Sports - Lower Extremity Flashcards

Question

Associated injuries in cam impingement include? [Orthop Clin N Am 44 (2013) 575–589]

Answer 1

1. Labral detachment from the acetabular rim 2. Cartilage delamination (full and partial-thickness) * Deeper compared to peripheral cartilage delamination in pincer impingement

Answer 2

1. Labral pathology 2. Peripheral cartilage delamination 3. Contracoup chondrolabral lesions in the posterior acetabulum * Due to anterior levering of the femur causing posterior shear

Answer 3

1. symptomatic FAI that fails conservative treatment 2. patients with a history and physical exam consistent with FAI with radiographic evidence of focal impingement (cam, pincer or both, labral tears or chondrolabral disruptions) and minimal to no arthritic changes are the best candidates

Answer 4

1. advantages of open surgical dislocation 1. 360 ° access to femoral head and acetabulum 2. optimal visualization for correction of deformity 3. ability confirm sphericity with open templates 4. treatment of extra-articualr and intra-articular deformity 5. optimal visualization with open dynamic assessment 6. ability to perform relative neck lengthening 2. advantages of hip arthroscopy 1. minimally invasive 2. outpatient procedure 3. potentially reduced pain 4. potentially faster rehab 5. potential for reduced soft tissue injury

Answer 5

- disadvantages of open - trochanteric osteotomy and potential for symptomatic hardware/nonunion - increased blood loss - ligamentum teres disruption - potential for prolonged rehabilitation - risk of AVN - disadvantages of hip arthroscopy - traction-related complications and nerve injury - steep learning curve - incomplete access and correction of deformity - inability to directly confirm restoration of sphericity and offset - iatrogenic chondral injury - fluid extravasation and thigh or abdominal compartment syndrome - portal complications (lateral femoral cutaneous nerve injury)

Answer 6

1. large cam deformity with significant posterior and posterolateral extension 2. associated femoral chondral defects 3. confirmed or suspected extra-articular ischiofemoral or trochanteric-pelvic impingement 4. protrusio and coxa profunda 5. secondary acetabular overcoverage due to cirumferential labral ossification 6. revision cases

Answer 7

- pain relief from preop intra-articular hip injections - lower BMI (<24.5kg/m2) - younger age - male sex - tonnis grade 0 - increased joint space

Answer 8

- older age (>45 years) - female sex - longer duration of preop pain symptoms (>8 months) - elevated BMI - OA changes - increased Tonnis grade ≥1), increased Kellgren-Lawrence grade (>3) - decreased joint space (≥2mm) - chondral defects - increased lateral center edge angle (LCEA) - undergoing of labral debridement rather than labral repair

Answer 9

1. Femoral osteochondroplasty 2. Early WB 3. Resection depth 10-33% the width of the femoral neck 4. Increased age

Answer 10

- - extra-articular - external (most common) - cause posterior ITB or anterior gluteus maximums over the greater trochanter - when the hip is extended the ITB lies posterior to the greater trochanter and moves anterior over the trochanter when the hip is flexed - internal - cause - iliopsoas tendon over the iliopectineal eminence of the pelvis or femoral head - when the hip is flexed, abducted and externally rotated the iliopsoas lies lateral and moves medial with hip extension, adduction and internal rotation - other suspected causes - iliopsoas tendon over the lesser trochanter - iliopsoas tendon over THA acetabualr component - iliofemoral ligament over the femoral head - long head of the biceps over the ischium - accessory iliopsoas tendon slips - intra-articular - causes- labral tears, Ligamentum tears, loose bodies, subtle instability

Answer 11

1. external - lateral snapping sensation, sensation that the hip dislocates 2. internal - anterior sensation of snapping, “ getting stuck” or locking often assciated with an audible snap 3. intra-articular - sensation of intermittent clicking or catching (rather than snapping) note - snapping may be painless and may be reproducible by the patient

Answer 12

- first line - non op - second line - open or arthroscopic release or lengthening of offending structure - external - open z-lengthening or release of ITB, open or arthroscopic release of the gluteus maximums tendon insertion on femur - internal - open or arthroscopic lengthening or release of iliopsoas tendon - intra-articular - arthroscopic debridement or repair of offending structure

Answer 13

- semimembranosus (arises from superolateral ischial tuberosity) - semitendinosus (arises from the inferomedial ischial tuberosity) - long head of the biceps femoris (arises from the inferomedial ischial tuberosity)

Answer 14

- muscle belly tear - acute avlsions (tendinous or osseous from ischial tuberosity)

Answer 15

high speed running

Answer 16

1. concerning physical exam findings (ecchymosis or palpable defect) 2. failure to improve with conservative care

Answer 17

1. nonop 1. acute hamstring strains, partial tears, and single tendon avulsions 2. op 1. complete avulsion of all 3 tendons with retraction exceeding 2.5 cm 2. avulsion fracture with displacement exceeding 1cm 3. sciatic nerve involvement with paresthesia or pain in the posterior aspect of the thigh

Answer 18

increase pump pressure, reduce outflow suciton, add epi tofluid, controled hypotension, tourniquet, drive scope to bleeding source, cautery, TXA

Answer 19

1. acl tear 2. pcl tear 3. mcl tear 4. patellar dislocation 5. OC fracture 6. fracture of tib plateau, distal femur or patella 7. tibial spine avulsion 8. emniscus tear 9. psterolateral corner injury (avulsion of pop tendon

Answer 20

1. Osseous anatomy * Trochlear groove * Most important stabilizer at flexion \>30° * Height and slope of the lateral trochlear facet provides the primary resistance 2. Static stabilizers * MPFL and medial patellotibial ligament * Most important in full extension when patella is not engaged in trochlea (between 0-30) * Function to guide the patella into the groove from 0-20° flexion 3. Dynamic stabilizers * VMO * More variable contribution to patella instability

Answer 21

MPFL summary - femoral attachment - center of attachment is between the medial epicondyle and adductor tubercle - patella attachment - proximal third of the medial patella * Femoral attachment * Center of attachment is between the medial epicondyle and the adductor tubercle * Patella attachment * 7.4mm anterior to a tangent to the posterior patellar cortical line and 5.4mm distal to the proximal edge of the articular surface of the patella * Located at the junction of the proximal 1/3 and distal 2/3 * Encompasses 33% of the total length of the patella [JAAOS 2014;22:175-182]

Answer 22

- Femoral attachment - between the adductor tubercle and medial epicondyle - Insertion - deep layer of the quadriceps tendon

Answer 23

1. Unfavourable bone anatomy * Trochlea dysplasia (shallow, flattened trochlea groove) * Seen in \<2% of the general population but in 85% of recurrent patellar instability * Patella alta * Increased TT-TG distance * Increased Q angle * Lower extremity rotational malalignment * femoral anteversion +/- external tibial torsion 2. Dynamic stabilizer imbalance * ITB * Increased tension causes lateral patellar tracking * VMO/VLO * Imbalance in strength can lead to instability 3. Incompetent static stabilizers * Generalized ligamentous laxity

Answer 24

Femoral origin

Answer 25

Dejour classification * Type A = shallow * Radiographic findings = crossing sign * Type B = flat * Radiographic findings = crossing sign, supratrochlear spur * Type C = lateral convexity/medial hypoplasia * Radiographic findings = crossing sign, double contour sign * Type D = cliff * Radiographic findings = crossing sign, double contour sign, supratrochlear spur

Answer 26

- Wiberg's classification (modified by Baumgart] to include Type 4) - Type 1 - the facets are concave, symmetrical and roughly of equal size - Type 2 - the medial facet is distinctly smaller than the lateral facet. The lateral facet remains concave, but the medial facet is either flat or slightly convex - Type 3 - the medial facet is considerably smaller and convex. The angle subtended by the two facets is nearly 90° - Type 4 - no medial facet or median ridge

Answer 27

1. Q-angle is greatest in knee extension 2. Lowest quadriceps and patellar tendon tension * Low posterior directed force 3. Patella disengages from the trochlear groove

Answer 28

1. J sign * Knee is actively brought from flexion to extension * Positive = Patella demonstrates a sudden, exaggerated lateral deviation after it fully exits the trochlear groove in full extension * Indicates either trochlear dysplasia or patella alta 2. Moving patellar apprehension test * Most sensitive and specific * Part 1: * Knee held in full extension and the patella is manually translated laterally with the thumb * Knee is then flexed to 90^oand then brought back to full extension while the lateral force on the patella is maintained * Positive: * Patient orally expresses apprehension and may activate his or her quadriceps in response to apprehension * Part 2: * Knee is started in full extension, brought to 90^oof flexion, and then back to full extension while the index finger is used to translate the patella medially * Positive: * Patient experiences no apprehension and allows free flexion and extension of the knee 3. Lateral patellar translation * Normal = Lateral translation of the patella should be ¼ to ½ the width of the patella

Answer 29

1. Schottle point * 1 mm anterior to the posterior cortex extension line * 2.5 mm distal to the posterior origin of the medial femoral condyle * Proximal to the level of the posterior point of the Blumensaat line 2. Stephens normalized dimensions [JAAOS 2014;22:175-182] * If AP dimension of medial femoral condyle is 100%, MPFL attachment is: * 40% from posterior * 50% from distal * 60% from anterior

Answer 30

1. Patella alta * Insall-Salvati ratio (normal = 0.8-1.2) * Caton-Deschampe ratio (normal = 0.6-1.3) * Blackburn-Peel ratio (normal = 0.5-1.0) * Blumensaat’s line should extend to the inferior pole of the patella at 30° of knee flexion 2. Trochlear dysplasia * Signs on lateral radiograph include: * Normally, floor of the trochlea should not pass anterior to a line extended along the anterior femoral cortex * Crossing sign: * A line represented by the deepest part of the trochlear groove crossing the anterior aspect of the condyles * Supratrochlear spur/prominence * Extension of the trochlear groove above the projection of the anterior cortex of the femur * Measured as the distance between the anterior femoral cortex and most anterior point of the trochlear floor * Abnormal = \>4mm * Double contour * Signs on the skyline view * Sulcus angle * Measured from the highest point on the condyles to the lowest point in the intercondylar sulcus * Normal = 138 ± 6° * Abnormal = \>145° * Indicates trochlear dysplasia 3. Lateral patellar tilt/subluxation * Assess on skyline/Merchant view

Answer 31

Laurin radiograph * Knee flexed only 20° * Imaging beam directed from inferior to superior \*\*\*45° sunrise view does not visualize the proximal trochlear groove (may miss supratrochlear spur)

Answer 32

Used to assess the tibial tubercle-trochlear groove distance * Measured by taking a line perpendicular to a line tangential to the posterior femoral condyles through the deepest part of the trochlear groove and through the apex of the tibial tubercle * Distance between these 2 lines is defined as the TT-TG distance - used to assess patellar maltracking - multistage Ct scan at various degrees of flexion - imaging at positions both less than and grater than 30 ° can be used to avoid missing maltracking that might be captured at only certain degrees of flexion

Answer 33

\>20mm (average normal is 9mm) * 10-15mm = normal * MPFL reconstruction is usually sufficient * 15-20mm = gray zone * Consider bony reconstruction in addition to MPFL reconstuction * \>20mm = abnormal * MPFL reconstruction unlikely to be sufficient * Needs bony reconstruction in addition to MPFL \*\*\*NOTE: 20mm is a guideline and not a rule; MRI values may be less

Answer 34

- Used to assess tibial tubercle - posterior cruciate ligament distance - May more accurately describe tibial tubercle lateralization (uses tibial reference points) - Measured by taking a line perpendicular to the dorsal tibial condylar line through the midpoint of the tibial tubercle and the medial border of the PCL. The distance between the two lines is defined as the TT-PCL distance - Abnormal = >20mm - Detects acute soft tissue and bony injuries - Bone bruising - edema on lateral aspect of lateral femoral condyle and inferomedial patella - Cartilage damage - osteochondral fracture of the medial patellar facet or lateral trochlear ridge - MPFL damage - VMO injury - Used to assess patellar tilt - Lateral patellofemoral angle - Angle formed between a line drawn along the lateral patellar facet and a line along the anterior most points of the medial and lateral femoral condyles - Normal = angle should be >8° with the opening laterally - Abnormal = angle <8° or medial opening - Patella tilt angle - Angle between the posterior condylar line and the maximal patella width line - Used to assess trochlear dysplasia - Lateral trochlear inclination angle - Measured on the superior-most axial image showing trochlear cartilage. - It is the angle between the plane of the subchondral bone of the lateral trochlear facet, and the posterior femoral condylar line - Abnormal = angle of <11° - Trochlear depth - Trochlear depth = [a + b)/2] - c - Where, the maximum AP distance of the medial femoral condyle (a), lateral femoral condyle (b) and trochlear groove (c) as measured from a line parallel to the posterior femoral condyles - Facet asymmetry - Determined by calculating the percentage of the medial to the lateral femoral facet length - Asymmetry of < 40% suggests trochlear dysplasia

Answer 35

Tibial tubercle – posterior cruciate ligament distance * Normal \<24mm * Both are tibial reference points * Not affected by knee rotation like TT-TG

Answer 36

1. Bone bruising * Edema on lateral aspect of lateral femoral condyle and inferomedial patella 2. Cartilage damage * Osteochondral fracture of the medial patellar facet or lateral trochlear ridge 3. MPFL damage 4. VMO injury

Answer 37

Nonoperative treatment * Bracing * ROM * Strengthening * Gradual return to play

Answer 38

Anatomic MPFL reconstruction * Miniopen technique * Using a graft stronger than the native MPFL * Semi-T or gracilis * Compensates for the uncorrected predisposing patellar instability factors

Answer 39

1. Recurrent lateral patellar dislocation 2. TT-TG distance \<20 mm 3. Positive apprehension test until 30° of knee flexion 4. Caton-Deschamps index of \<1.2 5. Normal trochlea or Dejour type A dysplasia

Answer 40

1. Too proximal * Graft lax in extension and tight in flexion * Clinically: * Anterior knee pain * Loss of flexion * Graft stretch and failure 2. Too distal * Graft tight in extension and lax in flexion * Clinically: * Extension lag

Answer 41

Between layer 2 (medial patellar retinaculum) and layer 3 (capsule)

Answer 42

- ≥60 degrees of knee flexion - The key is setting the length at the degree of flexion at which the attachment sites are farthest apart so the graft will become more lax at other degrees of flexion

Answer 43

The MPFL is nonisometric over the complete ROM * Tight in extension, Lax in flexion

Answer 44

1. The ROM after MPFL graft fixation should be complete 2. The MPFL graft should be isometric from 0-30° 3. The MPFL graft should tighten in extension and be lax in flexion 4. There should be a good endpoint to lateral patellar translation from 0-30° 5. The MPFL should only tighten on lateral patellar translation 6. Should permit 1cm of lateral translation or the equivalent of two quadrants of lateral deviation with a firm end point

Answer 45

1. Recurrent apprehension 2. Arthrofibrosis 3. Pain 4. Clinical failure 5. Patellar fracture

Answer 46

Indications: * TT-TG \>20mm (measured on CT) * High TT-PCL distance (\>24mm) * Caton-Deschamp ratio \>1.2 Contraindications [JBJS 2016;98:417-27] * Open tibial apophysis * Causes growth arrest and recurvatum * Medial dislocations * Patellofemoral OA of the proximal and medial facets

Answer 47

1. 10mm [JAAOS 2018;26:429-439] 2. 9-15mm [JBJS 2016;98:417-27]

Answer 48

Symptomatic hardware

Answer 49

1. First-line * Procedures to address associated factors rather than trochleoplasty * TT-TG and patella height normal = MPFL reconstruction * TT-TG \>20mm = tibial tubercle transfer or femoral derotation osteotomy 2. Second-line * Trochleoplasty * Involves reshaping the trochlea by deepening the groove by removing subchondral bone and impacting the overlying catilage into the defect * Indications: * High-grade trochlear dysplasia (where other options won’t provide stability) and salvage situations

Answer 50

Type B and D * Both have supratrochlear spurs – tend to displace the patella laterally

Answer 51

- Indications - dejour tpe B or D trochlear dysplasia - Supratrochlear spur height > 5mm - Presence of J-sign - Contraindications - Dejour type A or C trochlear dysplasia - Advanced patellofemoral OA - Open physes

Answer 52

- Eliminating the supratrochlear spur - Deepening the trochlear sulcus - Lateralizing the trochlear sulcus (effectively decreases the TT-TG distance)

Answer 53

1. Recurrent patella instability if * Skeletally mature * Proximal tibia and tibial tubercle physis closed * TT-TG \>15 * Caton-Deschamps \>1.2 2. Unload focal patella cartilage lesions * Without cartilage resurfacing for lateral or distal lesions * With cartilage resurfacing for central or medial lesions 3. Isolated lateral patellofemoral compression, tilt or overload in patients who fail lateral release

Answer 54

1. Skeletally immature 2. Medial patellar subluxation/dislocation 3. Diffuse patellofemoral arthrosis 4. Smoking

Answer 55

1. Medialization (Elmslie-Trillat procedure) * Reduces the TT-TG * Decreases pressure on lateral facet * Amount of medialization is limited by the amount of bony contact available 2. Anterior transfer (Maquet) * Goal is to reduce patellofemoral contact pressures * Transfers the contact forces from distal to proximal patella * Requires allograft or autograft bone block * Not routinely done * Anteriorization usually combined with medialization * Can be indicated for unloading large distal patellar chondral lesions, bipolar kissing lesions or arthritis in setting of normal TT-TG 3. Distalization * Indications: * Caton-Deschamps or Insall-Salvati \>1.2 (usually \>1.4) * Rarely done in isolation * Usually combined multiplanar osteotomy * Caution with overdistalization which can limit knee flexion 4. Anteromedialization (Fulkerson) * The amount of anteriorization and medialization is determined by the obliquity of the osteotomy * Increased obliquity [A-P] = increased anteriorization * With a constant anteriorization of 15mm: [AJSM 2014; 42(8): 2006) * 60° slope creates ~9mm of medialization * 45° slope creates ~15mm of medialization * Advantages: * Preserves extensor mechanism * Large surface for bone healing * Ability to place multiple screws * Multiplanar adjustments * Early ROM * Disadvantages * Does not address incompetent MPFL * Hardware irritation * Potential NV injury * Increased medial PF contact pressures * Delayed union/nonunion * Cannot perform in skeletally immature

Answer 56

1. Hardware irritation (50% require removal) 2. Nonunion/delayed union 3. Compartment syndrome 4. Anterior tibial artery injury 5. Deep peroneal injury 6. Infection 7. DVT 8. Medial patellar instability 9. Fracture of tubercle 10. Fracture of proximal tibia 11. Skin necrosis

Answer 57

1. Noncontact injuries (70%) * Most commonly a deceleration event and change in direction with a planted foot (cutting maneuver) 2. Trauma (30%)

Answer 58

1. Female sex 2. Increased friction and shoe-playing surface interface (eg. cleats) 3. Notch stenosis 4. Increased posterior tibial slope 5. Increased Q-angle 6. Smaller ACL 7. Increased quadriceps to hamstring strength 8. Poor landing position * Erect, hips adducted/internally rotated, knee relatively extended/valgus, tibia externally rotated

Answer 59

1. Increased Q angle 2. Notch stenosis 3. Smaller ACL 4. Increased quadriceps to hamstring strength and recruitment ratio 5. Poor landing position 6. Others: * Increased medial posterior tibial slope * Hormonal factors * Increased generalized ligamentous laxit * Increased knee laxity

Answer 60

- anterior drawer test - patient supine, hip flexed at 45° knee flexed at 90°, the foot is fixed to the table, anterior force is applied to proximal tibia while palpating the joint line for anterior translation - positive = increased anterior tibial translation - lachman test - with the patient supine and the knee flexed 20-30°, the femur is stabilized laterally with one hand and the other hand grasps the tibia medially and translates the tibia anteriorly - positive = increased anterior tibial translation - grading - anterior translation of affected knee compared to contralateral knee - Grade I = >1-5mm - Grade II = 6-10mm - Grade III = >10mm - pivot shift test - with the patient supine one hand grasps the heel and the other hand is placed over the fibular head and applies a valgus force while taking the knee form extension into flexion - positive = reduction of a subluxated tibia at 30-40 ° sensed as a clunk or a glide - Grading - I = glide - II = clunk - III = gross reduction

Answer 61

1. Athletes who perform cutting and pivoting sports 2. High demand occupations (eg. police or military) 3. High risk occupations (eg. firefighter) 4. Recurrent instability

Answer 62

1. Low physical demand patients 2. Older age 3. Advanced osteoarthritis 4. Patients unwilling or unable to comply with postoperative rehab

Answer 63

1. Effusion 2. Segond fracture 3. Tibial tubercle avulsion 4. Lateral femoral notch sign/deep sulcus sign

Answer 64

1. Direct * Fibre discontinuity * Increased signal intensity * Abnormal orientation * ‘Empty notch sign’ (chronic) 2. Indirect * Bone bruises * Anterior tibial translation * PCL buckling (reduced PCL angle) * Uncovering of the posterior horn of the lateral meniscus

Answer 65

Type I – 90% Type III – 10%

Answer 66

Bundle named based on tibial insertion * Anteromedial * Main contributor to AP stability * Taught in flexion, relaxed in extension * Posterolateral * Main contributor to rotational stability * Taught in extension, relaxed in flexion

Answer 67

Medial wall of the lateral femoral condyle * Posterior to the resident’s ridge (lateral intercondylar ridge) * Lateral bifurcate ridge separating the AM from the PL bundle * AM bundle superior and PL bundle is inferior to bifurcate ridge

Answer 68

1. 8mm anterior to the posterior articular margin of the lateral femoral condyle 2. 1.7mm proximal to the bifurcate ridge

Answer 69

For single-bundle reconstruction: * Center of the femoral footprint can be referenced on a grid using the Blumensaat line * 28% of the distance from proximal to distal * 34% posterior to the Blumensaat line

Answer 70

Broad insertion anterior and between the medial and lateral tibial spines * AM bundle located more anterior and medial * PL bundle located more posterior and lateral

Answer 71

1. 9mm posterior to the posterior edge of the intermeniscal ligament 2. 5mm anterior to the peak of the medial tibial spine 3. Midway between the medial and lateral tibial spines in the coronal plane \*\*\*Note: not recommended to use the lateral meniscus as a reference as the anterior horn insertion is variable * If used the centre of the footprint is posterior and medial to the anterior insertion

Answer 72

1. 43% of the distance anterior to posterior of the midsagittal tibial diameter 2. 51% medial to lateral on the AP view

Answer 73

1. Lateral * Anterior wall of the tibial tunnel should be posterior to a line extended along Blumensaat’s line with knee in extension * No part of the femoral tunnel should intersect Blumensaat’s line 2. AP * Angle between the femoral anatomical axis and the femoral tunnel ideally is 39° * ≤17° is associated with rotational instability

Answer 74

1. Extension * Femoral insertions are vertical (AM above PL) * Bundles are parallel * PL bundle is tight and AM bundle is relaxed 2. Flexion * Femoral insertions are horizontal (AM posterior to PL) * Bundles are crossed * PL bundle is relaxed and AM bundle is tight

Answer 75

With knee in flexion as occurs during surgery: * Shallow/deep (A-P) * High/low (superior-inferior)

Answer 76

No * “Isometry in ACL does not exist as there is no one point on femur that maintains a fixed distance from a single point on the tibia during the range of motion of the knee.”

Answer 77

1. An isometric graft avoids changes in graft length and tension during knee flexion and extension which avoids graft failure by overstretching 2. Downside is it results in a more vertical graft which is not as effective in controlling rotation 3. Isometric point on the femoral side is high in the notch and posterior

Answer 78

11 o’clock (right) and 1 o’clock (left) * Apex of the notch represented by 12 o’clock \*\*\*NOTE – changing the position to 10 o’clock (right) or 2 o’clock (left) improves the rotational stability * Graft becomes less vertical

Answer 79

1. Primary – middle genicular artery 2. Secondary – inferomedial and inferolateral genicular arteries

Answer 80

Branches of the tibial nerve

Answer 81

Focal nodule of fibrous tissue sitting in the intercondylar notch anterior to the reconstructed ACL * Significance: * Limits complete knee extension due to intercondylar notch impingement

Answer 82

1. Anterolateral femoral condyle (sulcus terminalis) and posterolateral tibial plateau (“kissing lesion”) 2. Compared to those without bone bruises: * Protracted clinical recovery * Greater effusions and pain scores * Slower return of motion

Answer 83

1. Acute ACL injury – lateral meniscus tear 2. Chronic ACL injury – medial meniscus tear

Answer 84

1. Hamstring autograft 2. Bone-patellar-bone autograft 3. Quadriceps tendon autograft 4. Allograft

Answer 85

Quadrupled-strand hamstring graft

Answer 86

8mm * “Quadrupled-strand hamstring autograft with a diameter equal to or larger than 8 mm decreases failure rates. Grafts larger than 8 mm were found to provide a protective effect in patients aged younger than 20 years, a group identified to be at increased risk of failure”

Answer 87

Impingement of the graft on the roof and PCL

Answer 88

Increase screw length or diameter

Answer 89

Notchplasty is not recommended during ACL reconstruction * Smaller intercondylar notch dimensions are not associated with ACL graft failure

Answer 90

1. Anterior knee pain 2. Loss of sensation 3. Patellar fracture 4. Inferior patellar contracture 5. Patellar tendon rupture 6. Quadriceps weakness 7. increaserd risk of patellofemoral OA 8. kneeling pain

Answer 91

Twisting the graft * “Twisting the graft by 90° increased the ultimate strength by 30%”

Answer 92

Central 1/3

Answer 93

1. Rotate the graft * Based on rotation from the proximal (patellar) end * External rotation has been shown to more significantly reduce graft length compared with internal rotation * Shortening of 25% at 630° external rotation 2. Single bone plug * Proximal patellar tendon is removed from patella without a bone plug

Answer 94

1. Decreased hamstring strength and endurance 2. Difficult to harvest due to variable graft length and diameter 3. higher failure rate than BTB

Answer 95

Advantages * Avoid donor-site morbidity * Reduced operative time * Availability of larger grafts * Superior cosmesis * Possibility for multiple ligament reconstructions Disadvantages * Delayed graft incorporation * Disease transmission * Potential immune reactions * Altered mechanical properties caused by sterilization * Cost of the allograft

Answer 96

1. Anteromedial 2. Transtibial 3. Outside-in 4. all inside

Answer 97

transtibial

Answer 98

1. sockets are drilled from inside out 2. graft is introduced into the knee from an arthroscopic portal rather than a tunnel

Answer 99

- improved cosmesis - preserves bone - reduced postop pain and swelling - retrograde drilling of the femoral tunnel results in longer intraosseous distances - quadrupled semitendinosus graft can be utilized which preserves the gracilis tendon - flexion strength is improved postop - gracilis can be used for other ligament reconstruction or revision ACL

Answer 100

Anteromedial portal technique

Answer 101

No significant difference * DB ACL-R provides significantly better knee stability (by KT arthrometry and pivot-shift testing) than SB ACL-R but no advantages in clinical outcomes or risk of graft failure

Answer 102

Technical error * Improper tunnel placement outside the native femoral and tibial ACL footprints

Answer 103

1. Errors in femoral tunnel placement * Too anterior * Excessive graft tensioning with flexion leading to loss of knee flexion or stretching of the graft * Too posterior * Excessive graft tension in extension with laxity in flexion * Too vertical * Inadequate rotational stability 2. Errors in tibial tunnel placement * Too anterior * Notch impingment and loss of extension * Too posterior * PCL impingement and loss of flexion * Too medial/lateral * Notch impingement and iatrogenic tibial plateau cartilage damage

Answer 104

1. No brace has been validated in the literature to improve patient outcomes or reduce the risk of reinjury 2. Functional bracing improves proprioception, feelings of stability and confidence 3. Functional bracing reduces anterior tibial translation (up to 140N) and rotational torques (up to 8Nm)

Answer 105

1. Meniscus injury * Status of the meniscus may be the most important factor for the development of OA regardless of nonoperative or ACL reconstruction 2. BMI * Correlation between BMI and development of OA 3. Chondral injury * May occur at time of injury or secondary to instability 4. Graft choice * BTB graft may have an increased prevalence of OA compared to hamstring graft 5. Timing of ACL reconstruction * Acute surgery may prevent secondary meniscal and chondral injuries

Answer 106

1. The relative risk of developing OA after an ACL injury (regardless of associated injuries or treatment) is 3.89 compared to the contralateral uninjured knee * i.e. The ACL injured knee is almost 4x more likely to develop OA compared to the contralateral knee 2. The relative risk of developing OA after ACL reconstruction (regardless of meniscal injury) is 3.62 compared to the contralateral knee 3. The relative risk of developing OA treated nonoperative (regardless of meniscal injury) is 4.98 compared to the contralateral knee 4. Therefore, ACL reconstruction reduces the risk of developing OA compared to nonoperative treatment

Answer 107

wrist/hand xray - determines Sanders bone age

Answer 108

- meniscal and chondral injury - psychological effects resulting from activity restrictions

Answer 109

- proportion of physis violation - <5% = low risk - location of tunnel within physis - central = low risk of arrest(compared to peripheral) - orientation of tunnel - vertical tunnel = low risk due to lower proportion of physis affected

Answer 110

- nonop - partial tear - normal or near normal physical exam - operative - older patients - instability on physical exam

Answer 111

1. intra-articular extraphyseal 2. all-epiphyseal 3. partial transphyseal 4. physeal-respecting transphyseal 5. traditional transphyseal

Answer 112

1. bone age ≤8 1. intra-articular extraphyseal 2. bone age >8 and ≥ 2 years of growth remaining 1. all-epiphyseal 3. <2 years of growth remaining (approaching skeletal maturity) 1. partial transphyseal 2. physeal-respecting transphyseal 4. skeletally mature 1. traditional transphyseal

Answer 113

- IT band reconstruction (Kocher technique) 1. nonanatomic 2. midsubstance slip of the iliotibial band is looped posterolaterally over the lateral femoral condyle then passed through the intercondylar region, through the joint, and under the intermeniscal ligament to form a new ACL. A trough is placed under the intermeniscal ligament to allow for more anatomic graft placement without causing direct physeal injury 3. proximally, autogenous graft is sutured to the periosteum of the lateral femoral condyle at the insertion of the intermuscular septum. Distal to the joint, the graft is sutured to periosteal flaps at the proximal anterior tibia with the use of heavy nonabsorbable sutures

Answer 114

- tunnels are drilled in femoral and tibial epiphysis under fluoro visualization - hamstring autograft is fixed on the femoral side with a cortical button or interference screw - fixation on the tibial side can be with a cortical button or interference screw or distally over a post

Answer 115

1. all epiphyseal femoral tunnel 1. avoidance is suggested due to 1. more longitudinal growth from the distal femoral physis compared to the proximal tibial physis 2. femoral tunnel is more peripheral - higher risk of angular deformity 2. central transphyseal tibial tunnel

Answer 116

femoral and tibial tunnels are transphyseal

Answer 117

1. vertical tunnel 2. tunnel diameter ≤ 8mm 3. central tunnels (avoid peripheral tunnels) 4. avoid perichondral ring 5. hardware and bone should not be placed across the physes 6. soft tissue grafts preferred 7. heat necrosis should be avoided by hand drilling or slow drilling speeds

Answer 118

1. all soft tissue and autograft 2. note - if BTB graft is used avoid placement of bone at the level of the physis, which may increase risk of bony bridging across the physis

Answer 119

1. Mechanical factors * Mechanical theory suggests that graft motion within the tunnel can abrade the tunnel edge producing widening * Graft position * Malpositioned tunnels can lead to increased graft forces being transmitted to the graft-bone interface * Eg. anterior tibial tunnel leads to notch impingement and increased force on the graft * Fixation method * Increased distance between fixation points leads to decreased stiffness and increased graft motion * Bungee cord effect * Longitudinal graft motion with elongation and retraction of the graft in the tunnel * Seen with suspensory fixation compared to aperture fixation * Windshield wiper effect * Transverse graft motion within the tunnel * Seen with fixation not at the aperture of the tunnel 2. Biological factors * Graft sterilization * Ethylene oxide sterilization associated with tunnel widening * Inflammatroy cytokines * May increase osteoclastic activity * Implant material * Bioabsorbable screws may have greater tunnel widening compared to metal screws * Graft type * Hamstring autograft shows greater tunnel widening compared to BTB * Graft donor * May be more widening with allograft compared to autograft * Synovial fluid propagation * Influx of synovial fluid may delay healing

Answer 120

1. Widening \>2mm 2. Loss of parallel walls (cone-shaped)

Answer 121

1. No implication to clinical outcome 2. Significant if ACL revision surgery undertaken

Answer 122

1. Allograft achilles tendon * If autograft was used for primary 2. Autograft BTB * If allograft was used for primary 3. Implant – aperature fixation with metallic screw

Answer 123

1. Single stage (\<100% widening) * Option in good bone stock * Divergent tunnel (funnel) technique * Options in poor bone stock * Stacked screw * Matchstick (bullet) graft * Large bone plug graft 2. Two-stage (\>100% widening or tunnel diameter \>15mm) [Skeletal Radiol (2017) 46:161–169] * Primary bone graft with delayed reconstruction * 3-4 months post-bone grafting

Answer 124

Staph aureus (31%)

Answer 125

Cleanse with NS, followed by chlorhexidine then NS

Answer 126

1. Perform arthrocentesis and blood culture prior to antibiotics * Septic arthritis suggested if cell count \>100,000 (may be as low as 25,000) and cell differential \>90 PMNs 2. Start broad-spectrum antibiotics * Can delay until after intra-operative cultures are sent if patient is stable 3. Immediate arthroscopic I&D * Assess graft integrity and viability (probe graft, pivot-shift) * Send intraoperative synovial fluid and synovium samples for culture * Extensive lavage and synovectomy * Graft removal is recommended in the setting of: * Significant intrasubstance degeneration * Gross evidence of infection compromising the graft * Nonfunctional graft as determined by inadequate graft tension or significant pivot shift performed under anesthesia * A closed-suction drainage system is typically used postoperatively to assist in wound drainage and is kept in place until there is minimal output * Immobilize knee in extension for 24 hours 4. Second arthroscopic I&D is recommended * Repeat synovial fluid aspiration and synovium cultures 5. 6 weeks of IV antibiotics tailored to culture and sensitivity 6. When the graft and associated hardware must be removed, a minimum 6-month waiting period after infection eradication is generally recommended before proceeding with graft reimplantation * Inection eradication indicated by normalized inflammatory markers and/or normal joint aspirate cell count and culture

Answer 127

1. Superficial iliotibial band and iliopatellar band 2. Deep iliotibial comprised of: a. Proximal Kaplan fibers - traverse from the undersurface of the ITB in an anterior and proximal orientation to its femoral insertion distal to the lateral intermuscular septum b. Distal Kaplan fibers - originate adjacent to the proximal bundle and insert distal to it along the supracondylar ridge of the distal femur c. Capsule-osseous layer - originates in close proximity to the lateral gastrocnemius tubercle and inserts near a tubercle, called the lateral tibial tubercle, on the anterolateral aspect of the proximal tibia, between the Gerdy tubercle and the fibular head 3. Anterolateral ligament (ALL) and capsule

Answer 128

1. Femoral footprint * Proximal and posterior to the lateral epicondyle * Most variable in the literature but recent trend is proximal and posterior to lateral epicondyle 2. Tibial footprint * Midpoint between the fibular head and Gerdy’s tubercle * 4-7mm distal to tibial plateau 3. Lateral meniscus attachment * Between the body and anterior horn of the meniscus 4. Orientation * Fibres run anteroinferior 5. Length = 30.41 - 59mm 6. Thickness = 1 - 2mm

Answer 129

1. ACL 2. ALL 3. Posterior horn of the lateral meniscus 4. ITB

Answer 130

1. Protects the ACL graft * Demonstrates load-sharing during anterior translation and internal rotation of the tibia 2. Reduces tibial internal rotation

Answer 131

Posterolateral corner injury * In such cases a tenodesis may tether the tibia in a posterolateral subluxed position

Answer 132

1. Revision ACL reconstruction 2. Grade 2 or 3 pivot shift (high-grade rotational laxity) 3. Young age of \<25 years 4. Generalized ligamentous laxity 5. Genu recurvatum \>10^o 6. Returning to pivoting sport (ie, soccer, basketball)

Answer 133

1. A 5-cm curvilinear incision is placed just posterior to the lateral femoral epicondyle 2. An 8-cm-long x 1-cm-wide strip of ITB is harvested from the posterior half of the ITB 3. It is left attached distally at the Gerdy tubercle, freed of any deep attachments to vastus lateralis, released proximally, and a #1 Vicryl whip stitch is placed in the free end of the graft 4. The LCL is identified and small capsular incisions are made anterior and posterior to the proximal portion and Metzenbaum scissors are placed deep to the FCL to bluntly dissect out a tract for graft passage 5. The ITB graft is then passed beneath the LCL from distal to proximal 6. The lateral femoral supracondylar area is then cleared of soft tissue posterior and proximal to the lateral epicondyle 7. The graft is then held taught but not overtensioned, with the knee at 60 degrees flexion and the foot in neutral rotation to avoid lateral compartment overconstraint 8. The graft is secured using a small Richards staple and then folded back distally and sutured to itself using the #1 Vicryl whip stitch. 9. The posterior aspect of the ITB, where the graft was harvested, to avoid overtightening the lateral patellofemoral joint

Answer 134

1. Fixation of the graft with the tibia in external rotation 2. Over-tensioning the graft

Answer 135

The addition of LET to a single-bundle hamstring tendon autograft ACLR in young patients at high risk of failure results in a statistically significant, clinically relevant reduction in graft rupture and persistent rotatory laxity at 2 years after surgery

Answer 136

Primary restraint to posterior tibial translation at all flexion angles

Answer 137

1. Posteromedial 2. Anterolateral – larger and stronger

Answer 138

1. Anterior meniscofemoral ligament (of Humphry) * From the posterior horn of the lateral meniscus and inserts on the femur anterior to the PM bundle 2. Posterior meniscofemoral ligament (of Wrisberg) * From the posterior horn of the lateral meniscus and inserts on the femur posterior to the PM bundle

Answer 139

Posteriorly directed force on the proximal tibia with the knee flexed * “When the foot is dorsiflexed, force is transmitted through the patella and extensor mechanism. When the foot is plantarflexed, a posteriorly directed force is imparted to the proximal tibia.”

Answer 140

Midsubstance (69%) > proximal insertion (27%)

Answer 141

1. The medial tibial plateau normally lies approximately 1cm anterior to the medial femoral condyle 2. This position must be restored when performing a Lachman’s test to prevent false positive and when performing a posterior drawer to prevent a false negative

Answer 142

1. Posterior drawer (most sensitive and specific) * Graded based on posterior translation of the tibial plateau relative to its position on the contralateral side or relative to the medial femoral condyle (MFC) * Grade I * 0-5mm posterior translation OR anterior relative to MFC * Grade II * 6-10mm posterior translation OR even relative to MFC * Grade III * \>10mm posterior translation OR posterior relative to MFC 2. Quadriceps active test * Patient lies supine with the hip flexed to 45° and the knee flexed to 90° and is instructed to slide his or her foot down the table * Positive = tibia shifts anterior 3. Posterior sag * Examiner holds the patient’s lower extremity with the hip and knee each flexed to 90° * Positive = posterior sagging of the tibia or loss of prominence of the tibial tubercle. 4. Dynamic posterior shift test * Leg is extended from start position of hip and knee flexed to 90° * Positive = palpable clunk from reduction of the tibiofemoral joint

Answer 143

Posterolateral corner injury * Dial test * With the patient prone an external rotation force is applied to the feet with the knees at 30° and 90° * Positive = \>10° difference side to side * Only at 30° = PLC * Both at 30° and 90° = PLC and PCL Grade 3 posterior drawer (>10mm) translation is associated with a PLC injury

Answer 144

Kneeling stress views * Measurement between a line parallel to the posterior cortex of the tibia and the posterior aspect of Blumensaat’s line is compared between knees * 0–7 mm of side-to-side difference in posterior displacement constitutes a partial PCL tear * 8–11 mm constitutes an isolated complete PCL tear * ≥12 mm of posterior translation constitutes a combined PCL and PLC or PMC knee injury

Answer 145

Patellofemoral and medial compartment OA * Medial compartment experiences more anterior and medial contact pressures

Answer 146

1. Nonoperative * Isolated grade I and II * Grade III with mild symptoms or low activity demands 2. Operative * Acute or chronic grade III who fail nonoperative management

Answer 147

1. Transtibial tunnel 2. Tibial inlay * Involves creating a trough at the tibial attachment of PCL to match with the graft bone plug fixed with a cannulated screw * Traditional inlay technique requires an open posteromedial approach (Burks) between the semimembranosus tendon and the medial head of the gastrocnemius muscle * Potential benefits * Bony healing * Avoidance of graft abrasion at the so-called killer tibial turn * Large graft sizes

Answer 148

1. Patient is prepped and draped in the lateral decubitus position with affected leg up 2. Outside-in femoral tunnel * Patient is positioned supine * Diagnostic arthroscopy performed and remnant PCL debrided and footprint identified * Medial skin incision is made medial to the patella and through the capsule to identify the guide placement * An outside-in arthroscopic guide is used to place the guide pin which is over-reamed (usually 10mm) * An 18-gauge metal wire loop is then placed through the femoral tunnel into the posterior aspect of the femoral notch for later graft passage 3. PCL graft preparation * Achilles tendon allograft * Bone plug is shaped and predrilled and tapped for a 6.5mm cancellous screw * Tendinous portion is tubularized and sized (10mm) 4. Open tibial inlay * Patient is positioned prone * Burks posteromedial approach is made between the medial head of gastrocs and semimembranosus * Vertical capsulotomy is made and the native PCL insertion is resected with osteotomes and shaped to accept the graft * The graft is fixed bone-to-bone with the 6.5mm screw * The tendinous portion is shuttled to the femoral tunnel with the 18-gauge wire * Wound is closed 5. Graft tensioning * Patient is positioned supine * Graft is tensioned with the knee at 90 and interference screw is used for fixation

Answer 149

One femoral and two tibial attachments * Femoral attachment = 3.2mm proximal and 4.8mm posterior to the medial epicondyle * Proximal tibial attachment = 12.2mm distal to the tibial joint line * Primarily to soft tissue over the termination of the anterior arm of the semimembranosus tendon * Distal tibial attachment = 61.2mm distal to the tibial joint line

Answer 150

1. Primary restraint against valgus stress at 30^oflexion * Secondary restraint to external rotation of the tibia 2. Secondary restraing to tibial internal rotation (along with the posterior oblique ligament) at all flexion angles

Answer 151

Thickening of the capsule with attachments to the medial meniscus * Divided into meniscotibial and meniscofemoral components * Meniscofemoral attachment = 12.6 mm distal and deep to the femoral attachment of the superficial MCL * Meniscotibial attachment = 3.2 mm distal to the medial joint line * Just distal to the tibial articular cartilage

Answer 152

1. Tibial origin * A reflection from the distal semimembranosus tendon insertion on the posteromedial tibia 2. Femoral origin * Central arm of the posterior oblique ligament attaches on the femur 7.7 mm distal and 2.9 mm anterior to the gastrocnemius tubercle

Answer 153

1. American Medical Association Standard Nomenclature of Athletic Injuries * Severity system * Grade I = Localized tenderness and no laxity * Grade II = Localized tenderness and partially torn medial collateral and posterior oblique fibers * Fibers are still opposed, and there may or may not be pathologic laxity * Grade III = Complete disruption and laxity with an applied valgus stress. * Laxity system (subjective gapping of the medial joint line) * Grade 1+ = 3 to 5 mm * Grade 2+ = 6 to 10 mm * Grade 3+ \>10 mm 2. Fetto and Marshall Classification [Iowa Orthop J. 2006; 26: 77–90.] * Grade I = no valgus laxity at both 0 and 30 degrees of flexion * Grade II = valgus laxity at 30 degrees of flexion but stable at 0 degrees of flexion * Grade III = valgus laxity at both 0 and 30 degrees of flexion

Answer 154

Grade I * No valgus laxity at both 0 and 30^oof flexion * Both superficial MCL and POL intact Grade II * Valgus laxity at 30^o of flexion but stable at 0^o of flexion * Superficial MCL disrupted and POL intact Grade III * Valgus laxity at both 0 and 30^o of flexion * Both superficial MCL and POL disrupted * Often associated with an ACL injury

Answer 155

Femoral insertion \> tibial insertion \> midsubstance

Answer 156

1. Stress radiographs [Am J Sports Med. 2010;38:330-8] * Isolated superficial MCL * Medial joint gapping of 1.7mm at 0° and 3.2mm at 20° of flexion * Superficial MCL, deep MCL and POL * Medial joint gapping 6.5mm at 0° and 9.8 mm at 20° of flexion 2. Pellegrini-Stieda syndrome * Intraligamentous calcification in the region of the femoral attachment of the MCL caused by the chronic tear of the ligament

Answer 157

1. Grade 1 or 2 injuries with concern for associated injuries * Relative indications: * Effusion * Suspected cruciate injury * Patellar instability * Lateral joint line pain 2. Grade 3 injuries * Assess for concomitant injuries * Eg. cruciate injury, stener-like lesion of the knee, etc

Answer 158

Grade I * Ligament swelling and edema * Partial tearing with all structures overall intact Grade II * Tearing of some medial structures with others intact * Eg. superficial MCL is torn with deep MCL intact, or vice versa Grade III * Complete disruption of the superficial and deep layers * Often with significant soft tissue fluid and edema from intra-articular fluid leak Bone bruises [J Bone Joint Surg Am. 2010;92:1266-80] * Lateral tibial plateau and lateral femoral condyle \*\*\*Best assessed on the coronal images

Answer 159

Defined as a distal tear of the superficial MCL with proximal retraction and interposition of osseous or soft-tissue structures between the ligament and its tibial attachment * Prevents anatomic healing and with potential for secondary dynamic valgus instability * Most commonly stener-like lesions represent interposition of the pes anserinus (83%) * May also involve entrapment of the distal tibial portion of the superficial MCL in the tibiofemoral joint or in a reverse Segond fracture (17%)

Answer 160

1. High association with multi-ligament knee injuries * Most common associated ligament injury being ACL 2. Prevents anatomic reduction and healing resulting in valgus instability

Answer 161

Acute open reduction and repair

Answer 162

Isolated Grade I, II and III MCL injuries

Answer 163

1. Acute repair * Large bony avulsion * Stener-like lesion of the knee * Pes anserine entrapment * Intra-articular entrapment * MRI finding of complete tibial sided avulsion in athletes * Presence of AMRI * Presence of valgus instability in 0 degrees of flexion in an underlying valgus knee alignment * Associated tibial plateau fracture 2. Delayed repair * Combined ACL or other ligament reconstruction if the EUA shows valgus laxity in 0 degrees of flexion 3. Augmentation * Combined with any repair if local tissue is deficient 4. Reconstruction * Symptomatic chronic valgus laxity/medial instability 5. Distal femoral varus osteotomy * Chronic valgus laxity and valgus bony alignment

Answer 164

1. Sutures alone 2. Suture plus suture anchor 3. Staple 4. Screw and washer

Answer 165

Semitendinosus autograft * Released proximally at the musculotendinous junction leaving the distal insertion intact * Distal tibial fixation 6 cm from the proximal joint line with two double-loaded suture anchors * Graft is then passed deep to the sartorius fascia * Femoral fixation in a closed socket tunnel 3.2 mm proximal and 4.8 mm posterior to the medial epicondyle and fixed with an interference screw * Proximal tibial attachment is then secured 12 mm distal from the proximal joint line using a double loaded suture anchor

Answer 166

1. Single anteromedial incision 2. Two separate grafts 3. 4 reconstruction tunnels at anatomic femoral and tibial insertions of the superficial MCL and POL 4. Proximal tibial insertion of the superficial MCL is recreated with suture anchors 5. Superficial MCL is tensioned at 30^o flexion 6. POL is tensioned at 0^oflexion

Answer 167

1. Femoral origin * 1.4 mm proximal and 3.1 mm posterior to the lateral epicondyle 2. Fibula origin * 28.4 mm distal to the tip of the fibular styloid

Answer 168

1. Primary varus stabilizer at 0° and 30° of flexion 2. Secondary restraint against tibial internal and external rotation

Answer 169

Varus stress test * Isolated LCL injury * Laxity at 30° and stable at 0° of flexion * LCL injury combined with PLC +/- cruciates * Laxity at both 30° and 0° of flexion

Answer 170

1. Arcuate fracture * Avulsion of the fibular head or portion of 2. Varus stress radiograph * Isolated LCL injury = 2.7mm lateral gapping * LCL and grade III PLC injury = 4.0mm lateral gapping

Answer 171

Grade I * Subcutaneous fluid surrounding the midsubstance of the ligament at one or both insertions Grade II * Partial tearing of ligament fibers at either the midsubstance or one of the insertions, with increased edema in the area Grade III * Complete tearing of ligament fibers at either the midsubstance or one of the insertions * Associated with increased edema

Answer 172

Grade I and II injury

Answer 173

Acute avulsion injury (within 3 weeks)

Answer 174

1. Acute Grade III midsubstance tears or attenuation 2. Chronic LCL injury with symptomatic instability

Answer 175

Chronic symptomatic LCL injury with varus deformity * HTO should precede reconstruction * May eliminate need for reconstruction in some cases

Answer 176

1. Lateral collateral ligament 2. Popliteus tendon 3. Popliteofibular ligament

Answer 177

1. Posterolateral capsule 2. Lateral meniscus 3. Iliotibial band 4. Fabellofibular ligament 5. Long and short heads of the biceps femoris 6. Lateral head of gastrocnemius muscle

Answer 178

1. Lateral collateral ligament * Proximal attachment * Proximal and posterior to the lateral epicondyle of the femur * Distal attachment * Lateral aspect of the fibular head * 8.2mm posterior to the anterior margin of the fibular head and 28.4mm distal to the fibular styloid tip 2. Popliteus tendon * Proximal attachment * Anterior and distal to the lateral epicondyle * At the anterior 1/5 of the popliteal sulcus, just posterior to the lateral femoral condyle articular cartilage * Attachment is 18.5mm oblique from the LCL femoral attachment * Distal attachment * Proximal posteromedial aspect of the tibia * \*\*\*Note: The tendon passes from intra-articular through the popliteal hiatus to become extra-articular * Gives off 3 popliteomeniscal fascicles to anchor to the lateral meniscus 3. Popliteofibular ligament * Proximal attachment * Musculotendinous junction of the popliteus * Distal attachment * Posteromedial downslope of the fibular styloid process

Answer 179

1. Failure of cruciate reconstructions 2. Recurrent instability

Answer 180

1. External rotation recurvatum test * Lower leg is picked up by the great toe * Relative hyperextension, tibial external rotation and knee varus compared to the contralateral side 2. Posterolateral rotary drawer test * With the knee flexed to 90°, the hip flexed to 45°, and the foot fixed in slight external rotation (usually best at 15°), a posteriorly directed force is applied through the tibial tuberosity * The PCL is relaxed in this position, allowing rotary and translator laxity * With an isolated PLC injury * More rotatory instability with slight ER than with neutral rotation because the PCL provides more translational stability with neutral rotation * With an isolated PCL injury * More translatory instability than rotary instability will be present 3. Dial test * Patient prone, external rotation applied to foot and thigh foot angle compared side to side at 30 and 90 of knee flexion (Positive = 10^odifference) * Increased at 30° = isolated PLC * Increased at 30° and 90° = PLC and PCL 4. Standing apprehension test * Patient stands with the knee slightly bent and internally rotates the torso away from the leg, producing an internal rotation of the femur on the tibia * Positive = Apprehension or instability

Answer 181

1. Hughston classification * Severity graded on varus laxity * Grade I = 0 to 5mm * Sprains without tensile failure of any capsule-ligamentous structures * Grade II = 6-10mm * Partial injuries with minimal abnormal laxity * Grade III = \>10mm * Complete disruptions with significant laxity 2. Fanelli classification * Severity graded on external rotation and varus laxity * Type A * Isolated rotational injury to the PFL and popliteus tendon complex * Type B * Rotational injury with a mild varus component * Represents an injury to the PFL and popliteus tendon complex, as well as attenuation of the LCL * Type C * Posterolateral instability with significant rotational and varus component secondary to complete disruption of the PFL, popliteus tendon complex, LCL, lateral capsule, and cruciate ligament or ligaments 3. Modified Hughston classification * Severity graded on ER and varus laxity * Grade I * Minimal instability * Either varus or rotational instability of 0 to 5mm or 0° to 5° * Grade II * Moderate instability (6 to 10mm or 6° to 10°) * Grade III * Significant instability (\>10 mm or \>10°)

Answer 182

Acute, isolated Grade I and II PLC injuries

Answer 183

1. Isolated grade III PLC injuries 2. Combined PLC injuries 3. Chronic symptomatic PLC injury failing nonoperative management

Answer 184

Acute (\<3 weeks) LCL and popliteus tendon avulsions, without midsubstance injury

Answer 185

Anatomical reconstruction * Reconstruction of primary PLC components * LCL, popliteus tendon and PFL * Repair of secondary structures (hybrid construct) \*\*\*Note: Valgus producing HTO should precede or occur concurrently with reconstruction in varus knees

Answer 186

1. Larson [Arthroscopy. 2002 Feb; 18(2 Suppl 1): 1-8] 1. Main features 1. Single femoral tunnel at the lateral epicondyle (isometric point) ii. Fibular tunnel directed from anterior to posterior ili. Graft limbs reconstruct the LCL and popliteofibular ligament 2. Arciero [Arthroscopy: 2005 Sep;21(9): 1147] 1. Main features 1. 2 femoral tunnels near the anatomic footprint of the LCL and popliteus 2. Fibular tunnel oriented anterolateral to posteromedial starting just distal to the LCL fibular insertion 3. 2 separate graft limbs reconstruct the LCL and popliteus tendon in a more anatomic orientation 3. Laprade /Arthrosc Tech. 2016 Jun; 5(3): e563-e572.] 1. Main features 1. 2 femoral tunnels at the anatomic footprint of the LCL and popliteus 2. Tibial tunnel located from posterolateral proximal tibia (location of popliteus musculotendinous junction) to anterior tibia between tibial tubercle and Gerdy's tubercle 3. Fibular tunnel from LCL attachment to the posteromedial down slope of the fibular styloid 4. Graft limbs reconstruct the LCL, popliteus and popliteofibular ligament

Answer 187

- length = 7.5-8cm (myotendinous junction to superior pole of patella) - patient heightis the strongest predictor of length - width = 2.5-3cm - widest point is 3cm proximal to the superior pole of the patella - thickness = 18 +/- 3mm for males, 16 +/- 2mm for females

Answer 188

- all soft tissue - quadriceps tendon with proximal patellar bone block

Answer 189

- thicker - patellar tendon thickness is less than 6mm - greater intra-articular volume - 87.5% greater compared to BTB - more native quadriceps tendon remaining after harvest compared to patellar tendon

Answer 190

1. predictability of graft size and volume 1. compared to BTB autograft, there is a greater intra-articular volume and greater residual tendon remaining 2. no studies demonstrating tunnel-widening 3. decreased anterior knee pain and kneeling (compared to BTB) 4. less risk to the infrapatellar branch of the saphenous nerve (compared to BTB) 5. more flexion strength and hanstring/quad isokinetic ratio compared to hamstring 6. similar funcitonal outcomes compared to BTB and hanstring 1. including stability, patient reported outcomes, ROM, strength and failure/rupture rates

Answer 191

- hematoma formation (Due to hypervascular region) - cosmetic defects - popeye like sign has been associated with too proximal harvest into rectus myofascia funciton - patellar fractures - recommended that harvest is less than 30% thickness of patella

Answer 192

1. <5% 1. failure rate as high as 28% in young active males

Answer 193

1. technical errors 2. younger age 3. higher activity level 4. irradiated allograft 5. lower limb malalignment 6. increased posterior tibial slope

Answer 194

technical error - improper tunnel placement outside the native femoral and tibial ACL footprints

Answer 195

1. non anatomic tunnel placement 2. improper graft tensioning 3. inadequate graft fixation 4. insufficient graft material

Answer 196

1. Errors in femoral tunnel placement a. Too anterior = excessive graft tensioning with flexion leading to loss of knee flexion or stretching of the graft b. Too posterior = excessive graft tension in extension with laxity in flexion c. To vertical = inadequate rotational stability 2. Errors in tibial tunnel placement a. Too anterior = notch impingment and loss of extension b. Too posterior = PCL impingement and loss of flexion c. Too medial/lateral = notch impingement and iatrogenic tibial plateau cartilage damage

Answer 197

tunnel widening >15mm or >100% original diameter substantial tunnel overlap infection arthrofibrosis

Answer 198

1. appropriately placed tunnels 2. good bone stock 3. hardware that can be removed or will not obstruct revision 4. inappropriately placed tunnels that do not interfere with anatomically placed tunnels - if previous femoral tunnes violate blumensaat's line then an anatomically placed tunnel can be placed while avoiding the previous tunnel

Answer 199

- increased posterior tibial slope - procedure tibial deflexion osteotomy (anterior closing wedge) - failed revision ACL reconstruction with posterior tibial slop >12° - varus malalignment - procedure - high tibial osteotomy - indications - medial compartment arthritis - varus thrust - instability in double and triple varus - anterolateral rotatory instability - procedure - anterolateral ligament reconstruction or lateral extra-articular tenodesis - indications - grade 3 pivot shifts - ACL reconstruction failure with no other identifiable cause - meniscal deficiency - procedure = meniscal repair - indications - RAMP lesions - repairable meniscal lesions - procedure = meniscal allograft transplantation - indications = irreparable meniscal tears or previous total or near-total meniscectomies

Answer 200

Anterior 1/3 * Medial border of the patellar tendon to the anterior border of the superficial MCL Middle 1/3 * Width of the superficial MCL Posterior 1/3 * Posterior border of the superficial MCL to the medial border of the medial head of gastrocnemius * Posterior 1/3 = posteromedial corner

Answer 201

1. Posterior oblique ligament 2. Semimembranosus tendon and its expansions 3. Oblique popliteal ligament 4. Posteromedial joint capsule 5. Posterior horn of the medial meniscus

Answer 202

1. Proximal attachment * Distal and posterior to the adductor tubercle 2. Runs distally and posterior at 25° to the superficial MCL fibres 3. Distally has 3 arms * Superficial * Central (tibial) * Largest and thickest * Reinforces the posteromedial capsule * Attaches to the posteromedial aspect of the medial meniscus and adjacent tibia * Main structure requiring repair or reconstruction * Capsular

Answer 203

1. Pars reflecta (anterior arm) * Inserts into medial tibia 2. Direct posteromedial tibial insertion (primary attachment) * Inserts into posteromedial tibia (tuberculum tendinis) 3. OPL insertion 4. POL insertion 5. Popliteus aponeurosis expansion

Answer 204

Extends from the main semimembranosus tendon passing laterally and proximal to attach to the posterior capsule (meniscofemoral portion), fabella, and plantaris muscle * Difficult to distinguish from the posterior capsule

Answer 205

1. Posteromedial capsule (deep MCL) 2. POL 3. Semimembranosus expansion

Answer 206

1. POL + semimembranosus tendon [capsular arm] (70%) 2. POL + complete peripheral meniscus detachment (30%) 3. POL + semimembranosus tendon + peripheral meniscus detachment (19%) NOTE: isolated PMC injury is rare

Answer 207

1. AMRI (anteromedial rotatory instability) * Hallmark of PMC injury * Characterized by anterior subluxation of the anteromedial tibia on the femoral condyle * Valgus stress at 30° flexion with foot externally rotated * Positive = medial joint gapping and anterior subluxation of the medial tibial plateau relative to the femur * Correlates with combined MCL and PMC 2. Anterior drawer with foot 15° externally rotated * Positive = anteromedial tibial plateau subluxation * Indicates PMC injury 3. Valgus stress at 0° * Positive = gapping of medial joint line * Suggests MCL, cruciate and PMC injury 4. Posterior drawer with tibia in neutral and internal rotation * Positive = equal posterior translation * PCL and PMC injury * Decreased posterior translation with internal rotation suggests isolated PCL injury

Answer 208

1. Multiligamentous injuries with AMRI 2. Medial gapping or instability with valgus stress at full extension 3. Positive posterior drawer with internal rotation

Answer 209

Acute injury * Particularly with distal tibial sided MCL and PMC tears

Answer 210

1. PMC tissue is not favourable (attenuated, midsubstance) 2. Chronic, symptomatic PMC injuries

Answer 211

2 grafts to reconstruct * Superficial MCL * Distal tunnel 6cm below joint line * Proximal tunnel just proximal and anterior to the medial epicondyle * Tensioned in 20° flexion and neutral rotation * Proximal tibial attachment is made with a suture anchor 12-13mm distal to joint line * POL * Distal tunnel just anterior to the direct arm attachment of the semimembranosus * Proximal tunnel 8mm distal and 3mm anterior to the gastrocnemius tubercle * Tensioned and fixed in full extension and neutral rotation

Answer 212

1. Chronic valgus laxity 2. Late graft failure after ACL reconstruction

Answer 213

Quadriceps tendon can be divided into 3 zones relative to the superior pole of the patella a. Zone 1 (0 to 1cm) b. Zone 2 (>1 to 2cm) - most common (relatively avascular) c. Zone 3 (>2cm)

Answer 214

1. Long standing tendinopathy 2. Diabetes 3. Thyroid disorders 4. Renal disease 5. Hyperlipidemia 6. Systemic inflammatory disease 7. Medications (statins, fluoroquinolones) 8. Age (>40) 9. Men

Answer 215

Within 2 weeks of injury

Answer 216

Heavy non-absorbable suture in locking fashion grasping the quadriceps tendon, sutures are passed through drill holes in the patella and tied over bone bridge (transosseous tunnel fixation)

Answer 217

Smaller incision, less dissection, reduced operative time, decreased gap formation, increased load to failure

Answer 218

1. Primary = medial and lateral geniculate arteries (both superior and inferior) * Gives rise to a perimeniscal capillary plexus in the synovial and capsular tissue supplying the peripheral meniscus (10-30%) 2. Secondary - middle geniculate artery * Within the synovial sheath of the cruciate ligaments * Supplies the anterior and posterior horns for short distance 3. Relative avascular area of the lateral meniscus at the posterolateral aspect adjacent to the popliteus tendon 4. Three vascular zones [AAOS comprehensive review 2, 2014] * Red-red – peripheral 1/3 (vascular) * Red-white – middle 1/3 (avascular) * White-white – central 1/3 (avascular)

Answer 219

no differences in patient reported outcomes, strength, ROM or re-tear rate

Answer 220

1. Recurrent peroneal branch of the common peroneal nerve 2. Mechanoreceptors and free nerve endings located in the anterior and posterior horns and peripheral 1/3-2/3

Answer 221

- Transverse/intermeniscal ligament - Coronary ligament - Anterior meniscofemoral ligament (of Humphrey) - Posterior meniscofemoral ligament (of Wrisberg) - Deep MCL (meniscotibial and meniscofemoral ligaments) - (meniscal root attachment)

Answer 222

1. Meniscal flounce = a buckle in the meniscus due to knee position 2. Significance = normal finding, the absence of a flounce should prompt the surgeon to probe the meniscus for an occult tear

Answer 223

1. Double-PCL sign (sagittal) 2. Fragment in the intercondylar notch (coronal) 3. Double anterior horn sign/Double delta sign (sagittal) 4. Absent bow-tie sign (sagittal)

Answer 224

- Based on history, physical and imaging there are five main meniscal tear scenarios: - Locked knee - Treatment = urgent arthroscopic surgery - Acute injury + repairable meniscus tear - Treatment = consider arthroscopic surgery if patient is a suitable candidate - No recommended timeline for repair - shared decision between surgeon and patient - Non-Acute injury + meniscus tear is treatable - Treatment = at least 3 months of non-operative treatment - Consider non-urgent arthroscopic surgery if symptoms persist >3 months - Non-Acute injury + meniscus tear is possibly treatable - Treatment = at least 6 months of nonoperative treatment - Consider non-urgent arthroscopic surgery in selected cases if symptoms persist >6 months - Advanced arthritis + meniscus tear - Treatment = nonoperative - Arthroscopic surgery is not appropriate

Answer 225

1. Load transmission * Converts compressive forces into concentric forces * Hoop stresses transmitted to bony anchors of meniscal horns by circumferential fibres of meniscus * Diminishes forces on articular cartilage * 40-60% of the load in extension and up to 90% in flexion 2. Shock absorption 3. Stability (limits motion in all directions) 4. Proprioception 5. Joint lubrication and nutrition (?theoretical)

Answer 226

1. Tear > 1cm but <4cm in length 2. Red-red zone tears (that tears within 2 mm of the meniscal vascular rim) 3. Vertical/longitudinal tears 4. Age <40 years 5. Acute tears (<6 weeks) 6. Concurrent ACL reconstruction 7. No mechanical malalignment 8. Radial tears that extend entire width of meniscus 9. Meniscal root tears

Answer 227

1. Inside-out (gold standard) 2. Outside-in 3. All inside

Answer 228

1. Medial approach * 4cm vertical incision posterior to MCL * 1/3 above joint and 2/3 below joint * Sartorial fascia is opened inline * Pes anserinus tendons are taken distal * Interval between the medial head of gastrocs and capsule is developed staying proximal to semimembranosus tendon * Spoon is inserted in this interval 2. Lateral approach * 4cm oblique incision starting at Gerdy’s extending proximal and anterior * ITB is split in line with its fibres * Staying posterior to LCL and anterior to the biceps femoris the interval between the lateral head of gastrocs and the capsule is developed * Spoon is inserted in to this interval

Answer 229

Dissipate axial loads by conversion to hoop stresses * Axial load causes circumferential fibres to stretch and meniscus to extrude * Tensile ‘hoop stress’ resists this extrusion in the presence of intact meniscal roots * Distribution of hoop stresses by the circumferential fibers helps to transmit relatively even axial loads across the joint surfaces

Answer 230

1. Meniscal extrusion 2. Loss of hoop stress 3. Increased tibiofemoral contact pressures * Equivalent to total meniscectomy 4. Accelerated degenerative changes

Answer 231

1. Joint line tenderness 2. Pain in deep knee flexion 3. Positive McMurray test 4. Effusion 5. Locking 6. Giving way

Answer 232

1. Radial tear of the meniscal root on axial imaging 2. Truncation sign * Vertical linear defect in the meniscal root on coronal imaging 3. Ghost sign * Increased signal in the meniscal root on sagittal sequences 4. Meniscal extrusion \>3 mm outside the peripheral margin of the joint on coronal imaging 5. Ipsilateral tibiofemoral compartment bone marrow edema and insufficiency fractures are commonly noted in the presence of posterior meniscal tears

Answer 233

Posterior root of the medial meniscus * Least mobile of all roots

Answer 234

LaPrade classification * Type I * Partial root tear * Type II * Complete radial root tear * Type III * Complete root tear + bucket handle tear * Type IV * Oblique tear into root attachment * Type V * Root avulsion fracture

Answer 235

Nonoperative * Sedentary lifestyle * Extensive medical comorbidities * Advanced signs of osteoarthritis * Outerbridge grade 3 or 4 * Joint-space narrowing * Marked varus malalignment (\>5°) * Chronic, degenerative, irreparable tears Operative * Healthy individuals * Minimal or no degenerative changes * Outerbridge grade 1 or 2 * Minimal to no joint-space narrowing * Normal mechanical alignment * Intact cruciate ligaments

Answer 236

1. Partial meniscectomy * Chronic tears with advanced degenerative changes * Outerbridge grade 3 or 4 2. Meniscal root repair * Acute tears * Goal of preventing arthritis * Chronic tears with no or little articular cartilage wear * Outerbridge grade 1 or 2 * Goal of symptomatic relief

Answer 237

Restore an anatomical attachment of the meniscal root to bone that is capable of converting axial weight-bearing loads into hoop stresses * Thereby improving symptoms and function and ultimately preventing or delaying onset of degenerative changes

Answer 238

1. Transtibial pullout repair * Anatomical position of the meniscal root is identified, debrided, and prepared for repair * An ACL tibial drill guide is utilized to drill a guide pin or a retro-cutting reamer into position through a small incision at the anteromedial aspect of the proximal aspect of the tibia * #2 nonabsorbable sutures are passed through the substance of the torn meniscal root with a suture-passage device * Suture limbs are shuttled through the transtibial tunnel, tensioned, and fixed with use of whatever fixation construct the surgeon prefers with the knee in 30° of flexion * Typically a cortical button or screw and washer 2. Suture anchor repair * Utilizes accessory posteromedial and posterolateral portals * Under arthroscopic visualization, the anatomical position of the meniscal root is identified, debrided, and prepared for repair * A double-loaded suture anchor is inserted at the meniscal root site and suture passage is performed with use of a suture lasso through the accessory portal or with use of a rotator cuff-type suture-passage device through the anteromedial or anterolateral portal * Once passed, the suture limbs are tied arthroscopically with the knee in 30° of flexion, with the arthroscopic knots being kept posterior, away from the articular surfaces of the affected compartment

Answer 239

1. Transosseous fixation * Bone tunnels may interfere with concomitant ligament reconstruction * Risk of suture abrasion within bony tunnel * Risk of creep in the suture * Decreases strength of repair 2. Suture anchor repair * Anchor pullout * Technically difficult 3. Other * Retear and progression of arthritis * Infection * Arthrofibrosis * DVT * Iatrogenic injury to cruciates * Iatrogenic injury to posterior neurovascular structures

Answer 240

1. Thicker 2. Less peripheral vascularity 3. Cover a larger surface area of the tibial plateau (may cover entire plateau - "true disc") 4. Decreased collagen fibers in a more disorganized circumferential arrangement 5. Intrameniscal mucoid degeneration

Answer 241

1. Watanabe 1. Type I - stable, complete discoid meniscus (most common) 2. Type II - stable, incomplete discoid meniscus (covers ≤80% of plateau) 3. Type III - unstable Wrisberg variant (lacks posterior meniscotibial attachment; only has the meniscofemoral ligament of Wrisberg)

Answer 242

1. Knee pain, popping, snapping, and a lack of terminal extension

Answer 243

1. Squaring of the lateral femoral condyle 2. Cupping of the lateral tibial plateau 3. Widening of the lateral joint space up to 11 mm 4. Hypoplastic lateral tibial spine

Answer 244

1. Transverse meniscal diameter > 15 mm between the free margin and the periphery of the body on a coronal view 2. Continuity between the anterior and posterior horns of the menisci (i.., bow tie sign) noted on at leas three consecutive 5-mm-thick sagittal slices 3. Enlarged "bow-tie" appearance on a single sagittal slice 4. Ratio of the minimal meniscal width to maximal tibial width (on the coronal MRI slice) of more than 20%

Answer 245

1. Nonoperative a. Asymptomatic b. Discoid menisci identified incidentally at arthroscopy should not be treated 2. Operative 1. Symptomatic

Answer 246

1. arthroscopic saucerization with rim preservation +/- stabilization 1. preserve meniscus with intact 6-8mm peripheral rim of meniscal tissue is recommended 2. stabilization is added for watanabe type III

Answer 247

1. 70% - posterolateral aspect of the medial femoral condyle 2. 15% - inferior central aspect of the lateral femoral condyle 3. 5-10% - inferior medial aspect of the patella 4. \<1% - trochlea

Answer 248

Discoid lateral meniscus

Answer 249

1. Juvenile (open physis) 2. Adult (closed physis)

Answer 250

The knee is extended from 90-30 while internally rotating the tibia * Positive = reproduction of symptoms with internal rotation and relief with external rotation

Answer 251

1. High-signal intensity behind the lesion 2. Cystic area beneath the lesion 3. High-signal intensity through the articular cartilage 4. Focal articular defect

Answer 252

radiograhpic - berndt and harty - stage 1 - small area, compression of subchondral bone - stage 2 - partially detached OCD fragment - stage 3 - fully detached OCD fragment, still in underlying crater - stage 4 - compete detachment/loose body mri = di paola type I - thickening of articular cartilage but no break type II - breached articular cartilage, low signal rim behind fragment indicating attachment type III - breached articular cartilage, with high signal T2 changes behind fragment suggesting fluid around lesions type IV - loose body and defect of articular surface arthroscopic - rock studh group 6 arthroscopic categories 3 immobiles types 1. cue ball - no abnormality 2. shadow - cartilage is intact and suptly demarcated 3. wrinkle in the rug - cartilage is demarcated with a fissure, buckle and/or wrinkle 3 mobile types 1. locked door = cartilage fissuring at periphery unable to hinge open 2. trapdoor = cartilage fissuring at periphery able to hinge open 3. crater = exposed subchondral bone defect

Answer 253

1. High signal line between the OCD lesion and underlying bone on T2-MRI (unstable) 2. Skeletal maturity (older age) 3. Larger lesion 4. Patellar and lateral femoral condyle OCD lesions 5. Cyst ≥1.3mm behind the lesion 6. abnormal surface cartilage 7. viability of the fragment 1. can be determine on MRI post-gad T1 image with fat saturation - low signal compared epiphyseal bone suggests poor viability

Answer 254

Clanton Classification * Type I - depressed osteochondral fracture * Type II - fragment attached by osseous bridge * Type III - detached non-displaced fragment * Type IV - displaced fragment

Answer 255

Stable lesion

Answer 256

\*\*\*No consensus 1. TTWB 4 weeks 2. Activity restriction (no running and sport) for 8 weeks 3. MRI at 12 weeks * If no improvement in symptoms = consider surgery * If symptoms resolved and MRI improved = progress activity with full return after 4 weeks * If symptoms improved but MRI is unchanged = continue activity restriction and repeat MRI in 12 months * If no improvement = surgery

Answer 257

1. Unstable lesion 2. Displaced lesion 3. Failure of nonoperative management * 6 months for juvenile, 3-6 months for adult 4. Symptomatic loose bodies

Answer 258

1. Stable symptomatic lesion * Retrograde or transarticular drilling * Equivalent effectiveness 2. Unstable, nondisplaced * Internal fixation with bioabsorbable or metal pins, nails or screws 3. Unstable, nondisplaced with cyst * bone grafting and internal fixation 4. Unstable, displaced * internal fixation of fragment * Fragment trimming due to hypertrophy 5. Unsalvageable fragment * Excision = small fragments (\<2cm) * Microfracture * ACI/MACI * Osteochondral autograft or allograft 6. Consider osteotomy or patellar realignment to offload the lesion

Answer 259

Indications * Outerbridge or International Cartilage Repair Society grade III or IV focal chondral or osteochondral defects Contraindications * Inflammatory arthritis * Lower grade lesions * Inability to comply with postoperative protocol

Answer 260

\<2cm² – microfracture OR OATs * OATS better in higher demand patient 2-4cm²- OATs or ACI \>4cm2 – ACI or osteochondral allograft (better in defects with bone loss or deformity)

Answer 261

1. Create a contained lesion with stable shoulders * Remove the calcified cartilage layer at the base of the lesion * Prepare the channels by perforating the subchondral bone with a 45° awl approx. 3-4mm in depth * Fat droplets from the marrow should be visualized, blood should be visualized with water off * Space the channels 3-4mm apart * Allows for clot formation and migration of marrow-derived mesenchymal stem cells promoting fibrocartilage repair 2. Postoperative * nonWB for 6 weeks with crutches * CPM from 0-60° for 6 weeks, 6-8 hours per day * Full ROM and closed chain exercises at 2 months * Full return to activity at 3 months

Answer 262

Advantages * Technically straightforward * Low cost * Minimal morbidity Disadvantages * Fibrocartilage rather than hyaline cartilage * Results deteriorate over time

Answer 263

Multiple small autogenous osteochondral plugs are harvested from less weightbearing areas and transferred to fill a defect * Plugs are approx. 10mm in depth, impacted in donor site to match the height of the adjacent cartilage * Periphery of femoral condyles and intercondylar notch are donor sites

Answer 264

Advantages * Hyaline cartilage transferred * Less postoperative restrictions * Single procedure Disadvantages * Limited availability of graft * Donor site morbidity * Different thickness and mechanical properties of cartilage from donor to recipient site * Graft subsidence * Dead space between grafts * May require arthrotomy

Answer 265

Cadaver graft consisting of intact, viable articular cartilage and subchondral bone is transferred in the defect

Answer 266

Advantages * No donor site morbidity * Can fill large defects * Hyaline cartilage transferred * Single stage * Can achieve precise surface architecture * Eliminates dead space Disadvantages * Limited graft availability * High cost * Risk of immunological reaction and disease transmission * Possible incomplete graft incorporation * Technically demanding machining and sizing the allograft

Answer 267

- Young active patient - Posttraumatic osteochondral defects - Osteonecrosis - Osteochondritis dissecans - Large (≥2 cm2) focal defects - Previous cartilage repair failure - Patellofemoral joint cartilage lesion

Answer 268

- Relative - BMI >35 - Concomitant ligament or meniscal injury - Uncorrectable malalignment of the knee joint - Inflammatory arthritis - Smoking or corticosteroid use - Absolute - Advanced osteoarthritis (bipolar lesions) - Poor surgical candidate - Chronic posttraumatic defect

Answer 269

- radiographs - routine WB with sizing markers - full length alignment films - MRI - assess for concomitant pathology - assess lesion size and location

Answer 270

Two stage procedure * First for tissue harvest * 100-300mg of articular cartilage from nonWB surface * Sent for culture and expansion of donor chondrocytes * Second for cell implantation into the prepared recipient site * 3-8 weeks after the first stage * Cells are injected beneath a collagen membrane or periosteal patch sutured over the defect

Answer 271

Advantages * Hyaline cartilage produced Disadvantages * Two stage procedure * Technically demanding * High cost * Requires arthrotomy

Answer 272

Chondrocytes are incorporated into a collagen membrane eliminating the need for periosteal harvest and makes for a more even cell distribution on the membrane

Answer 273

1. Standard * Anterolateral * Anteromedial 2. Accessory [JBJS 2006; 88(4):110] * Posteromedial * Location * Soft spot between MCL, medial head of gastrocs and semitendinosus tendon * Technique * Perform with knee at 90 * Knee joint distended * Direct visualization with transcondylar notch view * Soft spot is localized with a spinal needle * Superficial incision * Blunt dissection with hemostat and joint capsule is penetrated * Risk * Saphenous nerve (sartorial branch) * Posterolateral * Location * Soft spot between LCL, lateral head of gastrocs, posterolateral tibial plateau and biceps femoris * Technique * Perform with knee at 90 * Knee joint distended * Direct visualization with transcondylar notch view * Soft spot is localized with a spinal needle * Superficial incision * Blunt dissection with hemostat and joint capsule is penetrated * Risk * Common peroneal nerve * Posterior transeptal portal * Location * Involves resection of the posterior septum from the posterolateral portal to enter the posteromedial compartment under visualization from the posteromedial portal * Posterior septum is a triangle-shaped two-layer synovial reflection that divides the posterior aspect of the knee into posteromedial and posterolateral compartments * Bounded by the posterior cruciate ligament anteriorly, the posterior portion of the femoral intercondylar notch superiorly, and the posterior aspect of the capsule posteriorly * Risk * Popliteal artery (inferiorly) and middle geniculate artery (superiorly)

Answer 274

1. Increased pump pressure 2. Reduce outflow suction 3. Asd epinephrine to fluid 4. Controlled hypotension (anaesthesia) 5. Tourniquet 6. Drive arthroscope to bleeding source 7. Cautery 8. TXA