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Knee Sports MCQs

Practice Set 22 of 102

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 421

Topic: Knee Sports

During the viva, the candidate describes the posterior approach to the knee. Which of the following is NOT a commonly accepted indication for utilizing a posterior approach to the knee?

. Open reduction and internal fixation of posterior tibial plateau shear fractures
. Fixation of bone avulsions associated with a posterior cruciate ligament (PCL) injury
. Repair of posterior vascular injuries
. Arthroscopic meniscal repair of a posterior horn tear
. Removal of popliteal cysts and neoplasms

Correct Answer & Explanation

. Arthroscopic meniscal repair of a posterior horn tear

Explanation

Correct Answer: DThe candidate explicitly lists the indications for a posterior approach to the knee: 'The indications include removal of popliteal cysts and neoplasms, posterior synovectomy, open reduction and internal fixation of posterior tibial plateau shear fractures, fixation of bone avulsions associated with a posterior cruciate ligament (PCL) injury, repair of posterior vascular injuries, and more recently, posterior inlay PCL reconstructions.'Option A (Open reduction and internal fixation of posterior tibial plateau shear fractures):This is a direct indication mentioned in the text.Option B (Fixation of bone avulsions associated with a posterior cruciate ligament (PCL) injury):This is the specific injury discussed in the case and is a direct indication mentioned.Option C (Repair of posterior vascular injuries):This is a direct indication mentioned in the text.Option E (Removal of popliteal cysts and neoplasms):This is a direct indication mentioned in the text.Option D (Arthroscopic meniscal repair of a posterior horn tear):While posterior horn meniscal tears are common, their repair is almost universally performed arthroscopically through standard anterior portals, sometimes with an accessory posteromedial or posterolateral portal, but not via a formal open posterior approach as described. The posterior approach is for deeper, more extensive posterior pathology or direct access to the PCL and vessels.

Question 422

Topic: Knee Sports

A 30-year-old professional soccer player undergoes single-bundle ACL reconstruction for a right knee injury. To achieve optimal anatomical and isometric tunnel placement, where should the femoral tunnel ideally be positioned?

. At 12 o'clock, anterior to the resident's ridge
. At 3 o'clock, in the intercondylar notch
. At 10 to 10:30 o'clock, targeting the posterolateral bundle footprint
. At 1:30 to 2 o'clock, targeting the anteromedial bundle footprint
. Posterior to the resident's ridge, at 7 o'clock

Correct Answer & Explanation

. At 10 to 10:30 o'clock, targeting the posterolateral bundle footprint

Explanation

Correct Answer: CThe candidate states: 'For the femoral tunnel the isometric point lies at about 10 to 10.30 o’clock for right knee and 1.30 to 2 for left knee. The anteromedial bundle is thought to be the most isometric but most surgeons feel that it’s important to replace the posterolateral bundle.' The question specifies a right knee and single-bundle reconstruction aiming for anatomical and isometric placement.Option A (At 12 o'clock, anterior to the resident's ridge):Placing the tunnel too anterior (e.g., 12 o'clock or anterior to the resident's ridge) is described as a common mistake that restricts knee flexion and may result in graft elongation.Option B (At 3 o'clock, in the intercondylar notch):This position is not described as optimal for a right knee ACL femoral tunnel.Option C (At 10 to 10:30 o'clock, targeting the posterolateral bundle footprint):This is the exact optimal position described for a right knee, with the aim of replacing the posterolateral bundle.Option D (At 1:30 to 2 o'clock, targeting the anteromedial bundle footprint):This position is described for a left knee, not a right knee. While the anteromedial bundle is isometric, the text states most surgeons aim to replace the posterolateral bundle.Option E (Posterior to the resident's ridge, at 7 o'clock):While avoiding the resident's ridge is important, placing the tunnel too posterior (e.g., 7 o'clock) results in excessive tightening of the graft when the knee is extended.

Question 423

Topic: Knee Sports

A 28-year-old patient undergoes an arthroscopic single-bundle ACL reconstruction. Post-operatively, the patient complains of significant restriction in knee flexion, particularly beyond 90 degrees. Based on the principles discussed in the case, which of the following is the most likely technical error during the procedure?

. Femoral tunnel placed too posterior
. Tibial tunnel placed too posterior
. Graft tensioned excessively in extension
. Femoral tunnel placed too anterior ('resident's ridge')
. Inadequate notchplasty leading to impingement in extension

Correct Answer & Explanation

. Femoral tunnel placed too anterior ('resident's ridge')

Explanation

Correct Answer: DThe candidate explicitly states: 'The most common mistake is to place femoral tunnel too anterior or ‘resident’s ridge’. This restricts flexion of the knee and may result in elongation of graft.'Option A (Femoral tunnel placed too posterior):A femoral tunnel placed too posterior would result in excessive tightening of the graft when the knee is extended, not restricted flexion.Option B (Tibial tunnel placed too posterior):While tibial tunnel malpositioning can cause issues, the text specifically links restricted flexion to an anterior femoral tunnel. A too-posterior tibial tunnel might lead to impingement in flexion or extension, but the primary cause of restricted flexion is often an anterior femoral tunnel.Option C (Graft tensioned excessively in extension):While excessive tensioning can cause stiffness, the specific pattern of restricted flexion is most directly linked to an anterior femoral tunnel.Option E (Inadequate notchplasty leading to impingement in extension):Impingement from an inadequate notchplasty is mentioned, but the text links it to impingement on the lateral femoral condyle, and the specific complication of restricted flexion is attributed to an anterior femoral tunnel. Impingement in extension would typically be due to a too-anterior tibial tunnel or an inadequate notchplasty.

Question 424

Topic: Knee Sports

During an arthroscopic ACL reconstruction, after drilling the femoral tunnel in the anatomically correct position (10-10:30 o'clock for a right knee), the surgeon observes that the graft impinges against the anterior portion of the lateral femoral condyle when the knee is flexed. What is the most appropriate next step to address this issue?

. Redrill the femoral tunnel in a more posterior position
. Perform a notchplasty of the anterior portion of the lateral femoral condyle
. Tension the graft less aggressively to avoid impingement
. Redrill the tibial tunnel in a more anterior position
. Proceed with graft fixation, as minor impingement is expected

Correct Answer & Explanation

. Perform a notchplasty of the anterior portion of the lateral femoral condyle

Explanation

Correct Answer: BThe candidate discusses this exact scenario: 'Careful assessment of notch should be done prior to graft insertion using a pin to ensure no impingement on lateral femoral condyle. The presence of impingement with correct placement of tunnels necessitates notchplasty of the anterior portion of lateral femoral condyle.'Option A (Redrill the femoral tunnel in a more posterior position):The text explicitly states that the tunnel is already in the 'correct placement.' Redrilling it more posteriorly would lead to excessive tightening of the graft in extension, as mentioned in the case.Option C (Tension the graft less aggressively to avoid impingement):Graft tensioning is crucial for stability. Reducing tension to avoid impingement would compromise the stability of the reconstruction. The issue is mechanical impingement, not tension.Option D (Redrill the tibial tunnel in a more anterior position):This would likely exacerbate impingement or lead to other issues, as the problem is identified at the femoral side with the lateral femoral condyle.Option E (Proceed with graft fixation, as minor impingement is expected):Impingement, even if minor, can lead to graft wear, failure, and restricted range of motion. It should be addressed.

Question 425

Topic: Knee Sports
During a medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar dislocation, identifying the correct femoral attachment site is critical to prevent abnormal joint kinematics. According to Schöttle's point, where is the anatomic femoral origin of the MPFL located?
. Anterior to the medial epicondyle and distal to the adductor tubercle
. Posterior to the medial epicondyle and proximal to the adductor tubercle
. Between the medial epicondyle and the adductor tubercle
. Directly on the adductor tubercle
. At the insertion of the medial collateral ligament

Correct Answer & Explanation

. Between the medial epicondyle and the adductor tubercle

Explanation

The anatomic femoral origin of the MPFL (Schöttle's point) is located radiographically between the medial epicondyle and the adductor tubercle. Non-anatomic placement, particularly too proximal, results in excessive graft tension during knee flexion, leading to medial patellar overload and loss of flexion. Accurate placement is essential for restoring native kinematics.

Question 426

Topic: Knee Sports

A patient presents with lateral knee pain and a sensation of giving way following a hyperextension injury. Physical examination reveals a positive dial test with 15 degrees of increased external rotation at 30 degrees of knee flexion compared to the contralateral side. At 90 degrees of knee flexion, the external rotation is equal bilaterally. What is the most likely diagnosis?

. Isolated anterior cruciate ligament (ACL) tear
. Isolated posterior cruciate ligament (PCL) tear
. Isolated posterolateral corner (PLC) injury
. Combined PCL and PLC injury
. Medial collateral ligament (MCL) tear

Correct Answer & Explanation

. Isolated posterolateral corner (PLC) injury

Explanation

The dial test evaluates for posterolateral corner (PLC) and posterior cruciate ligament (PCL) injuries. Asymmetry of more than 10 degrees at 30 degrees of flexion, but symmetric rotation at 90 degrees, indicates an isolated PLC injury. If the asymmetry persists at both 30 and 90 degrees, it indicates a combined PCL and PLC injury.

Question 427

Topic: Knee Sports

During a posterior cruciate ligament (PCL) reconstruction, the surgeon must address the distinct functional bundles of the native PCL. Which of the following statements accurately describes the biomechanics of the PCL bundles?

. The anterolateral bundle is tight in flexion, and the posteromedial bundle is tight in extension.
. The anterolateral bundle is tight in extension, and the posteromedial bundle is tight in flexion.
. Both bundles maintain constant, equal tension throughout the entire range of motion.
. The anteromedial bundle is tight in flexion, and the posterolateral bundle is tight in extension.
. The posteromedial bundle is the primary restraint to posterior tibial translation at 90 degrees of flexion.

Correct Answer & Explanation

. The anterolateral bundle is tight in flexion, and the posteromedial bundle is tight in extension.

Explanation

The PCL consists of two main bundles: the larger anterolateral (AL) bundle and the smaller posteromedial (PM) bundle. The AL bundle is tight in knee flexion and is the primary restraint to posterior translation at 90 degrees. The PM bundle is tight in extension and deep flexion.

Question 428

Topic: Knee Sports

A 22-year-old female soccer player sustains a non-contact twisting injury to her knee, feeling a "pop" and developing a rapid effusion. MRI confirms an acute anterior cruciate ligament (ACL) rupture. Which concomitant intra-articular injury is most commonly associated with this acute presentation?

. Medial meniscus tear
. Lateral meniscus tear
. Posterior cruciate ligament tear
. Medial collateral ligament tear
. Osteochondral defect of the medial femoral condyle

Correct Answer & Explanation

. Lateral meniscus tear

Explanation

In the acute setting, lateral meniscus tears are the most common concomitant injury with an ACL rupture. Medial meniscus tears become more common in chronic ACL-deficient knees due to repetitive anterior tibial translation.

Question 429

Topic: Knee Sports

A 30-year-old male is evaluated for knee instability following a motor vehicle accident. On physical examination, the dial test reveals 15 degrees of increased external rotation of the tibia at 30 degrees of knee flexion compared to the contralateral side. At 90 degrees of flexion, the external rotation is equal bilaterally. What is the most likely diagnosis?

. Isolated posterior cruciate ligament (PCL) injury
. Isolated posterolateral corner (PLC) injury
. Combined PCL and PLC injury
. Isolated medial collateral ligament (MCL) injury
. Combined ACL and MCL injury

Correct Answer & Explanation

. Isolated posterolateral corner (PLC) injury

Explanation

Increased external rotation at 30 degrees of flexion that reduces to normal at 90 degrees indicates an isolated posterolateral corner (PLC) injury. Combined PCL and PLC injuries show increased external rotation at both 30 and 90 degrees.

Question 430

Topic: Knee Sports

A 16-year-old female presents with recurrent lateral patellar dislocations. You decide to surgically reconstruct the primary restraint to lateral patellar translation. Where is the normal anatomic femoral origin of this ligament located?

. The lateral epicondyle
. The saddle region between the medial epicondyle and the adductor tubercle
. Directly on the medial collateral ligament (MCL) bursa
. Gerdy's tubercle
. The fibular head

Correct Answer & Explanation

. The saddle region between the medial epicondyle and the adductor tubercle

Explanation

The medial patellofemoral ligament (MPFL) is the primary restraint to lateral translation from 0 to 30 degrees of flexion. Its femoral attachment (Schottle's point) is situated between the medial epicondyle and the adductor tubercle.

Question 431

Topic: Knee Sports

What is the optimal knee flexion angle for tensioning a posterior cruciate ligament (PCL) graft during a single-bundle reconstruction?

. Full extension
. 30 degrees
. 60 degrees
. 90 degrees
. 120 degrees

Correct Answer & Explanation

. 90 degrees

Explanation

Single-bundle PCL grafts are typically tensioned at 90 degrees of flexion, where the anterolateral bundle is most taut. An anterior drawer force is applied concurrently to restore the normal anatomic tibial step-off.

Question 432

Topic: Knee Sports

A 55-year-old female presents with acute medial knee pain after a deep squat. MRI reveals a posterior root tear of the medial meniscus. If left untreated, this injury alters knee biomechanics most similarly to:

. A complete anterior cruciate ligament tear
. A complete posterior cruciate ligament tear
. A total meniscectomy
. A partial medial meniscectomy
. An isolated MCL sprain

Correct Answer & Explanation

. A complete posterior cruciate ligament tear

Explanation

A meniscal root tear disrupts the ability of the meniscus to convert axial loads into hoop stresses. Biomechanical studies have demonstrated that a complete posterior root tear results in contact pressures equivalent to those seen after a total meniscectomy.

Question 433

Topic: Knee Sports

A 22-year-old soccer player undergoes an anterior cruciate ligament (ACL) reconstruction. To address persistent anterolateral rotatory instability and a high-grade pivot shift, the surgeon performs an extra-articular tenodesis. Which anatomical structure is being reconstructed or augmented?

. Popliteofibular ligament
. Iliotibial band
. Oblique popliteal ligament
. Posterolateral corner
. Anterolateral ligament

Correct Answer & Explanation

. Anterolateral ligament

Explanation

The anterolateral ligament (ALL) is a distinct capsular structure that works synergistically with the ACL to control internal tibial rotation and the pivot shift phenomenon. ALL reconstruction or lateral extra-articular tenodesis is increasingly utilized in high-risk patients to prevent ACL graft failure.

Question 434

Topic: Knee Sports

During anterior cruciate ligament (ACL) reconstruction, non-anatomic vertical placement of the femoral tunnel primarily leads to which of the following outcomes?

. Loss of terminal extension
. Increased anterior tibial translation in deep flexion
. Residual rotatory instability and a positive pivot shift test
. Increased tension on the graft during early flexion
. Patella baja

Correct Answer & Explanation

. Residual rotatory instability and a positive pivot shift test

Explanation

A vertically placed femoral tunnel in ACL reconstruction fails to anatomically recreate both the anteromedial and posterolateral bundle kinematics. This geometry offers poor control of rotational forces, leading to residual rotatory instability and a persistent pivot shift.

Question 435

Topic: Knee Sports

During an anterior cruciate ligament (ACL) reconstruction, placing the femoral tunnel too anteriorly (shallow) relative to the anatomic footprint will result in which of the following kinematic abnormalities?

. The graft will be tight in flexion and loose in extension
. The graft will be tight in extension and loose in flexion
. The graft will restrict internal rotation only
. The graft will cause obligate external rotation during extension
. The graft will remain isometric throughout the entire range of motion

Correct Answer & Explanation

. The graft will be tight in flexion and loose in extension

Explanation

An anteriorly placed femoral tunnel (anterior to the normal isometric point) results in a graft that becomes excessively tight as the knee moves into flexion. This can lead to significant flexion loss or early graft rupture. Conversely, a posterior placement causes tightness in extension.

Question 436

Topic: Knee Sports

A 22-year-old soccer player presents with a locked knee. An MRI demonstrates an ACL rupture with a displaced bucket-handle tear of the medial meniscus. What is the recommended management?

. Immediate partial meniscectomy followed by delayed ACL reconstruction
. Simultaneous ACL reconstruction and meniscus repair
. ACL reconstruction and non-operative management of the meniscus
. Diagnostic arthroscopy only
. Knee immobilization for 6 weeks followed by physical therapy

Correct Answer & Explanation

. Simultaneous ACL reconstruction and meniscus repair

Explanation

Simultaneous ACL reconstruction and meniscal repair is the gold standard. The intra-articular bleeding from the ACL reconstruction enhances the healing environment for the meniscus repair.

Question 437

Topic: Knee Sports

A 45-year-old male falls from a ladder, sustaining an L1 burst fracture. He is neurologically intact. Which of the following is a universally accepted indication for operative stabilization of this fracture?

. Canal compromise of 20%
. Anterior wedge compression of 10 degrees
. Posterior ligamentous complex (PLC) disruption
. Intact neurological exam
. Loss of vertebral body height of 20%

Correct Answer & Explanation

. Posterior ligamentous complex (PLC) disruption

Explanation

Disruption of the posterior ligamentous complex (PLC) indicates a highly unstable three-column spine injury. Operative stabilization is indicated even in the absence of neurological deficits.

Question 438

Topic: Knee Sports

Regarding the medial patellofemoral ligament (MPFL), which statement is most accurate concerning its anatomy and function?

. The MPFL primarily resists lateral patellar translation at full knee extension.
. The femoral attachment of the MPFL is consistently found on the medial epicondyle.
. The MPFL is the primary static restraint to lateral patellar translation between 0 and 30 degrees of knee flexion.
. The patellar attachment of the MPFL is typically broader on the medial facet and superior border of the patella.
. Complete rupture of the MPFL is typically associated with a bone avulsion from the patella rather than the femur.

Correct Answer & Explanation

. The MPFL is the primary static restraint to lateral patellar translation between 0 and 30 degrees of knee flexion.

Explanation

Correct Answer: CThe MPFL is recognized as the primary static restraint to lateral patellar translation, particularly in the initial 20-30 degrees of knee flexion, where the trochlear groove is shallowest. At full knee extension, the joint is less constrained, but the MPFL's role is critical. The femoral attachment is variable but typically found distal and posterior to the adductor tubercle, often blended with the adductor magnus tendon and medial gastrocnemius origin, not consistently on the medial epicondyle. The patellar attachment is usually on the superior medial patella. While avulsions can occur at either end, femoral avulsions are more common in acute dislocations.

Question 439

Topic: Knee Sports

During an MPFL reconstruction using a semitendinosus autograft, the most critical step to prevent iatrogenic patellar fracture or over-constraining the patella is:

. Fixing the graft to the patella with a suture anchor.
. Ensuring the knee is in full extension during femoral fixation.
. Tensioning the graft with the knee in 30 degrees of flexion.
. Performing a lateral retinacular release prior to graft placement.
. Utilizing fluoroscopy to confirm proper femoral tunnel placement.

Correct Answer & Explanation

. Tensioning the graft with the knee in 30 degrees of flexion.

Explanation

Correct Answer: COver-constraining the patella is a known complication of MPFL reconstruction, leading to patellofemoral pain and stiffness. The MPFL is isometric in the initial 0-30 degrees of flexion. Tensioning the graft with the knee in 30 degrees of flexion is crucial. If the graft is tensioned in full extension or hyperflexion, it becomes too tight in mid-flexion, causing increased patellofemoral contact pressures and potentially pain or articular cartilage damage. Fluoroscopy for femoral tunnel placement is essential to avoid violating the physis in skeletally immature patients or drilling too anterior/posterior, but it doesn't directly prevent over-tensioning. Patellar fixation is standard; lateral retinacular release is not routinely performed with MPFL reconstruction unless specific lateral tightness is present.

Question 440

Topic: Knee Sports

Which of the following is an absolute contraindication to performing a tibial tubercle osteotomy in a patient with patellar instability?

. Patella alta.
. Open proximal tibial physis.
. Severe trochlear dysplasia.
. Generalized ligamentous laxity.
. History of a prior MPFL reconstruction.

Correct Answer & Explanation

. Open proximal tibial physis.

Explanation

Correct Answer: BAn open proximal tibial physis is an absolute contraindication for a standard tibial tubercle osteotomy (e.g., Fulkerson or Elmslie-Trillat) due to the significant risk of growth arrest, angular deformities, or leg length discrepancies. In skeletally immature patients, if a bony procedure is absolutely necessary, techniques that spare the physis (e.g., physis-sparing MPFL reconstruction) or physeal bridging procedures with careful monitoring are considered. Patella alta, severe trochlear dysplasia, and generalized ligamentous laxity are risk factors that may necessitate a tibial tubercle osteotomy, not contraindications. A prior MPFL reconstruction does not contraindicate a subsequent tibial tubercle osteotomy if malalignment persists.

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