Updated: 7/1/2020

ACL Tear

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https://upload.orthobullets.com/topic/3008/images/segond fx.jpg
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Introduction
  • Overview
    • ACL ruptures are common athletic injuries leading to knee anterior and lateral rotatory instability
      • treatment involves ligamentous reconstruction utilizing a variety of techniques and graft choices
  • Epidemiology
    • incidence
      • ~400,000 ACL reconstructions / year
      • account for half of all knee injuries
    • demographics 
      • more common among female athlete (4.5:1 ratio)  
      • females sustain ACL injuries at a younger age than males  
      • females get more ACL injuries on the supporting leg (males get more ACL injuries on the kicking leg)
      • table of differences  
    • risk factors
      • female participation in soccer, male participation in basketball
      • valgus moment at knee and adduction moment at hip upon landing  
  • Pathophysiology
    • pathoantomy
      • non-contact pivoting injury
        • tibia translates anteriorly while knee is in slight flexion and valgus
      • blow to the lateral aspect of the knee
      • common activities are soccer, basketball, skiing, and football
      • pre-ponderance for females due to landing biomechanics and neuromuscular activation patterns (quadriceps dominant) play the biggest role  
  • Associated conditions
    • meniscal tears  
      • lateral meniscal tears in 54% of acute ACL tears, medial in chronic cases   
    • PCL, LCL/PLC injuries  
    • chronic ACL deficient knees associated with 
      • chondral injuries  
      • complex, unrepairable meniscal tears   
  • Prognosis
    • natural history
      • ACL deficient knees believed to lead to an accelerated progression of arthritis
    • survival with treatment
      • near complete restoration of native kinematics following reconstruction
      • high level of return to sport at all levels of competition
Anatomy
  • Anatomy
    • two bundles measuring combined 32mm length x 7-12mm width
    • bundles named for tibial attachment   
      • anteromedial bundle
        • more isometric
        • tight throughout knee ROM, but tightest in flexion
        • primarily responsible for restraining anterior tibial translation (anterior drawer test)
      • posterolateral bundle     
        • greater length changes
        • tightest in extension, slack in mid-flexion
        • primarily responsible for rotational stability (pivot shift test)
      • femoral attachment  
        • lateral intercondylar ridge demarcates the anterior edge of the ACL
        • bifurcate ridge separates the anteromedial and posterolateral bundle attachment
      • tibial attachment
        • anterior tibia, between intercondylar eminences
  • Composition 
    • 90% Type I collagen 
    • 10% Type III collagen
  • Blood supply
    • middle geniculate artery   
  • Innervation
    • posterior articular nerve (branch of tibial nerve)
  • Biomechanics and Function   
    • provides 85% of the stability to prevent anterior translation of the tibia relative to the femur
    • acts as a secondary restraint to tibial rotation and varus/valgus rotation
    • 2200 N strength (anterior)
Presentation
  • History
    • felt a "pop"
    • pain deep in the knee
    • immediate swelling (70%) / hemarthrosis
  • Symptoms
    • generalized knee pain
    • feelings of instability preventing return to sport
    • difficulty weightbearing
  • Physical exam
    • inspection
      • effusion
      • quadricep avoidance gait (does not actively extend knee)
    • motion 
      • lack of full extension secondary to meniscal injury or arthrofibrosis
      • evaluate for meniscal or concomitant ligamentous injuries (McMurray, Dial test, varus/valgus stress)
  • Neurovascular
    • evaluate peroneal function following high energy mechanisms and suspicion for multi-ligamentous injury pattern
  • Provocative tests
    • Lachman's test  
      • most sensitive exam test
      • grading
        • A= firm endpoint, B= no endpoint
        • Grade 1: 3-5 mm translation
        • Grade 2 A/B: 5-10mm translation
        • Grade 3 A/B: > 10mm translation
      • PCL tear may give "false" Lachman due to posterior subluxation
    • Pivot shift        
      • knee brought from extension (anteriorly subluxated) to flexion (reduced) with valgus and internal rotation of tibia 
        • reduces at 20-30° of flexion due to IT band tension
      • patient must be completely relaxed (easier to elicit under anesthesia)
      • mimics the actual giving way event (see pathoanatomy section)
    • KT-1000 
      • useful to quantify anterior laxity
      • measured with the knee in slight flexion and externally rotated 10-30° 
Imaging
  • Radiographs
    • recommended views
      • AP, lateral, sunrise/merchant/skyline view
    • findings
      • often normal
      • Segond fracture (avulsion fracture of the proximal lateral tibia) is pathognomonic for an ACL tear   
        • represents bony avulsion by the anterolateral ligament (ALL)   
        • associated with ACL tear 75-100% of the time
      • deep sulcus (terminalis) sign  
        • depression on the lateral femoral condyle at the terminal sulcus, a junction between the weight bearing tibial articular surface and the patellar articular surface of the femoral condyle
  • MRI
    • indications
      • to confirm clinical diagnosis of ACL rupture and evaluate for concomitant pathology
    • findings of torn ACL  
      • sagittal view  
        • ACL fibers
          • discontinuity of fibers on T2
            • normal ACL fibers appear steeper than the intercondylar roof and in continuity of fibers all the way from the tibia to femur
          • abnormal orientation 
            • too "flat" compared with intercondylar roof / Blumensaat's line  
            • this acute angle is common in chronic cases where ACL scars to the PCL
          • non-visualization of ACL
        • bone bruising in > half of acute ACL tears   
          • middle 1/3 of LFC (sulcus terminalis)
          • posterior 1/3 of the lateral tibial plateau
          • subchondral changes on MRI can persist years after injury, may contribute to long-term chondral damage
        • tibial spine avulsion fracture 
      • coronal view
        • discontinuity of fibers (do not reach the femur)  
        • fluid against the lateral wall ("empty notch sign")  
    • sensitivity and specificity
      • 97% and 100% respectively
  • CT scan
    • indications
      • revision setting to evaluate for bone loss
    • sensitivity and specificity
      • most sensitive and specific test for bone loss associated with osteolysis and tunnel widening
Treatment
  • Treatment individualized to patient based on activity level, age, demands, and concomitant pathology
  • Nonoperative
    • physical therapy, lifestyle modifications
      • indications
        • low demand patients with decreased laxity
        • recreational athlete not participating in cutting/pivoting activities
      • outcomes
        • increased meniscal/cartilage damage linked to
          • loss of meniscal integrity, the frequency of buckling episodes, level I and II activity (e.g. jumping, cutting, side-to-side sports, heavy manual labor)
  • Operative
    • ACL reconstruction
      • indications
        • must have full motion of knee restored following injury (unless meniscal tear causing mechanical block)
          • lack of pre-operative motion risk factor for post-operative arthrofibrosis 
        • younger, more active patients (reduces the incidence of meniscal or chondral injury)
        • children (activity limitation is not realistic)
        • older active patients (age >40 is not a contraindication if high demand athlete)
        • partial/single bundle tears with clinical and functional instability
        • prior ACL reconstruction failure
      • outcomes
        • return to play largely influenced by psychological, demographic and functional outcomes  
    • ACL repair
      • indications
        • previously abandoned but increased interest recently in pediatric populations and avulsion rupture patterns
      • outcomes
        • previously abandoned due to high failure rates
        • arthroscopic bridge-enhanced ACL repair (BEAR) trial with a bridging scaffold is ongoing and promising  
    • ACL revision reconstruction
      • indications
        • failure of prior ACL reconstruction with instability during desired activities
      • outcomes
        • revision ACL reconstruction
  • Concurrent pathology
    • MCL injury
      • indications
        • if low grade MCL injury amenable to non-operative treatment, allow MCL to heal prior to ACL reconstruction
        • if high grade MCL injury necessitating repair/reconstruction, may be done concurrently with ACL
      • outcomes
        • failure to address valgus instability can jeopardize ACL graft with higher re-rupture rates
    • meniscal tears
      • indications
        • perform meniscal repair or meniscectomy at time of ACL reconstruction 
      • outcomes
        • increased meniscal healing rate when repaired at the same time as ACL
    • chondral injuries
      • indications
        • partial- or full-thickness chondral injury may be treated at time of ACL reconstruction in staged fashion if injury necessitates
      • outcomes
        • presence of chondral defects consistently lowers long-term patient-reported outcomes following ACL reconstruction
    • posterior cruciate ligament and posterolateral corner injuries
      • indications
        • may reconstruct concurrently with ACL reconstruction or as staged procedure
      • outcomes
        • failure to recognize and address PLC/PLC injuries will lead to varus instability and ACL graft overload
    • high tibial osteotomy or distal femoral osteotomy  
      • indications
        • limb malalignment in both the coronal and sagittal plane must be addressed before or at the same time as ligament reconstruction
      • outcomes
        • high ACL failure rates in unaddressed limb malalignment
Techniques
  • Physical therapy, lifestyle modifications
    • technique
      • early symptomatic treatment followed by 3 months of supervised physical therapy 
      • physical therapy focusing on range of motion and progressing to quad, hamstring, hip abductor and core strengthening
      • re-evaluation at conclusion to assess progress
      • functional braces demonstrate no added functional stability
  • ACL reconstruction
    • goal is to anatomically reconstruct ligament to restore anterior and rotational stability
    • approach
      • arthroscopic assisted
    • technique
      • clear out remnant ACL fibers to visualize native bone landmarks
        • in cases of single bundle ACL tears, no difference whether removal remnant ACL or remove all fibers prior to reconstruction
      • no patient-reported differences between single or double-bundle reconstructions
        • single bundle most common
        • double bundle may better restore native knee kinematics with less laxity
      • femoral tunnel placement  
        • may be drilled trans-tibial or independent of the tibia (inside-out or outside-in)
        • proper placement    
          • sagittal plane
            • 1-2 mm rim of bone between the tunnel and posterior cortex of the femur
          • coronal plane
            • tunnel should be placed on the lateral wall at 2 o'clock for left knee or 10 o'clock for right knee 
            • creates a more horizontal graft (and reduce rotational laxity)
            • anteromedial and far medial drilling portals may enhance ability achieve these tunnel locations  
              • no difference in clinical outcomes between trans-tibial and anteromedial drilling techniques
        • drilling tunnel in over 70 degrees of flexion will prevent posterior wall blowout
      • tibial tunnel placement
        • proper placement
          • sagittal plane
            • the center of tunnel entrance into joint should be 10-11mm in front of the anterior border of PCL insertion, 6mm anterior to the median eminence, 9mm posterior to the inter-meniscal ligament  
          • coronal plane
            • tunnel trajectory of < 75° from horizontal
            • obtain by moving tibial starting point halfway between tibial tubercle and a posterior medial edge of the tibia.
      • graft placement
        • graft pre-conditioning can reduce stress relaxation up to 50%
        • graft tensioning at 20N or 40N had no clinical outcome effects in a level 1 study 
        • fix the graft in 20-30° of flexion 
      • graft fixation
        • various options for graft fixation, dictated by graft selection and surgeon preference
        • can be used alone (i.e. all-inside suspensory fixation) or in combination (i.e. interference screw with screw and washer post)   
          • interference screws (aperture/compression fixation)
          • cortical buttons (suspensory fixation)
          • screw and washer post (suspensory fixation)
          • staple (suspensory fixation)
  • Revision ACL reconstruction
    • approach considerations
      • cause for prior ACL failure
      • concomittant pathology
      • prior graft selection
      • careful assessment of the underlying cause of re-rupture
    • technique post
      • high strength grafts (quad tendon, hamstring, allograft)
      • dual or back-up fixation (suspension + interference screws)
      • bone grafting and reconstruction in cases of previous tunnel dilation (15mm) or if interfering with anatomic tunnel creation
      • addition of anterolateral ligament/ALL reconstruction (lateral extra-articular tenodesis) controversial
      • re-harvesting BPTB is contraindicated
    • postoperative
      • conservative rehab
Graft Selection
  • Bone-patellar tendon-bone (BPTB) autograft post post
    • advantages of all autografts
      • using patient's own tissue 
      • most common source of graft
      • faster incorporation
      • less immune reaction
      • no chance of acquiring someone else's infection
    • pros and cons of bone-patella-bone
      • the longest history of use and considered the "gold standard"
      • bone to bone healing leads to faster incorporation time
      • ability to rigidly fix the joint line (screws)
      • the highest incidence of anterior knee pain (up to 10-30%) and kneeling pain  
      • maximum load to failure is 2600 Newtons (intact ACL is 1725 Newtons)
    • complications
      • patella fracture (usually postop during rehab), patellar tendon rupture 
      • re-rupture
        • associated with age < 20 years and graft size < 8mm 
  • Quadrupled hamstring autograft
    • technique
      • may be taken from contralateral side in revision situation when allograft is not desirable or available
    • pros and cons
      • smaller incision, less perioperative pain, less anterior knee pain 
      • fixation strength may be less than BPTB
      • maximum load to failure is approximately 4000 Newtons  
      • decreased peak flexion strength at 3 years compared to BPTB
      • concern about hamstring weakness in female athletes leading to increased risk of re-rupture
    • complications
      • "windshield wiper" effect (suspensory fixation away from joint line causes tunnel abrasion and expansion with flexion/extension of knee)
      • residual hamstring weakness
      • parasthesias due to injury to saphenous nerve branches during harvest
        • oblique or horizontal incisions lessen this risk
  • Quadriceps tendon autograft
    • pros & cons
      • small incision in area that does not see pressure during kneeling
      • does not involve physis
      • maximum load to failure 2185 Newtons
      • similar patient-reported and functional outcomes as other autografts
      • may include bone block or completely soft tissue
      • less commonly used so is often available in revision setting
      • same disadvantages as hamstring autograft with suspensory fixation
  • Allograft
    • pros & cons
      • useful in revisions
      • no harvest site morbidity
      • longer incorporation time
      • more expensive than autograft
      • risk of disease transmission (HIV is < 1:1.6 million, hepatitis is even greater)
      • increased risk of re-rupture in young athletes   
        • odds of graft re-rupture are 4.3 x higher in allograft for athletes aged 10-19
    • graft processing
      • fresh-frozen grafts lower re-rupture rates compared with chemically treated or irradiated
        • supercritical CO2: decreases the structural and mechanical properties 
        • radiation 
          • 3 Mrads is required to kill HIV (this decreases the structural and mechanical properties)
          • 2-2.8 Mrad decreases stiffness by 30%, 1-1.2 Mrad decreases stiffness by 20%
        • deep freezing destroys cells but does not affect the strength of the graft
        • 4% chlorhexidine gluconate destroys cells but does not affect the strength of the graft
Pediatric Considerations
  • Physis
    • < 14 yrs with open physis
    • the onset of menarche is the best determinant of skeletal maturity in females 
  • Treatment  
    • Nonoperative
      • indications
        • compliant, low demand patient with no additional intra-articular pathologies 
        • partial ACL tear (60% of adolescents have partial tears) with near normal Lachman and pivot shift
    • Surgery
      • indications
        • complete ACL tear
  • Techniques
    • intra-articular
      • physis-sparing (all intra-epiphyseal)  
      • trans-physeal (males ≤13-16, females ≤ 12-14)
      • partial trans-physeal 
        • leave either distal femoral or proximal tibial physis undisturbed 
      • no significant difference in growth disturbances between techniques
    • combined intra- and extra-articular (males ≤12, females ≤ 11)  
      • autogenous ITB harvested free proximally, left attached distally to Gerdy tubercle
      • looped through the knee in over the top position
      • passed through the notch and under intermeniscal ligament anteriorly
      • sutured to lateral femoral condyle and proximal tibia
    • adult type reconstruction (males >=16, females >=14)
  • Graft Selection 
    • trans-physeal soft tissue grafts rarely lead to growth disturbances
  • Instrumentation
    • Factors found to increase physeal injury include: 
      • large tunnel diameter (>12mm) is most important 
        • 8mm tunnel corresponds to <3% physeal cross-sectional area
        • 12mm tunnel corresponds to >7-9% of physeal cross-sectional area is violated
      • oblique tunnel position 
      • interference screw fixation
      • high-speed tunnel reaming 
      • lateral extra-articular tenodesis
      • dissection close to the perichondral ring of LaCroix
      • suturing near tibial tubercle
  • Complications
    • physeal disruption without growth disturbance (10%)
Rehabilitation
  • Early post-operative
    • immediate
      • aggressive cryotherapy (ice)
      • immediate weight bearing (shown to reduce patellofemoral pain)
      • emphasize early full passive extension (especially if associated with MCL injury or patella dislocation)
      • no long-term differences found between accelerated and non-accelerated protocols
    • early rehab
      • focus rehab on exercises that do not place excess stress on graft  
        • appropriate rehab  
          • eccentric strengthening at 3 weeks has been shown to result in increased quadriceps volume and strength  
          • isometric hamstring contractions at any angle
          • isometric quadriceps, or simultaneous quadriceps and hamstrings contraction
          • active knee motion between 35 degrees and 90 degrees of flexion
          • core and gluteal strengthening incorporated throughout therapy
          • emphasize closed chain (foot planted) exercises
            • i.e. squats or leg-press
        • avoid
          • isokinetic quadricep strengthening (15-30°) during early rehab
          • open chain quadriceps strengthening     
            • i.e. leg extensions mimic anterior drawer and Lachman maneuvers
  • Return to play
    • no widely accepted criteria supporting clearance or timing to return to sport
      • previously held consensus is no sooner than 9 months following surgery 
      • patient should pass series of functional tests that replictae sport-specific activities
        • various single- and double- leg hopping and jumping
        • dynamic valgus shown to increase risk of ipsilateral and contralateral rupture
        • higher rates of re-rupture following early return to sport prior to clearance 
      • clearance for return to play should be made between surgeon and patient 
      • psychological factors play large role in timing of return and should not be overlooked
  • Injury prevention
    • female athlete
      • neuromuscular training/plyometrics (jump training)
      • land from jumping in less valgus and more knee flexion
      • increasing hamstring strength to decrease quadriceps dominance ratio
    • skier training
      • teach skiers how to fall
    • ACL bracing
      • no proven efficacy except for ACL-deficient skiers
Complications
  • Intra-operative complications
    • graft-tunnel mismatch
      • BPTB graft total length greater than combined length of femoral tunnel, tibial tunnel, and intra-articular distance connecting them
        • leads to prominent tibial bone plug and inadequate fixation
      • risk factors
        • BPTB allograft
        • patella alta
        • non-transtibial drilling techniques
      • treatment
        • precise intra-operative measuring of tunnels and graft
        • twisting graft tendon on itself to effectively shorten graft length
    • posterior wall blowout 
      • cortical breach of psoterolateral cortical wall of lateral femoral condyle
      • risk factors
        • inadequate exposure of posterior wall prior to drilling
        • failure to evaluate tunnel walls after drilling
        • drilling femoral tunnel while knee flexed less than 70-90 degrees
      • treatment
        • if minimal defect at notch opening (3-5mm)
          • can re-drill tunnel deviating anteriorly and proceed with prior intended fixation method
        • if substantial cortical defect 
          • keep previous tunnel but graft fixed with suspensory fixation (screw and washer post, cortical button, or staple) and/or interference screw fixation
            • intereference screw fixation may be added to supplement suspensory device
  • Graft failure due to tunnel malposition  
    • incidence
      • graft failure for any cause approximates 5%
      • is the most common cause of ACL failure, attributed to 70% of failures     
    • femoral tunnel malposition
      • coronal plane
        • vertical femoral tunnel placement 
          • cause by starting femoral tunnel at the vertical position in the notch (12 o'clock) as opposed to lateral wall (10 o'clock)
          • will cause continued rotational instability which can be identified on physical exam by a positive pivot shift     
      • sagittal plane
        • anterior tunnel placement    
          • leads to a knee that is tight in flexion and loose in extension 
          • occurs from failure to clear "residents ridge"
        • posterior misplacement (over-the-top) 
          • leads to a knee that is lax in flexion and tight in extension
    • tibial tunnel malposition
      • sagittal plane
        • anterior misplacement
          • leads to knee that is tight in flexion with roof impingement in extension  
      • posterior misplacement
        • leads to an ACL that will impinge with the PCL
  • Graft failure due to other causes
    • inadequate graft fixation or hardware failure
      • can be caused by graft-screw divergence >30 degrees  
    • attritional graft failure
      • graft less then 8mm in width 
    • intra-articular femoral bone plug dislodgement  
      • treatment
        • requires revision surgery
    • missed diagnosis of concomitant ligamentous injuries
      • in combined ACL and PLC injuries, failure to treat the PLC will overload graft lead to failure 
    • over-aggressive or improper rehab
      • open-chain exercises
  • Infection and septic arthritis
    • incidence
      • less than 1% of all ACL reconstructions
      • most commonly superficial
        • coagulase negative Staph (S. epidermidis) most common organism
        • Staph aureus 2nd most common
        • routine soaking graft intra-operative in vancomycin solution may lower risk of infection
    • risk factors
      • graft contamination during routine intra-operative handling
      • graft dropped on floor
    • presentation
      • pain, swelling, erythema, and increased WBC at 2-14 days postop
    • diagnosis
      • joint aspiration with gram stain and cultures 
    • treatment
      • intra-operative
        • routine soaking of graft in various antibiotic solutions before placement
        • sequential washing in various antibiotic solutions showed no increase in infection risk for dropped grafts
      • post-operative
        • immediate arthroscopic I&D
        • often can retain graft with multiple I&Ds and antibiotics (6 weeks minimum)
          • more likely to be successful with S. epidermidis, less likely with S. aureus
  • Loss of motion & arthrofibrosis 
    • incidence
      • most common complication following ACL reconstruction
    • risk factors
      • lack of pre-operative motion
    • presentation
      • loss of patellar translation
    • treatment
      • pre-operative prevention
        • patient has regained full ROM before you operate ("pre-hab")   
        • wait until swelling (inflammatory phase) has gone down to reduce the incidence of arthrofibrosis
      • operative prevention
        • proper tunnel placement critical to have a full range of motion
      • post-operative prevention
        • aggressive cryotherapy (ice)
      • < 12 weeks, aggressive PT and serial splinting
      • > 12 weeks, lysis of adhesions/manipulation under anesthesia
  • Infrapatellar contracture syndrome
    • incidence
      • an uncommon complication which results in knee stiffness
      • physical exam will show decreased patellar translation   
  • Patella Tendon Rupture
    • will see patella alta on the lateral radiograph 
  • RSD (complex regional pain syndrome)
  • Patella fracture
    • BPTP and quadriceps grafts w bone block implicated
    • most fractures occur 8-12 weeks post-op
  • Tunnel osteolysis
    • treatment
      • observation unless graft laxity and knee instability
  • Late osteoarthritis
    • related to meniscal integrity 
    • increased rates noted in patients > age 50 at the time of ACL reconstruction 
  • Local nerve irritation
    • incidence
      • saphenous nerve due to hamstring autograft harvest  
  • Cyclops lesion
    • fibroproliferative tissue blocks extension
    • "click" heard at terminal extension
 
 

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(OBQ13.275) 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? Review Topic | Tested Concept

QID: 4910
1

Lachman 2+, negative pivot shift and higher Lysholm scores

3%

(101/3218)

2

Lachman 2+, positive pivot shift and no change in Lysholm scores

8%

(262/3218)

3

Positive pivot shift and lower Lysholm scores

78%

(2523/3218)

4

Lachman 1+, negative pivot shift and lower Lysholm scores

8%

(262/3218)

5

Lachman 1+, negative pivot shift and no change in Lysholm scores

1%

(46/3218)

L 2 B

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(OBQ12.249) 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? Review Topic | Tested Concept

QID: 4609
1

Vertical transphyseal tunnel position

9%

(344/3858)

2

Slow transphyseal tunnel reaming

4%

(170/3858)

3

Hamstring autograft

0%

(17/3858)

4

Small transphyseal tunnel diameter

1%

(35/3858)

5

Horizontal and oblique transphyseal tunnel position

85%

(3265/3858)

L 2 B

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(OBQ12.94) Which of the following bone bruise patterns seen on magnetic resonance imaging (MRI) is most consistent with an anterior cruciate ligament (ACL) tear? Review Topic | Tested Concept

QID: 4454
1

Medial tibial spine and medial femoral condyle

2%

(90/5985)

2

Medial facet of patella and lateral femoral condyle

1%

(31/5985)

3

Posterolateral tibia and lateral femoral condyle

78%

(4688/5985)

4

Posterolateral tibia and medial femoral condyle

10%

(574/5985)

5

Medial tibial spine and lateral femoral condyle

10%

(573/5985)

L 2 B

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(OBQ12.41) A genotype within the COL5A1 gene is associated with a reduced risk of which of the following injuries in women? Review Topic | Tested Concept

QID: 4401
1

Glenohumeral dislocation

4%

(241/5806)

2

Rotator cuff tear

7%

(395/5806)

3

Lateral patellar dislocation

8%

(463/5806)

4

Anterior cruciate ligament rupture

75%

(4362/5806)

5

Torn discoid meniscus

5%

(289/5806)

L 3 B

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(OBQ11.271) 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? Review Topic | Tested Concept

QID: 3694
1

Isometric hamstring contractions at 60 degrees of knee flexion

49%

(1217/2486)

2

Isolated quadriceps contractions with the knee at 30 degrees of flexion

10%

(240/2486)

3

Simultaneous quadricep and hamstring contractions at 15 degrees of knee flexion

26%

(650/2486)

4

Isolated quadriceps contractions with the knee at 15 degrees of flexion

11%

(273/2486)

5

Active resisted knee motion from terminal extension to 30 degrees of flexion

3%

(87/2486)

L 4 B

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(OBQ11.129) A patient develops infrapatellar contracture syndrome after undergoing ACL surgery. All of the following findings are consistent with this diagnosis EXCEPT? Review Topic | Tested Concept

QID: 3552
1

Patella infera

2%

(43/2713)

2

Decreased patellar mobility

1%

(32/2713)

3

Loss of active but not passive flexion

66%

(1802/2713)

4

Loss of full extension

16%

(429/2713)

5

Loss of passive flexion

15%

(397/2713)

L 3 C

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(OBQ11.215) 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? Review Topic | Tested Concept

QID: 3638
1

Positive pivot shift test and instability with cutting activities due to failure to reconstruct the posterolateral bundle of the ACL

77%

(2224/2894)

2

Positive Lachman's test and instability with forward running activites due to failure to reconstruct the anteromedial bundle of the ACL

6%

(171/2894)

3

Positive pivot shift test and instability with cutting activities due to failure to reconstruct the anterolateral bundle of the ACL

9%

(258/2894)

4

Positive Lachman's test and instability with forward activites due to failure to reconstruct the posteromedial bundle of the ACL

2%

(52/2894)

5

Positive pivot shift test and instability with forward running activities due to failure to reconstruct the posterolateral bundle of the ACL

6%

(162/2894)

L 2 B

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(OBQ10.223) 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? Review Topic | Tested Concept

QID: 3322
1

Improper graft selection

4%

(127/3044)

2

Lack of sufficient physical rehabilitation prior to return to basketball

9%

(284/3044)

3

Overly aggressive physical rehabilitation during the first 3 months following reconstructive surgery

4%

(110/3044)

4

Surgical error in graft tensioning

4%

(119/3044)

5

Surgical error in tunnel position

78%

(2388/3044)

L 2 B

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(OBQ10.229) Which of the following exercises should typically be avoided during the initial therapy following ACL reconstruction? Review Topic | Tested Concept

QID: 3328
1

Light leg press

1%

(29/2261)

2

Use of a stair climbing machine

3%

(61/2261)

3

Vertical squat with light dumbbells in each hand

6%

(146/2261)

4

Seated leg extensions

89%

(2005/2261)

5

Use of a stationary bike

1%

(15/2261)

L 1 B

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(OBQ09.157) 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?
Review Topic | Tested Concept

QID: 2970
FIGURES:
1

Posterior cruciate ligament

0%

(7/2737)

2

Anterior cruciate ligament

86%

(2358/2737)

3

Popliteus

1%

(27/2737)

4

Lateral collateral ligament

11%

(308/2737)

5

Medial collateral ligament

1%

(17/2737)

L 2 B

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(OBQ09.147) Tunnel malposition is thought to be a primary etiology for ACL graft failure. All of the following are true of tunnel position EXCEPT: Review Topic | Tested Concept

QID: 2960
1

Vertical placement of the femoral tunnel can result in rotational instability and impingement against the PCL

3%

(22/730)

2

Anterior placement of the femoral tunnel can result in elongation of the graft

7%

(48/730)

3

Tibial tunnel placement should be placed posterior to a line extending from Blumenstaat's line when the knee is in full extension

9%

(68/730)

4

Transtibial drilling through a tibia tunnel that is too far anterior can result in a vertical (12:00) graft

24%

(176/730)

5

Transtibial drilling through a tibia tunnel that is too far anterior can result in an oblique (10:30 or 1:30 position) graft

56%

(409/730)

L 3 D

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(OBQ09.26) 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? Review Topic | Tested Concept

QID: 2839
1

Unrecognized varus malalignment preop

2%

(37/1953)

2

Improper bone tunnel placement

95%

(1860/1953)

3

Reconstruction with a single bundle

1%

(10/1953)

4

Improper graft selection

1%

(11/1953)

5

Meniscal injury

1%

(24/1953)

L 1 B

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(OBQ08.186) 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? Review Topic | Tested Concept

QID: 572
1

Suprapatellar branch of the saphenous nerve

11%

(101/921)

2

Infrapatellar branch of the saphenous nerve

81%

(749/921)

3

The common peroneal nerve

2%

(16/921)

4

The superficial femoral nerve

2%

(20/921)

5

The lateral femoral cutaneous nerve

4%

(33/921)

L 1 C

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(OBQ08.120) 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? Review Topic | Tested Concept

QID: 506
1

Continued standard ACL rehab protocol

3%

(26/784)

2

Quadraceps tendon repair

3%

(21/784)

3

WBAT in a cylinder cast

1%

(4/784)

4

Patellar tendon repair or reconstruction

93%

(728/784)

5

Revision ACL reconstruction with hamstring autograft

0%

(3/784)

L 1 C

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(OBQ08.193) Strategies which focus on increasing patient neuromuscular control are most effective at preventing which of the following female sporting injuries? Review Topic | Tested Concept

QID: 579
1

Shoulder dislocations

1%

(16/1538)

2

Concussion

0%

(7/1538)

3

Anterior cruciate ligament ruptures

95%

(1459/1538)

4

Frieberg's infarction

0%

(4/1538)

5

Patellofemoral instability

3%

(48/1538)

L 1 C

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(OBQ08.213) 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? Review Topic | Tested Concept

QID: 599
1

Decreased tunnel widening

1%

(29/2421)

2

Decreased pivot shift

1%

(16/2421)

3

Decreased incidence of anterior knee pain

94%

(2274/2421)

4

Increased knee flexion strength on Cybex testing

2%

(38/2421)

5

Increased stability on KT-1000

2%

(53/2421)

L 1 B

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(SAE07SM.84) 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? Review Topic | Tested Concept

QID: 8746
FIGURES:
1

Fixation in the tibial tunnel

6%

(21/345)

2

Fixation in the femoral tunnel

4%

(15/345)

3

Posterior placement of the tibial tunnel

3%

(10/345)

4

Anterior placement of the femoral tunnel

83%

(287/345)

5

Size of the patellar autograft

3%

(11/345)

L 2 E

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(SAE07SM.46) What is the effect on knee kinematics following placement of an anterior cruciate ligament (ACL) graft at the 12 o’clock position? Review Topic | Tested Concept

QID: 8708
1

Decreased rotational stability

86%

(272/316)

2

Decreased anterior-posterior stability

6%

(18/316)

3

Decreased flexion

2%

(6/316)

4

Decreased extension

3%

(9/316)

5

Graft failure secondary to impingement

3%

(10/316)

L 1 E

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(SBQ07SM.46) 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? Review Topic | Tested Concept

QID: 1431
FIGURES:
1

Positive Lachman's exam

6%

(88/1536)

2

Positive external rotation dial test at 30 degrees

8%

(118/1536)

3

Positive anterior drawer sign

2%

(38/1536)

4

Positive posterior drawer sign

0%

(7/1536)

5

Positive pivot shift sign

83%

(1272/1536)

L 2 B

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(OBQ07.155) 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? Review Topic | Tested Concept

QID: 816
1

Quadriceps

39%

(378/964)

2

Hamstrings

58%

(555/964)

3

Gluteus muscles

1%

(11/964)

4

Adductors

1%

(9/964)

5

Abdominals

0%

(3/964)

L 3 C

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(SBQ07SM.14) 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? Review Topic | Tested Concept

QID: 1399
1

Risk of failure is eliminated using an accessory anteromedial drilling portal

1%

(15/1288)

2

Complications occur more commonly with soft tissue grafts

4%

(47/1288)

3

Loss of fixation becomes a greater risk if the graft-screw divergence is >30 degrees

86%

(1102/1288)

4

Excessive graft-screw divergence more commonly occurs during tibial fixation

3%

(37/1288)

5

Graft-screw divergence is a common cause of late failure of ACL reconstructions

6%

(75/1288)

L 2 C

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(OBQ07.87) A patient sustains a knee injury. The MRI image shown in Figure A is indicative of which of the following injuries? Review Topic | Tested Concept

QID: 748
FIGURES:
1

ACL tear

90%

(1481/1646)

2

PCL tear

6%

(101/1646)

3

Medial meniscus tear

1%

(10/1646)

4

Lateral meniscus tear

1%

(24/1646)

5

Patellar tendon tear

1%

(24/1646)

L 1 B

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(OBQ07.66) 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? Review Topic | Tested Concept

QID: 727
1

MCL tear

1%

(6/766)

2

Medial meniscus tear

2%

(12/766)

3

ACL tear

95%

(726/766)

4

Patellar dislocation

1%

(11/766)

5

Contusion

1%

(5/766)

L 1 C

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(OBQ07.274) Which of the following risk factors is felt to contribute greatest to the higher rate of ACL rupture in female compared to male athletes? Review Topic | Tested Concept

QID: 935
1

Body mass index

1%

(6/849)

2

Femoral notch width

5%

(40/849)

3

Generalized ligamentous laxity

9%

(77/849)

4

Neuromuscular factors

69%

(590/849)

5

Limb alignment

16%

(135/849)

L 2 C

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(SBQ07SM.37) 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? Review Topic | Tested Concept

QID: 1422
1

Cessation of changes in shoe size

2%

(11/674)

2

Onset of menarche

84%

(564/674)

3

Secondary sex characteristics

9%

(58/674)

4

Doubling the child’s height when she was 2 years of age to determine final height

1%

(10/674)

5

Age at which patellar ossification began

4%

(26/674)

L 2 C

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(OBQ06.138) Following ACL reconstruction, which of the following tests most closely correlates with patient satisfaction with their reconstructed knee? Review Topic | Tested Concept

QID: 324
1

KT-1000 manual maximum value

13%

(107/834)

2

Lachman's test

15%

(124/834)

3

Anterior drawer test

5%

(38/834)

4

Pivot shift test

60%

(504/834)

5

Cybex testing

7%

(56/834)

L 3 C

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(OBQ06.112) 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? Review Topic | Tested Concept

QID: 298
FIGURES:
1

Knee immobilization

6%

(110/1932)

2

Physical therapy for range of motion

74%

(1431/1932)

3

Acute reconstruction followed by mobilization

11%

(216/1932)

4

Arthrocentesis to rule out infection

0%

(3/1932)

5

Rest, nonsteroidal anti-inflammatories, and follow-up in 4 weeks

9%

(166/1932)

L 2 C

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(OBQ06.177) 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? Review Topic | Tested Concept

QID: 363
1

Medial retinacular

4%

(33/824)

2

Inferior genicular

29%

(242/824)

3

Saphenous

64%

(530/824)

4

Superficial peroneal

2%

(15/824)

5

Tibial

0%

(1/824)

L 2 C

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(OBQ05.174) 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? Review Topic | Tested Concept

QID: 1060
1

0-15%

1%

(12/2175)

2

15-30%

4%

(86/2175)

3

30-45%

7%

(143/2175)

4

45-60%

12%

(260/2175)

5

>60%

77%

(1666/2175)

L 2 D

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(OBQ05.28) At what range of motion do seated leg extension exercises place the greatest amount of stress on the anterior cruciate ligament? Review Topic | Tested Concept

QID: 65
1

0 to 30 degrees

44%

(990/2237)

2

30 to 60 degrees

33%

(734/2237)

3

60 to 90 degrees

13%

(299/2237)

4

90 to 120 degrees

6%

(124/2237)

5

flexion greater than 120 degrees

3%

(76/2237)

L 4 C

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(OBQ05.96) Most surgeons prefer to avoid or limit which of the following exercises in the initial post-operative rehabilitation following ACL reconstruction? Review Topic | Tested Concept

QID: 982
1

Quadriceps sets

8%

(68/835)

2

Seated leg extensions

76%

(635/835)

3

Straight leg raises

6%

(53/835)

4

Active range of motion

2%

(19/835)

5

Closed chain exercises

7%

(60/835)

L 2 C

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(OBQ05.190) The middle genicular artery is the primary blood supply of which of the following structures? Review Topic | Tested Concept

QID: 1076
1

Medial collateral ligament

2%

(15/883)

2

Lateral collateral ligament

0%

(2/883)

3

Medial meniscus

8%

(68/883)

4

Lateral meniscus

0%

(2/883)

5

Anterior cruciate ligament

90%

(792/883)

L 1 B

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(OBQ05.40) During anterior cruciate ligament reconstruction, a graft that is tight in flexion but lax in extension may be due to which technical error? Review Topic | Tested Concept

QID: 1
1

Femoral tunnel is too posterior

9%

(229/2624)

2

Femoral tunnel is too anterior

72%

(1884/2624)

3

Femoral tunnel placed at 12:00 position

4%

(103/2624)

4

Tibial tunnel is too anterior

14%

(360/2624)

5

Tibial tunnel is too medial

1%

(22/2624)

L 2 B

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(OBQ05.214) All of the following are true regarding excessively anterior femoral tunnel placement during ACL reconstruction EXCEPT? Review Topic | Tested Concept

QID: 1100
1

It may cause loss of knee flexion

16%

(153/977)

2

It may cause graft over-stretching and failure

8%

(75/977)

3

It is the most common technical error

19%

(187/977)

4

It may cause interference screw divergence

51%

(501/977)

5

It is often due to poor visualization

6%

(55/977)

L 3 C

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(OBQ04.9) When evaluating patients that needed revision surgery, what is the most common cause of a failed primary ACL reconstruction? Review Topic | Tested Concept

QID: 120
1

Tunnel malposition

90%

(798/888)

2

Obesity

0%

(2/888)

3

Smoking

1%

(9/888)

4

Returning to sport too early

5%

(48/888)

5

Inadequate physical therapy

3%

(25/888)

L 1 C

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(OBQ04.174) Which of the following factors concerning ACL reconstruction has demonstrated definitive evidence of adverse effect on clinical outcomes? Review Topic | Tested Concept

QID: 1279
1

Center of tibia tunnel placement in-line with the posterior aspect of the anterior horn of the lateral meniscus

5%

(37/773)

2

Horizontal femoral tunnel placement (10 or 2 o’clock position)

8%

(64/773)

3

Femoral tunnel placement anterior to the lateral intercondylar ridge

72%

(553/773)

4

One-incision instead of two-incision tunnel drilling technique

7%

(52/773)

5

Tibial tunnel is parallel and posterior to Blumenstaat's line when knee is fully extended

8%

(60/773)

L 1 C

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(OBQ04.91) 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? Review Topic | Tested Concept

QID: 1196
FIGURES:
1

Grade IIB Lachman

6%

(57/950)

2

Presence of pivot shift

32%

(305/950)

3

Tenderness over MCL origin without opening on valgus

3%

(25/950)

4

Positive Ober test

1%

(9/950)

5

Painful pop on McMurray test

58%

(549/950)

L 2 D

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(SBQ04SM.32) In biomechanical testing, which of the following tissues has the highest maximum load to failure? Review Topic | Tested Concept

QID: 5
1

Quadruple semitendinosus and gracilis tendons

72%

(1553/2153)

2

Bone-patellar tendon-bone with a width of 10 mm

16%

(335/2153)

3

Bone-quadriceps tendon with a width on 10mm

3%

(66/2153)

4

Tibialis tendon allograft

1%

(26/2153)

5

Native anterior cruciate ligament (ACL)

7%

(157/2153)

L 2 C

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(OBQ04.56) 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? Review Topic | Tested Concept

QID: 2
1

Femoral tunnel drilled too anteriorly

28%

(607/2157)

2

Failure to cycle the knee prior to final tibial fixation

5%

(106/2157)

3

Femoral tunnel drilled too vertically

10%

(213/2157)

4

Tibial tunnel drilled too vertically

2%

(49/2157)

5

Tibial tunnel drilled too anteriorly

54%

(1171/2157)

L 4 B

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(OBQ04.240) In laboratory testing of quadrupled hamstring grafts (doubled over semitendinosis and gracilis), all of the following statements are true EXCEPT: Review Topic | Tested Concept

QID: 1345
1

Two equally tensioned semitendinosus strands have an average of 220 percent of the strength of one semitendinosus strand

5%

(35/685)

2

Single semitendinosis strand has a higher tensile strength than a single gracilis strand

5%

(32/685)

3

All strands of a hamstring graft must be equally tensioned to achieve optimum biomechanical properties

7%

(51/685)

4

Quadrupled grafts have tensile properties that are higher than 10mm patellar-ligament grafts

16%

(107/685)

5

Quadrupled hamstring grafts have lower tensile strength than the native ACL

66%

(454/685)

L 2 C

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(OBQ04.19) 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? Review Topic | Tested Concept

QID: 130
1

Ice, NSAIDS, elevation, compression wrap and restart therapy once symptoms improve

30%

(209/699)

2

Recommend immediate knee aspiration with gram stain and cultures

63%

(441/699)

3

Increase CPM use to 10 hours a day

0%

(2/699)

4

Call the office staff in the morning to schedule an appointment

6%

(42/699)

5

Start physical therapy visits once daily

0%

(3/699)

L 2 D

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(OBQ04.212) 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? Review Topic | Tested Concept

QID: 1317
FIGURES:
1

Figure A

88%

(2050/2324)

2

Figure B

2%

(58/2324)

3

Figure C

5%

(105/2324)

4

Figure D

2%

(48/2324)

5

Figure E

2%

(54/2324)

L 1 C

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(OBQ04.258) 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? Review Topic | Tested Concept

QID: 1363
1

Incision for an anteromedial portal with the knee flexed

6%

(38/627)

2

Incision for an anteromedial portal with the knee extended

10%

(62/627)

3

Incision for an accessory medial portal the with knee flexed

10%

(64/627)

4

Hamstring harvest with the knee extended

71%

(443/627)

5

Tibial tunnel aperture fixation with the knee at 30 degrees of flexion

2%

(15/627)

L 2 C

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(OBQ04.262) Which of the following physical exam maneuvers would be MOST expected for a patient with the following radiograph? Review Topic | Tested Concept

QID: 1367
FIGURES:
1

Positive Lachman's test

83%

(1461/1758)

2

Positive McMurray's test with leg internally rotated

2%

(31/1758)

3

Positve McMurray's test with leg externally rotated

3%

(51/1758)

4

Positive external rotation dial test with knee flexed at 30 degrees

8%

(138/1758)

5

Positive external rotation dial test with knee flexed at 30 degrees and 90 degrees

4%

(74/1758)

L 2 C

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(OBQ04.246) 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? Review Topic | Tested Concept

QID: 1351
1

BTB autograft is biomechanically stronger than quadrupled hamstring autograft

4%

(38/912)

2

BTB autograft shows less evidence of post-operative pivot shift

1%

(10/912)

3

Quadrupled hamstring autograft shows lower rate of graft failure

3%

(28/912)

4

BTB shows higher incidence of anterior knee pain

90%

(821/912)

5

Quadrupled hamstring autograft shows lower incidence of knee hardware removal

1%

(5/912)

L 1 C

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(OBQ03.166) A patient undegoes an uncomplicated anterior cruciate ligament reconstruction. Which of the following activities are generally not recommended during the first 6 weeks of physical therapy? Review Topic | Tested Concept

QID: 3
1

Patellar mobilizations

1%

(5/662)

2

Passive extension

3%

(19/662)

3

Heel slides to improve flexion

5%

(36/662)

4

Isometric quadriceps strengthening

16%

(109/662)

5

Isokinetic quadriceps strengthening

74%

(488/662)

L 2 C

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