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5. Sports Medicine MCQs

Practice Set 61 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 1201

Topic: Knee Sports

A 55-year-old patient presents with a significant varus deformity of the knee, as depicted in the full-length standing radiograph below. The text highlights the biomechanical consequences of such a deformity if left uncorrected. What is the most likely long-term consequence of this uncorrected varus deformity on the knee joint?

. A. Accelerated lateral compartment arthrosis.
. B. Accelerated medial compartment arthrosis.
. C. Development of genu valgum in the contralateral limb.
. D. Increased risk of patellar instability.
. E. Improved range of motion due to joint laxity.

Correct Answer & Explanation

. B. Accelerated medial compartment arthrosis.

Explanation

Correct Answer: BThe text explicitly states: 'In a varus knee, the medial compartment bears a disproportionate amount of the load, leading to accelerated medial compartment arthrosis.' The image clearly shows a varus deformity, where the mechanical axis passes medial to the center of the knee, thus overloading the medial compartment.Incorrect Options:A. Accelerated lateral compartment arthrosis:This is the consequence of a valgus deformity, where the lateral compartment is overloaded, not a varus deformity.C. Development of genu valgum in the contralateral limb:While compensatory mechanisms can occur, the text does not describe this as a direct biomechanical consequence of an uncorrected varus deformity in the ipsilateral knee.D. Increased risk of patellar instability:Patellar instability is typically associated with factors like trochlear dysplasia, patella alta, or excessive tibial tuberosity-trochlear groove distance, not primarily with frontal plane varus deformity of the knee.E. Improved range of motion due to joint laxity:Uncorrected deformity and subsequent arthrosis typically lead to decreased and painful range of motion, not improved range of motion.

Question 1202

Topic: Knee Sports

A patient presents with a severe long-standing varus deformity of the tibia and a compensatory valgus deformity of the femur. If the surgeon only corrects the tibial varus deformity to mechanical neutrality without addressing the femur, what will be the likely effect on the knee joint?

. The mechanical axis will remain strictly in the medial compartment.
. The joint line will become unacceptably oblique (loss of joint line congruity with the ground).
. The patella will dislocate medially.
. The anterior cruciate ligament will become acutely attenuated.
. The knee will develop a fixed flexion contracture.

Correct Answer & Explanation

. The joint line will become unacceptably oblique (loss of joint line congruity with the ground).

Explanation

Correcting only one component of a compensatory dual-bone deformity shifts the mechanical axis but often creates an abnormally oblique joint line. A level knee joint line is critical for mitigating shear forces during weight-bearing.

Question 1203

Topic: Knee Sports

A 70-year-old female presents with severe bilateral knee osteoarthritis, with the right knee exhibiting a significant valgus deformity and the left knee a varus deformity. The image below shows the left lower extremity. For the left knee, the mechanical axis line passes significantly medial to the center of the knee. Which of the following statements accurately describes the biomechanical consequence of this specific alignment?

. It results in severe overloading of the lateral compartment of the knee.
. It leads to stretching of the medial collateral ligament (MCL) over time.
. It causes compression of the lateral meniscus.
. It results in accelerated articular cartilage wear in the medial compartment.
. It is indicative of a valgus malalignment.

Correct Answer & Explanation

. It results in accelerated articular cartilage wear in the medial compartment.

Explanation

Correct Answer: DThe image and description indicate a varus malalignment (bow-legged deformity) where the mechanical axis line passes significantly medial to the center of the knee. The case explicitly states that 'Varus Malalignment... results in severe overloading of the medial compartment of the knee, leading to accelerated articular cartilage wear, medial meniscus tearing, and early-onset osteoarthritis.' Therefore, accelerated articular cartilage wear in the medial compartment is a direct biomechanical consequence.Options A, B, and C are incorrectbecause these are biomechanical consequences typically associated with a valgus malalignment (knock-kneed deformity), where the mechanical axis passes lateral to the center of the knee, overloading the lateral compartment, stretching the MCL, and compressing the lateral meniscus.Option E is incorrectbecause the description 'mechanical axis line passes significantly medial to the center of the knee' and the 'bow-legged' appearance are characteristic of varus malalignment, not valgus.

Question 1204

Topic: Knee Sports

When utilizing a Taylor Spatial Frame for a complex six-axis deformity correction of the tibia, which of the following is an essential parameter required by the software to accurately calculate the daily strut adjustments?

. Patient's BMI
. Mounting parameters
. Bone mineral density
. Joint line convergence angle
. Tibial tubercle to trochlear groove (TT-TG) distance

Correct Answer & Explanation

. Mounting parameters

Explanation

The TSF software requires precise input of deformity parameters, frame parameters, and mounting parameters (the exact position of the reference ring relative to the bone) to accurately generate the correction schedule.

Question 1205

Topic: 5. Sports Medicine

A 30-year-old patient with a post-traumatic tibial varus deformity and associated limb length discrepancy is being evaluated for corrective osteotomy. The surgeon plans a proximal tibial osteotomy to correct the angular deformity. Considering the principles illustrated in the diagram below, which type of osteotomy would be most appropriate if the goal is to correct the varus while simultaneously lengthening the limb?

. A closing wedge osteotomy.
. An opening wedge osteotomy with bone graft.
. A dome osteotomy.
. A transverse osteotomy with translation.
. A biplanar osteotomy without fixation.

Correct Answer & Explanation

. An opening wedge osteotomy with bone graft.

Explanation

Correct Answer: BThe image depicts a wedge osteotomy, illustrating the principles of angular correction. To correct a varus deformity and simultaneously lengthen the limb, an opening wedge osteotomy is the most appropriate choice. In an opening wedge osteotomy, a cut is made through the bone, and a wedge-shaped gap is created on the concave side of the deformity. This gap is then filled with bone graft (autograft or allograft) or a bone substitute, which corrects the angular deformity and increases the overall length of the bone. This is particularly useful when there is an associated limb length discrepancy that needs to be addressed.Option A, a closing wedge osteotomy, involves removing a wedge of bone from the convex side of the deformity. While it corrects the angular deformity, it results in limb shortening, which is contrary to the goal of lengthening. Option C, a dome osteotomy, involves creating a curved cut, allowing rotation and translation, but it does not inherently lengthen the limb. Option D, a transverse osteotomy with translation, primarily corrects translation and can be used for angular correction with complex maneuvers, but it's not the primary method for lengthening in this context. Option E, a biplanar osteotomy, refers to cuts in two planes, often used for stability or specific corrections, but 'without fixation' is generally not a viable surgical approach for osteotomies requiring stability for healing.

Question 1206

Topic: 5. Sports Medicine

A 28-year-old patient with a severe valgus deformity of the distal femur requires surgical correction. The surgeon is concerned about potential limb lengthening, as the patient already has equal limb lengths, and wants to prioritize immediate stability without the need for bone grafting. Which osteotomy technique, as described in the teaching case, would be most appropriate for this patient?

. A. Opening wedge osteotomy with allograft.
. B. Opening wedge osteotomy with autograft.
. C. Dome osteotomy.
. D. Closing wedge osteotomy.
. E. Callus distraction osteogenesis.

Correct Answer & Explanation

. D. Closing wedge osteotomy.

Explanation

Correct Answer: DThe teaching case describes the closing wedge osteotomy as 'the conceptual and geometric inverse of the opening wedge. It is an excellent, stable choice when limb shortening is desired, when the deformity is excessively large, or when avoiding the morbidity of bone grafting is a top priority.' This aligns perfectly with the patient's needs: avoiding limb lengthening (implying a desire for shortening or no change), prioritizing stability, and avoiding bone grafting. A closing wedge osteotomy involves removing a wedge of bone, which inherently shortens the limb (or prevents lengthening) and provides inherent stability upon compression, often negating the need for additional graft material.Options A and B (opening wedge osteotomies) inherently lengthen the limb and require bone grafting, which are contrary to the patient's requirements. Option C (dome osteotomy) is a different technique, not specifically detailed for these advantages in the provided text. Option E (callus distraction osteogenesis) is a lengthening technique, which is not desired here.

Question 1207

Topic: 5. Sports Medicine
The patient undergoes hip arthroscopy and the image of the right hip is shown in Figure 39. Repair of the injured structure would be expected to improve
. hip joint survival.
. hip joint lubrication.
. hip joint motion.
. hip joint stability.

Correct Answer & Explanation

. hip joint lubrication.

Explanation

DISCUSSION: The radiographic studies reveal both acetabular dysplasia and cam-type femoroacetabular impingement. The MRI image shows an acetabular labral tear. Structural abnormalities of the hip, including femoroacetabular impingement, have commonly been identified in association with labral tears. Disruption of the ligamentum teres is not associated with impingement conditions in the absence of trauma. The patient has acetabular dysplasia with a decreased lateral center-edge angle and also has visible cam-type femoroacetabular impingement. The common pathway for joint degeneration in hips with cam-type femoral head anatomy includes the development of cartilage damage in the anterior or superolateral aspects of the acetabular cartilage. Paralabral cysts may be seen more commonly in association with acetabular dysplasia, although the patient’s radiographs did not demonstrate substantial cystic changes. Osteochondral loose bodies and ligamentum teres ruptures can be seen at arthroscopy in a small number of cases. There are several proposed roles of the acetabular labrum. It can increase the depth of the acetabular socket by as much as 21% to 28%. Roles of the acetabular labrum include joint lubrication, shock absorption, and pressure distribution. Recent studies assessing the effects of loading on joint stability for both normal and dysplastic hips did not demonstrate a substantial role of the labrum in differences in loading. Although joint stability might be improved following surgical repair, acetabular dysplasia is not likely to be resolved with acetabular labral repair alone.

Question 1208

Topic: 5. Sports Medicine
Second-impact syndrome following a concussion
. poses minimal concern for morbidity or mortality.
. is less common in adolescents than in adults.
. is related to a disruption of cerebral autoregulation.
. refers to a second head injury after the athlete has been medically cleared to return to play.

Correct Answer & Explanation

. is related to a disruption of cerebral autoregulation.

Explanation

DISCUSSION: According to several consensus statements, no child or adolescent athlete with a concussion should be allowed to return to play on the same day, regardless of severity. Second-impact syndrome refers to a second traumatic head injury that occurs while an athlete is still experiencing symptoms from the first injury. Young athletes are particularly vulnerable to second-impact syndrome. The mechanism by which this syndrome occurs likely is disruption of cerebral autoregulation, which may result in cerebral vascular congestion, diffuse brain swelling, and death.

Question 1209

Topic: Shoulder & Hip Sports

A 60-year-old right hand-dominant women fell on her outstretched arm and sustained an anterior shoulder dislocation. The shoulder is reduced in the emergency department and she is seen for follow-up 1 week later wearing a sling. Examination reveals that she has significant difficulty raising her arm in forward elevation and has excessive external rotation compared to the contralateral shoulder. What is the next most appropriate step in management? Review Topic

. MRI
. Electromyography
. Open repair of the supraspinatus
. Arthrography
. Arthroscopic labral repair

Correct Answer & Explanation

. MRI

Explanation

In patients older than age 40 years, a high suspicion of a rotator cuff tear should be kept in those patients with weakness after shoulder dislocation. Both posterior rotator cuff and subscapularis injuries have been documented. The next most appropriate stepin management should be MRI. If the findings are negative, suspicion of nerve injury should lead to electromyography.

Question 1210

Topic: Knee Sports

Figures A and B show routine postoperative radiographs obtained 2 weeks after anterior cruciate ligament (ACL) reconstruction with autologous patellar tendon graft. Based on these findings, what is the next most appropriate action? Review Topic

. CT
. Routine ACL rehabilitation
. Modified ACL rehabilitation to limit weight bearing
. Modified ACL rehabilitation to limit flexion
. Revision ACL surgery

Correct Answer & Explanation

. Revision ACL surgery

Explanation

The radiographs reveal an intra-articular position of the femoral bone plug; therefore, revision ACL surgery is indicated. Recognized early, this graft may be suitable to use for the revision, but an alternate should be available.

Question 1211

Topic: Shoulder & Hip Sports

A 47-year-old landscaper presents with worsening left shoulder pain and weakness. Three years ago, he injured the left shoulder in a fall and elected for nonoperative management to minimize time off from work. Physical therapy was effective until 6 months ago when his shoulder function worsened to the point that he is now unable to work. Examination of his active range of motion reveals forward elevation 120° with pain, abduction 100°, IR at neutral to T8 and ER at neutral 5°. He has a positive ER lag sign and Hornblower's sign. Belly press and lift-off tests are normal. A recent radiograph is shown in Figures A. MRI images are shown in Figures B and C. Which of the following is the best treatment option? Review Topic

. Continue physical therapy
. Latissimus dorsi transfer
. Arthroscopic rotator cuff repair
. Pectoralis major transfer
. Reverse total shoulder arthroplasty

Correct Answer & Explanation

. Latissimus dorsi transfer

Explanation

This patient has a chronic massive posterosuperior rotator cuff tear with marked atrophy, tendon retraction and loss of external rotation strength that is impacting his daily life. The best treatment option for this middle-aged laborer with an irreparable posterosuperior rotator cuff tear is a latissimus dorsi transfer to restore external rotation strength and motion.Irreparable rotator cuff tears are marked by: (1) Superior displacement of the humeral head (AHI < 5-7mm), (2) Fatty infiltration of the rotator cuff muscles (Goutallier stage 3-4), (3) Increased duration of the tendon tear and (4) Profound external rotation weakness. These findings are predictive of poor-quality tissue and stiffness of the muscle-tendon unit, not amenable to primary repair. In this setting, a latissimus dorsitransfer can be utilized to restore shoulder strength, function and improve pain. Relative contraindications include subscapularis deficiency, deltoid deficiency, pseudoparalysis of the shoulder and advanced glenohumeral arthritis.Gerber et al. performed a case series analysis of 67 patients with irreparable rotator cuff tears managed with latissimus dorsi transfer. Patients with an intact subscapularis demonstrated improvement in pain, range of motion and strength postoperatively, while no improvement was noted in patients with subscapularis deficiency. The authors conclude that latissimus dorsi transfer should not be performed in the setting of poor subscapularis function.Iannotti et al. found that better clinical results following latissimus dorsi transfer were associated with: preserved active shoulder range of motion and strength (specifically forward elevation > 90° and external rotation > 20°), synchronous firing of the transferred latissimus dorsi muscle and male gender.Figure A is an AP radiograph of the left shoulder with superior migration of the humeral head (AHI < 5mm) and no evidence of glenohumeral arthritis. Figures B and C show a retracted posterosuperior rotator cuff tear and Goutallier stage 4 atrophy (more fat than muscle) of the supraspinatus, infraspinatus and teres minor, rendering this tear irreparable. Illustration A shows a latissimus dorsi transfer. The latissimus dorsi tendon is positioned over the top of the humeral head, covering most of the rotator cuff defect. The tendon is then secured to the subscapularis tendon edge and lesser tuberosity anteriorly, the remnant supraspinatus and infraspinatus tendons medially, and the greater tuberosity laterally.Incorrect Answers:

Question 1212

Topic: 5. Sports Medicine
With respect to the structure identified by the arrow in Figure 22b, the meniscofemoral ligaments are
. uniformly present, and are positioned posterior to the injured ligament.
. uniformly present, with one positioned anterior and the other positioned posterior to the injured ligament.
. variably present, and are positioned posterior to the injured ligament.
. variably present, with one positioned anterior and the other positioned posterior to the injured ligament.

Correct Answer & Explanation

. variably present, with one positioned anterior and the other positioned posterior to the injured ligament.

Explanation

DISCUSSION: The stress radiographs demonstrate posterior instability of the right knee in flexion. The MRI images demonstrate injury to both the anterior and posterior cruciate ligament (PCL), with the stump identified with the arrow on the MRI image (Figure 22b). The PCL has 2 functional bands. The anterolateral bundle originates from the roof of the intercondylar notch. It runs in a posterolateral direction onto the tibial crest between the posterior attachment of the medial and lateral menisci. During a double-bundled posterior ligament reconstruction, the anterolateral bundle is tensioned with the knee in a position of mid flexion. The posteromedial bundle has a variable pattern of tension both in extension and in high flexion. Tensioning of the posteromedial bundle in extension may contribute to resistance against knee hyperextension. The meniscofemoral ligaments are variably present. Although 93% of knees have been reported to have at least 1 meniscofemoral ligament present, both ligaments are simultaneously present in approximately 50% of knees. The ligament of Humphrey (anterior meniscofemoral ligament) and ligament of Wrisberg (posterior meniscofemoral ligament) are delineated by their anatomic relationship to the posterior cruciate. RECOMMENDED READINGS: Amis AA, Bull AM, Gupte CM, Hijazi I, Race A, Robinson JR. Biomechanics of the PCL and related structures: posterolateral, posteromedial and meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 2003 Sep;11(5):271-81. Epub 2003 Sep 5. Review. PubMed PMID: 12961064. Amis AA, Gupte CM, Bull AM, Edwards A. Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 2006 Mar;14(3):257-63. Epub 2005 Oct 14. Review. PubMed PMID: 16228178.

Question 1213

Topic: Shoulder & Hip Sports
A 54-year-old man undergoes total shoulder arthroplasty for osteoarthritis. Despite compliance with an early passive range-of-motion exercise program, he does not regain more than 90 degrees of elevation, 10 degrees of external rotation, and has internal rotation to the fifth lumbar vertebra. At 6 months, his motion fails to improve. Radiographs are shown in Figures 18a and 18b. What is the best course of action?
. Continue with a more aggressive passive range-of-motion exercise program.
. Perform an open release.
. Revise the humeral component and increase retroversion.
. Revise the humeral component alone after osteotomizing more of the humeral neck and seating the component lower.
. Remove the glenoid component to decrease tension in the rotator cuff.

Correct Answer & Explanation

. Perform an open release.

Explanation

DISCUSSION: The patient has a global loss of motion that has failed to improve with 6 months of nonsurgical treatment; because he has reached a plateau, further nonsurgical management will likely be ineffective. Revision in the form of an open release is indicated to lyse intra- and extra-articular adhesions; subscapularis lengthening may be done concurrently as needed. Revising to a smaller head can be considered if adequate motion is not achieved. The radiographs reveal an adequate neck cut with appropriate seating of the component. Removing the glenoid component will decrease capsular tension but will probably increase pain because of the lack of glenoid resurfacing. Increasing humeral retroversion will not improve motion. REFERENCES: Cuomo F, Checroun A: Avoiding pitfalls and complication in total shoulder arthroplasty. Orthop Clin North Am 1998;29:507-518. Wirth MA, Rockwood CA Jr: Complications of shoulder arthroplasty. Clin Orthop 1994;307:47-69.

Question 1214

Topic: Shoulder & Hip Sports

A 35-year-old man presents one week after an acute right shoulder posterior dislocation after being electrocuted. He is evaluated in the emergency department and undergoes closed reduction. The patient reports global right shoulder pain and limited active and passive range of motion. He has mild anterior and lateral bruising. He is distally neurovascularly intact. Current radiographs and an MRI scan are shown in Figures 1 through 3. What is the best next step?

. Open reduction internal fixation (ORIF)
. Sling immobilization in external rotation
. Bristow-Latarjet
. Shoulder hemiarthroplastyThe patient has sustained a displaced lesser tuberosity fracture with medial displacement following a posterior shoulder dislocation. Nonoperative management would risk long-term loss of normal subscapularis function, as well as anterior shoulder instability. An ORIF of lesser tuberosity is recommended. The current radiographs do not demonstrate any obvious compromise of glenoid bone stock that would necessitate a coracoid transfer. The humeral head is not compromised; therefore, a hemiarthroplasty is not indicated. Correct answer : A 5776- A 51-year-old man sustains the injury shown in the MRI scan in Figures 1 and 2 following a fall. After a thorough discussion regarding risks and benefits, he elects to proceed with surgery. What is the most appropriate surgical treatment for his fracture?
. Open reduction internal fixation with locking plate
. Intramedullary (IM) nail
. Hemiarthroplasty
. Closed reduction and percutaneous pinningThe patient has sustained a complex proximal humerus fracture with head split component and multiple articular fragments. When the articular surface is significantly compromised, arthroplasty procedures are favored. The only procedure listed that addresses the damaged humeral head is hemiarthroplasty, making it the correct response. Although a possible option, ORIF would be difficult due to the fragmented humeral head, and there would be a high risk for fracture collapse or avascular necrosis. IM nailing will not provide enough control of the fracture pieces, nor will it replace the damaged articular surface. Closed reduction is not an option given the complex nature of the fracture.

Correct Answer & Explanation

. Open reduction internal fixation (ORIF)

Explanation

A 68-year-old man presents with chronic progressive right shoulder pain and loss of motion. He has active shoulder elevation of 120° and 5-/5 shoulder forward flexion strength limited by pain. He has exhausted nonsurgical management over the past year and is now interested in surgical intervention. Figure 1 is the preoperative axial CT scan of his shoulder. During surgical reconstruction, the surgeon should anticipate the location of maximal glenoid erosion to be

Question 1215

Topic: Shoulder & Hip Sports

A 38-year-old man reports a 6-week history of shoulder pain and stiffness after falling on the stairs and landing onto the affected side. Radiographs are shown in Figures 54a and 54b. What is the most appropriate treatment? Review Topic

. Physical therapy including ultrasound and gentle stretches
. Closed manipulation of the shoulder
. MRI and possible rotator cuff repair
. Open glenohumeral reduction, with possible lesser tuberosity transfer
. Shoulder hemiarthroplasty

Correct Answer & Explanation

. Open glenohumeral reduction, with possible lesser tuberosity transfer

Explanation

The patient has a chronic posterior shoulder dislocation of 6-weeks duration. A CT scan will provide preoperative information regarding the size of the McLaughlin or reverse Hill-Sachs lesion. Open glenohumeral reduction with transfer of the lesser tuberosity and attached subscapularis has been shown to be successful in stabilizing a posterior dislocation. Closed reduction is highly unlikely to achieve a reduction and may cause displacement of an unrecognized humeral surgical neck fracture. Hemiarthroplasty would be considered for lesions involving more than 50% of the humeral head or when the joint has been dislocated for several months and late collapse of the head postreduction is likely. Rotator cuff tears are not commonly associated with posterior shoulder dislocation.

Question 1216

Topic: Shoulder & Hip Sports

A 52-year-old man underwent arthroscopic repair of a 1-cm supraspinatus tendon tear 3 weeks ago. He was doing well until he fell down three stairs. One week after the fall he continues to report pain similar to his preoperative pain. An MRI scan reveals a minimally retracted 1-cm supraspinatus tendon tear in the same location as his original tear. Management should now consist of Review Topic

. continued physical therapy that focuses on stretching and advances to strengthening in 4 weeks.
. a cortisone injection into the subacromial space.
. revision rotator cuff repair.
. a sling with an abduction pillow for 2 weeks, followed by a stretching program.
. open rotator cuff debridement without repair.

Correct Answer & Explanation

. revision rotator cuff repair.

Explanation

The patient has retorn his rotator cuff repair. This traumatic retear is different from a chronic tear and should be treated similar to an acute rotator cuff tear. Because the patient is younger than age 65 and has a small, single tendon tear, a revision rotation cuff repair is indicated with an expected tendon healing rate of greater than 95%. A physical therapy program is not indicated, and further delay in repair compromises his functional recovery. A cortisone injection is not indicated for this repairable tendon tear. Immobilization will not allow the tendon to heal once it has retorn. A debridement procedure is not indicated on this repairable tendon tear; this procedure is indicated in painful, chronic, irreparable tendon tears.

Question 1217

Topic: Knee Sports
Below show the radiographs and the MRIs obtained from a 40-year-old man with worsening left knee pain. A full hip-to-ankle radiograph shows a 5-degree varus knee deformity. The patient sustained a major left knee injury 5 years ago and a confirmed complete anterior cruciate ligament (ACL) tear. He managed this injury nonsurgically with a functional brace but experienced worsening pain. He was seen by an orthopaedic surgeon 18 months ago, and a medial meniscus tear was diagnosed; the tear was treated with an arthroscopic partial medial meniscectomy. Since then, his knee has been giving way more often, and he no longer feels safe working on a pitched roof. The patient received 6 months of formal physical therapy and was fitted for a new functional ACL brace, but he still has pain and instability. He believes he has exhausted his nonsurgical options and would like to undergo surgery. What is the most appropriate treatment at this time?
. ACL reconstruction and subsequent proximal tibial osteotomy
. ACL reconstruction alone
. Distal femoral osteotomy with simultaneous ACL reconstruction
. Proximal tibial osteotomy with subsequent ACL reconstruction

Correct Answer & Explanation

. Proximal tibial osteotomy with subsequent ACL reconstruction

Explanation

DISCUSSION: Proximal tibial osteotomy is the most appropriate intervention to correct varus malalignment and to reduce stress on the ACL. In some cases, proximal tibial osteotomy alone may address both pain and instability, but if instability persists, particularly in the setting in which instability can be dangerous, subsequent ACL reconstruction can further stabilize the knee with less stress on the graft after the correction of malalignment. Varus alignment places increased stress on the native or reconstructed ACL. ACL reconstruction should be performed only at the same time as or following proximal tibial osteotomy to correct alignment in the setting of varus malalignment. It is not appropriate to perform ACL reconstruction prior to proximal tibial osteotomy in this setting. Distal femoral osteotomy is not indicated to correct varus malalignment. Varus alignment places increased stress on the native or reconstructed ACL, and ACL reconstruction alone is not indicated for this patient.

Question 1218

Topic: 5. Sports Medicine
A 47-year-old male tennis player has pain in his nondominant shoulder that has failed to respond to 4 months of nonsurgical management. Examination reveals acromial tenderness and pain at the supraspinatus tendon insertion. He has a positive impingement sign, pain on forward elevation, and minimal cuff weakness. The MRI scans are shown in Figures 30a and 30b. To completely resolve his symptoms, treatment should consist of:
. Rigid open reduction and internal fixation of the os acromiale with autologous bone graft.
. Arthroscopic repair of the rotator cuff and acromioplasty.
. Arthroscopic excision of the os acromiale.
. Arthroscopic decompression of the supraglenoid cyst.
. Open distal clavicle excision (Mumford procedure).

Correct Answer & Explanation

. Rigid open reduction and internal fixation of the os acromiale with autologous bone graft.

Explanation

DISCUSSION: The MRI scans show a mesoacromion with tendinopathy of the supraspinatus. The history and physical findings indicate that the patient has a symptomatic os acromiale. Simple excision of the unstable os acromiale has not yielded consistently good results. Meticulous internal fixation using tension banding with cannulated screws and autologous bone grafting has shown good results for this problem. REFERENCES: Hutchinson MR, Veenstra MA: Arthroscopic decompression of shoulder impingement secondary to os acromiale. Arthroscopy 1993;9:28-32. Warner JJ, Beim GM, Higgins L: The treatment of symptomatic os acromiale. J Bone Joint Surg Am 1998;80:1320-1326.

Question 1219

Topic: 5. Sports Medicine
The patient is offered a valgus-producing high tibial osteotomy (VPHTO). What aspect of his history will determine the most appropriate VPHTO technique?
. Prior arthroscopy
. Current smoking history
. BMI of 22
. Age of 40

Correct Answer & Explanation

. Current smoking history

Explanation

DISCUSSION: This patient has a classic presentation of postmeniscectomy medial compartment arthritis. The appropriate diagnostic study is weight-bearing radiographs to confirm the diagnosis. An MRI scan will reveal medial compartment arthritis but will not provide information about alignment. A CT scan would be appropriate to detect an occult fracture; however, this condition is not suspected in this clinical scenario. An ultrasound can provide information about fluid collection around the knee or a deep vein thrombosis; however, these conditions also are not suspected in this clinical scenario. Because the patient has a correctable deformity (gaps 3 mm with valgus stress) and his symptoms are localized to the involved compartment, a trial of a medial unloader brace is appropriate both diagnostically and therapeutically. If unloading the medial compartment resolves the patient’s symptoms, he would be an excellent candidate for an osteotomy. An MRI scan may be obtained to evaluate ligamentous integrity or to evaluate degenerative involvement of the lateral and patellofemoral compartment for presurgical planning of an osteotomy; however, the integrity of the medial meniscus has no clinical importance in a patient with severe medial compartment arthritis. A repeat corticosteroid injection is not indicated within 1 month of his last injection, and referral to pain management is not appropriate with other options available to help this patient. A VPHTO is the appropriate intervention considering the patient’s young age, high-functional occupation, examination, radiographic findings, and response to medial unloader bracing. A revision knee arthroscopy would be appropriate for a recurrent medial meniscus tear, but not in a patient with severe medial compartment arthritis. The patient’s young age and high functional requirements are contraindications to TKA. The presence of severe arthritis is a contraindication to medial meniscus transplant. The patient is a candidate for a VPHTO. The technical options include a medial opening-wedge or a lateral closing-wedge osteotomy. Both techniques have advantages and disadvantages; however, a medial opening-wedge osteotomy is contraindicated in a smoker because of concern for nonunion. As a result, current smoking history is the only factor listed that would influence the technique used. The history of prior arthroscopy has no relevance in the decision about which type of osteotomy is appropriate. Normal BMI is between 18.5 and 24.9, so this patient’s BMI is considered normal and would not affect the surgical technique. His age of 40 is an indication for HTO but does not influence technique.

Question 1220

Topic: Shoulder & Hip Sports

Atraumatic suprascapular nerve compression usually occurs at which of the following anatomic locations if it develops atraumatically? Review Topic

. Scalenus anterior
. Suprascapular and spinoglenoid notches
. Cervical rib
. Conjoined tendon
. Subcoracoid

Correct Answer & Explanation

. Suprascapular and spinoglenoid notches

Explanation

The suprascapular nerve has the potential to be compressed as it passes through the suprascapular and spinoglenoid notches. If the site of compression occurs at the suprascapular notch, both the supraspinatus and infraspinatus muscles will be affected. If the site of compression occurs at the spinoglenoid notch, only the infraspinatus muscle will be affected. Fascial bands and ganglion cysts often compress the nerve in these areas. The other anatomic areas are not associated with suprascapular nerve compression.

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