Full Question & Answer Text (for Search Engines)
Question 1:
Studies have shown that anterior cruciate ligament (AC L) deficiency may result in abnormal meniscal strain found particularly in what region:
Options:
- Anterior horn of the lateral meniscus
- Anterior horn of the medial meniscus
- Patellofemoral joint
- Posterior horn of the lateral meniscus
- Posterior horn of the medial meniscus
Correct Answer: Posterior horn of the lateral meniscus
Explanation:
While acute anterior cruciate ligament (AC L) injury alters the strain patterns in the lateral meniscus, chronic AC L insufficiency increases the strain in the medial meniscus and often results in tears of the posterior horn. In a study of 176 consecutive patients undergoing AC L reconstruction, there was an increasing incidence of meniscal tears as the AC L injury became more chronic with a significant increase in all medial meniscal tears and a relatively constant incidence of lateral meniscal tears.
Question 2:
When comparing women to men, the NC AA Injury Surveillance System has demonstrated a higher rate of injury to what structure:
Options:
- Patellar tendon
- Anterior cruciate ligament (AC L)
- Posterior cruciate ligament (PC L)
- Posterolateral ligament complex
- Medial collateral ligament
Correct Answer: Anterior cruciate ligament (AC L)
Explanation:
Anterior cruciate ligament injury has been observed to be 2 to 3 times more common in female basketball players than in their male counterparts. The higher risk of AC L injury in women may be related to laxity, larger Q angles, excessive pronation, increased hamstring flexibility, decreased notch width index, posture (less knee and hip flexion), and possible hormone influences.
Question 3:
After landing awkwardly on his flexed knee, a 22-year-old basketball player has immediate onset of pain and difficulty bearing weight. With the knee flexed 30°, examination reveals increased varus, external rotation, and posterior translation which decreases when the knee is flexed to 90°. The patient most likely has injured what structure(s):
Options:
- Posterolateral complex
- Posterolateral complex and posterior cruciate ligament
- Posterior cruciate ligament
- Lateral collateral ligament
- Posterior cruciate ligament and medial collateral ligament
Correct Answer: Posterolateral complex
Explanation:
With an isolated injury to the posterior cruciate ligament (PC L), posterior translation increases at greater degrees of flexion demonstrating the greatest posterior translation at 90°. Injury to the lateral collateral ligament leads to varus laxity in 30° flexion without posterior translation. With an injury to the PC L and posterolateral complex, varus, external rotation, and posterior translation are detectable at 30° and increase as the knee is flexed to 90°. Isolated tears of the posterolateral complex lead to increased varus, external rotation, and posterior translation at 30° that decreases as the knee is flexed to 90° and the PC L tightens.
Question 4:
When interference screws are used for femoral fixation during an endoscopic anterior cruciate ligament (AC L) reconstruction using autograft patellar tendon, how much divergence between the screw and bone plug is acceptable before pull-out strength is compromised to a clinically significant level:
Options:
Correct Answer: 0º
Explanation:
Recent studies have indicated that nearly 40% of endoscopic anterior cruciate ligament reconstructions demonstrate screw-bone plug divergence. Divergence angles of less than 30° do not significantly alter pull-out strength clinically.
Question 5:
All of the following structures have attachment to the medial femoral condyle except the:
Options:
- Adductor magnus
- Medial head of the gastrocnemius
- Superficial medial collateral ligament
- Patellofemoral ligament
- Popliteus
Correct Answer: Popliteus
Explanation:
The popliteus attaches to the posterior aspect of the lateral femoral condyle. All of the other mentioned structures attach to the medial femoral condyle: the adductor magnus superiorly, the superficial medial collateral ligament and the gastrocnemius inferiorly, and the medial patellofemoral ligament anteriorly deep to the vastus medialis.
Question 6:
In anterior cruciate ligament (AC L) rehabilitation, closed-chain kinetic exercises are associated with all of the following except:
Options:
- Allow for co-contraction of the musculature around the knee
- Stabilize the foot
- Allow hip muscular activity for stability
- Apply physiologic compressive loads to the knee
- Improve aerobic power and endurance in the leg
Correct Answer: Improve aerobic power and endurance in the leg
Explanation:
Closed-chain exercises for the lower extremity have been shown to be effective following anterior cruciate ligament reconstruction for several reasons. They allow co-contraction of the muscles crossing the knee, stabilize the foot against resistance, apply compressive loads to the knee, and allow for hip motion for stability. Such exercises have not been shown to have any effect on the aerobic capacity of the leg.
Question 7:
A 24-year-old cross-country runner complains of anterior knee pain after running. Palpation reveals point tenderness at the inferior pole of the patella. Range of motion is full and exam demonstrates no patellofemoral crepitus. Management should include:
Options:
- C ortisone injection into the site of tenderness
- Use of a knee immobilizer for 6 weeks
- Nonsteroidal anti-inflammatory medication and quadriceps stretching exercises
- Arthroscopic lateral release
- Open patellar tendon debridement
Correct Answer: Nonsteroidal anti-inflammatory medication and quadriceps stretching exercises
Explanation:
This scenario is consistent with infrapatellar tendinitis (jumpers knee), which is common in runners and jumpers. The mechanism often involves chronic overloads of the tendon. Anti-inflammatory medication may alleviate symptoms while quadriceps stretching decreases the load on the tendon by increasing the resting length of the muscle-tendon unit. Open patellar tendon debridement should be reserved for cases of chronic tendonitis that are refractory to conservative management.
Question 8:
To be considered for repair, a meniscal tear must fulfill all of the following criteria except:
Options:
- The tear should be longer than 10 mm.
- The tear must be contained entirely within the vascular zone.
- The torn segment must be minimally damaged.
- A peripheral rim of meniscal tissue must exist.
- The tear should not be degenerative.
Correct Answer: The tear should be longer than 10 mm.
Explanation:
Meniscal repair is now recognized as an effective treatment method for certain types of meniscal tears. To be considered for repair, a meniscal tear must be long enough to cause instability of the torn portion (usually longer than 10 mm). The tear should also be within the vascular zone of the mensicus where healing is most likely to occur. There must also be minimal damage to the torn segment. In general, meniscal tears in older patients tend to be degenerative in nature, precluding a successful repair. Although the peripheral tissue must be minimally damaged for a successful repair, the presence of meniscal tissue peripherally is not necessary prior to considering repair.
Question 9:
In which of the following anatomic locations have authors described a characteristic MRI edema pattern lesion that occurs with an acute anterior cruciate ligament (AC L) injury:
Options:
- Posterolateral aspect of the tibia and the middle aspect of the lateral femoral condyle
- Posterolateral aspect of the tibia and the posteriar aspect of the lateral femoral condyle
- Lateral patellar facet and lateral trochlear groove
- Anterolateral aspect of the tibia and the posterolateral aspect of the lateral femoral condyle
- Posteromedial aspect of the tibia and the anteromedial aspect of the lateral femoral condyle
Correct Answer: Posterolateral aspect of the tibia and the middle aspect of the lateral femoral condyle
Explanation:
During anterior cruciate ligament (AC L) injury, anterior translation of the tibia and the associated valgus force create a compressive load on the articular cartilage in the posterolateral aspect of the tibia and the anterolateral aspect of the lateral femoral condyle. It has been estimated that approximately 80% of acute AC L injuries demonstrate this pattern on magnetic resonance imaging.
Question 10:
Six days following anterior cruciate ligament (AC L) reconstruction, a patient returns for follow-up with a fever of 102° F, local incisional drainage, painful decreased knee motion, effusion, erythema, and warmth in the knee. Aspiration of the knee reveals cloudy, blood-tinged synovial fluid. A white blood cell count of the aspirate was 60,000 with 85% polymorphonuclear cells. Appropriate management at this time should include:
Options:
- Admission to the hospital and administration of IV antibiotics.
- Starting the patient on oral antibiotics followed by careful outpatient observation over the next several days.
- Immediate arthroscopic lavage with incision and drainage of all associated wounds.
- Immediate arthroscopic lavage with incision and drainage of all associated wounds, partial synovectomy, and graft debridement.
- Immediate arthroscopic lavage with incision and drainage of all associated wounds, partial synovectomy, and debridement with graft retention.
Correct Answer: Immediate arthroscopic lavage with incision and drainage of all associated wounds.
Explanation:
Although reported infection rates following anterior cruciate ligament (AC L) reconstruction are as low as 0.3%, the treatment of septic arthritis in the early postoperative period can be challenging. In a patient with a suspected infection, immediate arthroscopic lavage with debridement of necrotic tissue and partial synovectomy is paramount. In a recent review of 831 arthroscopically guided AC L reconstructions, McAllister and associates reported complete resolution of all four infected cases with early lavage, debridement, and graft retention followed by IV, then oral antibiotics. However, the clinical outcome of these patients was inferior to that of patients who had undergone uncomplicated AC L reconstruction due to the damage of the articular cartilage as a result of the infection.
Question 11:
In a congruent patellofemoral joint, the patella centers within the trochlear groove by what degree of flexion:
Options:
- 5° to 10°
- 10° to 15°
- 15° to 20°
- 20° to 25°
- 25° to 30°
Correct Answer: 15° to 20°
Explanation:
Laurin and colleagues recognized that the normally tracking patella centered within the trochlea by 20° of knee flexion. Fulkerson and Hungerford demonstrated patellar engagement between 15° to 20° using computerized tomography scans.
Question 12:
Which of the following statements correctly describes the relationship of screw length to pull-out strength in anterior cruciate ligament (AC L) fixation using hamstring tendon graft fixation with soft tissue interference screws:
Options:
- Use of a longer screw provides stronger fixation strength.
- A small diameter screw provides stronger fixation strength.
- Fixation strength has not been shown to be affected by screw length.
- The best fixation is achieved with a long screw and aperture fixation.
- Better fixation is achieved with larger bone tunnel diameter.
Correct Answer: Fixation strength has not been shown to be affected by screw length.
Explanation:
A recent study compared the cyclic and time-zero pull-out forces of 7 25 mm and 7 40 mm blunt-threaded metal interference screws for hamstring graft tibial fixation in 8 paired human cadaveric specimens. There were no measurable differences in the mean cyclic failure strength, pull-out strength, or stiffness between the 2 sizes of screws. One potential advantage of using a longer screw is the relative ease with which it can be removed compared with a shorter screw should revision surgery become necessary.
Question 13:
Which of the following statements concerning allograft use in anterior cruciate ligament (AC L) reconstruction is incorrect:
Options:
- Allograft sterilization using gamma irradiation has not been shown to adversely affect its tensile properties.
- Allograft use avoids donor site morbidity.
- Allograft use diminishes postoperative pain.
- Allograft use decreases surgical time.
- Allograft incorporation is slower than autograft.
Correct Answer: Allograft sterilization using gamma irradiation has not been shown to adversely affect its tensile properties.
Explanation:
Secondary sterilization is achieved with the use of ethylene oxide or gamma irradiation, both of which have detrimental effects on the allograft. Ethylene oxide residues remain on the tissue and stimulate an intra-articular reaction. Gamma radiation has been shown to decrease structural and mechanical properties of the tissue. Irradiation also alters the collagen morphology of sterilized tissues. C urrently, the most accepted method of allograft sterilization involves sterile harvesting and deep freezing.
Question 14:
Which of the following choices represents the correct order of layers in the direct insertion of a human ligament:
Options:
- Bone, uncalcified fibrocartilage, calcified fibrocartilage, and ligament
- Bone, fibrous layer, hypertrophic layer, and ligament
- Bone, hypertrophic layer, fibrous layer, and ligament
- Bone, calcified fibrocartilage, uncalcified fibrocartilage, and ligament
- Bone, calcified fibrous layer, uncalcified fibrous layer, and ligament
Correct Answer: Bone, calcified fibrocartilage, uncalcified fibrocartilage, and ligament
Explanation:
Histologic sectioning of a direct ligament insertion of rotator cuffs in cadavers demonstrates 4 discrete layers: ligament, uncalcified fibrocartilage layer, calcified fibrocartilage layer, and bone. Some authors have suggested that the uncalcified fibrocartilage ensures that the tendon fibers do not compress at a hard tissue interface.
Question 15:
When describing patellar instability, which of the following is the correct relationship between maltracking and malalignment:
Options:
- Maltracking describes the bony anatomy, while malalignment describes the soft tissue anatomy.
- Maltracking refers to the patellar articulation only.
- Malalignment refers to the patellar articulation only.
- Malalignment refers to passive instability, while maltracking refers to active instability.
- Malalignment describes a static relationship, while maltracking describes a dynamic relationship.
Correct Answer: Maltracking describes the bony anatomy, while malalignment describes the soft tissue anatomy.
Explanation:
Terminology describing the setting for patellar instablility can be confusing when the terms â malalignment,â â maltracking,and instabilityâ are used interchangeably. Malalignment is an abnormal static relationship between the patella, its associated soft tissues, and the femoral and tibial axes. Maltracking is an expression of the dynamic relationships of these components and is noted during both active and passive motion.
Question 16:
Which of the following findings has not been reported following abrasion arthroplasty as treatment for the painful, arthritic knee:
Options:
- An increase of the medial joint space on radiograph
- Intermediate or long-term symptomatic improvement in the majority of patients
- Formation of a fibrocartilage articular surface
- Formation of primarily type I collagen
- Worsening of symptoms in 10% to 20% of patients
Correct Answer: An increase of the medial joint space on radiograph
Explanation:
Although popular in the 1980s, abrasion arthroplasty for the treatment of osteoarthritis of the knee has not been shown to reliably improve patientsâ symptoms. Although some authors have found radiographic evidence of an increased joint space inapproximately 50% of patients, these findings have not corresponded to an improvement in symptomatology. Abrasion arthroplasty results in the formation of a fibrocartilaginous articular surface that varies in composition with immature type I collagen predominant.C orrect Answer: Intermediate or long-term symptomatic improvement in the majority of patients
Question 17:
Which of the following anatomic landmarks of the knee represents the contact area between the lateral femoral condyle and the anterior horn of the lateral meniscus when the knee is in full extension:
Options:
- Outerbridgeâ s ridge
- Blumensattâ s line
- Notch of Grant
- Davidâ s point
- Sulcus terminalis
Correct Answer: Sulcus terminalis
Explanation:
The indentation on the lateral femoral condyle often seen on the lateral radiograph of the knee represents the contact area between the femoral condyle and the anterior portion of the lateral meniscus and is often referred to as the sulcus terminalis. After an acute anterior cruciate ligament (AC L) injury or recurrent giving way episode in a chronically AC L deficient knee, the sulcus terminalis is the region in which a bone contusion is typically seen on an magnetic resonance image.
Question 18:
Following tibial eminence fractures in skeletally-immature patients, all of the following sequelae have been described except:
Options:
- Residual anterior cruciate ligament laxity
- Osteophytes near the tibial spine
- Loss of knee flexion
- Hypertrophy of the tibial spine
- Loss of terminal knee extension
Correct Answer: Loss of knee flexion
Explanation:
The overall results following adequate reduction of the tibial spine are good to excellent. Loss of terminal knee extension is thought to occur due to hyperemia, subsequent hypertrophy or displacement of the tibial spine and resultant bony blockage.
Question 19:
Which of the following initial treatment regimens is most appropriate for a 12-year-old boy with osteochondritis dissecans and no effusion or mechanical symptoms:
Options:
- Arthroscopic fixation of the lesion
- Arthroscopic drilling of the lesion
- Moderation of activities
- Arthroscopic removal of loose bodies
- Arthroscopic synovectomy and debridement
Correct Answer: Moderation of activities
Explanation:
Arthroscopic treatment of osteochondritis dissecans is limited to those patients with mechanical symptoms, effusion, and/or radiographic evidence of loose bodies in the joint. Osteochondritis of the femoral condyle may well heal with moderation of activities.
Question 20:
Which of the following radiographic views allows the best visualization of the acromioclavicular (AC ) joint:
Options:
- Stryker notch view
- Zanca view
- Garth view
- Serendipity view
- Anteroposterior shoulder view
Correct Answer: Zanca view
Explanation:
In addition to standard views, a 10° cephalic tilt (Zanca) view is helpful to evaluate anteroposterior arthritis or distal clavicle osteolysis. This view is taken with approximately half the voltage of a standard anteroposterior shoulder radiograph and allows an unobstructed look at the acromioclavicular joint without soft tissue or bony overlay. The Stryker notch radiograph allows visualization of a Hill-Sachs impression fracture of the posterior humeral head. The glenoid fossa, or Garth view, is a true anteroposterior of the glenohumeral joint with the radiograph beam directed 45° from the plane of the thorax. The Serendipity view is used to evaluate the sternoclavicular joint and is a 40° cephalic tilt view with the patient supine.
