have superior results regarding general HRQoL in comparison to open treatment. 
• • Health-related quality of life (HRQoL) is a multi-dimensional concept that includes domains related to physical, mental, emotional, and social functioning. It goes beyond direct measures of population health, life expectancy, and causes of death, and focuses on the impact health status has on quality of life.
• • Arthroscopic Versus Open Treatment of Femoroacetabular Impingement: A Systematic Review of Medium- to Long-Term Outcomes.

Question 52

52.Which of the following is not involved in stabilizing the posterolateral corner

1. Popliteus
2. LCL
3. Popliteofibular ligament
4. PCL

Answer 52

Answer: D (2017)

Question 53

53. All of the following in regards to a chronic ACL injury are true except
54. Reconstruction of the ACL does not re alter the course of arthritis
55. Recurrent instability can lead to further degenerative changes
56. Lateral meniscal tears are more common than medial
57. Increased chance of meniscal and chondral injury.

Answer 53

Answer: C (2017)

A – true, doesn’t change the course.

B – true

C – opposite

D - true

•  While acute injuries show a higher rate of lateral meniscus tears, chronic laxities are very frequently associated with severe medial meniscus lesions.
• • ACL insufficiency results in deterioration of the normal physiologic knee bending culminating in increased anterior tibial translation and increased internal tibial rotation. This leads to increased mean contact stresses in the posterior medial and lateral compartments under anterior and rotational loading. However, surgical reconstruction of the ACL has not been shown to reduce the risk of future OA development back to baseline and has variability based on operative factors of graft choice, timing of surgery, presence of meniscal and chondral abnormalities, and surgical technique. Known strategies to prevent OA development are applicable to patients with ACL deficiency or after ACL reconstruction and include weight management, avoidance of excessive musculoskeletal loading, and strength training. Reconstruction of the ACL does not necessarily prevent osteoarthritis in many of these patients and may depend on several external variables.

Question 54

54. Which of the following is true regarding scapular winging
55. The direction of winging is classified based on the position of the superomedial corner
56. The direction of winging is classified based on the position of the inferomedial angle
57. Cannot be caused by brachial plexus palsy
58. Long thoracic nerve palsy causes lateral scapular winging

Answer 54

Answer: A

2017

• Orthobullet = superomedial
• JAAOS 2011 said medial border (makes more sense), sagar says inferomedial angle.

Question 55

55. When doing a medial opening HTO for a 5 degree varus deformity, what do you want to accomplish?
56. Correct mechanical axis to 10-15 degrees of valgus
57. Make joint line perpendicular to the floor - make perpendicular to MECH AXIS
58. Have the weight bearing axis pass through the medial portion of the lateral plateau
59. Make the tibiofemoral angle in 3-5 degrees of valgus (8-10)

Answer 55

ANSWER: C

Charles changed to what is true…previously all are true except

2018

JAAOS 2011

This point lies slightly lateral to the tip of the lateral tibial spine and equates to 3° to 5° of mechanical valgus

Question 56

56. All of the following are disrupted in posterolateral instability of the knee EXCEPT:
57. Lateral head of gasrocs
58. Popliteus
59. Arcuate ligament
60. Posterior oblique ligament

Answer 56

ANSWER: D

2018

Question 57

57. Which of the following is TRUE regarding ACL tunnel placement?
58. Femoral tunnel placed too anterior is tight in flexion
59. Femoral tunnel placed too posterior is tight in flexion
60. The tibial tunnel placement is the most important thing for tensioning
61. Over the top technique doesn’t effect tension (?in extension?)

Answer 57

ANSWER: A

2018

• femoral tunnel malposition
• coronal plane
• vertical femoral tunnel placement
• cause by starting femoral tunnel at the vertical position in the notch (12 o’clock) as opposed to lateral wall (10 o’clock)
• will cause continued rotational instability which can be identified on physical exam by a positive pivot shift
• sagittal plane
• anterior tunnel placement
• leads to a knee that is tight in flexion and loose in extension
• occurs from failure to clear “residents ridge”
• posterior misplacement (over-the-top)
• leads to a knee that is lax in flexion and tight in extension
• tibial tunnel malposition
• sagittal plane
• anterior misplacement
• leads to knee that is tight in flexion with roof impingement in extension
• posterior misplacement
• leads to an ACL that will impinge with the PCL
  *

Question 58

58. In regards to ACL reconstruction, which is TRUE?
59. Posterolateral bundle of the ACL is shorter
60. Double bundle reconstruction is clinically superior
61. Single bundle reconstruction is biomechanically superior
62. Hamstring strength with rehab can be regained after hamstring autograft is used for ACL reconstruction

Answer 58

ANSWER: A
2018

• Posterolateral bundle of the ACL is shorter
• In the sagittal plane, the anteromedial bundle averaged 36.9+/-2.8 mm in length and 5.1+/-0.7 mm in width. The posterolateral bundle, by contrast, averaged 20.5+/-2.4 mm in length and 4.4+/-0.8 mm in width.
• Double bundle reconstruction is clinically superior
• Single bundle reconstruction is biomechanically superior
• Double bundle biomechanically superior BUT clinically the same
• Hamstring strength with rehab can be regained after hamstring autograft is used for ACL reconstruction
• Both graft choices showed strength deficits of between 3% and 27% compared with the nonoperated limb, indicating that hamstring strength deficits persist despite successful completion of rehabilitation.
• TRICK: Having sex with a big booty girl
• Feels longer anterior (from the front) - no butt interposed
• Feels bigger but shorter from posterior (from the back) since butt interposed/ occupies space