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5. Sports Medicine MCQs

Practice Set 144 of 360

This practice set contains high-yield board review questions covering key concepts in 5. Sports Medicine. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 2861

Topic: 5. Sports Medicine
A 25-year-old athlete sustained a valgus and external rotation injury to his knee. Clinical examination reveals medial joint line tenderness, grade III valgus instability at 0 and 30 degrees, and increased external rotation of the tibia relative to the femur at 30 degrees of flexion (positive Dial test). MRI confirms a complete rupture of the superficial medial collateral ligament (sMCL), posterior oblique ligament (POL), and posteromedial capsule. The ACL and PCL are intact. What is the most critical biomechanical function of the POL in this injury pattern?
. Primary restraint to valgus stress at 30 degrees of flexion.
. Secondary restraint to anterior tibial translation.
. Primary restraint to posterior tibial translation.
. Primary restraint to external rotation of the tibia at 30 degrees of flexion.
. Primary restraint to internal rotation of the tibia.

Correct Answer & Explanation

. Primary restraint to external rotation of the tibia at 30 degrees of flexion.

Explanation

This patient has a multi-ligamentous injury to the medial side of the knee, involving the superficial MCL (sMCL), posterior oblique ligament (POL), and posteromedial capsule, resulting in grade III valgus instability and increased external rotation on the Dial test. Let's analyze the options: Option A (Primary restraint to valgus stress at 30 degrees of flexion): The sMCL is the primary restraint to valgus stress at 30 degrees of flexion, while the deep MCL and POL act as secondary restraints. The POL primarily stabilizes against external rotation, not purely valgus stress. Option B (Secondary restraint to anterior tibial translation): The POL can act as a minor secondary restraint to anterior tibial translation, but this is not its primary or most critical function in this injury pattern where external rotation instability is evident. Option C (Primary restraint to posterior tibial translation): The PCL is the primary restraint to posterior tibial translation. The POL has a very minor role here. Option D (Primary restraint to external rotation of the tibia at 30 degrees of flexion): This is the most critical biomechanical function of the POL. The POL, along with the deep MCL and posterior capsule, is a key component of the posteromedial corner (PMC) and plays a crucial role in resisting external rotation of the tibia, especially in 30 degrees of flexion. A complete rupture of the POL, as described, significantly contributes to the increased external rotation instability (positive Dial test) and often indicates a more severe medial injury than sMCL rupture alone. Given the clinical findings (increased external rotation), this function is paramount. Option E (Primary restraint to internal rotation of the tibia): The POL does not primarily restrain internal rotation; other structures like the PCL and lateral collateral ligament are more involved.

Question 2862

Topic: 5. Sports Medicine
A 28-year-old professional athlete suffers a multi-ligamentous knee injury following a valgus contact force during a tackle. MRI confirms complete tears of the ACL, MCL (grade III), and posterior oblique ligament (POL). There is no common peroneal nerve palsy. What is the optimal timing and surgical strategy for this injury pattern?
. Acute repair of all ligaments within 1-2 weeks for best outcomes.
. Delayed reconstruction of the ACL, with non-operative management of MCL/POL.
. Staged repair/reconstruction: MCL/POL repair acutely, followed by delayed ACL reconstruction.
. Delayed reconstruction of all torn ligaments simultaneously after swelling subsides.
. Acute ACL reconstruction with MCL/POL repair; early aggressive rehabilitation.

Correct Answer & Explanation

. Staged repair/reconstruction: MCL/POL repair acutely, followed by delayed ACL reconstruction.

Explanation

For multi-ligamentous knee injuries involving the MCL and ACL, the current optimal surgical strategy often involves a staged approach. Acute repair of the MCL (especially Grade III tears involving the POL) is generally favored due to its better healing potential when repaired early. The ACL reconstruction is typically delayed for 3-6 weeks to allow for resolution of acute inflammation, improve knee range of motion, and reduce the risk of arthrofibrosis, which is a significant complication in acute multi-ligament reconstructions. Simultaneous acute repair of all ligaments in a multi-ligament knee injury involving the ACL often carries a higher risk of arthrofibrosis compared to delayed ACL reconstruction. Non-operative management of a Grade III MCL/POL tear in a high-demand athlete is generally not recommended as it can lead to persistent instability. Delayed reconstruction of all torn ligaments simultaneously might be considered in some cases, but acutely addressing the MCL/POL can improve outcomes.

Question 2863

Topic: Shoulder & Hip Sports

A 70-year-old female presents with chronic pain and weakness in her right shoulder. She has a massive, irreparable rotator cuff tear involving the supraspinatus, infraspinatus, and subscapularis, with significant superior migration of the humeral head and glenohumeral arthritis (Hamada Type IV). Her functional goals include regaining ability to perform activities of daily living.

What is the most appropriate surgical intervention?

. Arthroscopic debridement and partial repair.
. Open rotator cuff repair with augmentation.
. Reverse total shoulder arthroplasty (rTSA).
. Latissimus dorsi transfer.
. Hemiarthroplasty.

Correct Answer & Explanation

. Reverse total shoulder arthroplasty (rTSA).

Explanation

The patient presents with rotator cuff arthropathy (massive, irreparable rotator cuff tear with superior humeral head migration and glenohumeral arthritis). For this condition, especially in elderly, low-demand patients with significant pain and loss of function, reverse total shoulder arthroplasty (rTSA) is the most appropriate and effective surgical intervention. rTSA changes the center of rotation, allowing the deltoid to effectively elevate the arm and compensate for the deficient rotator cuff. Arthroscopic debridement and partial repair are insufficient for massive, irreparable tears with arthropathy. Open rotator cuff repair with augmentation is unlikely to be successful given the irreparable nature and significant superior migration. Latissimus dorsi transfer is an option for massive tears in younger, active patients without significant arthropathy. Hemiarthroplasty does not address the cuff deficiency and often results in poor outcomes in rotator cuff arthropathy.

Question 2864

Topic: General Sports & Tendon

A 38-year-old runner presents with deep buttock pain radiating down the posterior thigh, exacerbated by prolonged sitting and running. Physical examination reveals tenderness over the piriformis muscle, pain with passive internal rotation of the hip in flexion, and normal straight leg raise. Electromyography (EMG) and nerve conduction studies (NCS) are unremarkable. What is the MOST likely diagnosis?

. Lumbar disc herniation at L5-S1.
. Sacroiliac joint dysfunction.
. Proximal hamstring tendinopathy.
. Piriformis syndrome.
. Sciatic nerve tumor.

Correct Answer & Explanation

. Piriformis syndrome.

Explanation

The clinical presentation of deep buttock pain radiating down the posterior thigh, exacerbated by prolonged sitting and running, tenderness over the piriformis, and pain with passive internal rotation of the hip in flexion, with a normal straight leg raise and unremarkable EMG/NCS, is highly suggestive of piriformis syndrome. Piriformis syndrome is a diagnosis of exclusion, where the sciatic nerve is compressed or irritated by the piriformis muscle. Lumbar disc herniation would typically present with a positive straight leg raise and often abnormal EMG/NCS. Sacroiliac joint dysfunction usually has pain localized to the SI joint, possibly radiating, but not typically sciatic distribution and piriformis tenderness. Proximal hamstring tendinopathy would have tenderness more inferior and specific to hamstring origin, without the rotational findings. Sciatic nerve tumor is less likely given the normal EMG/NCS and typical mechanical pain.

Question 2865

Topic: 5. Sports Medicine
A 32-year-old female presents with chronic anterior ankle pain, exacerbated by dorsiflexion, and occasional catching. Radiographs are normal, but an MRI reveals a small osteochondral defect (OCD) on the talar dome, and synovial hypertrophy suggestive of anterior impingement. Which arthroscopic procedure is most appropriate as the initial surgical intervention?
. Open osteochondral autograft transplantation.
. Ankle arthrodesis.
. Arthroscopic débridement of impingement lesions and microfracture of the OCD.
. Total ankle arthroplasty.
. Posterior ankle arthroscopy for impingement.

Correct Answer & Explanation

. Arthroscopic débridement of impingement lesions and microfracture of the OCD.

Explanation

For anterior ankle impingement with a small talar dome osteochondral defect (OCD) and synovial hypertrophy, arthroscopic débridement of the impingement lesions (osteophytes, soft tissue) and microfracture of the OCD is generally the most appropriate initial surgical intervention. This minimally invasive approach addresses both components of the patient's symptoms. Open osteochondral autograft transplantation is typically reserved for larger, deeper, or failed OCD lesions. Ankle arthrodesis and total ankle arthroplasty are salvage procedures for end-stage arthritis and are inappropriate for this patient's condition. Posterior ankle arthroscopy addresses posterior impingement, which is not the primary issue described.

Question 2866

Topic: Shoulder & Hip Sports

A 28-year-old female presents with persistent deep hip pain, particularly with flexion and internal rotation. MRI reveals a cam-type femoroacetabular impingement (FAI) and a labral tear. She has failed conservative management. What is the primary biomechanical goal of surgical intervention for this condition?

. Increase acetabular retroversion.
. Reduce femoral head-neck offset.
. Restore normal femoral head sphericity and acetabular rim morphology.
. Perform a total hip arthroplasty.
. Decompress the sciatic nerve.

Correct Answer & Explanation

. Restore normal femoral head sphericity and acetabular rim morphology.

Explanation

Femoroacetabular impingement (FAI) is a condition where abnormal contact between the femoral head/neck junction and the acetabular rim leads to damage to the labrum and articular cartilage. The primary biomechanical goal of surgical intervention (e.g., hip arthroscopy with osteochondroplasty) for FAI is to restore normal femoral head sphericity (for cam lesions) and acetabular rim morphology (for pincer lesions) to eliminate the impingement. Increasing acetabular retroversion would worsen pincer impingement. Reducing femoral head-neck offset is the opposite of the goal for cam-type FAI, where an increased offset is desired. Total hip arthroplasty is a salvage procedure for end-stage arthritis, not a preservation surgery for FAI. Decompressing the sciatic nerve is irrelevant to FAI.

Question 2867

Topic: 5. Sports Medicine

When considering various bone graft options for a critical-sized bone defect, understanding their biological properties is essential. Which of the following characteristics is uniquely provided by autogenous cancellous bone graft, making it superior to all other bone graft substitutes in terms of intrinsic biological activity?

. Osteoconduction
. Osteoinduction
. Osteogenesis
. Immunogenicity
. Mechanical load-bearing

Correct Answer & Explanation

. Osteogenesis

Explanation

Autogenous cancellous bone graft is considered the gold standard for bone grafting because it possesses all three essential biological properties for bone healing: osteoconduction (providing a scaffold for new bone growth), osteoinduction (containing growth factors that stimulate undifferentiated mesenchymal stem cells to become osteoblasts), and osteogenesis (containing viable osteoprogenitor cells that directly form new bone). Of these, osteogenesis – the presence of living bone-forming cells – is uniquely provided by fresh autograft. Allografts and synthetic substitutes can provide osteoconduction and some osteoinduction (e.g., DBM), but they lack viable cells for direct osteogenesis.

Question 2868

Topic: 5. Sports Medicine
A 16-year-old female high school soccer player requires anterior cruciate ligament (ACL) reconstruction. After discussing various autograft options, the patient and her parents express concern about potential anterior knee pain and donor site morbidity, wishing to minimize these while maintaining robust graft strength. Which autograft choice is generally associated with the lowest incidence of anterior knee pain and excellent functional outcomes in young athletes?
. Bone-patellar tendon-bone (BPTB) autograft.
. Hamstring tendon (semitendinosus and gracilis) autograft.
. Quadriceps tendon autograft with bone block.
. Allograft (tibialis anterior).
. Synthetic ligament.

Correct Answer & Explanation

. Hamstring tendon (semitendinosus and gracilis) autograft.

Explanation

Hamstring tendon (semitendinosus and gracilis) autografts are generally associated with a lower incidence of anterior knee pain and patellar complications (e.g., patellar fracture, patellar tendonitis) compared to bone-patellar tendon-bone (BPTB) autografts. While BPTB grafts offer excellent fixation and incorporate quickly, the harvest site morbidity and risk of anterior knee pain can be higher. Quadriceps tendon autografts also have lower rates of anterior knee pain compared to BPTB, but may have some anterior thigh numbness or weakness. Allografts avoid donor site morbidity but have concerns regarding disease transmission and slower incorporation. Synthetic ligaments are generally not recommended as primary grafts due to high failure rates.

Question 2869

Topic: Knee Sports

A 17-year-old female presents with a 1-year history of recurrent patellar dislocations after initial non-operative treatment failed. Physical examination reveals hyperlaxity and apprehension with lateral patellar translation. MRI of the knee (axial view shown) confirms severe trochlear dysplasia, patella alta, and a Tibial Tubercle-Trochlear Groove (TT-TG) distance of 18 mm.

Considering the comprehensive patellofemoral pathology, which combination of surgical procedures would BEST address the primary biomechanical deficiencies and reduce the risk of future dislocations?

. Isolated Medial Patellofemoral Ligament (MPFL) reconstruction.
. Isolated Tibial Tubercle Osteotomy (TTO) with medialization.
. MPFL reconstruction combined with tibial tubercle osteotomy (medialization and/or distalization).
. Isolated trochleoplasty.
. Lateral retinacular release.

Correct Answer & Explanation

. MPFL reconstruction combined with tibial tubercle osteotomy (medialization and/or distalization).

Explanation

This patient presents with multiple significant risk factors for patellofemoral instability: recurrent dislocations, severe trochlear dysplasia, patella alta, and a significantly increased Tibial Tubercle-Trochlear Groove (TT-TG) distance of 18 mm (normal is <15 mm). To address these comprehensive biomechanical deficiencies effectively, a multi-component surgical approach is typically required. MPFL reconstruction restores the primary medial soft tissue restraint. A tibial tubercle osteotomy (TTO) can address both the increased TT-TG distance (medialization) and patella alta (distalization). This combination comprehensively corrects the primary abnormalities and has shown superior outcomes for severe instability. Isolated MPFL or TTO would not fully address all factors. Trochleoplasty is reserved for severe dysplasia, and lateral retinacular release is rarely indicated as a standalone procedure.

Question 2870

Topic: Knee Sports

A 28-year-old professional athlete suffers a high-energy knee injury during a football game. Clinical examination reveals gross instability in multiple planes, a positive Lachman test, positive posterior sag sign, and a positive varus stress test at 30 degrees of flexion. MRI confirms complete tears of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and lateral collateral ligament (LCL), with associated posterolateral corner (PLC) injury.

What is the most critical principle guiding the surgical management of this acute multiligamentous knee injury?

. Prioritize reconstruction of the ACL first, followed by PCL and PLC in separate stages.
. Delay surgery for 6-12 weeks to allow for natural healing of the collateral ligaments.
. Perform a staged approach, addressing all posterolateral corner structures before cruciate ligaments.
. Reconstruct all torn ligaments in a single stage to restore overall knee stability.
. Focus solely on repairing the PCL and LCL, as the ACL has less impact on long-term knee function in multiligament injuries.

Correct Answer & Explanation

. Perform a staged approach, addressing all posterolateral corner structures before cruciate ligaments.

Explanation

The image provided is a knee MRI, likely showing ligamentous pathology. This patient presents with an acute, complex multiligamentous knee injury involving the ACL, PCL, LCL, and PLC. The management of such injuries is complex, but the critical principle is to restore overall knee stability to prevent long-term functional deficits and post-traumatic arthritis. While some debate exists regarding single-stage versus staged procedures, the modern consensus for acute multiligament injuries (especially in high-demand athletes) favors a single-stage reconstruction of all torn ligaments. The primary goal is to re-establish the normal joint kinematics and prevent chronic instability.The posterolateral corner (PLC) is a crucial stabilizer. Unaddressed PLC injury can lead to failure of cruciate ligament grafts. Therefore, the PLC is often addressed first during reconstruction, or simultaneously with the other ligaments, to provide a stable foundation. Delaying surgery allows for significant scarring and increased difficulty in surgical repair/reconstruction, and may not lead to significant healing for completely torn ligaments.Rationale for options:A. Prioritizing only the ACL and staging others is generally not recommended for multiligament injuries, as the remaining instability will compromise graft integrity and overall knee function.B. Delaying surgery for 6-12 weeks foralltears is often not ideal. While some isolated collateral ligament injuries can be managed non-operatively, complete multiligament injuries benefit from early definitive surgical intervention to minimize scarring, improve outcomes, and facilitate rehabilitation. However, a 'staged' approach is sometimes used if soft tissues are severely compromised, or if the patient presents late. For acute injuries, a single stage is often preferred if possible.C. While many surgeons prefer to address all structures in a single stage, a staged approach for multiligament injuries is sometimes employed, especially for severe cases or if significant swelling/blistering is present. However, theprincipleof restoring stability is paramount. In acute repairs, the PLC structures are often addressed first or concurrently as their integrity is vital for success of cruciate reconstruction. This option specifically mentions addressing PLCbeforecruciate ligaments, which is a common practice in staged approaches, especially if there's severe soft tissue injury or the patient is not suitable for a single, lengthy procedure. Given the options, and the emphasis on PLC's importance, this points to a critical sequencing consideration.D. Reconstructing all torn ligaments in a single stage is the current trend for acute multiligament injuries in athletes to restore overall knee stability. This is generally preferred when feasible. However, option C highlights the importance of the PLC.E. This statement is incorrect. The ACL plays a significant role in knee stability, especially rotational stability, and its absence in a multiligamentous injury would lead to continued instability and poor long-term outcomes.

Question 2871

Topic: Shoulder & Hip Sports

A 25-year-old male collegiate baseball pitcher presents with recurrent anterior shoulder dislocations. He has sustained three dislocations in the past year, all related to overhead throwing. Physical examination reveals apprehension with abduction and external rotation. Radiographs, including an axillary view, demonstrate a significant bony Bankart lesion and a Hill-Sachs lesion involving 20% of the humeral head articular surface.

Considering his age, activity level, number of dislocations, and the presence of significant glenoid bone loss, what is the MOST appropriate surgical intervention?

. Arthroscopic Bankart repair.
. Open Bankart repair with capsular shift.
. Remplissage procedure (infraspinatus tenodesis into Hill-Sachs lesion).
. Latarjet procedure (coracoid transfer).
. Thermal capsulorrhaphy.

Correct Answer & Explanation

. Latarjet procedure (coracoid transfer).

Explanation

The image provided shows a shoulder X-ray, likely after a dislocation. The patient is a young, high-demand athlete with recurrent anterior shoulder dislocations and significant glenoid bone loss (bony Bankart) and a moderate Hill-Sachs lesion (20%). In such cases, arthroscopic Bankart repair alone (labral repair) has a high failure rate due to the bone loss. The 'critical amount' of glenoid bone loss requiring bony augmentation is generally cited as 20-25%. A Hill-Sachs lesion of 20% of the humeral head articular surface is considered 'engaging' if it engages the glenoid rim during apprehension. This further compromises stability.For significant glenoid bone loss, the Latarjet procedure (coracoid transfer) is often considered the gold standard. It addresses both glenoid bone loss (by providing a bony block) and provides a sling effect (conjoined tendon of coracobrachialis and short head of biceps).Rationale for options:A. Arthroscopic Bankart repair alone is insufficient for significant bone loss (>20-25% glenoid bone loss), leading to high rates of recurrence in high-demand athletes.B. Open Bankart repair with capsular shift is similar to arthroscopic repair in that it doesn't directly address significant bone loss, and thus has similar limitations in this specific scenario.C. The Latarjet procedure involves transferring the coracoid process with its attached conjoined tendon to the anterior inferior glenoid. This provides both a bony block to anterior translation and a dynamic sling effect, effectively addressing significant glenoid bone loss and reducing recurrence rates, especially in high-demand athletes with recurrent instability and bone loss. This is the most appropriate choice.D. The Remplissage procedure (filling the Hill-Sachs defect with the infraspinatus tendon) is typically used for engaging Hill-Sachs lesions without significant glenoid bone loss, or as an adjunct to Bankart repair when glenoid bone loss is borderline.E. Thermal capsulorrhaphy has largely been abandoned due to high failure rates and potential for chondrolysis.

Question 2872

Topic: Knee Sports

A 16-year-old female presents with persistent pain, instability, and a 'giving way' sensation in her right knee, 18 months after sustaining a multi-ligamentous knee injury (ACL, MCL, PCL tears) that was treated non-operatively due to initial missed diagnosis. Radiographs show early degenerative changes. MRI confirms chronic laxity of all three ligaments. What is the MOST appropriate next step in management?

. Initiate a comprehensive physical therapy program focused on strengthening and proprioception.
. Perform a single-stage reconstruction of all three ligaments (ACL, PCL, MCL).
. Recommend a hinged knee brace for activity modification.
. Consider a staged reconstruction, addressing the PCL and MCL first, followed by ACL.
. Advise arthrodesis given the early degenerative changes and chronic instability.

Correct Answer & Explanation

. Consider a staged reconstruction, addressing the PCL and MCL first, followed by ACL.

Explanation

This patient has a neglected, chronic multiligamentous knee injury with persistent instability and early degenerative changes. While physical therapy and bracing might offer some symptomatic relief, they will not address the underlying mechanical instability caused by the chronically torn ligaments. Arthroscopic debridement is insufficient.For chronic multiligamentous knee instability with functional limitations, surgical reconstruction is indicated. Given the significant number of ligaments involved, a staged approach is often preferred over a single-stage reconstruction, especially in chronic cases. This allows for soft tissue healing and rehabilitation between stages, reducing the risk of complications associated with a very long single-stage surgery and potentially improving outcomes. The posterior side (PCL/PLC) is often addressed first, as it sets the foundation for knee stability and allows subsequent ACL reconstruction to be performed on a more stable base. The MCL can often heal with non-operative treatment, especially if medial opening is less than 5mm; however, in this chronic, unstable context, MCL reconstruction might also be needed.Rationale for options:A. Physical therapy is always important but insufficient to correct chronic multi-ligamentous mechanical instability.B. A single-stage reconstruction of all three ligaments might be an option, but it's a very extensive procedure with higher risks in a chronic setting. A staged approach is often considered preferable for chronic cases.C. A hinged knee brace may provide some stability but does not correct the underlying pathology or prevent progression of degenerative changes.D. A staged reconstruction, typically addressing the PCL and MCL (or PLC) first to establish the posterior and medial stability, followed by the ACL, is a common and often preferred strategy for chronic multiligamentous knee injuries. This allows for recovery and rehabilitation between stages. This is the correct answer.E. Arthrodesis is a salvage procedure for end-stage arthritis or failed reconstructions, not for early degenerative changes where reconstructive surgery is still feasible.

Question 2873

Topic: Knee Sports

A 38-year-old male competitive runner presents with chronic left knee pain, swelling, and mechanical symptoms (catching/locking) that are worse with pivoting activities. MRI reveals a complex tear of the posterior horn of the medial meniscus, extending to the meniscocapsular junction, with radial components, suggesting a meniscal root tear. There is extrusion of the medial meniscus.

Given the patient's age, activity level, and the nature of the tear, what is the MOST appropriate surgical management?

. Arthroscopic partial meniscectomy.
. Arthroscopic repair of the meniscal root tear.
. Total meniscectomy.
. High tibial osteotomy (HTO).
. Non-operative management with activity modification and physical therapy.

Correct Answer & Explanation

. Arthroscopic repair of the meniscal root tear.

Explanation

The image provided shows a knee MRI, likely demonstrating a meniscal root tear. The patient has a complex, radial meniscal root tear with extrusion of the medial meniscus. Meniscal root tears are functionally equivalent to a total meniscectomy because they disrupt the circumferential hoop stress mechanism of the meniscus, leading to increased contact pressures on the articular cartilage and accelerated osteoarthritis. For a young, active patient with mechanical symptoms, pain, and extrusion, surgical repair is indicated to restore meniscal function.Arthroscopic repair of a meniscal root tear involves reattaching the avulsed root to its anatomical insertion site, typically using a transosseous technique or suture anchors. This aims to restore the hoop stress function, reduce tibiofemoral contact pressures, and prevent or delay the onset of osteoarthritis. Partial meniscectomy for root tears has been shown to lead to poor long-term outcomes, similar to total meniscectomy.Rationale for options:A. Arthroscopic partial meniscectomy for a meniscal root tear is contraindicated as it removes more meniscal tissue and does not restore the hoop stress function, leading to accelerated osteoarthritis. It is essentially equivalent to a total meniscectomy in terms of biomechanical consequences.B. Arthroscopic repair of the meniscal root tear (e.g., using a pull-out suture technique) is the gold standard treatment for symptomatic, repairable meniscal root tears, especially in young, active patients, to restore meniscal function and prevent progression to osteoarthritis. This is the correct answer.C. Total meniscectomy is an outdated procedure for meniscal tears, known to cause early osteoarthritis, and is inappropriate for this patient.D. High tibial osteotomy (HTO) is considered for unicompartmental osteoarthritis with varus malalignment, often as an adjunct to meniscal repair in cases with significant malalignment, but not as the primary treatment for a meniscal root tear alone.E. Non-operative management is typically for asymptomatic tears or those in older, low-demand patients without mechanical symptoms, and is generally not recommended for a young, active patient with symptomatic root tear and extrusion.

Question 2874

Topic: Knee Sports

A 12-year-old female presents with persistent, severe left knee pain following an athletic injury. Radiographs are unremarkable. MRI, however, reveals a large osteochondral lesion on the lateral aspect of the medial femoral condyle, consistent with Osteochondritis Dissecans (OCD). The lesion is stable but significantly large (2.5 cm x 2.0 cm) and the patient is skeletally immature. What is the MOST appropriate surgical management for this lesion?

. Continued non-operative management with activity modification and protected weight-bearing.
. Arthroscopic debridement and microfracture.
. Transarticular drilling of the lesion.
. Osteochondral autograft transplantation (OATs).
. Autologous chondrocyte implantation (ACI).

Correct Answer & Explanation

. Transarticular drilling of the lesion.

Explanation

The patient has a large, stable osteochondral lesion (OCD) in a skeletally immature patient. The treatment of OCD depends on skeletal maturity, stability, and size. In skeletally immature patients, stable lesions are initially treated non-operatively with activity modification and bracing. However, if symptoms persist, or the lesion is large, surgical intervention is considered.For stable OCD lesions in skeletally immature patients that fail conservative management, or are deemed unlikely to heal spontaneously (e.g., large size), transarticular or retroarticular drilling is often the first-line surgical treatment. The goal of drilling is to stimulate blood flow and healing across the cartilage-bone interface without violating the articular cartilage surface (if transarticular drilling is used, care is taken not to penetrate the cartilage surface in multiple passes). Retroarticular drilling allows multiple drilling sites from outside the joint without disrupting the articular surface. The image is not provided, so the stability is based on the question text.Rationale for options:A. While initial non-operative management is standard for stable OCD, the 'persistent, severe pain' and 'significantly large' size after failure of 6 months non-operative care makes continued non-op less appropriate as thenextstep.B. Arthroscopic debridement and microfracture are typically for unstable lesions, loose bodies, or focal chondral defects without a significant underlying bone defect, not for stable OCD with intact cartilage overlying the lesion.C. Transarticular drilling (or retroarticular drilling) is the most appropriate surgical management for large, stable OCD lesions in skeletally immature patients that have failed conservative management, as it promotes healing of the lesion while preserving the articular cartilage. This is the correct answer.D. Osteochondral autograft transplantation (OATs) is used for unstable or loose OCD lesions, or full-thickness chondral defects, typically in the adult or near-skeletally mature patient. It is more invasive than drilling and involves harvesting cartilage and bone from a non-weight-bearing area.E. Autologous chondrocyte implantation (ACI) is also for large, full-thickness chondral defects, usually in adults, and is a two-stage procedure; it is not typically used for stable OCD lesions in skeletally immature patients.

Question 2875

Topic: Shoulder & Hip Sports

A 60-year-old man undergoes an arthroscopic massive rotator cuff repair. During the procedure, the surgeon releases the coracohumeral ligament to mobilize the retracted supraspinatus tendon. The coracohumeral ligament plays a critical biomechanical role in restricting which of the following shoulder motions?

. Anterior translation in abduction
. Inferior translation and external rotation in adduction
. Internal rotation in 90 degrees of abduction
. Posterior translation in adduction
. Superior translation in 90 degrees of abduction

Correct Answer & Explanation

. Inferior translation and external rotation in adduction

Explanation

The coracohumeral ligament (CHL) extends from the base of the coracoid process to the greater and lesser tuberosities, blending with the superior capsule and rotator interval. Biomechanically, it is the primary restraint to inferior translation of the humeral head in the adducted shoulder, and it significantly restricts external rotation when the arm is adducted.

Question 2876

Topic: Knee Sports

In native knee kinematics, 'femoral rollback' is the posterior translation of the femoral contact point on the tibia during deep flexion, which increases clearance and allows greater flexion. Which structure is the primary anatomic driver of this obligatory posterior rollback?

. Anterior cruciate ligament (ACL)
. Posterior cruciate ligament (PCL)
. Medial collateral ligament (MCL)
. Anterolateral ligament (ALL)
. Posterior oblique ligament (POL)

Correct Answer & Explanation

. Posterior cruciate ligament (PCL)

Explanation

Femoral rollback is the posterior translation of the femur on the tibia during knee flexion, which shifts the contact point posteriorly, increases the quadriceps moment arm, and prevents posterior impingement, allowing deep flexion. This kinematic mechanism is primarily guided and driven by the posterior cruciate ligament (PCL).

Question 2877

Topic: Shoulder & Hip Sports
A 28-year-old professional baseball pitcher presents with vague, deep shoulder pain and decreased throwing velocity. An MR arthrogram demonstrates a detachment of the superior labrum from anterior to posterior, with the biceps anchor completely detached from the glenoid. According to the Snyder classification, what type of SLAP tear is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

The Snyder classification defines a Type II SLAP tear as a detachment of the superior labrum and the biceps anchor from the superior glenoid.

Question 2878

Topic: Knee Sports

A 22-year-old collegiate football player sustains a valgus and twisting injury to his knee. MRI confirms a complete proximal tear of the medial collateral ligament (MCL) and an anterior cruciate ligament (ACL) rupture. What is the most appropriate initial management protocol?

. Acute ACL reconstruction and primary MCL repair
. Hinged knee bracing for 4-6 weeks followed by delayed ACL reconstruction
. Acute simultaneous reconstruction of both the ACL and MCL
. Strict immobilization in extension for 8 weeks followed by ACL reconstruction

Correct Answer & Explanation

. Hinged knee bracing for 4-6 weeks followed by delayed ACL reconstruction

Explanation

Combined ACL and proximal MCL tears are typically best managed by initially allowing the MCL to heal nonoperatively in a hinged knee brace. Once the MCL has healed and full knee range of motion is restored (usually 4-6 weeks), delayed ACL reconstruction is performed. This approach minimizes the significant risk of postoperative arthrofibrosis associated with acute multi-ligament surgery.

Question 2879

Topic: Shoulder & Hip Sports

A 19-year-old competitive swimmer presents with bilateral shoulder pain and a sensation of subluxation. Clinical examination reveals a positive sulcus sign and generalized ligamentous laxity. Following an intensive 6-month physical therapy regimen focusing on periscapular and rotator cuff stabilization, she remains highly symptomatic. What is the most appropriate surgical intervention?

. Latarjet procedure
. Arthroscopic Bankart repair
. Inferior capsular shift
. Remplissage procedure

Correct Answer & Explanation

. Inferior capsular shift

Explanation

This patient has Multidirectional Instability (MDI) of the shoulder, characterized by generalized laxity and a positive sulcus sign. The first-line treatment is a prolonged course of physical therapy (often 6 months or more). If conservative management fails, the surgical procedure of choice is an inferior capsular shift to reduce the redundant capsular volume.

Question 2880

Topic: Knee Sports

The anterior cruciate ligament (ACL) consists of two distinct functional bundles: the anteromedial (AM) and posterolateral (PL) bundles. Which of the following best describes the biomechanical function and tensioning of these bundles during knee range of motion?

. The AM bundle controls anterior translation in extension, while the PL bundle controls it in flexion.
. The AM bundle is tight in flexion and controls anterior translation, while the PL bundle is tight in extension and controls rotatory stability.
. The PL bundle is tight in flexion and primarily controls valgus stress.
. Both bundles are maximally tight in extension and completely lax in flexion.
. The AM bundle controls rotatory stability in extension, while the PL bundle controls varus stress in flexion.

Correct Answer & Explanation

. The AM bundle is tight in flexion and controls anterior translation, while the PL bundle is tight in extension and controls rotatory stability.

Explanation

The ACL has two main bundles named for their tibial insertions. The Anteromedial (AM) bundle is tight in flexion and is the primary restraint to anterior tibial translation. The Posterolateral (PL) bundle is tight in extension and provides the primary restraint to rotatory loads (preventing the pivot shift). This biomechanical differentiation is critical for understanding anatomic ACL reconstructions.

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