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Question 1521

Topic: Shoulder & Hip Sports

The arthroscopic remplissage procedure, utilized for engaging Hill-Sachs lesions, involves capsulotenodesis of which structures into the humeral defect?

. Supraspinatus and superior capsule
. Infraspinatus and posterior capsule
. Teres minor and inferior capsule
. Subscapularis and middle glenohumeral ligament
. Long head of the biceps tendon

Correct Answer & Explanation

. Supraspinatus and superior capsule


Explanation

Remplissage involves suturing the posterior capsule and the infraspinatus tendon into the Hill-Sachs defect. This converts an intra-articular engaging defect into an extra-articular non-engaging defect.

Question 1522

Topic: Shoulder & Hip Sports

During a Superior Capsular Reconstruction (SCR) for a massive irreparable rotator cuff tear, the graft is anchored to the superior glenoid medially. Where is it anchored laterally?

. Lesser tuberosity
. Greater tuberosity footprint
. Superior margin of the subscapularis
. Anterior lip of the acromion
. Coracoid process

Correct Answer & Explanation

. Lesser tuberosity


Explanation

In SCR, the dermal or fascia lata graft is secured medially to the superior glenoid and laterally to the greater tuberosity, aiming to restore the superior restraint to humeral head translation.

Question 1523

Topic: Shoulder & Hip Sports

A patient is evaluated for anterior shoulder pain. They demonstrate a positive belly-press test and increased passive external rotation. If an MRI confirms a full-thickness subscapularis tear, what associated pathology is most likely to be found?

. Posterior labral tear
. Medial subluxation/dislocation of the long head of the biceps
. Type II SLAP tear
. Spinoglenoid notch cyst
. Os acromiale

Correct Answer & Explanation

. Posterior labral tear


Explanation

The superior fibers of the subscapularis and the coracohumeral ligament create the medial sling for the biceps tendon. A tear of the subscapularis footprint frequently leads to medial subluxation or dislocation of the long head of the biceps.

Question 1524

Topic: Shoulder & Hip Sports

A 34-year-old man presents with severe shoulder pain and inability to externally rotate the arm following a generalized seizure. An axillary lateral radiograph is obtained.

Advanced imaging reveals a locked posterior shoulder dislocation with an anteromedial humeral head defect (reverse Hill-Sachs lesion) involving 30% of the articular surface. What is the most appropriate surgical management?

. Closed reduction and immobilization in internal rotation
. Arthroscopic posterior Bankart repair
. Open reduction and subscapularis tendon transfer into the defect
. Total shoulder arthroplasty
. Latarjet procedure

Correct Answer & Explanation

. Closed reduction and immobilization in internal rotation


Explanation

A reverse Hill-Sachs lesion involving 20% to 40% of the articular surface is best treated with a McLaughlin procedure or its modification (transfer of the subscapularis tendon or lesser tuberosity into the defect). Defects >40% typically require arthroplasty, while small defects <20% may be stable after reduction alone.

Question 1525

Topic: Shoulder & Hip Sports

A 55-year-old man presents with profound weakness in active internal rotation after a traumatic lifting injury. MRI confirms an isolated, full-thickness, retracted tear of the subscapularis tendon. Which of the following physical examination findings is most specific for this condition?

. Positive Hornblower's sign
. Increased passive external rotation compared to the contralateral shoulder
. Weakness in forward elevation in the scapular plane
. Positive Jobe test
. Positive Neer impingement sign

Correct Answer & Explanation

. Positive Hornblower's sign


Explanation

An isolated subscapularis tear results in a loss of the anterior restraint, leading to increased passive external rotation. The lift-off and bear-hug tests would also be positive, but among the choices, asymmetric increased passive external rotation is highly specific for subscapularis deficiency.

Question 1526

Topic: Shoulder & Hip Sports

A 22-year-old collegiate rugby player experiences recurrent anterior shoulder instability. A pre-operative 3D CT scan reveals 27% anterior glenoid bone loss with an "inverted pear" appearance. What is the most appropriate definitive management?

. Arthroscopic Bankart repair with capsulolabral advancement
. Open anterior capsulolabral shift
. Coracoid process transfer to the anterior glenoid (Latarjet procedure)
. Arthroscopic remplissage
. Humeral head osteochondral allografting

Correct Answer & Explanation

. Arthroscopic Bankart repair with capsulolabral advancement


Explanation

Critical anterior glenoid bone loss (typically >20-25%) alters the glenoid shape to an "inverted pear" and is a primary indication for a bony augmentation procedure like the Latarjet. Soft tissue Bankart repairs have an unacceptably high failure rate in the setting of critical bone loss.

Question 1527

Topic: Shoulder & Hip Sports

A 40-year-old man sustains a severe proximal humerus fracture and presents with decreased sensation over the lateral aspect of his shoulder. Assuming the nerve supplying this area is injured, which of the following muscles is most likely to exhibit denervation weakness?

. Supraspinatus
. Infraspinatus
. Teres minor
. Teres major
. Subscapularis

Correct Answer & Explanation

. Supraspinatus


Explanation

Decreased sensation over the lateral shoulder (regimental badge area) indicates axillary nerve injury. The axillary nerve innervates both the deltoid and the teres minor muscles.

Question 1528

Topic: Shoulder & Hip Sports

An MRI of a 45-year-old recreational tennis player reveals a partial articular-sided supraspinatus tendon avulsion (PASTA lesion). The tear is estimated to involve 65% of the tendon footprint thickness. Nonoperative management has failed. What is the most appropriate surgical intervention?

. Arthroscopic debridement of the rotator cuff alone
. Arthroscopic completion of the tear and repair, or transtendon repair
. Open subacromial decompression without rotator cuff repair
. Mini-open rotator cuff repair with biceps tenodesis
. Arthroscopic isolated coracoacromial ligament release

Correct Answer & Explanation

. Arthroscopic debridement of the rotator cuff alone


Explanation

For partial-thickness articular-sided rotator cuff tears that involve >50% of the tendon footprint, the standard of care is to either perform a transtendon repair or complete the tear to a full-thickness defect followed by standard repair. Debridement alone is indicated for tears <50%.

Question 1529

Topic: Shoulder & Hip Sports

A 25-year-old man undergoes an arthroscopic anterior stabilization procedure. Intraoperatively, an engaging Hill-Sachs lesion is identified, and the surgeon decides to perform an arthroscopic remplissage. This procedure involves securing which of the following structures into the humeral head defect?

. Supraspinatus tendon
. Subscapularis tendon and middle glenohumeral ligament
. Infraspinatus tendon and posterior capsule
. Long head of the biceps tendon
. Teres minor tendon

Correct Answer & Explanation

. Supraspinatus tendon


Explanation

An arthroscopic remplissage (French for "to fill") addresses an engaging Hill-Sachs lesion by tenodesing the infraspinatus tendon and the posterior joint capsule into the bony defect. This prevents the defect from engaging the anterior glenoid rim during external rotation and abduction.

Question 1530

Topic: Shoulder & Hip Sports

A 21-year-old collegiate baseball pitcher complains of posterior shoulder pain during the late cocking phase of throwing. Physical examination reveals a positive apprehension test, but pain is completely relieved with the relocation test. MR arthrogram demonstrates posterior/superior labral fraying and a partial articular-sided supraspinatus tear. What is the most likely diagnosis?

. Internal impingement
. Subacromial impingement
. Anterior instability with a classic Bankart lesion
. Isolated anterior SLAP tear
. Suprascapular neuropathy

Correct Answer & Explanation

. Internal impingement


Explanation

Internal impingement occurs in overhead athletes during the late cocking phase (abduction and maximal external rotation), causing the undersurface of the supraspinatus/infraspinatus to impinge against the posterosuperior labrum. It classically presents with posterior pain relieved by the relocation test.

Question 1531

Topic: Shoulder & Hip Sports

A 19-year-old female competitive swimmer presents with bilateral shoulder pain and a sensation that her shoulders "slide out of place." Examination shows generalized hyperlaxity, a positive sulcus sign that does not reduce with external rotation, and normal rotator cuff strength. What is the most appropriate initial management?

. Arthroscopic capsular plication
. Open inferior capsular shift
. Physical therapy focusing on periscapular and rotator cuff strengthening
. Immobilization in a sling for 6 weeks
. Thermal capsulorrhaphy

Correct Answer & Explanation

. Arthroscopic capsular plication


Explanation

The patient has multidirectional instability (MDI), characterized by symptomatic generalized laxity and a positive sulcus sign. The first-line and most effective initial treatment is a prolonged course (typically 6 months) of targeted physical therapy emphasizing periscapular and rotator cuff strengthening.

Question 1532

Topic: Shoulder & Hip Sports

A 38-year-old weightlifter presents with vague posterior shoulder pain and isolated weakness in external rotation. Abduction strength is fully preserved. MRI demonstrates a paralabral cyst located strictly within the spinoglenoid notch. Which of the following muscles is most likely selectively denervated?

. Supraspinatus
. Infraspinatus
. Teres minor
. Subscapularis
. Deltoid

Correct Answer & Explanation

. Supraspinatus


Explanation

The suprascapular nerve innervates the supraspinatus before passing through the spinoglenoid notch to innervate the infraspinatus. A cyst isolated to the spinoglenoid notch will compress the distal branches, resulting in isolated infraspinatus weakness (decreased external rotation) while sparing supraspinatus function.

Question 1533

Topic: Shoulder & Hip Sports

A 60-year-old male with an irreparable massive rotator cuff tear (supraspinatus and infraspinatus) without advanced glenohumeral arthritis undergoes a superior capsular reconstruction (SCR) using dermal allograft. The primary biomechanical goal of this procedure is to:

. Restore the force couple in the transverse plane to normalize internal rotation.
. Provide a static restraint to prevent superior translation of the humeral head.
. Re-establish active external rotation via the graft.
. Replace the subacromial bursa to reduce frictional forces.
. Augment the anterior capsular restraint to prevent dynamic anterior subluxation.

Correct Answer & Explanation

. Restore the force couple in the transverse plane to normalize internal rotation.


Explanation

Superior capsular reconstruction (SCR) is designed to restore the superior constraint of the glenohumeral joint in the setting of an irreparable supraspinatus tear. By anchoring the graft between the superior glenoid and the greater tuberosity, it statically prevents superior migration of the humeral head.

Question 1534

Topic: Shoulder & Hip Sports

During open repair of a massive rotator cuff tear, the surgeon meticulously decorticates the greater tuberosity to enhance biological healing. To fully restore native biomechanics, the healing tissue must eventually replicate the normal enthesis. The native, direct rotator cuff tendon insertion onto the bone consists of how many distinct histological zones?

. Two
. Three
. Four
. Five
. Six

Correct Answer & Explanation

. Two


Explanation

The normal native rotator cuff insertion is a direct fibrocartilaginous enthesis consisting of four distinct histological transition zones: tendon, uncalcified fibrocartilage, calcified fibrocartilage, and bone. This gradual transition minimizes stress risers at the insertion site.

Question 1535

Topic: Shoulder & Hip Sports

A 22-year-old collegiate rugby player presents with recurrent anterior shoulder instability. A 3D CT scan of the shoulder reveals an anteroinferior glenoid bone loss of 26%. Which of the following is the most appropriate surgical intervention?

. Arthroscopic Bankart repair
. Arthroscopic Bankart repair with Remplissage
. Latarjet procedure
. Open inferior capsular shift
. Arthroscopic thermal capsulorrhaphy

Correct Answer & Explanation

. Arthroscopic Bankart repair


Explanation

Critical glenoid bone loss (>20-25%) in a collision athlete is a contraindication to isolated soft-tissue stabilization. The Latarjet procedure (coracoid transfer) is indicated as it provides a bony block and a dynamic sling effect from the conjoined tendon.

Question 1536

Topic: Shoulder & Hip Sports

A 74-year-old man presents with chronic shoulder pain and inability to actively elevate his arm above 60 degrees. MRI demonstrates a massive, retracted posterosuperior rotator cuff tear with Goutallier stage 4 fatty infiltration of the supraspinatus and infraspinatus. The subscapularis is intact. What is the most appropriate definitive surgical treatment?

. Latissimus dorsi tendon transfer
. Arthroscopic superior capsule reconstruction
. Reverse total shoulder arthroplasty
. Hemiarthroplasty
. Arthroscopic debridement and subacromial decompression

Correct Answer & Explanation

. Latissimus dorsi tendon transfer


Explanation

Reverse total shoulder arthroplasty is the treatment of choice for elderly patients with massive, irreparable rotator cuff tears and pseudoparalysis. Tendon transfers and superior capsular reconstructions require an intact, functioning deltoid and are generally contraindicated in the setting of true pseudoparalysis.

Question 1537

Topic: Shoulder & Hip Sports

During a physical examination of a patient with suspected rotator cuff pathology, the examiner asks the patient to place the palm of their hand on the opposite shoulder with the elbow anterior to the body, and the examiner applies an upward force to the wrist. Which specific structure is primarily being evaluated?

. Supraspinatus tendon
. Infraspinatus tendon
. Subscapularis tendon
. Teres minor tendon
. Long head of the biceps tendon

Correct Answer & Explanation

. Supraspinatus tendon


Explanation

This describes the bear hug test, which is a highly sensitive and specific maneuver for evaluating subscapularis tendon tears. The belly-press and lift-off tests also evaluate the subscapularis.

Question 1538

Topic: Shoulder & Hip Sports

A 24-year-old man with recurrent anterior instability undergoes a preoperative MRI which reveals an "off-track" Hill-Sachs lesion and 10% anterior glenoid bone loss. What is the most appropriate surgical intervention?

. Arthroscopic Bankart repair alone
. Arthroscopic Bankart repair with Remplissage
. Open Latarjet procedure
. Open Bankart repair
. Humeral head structural allograft

Correct Answer & Explanation

. Arthroscopic Bankart repair alone


Explanation

An "off-track" Hill-Sachs lesion combined with subcritical glenoid bone loss (<20%) is best treated with an arthroscopic Bankart repair combined with a Remplissage (infraspinatus tenodesis into the humeral defect). This combination effectively converts the lesion to an "on-track" state, reducing recurrence risk.

Question 1539

Topic: Shoulder & Hip Sports

Normal tendon-to-bone healing in the rotator cuff footprint is characterized by four distinct histological zones. What is the correct sequence of these zones from the tendon to the bone?

. Bone, calcified fibrocartilage, uncalcified fibrocartilage, tendon
. Tendon, uncalcified fibrocartilage, calcified fibrocartilage, bone
. Tendon, bone, calcified fibrocartilage, uncalcified fibrocartilage
. Calcified fibrocartilage, tendon, bone, uncalcified fibrocartilage
. Bone, tendon, uncalcified fibrocartilage, calcified fibrocartilage

Correct Answer & Explanation

. Bone, calcified fibrocartilage, uncalcified fibrocartilage, tendon


Explanation

The native direct insertion of the rotator cuff transitions through four distinct zones: tendon, uncalcified fibrocartilage, calcified fibrocartilage, and bone. Surgical repair typically heals via a fibrovascular scar rather than recreating this specialized native anatomy.

Question 1540

Topic: Shoulder & Hip Sports

A 45-year-old manual laborer presents with deep shoulder pain and mechanical catching. He has a positive O'Brien test and dynamic labral shear test. MRI arthrogram demonstrates a Type II SLAP tear. After failing 6 months of nonoperative management, what is the most strongly supported surgical recommendation?

. Arthroscopic SLAP repair
. Arthroscopic biceps tenodesis
. Arthroscopic posterior capsular release
. Subacromial decompression alone
. Coracoid transfer

Correct Answer & Explanation

. Arthroscopic SLAP repair


Explanation

For a Type II SLAP tear in patients over age 35-40, particularly manual laborers, biceps tenodesis is highly recommended over SLAP repair. Tenodesis yields superior pain relief, lower complication rates, and lower reoperation rates in this demographic.