Sports - RC Q's

Question 1

RC 2012 - Contra-indications to HTO?

Answer 1

-Pt: BMI>35, older age<div>-O/E: flex<90, flex contracture>15 deg</div><div>-inflammatory arthritis, PF arthritis,</div><div>-alignment >20 deg</div><div>-absent contra-lateral meniscus</div>

Question 2

RC 2017 - Complications of valgus producing HTO

Answer 2

early: compartment syndrome, peroneal nerve palsy, patella baja, loss of posterior slope<div>late: non-union, malunion, recurrent deformity</div>

Question 3

<div>RC 2016 - All of the following are risk factors for ACL tear except:</div>

<ol> <li>Female</li> <li>Cavovarus</li> <li>Increased Q-angle</li> <li>Increased BMI</li></ol>

Answer 3

<ul> <li>Answer: B</li><li>JAAOS 2000 - Noncontact ACL Injuries: Risk Factors and Prevention Strategies</li> <ul> <li>Environmental:</li> <ul> <li>Equipment</li> <li>Shoe-surface interaction</li> </ul> <li>Anatomic:</li> <ul> <li>Knee angle</li> <li>Hip angle</li> <li>Laxity</li> <li>Notch size</li> </ul> <li>Hormonal</li> <li>Biomechanical:</li> <ul> <li>Muscular strength</li> <li>Skill level</li> <li>Neuromuscular control</li> <li>Body movement</li> </ul> </ul></ul>

Question 4

<div>RC 2014 - Where is the posterolateral bundle of the ACL tightest?</div>

<ol> <li>Extension </li> <li>30 degrees flexion </li> <li>90 degrees flexion</li> <li>Same in all degrees flexion/extension</li></ol>

Answer 4

“A.<div>posterior bundles are always tightest in EXTENSION<div>-PL bundle of ACL</div><div>-PM bundle of PCL</div></div><div><img></img><br></br></div><div><img></img><br></br></div>”

Question 5

<div>RC 2012, 2008 - What is true regarding ACL tunnel Placement</div>

<ol> <li>Tibial tunnel is most important</li> <li>If femoral tunnel is too posterior, graft lengthens in flexion</li> <li>If femoral tunnel too anterior, graft lengthens in flexion</li> <li>Over the top femoral placement of graft does not change in extension</li></ol>

Answer 5

“<div>Answer: C</div><div><img></img><br></br></div><div>IN GENERAL:</div>Too anterior: excessive graft tension in flexion<div>Too posterior: excessive graft tension in ext (remember posterior structures always tight in extension!)</div><div><br></br></div><div><img></img><br></br></div>”

Question 6

RC 2013 - Chronic ACL all associated except: <ol> <li>Increased risk of OA</li> <li>ACL recon has not been shown to decrease OA </li> <li>More chance of damaging cartilage and meniscus</li> <li>More likely to damage lateral as opposed to medial meniscus</li></ol>

Answer 6

<div>D.</div>

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

-medial meniscus injury<div>-increase chondral injury<br></br><div>-increase risk OA</div><div><br></br></div><div>note: ACL recon has not been shown to decrease risk of OA</div></div>

Question 7

<div>RC 2010 -What is not associated with a poor prognosis after ACL injury?</div>

<ol> <li>Hearing a pop at time of injury</li> <li>Smoking</li> <li>Gain 15lbs in first year</li> <li>Wearing a brace for 1-year post-op</li></ol>

Answer 7

<div>Answer: D</div>

<div><ul> <li>OKU 9:</li> <ul> <li>Independent poor predictors after ACL reconstruction:</li> <ul> <li>Smoking</li> <li>Recollection of hearing a pop at injury</li> <li>Weight gain of 15lbs</li> <li>No change in educational level since injury</li> </ul> </ul></ul></div>

Question 8

RC 2008 Hamstrings tendon grafts in ACL reconstruction, all are true except: <ol> <li>Previous MCL injury is a contra-indication to using hamstring tendon</li> <li>Ligamentous laxity is a contraindication to using hamstring tendon</li> <li>Sprinter is a contraindication to using hamstring tendon</li> <li>Previous hamstring injury is a contra-indication to using hamstring tendon</li></ol>

Answer 8

<div>ANSWER: A</div>

<ul> <li>JAAOS 2005 - Graft Selection in ACL Reconstruction</li> <ul> <li>Contra-indications to hamstring autograft:</li> <ul> <li>Generalized ligamentous laxity</li> <li>Competitive sprinters</li> <li>Previous hamstring injury</li> </ul> </ul></ul>

Question 9

<div>RC 2011 - Post ACL reconstruction. What will predict arthritis?</div>

<ol> <li>degree of pre-op AP laxity</li> <li>intra-op findings of a chondral lesion</li> <li>use of a hamstring graft</li> <li>Wrestling with Brendan oneil early</li></ol>

Answer 9

<div>ANSWER: B</div>

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

Question 10

RC 2013 List in order from weakest to strongest the tensile loads to failure of the knee ligaments?

Answer 10

“Weakest to strongest (‘lap me’ = LAPM)<div>LCL 750N</div><div>ACL 2200-2500N</div><div>PCL 2500-3000N</div><div>MCL 5000N</div>”

Question 11

<div>RC 2012 - List 4 components of the PLC?</div>

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

<div>RC 2014, 2013 - Which of the following are not part of the posterolateral corner</div>

<ol> <li>LCL</li> <li>PCL</li> <li>Popliteofibular ligament</li> <li>Popliteus</li></ol>

Answer 11

<div>2.</div>

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

Static<div>-LCL</div><div>-PFL</div><div>-Popliteus</div><div>-lateral capsulte</div><div><br></br></div><div>Dynamic</div><div>-BF</div><div>-ITB</div><div>-LHG</div><div><br></br></div>

Question 12

<div>RC 2016, 2014 - List 4 things that can cause loss of extension after ACL reconstruction?</div>

Answer 12

<div><div><ul> <li>Intra-op</li> <ul> <li>Non-anatomic graft placement</li> <ul> <li>Tibial tunnel too anterior</li> <li>Femoral tunnel too posterior</li> </ul> </ul> <li>Post-op</li> <ul> <li>Cyclops lesion </li> <li>Capsulitis leading to arthrofibrosis</li> <li>Post-operative immobilization</li> <li>Lack of post-operative rehabilitation</li> </ul> <li>Infection</li> <li>Trauma - bucket handle of meniscal tear</li></ul></div></div>

Question 13

<div>RC 2015 - What is true regarding pediatric ACL reconstruction:</div>

<ol> <li>Transphyseal tibial tunnel is an option</li> <li>Bone-patellar-tendon-bone graft is a good option</li> <li>Screw placement across the physis is acceptable</li> <li>Non-operative treatment has good outcomes</li></ol>

Answer 13

“<div>Answer: A</div><div><ul> <li>JAAOS - ACL in the Skeletally Immature</li> <ul> <li>"”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””</li> </ul> <li>Non-operative</li> <ul> <li>Kocher found that partial tears-1/3 of them required surgery for persistent instability</li> <li>50% will drop out of sports b/c of instability</li> <li>Increased rate of meniscal and chondral damage</li> </ul></ul></div><div><br></br></div>-ITB extraphyseal reconstruction<div>-all epiphyseal reconstruction (suspensory technique on femur; tibial interference screw can be below physis to tether graft or above physis)</div><div>-partial trans-physeal (epiphyseal femur, transphyseal tibia)</div><div>-transphyseal reconstruction (avoid in younger)</div>”

Question 14

RC 2015, 2014 - RFs for recurrent patellar dislocation?

Answer 14

Pt factors: female, young (10-20), sports participation, previous instability, ligamentous laxity<div>Anatomic: patella alta, trochlear/patellar dysplasia, generalized lig laxity, VMO atrophy, malalignment (increase fem anteversion, genu valgum, ER tibia - increased Q angle)</div>

Question 15

“RC 2012 - Label the 19 structures in this cross-section of the proximal leg (it was this cross-section exactly). (5 points)<div><img></img><br></br></div><div><br></br></div>”

Answer 15

“<ol> <li>Fibula</li> <li>Tibia</li> <li>Tibial Tubercle</li> <li>Patellar Tendon</li> <li>Tib Ant</li> <li>EDL</li> <li>Common Peroneal Nerve</li> <li>Lateral Gastroc</li> <li>Soleus</li> <li>Tibial Posterior (Popliteus?)</li> <li>Popliteal Artery</li> <li>Tibial Nerve</li> <li>Medial Gastroc</li> <li>Lesser Saphrenous Vein</li> <li>Semi-tendinosis</li> <li>Greater Saphrenous Vein</li> <li>Semi-membranosus (Jer: I think this is MCL)</li> <li>Gracilis</li> <li>Sartorius</li></ol><div><img></img><br></br></div>”

Question 16

<div>RC 2011 - What guides the dissection to the popliteal fossa? </div>

<ol> <li>medial sural cutaneous nerve </li> <li>small saphenous vein</li> <li>peroneal nerve</li> <li>Achilles tendon</li></ol>

Answer 16

“A.<div><ul> <li>Identify and protect medial sural cutaneous nerve - track proximally into popliteal fossa</li> <li>Identify and protect CPN, track to tibial nerve and NVB</li> <li>Incise or retract gastrocs laterally</li> </ul> <div></div> <div><img></img></div> <div></div> <ul> <li><img></img></li></ul></div>”

Question 17

<div>RC 2016 - List 4 advantages of doing a medial opening wedge HTO over a lateral closing wedge</div>

Answer 17

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

Question 18

<div>RC 2015 - In performing an opening wedge HTO, all of the following are true except:</div>

<ol> <li>In an ACL deficient knee, placing the bone wedge posteromedially will decrease the tibial slope and decrease anterior translation </li> <li>In a PCL deficient knee, placing the bone wedge anteromedially will increase the tibial slope and increase posterior translation</li> <li>Placing the bone wedge direct medial will not affect the slope</li> <li>Smaller anterior gap with a larger posterior gap will preserve the native tibial slope</li></ol>

Answer 18

“Answer: B<div><ul> <li>Increased tibial slope will DECREASE posterior translation</li> <li>JAAOS 2011 - Role of the HTO in the varus knee</li> <ul> <li>ACL deficiency –> decrease tibial slope</li> <li>PCL deficiency –> increase tibial slope</li> </ul> </ul> <div><img></img></div> <ul> <li>Noyes (AJSM 2005) Opening wedge tibial osteotomy: the 3-triangle method to correct axial alignment and tibial slope</li> </ul> <div><img></img></div> <div>Need a 2:1 opening of posterior to anterior to preserve native slope when doing a medial opening wedge (Dr. French via Noyes)</div><div><br></br></div><div><br></br></div></div>”

Question 19

RC 2016 - When treating an infection post-ACL reconstruction, all are true EXCEPT: <ol> <li>Blood cultures are usually not positive</li> <li>Every reasonable effort should be made to retain the graft and hardware</li> <li>Acute infections have the same prevalence as delayed infections </li> <li>Arthrocentesis is the diagnostic modality of choice</li></ol>

Answer 19

“C.<div><ul> <li>"”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””</li> <li>"”All reasonable attempts are initially made to preserve the reconstructed graft and associated hardware””</li> <li>"”Typically presents either acutely (<2 weeks from surgery) or subacutely (2 weeks to 2 months). Late presentation is relatively infrequent””</li> <li>"”Arthrocentesis remains the standard of care for diagnosis of septic arthritis following ACL reconstruction””</li></ul></div>”

Question 20

“<div>RC 2018, 2015 - What is true regarding ACL graft choices:</div> <ol> <li>Single bundle reconstruction restores normal knee kinematics</li> <li>Posterolateral bundle is shorter</li> <li>Double bundle reconstruction has better clinical outcomes</li> <li>Can regain hamstring strength following hamstring graft harvest with appropriate PT</li></ol>”

Answer 20

“B. AM bundle is 38mm in length, PL bundle is 17.8mm<div><br></br></div><div>D- All had 3-27% hamstring strength deficit compared to contra-lateral side<div><br></br></div><div><img></img><br></br><div><br></br></div></div></div>”

Question 21

“RC 2014 - Which of the following is true about cruciate synovial cysts? <ol> <li>Cause pain during deep squatting</li> <li>Are very rare and have no classification system</li> <li>Are impossible to distinguish from synovial sarcoma on MRI/”“are confused with””</li> <li>Have a high risk of recurrence following arthroscopic excision</li></ol>”

Answer 21

A. True: Pain can be intermittent or constant, and often worse with exercise especially squatting (squeezing the cyst)<div><ul> <li>Cysts about the Knee: Evaluation and Management. JAAOS August 2013 </li> <ul> <li>B - Untrue: Prevalence of 0.2 to 1.9%, and classification is anterior to ACL, between ACL and PCL and posterior to PCL</li> <li>D - Untrue: Arthroscopic excision is the treatment of choice with “no” symptomatic recurrences</li> <li>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</li> </ul></ul></div>

Question 22

<div>RC 2011 - Proper placement of ACL tibial tunnel to prevent graft impingement is achieved by?</div>

<ol> <li>Placement of tunnel in the center of the ACL footprint</li> <li>Placement of tunnel posterior to the ACL footprint, 6mm anterior to PCL</li> <li>Placement of tunnel in front of the ACL footprint</li> <li>Placement of tunnel posterior to ACL foot print</li></ol>

Answer 22

“A.<div><div>JAAOS 2016 Anatomic tunnel placement in ACL reconstruction</div><div>Centre of ACL tibial attachement = 9mm posterior to intermeniscal ligament</div> <div>= 5.3mm anterior to a line projected from the peak of the medial tibial spine</div> <div><img></img></div></div>”

Question 23

<div>RC 2011 - What position do you tighten your ACL graft?</div>

<ol> <li>full extension</li> <li>30 degrees of flexion</li> <li>90 degrees of flexion</li> <li>ryan martin is gay</li></ol>

Answer 23

A>B<div><ul> <li>Orthobullets says 30 degrees</li> <li>French and Rezansoff say full extension now-a-days</li></ul></div>

Question 24

<div>RC 2008 - Which of the following activities places the greatest peak strain on the ACL:</div>

<ol> <li>Ascending stairs</li> <li>Ascending a ramp</li> <li>Descending stairs</li> <li>Descending a ramp</li></ol>

Answer 24

“C.<div><br></br></div><div><div>The mechanics of the knee joint in relation to normal walking.</div> <div>Morrison JB</div> <div>J Biomech. 1970 Jan; 3(1):51-61</div> <div></div> <div>Estimations of ACL forces during activities of daily living calculated by Morrison revealed that ACL loads of 169 N may be expected during normal level walking, while descending stairs generated 445 N ofin situforce due to the activation of the knee extensor apparatus [<a>29</a>–<a>31</a>]. In contrast, ascending stairs as well as ascending or descending a ramp generatedin situforces below 100 N</div></div>”

Question 25

<div>RC 2008 - Which of these is true about ACL injuries?</div>

<ol> <li>MRI shows bruise on the posterior medial femur</li> <li>40% of patients with ACL tear show bruising on MRI</li></ol>

Answer 25

B.<div><br></br></div><div><ul> <li>Graf (AJSM 1993)</li> <ul> <li>Middle third of the lateral femoral condyle and the posterior third of the lateral tibial plateau</li> <li>48% had bone bruising</li> <li>Other studies say up to 70-80% have bone bruising</li> </ul></ul></div>

Question 26

<div>RC 2008 - Grade III MCL & ACL rupture. What to do?</div>

<ol> <li>Rehab as per ACL</li> <li>Brace in extension x 2-3wks</li> <li>Reconstruct ACL, fix MCL, brace 30-90deg</li> <li>Reconstruct ACL, brace 30-90deg</li></ol>

Answer 26

“B.<div><br></br></div><div><div>Combined anterior and posterior cruciate and medial collateral ligament injury: nonsurgical and delayed surgical treatment (ICL 2003)</div> <ul> <li>"”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.””</li> </ul> <div></div> <div>Medvecky M (Sports Med and Arthrosc Revew 2015) Management of Acute combined ACL-Medial and posteromedial instability of the knee</div> <ul> <li>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</li> <li>Recommend short term immobilization in extension</li></ul></div>”

Question 27

RC 2018, 2015, 2013 - Patient with a PCL and Posterolateral corner injury: <ol> <li>Increased external rotation of tibia with knee at 30 degrees but not at 90 degrees</li> <li>Increased external rotation of tibia with knee at 30 degrees and at 90 degrees</li> <li>Increased laxity with varus stress</li> <li>Pivot shift positive</li></ol>

Answer 27

B.<div><ul> <li>Dial Test:</li> <ul> <li>>10 deg ER in 30 deg: PLC</li> <li>>10 deg ER in 30 deg and 90 deg : PLC and PCL</li> </ul></ul></div>

Question 28

<div>RC 2016, 2011 What vessel provides blood supply to the PCL?</div>

<ol> <li>Inferior geniculate </li> <li>Superior geniculate </li> <li>Middle geniculate </li> <li>?</li></ol>

Answer 28

C. same as ACL<div><br></br></div><div><br></br></div>

Question 29

<div>RC 2009 - Late complaint after PCL insufficient Knee?</div>

<ol> <li>Medial compartment OA</li> <li>Instability</li> <li>Lateral Compartment OA</li></ol>

Answer 29

“A. ““The natural history of the PCL-deficient knee leads to increased contact pressures in both the medial and PF compartments”””

Question 30

<div>RC 2018 - Regarding ACL recon which is true?</div>

<div>a.Double bundle repair gives superior results</div>

<div>b.Single bundle repair restores normal kinematics of the knee</div>

<div>c.Over the top repair has no issues with instability (wording…)</div>

<div>d.Femoral tunnel position too anterior leads to stretch of graft in flexion</div>

<div>e.Femoral tunnel too posterior leads to stretching in flexion</div>

Answer 30

“D.<div><img></img><br></br></div><div><img></img><br></br></div>”

Question 31

<div>RC 2014, 2011 - What type of fibres in the meniscus resist hoop stresses?</div>

<ol> <li>Circumferential</li> <li>Crossing</li> <li>Radial</li> <li>Vertical</li></ol>

Answer 31

a.<div><br></br></div><div><div>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</div></div>

Question 32

RC 2013, 2010 - When performing the Thesally physical exam on the knee, what are 3 conditions that can give you a false positive

Answer 32

<div><ul> <li>OA</li> <li>Osteochondral Injury</li> <li>Collateral Ligament Injury</li> <li>Posterolateral Corner Injury</li> <li>Associated ACL Injury</li> <li>Tibial Plateau #</li> <li>Loose body</li></ul></div>

Question 33

<div>RC 2017, 2013 - All are factors that contribute to increased chance of PF instability, EXCEPT</div>

<ol> <li>Internal tibial torsion</li> <li>Increased femoral anteversion</li> <li>Increased Q angle</li> <li>Genu valgum</li></ol>

Answer 33

A. ER tibial torsion is assx<div><br></br></div><div>miserable malalignment: femoral anteversion, genu valgum, ER tibia, increase Q angle<br></br><div><br></br></div><div><br></br></div></div>

Question 34

RC 2011 - With lateral patellar dislocation, what describes the J sign? <ol> <li>lateral to medial with knee in full extension to flexion</li> <li>medial to lateral with knee in full extension to flexion</li> <li>goes lateral with knee held in 30° flexion</li></ol>

Answer 34

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

Question 35

<div>RC 2018 - Describe what investigation to order and how to measure the tibial-tubercle trochlear-groove (TT-TG) ratio in patellar instability. If the TT-TG is greater than 25 mm, what does this imply you will have to add to your surgical management?</div>

Answer 35

“<ul> <li>Axial CT, measuring from deepest trough of the trochlea to most prominent aspect of tibial tubercle</li> <ul> <li>Set line along posterior femoral condyles</li> <ul> <li>Femoral cut should be one where the notch = 1/3 the total AP distance of the condyles</li> </ul> <li>Compare perpendicular lines to deepest part of groove (femur) and most prominent TT (tibia)</li> </ul> <li></li> </ul> <div></div> <div><img></img></div><div>if >25 –> TTO</div>”

Question 36

<div>RC 2013 - List 5 features of traumatic proximal tibia fibula dislocation</div>

Answer 36

<ul> <li>JAAOS 2003 - Instability of the Proximal Tibiofibular Joint</li> <ul> <li>History</li> <ul> <li>Pain over lateral knee, radiates up biceps femoris</li> <li>Instability to weightbearing</li> <li>Peroneal nerve symptoms</li> </ul> <li>Look: </li> <ul> <li>Prominence of fibular head</li> </ul> <li>Feel:</li> <ul> <li>Tender laterally</li> </ul> </ul> <ul> <li>Move: </li> <ul> <li>Pain and loss of knee ROM</li> </ul> </ul> <ul> <li>Special Tests</li> <ul> <li>Pain aggravated by ankle ROM</li> <li>Posterolateral corner instability</li> <li>LCL instability</li> </ul> </ul></ul>

Question 37

<div>RC 2013 - In regards to an acute, traumatic proximal tibia fibula dislocation:</div>

<div>Explain the mechanism of injury, including position of limb and knee position. (2 marks)</div>

<div><div>Two features seen on examination</div></div>

<div><div>Explain your reduction technique (2 marks)</div></div>

Answer 37

MOI: Axial load to hyperflexed knee, plantarflexed and internally rotated foot<div><br></br></div><div><div>Two features seen on examination</div> <ul> <li>Prominence of fibular head and lateral knee</li> <li>Instability of posterolateral corner</li> <li>Symptoms at tibfib joint with ankle ROM</li> </ul><div><div>Explain your reduction technique</div> <ul> <li>Knee at 80-110o of flexion (relax biceps femoris)</li> <li>Ankle dorsiflexed, foot everted and externally rotated (relax peroneals)</li> <li>Pressure to fibular head in appropriate direction</li></ul></div> <div></div></div>

Question 38

RC 2018, 2013 - Components of WOMAC?

Answer 38

“Pain (5 items)<div>Stiffness (2 items)</div><div>Physical Function (17 items)</div><div>Index/Global Score (summary of 3 subscales)<br></br></div><div><br></br></div><div>Note: WOMAC specific to OA</div><div><img></img><br></br></div>”

Question 39

<div><b>RC 2018 - </b><b>18 year old shown comes with progressive knee pain and locking symptoms. Shown an MRI with a meniscus tear and bucket displaced into the notch. What’s the best treatment?</b></div>

<div>A. Total meniscectomy </div>

<div>B. Partial meniscectomy </div>

<div>C. INtrasubstance repair </div>

<div>D. Meniscal transplant</div>

<div></div>

Answer 39

<br></br><div><div>Answer is C</div><div></div><div>From orthobullets</div><div>- outcomes</div><div>o 70-95% successful</div><div>o highest success when done with concomitant ACL reconstruction</div></div>

Question 40

<div>RC 2013 - List in order from weakest to strongest the tensile loads to failure of the knee ligaments (medial, lateral, posterior cruciate and anterior cruciate).</div>

Answer 40

“<ul> <li>‘lap me’ = LAPM = LCL, ACL, PCL, MCL</li> <ul> <li>Miller’s Orthopedics (p.289)</li> <ul> <li>LCL 750N</li> <li>ACL 2200-2500N</li> <li>PCL 2500-3000N</li> <li>MCL 5000N</li> </ul> </ul></ul>”

Question 41

RC 2016, 2012 - List 4 things that can cause loss of extension after ACL reconstruction?

Answer 41

<ul> <li>Intra-op</li> <ul> <li>Non-anatomic graft placement</li> <ul> <li>Tibial tunnel too anterior</li> <li>Femoral tunnel too posterior</li> </ul> </ul> <li>Post-op</li> <ul> <li>Cyclops lesion </li> <li>Capsulitis leading to arthrofibrosis</li> <li>Post-operative immobilization</li> <li>Lack of post-operative rehabilitation</li> </ul> <li>Infection</li> <li>Trauma - bucket handle of meniscal tear</li></ul>

Question 42

<div>RC 2012, 2008 - What is true regarding ACL tunnel Placement</div>

<ol> <li>Tibial tunnel is most important</li> <li>If femoral tunnel is too posterior, graft lengthens in flexion</li> <li>If femoral tunnel too anterior, graft lengthens in flexion</li> <li>Over the top femoral placement of graft does not change in extension</li></ol>

Answer 42

“C.<div><img></img><br></br></div>”

Question 43

RC 2008 - What is the risk of doing a fibular osteotomy versus resection of the medial fibula when doing a lateral closing wedge osteotomy? <ol> <li>Increased peroneal nerve injury</li> <li>Risk of non-union</li> <li>Failure of correction</li></ol>

Answer 43

C<div><ul> <li>Incidence of peroneal nerve palsy after lateral closing wedge 0-20%</li> <li>Osteotomy in vicinity of the fibular head associated with higher incidence of peroneal nerve palsy than fibular osteotomy >15cm distal to head</li> <li>Not a complete answer but I got tired of this question.</li></ul></div>

Question 44

RC 2008 - Which position of the knee places the ACL at its greatest strain? <ol> <li>Hyperextension</li> <li>30 deg flexion</li> <li>90 deg flexion</li> <li>hyperflexion</li></ol>

Answer 44

A>B<div><ul> <li>Wheeless:</li> <ul> <li>Hyper-extension</li> <ul> <li>At 5o of hyperextension the ACL ligament forces range between 50 and 240 Newtons</li> <li>Hyperextension of the knee develops much higher forces in ACL than in the PCL</li> </ul> <li>ACL strain at 30o of knee flexion are significant higher than at 90o where the ligament remains unstrained</li> </ul> </ul> <ul> <li></li> <li>Frank (JBJS 1997) Current Concepts Review</li> <ul> <li>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</li> </ul> </ul> <div></div> <ul> <li>Markolf K L, Burchfield D M, Shapiro M M.et alCombined knee loading states that generate high anterior cruciate ligament forces.J Orthop Res199513930–935</li> <ul> <li>We conclude that the combination of anterior tibial force and internal tibial torque near full extension presents the greatest risk for injury to the anterior cruciate ligament.</li> </ul> <li></li> <li>Spence: I think A makes the most sense.</li></ul></div>

Question 45

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

Answer 45

“<ul> <li>Iliotibial band extra-physeal reconstruction (modified McIntosh)</li> <ul> <li>IT band remains attached to Gerdy’s tubercle, passes over femoral condyle and under intermeniscal ligament to suture under flaps of anterior tibial periosteum</li> </ul> </ul> <div></div> <ul> <li>All Epiphyseal Reconstruction</li> <ul> <li>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</li> <li>Ganley technique - 4 string hamstring graft with epiphyseal femoral interference screw and epiphyseal vertical tibial interference screw</li> <li>Cordasco-Green - epiphyseal tunnels in femur and tibia; suspensory fixation for both</li> </ul> </ul> <div></div> <ul> <li>Partial trans-physeal</li> <ul> <li>Epiphyseal femoral tunnel and trans-physeal tibial tunnel</li> </ul> </ul> <div></div> <ul> <li>Trans-physeal reconstruction</li> <ul> <li>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</li> </ul></ul>”

Question 46

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

Answer 46

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

Question 47

<div>RC 2014, 2013 - Which of the following are not part of the posterolateral corner</div>

<ol> <li>LCL</li> <li>PCL</li> <li>Popliteofibular ligament</li> <li>Popliteus</li></ol>

Answer 47

B.<div><ul> <li>Static:</li> <ul> <li>LCL</li> <li>Popliteus Tendon</li> <li>Popliteofibular ligament</li> <li>Lateral Capsule</li> </ul> <ul> <li>Variable –> arcuate ligament, fabellofibular ligament</li> </ul> <li>Dynamic Structures:</li> <ul> <li>Biceps femoris</li> <li>Popliteus muscles</li> <li>IT band</li> <li>Lateral head of gastrocs</li> </ul></ul></div>

Question 48

RC 2012 - 4 components of the PLC

Answer 48

“<ul> <li>Lateral Collateral Ligament</li> <li>Popliteofibular Ligament</li> <li>Popliteus tendon</li> <li>Less Consistently Described:</li> <ul> <li>Biceps Femoris</li> <li>IT Band</li> <li>Arcuate ligament complex</li> <li>Lateral Joint Capsule</li> <li>Fabellofibular ligament</li> <li>Lateral Head of Gastroc</li> </ul></ul><div><img></img><br></br></div>”

Question 49

RC 2015, 2014 - What are 6 risk factors for recurrent patellar dislocation?

Answer 49

<ul> <li>Patient demographics: young (10-20), female, sports participation</li> <li>Previous patellar instability</li> <li>Increased ligamentous laxity</li> <li>Anatomic RFs</li> <ul> <li>Patella alta</li> <li>Trochlear dysplasia/Hypoplastic lateral condyle</li> <li>Patellar dysplasia</li> <li>Malalignment (increased femoral anteversion, genu valgum, increase ER of tibia)</li> <ul> <li>Increased Q Angle</li> </ul> <li>VMO Atrophy</li> </ul></ul>

Question 50

RC 2012 - 4 contraindications to an HTO

Answer 50

<ul> <li>Disease of the contra-lateral compartment</li> <li>Absent contra-lateral meniscus</li> <li>Symptomatic patellofemoral disease</li> <li>Inflammatory arthritis</li> <li>Severe angular malalignment (deformity requiring >20 degrees correction)</li> <li>Non-concordant pain pattern</li> <li>Older physiologic age (better suited to TKA)</li> </ul>

<div></div>

<ul> <li>Patient Factors</li> <ul> <li>Inflammatory arthritis</li> <li>BMI > 35</li> <li>Flexion contracture > 15deg</li> <li>Knee Flexion < 90</li> </ul> <li>Deformity</li> <ul> <li>>20o varus/valgus deformity</li> <li>Patellar arthritis</li> <li>Ligamentous instability/thrusting gait</li> <ul> <li>Can consider combined ACL reconstruction (controversial)</li> </ul> </ul></ul>

Question 51

<div>18F with ACL tear, what is true?</div>

<div>a. More likely to tear reconstructed ACL than ACL in other knee</div>

<div>b. Will have a predictably different psychological response than same aged male</div>

<div>c. < 5% chance she tears the other side</div>

<div>d. Risk of ipsilateral rupture after autograft reconstruction greater than native contralateral</div>

Answer 51

“<div><i>Ref: JAAOS 2019 </i><b><i></i></b></div> <div>• Higher rates of<b> lateral</b> meniscal tears in acute injuries, but with advancing chronicity,<b> medial</b> meniscal tear rates increase <br></br> <br></br> </div> <div><i>Ref: </i><i>JBJS 2011 </i><i></i></div> <div>• Systematic review demonstrates that the risk of ACL tear in the contralateral knee (11.8%) is double the risk of ACL graft rupture in the ipsilateral knee (5.8%).<br></br> <br></br> </div> <div><i><span>Ref: </span></i><i><span>Wiggins (2016) </span></i><i><span>AJSM.</span></i><i><span> </span></i><i><span>A m</span></i><i><span>eta-analysis</span></i><i></i></div> <div>• <b><span><span>Overall risk of secondary ACL injury 15% (ipsilateral re-injury 7% «/span></span></b><b><span><span> contralateral 8%)</span></span></b><b><span><span></span></span></b><b><span></span></b></div> <div>• <b><span>An ACL tear on one limb has been shown to increase the risk of a contralateral ACL tear.</span></b><b><span></span></b></div> <div>• <span>If «/span><span> 25</span><span> years, combined risk of second ACL injury 21%</span><span></span></div> <div>• <span>If return to sport, secondary injury risk is 20%</span><span></span></div> <div>• <span>If < 25 and return to sport, combined risk 23%</span><span></span><br></br> <br></br> </div> <div><i><span>Ref: Christino et al. Psychological Aspects of Recovery Following Anterior Cruciate Ligament Reconstruction. JAAOS 2015</span></i><i><span></span></i></div> <div><span>• </span><span>Thome</span><span>é </span><span>and colleagues</span><span> </span><span>developed a validated Knee Self-Efficacy Scale (K-SES) and demonstrated that <b>high postoperative self-efficacy </b>was positively associated with:</span><span> </span><span></span></div> <div><span>• </span><b><span>Higher activity levels</span></b></div> <div><span>• </span><b><span>Younger age</span></b></div> <div><span>• </span><b><span>M</span></b><b><span>ale gender</span></b><b><span></span></b></div> <div><span>• </span><b><span>KOOS outcomes</span></b></div> <div><span></span></div> <div><i>Ref: Sex-Specific Differences in Psychological Response to Injury and Return to Sport Following ACL Reconstruction. JBJS 2018</i><i></i></div> <div>• Men and women display different psychological responses to injury; <b><span>men report greater self-efficacy postoperatively</span></b> and a loss of overall self-worth with injury, whereas <b><span>women are self-directed and exhibit greater anxiety</span></b> concerning an injury’s impact on their lives and a loss of physical self-worth with injury.</div> <div>• Women have higher anxiety post-op, more self-directed and outcome oriented, injury compromises self-worth, similar kinesiophobia level overall but women with high kinesiophobia had greater stress reactions to injury.</div> <div>• <i>Kinesiophobia has been defined as </i><i>“</i><i>an excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or rein jury.”</i></div> <div></div> <div><i>Ref: </i><i>Anterior Cruciate Ligament Reconstruction in Young Female Athletes: Patellar Versus Hamstring Tendon Autografts. AJSM 2019</i><i></i></div> <div>• Retrospective review of females 15-20 and 21-25</div> <div>• <b>Graft rupture 9%</b><b></b></div> <div>• <b>Contralateral rupture 7%</b><b></b></div> <div>• <b><span>Hamstring more likely to re-rupture than BTB</span></b></div>”</span></span></b>

Question 52

50F with symptomatic labral tear, gets hip arthroscopy for debridement. What do you expect?<div>A. >15% rate of repeat OR within 2 years</div><div>B. 10% pudendal nerve injury</div><div>C. No significant functional improvement</div><div>D. Unacceptable rate of infection</div>

Answer 52

Ans: A<div><br></br></div><div>JAAOS Green Journal article 2019</div><div>Infection 0.9% (D wrong)</div><div>Repeat OR</div><div>- Arthroplasty procedure 38/267 – ~11%</div><div>- 2nd Arthroscopy 37/267 – ~11%</div><div>- The average for the above was about 2 years after initial OR</div><div>Paresthesias 4.9% (B wrong)</div><div>All PROs improved (C wrong)</div>

Question 53

“<div>Posterolateral corner anatomy, what are the 3 main static stabilizers?</div><div><span>A. Fibular collateral ligament, popliteus tendon, popliteofibular ligament</span></div><div><span>B. Fibular collateral ligament, fabellofibular ligament, popliteofibular ligament</span></div><div><span>C. Fibular collateral ligament, popliteus, fabellofibular ligament</span></div><div><span>D. Fibular collateral ligament, popliteus, arcuate ligament</span></div>”

Answer 53

“<div><div><span>Answer: A</span></div><br></br><div><span>Ref: Chahla J, et al. Posterolateral Corner of the Knee: Current Concepts.</span><span> </span><span>Arch Bone Jt Surg. 2016 Apr; 4(2): 97-103.</span></div><ul><li><div>The three major static stabilizers of the PLC are:</div></li><ul><li><div>Fibular (lateral) collateral ligament (LCL)</div></li><li><div>The popliteus <span>tendon</span></div></li><li><div>Popliteofibular ligament</div></li><li><div><img></img><br></br></div></li></ul></ul></div>”

Question 54

“<div>PCL - all are true, EXCEPT? (RC 2019)</div><ol><li><div><span>MRI is not as useful in chronic injuries compared to acute</span></div></li><li><div><span>Chronic findings of change are located in the lateral and PF compartment</span></div></li><li><div><span>Dial test is positive at 30° and 90° in PLC</span></div></li><li><div><span>Anterolateral portion of PCL is the largest</span></div></li></ol>”

Answer 54

“<div>Answer: B</div><br></br><div>PCL Anatomy - <span>JAAOS 2016;24:277-289</span></div><ul><li><div>Origin ~1-1.5cm below the articular surface of the tibial plateau</div></li><li><div>Average length, width and midsubstance cross-sectional area:</div></li><ul><li><div>32-38mm x 13mm. CSA 31.2mm^2</div></li></ul><li><div>Intra-synovial and extra-articular structure</div></li><li><div>Bundles</div></li><ul><li><div>Posteromedial</div></li><li><div>Anterolateral</div></li><ul><li><div><span>Anterolateral bundle is larger and stronger (ALB, A Lot Bigger)</span></div></li></ul></ul><li><div><img></img></div></li><li><div>PCL complex also consists of:</div></li><ul><li><div>Anterior meniscofemoral ligament (Humphry)</div></li><li><div>Posterior meniscofemoral ligament (Wrisberg)</div></li><li><div>Originate from the posterior horn of the lateral meniscus and insert on the femur anterior and posterior to the PMB, respectfully</div></li><li><div>Secondary restraints?</div></li></ul><li><div><span>PCL deficiency results in abnormal kinematics and contact pressures in the medial and patello-femoral compartments of the knee</span></div></li></ul><br></br><div><span>REF: Strobel MJ et al. Arthroscopic evaluation of articular cartilage lesions in posterior-cruciate-ligament-deficient knees. Arthroscopy. 2003 Mar;19(3):262-8.</span></div><ul><li><div>PCL insufficiency significantly increased the risk of developing <span>medial</span><span> femoral condyle and patellar cartilage degeneration</span> over time.</div></li><li><div>Of patients whose PCL deficiency was present for more than 5 years, 77.8% showed degenerative cartilage lesions of the <span>medial</span> femoral condyle and 46.7% showed cartilage degeneration of the patella.</div></li><li><div>After 1 year of PCL insufficiency, the number of medial femoral cartilage lesions increased threefold (13.6% v 39.1%).</div></li><li><div>With the presence of combined PCL/posterolateral insufficiency the amount of medial femoral degeneration was significantly increased (36.6% v 60.6%).</div></li><li><div><span>Both the PCL and ACL’s secondary function is resist </span><span>varus deformity. </span><span><br></br><br></br></span></div></li></ul><ul><li><div><span>Dial Test:</span></div></li></ul><ul><li><div>>10° ER asymmetry at 30° = Isolated PLC injury</div></li></ul>>10° ER asymmetry at 30° and 90° = PLC and PCL injury”

Question 55

“<div>All are true regarding HTO, except? (RC 2019)</div><div><span><br></br></span></div><div><span>A. In an ACL deficient knee, placing the bone wedge posteromedially will decrease the tibial slope and decrease anterior translation</span></div><div><span>B. In a PCL deficient knee, placing the bone wedge anteromedially will increase the tibial slope and increase posterior translation</span></div><div><span>C. Placing the bone wedge direct medial will not affect the slope</span></div><div><span>D. Smaller anterior gap with a larger posterior gap will preserve the native tibial slope</span></div>”

Answer 55

“<div><span>Answer: B</span></div><ul><li><div><span>Because of the triangular shape of the proximal tibia, the millimeter reading of the posterior tine will be greater than that of the anterior tine in the osteotomy is in the proper sagittal alignment</span></div></li><li><div><span>The opening of the anterior half of the osteotomy should be 1/3 the height of the posterior half.</span></div></li><ul><li><div><span>This will verify that the tibial slope has not been significantly altered.</span></div></li></ul></ul>”