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5. Sports Medicine MCQs

Practice Set 62 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 1221

Topic: Knee Sports

After surgery, this patient continues to experience pain and swelling of the knee with recurrent effusions. He returns to the office with continued pain 2 years after surgery. He describes instability, particularly when descending stairs. Upon examination, there is range of motion from 0 to 120 degrees with no extensor lag. The knee is stable to varus and valgus stress in extension, but there is flexion instability in both the anterior-posterior direction and in the varus-valgus direction. Bracing leads to a slight decrease in symptoms but is not well tolerated. Isokinetic testing demonstrates decreased knee extension velocity at mid push. Radiographs demonstrate well-aligned and fixed knee implants. An infection workup is negative. What is the most appropriate surgical intervention at this time?

. Tibial polyethylene exchange
. Revision of the femoral and tibial components and conversion to a posterior stabilized insert
. Revision of femoral and tibial components to a constrained rotating hinge prosthesis
. Isolated femoral component revision and upsizing the femoral implant with a new PCL-retaining polyethylene insert

Correct Answer & Explanation

. Tibial polyethylene exchange

Explanation

DISCUSSIONVideo 99 for referenceThis patient has valgus knee alignment, and, after undergoing appropriate bone resections and soft-tissue balancing, has demonstrated a tight PCL on trial reduction as evidenced by lift-off of the trial insert as described by Scott and Chmell. The appropriate maneuver is PCL recession with partial release of tight (usually anterolateral) PCL fibers. However, for this patient, instability resulted in increased anterior translation. At this stage, the options are to convert to either a deeper-dish insert with increased sagittal conformity or a posterior stabilized insert. The only appropriate choice among the responses is use of an insert with increased sagittal conformity to prevent excessive anterior translation. Increasing the polyethylene could improve stability in flexion, but, considering there is good stability in extension, this likely would lead to an inability to achieve full extension. The patient’s valgus deformity, flexion contracture, correction with release of the iliotibial band, and posterolateral capsule predispose him to increased risk for peroneal nerve palsy. His symptoms at follow-up suggest knee flexioninstability with pain, swelling, and difficulty descending stairs. Considering his history, an incompetent PCL must be considered. Revision of the knee to a posterior stabilized or nonlinked constrained condylar implant depending on the condition of the ligaments likely is needed to address his symptoms. The difference in extension vs flexion stability makes polyethylene exchange a poor option. There is no reason to believe a constrained rotating hinge design is necessary. Repeat use of a PCL-retaining insert is not recommended.

Question 1222

Topic: Shoulder & Hip Sports

A 20-year-old man has activity-related deep-seated shoulder pain in his dominant right shoulder. He has taken 3 months off training as a college javelin thrower, and management consisting of physical therapy has failed to provide relief. Shoulder arthroscopic views are shown in Figures 16a through 16c. What is the underlying association with this condition? Review Topic

. Ehlers-Danlos syndrome
. Traumatic anterior instability
. Humeral head osteonecrosis
. Internal impingement
. Partial-thickness supraspinatus tear

Correct Answer & Explanation

. Internal impingement

Explanation

The patient is involved in overhead athletics and reports deep-seated pain. The arthroscopic views show a SLAP tear with posterior extension that is typical of internal impingement. The history lacks a component of gross instability expected in traumatic anterior dislocations or multidirectional instability associated with a connective tissue disorder, and it also lacks risk factors for osteonecrosis. The images do not show evidence of an unstable humeral cartilage flap or a supraspinatus tear.

Question 1223

Topic: 5. Sports Medicine

A 25-year-old male professional lacrosse player collides with another player, with injury resulting from a knee impacting the athlete’s thigh. He has immediate pain in the mid-thigh area and is unable to return to the game because of difficulty with running. Examination reveals developing swelling in the anterior mid-thigh area. The thigh compartments are soft, and he is able to extend his knee against gravity. Knee flexion at 90° gives him discomfort in the thigh but no knee pain. The knee and hip examinations are otherwise unremarkable. Plain films of the femur are negative. What is the best next step?

. Intracompartmental pressure monitoring
. Immobilization of the knee in a flexed position
. Fasciotomy of the thigh
. MRI scan of the femurThis athlete has experienced a quadriceps contusion with hemorrhage and swelling into the anterior compartment of the thigh. Initial treatment for these injuries is immobilization of the knee in flexion to reduce the amount of bleeding into the anterior compartment. Rest and anti-inflammatory medication may be used in the rehabilitation process but should not take the place of immobilization in flexion. The compartments are soft and therefore, there is no indication for fasciotomy. MRI scan of the femur may demonstrate hematoma in the anterior thigh compartment but is not required to make the diagnosis.

Correct Answer & Explanation

. Immobilization of the knee in a flexed position

Explanation

The lesion seen in the MRI scan in Figure 1 is treated with a marrow stimulation technique. The reparative tissue formed by this technique is predominantly composed ofA. only type 1 collagen.B. only type 2 collagen.C. type 1 and type 2 collagen.D. neither type 1 or type 2 collagen.The MRI scan shows a full-thickness cartilage defect. When treated with a marrow stimulation technique, such as a microfracture, the reparative tissue is fibrocartilage. Unlike hyaline cartilage, which is composed of only type 2 collagen, fibrocartilage is composed of both type 1 and type 2 collagen.15- Figures 1 and 2 are the radiographs of a 58-year-old retired laborer who has had many years of right shoulder pain. He initially experienced relief with anti-inflammatory medication over the past year, but this no longer provides him pain relief. He has pain with overhead activities and is dissatisfied with his shoulder function. Examination indicates active and passive forward elevation to 130°, full strength with external rotation, and a negative belly press test. MRI demonstrates an intact rotator cuff. What is the best next step in treatment?A. Anatomic total shoulder arthroplasty (TSA)B. HemiarthroplastyC. Reverse shoulder arthroplastyD. Arthroscopy with debridement and biceps tenodesisThe patient has glenohumeral osteoarthritis based on the radiograph. His examination demonstrates limited motion and no significant rotator cuff pathology – full strength with external rotation, negative belly press, and no pseudoparalysis. Of all the answer choices, an anatomic TSA would be the most appropriate treatment option. Hemiarthroplasty does not address glenoid pathology and provides inferior pain relief and function, compared with TSA. A reverse shoulder arthroplasty is utilized for patients with degenerative shoulder changes in conjunction with irreparable rotator cuff pathology. Shoulder arthroscopy with debridement and biceps tenodesis is not appropriate for those with severe degenerative changes of the shoulder.16- According to the MRI scan shown in Figure 1, which pathologic finding is expected to be encountered during arthroscopy?A. Figure 2B. Figure 3C. Figure 4D. Figure 5The sagittal MRI scan is a clear example of a double posterior cruciate ligament (PCL) sign. This sign has a high specificity for a displaced bucket handle tear of the medial meniscus as seen in Figure 4. The other arthroscopicimages show a flap tear of the medial meniscus (Figure 2), anterior cruciate ligament tear (Figure 3), and a full thickness articular cartilage defect (Figure 5). Other less likely causes of a double PCL sign include intermeniscal ligament, meniscofemoral ligaments, loose bodies, osteophytes, and fracture fragments. Correct answer : C 1317- Figures 1 and 2 are the radiographs of a 21-year-old football player who underwent anterior cruciate ligament (ACL) reconstruction with patellar tendon autograft 1 year ago. He reports mild stiffness in his knee. Upon examination, he has a negative Lachman test, trace effusion, and range of motion from 0 to 85° of knee flexion. Which factor is most contributory to his examination findings?A. Incorrect graft choiceB. Improper tunnel positionC. Tibial graft-tunnel mismatchD. Femoral fixation at 80° flexionTechnical failure is the most common reason for ACL reconstruction failure. Tunnel position is the most frequent cause of technical failure. Malpositioning of the tunnel affects the length of the graft, causing either decreased range of motion or increased graft laxity. This patient has anterior and vertical placement of his femoral tunnel, which has been shown to cause stiffness in knee flexion. Although graft choice is an important factor when planning ACL reconstruction, overall outcomes with autograft tissues are fairly similar. Fixation of the graft at the femoral or tibial end is not as important as tunnel position. Fixing the graft in flexion can cause extension loss when isometry is not achieved, but this condition is not touched upon in this scenario.

Question 1224

Topic: Shoulder & Hip Sports

A 32-year-old volleyball player has dull posterior shoulder pain. An examination reveals moderate external rotation weakness with his arm at his side but normal strength on supraspinatus isolation. Deltoid and supraspinatus bulk appear normal, although there appears to be mild infraspinatus atrophy. Sensation is normal throughout the shoulder and shoulder girdle. What is the most likely diagnosis?

. Calcified transverse scapular ligament
. Parsonage-Turner syndrome
. Spinoglenoid notch cyst
. Quadrilateral space syndrome

Correct Answer & Explanation

. Spinoglenoid notch cyst

Explanation

This clinical scenario describes a patient with an isolated injury affecting the infraspinatus muscle. The anatomic location of such a lesion would be at the spinoglenoid notch, at which the suprascapular nerve may be compressed distal to its innervation of the supraspinatus but proximal to the infraspinatus innervation. A calcified transverse scapular ligament would also affect the suprascapular nerve but is proximal to the innervation of both muscles. Quadrilateral space syndrome would affect innervation of the deltoid (and teres minor). Parsonage-Turner syndrome is a more diffuse, and often severely painful, brachial plexus neuropathy.

Question 1225

Topic: Shoulder & Hip Sports

Figures 1 and 2 are the most recent radiographs of an 18-year-old high school student who sustains an anterior shoulder dislocation playing recreational football. He has a low Beighton score on physical examination. He was closed reduced and underwent a course of physical therapy but had a second dislocation playing recreational basketball. What is the most appropriate course of treatment, with the lowest complication rate, to prevent further dislocation?

. Arthroscopic Bankart procedure
. Physical therapy
. SAWA shoulder brace
. Latarjet procedure

Correct Answer & Explanation

. Arthroscopic Bankart procedure

Explanation

The patient has recurrent instability and is at a high rate of further dislocations due to his young age. Therefore, therapy and bracing are unlikely to decrease his dislocation rate. The radiographs are normal, and there is no Hill-Sachs lesion or bony Bankart lesion. His instability severity index score is 3, and; therefore, a bony procedure such as Latarjet is not necessary. Furthermore, the rate of complication following a Latarjet procedure, especially nerveinjury and hardware problems, exceeds that of arthroscopic Bankart repair.

Question 1226

Topic: 5. Sports Medicine
  • In revision hip arthroplasty, which of the following is the 5- to 10-year reported graft failure rate when using structural acetabular allografts in the repair of acetabular deficiencies?
. 20% with cemented and uncemented sockets
. 40% with cemented and uncemented sockets
. 60% with cemented sockets
. 90% with cemented and uncemented sockets
. 90% with cemented sockets

Correct Answer & Explanation

. 20% with cemented and uncemented sockets

Explanation

This answer was based on studies by Hooten, Engh. They found that the overall failure rate was 44 %. Selections 1, 3, 4, and 5 were incorrect. They also reported an increase failure rate if more than 50% of the cup rested on allograft. When there is no satisfactory alternative to a bulk allograft available, close radiographic monitoring was recommended. [JBJS 1994, 76B pg. 419-422.

Question 1227

Topic: Shoulder & Hip Sports

A 38-year-old man sustained a complete thoracic spinal cord injury at age 14. An MRI scan of his shoulder, when compared with studies from uninjured controls, is more likely to show which of the following? Review Topic

. Hypertrophied subscapular muscle
. Rotator cuff tear
. Posterior glenohumeral subluxation
. Increased bone density
. Supraspinatus nerve compression

Correct Answer & Explanation

. Rotator cuff tear

Explanation

Children that sustain a spinal cord injury or otherwise use a wheelchair for mobility, and thus often have more pain and a higher incidence of structural and functional changes of the shoulder joint as an adult. MRI studies have shown a four-fold risk of rotator cuff tears in people with long-term paraplegia when compared with age-matched controls. An MRI scan would not show bone density changes. The other answer choices have not been demonstrated in higher numbers on MRI in paraplegics.

Question 1228

Topic: Shoulder & Hip Sports
After closed reduction of the dislocation shown in Figure 42, it is essential to avoid placing the upper extremity in what position for the first 4 to 6 weeks?
. Abduction
. External rotation
. Internal rotation
. Extension
. Elevation

Correct Answer & Explanation

. External rotation

Explanation

Acute posterior dislocations occur rarely, accounting for less than 5% of acute dislocations. They are most often the result of falls on an outstretched hand. Reduction can be accomplished with flexion of the arm to 90 degrees and adduction to disimpact the humeral head from the glenoid rim. The arm is then externally rotated until the head has cleared the glenoid rim. Following brace immobilization in neutral to 5 to 10 degrees of external rotation and slight abduction, it is critical to avoid internal rotation for 4 to 6 weeks.

Question 1229

Topic: Knee Sports

An elite football player has sustained a left knee injury during play. A dynamic imaging analysis is performed on the affected knee, which shows anterior shift and internal rotation of the tibia at low flexion angles. There is also some mild medial translation of the tibia at greater flexion angles. What structure(s) have most likely been injury? Review Topic

. Anterior cruciate ligament
. Posterior cruciate ligament
. Posterior cruciate ligament and medial collateral ligament
. Medial collateral ligament
. Lateral collateral ligament, popliteal tendon and arcuate ligament

Correct Answer & Explanation

. Anterior cruciate ligament

Explanation

This patient has sustained an anterior cruciate ligament (ACL) rupture.The ACL is the primary restraint to anterior translation of the tibia relative to the femur. It also acts as secondary restraint to tibial rotation and varus/valgus rotation. ACL-deficient knees have been shown to have abnormal knee kinematics, which has been thought to contribute to the osteoarthritis that develops after injury.DeFrate et al. examined the knee joint kinematics of 8 patients with unilateral anterior cruciate ligament rupture using in vivo imaging. They found significant anterior shift and internal rotation of the tibia at low flexion angles in ACL-deficient knees. They also noted some medial translation of the tibia between 15° and 90° of flexion.Illustration A shows the effect of medial tibial translation on tibiofemoral contact in ACL-deficient knees. The medial translation of the tibia causes increased contact between the tibial spine and inner surface of the medial femoral condyle. This might be a contributing factor to the joint degeneration observed in ACL-deficient patients.Incorrect Answers:

Question 1230

Topic: Knee Sports
During a posterior cruciate ligament (PCL)-retaining total knee arthroplasty, a critical principle to remember is to
. accurately tension the PCL.
. use bony resection to adjust the joint line.
. maintain a small amount of residual deformity.
. use intraoperative fluoroscopy to ensure femoral roll back.

Correct Answer & Explanation

. accurately tension the PCL.

Explanation

Maintenance of the joint line and accurately tensioning the PCL are critical in the proper execution of a PCL-retaining total knee arthroplasty. Appropriate tension helps ensure femoral rollback and avoid stiffness or instability. Raising the joint line to help ensure full extension should be avoided in cruciate-retaining knees, because doing so creates an unfavorable kinematic environment. The three important principles of surgical technique needed to maintain appropriate tensioning of the PCL include 1) choosing the proper femur size to reproduce the native femoral anterior/posterior dimension, 2) reproducing the joint line by resecting as much tibia from the healthy side as will be replaced by the smallest thickness of the tibial component and, 3) ensuring that full extension is achieved by soft-tissue releases and not by taking additional distal femur, as may be done in a posterior stabilized approach. Another important principle is to re-create the natural degree of the patient’s posterior tibial slope to avoid tightness in flexion.

Question 1231

Topic: 5. Sports Medicine
All of the following conditions are associated with the female athlete triad EXCEPT?
. Amenorrhea
. Osteoporosis
. Low LDL levels
. Decreased immune function
. Insufficient caloric intake

Correct Answer & Explanation

. Low LDL levels

Explanation

All of the following listed are associated with the female athlete triad except for Low LDL cholesterol levels. In fact, these patients often have elevated levels of LDL due to the hypoestrogenism caused by menstrual dysfunction. The female athlete triad is an interrelationship of menstrual dysfunction (i.e., amenorrhea or oligomenorrhea), low energy availability (insufficient caloric intake for demand, with or without an eating disorder) and decreased bone mineral density. It is relatively common among young women participating in sports. More recently, it has been suggested that endothelial dysfunction also results, due to an imbalance between vasodilating and vasoconstricting agents triggered from inappropriate levels of nitric oxide on the microscopic level, which predisposes these women to atherosclerotic changes and increases their risk of cardiovascular disease in the future.

Question 1232

Topic: 5. Sports Medicine
A 23-year-old professional baseball pitcher reports shoulder pain and decreased velocity while pitching. Physical examination reveals a side-to-side internal rotation deficit of 25 degrees. The O’Brien sign is negative; Neer and Hawkins signs are negative. Rotator cuff strength is full. Radiographs are unremarkable. What is the next step in management?
. MRI-arthrogram to evaluate the rotator cuff
. Rotator cuff strengthening program
. Posterior capsular stretching program
. Shoulder arthroscopy with SLAP repair
. Shoulder arthroscopy with posterior capsular release

Correct Answer & Explanation

. Posterior capsular stretching program

Explanation

DISCUSSION: Throwing athletes with symptomatic internal rotation deficits often benefit from an intensive posterior capsular stretching program. Patients that fail to respond to nonsurgical management may benefit from an arthroscopic posterior capsular release. REFERENCES: Wilk KE, Meister K, Andrews JR: Current concepts in rehabilitation of the overhead throwing athlete. Am J Sports Med 2002;30:136-151. Myers JB, Laudner KG, Pasquale MR, et al: Glenohumeral range of motion deficits and posterior shoulder tightness in throwers with pathologic internal impingement. Am J Sports Med 2006;34:385-391.

Question 1233

Topic: Knee Sports

Performing reconstruction of the anterior cruciate ligament by drilling the femoral tunnel via an anteromedial portal, in contrast to transtibial drilling, affords what theoretical benefit? Review Topic

. Longer femoral tunnel
. More anatomic graft placement
. A more vertically oriented graft
. Diminished risk of posterior tunnel wall violation ("blowout")
. Diminished risk to lateral femoral articular cartilage and subchondral bone posteriorly

Correct Answer & Explanation

. Diminished risk to lateral femoral articular cartilage and subchondral bone posteriorly

Explanation

Recent trends in anterior cruciate ligament reconstruction include an emphasis on anatomic rather than isometric reconstruction of the ligament. According to some studies, this more effectively restores knee kinematics and with this, rotatory stability. Transtibial drilling affords limited access to the lateral intercondylar wall and has been associated with vertical graft orientation. The anteromedial portal, in contrast, allows independent femoral tunnel drilling and more anatomic positioning of the graft. A more anatomically positioned tunnel established via an anteromedial portal may afford increased tunnel and graft obliquity. This has been suggested to resolve rotatory instability. Knee flexion angle during the course of reaming has been studied to assess favorable and negative tunnel characteristics and hazards to regional anatomic structures. When compared with transtibial drilling, the anteromedial portal is associated with shorter femoral tunnels, posterior tunnel wall integrity compromise, and increased risk to lateral femoral articular cartilage and subchondral bone posteriorly.

Question 1234

Topic: 5. Sports Medicine
A coronal MRI scan through the shoulder joint is shown in Figure 26. The cyst indicated by the arrow will most likely cause compression of what nerve?
. Subscapular
. Suprascapular
. Axillary
. Musculocutaneous
. Medial pectoral

Correct Answer & Explanation

. Suprascapular

Explanation

DISCUSSION: The MRI scan shows a ganglion cyst in the region of the spinoglenoid notch. These are difficult to diagnose clinically but are readily apparent on MRI. They usually cause compression of the suprascapular nerve and weakness of the infraspinatus and supraspinatus muscles. REFERENCES: Resnick D, Kang HS (eds): Internal Derangements of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 306-309. Iannotti JP, Ramsey ML: Arthroscopic decompression of a ganglion cyst causing suprascapular nerve compression. Arthroscopy 1996;12:739-745.

Question 1235

Topic: 5. Sports Medicine

Which of the following factors is most likely to contribute to pseudarthrosis in a patient who has undergone a single-level anterior decompression and fusion procedure for the treatment of cervical radiculopathy? Review Topic

. Sagittal alignment
. History of diabetes mellitus and tobacco use
. Performance of an uninstrumented fusion (ie, no plate and screws)
. Use of allograft (instead of autograft)
. Fusion at the C3-C4 level

Correct Answer & Explanation

. History of diabetes mellitus and tobacco use

Explanation

Various factors affect the pseudarthrosis rate in patients who undergo anterior cervical decompression and fusion. Patient factors, including history of smoking and history ofdiabetes mellitus, have been shown to significantly increase pseudarthrosis rates. The literature has been mixed with regard to fusion rates for allograft versus autograft, especially for one-level fusions; in that category, there is minimal, if any, difference. Similarly, several authors have shown higher rates of fusion with uninstrumented single-level rather than instrumented anterior cervical decompressions and fusions. The level (ie, cranial or caudal) of fusion and sagittal alignment have not been correlated with fusion rates.

Question 1236

Topic: Shoulder & Hip Sports

A 21-year-old throwing athlete has persistent shoulder pain. Figures 73a and 73b are arthroscopic photographs taken from a posterior viewing portal and an anterior viewing portal. During which phase of the throwing motion did the injury most likely occur? Review Topic

. Wind-up
. Early cocking
. Late cocking
. Acceleration
. Deceleration

Correct Answer & Explanation

. Late cocking

Explanation

Five distinct phases of the throwing motion have been identified, each of which places the static and dynamic stabilizers of the shoulder under different stresses. In the late cocking phase, the throwing arm is abducted and maximally externally rotated.Rotator cuff tears in throwing athletes may be the result of either tensile or compressive forces. Tensile failure is believed to be the result of repetitive eccentric contractions. Compressive failure is thought to result from direct contact of the articular side of the rotator cuff between the greater tuberosity and posterior glenoid. Compressive failure results in tearing of the posterior supraspinatus and anterior infraspinatus, in contrast to the more common partial tearing of the anterior supraspinatus seen in the general population. In addition to tearing of the articular side of the rotator cuff, compressive forces also contribute to the peel-back mechanism and resultant avulsion of the posterosuperior labrum and biceps anchor. Articular-sided posterior supraspinatus and infraspinatus tears in combination with posterosuperior labral and biceps anchor detachment has been termed internal impingement. It is believed to be the primary result of either posterior capsular contracture (GIRD) or anterior capsular laxity.

Question 1237

Topic: 5. Sports Medicine
Which of the following cardiac conditions is considered an absolute contraindication to vigorous exercise?
. Hypertrophic cardiomyopathy (HCM)
. Sclerosis of the aortic valve without stenosis
. Mild mitral valve regurgitation
. Left ventricular hypertrophy (LVH)
. Functional murmurs

Correct Answer & Explanation

. Hypertrophic cardiomyopathy (HCM)

Explanation

DISCUSSION: Hypertrophic cardiomyopathy (HCM) accounts for up to 50% of cases of sudden death in young athletes. HCM phenotype becomes evident by age 13 to 14 years. Those at higher risk include individuals with cardiac symptoms, a family history of inherited cardiac disease, and those with a family history of premature sudden death. Echocardiography is useful for detecting structural heart disease, including the cardiomyopathies and valvular abnormalities. Trained adolescent athletes demonstrated greater absolute left ventricular wall thickness (LVWT) compared to controls. HCM should be considered in any trained adolescent male athlete with a LVWT of more than 12 mm (female of more than 11 mm) and a nondilated ventricle. Adolescent and adult athletes differ with respect to the range of LVWT measurements, as a manifestation of left ventricular hypertrophy (LVH). Differentiating LVH (“athlete’s heart”) from HCM involves looking at additional echocardiographic features. Sharma and associates reported that adolescents with HCM had a small or normal-sized left ventricle (less than 48 mm) chamber size, while those with LVH had a chamber size at the upper limits of normal (52 mm to 60 mm). REFERENCES: Sharma S, Maron BJ, Whyte G, et al: Physiologic limits of left ventricular hypertrophy in elite junior athletes: Relevance to differential diagnosis of athlete’s heart and hypertrophic cardiomyopathy. J Am College Cardiol 2002;40:1431-1436. Maron BJ, Spirito P, Wesley Y, et al: Development and progression of left ventricular hypertrophy in children with hypertrophic cardiomyopathy. N Engl J Med 1986;315:610-614. Pelliccia A, Culasso F, Di Paolo FM, et al: Physiologic left ventricular cavity dilatation in elite athletes. Ann Intern Med 1999;130:23-31.

Question 1238

Topic: 5. Sports Medicine
A 20-year-old athlete sustains a 2- x 3-cm grade IV chondral injury to the right knee. After failure of nonsurgical management, which of the following procedures would ensure the highest percentage of hyaline-like cartilage?
. Arthroscopic chondroplasty
. Autologous chondrocyte implantation
. Microfracture
. Arthroscopic drilling
. Abrasion arthroplasty

Correct Answer & Explanation

. Autologous chondrocyte implantation

Explanation

DISCUSSION: Autologous chondrocyte implantation was first reported by Brittberg in 1994 and has resulted in predominantly type II collagen (hyaline-like articular cartilage) in the repair tissue. The extracellular matrix in articular cartilage is made up primarily of type II collagen, proteoglycans, and water. Arthroscopic chondroplasty, microfracture, drilling, and abrasion arthroplasty all result eventually in fibrocartilage fill of the defect (predominantly type I collagen). REFERENCES: Brittberg M, Lindahl A, Nilsson A, et al: Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. N Engl J Med 1994;331:889-895. Garrett WE, Speer KP, Kirkendall DT (eds): Principles & Practice of Orthopaedic Sports Medicine. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 787-804.

Question 1239

Topic: Knee Sports

A 19-year-old running back lands directly on his anterior knee after being tackled. He has mild anterior knee pain, a trace effusion, a 2+ posterior drawer, a grade 1+ stable Lachman, no valgus laxity, and negative dial tests at 30 degrees and 90 degrees. What is the best treatment strategy at this time? Review Topic

. Physical therapy with a focus on quadriceps strengthening
. Physical therapy and delayed posterior cruciate ligament (PCL) reconstruction
. PCL reconstruction
. PCL and posterolateral corner reconstruction

Correct Answer & Explanation

. Physical therapy with a focus on quadriceps strengthening

Explanation

This patient has likely sustained an isolated PCL injury. The examination is consistent with a grade II injury to the PCL. In this scenario, the best initial option is nonsurgical treatment and return to play as symptoms subside and strength improves. Physical therapy with a focus on quadriceps strengthening and delayed PCL reconstruction is not the answer because this patient can likely be treated without surgery. The absence of valgus laxity and negative dial testing findings suggest that an injury to the posteromedial and posterolateral corners has not occurred. Initial nonsurgical treatment is indicated for this patient. If he completes rehabilitation and experiences persistent disability with anterior and/or medial knee discomfort or senses the knee is "loose," PCL reconstruction should be considered at that time.

Question 1240

Topic: Knee Sports
The blood supply to the anterior cruciate ligament is primarily derived from what artery?
. Anterior tibial artery
. Superolateral geniculate
. Middle geniculate
. Inferolateral geniculate
. Inferomedial geniculate

Correct Answer & Explanation

. Middle geniculate

Explanation

Microvascular studies have shown that the majority of the blood supply to the cruciate ligaments comes from the middle geniculate artery, although there is collateral flow through the other geniculates and from bone.

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