OITE & ABOS Orthopedic Review: Knee & Sports MCQs

Question 1

A 24-year-old athlete undergoes ACL reconstruction using an anteromedial portal technique for femoral tunnel drilling. Compared to a transtibial technique, which of the following is true regarding the femoral tunnel position and biomechanics?

Explanation

Drilling the femoral tunnel independently through an anteromedial (AM) portal allows for anatomic placement lower on the lateral wall of the intercondylar notch (closer to the native footprint). This position improves rotational stability compared to traditional transtibial drilling, which often results in a more vertical graft placement that controls sagittal translation but is less effective for rotational control.

Question 2

A 55-year-old female presents with acute onset of medial knee pain and a 'pop' while squatting. MRI reveals a medial meniscus posterior root tear. Biomechanically, what is the consequence to the knee joint in this condition?

Explanation

A posterior root tear of the medial meniscus leads to meniscal extrusion and complete loss of circumferential hoop stresses. Biomechanically, this is equivalent to a total meniscectomy, leading to decreased contact area and significantly increased peak contact pressures in the medial compartment, which can lead to rapid cartilage degeneration and subchondral insufficiency fractures.

Question 3

During a medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability, the surgeon uses fluoroscopy to identify Schöttle's point. Which of the following describes the correct anatomic landmarks for the femoral attachment of the MPFL on a lateral radiograph?

Explanation

Schöttle's point is a validated radiographic landmark for the anatomic femoral attachment of the MPFL. On a strictly true lateral radiograph, it is located 1 mm anterior to a line extending the posterior femoral cortex, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to the level of the posterior point of the Blumensaat line.

Question 4

A 22-year-old female presents with recurrent patellar dislocations. Examination reveals a positive J-sign. Imaging shows a TT-TG distance of 22 mm, normal patellar height, and grade III chondromalacia isolated to the distal/inferior patellar pole. Which of the following is the most appropriate surgical intervention?

Explanation

Anteromedialization of the tibial tubercle (Fulkerson osteotomy) is indicated for patients with patellofemoral instability, an elevated TT-TG distance (>20 mm), and associated distal/inferior or lateral patellar chondral lesions. The anterior translation component offloads the distal and lateral patella, while medialization corrects the tracking vector. Straight medialization does not offload the patellofemoral joint.

Question 5

In a single-bundle posterior cruciate ligament (PCL) reconstruction, the graft is designed to recreate the primary functional bundle of the PCL. Which bundle is being reconstructed, and in what position is it tightest?

Explanation

The PCL consists of two main bundles: the anterolateral (AL) and posteromedial (PM). The AL bundle is the larger, stiffer bundle and is tightest in knee flexion. Single-bundle PCL reconstruction typically aims to reconstruct the AL bundle to control posterior translation at higher flexion angles.

Question 6

A 26-year-old male presents for revision ACL reconstruction after re-rupturing his graft. CT scan demonstrates significant tunnel widening with the femoral tunnel measuring 16 mm and tibial tunnel measuring 15 mm. What is the most appropriate management?

Explanation

In the setting of significant tunnel widening (>14 mm), a two-stage revision is indicated to ensure adequate graft fixation. The first stage involves hardware removal and bone grafting of the expanded tunnels (e.g., using iliac crest bone graft, allograft dowels, or synthetic bone substitutes). Once incorporated (usually 4-6 months later), the second stage involves the definitive revision ACL reconstruction.

Question 7

A 30-year-old male sustains a high-energy knee dislocation (KD-III). The knee is reduced in the ER. Ankle-brachial index (ABI) is measured at 0.85. What is the next most appropriate step in management?

Explanation

In a patient with a knee dislocation, vascular injury (popliteal artery) is a major concern. An ABI < 0.9 is a sensitive indicator of arterial injury and mandates further advanced vascular imaging, such as CT angiography. If there were hard signs of vascular ischemia (e.g., absent pulses after reduction, rapidly expanding hematoma, pulsatile bleeding), immediate surgical exploration would be indicated.

Question 8

A 12-year-old boy presents with vague knee pain. Radiographs reveal a 1.5 cm osteochondritis dissecans (OCD) lesion on the lateral aspect of the medial femoral condyle. His physes are wide open. MRI shows no fluid behind the lesion and the overlying cartilage is intact. What is the best initial management?

Explanation

This patient has a stable OCD lesion (intact cartilage, no fluid behind the lesion on MRI) and open physes (juvenile OCD). The initial management of stable juvenile OCD is non-operative, consisting of activity modification (restricting impact activities) and a period of non-weight-bearing or restricted weight-bearing, which yields a high rate of spontaneous healing. Operative intervention is reserved for patients who fail 3-6 months of conservative management or have unstable lesions.

Question 9

Which of the following structures constitutes the primary static stabilizer against external rotation of the tibia at 30 degrees of knee flexion?

Explanation

The posterolateral corner (PLC) of the knee consists primarily of the LCL, popliteus tendon, and popliteofibular ligament (PFL). The primary static stabilizers to external rotation at 30 degrees of knee flexion are the popliteus complex (specifically the popliteofibular ligament) and the LCL. The PFL plays a crucial role in resisting external tibial rotation.

Question 10

A 45-year-old male with end-stage renal disease on hemodialysis presents with inability to extend his knee after a stumble. Examination reveals a palpable gap superior to the patella. Which of the following histologic findings is most likely present in the torn tendon?

Explanation

Quadriceps tendon ruptures often occur in patients with systemic diseases (e.g., chronic kidney disease, diabetes, hyperparathyroidism) or fluoroquinolone use. The underlying pathophysiology involves chronic tendinopathy characterized by myxoid degeneration, loss of normal collagen architecture, and hypocellularity, rather than an acute inflammatory process.

Question 11

During an ACL reconstruction, a systematic arthroscopic evaluation is performed. A 'ramp lesion' is identified. Which of the following best describes this pathology?

Explanation

A ramp lesion refers to a tear at the peripheral meniscocapsular attachment of the posterior horn of the medial meniscus. It is commonly associated with ACL injuries. These lesions can be easily missed if the posteromedial compartment is not thoroughly visualized (e.g., via a posteromedial portal or trans-notch view).

Question 12

A 42-year-old manual laborer presents with isolated medial compartment knee pain. Standing alignment radiographs demonstrate 8 degrees of varus alignment. He has grade III medial compartment osteoarthritis and normal lateral and patellofemoral compartments. ROM is 5 to 120 degrees. He is a non-smoker. Which of the following is a relative contraindication to performing a medial opening wedge high tibial osteotomy (HTO) in this patient?

Explanation

High tibial osteotomy (HTO) is indicated for active patients with unicompartmental knee osteoarthritis and malalignment. Contraindications include inflammatory arthritis, patellofemoral arthritis, flexion contracture > 15 degrees, knee flexion < 90 degrees, bone loss/osteopenia, and smoking. A flexion contracture of 20 degrees is a relative/absolute contraindication as HTO does not correct sagittal plane contractures well.

Question 13

A 45-year-old female undergoes transtibial pull-out repair for a medial meniscus posterior root tear. Which of the following factors is most critical for restoring the hoop stresses of the meniscus during this procedure?

Explanation

The most critical factor in restoring the biomechanical function (circumferential hoop stresses) of the meniscus after a root tear is the anatomic placement of the root repair. Non-anatomic placement, even by a few millimeters, fails to adequately restore contact pressures and contact area in the joint.

Question 14

A 9-year-old Tanner stage 1 female sustains a complete ACL tear. Her parents opt for surgical reconstruction. Which of the following techniques minimizes the risk of growth arrest?

Explanation

In a skeletally immature patient with significant growth remaining (Tanner stage 1 or 2), a physeal-sparing ACL reconstruction technique is recommended to prevent growth disturbance (leg length discrepancy or angular deformity). The Micheli-Kocher technique utilizes the IT band routed over the top of the lateral femoral condyle and under the intermeniscal ligament, completely avoiding drilling through the open physes.

Question 15

A 38-year-old male presents with chronic knee swelling, catching, and mild pain. Radiographs reveal multiple loose bodies of uniform size scattered throughout the knee joint. MRI shows joint effusion and multiple calcified nodules. Which of the following is the underlying pathophysiology of this condition?

Explanation

Primary synovial chondromatosis is a benign neoplastic/metaplastic condition in which the synovial membrane undergoes metaplasia to form cartilaginous nodules. These nodules can detach, become loose bodies, and subsequently calcify or ossify. They are typically uniform in size, unlike secondary synovial chondromatosis (due to osteoarthritis or trauma), where loose bodies are usually fewer and of varying sizes.

Question 16

During the terminal 30 degrees of knee extension, the tibia externally rotates relative to the femur. Which of the following anatomic features is primarily responsible for this 'screw home' mechanism?

Explanation

The 'screw home' mechanism refers to the obligatory external rotation of the tibia during terminal knee extension. This is primarily driven by the asymmetry of the femoral condyles; the articular surface of the medial femoral condyle is longer and curves further anteriorly than that of the lateral condyle. As the lateral side stops gliding during extension, the medial side continues, resulting in external rotation of the tibia.

Question 17

A patient presents with knee pain and instability after a hyperextension injury. The Dial test demonstrates 20 degrees of increased external rotation on the injured side compared to the normal side at 30 degrees of flexion, but equal external rotation at 90 degrees of flexion. What is the most likely injury?

Explanation

The Dial test evaluates external rotation of the tibia at 30° and 90° of flexion. Increased external rotation (>10° compared to the contralateral side) only at 30° indicates an isolated posterolateral corner (PLC) injury. If increased external rotation is present at both 30° and 90°, it suggests a combined PCL and PLC injury.

Question 18

A 28-year-old female runner presents with anterior knee pain, exacerbated by descending stairs. She is diagnosed with patellofemoral pain syndrome. Which of the following anatomical factors is most likely to increase the lateral force vector on the patella?

Explanation

Increased femoral anteversion leads to internal rotation of the femur relative to the tibia. This, often combined with external tibial torsion and valgus knee alignment (the 'miserable malalignment syndrome'), increases the Q-angle. An increased Q-angle directly increases the lateral force vector on the patella, predisposing the patient to lateral patellar tracking and patellofemoral pain.

Question 19

A 32-year-old female presents with recurrent, spontaneous hemarthrosis of the knee without a history of trauma. MRI of the knee shows a joint effusion and nodular synovial proliferation that demonstrates blooming artifact on gradient-echo (GRE) sequences. What is the most likely diagnosis?

Explanation

Pigmented villonodular synovitis (PVNS), also known as tenosynovial giant cell tumor, is a benign but locally aggressive synovial proliferative disorder. It presents with recurrent monoarticular hemarthrosis. The classic MRI finding is low signal intensity on T1 and T2 weighted images with a prominent 'blooming artifact' on gradient-echo (GRE) sequences due to the paramagnetic effects of hemosiderin deposition.

Question 20

A 24-year-old healthy male collegiate sprinter complains of cramping calf pain and numbness in his foot that occurs only after sprinting 200 meters. Symptoms resolve with 10 minutes of rest. Resting ankle-brachial index (ABI) is 1.0. However, ABI drops to 0.6 with active plantar flexion of the ankle against resistance. What is the most likely anatomic etiology of his symptoms?

Explanation

Popliteal artery entrapment syndrome occurs most commonly in young athletes. It is caused by an anomalous relationship between the popliteal artery and the medial head of the gastrocnemius muscle (the artery typically deviates medially around or through an anomalous medial head). Symptoms are induced by active plantar flexion, which compresses the artery, leading to claudication-like symptoms and a drop in ABI.

Question 21

A 50-year-old female presents with acute medial knee pain after a deep flexion event. MRI demonstrates a medial meniscus posterior root tear. What is the biomechanical consequence of this injury if left untreated?

Explanation

A posterior root tear of the medial meniscus disrupts the circumferential hoop stresses of the meniscus, leading to extrusion and loss of load distribution. Biomechanical studies have shown that a posterior root tear is equivalent to a total meniscectomy in terms of peak contact pressure and contact area, ultimately predisposing the patient to rapid compartment degeneration.

Question 22

A 22-year-old female is undergoing an isolated medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability. To ensure proper graft anisometry, the femoral tunnel must be placed accurately. Based on Schöttle's radiographic point on a strict lateral radiograph, where is the anatomic femoral origin of the MPFL?

Explanation

Schöttle's point, which identifies the anatomic femoral origin of the MPFL on a true lateral radiograph, is located 1 mm anterior to the posterior femoral cortical line, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to the level of the posterior aspect of the Blumensaat line. Proper placement prevents the graft from being too tight in flexion.

Question 23

In posterior cruciate ligament (PCL) reconstruction, the 'killer turn' refers to the acute angle the graft makes at the posterior aspect of the tibia. What is the primary theoretical advantage of the tibial inlay technique over the transtibial technique?

Explanation

The tibial inlay technique was developed specifically to avoid the 'killer turn' associated with the transtibial tunnel technique, which can cause graft abrasion, attenuation, and ultimate failure. However, clinical outcome studies have generally demonstrated similar results between the two techniques.

Question 24

During an anatomical reconstruction of the posterolateral corner (PLC) of the knee, a surgeon intends to reconstruct the three major static stabilizing structures. Which of the following combinations represents these structures?

Explanation

The three main static stabilizers of the posterolateral corner of the knee are the lateral collateral ligament (LCL), the popliteus tendon (PLT), and the popliteofibular ligament (PFL). Anatomical reconstruction (e.g., LaPrade technique) typically involves reconstructing these three specific structures to restore varus and external rotation stability.

Question 25

A 30-year-old male sustains a knee dislocation (KD-III) with injuries to the ACL, PCL, and MCL. Vascular workup shows an ABI of 1.0. What is the recommended surgical timing for ligamentous reconstruction to balance the risk of arthrofibrosis and optimal tissue healing?

Explanation

For multiligament knee injuries without vascular compromise, early reconstruction (typically 1 to 3 weeks post-injury) is generally recommended. This allows initial capsular healing and decreases fluid extravasation risk during arthroscopy while facilitating earlier rehabilitation to prevent arthrofibrosis compared to acute or significantly delayed surgery.

Question 26

A 25-year-old professional soccer player sustains a severe valgus injury to the right knee. MRI demonstrates a complete tear of the superficial medial collateral ligament (sMCL). The distal aspect of the torn sMCL is flipped superficial to the pes anserinus. This specific finding is associated with:

Explanation

A Stener-like lesion of the knee occurs when the distal aspect of a torn superficial MCL is displaced superficial to the pes anserinus expansion. Because the pes anserinus blocks the torn ends from approximating, this lesion often fails nonoperative management and requires surgical repair or reconstruction.

Question 27

When comparing bone-patellar tendon-bone (BTB) autograft to quadriceps tendon autograft for anterior cruciate ligament (ACL) reconstruction, quadriceps tendon autografts have been shown to have:

Explanation

Quadriceps tendon autografts have a greater cross-sectional area and higher collagen density compared to patellar tendon autografts. They have lower rates of anterior knee pain and donor site morbidity compared to BTB autografts, while providing similar ultimate tensile load and clinical outcomes.

Question 28

Which of the following criteria is most commonly utilized to permit a patient to return to unrestricted cutting and pivoting sports after an ACL reconstruction?

Explanation

Return to play (RTP) criteria typically involve achieving a Limb Symmetry Index (LSI) of >90% on functional hop testing, and isokinetic quadriceps and hamstring strength within 10% of the uninjured contralateral limb (i.e., >90% symmetry). This helps reduce the risk of secondary ACL injury.

Question 29

A 12-year-old male with open physes presents with knee pain. MRI reveals an intact, stable osteochondritis dissecans (OCD) lesion on the lateral aspect of the medial femoral condyle. He has failed 6 months of nonoperative management (restricted weight-bearing and activity modification). What is the next best step in management?

Explanation

In a skeletally immature patient with a stable OCD lesion who has failed an adequate trial of nonoperative management (typically 3-6 months), subchondral drilling (retroarticular or transarticular) is indicated to promote revascularization and healing. Fixation is reserved for unstable lesions.

Question 30

Quadriceps tendon ruptures often occur in a known hypovascular zone. Where is this critical hypovascular zone of the quadriceps tendon located?

Explanation

The quadriceps tendon has a hypovascular zone located approximately 1 to 2 cm superior to its insertion on the superior pole of the patella. This 'watershed' area is structurally weaker and is the most common site for spontaneous quadriceps tendon ruptures in older adults or those with systemic risk factors.

Question 31

A 10-year-old boy presents to the emergency department after falling directly onto a flexed knee. Radiographs reveal a high-riding patella and a small bony avulsion at the inferior pole of the patella. What is the most appropriate management for this injury?

Explanation

The presentation is classic for a patellar sleeve fracture, a pediatric injury where a large cartilaginous cap is avulsed from the patella along with a small piece of bone. Because the cartilaginous fragment is large, there is a significant disruption of the articular surface and extensor mechanism. These fractures require open reduction and internal fixation.

Question 32

A 7-year-old girl presents with snapping and lateral joint line pain in her right knee. MRI demonstrates a Wrisberg variant discoid lateral meniscus. According to the Watanabe classification, what anatomical feature defines this specific variant?

Explanation

The Watanabe classification describes three types of discoid meniscus: Complete (Type I), Incomplete (Type II), and Wrisberg variant (Type III). The Wrisberg variant lacks the normal posterior meniscotibial (coronary) attachments; its only posterior tether is the meniscofemoral ligament of Wrisberg, leading to hypermobility and the classic 'snapping knee' presentation.

Question 33

A 14-year-old male jumping athlete presents with acute knee pain and inability to extend the knee against gravity. Radiographs reveal a fracture extending from the tibial tubercle proximally across the epiphyseal plate and into the articular surface. According to the Ogden classification of tibial tubercle fractures, which type is this?

Explanation

According to the Ogden classification: Type I is a fracture of the secondary ossification center. Type II extends to the junction of the primary and secondary ossification centers. Type III extends through the primary ossification center (physis) into the knee joint (intra-articular). Type IV is an avulsion of the entire proximal tibial epiphysis.

Question 34

A 19-year-old female soccer player undergoes revision ACL reconstruction. The surgeon decides to perform a lateral extra-articular tenodesis (LET) using a modified Lemaire technique. Where is the graft typically routed in relation to the lateral collateral ligament (LCL) to provide optimal rotational stability?

Explanation

In a modified Lemaire lateral extra-articular tenodesis (LET), a strip of the iliotibial band is harvested, left attached at Gerdy's tubercle, routed deep to the lateral collateral ligament (LCL), and fixed to the anterolateral distal femur. This biomechanically mimics the native anterolateral complex and provides a strong check against internal tibial rotation.

Question 35

A 28-year-old marathon runner presents with lateral knee pain that worsens after 3 miles of running. Examination reveals tenderness over the lateral femoral epicondyle, particularly when the knee is flexed to 30 degrees. The underlying pathophysiology of this condition involves friction of the iliotibial band over the lateral epicondyle during which phase of the gait cycle?

Explanation

Iliotibial (IT) band friction syndrome occurs as the IT band passes back and forth over the lateral femoral epicondyle. Maximum friction typically occurs at approximately 30 degrees of knee flexion. During running, the knee is at roughly 30 degrees of flexion at foot strike (early stance phase), which is when the impingement and pain are most pronounced.

Question 36

A 20-year-old male is tackled during a football game with his knee flexed and foot internally rotated. He presents with prominent lateral knee deformity and inability to bear weight. Radiographs confirm an anterolateral dislocation of the proximal tibiofibular joint. Which nerve is most commonly at risk in this type of injury or during its surgical management?

Explanation

Proximal tibiofibular joint dislocations are most commonly anterolateral. The common peroneal nerve wraps around the fibular neck and is intimately associated with the joint. It is at high risk of stretch injury from the initial trauma (though more commonly in posteromedial dislocations) and is at significant risk iatrogenically during surgical reduction or reconstruction.

Question 37

A 45-year-old female presents with symptomatic, isolated lateral compartment knee osteoarthritis. Standing alignment radiographs demonstrate 8 degrees of valgus mechanical axis deviation. The deformity is localized to the distal femur. Which of the following is the most appropriate surgical intervention to unload the lateral compartment?

Explanation

For a valgus knee deformity driving lateral compartment osteoarthritis, a distal femoral osteotomy (DFO) is indicated because the deformity typically arises from the femur. A medial closing-wedge DFO reliably corrects the mechanical axis towards the medial compartment, unloading the lateral joint.

Question 38

A 24-year-old male sustains an anterior knee dislocation that is reduced in the field. Upon arrival at the trauma bay, the knee is swollen but stable. Distal pulses are palpable but slightly asymmetric. The Ankle-Brachial Index (ABI) is calculated to be 0.85. What is the most appropriate next step in management?

Explanation

An ABI < 0.9 in the setting of a knee dislocation is highly suspicious for a significant popliteal artery injury. The appropriate next step in a patient with asymmetric pulses or an ABI < 0.9 is to obtain an advanced imaging study, typically CT angiography, to definitively evaluate for an intimal flap, occlusion, or other vascular injury before progressing to surgery.

Question 39

A 28-year-old active male presents with a symptomatic 4 cm^2 focal full-thickness chondral defect on the weight-bearing surface of the medial femoral condyle with minimal subchondral bone involvement. He previously underwent a microfracture procedure 2 years ago that failed. Which of the following cartilage restoration procedures is most appropriate?

Explanation

For larger chondral defects (typically > 2 to 3 cm^2) that have failed primary bone marrow stimulation techniques like microfracture, MACI is highly indicated, provided the subchondral bone is largely intact. OATS is generally reserved for smaller defects due to donor site morbidity.

Question 40

A 50-year-old man presents with posterior knee swelling and aching pain. MRI demonstrates a large popliteal (Baker's) cyst. Which two anatomical structures form the interval through which the synovial fluid typically herniates to form this cyst?

Explanation

A Baker's cyst is a fluid-filled distension of the gastrocnemio-semimembranosus bursa. It communicates with the knee joint through a one-way valve effect in the posterior joint capsule located between the medial head of the gastrocnemius and the semimembranosus tendon.

Question 41

A 22-year-old soccer player sustains an internal rotation injury to the knee resulting in an ACL tear. Radiographs show an avulsion fracture of the anterolateral proximal tibia (Segond fracture). Which of the following structures is most likely attached to this avulsed bony fragment?

Explanation

The Segond fracture is a pathognomonic avulsion fracture of the proximal anterolateral tibia strongly associated with ACL tears. It represents the bony avulsion of the anterolateral ligament (ALL) and associated capsular structures.

Question 42

A 30-year-old male is evaluated for knee instability. On physical examination, the dial test shows 15 degrees of increased external rotation at 30 degrees of flexion compared to the contralateral side, but symmetric rotation at 90 degrees of flexion. Which structure(s) is/are most likely injured?

Explanation

An isolated injury to the posterolateral corner (PLC) presents with increased external rotation at 30 degrees of flexion but not at 90 degrees. If both the PLC and PCL are injured, there is increased external rotation at both 30 and 90 degrees.

Question 43

During reconstruction of the posterior cruciate ligament (PCL), the surgeon aims to recreate its primary biomechanical bundles. Which of the following best describes the tensioning pattern of the normal PCL bundles during knee range of motion?

Explanation

The PCL consists of two main bundles: the larger anterolateral (AL) bundle and the smaller posteromedial (PM) bundle. Biomechanically, the AL bundle is tight in flexion, while the PM bundle is tight in extension.

Question 44

A 26-year-old patient presents to the emergency department after a high-energy dashboard injury resulting in a knee dislocation. The knee is currently reduced. Distal pulses are palpable but slightly asymmetric, and the ankle-brachial index (ABI) is 0.85. What is the most appropriate next step in management?

Explanation

An ABI of less than 0.9 in the setting of a knee dislocation is highly suspicious for a vascular injury, even if pulses remain palpable. CT angiography (or conventional arteriography) is the gold standard next step to evaluate for a popliteal artery intimal tear or occlusion.

Question 45

A 45-year-old active male with medial compartment osteoarthritis and varus alignment undergoes a medial opening wedge high tibial osteotomy (HTO). If the osteotomy gap is opened disproportionately more anteriorly than posteriorly, what biomechanical effect will this have on the knee?

Explanation

Opening a medial HTO gap more anteriorly than posteriorly increases the posterior tibial slope. An increased posterior tibial slope translates the tibia anteriorly, which correspondingly increases the resting strain on the anterior cruciate ligament (ACL).

Question 46

A 22-year-old female presents with an isolated 4.5 cm2 full-thickness chondral defect on the weight-bearing surface of her medial femoral condyle. She has failed conservative management. Which of the following is the most appropriate surgical intervention for this lesion?

Explanation

For large full-thickness chondral defects (>2-4 cm2) in young active patients, cell-based therapies like MACI or osteochondral allografts are indicated. Microfracture and OATS (autograft) are generally reserved for smaller defects (<2 cm2).

Question 47

A 7-year-old boy presents with a painless clunking sensation in his lateral knee during extension. MRI confirms a complete Wrisberg variant discoid lateral meniscus. What anatomical feature defines the Wrisberg variant of a discoid meniscus?

Explanation

The Wrisberg variant of a discoid lateral meniscus lacks the normal posterior meniscotibial (coronary) attachments. Its only posterior attachment is the meniscofemoral ligament of Wrisberg, leading to hypermobility and a snapping sensation during extension.

Question 48

The predominant vascular supply to the anterior cruciate ligament (ACL) is derived from which of the following arteries?

Explanation

The middle geniculate artery pierces the posterior capsule to supply the synovial sheath of the ACL and PCL. The intrinsic blood supply of the cruciate ligaments is predominantly from this vessel, with minor distal contributions from the inferior genicular arteries.

Question 49

A 28-year-old male sustains a multiligament knee injury. Physical examination reveals a +3 posterior drawer test and a positive dial test at both 30 and 90 degrees of flexion. Which combination of injured structures is most likely responsible for these findings?

Explanation

An isolated PLC injury results in increased external rotation asymmetry (>10 degrees) only at 30 degrees of knee flexion. A combined PCL and PLC injury results in increased external rotation at both 30 and 90 degrees, along with a positive posterior drawer.

Question 50

A 30-year-old male presents with a grossly deformed knee after a motorcycle crash. After successful closed reduction of the knee dislocation, palpable distal pulses are present but weak. The Ankle-Brachial Index (ABI) is calculated to be 0.85. What is the most appropriate next step in management?

Explanation

An ABI < 0.90 in the setting of a knee dislocation is highly sensitive for vascular injury and warrants advanced imaging such as CT angiography. Patients with absent pulses or hard signs of ischemia (e.g., expanding hematoma) should proceed directly to surgical exploration.

Question 51

A 22-year-old soccer player undergoes arthroscopic repair of a bucket-handle medial meniscus tear. Which of the following factors most significantly increases the biological healing rate of the meniscal repair?

Explanation

Concomitant ACL reconstruction enhances meniscal healing due to the release of pluripotent marrow cells and growth factors from tunnel drilling into the joint. Studies consistently show higher healing rates for meniscal repairs performed with concurrent ACL reconstruction compared to isolated repairs.

Question 52

A 12-year-old male presents with chronic anterior knee pain. Radiographs and an MRI

demonstrate a stable osteochondritis dissecans (OCD) lesion. What is the most common anatomical location for an OCD lesion of the knee?

Explanation

The lateral aspect of the medial femoral condyle is the classic and most common site for OCD lesions of the knee, accounting for roughly 70% of cases. Nonoperative management is the first-line treatment for stable lesions in patients with open physes.

Question 53

In comparing a 10-mm bone-patellar tendon-bone (BPTB) autograft to the native anterior cruciate ligament (ACL), which of the following biomechanical statements is most accurate regarding the graft's initial properties at the time of implantation?

Explanation

A 10-mm BPTB graft has an initial ultimate load (~2977 N) and stiffness (~620 N/mm) that exceed those of the native ACL (ultimate load ~2160 N, stiffness ~242 N/mm). Over time, the graft undergoes ligamentization and its mechanical properties decrease.

Question 54

A 6-year-old girl presents with a painless clicking and "snapping" sensation in her lateral knee with extension. MRI confirms a discoid lateral meniscus. The Wrisberg variant of a discoid meniscus causes this hypermobility due to the absence of which of the following normal anatomical structures?

Explanation

The Wrisberg variant of a discoid lateral meniscus is uniquely characterized by the lack of normal posterior meniscotibial (coronary) attachments. It is solely anchored posteriorly by the meniscofemoral ligament of Wrisberg, leading to meniscal subluxation and a snapping knee.

Question 55

When utilizing interference screws for soft-tissue ACL graft fixation in the tibial tunnel, which of the following screw configurations provides the optimal pullout strength and minimizes graft slippage?

Explanation

For soft tissue ACL grafts, an interference screw diameter that matches the tunnel diameter (line-to-line fit) provides optimal pullout strength. Screw divergence greater than 15 degrees relative to the tunnel significantly decreases fixation strength.

Question 56

During medial patellofemoral ligament (MPFL) reconstruction, identifying the correct femoral footprint is critical to ensure proper graft isometry. According to Schöttle's point on a true lateral radiograph, where should the femoral attachment be positioned?

Explanation

Schöttle's point for the MPFL femoral origin is radiographically defined as 1 mm anterior to the posterior femoral cortical line, 2.5 mm distal to the posterior border of the medial femoral condyle articular surface, and proximal to the posterior extension of Blumensaat's line. Positioning the graft too proximal results in pathologic tightness during knee flexion.

Question 57

A 28-year-old male sustains a varus-hyperextension injury to his knee. Examination reveals a positive dial test at 30 degrees of knee flexion, but symmetric external rotation at 90 degrees compared to the contralateral knee. Which of the following structures is most likely injured?

Explanation

A positive dial test (increased external rotation >10 degrees) at 30 degrees of flexion with a normal test at 90 degrees isolates an injury to the posterolateral corner (PLC). Combined PLC and PCL injuries show increased external rotation at both 30 and 90 degrees.

Question 58

A 22-year-old collegiate soccer player presents with a symptomatic 3.5 cm^2 full-thickness osteochondral defect on the weight-bearing surface of the medial femoral condyle. He has failed nonoperative management. Which of the following is the most appropriate surgical intervention?

Explanation

MACI or osteochondral allograft transplantation are indicated for large (>2-3 cm^2) symptomatic full-thickness cartilage defects. Microfracture and OATS (autograft) are typically reserved for smaller lesions (<2 cm^2) due to donor site morbidity.

Question 59

An 11-year-old female soccer player (Tanner stage 2) sustains a midsubstance ACL rupture. She has wide open physes. The surgeon plans an epiphyseal-sparing ACL reconstruction. Which of the following grafts and techniques avoids the femoral and tibial physes entirely?

Explanation

The modified MacIntosh (iliotibial band over-the-top) procedure is a purely extra-articular, physeal-sparing technique used in prepubescent patients to avoid growth arrest. Transphyseal drilling risks physeal injury, and bone blocks are contraindicated across open physes.

Question 60

A 24-year-old male undergoes arthroscopy for an acute ACL rupture. The surgeon evaluates the posterior horn of the medial meniscus through the intercondylar notch and identifies a ramp lesion. Biomechanically, untreated ramp lesions in the setting of ACL reconstruction primarily increase which of the following?

Explanation

Untreated meniscal ramp lesions significantly increase anterior tibial translation and external rotation forces on an ACL graft. Repair of the ramp lesion restores native knee kinematics and protects the ACL reconstruction.

Question 61

A 45-year-old active male has symptomatic isolated medial compartment osteoarthritis with a varus mechanical axis. A medial opening wedge high tibial osteotomy (HTO) is planned. To maintain native sagittal plane kinematics, where should the osteotomy gap be larger?

Explanation

In a medial opening wedge HTO, the posterior gap should be approximately twice the anterior gap to maintain the native posterior tibial slope. Equal or larger anterior opening inappropriately increases posterior tibial slope, which can alter knee kinematics and load the ACL.

Question 62

A 30-year-old male sustains a posterior dashboard injury to his knee. Physical examination reveals a 12-mm posterior step-off of the tibia relative to the femoral condyles at 90 degrees of flexion. The dial test shows 20 degrees of increased external rotation at both 30 and 90 degrees of knee flexion compared to the contralateral side. Which structures are injured?

Explanation

Increased external rotation at both 30 and 90 degrees of flexion on the dial test indicates a combined injury to the posterior cruciate ligament (PCL) and posterolateral corner (PLC). An isolated PLC injury increases ER at 30 degrees only.

Question 63

A 19-year-old female hears a "pop" while pivoting during basketball. Based on the classic MRI findings of a noncontact ACL rupture, what associated bone bruise pattern is most commonly seen?

Explanation

Noncontact ACL injuries (pivot-shift mechanism) characteristically produce bone bruises involving the lateral femoral condyle (terminal sulcus) and the posterolateral tibial plateau due to anterior subluxation and impaction.

Question 64

A 25-year-old football player is diagnosed with a grade 3 medial collateral ligament (MCL) tear. MRI reveals the tear is located at the distal (tibial) insertion with the ligament flipped superficial to the pes anserinus. What is the most appropriate management?

Explanation

A Stener-like lesion of the MCL occurs when the distal MCL avulses and flips superficial to the pes anserinus, preventing anatomic reduction and healing. This specific distal tear pattern is an indication for acute surgical repair.

Question 65

A 21-year-old female presents with recurrent lateral patellar instability. MRI demonstrates a normal trochlear groove, but her tibial tubercle-trochlear groove (TT-TG) distance is measured at 24 mm. Which of the following surgical interventions is most appropriate?

Explanation

A TT-TG distance >20 mm is considered pathologic and predisposes to patellar instability. A tibial tubercle osteotomy (medialization) is indicated to correct this anatomic abnormality, typically combined with MPFL reconstruction.

Question 66

A 50-year-old male presents with acute posterior knee pain after deep flexion. MRI demonstrates an extrusion of the medial meniscus >3mm and a defect at the posterior horn attachment. Which of the following best describes the biomechanical consequence of this injury?

Explanation

Medial meniscus posterior root tears cause a complete loss of hoop stresses, leading to meniscal extrusion. This results in decreased contact area and increased peak contact pressures biomechanically equivalent to a total meniscectomy.

Question 67

A 32-year-old male sustains a high-velocity knee dislocation (KD-IV). After closed reduction, his ankle-brachial index (ABI) is measured at 0.85. The limb is warm and well-perfused. What is the next best step in management?

Explanation

An ABI < 0.9 in the setting of a knee dislocation is highly suspicious for a vascular injury. CT angiography is indicated to definitively evaluate the popliteal artery and guide further vascular intervention.

Question 68

The anterolateral ligament (ALL) of the knee is increasingly recognized for its role in controlling rotational laxity. Where is the precise femoral origin of the ALL relative to the fibular collateral ligament (FCL)?

Explanation

The femoral origin of the anterolateral ligament (ALL) is located proximal and posterior to the origin of the fibular collateral ligament (FCL) on the lateral femoral epicondyle.

Question 69

A 14-year-old male presents with knee pain. Radiographs reveal a 1.5 cm osteochondritis dissecans (OCD) lesion of the lateral aspect of the medial femoral condyle. His physes are open. MRI shows no fluid behind the lesion. He has failed 6 months of non-weight bearing management. What is the next best step?

Explanation

For a stable, unfragmented OCD lesion in a patient with open physes who has failed 3-6 months of nonoperative treatment, in situ drilling (transarticular or retroarticular) is indicated to promote revascularization and healing. Fixation is for unstable lesions.

Question 70

A 25-year-old active male presents with claudication-like calf pain during running. Pulses are normal at rest but diminish with active plantar flexion of the ankle against resistance. What is the most common anatomic anomaly responsible for this condition?

Explanation

Popliteal artery entrapment syndrome is most commonly caused by an anomalous path of the popliteal artery, typically passing medial to (or behind) the medial head of the gastrocnemius, leading to compression during active plantar flexion.

Orthopedic Surgery Board Review MCQs: Arthroplasty, Trauma & Spine Part 255

OITE & ABOS Orthopedic Review: Knee & Sports Medicine MCQs | Part 194

Key Takeaway

OITE & ABOS Orthopedic Review: Knee & Sports Medicine MCQs | Part 194

Chapter Index