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A 22-year-old soccer player sustained an acute ACL rupture 4 years ago. He underwent an autograft hamstring reconstruction at that time. He presents today with a complaint of a persistent sensation of instability despite having a neutral radiographic mechanical alignment and appropriately placed tibial and femoral tunnels from his previous ACL reconstuction on repeat imaging. He denies any new injury. Figures A-E are clinical examination maneuvers for assessing knee stability. Which figure symbolizes a concomitant injury, that if missed initially, would increase the failure rate of an ACL reconstruction?
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A patient has persistent instability symptoms one year after ACL reconstruction. Radiographs and MRI show an intact graft with a femoral tunnel that enters the notch at the 12 o'clock position. These clinical findings have been associated with which of the following?
Lachman 2+, negative pivot shift and higher Lysholm scores
Lachman 2+, positive pivot shift and no change in Lysholm scores
Positive pivot shift and lower Lysholm scores
Lachman 1+, negative pivot shift and lower Lysholm scores
Lachman 1+, negative pivot shift and no change in Lysholm scores
A 12-year-old female sustained a right knee injury during a high-level gymnastic competition. Physical examination revealed a significant effusion, positive anterior drawer, and 3+ Lachman. She is a Tanner 3 on the scale of physical development. When considering transphyseal reconstruction techniques, which of the following factors has the greatest potential to cause physeal injury in the tibia?
Vertical transphyseal tunnel position
Slow transphyseal tunnel reaming
Small transphyseal tunnel diameter
Horizontal and oblique transphyseal tunnel position
Which of the following bone bruise patterns seen on magnetic resonance imaging (MRI) is most consistent with an anterior cruciate ligament (ACL) tear?
Medial tibial spine and medial femoral condyle
Medial facet of patella and lateral femoral condyle
Posterolateral tibia and lateral femoral condyle
Posterolateral tibia and medial femoral condyle
Medial tibial spine and lateral femoral condyle
A genotype within the COL5A1 gene is associated with a reduced risk of which of the following injuries in women?
Rotator cuff tear
Lateral patellar dislocation
Anterior cruciate ligament rupture
Torn discoid meniscus
A 23-year-old soccer player suffers an ACL rupture and undergoes reconstruction. Post-operatively she begins a rehabilitation program and her therapist develops a series of knee conditioning exercises to help her regain strength and range of motion. Which of the following exercises places the lowest strain in this patients properly placed ACL graft?
Isometric hamstring contractions at 60 degrees of knee flexion
Isolated quadriceps contractions with the knee at 30 degrees of flexion
Simultaneous quadricep and hamstring contractions at 15 degrees of knee flexion
Isolated quadriceps contractions with the knee at 15 degrees of flexion
Active resisted knee motion from terminal extension to 30 degrees of flexion
A patient develops infrapatellar contracture syndrome after undergoing ACL surgery. All of the following findings are consistent with this diagnosis EXCEPT?
Decreased patellar mobility
Loss of active but not passive flexion
Loss of full extension
Loss of passive flexion
A 25-year-old male is one year status post anterior cruciate ligament (ACL) reconstruction using patellar bone-tendon-bone (BTB) autograft. He complains of persistent instability with certain activities. His operative dictation notes excellent stability intra-operatively with femoral fixation at the 12 o'clock position. Based on his femoral tunnel position, his history and examination are most likely to reveal which of the following?
Positive pivot shift test and instability with cutting activities due to failure to reconstruct the posterolateral bundle of the ACL
Positive Lachman's test and instability with forward running activites due to failure to reconstruct the anteromedial bundle of the ACL
Positive pivot shift test and instability with cutting activities due to failure to reconstruct the anterolateral bundle of the ACL
Positive Lachman's test and instability with forward activites due to failure to reconstruct the posteromedial bundle of the ACL
Positive pivot shift test and instability with forward running activities due to failure to reconstruct the posterolateral bundle of the ACL
A collegiate men's basketball point guard undergoes ACL reconstruction with hamstring autograft. One year following reconstruction, he returns to playing and complains of recurrent instability episodes. He has an acute giving way episode on the court and is found to have an effusion and a positive pivot shift. Which of the following is the most likely cause of his injury?
Improper graft selection
Lack of sufficient physical rehabilitation prior to return to basketball
Overly aggressive physical rehabilitation during the first 3 months following reconstructive surgery
Surgical error in graft tensioning
Surgical error in tunnel position
Which of the following exercises should typically be avoided during the initial therapy following ACL reconstruction?
Light leg press
Use of a stair climbing machine
Vertical squat with light dumbbells in each hand
Seated leg extensions
Use of a stationary bike
A 27-year-old professional rugby player is sprinting down the field during a game and sustains a twisting injury to his right knee with immediate onset of swelling, pain, and difficulty with ambulation. Imaging of his right knee is demonstrated in Figures A, B, and C. Which of the following structures has most likely been injured?
Posterior cruciate ligament
Anterior cruciate ligament
Lateral collateral ligament
Medial collateral ligament
Tunnel malposition is thought to be a primary etiology for ACL graft failure. All of the following are true of tunnel position EXCEPT:
Vertical placement of the femoral tunnel can result in rotational instability and impingement against the PCL
Anterior placement of the femoral tunnel can result in elongation of the graft
Tibial tunnel placement should be placed posterior to a line extending from Blumenstaat's line when the knee is in full extension
Transtibial drilling through a tibia tunnel that is too far anterior can result in a vertical (12:00) graft
Transtibial drilling through a tibia tunnel that is too far anterior can result in an oblique (10:30 or 1:30 position) graft
A 31-year-old male is 1 year status post primary anterior cruciate ligament reconstruction. Despite adequate physical therapy, he has been unable to return to sport due to recurrent instability and elects to proceed with revision surgery. What is the most common reason for failure of his primary ACL reconstruction?
Unrecognized varus malalignment preop
Improper bone tunnel placement
Reconstruction with a single bundle
Improper graft selection
Patients may complain of numbness over the anterolateral aspect of the knee following ACL reconstruction. This is most commonly due to injury of which of the following?
Suprapatellar branch of the saphenous nerve
Infrapatellar branch of the saphenous nerve
The common peroneal nerve
The superficial femoral nerve
The lateral femoral cutaneous nerve
A 25-year-old male undergoes an ACL reconstruction with an ipsilateral bone-patella tendon-bone autograft. At his two week followup he is noted to have complete loss of his extensor mechanism on exam, stable Lachman and posterior drawer tests, and patella alta radiographically. Management should consist of?
Continued standard ACL rehab protocol
Quadraceps tendon repair
WBAT in a cylinder cast
Patellar tendon repair or reconstruction
Revision ACL reconstruction with hamstring autograft
Strategies which focus on increasing patient neuromuscular control are most effective at preventing which of the following female sporting injuries?
Anterior cruciate ligament ruptures
When comparing autologous graft options for ACL reconstruction, a hamstring graft is associated with which of the following findings when compared to a patellar tendon graft?
Decreased tunnel widening
Decreased pivot shift
Decreased incidence of anterior knee pain
Increased knee flexion strength on Cybex testing
Increased stability on KT-1000
A 28-year-old male presents with persistent knee symptoms 6 months following ACL reconstruction. Current radiographs are shown in Figure A. Based on the location of his femoral tunnel, which of the following physical exam findings is likely present?
Positive Lachman's exam
Positive external rotation dial test at 30 degrees
Positive anterior drawer sign
Positive posterior drawer sign
Positive pivot shift sign
Figure 23 shows the postoperative radiograph of a patient who underwent an anterior cruciate ligament (ACL) reconstruction (with bone-patella tendon-bone autograft) that failed. He initially had loss of flexion postoperatively. What is the most likely cause of this failure?
Fixation in the tibial tunnel
Fixation in the femoral tunnel
Posterior placement of the tibial tunnel
Anterior placement of the femoral tunnel
Size of the patellar autograft
What is the effect on knee kinematics following placement of an anterior cruciate ligament (ACL) graft at the 12 o’clock position?
Decreased rotational stability
Decreased anterior-posterior stability
Graft failure secondary to impingement
Increased ACL injury rates in women athletes compared to male athletes may be due to muscular imbalance and relative weakness in which of the following muscle groups?
During anterior cruciate ligament (ACL) reconstruction divergence between the graft and screw fixation within the bone tunnel can lead to complications. Which of the following statements regarding graft-screw divergence is true?
Risk of failure is eliminated using an accessory anteromedial drilling portal
Complications occur more commonly with soft tissue grafts
Loss of fixation becomes a greater risk if the graft-screw divergence is >30 degrees
Excessive graft-screw divergence more commonly occurs during tibial fixation
Graft-screw divergence is a common cause of late failure of ACL reconstructions
A patient sustains a knee injury. The MRI image shown in Figure A is indicative of which of the following injuries?
Medial meniscus tear
Lateral meniscus tear
Patellar tendon tear
A 16-year-old high school basketball player sustains a non-contact knee injury when she lands from a rebound. She develops immediate swelling and is noted to have a hemarthrosis. What is the most likely diagnosis?
Which of the following risk factors is felt to contribute greatest to the higher rate of ACL rupture in female compared to male athletes?
Body mass index
Femoral notch width
Generalized ligamentous laxity
You are considering performing an anterior cruciate ligament reconstruction on an adolescent female athlete but are concerned about the possibility of a resultant leg length discrepency. Which of the following history or physical findings is most reliable at predicting the amount of growth remaining?
Cessation of changes in shoe size
Onset of menarche
Secondary sex characteristics
Doubling the child’s height when she was 2 years of age to determine final height
Age at which patellar ossification began
A 25-year-old male soccer player twisted his left knee 4 days ago and developed immediate swelling and pain. On exam, he has a 2+ effusion and pain with active range of motion. Passively, he tolerates range of motion from 5-70 degrees. He has difficulty performing a straight leg raise exercise. MRI scan is shown in Figure A. What is the most appropriate initial management for his injury?
Physical therapy for range of motion
Acute reconstruction followed by mobilization
Arthrocentesis to rule out infection
Rest, nonsteroidal anti-inflammatories, and follow-up in 4 weeks
Following ACL reconstruction, which of the following tests most closely correlates with patient satisfaction with their reconstructed knee?
KT-1000 manual maximum value
Anterior drawer test
Pivot shift test
A patient develops anteromedial pain and altered sensation over the anterolateral infrapatellar region of the knee after autologous hamstring tendon harvest for an ACL reconstruction. Which of the following nerves has been injured?
A high school girls basketball player sustains a non-contact knee injury and develops an acute hemarthrosis. What is the likelihood that she has an ACL tear?
At what range of motion do seated leg extension exercises place the greatest amount of stress on the anterior cruciate ligament?
0 to 30 degrees
30 to 60 degrees
60 to 90 degrees
90 to 120 degrees
flexion greater than 120 degrees
Most surgeons prefer to avoid or limit which of the following exercises in the initial post-operative rehabilitation following ACL reconstruction?
Seated leg extensions
Straight leg raises
Active range of motion
Closed chain exercises
The middle genicular artery is the primary blood supply of which of the following structures?
Medial collateral ligament
During anterior cruciate ligament reconstruction, a graft that is tight in flexion but lax in extension may be due to which technical error?
Femoral tunnel is too posterior
Femoral tunnel is too anterior
Femoral tunnel placed at 12:00 position
Tibial tunnel is too anterior
Tibial tunnel is too medial
All of the following are true regarding excessively anterior femoral tunnel placement during ACL reconstruction EXCEPT?
It may cause loss of knee flexion
It may cause graft over-stretching and failure
It is the most common technical error
It may cause interference screw divergence
It is often due to poor visualization
A 29-year-old male undergoes ACL reconstruction with a quadruple hamstring autograft. He insists on doing his own therapy and subsequently goes on to need revision ACL reconstruction due to graft failure. Which of the following exercises is not recommended during rehabilitation?
You are called by a 35-year-old male patient who had ACL reconstruction with hamstring autograft 5 days ago. He reports his knee pain and swelling have significantly increased in the last day, and now it is difficult for him to raise his leg off the bed and is having more difficulty tolerating the CPM machine. Upon questioning he denies fever, chills, or any new trauma to the knee. What is the next step in management?
Ice, NSAIDS, elevation, compression wrap and restart therapy once symptoms improve
Recommend immediate knee aspiration with gram stain and cultures
Increase CPM use to 10 hours a day
Call the office staff in the morning to schedule an appointment
Start physical therapy visits once daily
When evaluating patients that needed revision surgery, what is the most common cause of a failed primary ACL reconstruction?
Returning to sport too early
Inadequate physical therapy
Which of the following factors concerning ACL reconstruction has demonstrated definitive evidence of adverse effect on clinical outcomes?
Center of tibia tunnel placement in-line with the posterior aspect of the anterior horn of the lateral meniscus
Horizontal femoral tunnel placement (10 or 2 o’clock position)
Femoral tunnel placement anterior to the lateral intercondylar ridge
One-incision instead of two-incision tunnel drilling technique
Tibial tunnel is parallel and posterior to Blumenstaat's line when knee is fully extended
A 30 year-old tennis player sustains the injury seen in Figure A and is considering nonoperative treatment of this injured structure. With nonoperative treatment, which of the following additional findings correlate most closely with the development of future arthritis?
Grade IIB Lachman
Presence of pivot shift
Tenderness over MCL origin without opening on valgus
Positive Ober test
Painful pop on McMurray test
In biomechanical testing, which of the following tissues has the highest maximum load to failure?
Quadruple semitendinosus and gracilis tendons
Bone-patellar tendon-bone with a width of 10 mm
Bone-quadriceps tendon with a width on 10mm
Tibialis tendon allograft
Native anterior cruciate ligament (ACL)
An 18-year-old athlete is now 3 months out from anterior cruciate ligament reconstruction. He has been unable to obtain full extension of the knee. His range of motion is from 12° to 125° compared to 0° to 140° on the contralateral knee. He has no effusion, no pain at rest, and a stable Lachman’s test. He is having difficulty ambulating without crutches. What is the most common technical error which can account for these findings?
Femoral tunnel drilled too anteriorly
Failure to cycle the knee prior to final tibial fixation
Femoral tunnel drilled too vertically
Tibial tunnel drilled too vertically
Tibial tunnel drilled too anteriorly
In laboratory testing of quadrupled hamstring grafts (doubled over semitendinosis and gracilis), all of the following statements are true EXCEPT:
Two equally tensioned semitendinosus strands have an average of 220 percent of the strength of one semitendinosus strand
Single semitendinosis strand has a higher tensile strength than a single gracilis strand
All strands of a hamstring graft must be equally tensioned to achieve optimum biomechanical properties
Quadrupled grafts have tensile properties that are higher than 10mm patellar-ligament grafts
Quadrupled hamstring grafts have lower tensile strength than the native ACL
A 16-year-old female volleyball player presents 1 week after sustaining a knee injury while landing from a jump. There was an audible popping sound at the time of injury and she developed swelling later that evening. On physical examination, the surgeon applies a valgus force to the fully extended and internally rotated knee. As the knee is then brought into flexion, a loud clunk occurs at 30° of flexion. Which of the following patterns of bone contusion shown on MRI in Figures A-E is most likely to be evident on this patient's MRI?
The saphenous nerve is most likely to be injured with which of the following steps during an anterior cruciate ligament (ACL) reconstruction with hamstring autograft?
Incision for an anteromedial portal with the knee flexed
Incision for an anteromedial portal with the knee extended
Incision for an accessory medial portal the with knee flexed
Hamstring harvest with the knee extended
Tibial tunnel aperture fixation with the knee at 30 degrees of flexion
Which of the following physical exam maneuvers would be MOST expected for a patient with the following radiograph?
Positive Lachman's test
Positive McMurray's test with leg internally rotated
Positve McMurray's test with leg externally rotated
Positive external rotation dial test with knee flexed at 30 degrees
Positive external rotation dial test with knee flexed at 30 degrees and 90 degrees
A 23-year-old soccer player sustains an anterior cruciate ligament (ACL) tear and is scheduled for reconstruction. He has questions regarding the use of autografts. Which of the following statements is true regarding bone-patellar tendon-bone (BTB) autograft in comparison to quadrupled hamstring autograft for ACL reconstruction?
BTB autograft is biomechanically stronger than quadrupled hamstring autograft
BTB autograft shows less evidence of post-operative pivot shift
Quadrupled hamstring autograft shows lower rate of graft failure
BTB shows higher incidence of anterior knee pain
Quadrupled hamstring autograft shows lower incidence of knee hardware removal