This practice set contains high-yield board review questions covering key concepts in Knee Sports. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.
Question 401
Topic: Knee Sports
A 13-year-old male with wide-open physes presents with recurrent patellar dislocations. Imaging confirms normal TT-TG distance but a torn MPFL. Surgical intervention is selected. Which of the following procedures is most appropriate while minimizing the risk of growth arrest?
Correct Answer & Explanation
. MPFL reconstruction with physeal-sparing femoral fixation
Explanation
In skeletally immature patients with open physes, bony procedures like tibial tubercle osteotomies carry a high risk of physeal arrest (e.g., recurvatum deformity). Soft-tissue MPFL reconstruction utilizing physeal-sparing techniques (avoiding the distal femoral physis) is the treatment of choice.
Question 402
Topic: Knee Sports
A patient undergoes a tibial tubercle medialization osteotomy for a TT-TG distance of 24 mm. If the surgeon over-medializes the tubercle excessively, what is the most likely postoperative complication?
Correct Answer & Explanation
. Increased medial compartment contact pressures
Explanation
Excessive medialization of the tibial tubercle alters the Q-angle to a varus alignment, unnaturally increasing the contact pressures in the medial tibiofemoral compartment and predisposing the patient to medial unicompartmental osteoarthritis.
Question 403
Topic: Knee Sports
The medial patellofemoral ligament (MPFL) serves as the primary restraint to lateral patellar translation at which of the following degrees of knee flexion?
Correct Answer & Explanation
. Full extension to 30 degrees
Explanation
The MPFL provides approximately 50-60% of the restraining force against lateral patellar displacement during early knee flexion (0 to 30 degrees). Beyond 30 degrees, the patella engages the trochlear groove, which then becomes the primary osseous stabilizer.
Question 404
Topic: Knee Sports
A 28-year-old female presents with patellar instability. MRI demonstrates isolated lateralization of the tibial tubercle. Her TT-TG distance is 22 mm, but her Tibial Tubercle-Posterior Cruciate Ligament (TT-PCL) distance is measured at 26 mm (Normal < 24 mm). What does an elevated TT-PCL distance primarily indicate in this context?
Correct Answer & Explanation
. Tubercle lateralization that is independent of tibiofemoral rotation
Explanation
The TT-PCL distance isolates true lateralization of the tibial tubercle relative to the proximal tibia. An elevated TT-TG with a normal TT-PCL suggests the lateralization is due to knee rotation, whereas an elevated TT-PCL confirms true structural lateralization of the tubercle itself.
Question 405
Topic: Knee Sports
Which anatomic landmark safely directs the femoral placement of the medial patellofemoral ligament (MPFL) graft on lateral fluoroscopy (Schöttle's point)?
Correct Answer & Explanation
. Anterior to the posterior cortical line, proximal to Blumensaat's line
Explanation
Schöttle's point is located 1 mm anterior to the posterior cortical line of the femur, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to Blumensaat's line.
Question 406
Topic: Knee Sports
During a TKR for a valgus knee, the surgeon encounters a situation where excessive posterior cruciate ligament (PCL) release is performed during soft tissue balancing. Based on the principles outlined in the case, what is the most likely consequence of this excessive PCL release and the appropriate implant choice?
Correct Answer & Explanation
. Option C: It will necessitate cruciate sacrificing implants in order to balance the knee.
Explanation
Correct Answer: CThe case explicitly states: 'Excessive PCL release usually requires cruciate sacrificing implants in order to balance the knee.' This is a direct consequence of losing the PCL's contribution to stability and balance.Option A is incorrectbecause excessive PCL release would lead to a looser, not tighter, flexion gap, and would preclude PCL retention.Option B is incorrectbecause excessive PCL release would destabilize the knee, making it unbalanced, and would not allow for PCL-retaining implants.Option D is incorrectbecause while soft tissue releases can affect the extension gap, excessive PCL release specifically impacts flexion stability and necessitates a change in implant type, not just insert thickness while retaining the PCL.Option E is incorrectbecause PCL release has a significant impact on knee kinematics and balance, directly influencing implant choice.
Question 407
Topic: Knee Sports
A 45-year-old female presents with acute medial knee pain after a squatting injury. MRI reveals a complete radial tear of the medial meniscus posterior root. Biomechanically, this injury is equivalent to which of the following?
Correct Answer & Explanation
. A total medial meniscectomy
Explanation
A complete medial meniscus posterior root tear disrupts the hoop stresses of the meniscus, leading to extrusion under load. Biomechanically, it alters contact pressures in the medial compartment to a degree equivalent to a total medial meniscectomy.
Question 408
Topic: Knee Sports
A 15-year-old male sustains a twisting injury to his knee. Plain radiographs demonstrate an avulsion fracture of the lateral tibial plateau (Segond fracture). In a clinical oral examination, you are asked about the biomechanical implications of this finding. A Segond fracture is pathognomonic for a tear of the anterior cruciate ligament (ACL) and is highly associated with injury to which of the following structures?
Correct Answer & Explanation
. Anterolateral ligament (ALL)
Explanation
A Segond fracture is a bony avulsion of the anterolateral capsule and is considered pathognomonic for an ACL tear. It is heavily associated with concurrent injury to the anterolateral ligament (ALL), which contributes to anterolateral rotatory instability.
Question 409
Topic: Knee Sports
During a total knee arthroplasty on a patient with a severe fixed valgus deformity, you find that the lateral collateral ligament (LCL) and posterolateral corner remain tight in extension after your bony cuts. When sequentially releasing structures to balance a valgus knee in extension, which structure is typically released first?
Correct Answer & Explanation
. Iliotibial (IT) band
Explanation
In the standard sequence for balancing a fixed valgus knee in extension, the iliotibial (IT) band is typically the first structure released (often via pie-crusting), followed by the posterolateral capsule, and then the popliteus or LCL if further correction is needed.
Question 410
Topic: Knee Sports
A 28-year-old professional basketball player presents with chronic anterior knee pain and instability, worsening with activity. He previously sustained a twisting injury to his knee. Examination reveals a positive Lachman test, pivot shift test, and a firm endpoint on anterior drawer. His X-rays are normal. MRI shows a complete tear of the anterior cruciate ligament (ACL) and a horizontal tear of the posterior horn of the medial meniscus. What is the most appropriate management?
Correct Answer & Explanation
. ACL reconstruction with repair of the medial meniscus.
Explanation
Correct Answer: DFor a young, active individual with a complete ACL tear and symptomatic instability, ACL reconstruction is indicated. Given the concomitant horizontal tear of the posterior horn of the medial meniscus, and assuming it's a reparable tear (e.g., in the red-red or red-white zone, stable, and of sufficient size), primary repair of the meniscus in conjunction with ACL reconstruction is often the preferred approach. ACL reconstruction provides a stable environment that can promote meniscus healing and reduces the risk of future degenerative changes. Partial meniscectomy, while common, removes meniscal tissue and increases the risk of osteoarthritis, and is generally avoided if repair is feasible, especially in younger patients with concomitant ACL injury. Conservative management is not suitable for a professional athlete with symptomatic instability.
Question 411
Topic: Knee Sports
A 4-year-old boy presents with an asymmetric, painless swelling on the medial aspect of his left ankle. Radiographs show an irregular, ossified mass arising from the medial distal tibial epiphysis. What is the most likely diagnosis?
Dysplasia Epiphysealis Hemimelica (Trevor disease) is a rare developmental disorder characterized by an osteochondroma-like overgrowth of cartilage arising from the epiphysis, most commonly affecting the medial side of the lower extremity joints.
Question 412
Topic: Knee Sports
The examiner asks about other causes for one or two loose bodies in a joint, and the candidate mentions osteoarthritis. The examiner then asks about multiple loose bodies. What is the most common diagnosis when multiple loose bodies are observed in an elbow joint?
Correct Answer & Explanation
. Primary synovial chondromatosis
Explanation
Correct Answer: CExplanation:When multiple loose bodies are observed in an elbow joint, the most common diagnosis isprimary synovial chondromatosis. This is a benign condition characterized by metaplastic changes in the synovial membrane, leading to the formation of cartilaginous nodules within the synovium. These nodules can then detach and become free-floating loose bodies within the joint, often calcifying over time and appearing as multiple, variably sized, calcified bodies on radiographs. Osteochondritis dissecans (A) typically results in one or a few loose bodies from a specific lesion. Post-traumatic osteochondral fragments (B) are usually limited in number. Rheumatoid arthritis (D) and gouty arthritis (E) are inflammatory conditions that do not typically produce multiple, calcified loose bodies as a primary feature, although joint destruction in severe cases could lead to some fragments.
Question 413
Topic: Knee Sports
In the surgical management of an unstable capitellar OCD lesion with a loose body, what size threshold generally supports arthroscopic fragment excision and microfracture over an osteochondral autograft transfer (OATS)?
Correct Answer & Explanation
. Lesions less than 1 cm in diameter without lateral wall involvement
Explanation
Arthroscopic excision and microfracture are typically successful for smaller, contained capitellar OCD lesions (<1 cm). Larger lesions (>1 cm), especially those compromising the lateral capitellar wall, generally require cartilage restoration techniques like OATS.
Question 414
Topic: Knee Sports
In a 13-year-old baseball pitcher with capitellar osteochondritis dissecans, which of the following MRI findings most strongly indicates an unstable lesion requiring surgical intervention?
Correct Answer & Explanation
. A high-signal T2 line between the lesion and native bone
Explanation
A T2 high-signal rim intervening between the OCD fragment and the underlying bone indicates synovial fluid has tracked under the fragment. This strongly suggests instability that often warrants surgical management.
Question 415
Topic: Knee Sports
A 45-year-old male presents with mechanical elbow pain, catching, and limited range of motion. Radiographs show multiple uniform, round, ossified bodies within the joint space with preserved radiocapitellar and ulnohumeral joint spaces. What is the most likely underlying pathophysiology?
Correct Answer & Explanation
. Synovial metaplasia
Explanation
Primary synovial chondromatosis is a benign condition characterized by synovial metaplasia producing multiple loose bodies of relatively uniform size. It typically presents in the absence of severe degenerative joint disease.
Question 416
Topic: Knee Sports
A 15-year-old right-hand-dominant baseball pitcher presents with a symptomatic 12 mm capitellar OCD lesion. Intraoperatively, the articular cartilage is breached, and the fragment is loose but unfragmented with adequate bone. What is the most appropriate surgical management?
Correct Answer & Explanation
. Internal fixation of the fragment
Explanation
For a large (>10 mm), unstable but intact (unfragmented) OCD lesion with sufficient attached bone, internal fixation is the preferred treatment to restore the native articular surface. Microfracture or OATS are reserved for non-salvageable or fragmented defects.
Question 417
Topic: Knee Sports
In the management of capitellar osteochondritis dissecans (OCD), osteochondral autograft transfer (OATS) is most strongly indicated for which of the following lesions?
Correct Answer & Explanation
. A 14 mm fragmented lesion involving the lateral capitellar margin
Explanation
OATS is indicated for large, unsalvageable (fragmented), or cystic capitellar OCD lesions. It is particularly necessary for lesions involving the lateral capitellar margin, where simple excision and microfracture have poorer clinical outcomes due to loss of lateral containment.
Question 418
Topic: Knee Sports
A 16-year-old baseball pitcher presents with a 4-month history of lateral elbow pain, clicking, and a 20-degree flexion contracture. MRI reveals an 8 mm unstable capitellar osteochondral lesion with an intra-articular loose body. What is the most appropriate surgical treatment?
Correct Answer & Explanation
. Arthroscopic loose body removal and capitellar microfracture
Explanation
For symptomatic, unstable capitellar OCD lesions with a loose body and a small defect (typically <10 mm), the recommended treatment is loose body removal, debridement of the crater, and marrow stimulation (microfracture) to promote fibrocartilage healing. OATS is generally reserved for larger lesions (>10 mm) or failed microfracture.
Question 419
Topic: Knee Sports
The meniscofemoral ligaments (of Humphry and Wrisberg) are associated with which meniscal horn and may provide some additional stabilization?
Correct Answer & Explanation
. Posterior horn of the lateral meniscus.
Explanation
Correct Answer: DThe meniscofemoral ligaments (MFLs) are typically associated with the posterior horn of the lateral meniscus. The ligament of Wrisberg passes posterior to the PCL, and the ligament of Humphry passes anterior to the PCL. While their primary function is debated, they are thought to provide some accessory stabilization to the posterior horn of the lateral meniscus and may provide stability in the setting of an absent or deficient PCL.
Question 420
Topic: Knee Sports
Which statement best describes the healing potential of a longitudinal tear in the inner one-third (white-white zone) of the meniscus?
Correct Answer & Explanation
. Poor, due to the inherent avascularity of the region.
Explanation
Correct Answer: CThe inner one-third (white-white zone) of the meniscus is avascular. Without a direct blood supply, intrinsic healing of tears in this region is extremely poor to non-existent. Surgical repair in this zone is generally not indicated as it has a very low success rate, hence partial meniscectomy is often the treatment. While age can influence healing, the primary determinant in this zone is the lack of vascularity.
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