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Knee Sports MCQs

Practice Set 41 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 801

Topic: Knee Sports

During reconstruction of the medial patellofemoral ligament (MPFL) for recurrent patellar instability, the surgeon inadvertently places the femoral tunnel 5 mm proximal and anterior to the anatomic footprint (Schottle point). What is the expected clinical consequence of this technical error?

. The graft will be tight in extension and loose in flexion
. The graft will be loose in extension and overly tight in flexion
. The graft will maintain isometric tension but the patella will subluxate laterally
. The patella will subluxate medially during terminal extension
. The risk of patella baja is significantly increased postoperatively

Correct Answer & Explanation

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

Explanation

A femoral tunnel placed proximal and anterior to the anatomic MPFL footprint results in non-isometric graft behavior. The graft will be relatively loose in extension and excessively tight in flexion, leading to restricted knee flexion and increased medial patellofemoral cartilage pressure.

Question 802

Topic: Knee Sports

A 24-year-old athlete sustains a multi-ligament knee injury involving the posterolateral corner (PLC). Based on clinical biomechanics, which of the following structures acts as the primary restraint to varus stress when the knee is tested at 30 degrees of flexion?

. Popliteofibular ligament
. Lateral collateral ligament (LCL)
. Popliteus tendon
. Posterior cruciate ligament (PCL)
. Biceps femoris tendon

Correct Answer & Explanation

. Lateral collateral ligament (LCL)

Explanation

The lateral collateral ligament (LCL) is the primary restraint to varus stress at all angles of knee flexion. However, it is most accurately isolated and tested clinically at 30 degrees of flexion, where the cruciate ligaments are relatively relaxed.

Question 803

Topic: Knee Sports

A 40-year-old female presents with isolated advanced lateral patellofemoral arthritis, a tibial tubercle-trochlear groove (TT-TG) distance of 22 mm, and patella alta (Caton-Deschamps index of 1.4). Which tibial tubercle osteotomy modification is most appropriate to optimize patellofemoral tracking and contact pressures?

. Anteromedialization (Fulkerson osteotomy)
. Straight anterior elevation (Maquet procedure)
. Medialization and distalization
. Lateralization and elevation
. Medialization and proximalization

Correct Answer & Explanation

. Medialization and distalization

Explanation

In the setting of lateral tracking (TT-TG > 20 mm) and patella alta (Caton-Deschamps > 1.2) with isolated patellofemoral arthritis, a medializing and distalizing tibial tubercle osteotomy is indicated. This combination corrects the lateral vector and normalizes patellar height, effectively unloading the lateral facet.

Question 804

Topic: Knee Sports

During a medial opening-wedge high tibial osteotomy (HTO), the surgeon realizes the anterior gap is inadvertently opened wider than the posterior gap. What is the direct biomechanical consequence of this asymmetric opening?

. Decreased posterior tibial slope and increased extension deficit
. Increased posterior tibial slope and risk of anterior cruciate ligament (ACL) strain
. Decreased posterior tibial slope and risk of posterior cruciate ligament (PCL) strain
. Unaltered sagittal alignment but increased valgus overcorrection
. Increased patellar height leading to patella alta

Correct Answer & Explanation

. Increased posterior tibial slope and risk of anterior cruciate ligament (ACL) strain

Explanation

Opening the anterior aspect of a medial opening-wedge HTO more than the posterior aspect increases the posterior tibial slope. This shifts the resting position of the tibia anteriorly, placing increased strain on the anterior cruciate ligament (ACL).

Question 805

Topic: Knee Sports

A 24-year-old football player sustains a direct blow to the anteromedial aspect of his knee while it is hyperextended. Examination reveals increased external rotation of the tibia at 30 degrees of knee flexion, but symmetrical external rotation at 90 degrees compared to the contralateral leg. What is the most likely injured structure?

. Anterior cruciate ligament
. Posterior cruciate ligament
. Posterolateral corner
. Posteromedial corner
. Medial collateral ligament

Correct Answer & Explanation

. Posterolateral corner

Explanation

An isolated posterolateral corner (PLC) injury presents with increased external rotation at 30 degrees of flexion but not at 90 degrees on the Dial test. If external rotation is increased at both 30 and 90 degrees, a combined PLC and PCL injury should be suspected.

Question 806

Topic: Knee Sports

A 45-year-old male laborer complains of medial-sided left knee pain. Radiographs show isolated medial compartment osteoarthritis and varus alignment. He has full range of motion and a stable knee. Which of the following is the primary biomechanical goal of a high tibial osteotomy (HTO) in this patient?

. To restore the anterior cruciate ligament tension
. To shift the mechanical axis to the lateral compartment
. To shift the mechanical axis slightly lateral to the center of the knee
. To promote regeneration of articular cartilage in the medial compartment
. To prevent the progression of patellofemoral arthritis

Correct Answer & Explanation

. To shift the mechanical axis slightly lateral to the center of the knee

Explanation

The primary goal of a valgus-producing high tibial osteotomy is to unload the arthritic medial compartment by shifting the mechanical axis slightly lateral to the midline of the knee (typically 62% of the tibial width). This relieves pain and slows the progression of medial compartment arthritis.

Question 807

Topic: Knee Sports

A 17-year-old female dancer requires medial patellofemoral ligament (MPFL) reconstruction for recurrent lateral patellar instability. Which of the following radiographic landmarks correctly describes the anatomic femoral attachment of the MPFL (Schottle's point)?

. Proximal and posterior to the medial epicondyle
. Distal and anterior to the adductor tubercle
. Proximal and anterior to the adductor tubercle
. Distal and posterior to the medial epicondyle
. Directly on the medial collateral ligament insertion

Correct Answer & Explanation

. Proximal and posterior to the medial epicondyle

Explanation

Schottle's point marks the anatomic femoral origin of the MPFL on lateral fluoroscopy. It is located dynamically between the medial epicondyle and the adductor tubercle, specifically proximal and posterior to the medial epicondyle.

Question 808

Topic: Knee Sports

Following a microfracture procedure for a symptomatic 1.5 cm^2 focal chondral defect on the medial femoral condyle, the resultant repair tissue is histologically evaluated. Compared to native articular cartilage, this repair tissue is predominantly characterized by an increased concentration of:

. Type I collagen
. Type II collagen
. Aggrecan
. Chondroitin sulfate
. Hyaluronan

Correct Answer & Explanation

. Type I collagen

Explanation

Microfracture is a marrow-stimulating technique that allows pluripotent mesenchymal stem cells to enter the chondral defect, resulting in the formation of fibrocartilage rather than native hyaline cartilage. Fibrocartilage is primarily composed of Type I collagen, which has inferior biomechanical wear characteristics compared to the Type II collagen predominant in normal hyaline articular cartilage.

Question 809

Topic: Knee Sports

A 14-year-old male baseball pitcher complains of lateral elbow pain and catching. Radiographs show a radiolucent lesion of the capitellum. MRI demonstrates an osteochondral lesion with fluid tracking behind the fragment. What is the most appropriate management?

. Cessation of throwing for 6 months
. Arthroscopic debridement and microfracture of the lesion
. Open reduction and internal fixation or osteochondral autograft transfer (OATS)
. Radial head excision
. Corticosteroid injection and physical therapy

Correct Answer & Explanation

. Open reduction and internal fixation or osteochondral autograft transfer (OATS)

Explanation

Fluid tracking behind an osteochondral fragment on MRI signifies an unstable osteochondritis dissecans (OCD) lesion. In an adolescent with an unstable lesion, operative management is indicated. Depending on fragment viability, fixation of the fragment or an osteochondral autograft transfer (OATS) provides the best chance to restore the articular surface. Microfracture alone for a large capitellar lesion in a high-demand thrower is often structurally insufficient.

Question 810

Topic: Knee Sports
Following arthroscopic microfracture for a 1.5 cm^2 symptomatic focal chondral defect on the medial femoral condyle, what is the predominant collagen type found in the reparative tissue at 1 year postoperatively?
. Type I collagen
. Type II collagen
. Type III collagen
. Type IX collagen
. Type X collagen

Correct Answer & Explanation

. Type I collagen

Explanation

Microfracture is a marrow-stimulating technique that leads to the formation of fibrocartilage rather than normal hyaline cartilage. Fibrocartilage is predominantly composed of Type I collagen, whereas normal hyaline articular cartilage is predominantly composed of Type II collagen. This histologic difference accounts for the poorer long-term biomechanical durability of microfracture repairs.

Question 811

Topic: Knee Sports
Matrix-induced Autologous Chondrocyte Implantation (MACI) was developed to overcome some limitations of first-generation ACI. Which of the following best describes the primary modification introduced in MACI?
. Use of mesenchymal stem cells instead of articular chondrocytes
. Seeding cultured chondrocytes onto a Type I/III collagen membrane prior to implantation
. Utilizing a periosteal patch harvested from the proximal tibia to cover the defect
. Single-stage procedure combining cell harvest and implantation
. Injection of cultured chondrocytes in a hyaluronic acid suspension without a scaffold

Correct Answer & Explanation

. Seeding cultured chondrocytes onto a Type I/III collagen membrane prior to implantation

Explanation

First-generation ACI utilized cultured chondrocytes injected under a periosteal patch, which was associated with high rates of patch hypertrophy. MACI (Matrix-induced ACI) involves culturing the autologous chondrocytes and seeding them onto a bioabsorbable porcine-derived Type I/III collagen membrane. This membrane is then cut to size and glued or sutured into the defect, bypassing the need for a periosteal harvest.

Question 812

Topic: Knee Sports

Autologous Chondrocyte Implantation (ACI / MACI) is an established cell-based treatment for full-thickness articular cartilage defects. Which of the following scenarios represents the most ideal indication for this procedure?

. 1.5 cm^2 defect on the medial femoral condyle in a 25-year-old
. 3.5 cm^2 unipolar defect on the lateral femoral condyle in a 30-year-old
. Bipolar 'kissing' lesions of the patellofemoral joint in a 40-year-old
. 3.0 cm^2 defect in a 65-year-old with moderate osteoarthritis
. Osteochondritis dissecans lesion with an intact cartilage cap in a 12-year-old

Correct Answer & Explanation

. 3.5 cm^2 unipolar defect on the lateral femoral condyle in a 30-year-old

Explanation

Autologous Chondrocyte Implantation (ACI/MACI) is indicated for symptomatic, large (>2.0 to 3.0 cm^2), full-thickness, unipolar articular cartilage defects in young, active patients (typically < 50 years old) without advanced osteoarthritis. Defects smaller than 2.0 cm^2 are better treated with microfracture or OATS. Bipolar kissing lesions and moderate-to-severe OA are contraindications.

Question 813

Topic: Knee Sports
The major blood supply to the cruciate ligaments arises from which of the following structures?
. Superior genicular artery
. Middle genicular artery
. Inferior genicular artery
. Infrapatellar fat pad
. Intramedullary vessels

Correct Answer & Explanation

. Middle genicular artery

Explanation

The major blood supply to the cruciate ligaments arises from the ligamentous branches of the middle genicular artery. Few terminal branches of the inferior genicular artery contribute to the blood supply. The synovial plexus and sheath covering the cruciate ligaments are also supplied by branches of the middle genicular artery. The blood supply to the cruciate ligaments is predominately of soft-tissue origin. There is no significant osseous vascular contribution to the ligaments.

Question 814

Topic: Knee Sports

A 16-year-old football player sustains a direct blow to the anterior aspect of his flexed right knee. Examination reveals a contusion over the anterior tibial tubercle and a small effusion. MRI scans are shown in Figures 33a through 33c. What is the most likely diagnosis?

. Partial tear of the patellar tendon
. Osteochondral fracture of the femur
. Anterior cruciate ligament (ACL) tear
. Posterior cruciate ligament (PCL) tear
. Patella fracture

Correct Answer & Explanation

. Posterior cruciate ligament (PCL) tear

Explanation

The MRI scans show disruption of the fibers of the PCL. Patients sustaining an isolated acute PCL injury can present with only minimal discomfort and have full range of motion. When examination reveals a contusion over the tibial tubercle and discomfort with the posterior drawer examination, with or without instability, a possible injury to the PCL should be considered. In acute injuries, the reported accuracy of MRI imaging for diagnosing PCL tears ranges from 96% to 100%. Resnick D, Kang HS: Internal Derangement of Joints: Emphasis on MRI Imaging. Philadelphia, PA, WB Saunders, 1997, pp 699-700. Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482.

Question 815

Topic: Knee Sports

Figures 21a through 21c show the MRI scans of a 21-year-old football player who sustained a valgus knee injury while changing direction. Examination reveals swelling and tenderness along the medial aspect of the knee. There is a positive Lachman test, 3+ valgus laxity at 30 degrees, and 1+ valgus laxity at 0 degrees extension. The anterior drawer test is increased with the tibia in external rotation. The increase in the anterior drawer test with the tibia in external rotation is most likely the result of

. an occult fracture of the tibial plateau.
. a tear of the medial collateral ligament and the posteromedial capsule.
. a tear of the posterior cruciate ligament.
. a tear of the anterior and posterior cruciate ligaments.
. a tear of the anterior cruciate and medial collateral ligaments and the posteromedial capsule.

Correct Answer & Explanation

. a tear of the anterior cruciate and medial collateral ligaments and the posteromedial capsule.

Explanation

The injury mechanism involves a valgus load applied to the knee with the foot in external rotation. The primary stabilizer to valgus laxity is the medial collateral ligament. The secondary restraints to valgus rotation are the cruciate ligaments. Examination indicates disruption of the medial collateral and anterior cruciate ligaments. Valgus opening in extension should also arouse suspicion for an injury to the posterior cruciate ligament; however, in this patient, the valgus opening in extension is mild. The slight opening in extension and the increased anterior drawer, especially with external rotation, indicates disruption of the posteromedial capsule and posterior oblique ligament. Figure 21a shows complete disruption of the superficial and deep medial collateral ligaments involving the meniscofemoral ligament. Figure 21b shows a more posterior coronal section with a torn posterior oblique ligament. Figure 21c shows disruption of the anterior cruciate ligament, while the posterior cruciate ligament at the tibial insertion appears with a homogenous normal signal. Warren LA, Marshall JL, Girgis F: The prime static stabilizer of the medial side of the knee. J Bone Joint Surg Am 1974;56:665-674.

Question 816

Topic: Knee Sports

A 10-year-old boy sustained an injury to the left knee. The radiographic findings shown in Figure 19 are most commonly associated with injury to which of the following structures?

Sports Medicine Board Review 2001: High-Yield MCQs (Set 2) - Figure 22

. Anterior cruciate ligament (ACL)
. Posterior cruciate ligament (PCL)
. Patellar tendon
. Lateral capsule
. Pes anserinus

Correct Answer & Explanation

. Anterior cruciate ligament (ACL)

Explanation

The radiograph shows a bony avulsion of the ACL attachment site on the tibial spine in this skeletally immature patient. In this age group, injury often results in failure of the bony attachment site rather than the substance of the ligament. Avulsion of the patellar tendon insertion site can occur, but this structure is located at the apophysis of the tibial tubercle. The attachment site of the PCL is much more posterior. In adults, bony avulsion is more commonly associated with PCL injuries than with ACL injuries. When a small bony avulsion of the lateral capsule from the lateral tibial plateau is seen on the AP view, this finding is considered pathognomonic of an ACL injury (Segond sign) in adults. The area of the pes anserinus is anterior and distal; avulsion would be unusual. Baxter MP, Wiley JJ: Fractures of the tibial spine in children: An evaluation of knee stability. J Bone Joint Surg Br 1988;70:228-230. Meyers MH, McKeever FM: Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-1684.

Question 817

Topic: Knee Sports

An 18-year-old man underwent open reduction and internal fixation of a tibial spine avulsion and a posterolateral corner repair. Two years later, he underwent lateral collateral ligament (LCL) and posterolateral corner reconstruction because of instability. Examination reveals a pronounced lateral varus knee thrust when ambulating. Varus stress in 30 degrees of flexion produces a 10-mm opening that is eliminated in extension. The Lachman's test is 2 mm with a firm end point, and the posterior drawer test is negative. Standing radiographs show widening of the lateral joint space and a 5-degree mechanical varus alignment. What is the most effective course of treatment?

. Physical therapy for quadriceps strengthening
. Functional bracing
. Anterior cruciate ligament (ACL) reconstruction
. Revision reconstruction of the LCL and posterolateral corner
. Valgus-producing high tibial osteotomy (HTO)

Correct Answer & Explanation

. Valgus-producing high tibial osteotomy (HTO)

Explanation

The patient has chronic posterolateral instability with a varus knee alignment; therefore, the most effective treatment is a valgus-producing HTO. A repeat soft-tissue reconstruction without correction of the varus alignment will most likely fail. An ACL reconstruction is not indicated with a normal Lachman's test. Physical therapy and bracing will have little effect. Naudie DD, Amendola A, Fowler PJ: Opening wedge high tibial osteotomy for symptomatic hyperextension-varus thrust. Am J Sports Med 2004;32:60-70.

Question 818

Topic: Knee Sports

A 48-year-old man has recurrent right knee pain. Figure 52a shows the sagittal proton density T2-weighted MRI scan, and Figure 52b shows the sagittal T2-weighted MRI scan at the same level. The arrow is pointing to a

. popliteal cyst.
. posterior cruciate ligament tear.
. torn and displaced posterior horn of the medial meniscus.
. normal meniscofemoral ligament of Humphry.
. normal meniscofemoral ligament of Wrisberg.

Correct Answer & Explanation

. torn and displaced posterior horn of the medial meniscus.

Explanation

Meniscal tears have many configurations and locations. The normal medial meniscus has a bow-tie configuration on the two most medial consecutive sagittal views. Toward the center of the joint the anterior and posterior horns have a triangular shape. These images show an abnormal intra-articular low-signal structure located anterior to the intact posterior cruciate ligament. This most likely represents a torn and displaced posterior horn of the medial meniscus, sometimes called "double PCL sign". A popliteal cyst and ligaments of Wrisberg and Humphry are not visible on these figures. Helms CA: MR image of the knee, in Fundamentals of Skeletal Radiology, ed 2. Philadelphia, PA, WB Saunders, 1995, pp 172-191.

Question 819

Topic: Knee Sports
A 19-year-old rugby player has severe knee pain after being injured in a game 2 weeks ago. Examination reveals a knee effusion, limited motion, and increased 3+ Lachman's test and anterior drawer. There is also increased external rotation at 30 degrees of knee flexion when the patient is placed in the prone position. Based on these findings, which of the following actions would most likely increase the risk of anterior cruciate ligament (ACL) reconstruction failure?
. Inadvertent rotation of the graft 90 degrees internally prior to its final fixation
. Lack of full knee extension at the time of surgery
. Persistent posterolateral corner injury
. Leaving 1 to 2 mm of bone posterior to the femoral tunnel at the time of the ACL reconstruction
. Placing the tibial tunnel within the ACL footprint

Correct Answer & Explanation

. Persistent posterolateral corner injury

Explanation

The patient has a combined ACL and posterolateral corner injury. Failure to diagnose and treat an injury of the posterolateral corner in a patient who has a tear of the anterior or posterior cruciate ligament can result in failure of the reconstructed cruciate ligament. The tibial external rotation test is best performed with the patient in the prone position. A 10-degree side-to-side difference of external rotation at 30 degrees of knee flexion indicates injury to the posterolateral corner. Acute grade III isolated or combined injuries of the posterolateral corner are best treated early by direct repair or by augmentation or reconstruction of all injured ligaments. Postoperative arthrofibrosis after an ACL reconstruction has been observed with preoperative deficiencies of knee motion.

Question 820

Topic: Knee Sports

Figure 16 shows an axial MRI scan through the knee joint. What structure is identified by the arrow?

Anatomy Board Review 2002: High-Yield MCQs (Set 2) - Figure 6

. Anterior cruciate ligament
. Posterior cruciate ligament
. Ligament of Wrisberg
. Ligamentum mucosum
. Popliteus tendon

Correct Answer & Explanation

. Anterior cruciate ligament

Explanation

The anterior cruciate ligament can be visualized on an axial MRI scan as a low-signal structure lying in the lateral aspect of the intercondylar notch. Visualization in multiple planes increases the accuracy of MRI to view the anterior cruciate ligament. The posterior cruciate ligament and ligament of Wrisberg are located on the medial wall of the notch. The ligamentum mucosum is anterior to the notch, and the popliteus tendon is posterior to the lateral femoral condyle. Resnick D, Kang HS (eds): Internal Derangements of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 675-699.

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