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5. Sports Medicine MCQs

Practice Set 58 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 1141

Topic: Knee Sports

A 55-year-old male presents with progressive right knee pain and a noticeable 'giving way' sensation during ambulation. On physical examination, he exhibits a visible and sudden shift of his knee into varus during the stance phase of gait on the affected limb. Varus stress testing at 30° of flexion reveals significant lateral joint line opening compared to the contralateral side. Which of the following is the most accurate interpretation of these clinical findings?

. The patient likely has isolated medial compartment osteoarthritis with compensatory lateral thrust.
. The primary pathology is a fixed bony varus deformity of the distal femur, causing the gait abnormality.
. These findings are pathognomonic for dynamic coronal plane instability due to Lateral Collateral Ligament (LCL) insufficiency.
. The 'giving way' sensation suggests anterior cruciate ligament (ACL) deficiency, which is causing secondary varus thrust.
. The sudden shift into varus indicates a severe medial collateral ligament (MCL) tear with associated posteromedial instability.

Correct Answer & Explanation

. These findings are pathognomonic for dynamic coronal plane instability due to Lateral Collateral Ligament (LCL) insufficiency.

Explanation

Correct Answer: CThe clinical presentation of a 'visible and sudden shift of his knee into varus during the stance phase of gait' is the classic description of alateral thrust. This sign, combined with significant lateral joint line opening on varus stress testing at 30° of flexion, is pathognomonic for dynamic coronal plane instability primarily due to Lateral Collateral Ligament (LCL) insufficiency. The LCL is the primary static restraint against varus stress, and its incompetence allows the lateral compartment to abnormally gap open under load.Option A is incorrectbecause while medial compartment osteoarthritis can be present, the dynamic lateral thrust and LCL laxity indicate a more complex instability that is not simply compensatory. The LCL insufficiency is a primary driver of the instability.Option B is incorrectbecause while a fixed bony varus deformity can contribute, the description emphasizes adynamicshift and 'giving way' sensation, which points to ligamentous instability rather than solely a fixed bony malalignment. The case highlights that bony malalignment is easily measured on static radiographs, but dynamic instability is often hidden.Option D is incorrectbecause an ACL deficiency primarily causes anteroposterior instability, not typically a sudden varus thrust during gait. While multi-ligamentous injuries can occur, the specific description points to coronal plane instability.Option E is incorrectbecause a severe MCL tear would lead to valgus instability and opening of the medial joint line, not a varus thrust or lateral joint line opening. The findings are opposite to what would be expected with MCL pathology.

Question 1142

Topic: Knee Sports

A 50-year-old patient with a severe varus knee deformity and significant LCL laxity is scheduled for surgical correction. The surgeon opts for the Paley method of gradual LCL retensioning via fibular transport using a circular external fixator. What is the most significant advantage of this method over acute fibular head advancement?

. It completely eliminates the need for any bony osteotomy, simplifying the procedure.
. It allows for simultaneous correction of multiplanar tibial or femoral bony deformities with enhanced safety for the peroneal nerve.
. It is a faster method, allowing for immediate full weight-bearing post-operatively.
. It relies solely on soft tissue plication, avoiding any bone cuts.
. It is primarily indicated for isolated LCL tears without associated bony malalignment.

Correct Answer & Explanation

. It allows for simultaneous correction of multiplanar tibial or femoral bony deformities with enhanced safety for the peroneal nerve.

Explanation

Correct Answer: BThe case highlights the 'profound, game-changing advantages' of the gradual fibular transport method. Specifically, it states: 'Greatly Enhanced Safety: The fibular osteotomy is made in the diaphysis, well distal to the nerve, and the transport is done gradually (typically 1 mm per day). This requires minimal dissection around the nerve itself, dramatically reducing the risk of iatrogenic nerve palsy.' And 'Simultaneous Bony Correction: The true beauty of this method is that the exact same external fixator used for the fibular transport can be utilized to simultaneously and perfectly correct any associated multiplanar tibial or femoral bony deformities.'Option A is incorrectbecause the method involves a fibular osteotomy and can simultaneously correct tibial or femoral bony deformities, meaning bony osteotomies are part of the process.Option C is incorrectbecause gradual correction involves a period of distraction and external fixation, which is not a faster method for immediate full weight-bearing. It's a controlled, slower process.Option D is incorrectbecause it involves a fibular osteotomy and transport, which is a bone-based procedure to retension ligaments, not solely soft tissue plication.Option E is incorrectbecause the method is presented as a solution for 'complex knee malalignment complicated by ligamentous incompetence,' implying its use for deformities with associated bony malalignment, not just isolated LCL tears.

Question 1143

Topic: Knee Sports

A 38-year-old female presents with early medial compartment osteoarthritis, genu varum, and chronic anterior cruciate ligament (ACL) deficiency. When performing a high tibial osteotomy, how should the surgeon manage the posterior tibial slope to optimize sagittal stability?

. Increase the posterior slope
. Decrease the posterior slope
. Maintain a 15-degree posterior slope
. Maximize the coronal varus overcorrection
. Perform an isolated fibular osteotomy

Correct Answer & Explanation

. Decrease the posterior slope

Explanation

Decreasing the posterior tibial slope reduces the anterior translation of the tibia relative to the femur during weight-bearing. This altered biomechanics is protective for an ACL-deficient knee.

Question 1144

Topic: 5. Sports Medicine

Which of the following is a known disadvantage of a medial opening wedge high tibial osteotomy (HTO) compared to a lateral closing wedge HTO in the treatment of genu varum?

. Higher risk of direct peroneal nerve injury during the osteotomy.
. Necessity of a concurrent proximal tibiofibular joint disruption.
. Decreased patellar height (patella baja) due to relative distalization of the tibial tubercle.
. Significant loss of bone stock requiring structural allograft in all cases.
. Obligatory detachment of the patellar tendon footprint.

Correct Answer & Explanation

. Decreased patellar height (patella baja) due to relative distalization of the tibial tubercle.

Explanation

A medial opening wedge HTO performed proximal to the tibial tubercle effectively elongates the proximal tibia, which relatively distalizes the tibial tubercle and decreases patellar height (patella baja). Lateral closing wedge HTO is associated with patella alta and a higher risk of peroneal nerve injury.

Question 1145

Topic: Knee Sports

A 45-year-old patient presents with a 15-degree lower extremity varus deformity. Deformity analysis reveals the mLDFA is 102 degrees and the mPTA is 87 degrees. The surgeon plans an isolated high tibial osteotomy (HTO) to completely correct the mechanical axis deviation. What is the primary biomechanical complication of this approach?

. Excessive joint line obliquity causing shear stress
. Excessive limb lengthening
. Disruption of the extensor mechanism
. Medial compartment hyper-compression
. Anterior cruciate ligament insufficiency

Correct Answer & Explanation

. Excessive joint line obliquity causing shear stress

Explanation

Correcting a purely femoral deformity (abnormal mLDFA) with a tibial osteotomy will result in an excessively oblique joint line (medial down/lateral up). This creates detrimental shear forces across the articular cartilage and alters knee kinematics.

Question 1146

Topic: Knee Sports

A patient with severe medial compartment osteoarthritis demonstrates a prominent lateral varus thrust during the stance phase of gait. This dynamic, multi-planar deformity is most directly exacerbated by the chronic stretching and loss of tension in which of the following structures?

. Medial collateral ligament
. Anterior cruciate ligament
. Lateral collateral ligament
. Posterior cruciate ligament
. Popliteus tendon

Correct Answer & Explanation

. Lateral collateral ligament

Explanation

A varus thrust is characterized by dynamic lateral opening of the joint during stance. This is primarily permitted and exacerbated by incompetence or chronic stretching of the lateral collateral ligament (LCL) and posterolateral corner structures.

Question 1147

Topic: Knee Sports
A 42-year-old female undergoes a standard medial opening wedge high tibial osteotomy (MOWHTO) proximal to the tibial tubercle for varus malalignment. Postoperatively, she develops new-onset anterior knee pain. Which of the following iatrogenic radiographic findings is the most likely cause?
. Patella alta
. Patella infera (baja)
. Increased lateral patellar tilt
. Trochlear dysplasia
. Excessive tibial tubercle lateralization

Correct Answer & Explanation

. Patella infera (baja)

Explanation

A supratubercle MOWHTO elevates the proximal joint surface while leaving the tibial tubercle distal, effectively shortening the distance between the joint line and the tubercle. This functionally lowers the patella, creating patella infera (baja) and increasing retropatellar contact pressures.

Question 1148

Topic: Knee Sports

A 58-year-old male presents with a long-standing, progressive genu varum deformity. Clinically, he exhibits a noticeable varus thrust during the stance phase of gait. Radiographs confirm severe medial compartment collapse. Which of the following statements best describes the soft tissue changes occurring on the lateral side of the knee in this progressive varus cascade?

. A. The lateral collateral ligament (LCL) and posterolateral corner (PLC) undergo adaptive shortening and contracture.
. B. The iliotibial (IT) band becomes hypertonic, increasing lateral compartment compression.
. C. The lateral soft tissue structures, including the LCL, IT band, and PLC, are subjected to chronic tensile overload, leading to structural attenuation and lateral ligamentous laxity.
. D. The lateral meniscus extrudes, causing a compensatory tightening of the lateral capsule.
. E. The lateral structures remain unaffected, as the deformity is primarily osseous.

Correct Answer & Explanation

. C. The lateral soft tissue structures, including the LCL, IT band, and PLC, are subjected to chronic tensile overload, leading to structural attenuation and lateral ligamentous laxity.

Explanation

Correct Answer: CThe case content describes the 'Varus Knee Cascade' and the 'Soft Tissue Envelope Under Duress.' It states that in progressive genu varum, while the medial side collapses due to massive compressive overload, the lateral soft tissue structures—including the lateral collateral ligament (LCL), the iliotibial (IT) band, and the complex posterolateral corner (PLC)—are subjected to chronic, repetitive tensile overload. This constant stretching leads to structural attenuation and profound functional lateral ligamentous laxity. This laxity, combined with medial collapse, allows for joint gapping and eventually lateral tibial subluxation, manifesting as a varus thrust.Option A is incorrectbecause the lateral structures are stretched and become lax, not shortened or contracted. Shortening would occur on the concave (medial) side in severe, chronic cases, but the primary issue on the lateral side is stretching.Option B is incorrectbecause the IT band is subjected to tensile overload and stretching, not hypertonicity that increases lateral compartment compression. The lateral compartment is typically unloaded in varus.Option D is incorrectbecause while lateral meniscus extrusion can occur, the primary soft tissue response described for the ligaments and IT band is stretching and laxity, not compensatory tightening of the capsule.Option E is incorrectbecause the case explicitly details how the soft tissue envelope is profoundly affected, with lateral structures becoming lax, which is a critical component of the progressive varus collapse and dynamic instability.

Question 1149

Topic: Knee Sports

A 60-year-old male presents with progressive right knee pain. A standing long-leg alignment radiograph reveals a mechanical axis that passes 15mm medial to the center of the knee joint. Which of the following best describes this patient's alignment and its biomechanical implication?

. Valgus malalignment, leading to lateral compartment overload.
. Neutral alignment, indicating balanced load distribution.
. Varus malalignment, leading to medial compartment overload.
. Varus malalignment, leading to lateral compartment overload.
. Valgus malalignment, leading to medial compartment overload.

Correct Answer & Explanation

. Varus malalignment, leading to medial compartment overload.

Explanation

Correct Answer: CThe Mechanical Axis Deviation (MAD) is a critical metric for assessing global limb alignment. The text states that in a perfectly aligned limb, the MAD passes near the center of the knee joint (1 to 8 mm medial to the tibial spine). If the mechanical axis falls medial to the center of the knee, it indicates a varus malalignment. This creates a destructive bending moment that overloads the medial compartment, leading to medial meniscus tearing, articular cartilage degradation, and eventual medial compartment osteoarthritis. Therefore, a MAD passing 15mm medial to the knee center signifies varus malalignment and medial compartment overload.Options A, D, and E are incorrect because they either misidentify the type of malalignment (valgus) or misstate the compartment overloaded. Option B is incorrect as 15mm medial is outside the normal range for neutral alignment.

Question 1150

Topic: 5. Sports Medicine
A 32-year-old professional overhead baseball pitcher sustains a Rockwood Type III AC joint separation in his dominant throwing arm. He is highly motivated to return to elite-level competition as quickly and safely as possible. Given the controversy surrounding Type III management, what is the most appropriate initial treatment recommendation for this patient?
. Non-operative management with a sling for 4-6 weeks, followed by progressive rehabilitation.
. Immediate surgical reconstruction of the AC joint and CC ligaments.
. A trial of non-operative management for 3 months, with surgery considered only if symptoms persist.
. Distal clavicle excision (Mumford procedure) to prevent future arthrosis.
. Placement of a coracoclavicular hook plate, with planned removal at 3 months.

Correct Answer & Explanation

. Immediate surgical reconstruction of the AC joint and CC ligaments.

Explanation

For Rockwood Type III injuries, operative indications include acute injuries in young, high-demand individuals (e.g., overhead athletes, manual laborers) where functional demands are high and an earlier return to full activity is desired. A professional overhead baseball pitcher with a dominant arm injury fits this description, making immediate surgical reconstruction the most appropriate initial recommendation.

Question 1151

Topic: 5. Sports Medicine

A 48-year-old male undergoes surgical reconstruction for a Rockwood Type IV AC joint separation using a suture-button system. Six months post-operatively, he presents with persistent pain, instability, and a noticeable superior prominence of the distal clavicle. Radiographs confirm a loss of reduction with significant superior displacement of the clavicle. Which of the following is the most appropriate initial salvage strategy?

. Initiate a more aggressive physical therapy protocol to strengthen the shoulder.
. Prescribe oral NSAIDs and observe for another 3 months.
. Perform a revision surgery with stronger fixation, potentially including allograft augmentation.
. Recommend a distal clavicle excision (Mumford procedure).
. Administer a corticosteroid injection into the AC joint.

Correct Answer & Explanation

. Perform a revision surgery with stronger fixation, potentially including allograft augmentation.

Explanation

Correct Answer: CThe patient presents with a clear loss of reduction and persistent instability after initial surgery. The case material explicitly lists 'Loss of Reduction / Re-dislocation' as a common complication (5-20%) and states the salvage strategy is 'Revision surgery with stronger fixation (e.g., additional suture-buttons, allograft augmentation, AC plate). Address technical errors (e.g., inadequate tensioning, improper tunnel placement, premature mobilization). For chronic cases, more robust reconstruction with graft.'Option A:While rehabilitation is crucial, it cannot correct a structural loss of reduction. Aggressive therapy without addressing the underlying instability would likely be ineffective and potentially harmful.Option B:Observation and NSAIDs are insufficient for a symptomatic loss of reduction, which indicates mechanical failure of the initial repair.Option D:Distal clavicle excision (Mumford procedure) is typically reserved for symptomatic AC joint arthrosis or osteolysis, not for acute or subacute loss of reduction of a Type IV injury, which requires restoration of stability.Option E:A corticosteroid injection might temporarily mask pain but does not address the mechanical instability caused by the loss of reduction.

Question 1152

Topic: 5. Sports Medicine
A 55-year-old sedentary patient, 3 years after non-operative management of a Rockwood Type III AC joint separation, presents with chronic, localized pain and crepitus over the AC joint, particularly with overhead activities and reaching across the body. Physical examination reveals tenderness and pain with cross-body adduction. Radiographs demonstrate significant degenerative changes and osteophytes at the AC joint. What is the most appropriate surgical intervention for this patient's current symptoms?
. Revision coracoclavicular ligament reconstruction with allograft.
. Open reduction and internal fixation of the AC joint with a hook plate.
. Distal clavicle excision (Mumford procedure).
. Arthroscopic subacromial decompression without addressing the AC joint.
. Physical therapy focusing on rotator cuff strengthening.

Correct Answer & Explanation

. Distal clavicle excision (Mumford procedure).

Explanation

The patient's presentation of chronic, localized pain, crepitus, and radiographic evidence of degenerative changes (arthrosis/osteophytes) at the AC joint, 3 years after injury, is characteristic of symptomatic AC joint arthrosis. For symptomatic AC joint arthrosis, the Mumford procedure is the definitive surgical treatment.

Question 1153

Topic: 5. Sports Medicine

A 29-year-old male undergoes a free tendon graft reconstruction of the coracoclavicular ligaments. Six weeks postoperatively, he reports a sudden pop after lifting a heavy box. Radiographs show recurrent superior clavicular displacement and an avulsion fracture of the coracoid base. What is the most likely technical cause of this complication?

. Failure to repair the AC capsule
. Use of an allograft instead of autograft
. Overtightening of the graft
. Placement of drill holes too medial or too large in the coracoid
. Improper immobilization time

Correct Answer & Explanation

. Placement of drill holes too medial or too large in the coracoid

Explanation

Coracoid fracture is a known complication of anatomic CC reconstructions. It is most often caused by drill holes that are too large (>4.5mm) or placed too medially on the coracoid base, creating a stress riser.

Question 1154

Topic: 5. Sports Medicine
A 28-year-old professional baseball pitcher sustains a Rockwood Type III AC joint separation of his throwing arm. After 3 months of nonoperative management, he still experiences severe pain and subjective weakness during throwing motions, with prominent scapular dyskinesia. What is the most appropriate next step in management?
. Continued physical therapy for another 6 months
. Diagnostic arthroscopy for rotator cuff repair
. Anatomic coracoclavicular ligament reconstruction
. Subacromial decompression
. Corticosteroid injection into the glenohumeral joint

Correct Answer & Explanation

. Anatomic coracoclavicular ligament reconstruction

Explanation

While most Type III AC joint injuries are treated nonoperatively, overhead athletes who fail a dedicated 3-month course of conservative therapy with ongoing pain and dyskinesia are candidates for surgical reconstruction.

Question 1155

Topic: 5. Sports Medicine

A 30-year-old athlete presents with chronic anterior knee pain and instability after a malunited proximal tibial fracture. Radiographic analysis reveals a normal MPTA and mLDFA, but the Posterior Proximal Tibial Angle (PPTA) is measured at 70°. What is the MOST likely biomechanical consequence of this specific sagittal plane deformity?

. Increased compressive forces on the medial compartment of the knee.
. Increased tensile strain on the lateral collateral ligament (LCL).
. Decreased anterior tibial translation and reduced strain on the anterior cruciate ligament (ACL).
. Increased anterior tibial translation and increased strain on the anterior cruciate ligament (ACL).
. Compensatory subtalar eversion and limited ankle dorsiflexion.

Correct Answer & Explanation

. Increased anterior tibial translation and increased strain on the anterior cruciate ligament (ACL).

Explanation

Correct Answer: DThe normal Posterior Proximal Tibial Angle (PPTA) is 77-84° (average 81°). A PPTA of 70° indicates a decreased posterior tibial slope (or increased anterior slope, depending on how it's measured, but the text implies a decrease from the normal 81°). The 'Surgical Pearl' for PPTA states: 'Altered tibial slope dramatically affects knee kinematics. Increasing slope increases anterior tibial translation and ACL strain.' While the question states a PPTA of 70°, which is less than normal, this implies a more vertical orientation of the proximal tibia, which would effectively increase the posterior slope relative to the mechanical axis if the distal segment is fixed. The text also mentions, 'An anterior translation of the distal tibia (procurvatum) effectively increases the posterior tibial slope, altering the tension on the anterior cruciate ligament (ACL) and changing patellofemoral tracking.' Therefore, a change in PPTA from the normal range, especially one that effectively increases the posterior slope, will lead to increased anterior tibial translation and increased strain on the ACL, contributing to instability and pain. The image is a generic full-length radiograph, which would be used to measure such angles.Option A and B are incorrectas these are consequences of coronal plane deformities (varus/valgus), not sagittal plane tibial slope changes.Option C is incorrectbecause an altered (increased) posterior tibial slope leads to increased, not decreased, anterior tibial translation and increased, not reduced, ACL strain.Option E is incorrectas this is a consequence of coronal plane tibial deformities affecting the ankle, not primarily sagittal plane tibial slope.

Question 1156

Topic: Knee Sports

A 38-year-old male presents with chronic knee pain and a noticeable limp following a malunited distal femoral fracture 5 years prior. Full-length weight-bearing radiographs reveal a mechanical axis deviation (MAD) of 25 mm medial to the center of the knee. Which of the following best describes the biomechanical consequence of this finding?

. A. Increased tensile stress on the lateral collateral ligament (LCL) and lateral compartment overload.
. B. Pathological overloading of the medial compartment of the knee, leading to accelerated medial compartment osteoarthritis.
. C. A primary indication for a medial opening wedge high tibial osteotomy (HTO) without further femoral assessment.
. D. A normal variant, as the mechanical axis can pass up to 30 mm medial or lateral to the knee center without clinical significance.
. E. Increased risk of patellofemoral instability due to altered Q-angle.

Correct Answer & Explanation

. B. Pathological overloading of the medial compartment of the knee, leading to accelerated medial compartment osteoarthritis.

Explanation

Correct Answer: BThe case explicitly states that a medial MAD (varus deformity) causes the mechanical axis to shift medially, pathologically overloading the medial compartment of the knee. This leads to medial meniscus tearing, subchondral sclerosis, and rapid-onset premature medial compartment osteoarthritis. A 25 mm medial MAD is a significant deviation, indicating severe varus malalignment.Option A is incorrectbecause increased tensile stress on the LCL and lateral compartment overload are characteristic of a lateral MAD (valgus deformity), not a medial MAD.Option C is incorrectbecause while an HTO might be considered for varus, the deformity is explicitly stated to be a malunited distal femoral fracture. Therefore, the primary source of the deformity is femoral, and a distal femoral osteotomy (DFO) would likely be indicated, not an HTO, without further assessment of joint orientation angles to pinpoint the exact source.Option D is incorrectbecause a normal MAD is zero, with the mechanical axis passing directly through the center of the knee or slightly medial to the tibial spines. A 25 mm medial deviation is highly pathological and not a normal variant.Option E is incorrectbecause while limb malalignment can affect patellofemoral mechanics, a medial MAD primarily impacts the tibiofemoral compartments, leading to medial compartment overload, rather than directly increasing the risk of patellofemoral instability, which is more commonly associated with valgus alignment or specific patellofemoral pathologies.

Question 1157

Topic: Shoulder & Hip Sports

A 28-year-old male presents with his third episode of anterior glenohumeral dislocation. Initial imaging in the emergency department confirms the dislocation. Given the patient's history and the provided radiograph, which of the following is the most appropriate next step in diagnostic evaluation after successful reduction?

. Immediate referral for physical therapy to initiate rotator cuff strengthening.
. Obtain a stress radiograph series to assess for ligamentous laxity.
. Order a non-contrast Computed Tomography (CT) scan with 3D reconstructions.
. Proceed directly to arthroscopic Bankart repair planning.
. Prescribe a sling for 6 weeks with strict immobilization.

Correct Answer & Explanation

. Order a non-contrast Computed Tomography (CT) scan with 3D reconstructions.

Explanation

Correct Answer: CExplanation:The patient's history of recurrent anterior glenohumeral dislocations (third episode in 18 months) and the mechanism of injury (high-energy fall during rugby with arm abducted and externally rotated) strongly suggest significant underlying structural damage, particularly bipolar bone loss (Hill-Sachs lesion and anterior glenoid bone loss). The initial AP radiograph confirms the dislocation but is insufficient for quantifying these osseous defects.Option C (Order a non-contrast Computed Tomography (CT) scan with 3D reconstructions)is the correct answer. The case explicitly states that 'non-contrast Computed Tomography (CT) with 3D reconstructions is the gold standard for evaluating osseous architecture' and is essential for 'quantifying bipolar bone loss' and 'accurate preoperative planning.' This advanced imaging is crucial to determine the extent of glenoid bone loss and the Hill-Sachs lesion, which dictates the appropriate surgical strategy (e.g., Bankart, Remplissage, Latarjet).Option A (Immediate referral for physical therapy to initiate rotator cuff strengthening)is premature and potentially harmful. While rehabilitation is critical post-operatively, without addressing the underlying structural instability, rotator cuff strengthening alone is unlikely to prevent recurrence in a patient with significant bone loss and recurrent dislocations.Option B (Obtain a stress radiograph series to assess for ligamentous laxity)is not the primary diagnostic step for recurrent instability with suspected bone loss. While ligamentous laxity can contribute, the immediate concern in this case is osseous deficiency, which stress radiographs do not adequately evaluate.Option D (Proceed directly to arthroscopic Bankart repair planning)is incorrect because the type of surgical repair depends entirely on the quantification of bone loss. An isolated Bankart repair would likely fail if critical glenoid bone loss or an 'off-track' Hill-Sachs lesion is present, as highlighted in the case.Option E (Prescribe a sling for 6 weeks with strict immobilization)represents non-operative management, which is explicitly contraindicated for recurrent instability with significant bone loss, especially in a young, competitive contact athlete. The case states, 'Recurrent instability with significant bone loss' is a contraindication for non-operative management.

Question 1158

Topic: Shoulder & Hip Sports

Following successful reduction and initial radiographs, a CT scan with 3D reconstructions is obtained for the 28-year-old rugby player. The CT scan, as depicted, reveals significant anterior glenoid bone loss. Based on the case description and the image, which method is widely employed to measure anterior glenoid bone loss on en face 3D CT views?

. The Sugaya method, measuring the glenoid width on an axial MRI slice.
. The Hill-Sachs interval measurement on a sagittal CT view.
. The Pico method, drawing a best-fit circle over the inferior portion of the intact glenoid.
. The glenoid track calculation, assessing the engagement of the Hill-Sachs lesion.
. The 'inverted pear' sign, qualitatively assessing the glenoid shape.

Correct Answer & Explanation

. The Pico method, drawing a best-fit circle over the inferior portion of the intact glenoid.

Explanation

Correct Answer: CExplanation:Accurate quantification of glenoid bone loss is critical for surgical decision-making in recurrent anterior shoulder instability.Option C (The Pico method, drawing a best-fit circle over the inferior portion of the intact glenoid)is the correct answer. The case explicitly states, 'The Pico method is widely employed to measure anterior glenoid bone loss on en face 3D CT views. A best-fit circle is drawn over the inferior portion of the intact glenoid (or the contralateral normal glenoid for comparison), and the area or width of the missing anterior bone is calculated as a percentage of the total circle.' This method provides a quantitative assessment of the bone defect.Option A (The Sugaya method, measuring the glenoid width on an axial MRI slice)is a method for assessing glenoid bone loss, but it is typically performed on MRI and measures the width, not necessarily the area based on a best-fit circle as described for the Pico method on CT. The case specifically mentions the Pico method for 3D CT.Option B (The Hill-Sachs interval measurement on a sagittal CT view)is used to quantify the Hill-Sachs lesion itself and its relationship to the glenoid, not primarily for measuring anterior glenoid bone loss.Option D (The glenoid track calculation, assessing the engagement of the Hill-Sachs lesion)is a biomechanical concept that integrates both glenoid bone loss and the Hill-Sachs lesion to determine if the Hill-Sachs lesion is 'on-track' or 'off-track.' While crucial for decision-making, it is not a direct method for measuring the anterior glenoid bone loss percentage itself.Option E (The 'inverted pear' sign, qualitatively assessing the glenoid shape)is a qualitative description of significant glenoid bone loss, where the normal pear shape of the glenoid becomes inverted due to erosion of the anterior-inferior aspect. While a relevant concept, it is a qualitative observation rather than a quantitative measurement method like the Pico method.

Question 1159

Topic: Shoulder & Hip Sports
The 28-year-old rugby player is found to have critical glenoid bone loss (>15%) and an 'off-track' Hill-Sachs lesion. An open Latarjet procedure is planned. During the procedure, the coracoid graft is being fixed to the anterior glenoid. Which of the following statements regarding the critical technical aspects of graft positioning and fixation is most accurate?
. The graft should be positioned 5mm lateral to the articular cartilage to maximize the blocking effect.
. The graft should be fixed with a single screw to allow for dynamic compression.
. The graft should be positioned flush with, or slightly medial (1-2 mm) to, the articular cartilage of the anterior glenoid rim.
. The subscapularis split should be performed at the junction of the inferior two-thirds and superior one-third to protect the axillary nerve.
. The coracoacromial ligament should be completely excised to prevent impingement.

Correct Answer & Explanation

. The graft should be positioned flush with, or slightly medial (1-2 mm) to, the articular cartilage of the anterior glenoid rim.

Explanation

Correct Answer: C. The Latarjet procedure requires meticulous technique to achieve stability and prevent complications. Option C is the correct answer. The case explicitly states, 'The prepared coracoid graft is passed through the subscapularis split. It is positioned flush with, or slightly medial (1-2 mm) to, the articular cartilage of the anterior glenoid rim.' This precise positioning is crucial to restore the glenoid arc without causing iatrogenic osteoarthritis. Option A is incorrect. The case warns, 'Positioning the graft lateral to the cartilage risks severe osteoarthritis.' While a blocking effect is desired, it must be achieved without encroaching on the articular surface. Option B is incorrect. The case states, 'Two 3.75 mm or 4.0 mm partially threaded cannulated screws are inserted over the K-wires to achieve rigid bicortical compression.' Two screws provide more stable fixation and prevent rotation of the graft. Option D is incorrect. The case states, 'A longitudinal split is created in the subscapularis tendon, typically at the junction of the superior two-thirds and inferior one-third, to protect the axillary nerve traversing inferiorly.' Reversing the split location would place the axillary nerve at greater risk. Option E is incorrect. The case states, 'The coracoacromial ligament is sharply released from the lateral aspect of the coracoid, leaving a 1 cm stump for later capsular repair.' This stump is used to repair the native capsule, contributing to the stability.

Question 1160

Topic: Shoulder & Hip Sports
A 28-year-old rugby player with recurrent anterior shoulder instability and an 'off-track' Hill-Sachs lesion, but subcritical glenoid bone loss (<13.5%), undergoes an arthroscopic Bankart repair combined with a remplissage procedure. During the diagnostic arthroscopy, the anterior labrum and capsule are mobilized from the anterior glenoid neck. Which of the following steps is most critical to ensure adequate superior shift during the anterior Bankart repair?
. Decorticating the anterior glenoid neck with a motorized burr.
. Placing suture anchors superiorly at the 1 o'clock position.
. Releasing the tissue inferiorly to the 6 o'clock position.
. Passing sutures through only the labrum, avoiding the capsule.
. Performing the remplissage procedure after tying the anterior Bankart anchors.

Correct Answer & Explanation

. Releasing the tissue inferiorly to the 6 o'clock position.

Explanation

Correct Answer: C. The arthroscopic Bankart repair aims to reattach the avulsed labrum and tighten the anterior capsule to restore stability. Option C is the correct answer. The case states, 'The anterior labrum and capsule are meticulously mobilized from the anterior glenoid neck using an elevator and electrocautery. It is critical to release the tissue inferiorly to the 6 o'clock position to allow for adequate superior shift during repair.' This extensive release is essential to achieve sufficient capsular shift and tension, which is key to preventing recurrent instability. Option A is an important step to create a bleeding bone bed for biological healing, but it does not directly facilitate the superior capsular shift. Option B is generally not the starting point for Bankart repair. Anchors are typically placed from inferiorly (5:30 position) and progressed superiorly to the 3:00 position to restore the anterior bumper and achieve the desired capsular shift. Option D is incorrect. The sutures should pass through the 'capsulolabral complex,' ensuring a healthy bite of the inferior glenohumeral ligament to achieve the superior and lateral capsular shift, as described in the case. Option E is incorrect. The case states, 'Before tying the anterior Bankart anchors, the remplissage is addressed... These sutures are left untied until the anterior repair is complete.' The remplissage sutures are tied after the anterior repair is complete, but the anchors are placed before tying the Bankart anchors.

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