(SAE12SN.35) What is the most commonly involved level for brachial plexus stretch
injuries or "stingers" in younger athletes involved in collision sports? Review Topic
1 C3-4
2 C4-5
3 C5-6
4 C6-7
5 C7-T1
PREFERRED RESPONSE 3
The most commonly involved level for brachial plexus traction injuries in young
athletes is C5-6, ostensibly due to the greater mobility in the midcervical spine.
"Stingers" in older athletes may be due to foraminal stenosis in combination with
extension and nerve root compression.
(SAE08OS.83) A 32-year-old man has groin pain that is aggravated by sitting. A frog
leg lateral and an axial MR arthrogram with gadolinium are shown in Figures 26a and
26b. Nonsurgical management has failed to provide relief and it has been decided to
proceed with surgical intervention. The most appropriate surgical approach should
include Review Topic
1 total hip arthroplasty.
2 arthroscopic labral debridement alone.
3 arthroscopic labral repair alone.
4 posterior hip dislocation with labral repair and femoral osteoplasty.
5 anterior transtrochanteric hip dislocation with labral repair and femoral osteoplasty.
,PREFERRED RESPONSE 5
An anterior labral tear is present in the setting of cam-type acetabulofemoral
impingement. Although labral tears of the hip can occur spontaneously or secondary
to a traumatic episode, many labral tears are related to an underlying predisposing
anatomy such as dysplasia or impingement. Labral tears are often treated successfully
with nonsurgical management. When surgical treatment is indicated, it is generally
recommended to address the predisposing anatomy in addition to management of the
labrum. Cam-type impingement is addressed by removal of the prominent bone at the
junction of the femoral head and neck to prevent abnormal contact between the neck
and the rim of the acetabulum through a normal range of motion. Most of the data
supporting this procedure show that it has been performed with a trochanteric
osteotomy, allowing for an anterior dislocation of the femoral head without
interrupting the blood supply to the femoral head (branches of the medial circumflex
artery). Some authors have reported success with an all-arthroscopic approach. In
general, the outcome of labral repair has been more favorable than labral resection.
(OBQ14.51) A healthy, active collegiate soccer player returns to your office
approximately 10 months after returning to full play and 18 months after undergoing
ACL reconstruction with bone-patellar tendon-bone (BTB) autograft. The patient
reports landing awkwardly after a jumping for a ball and felt his knee give way. He
presents with pain, worse with weight bearing. On physical exam, there is a mild
effusion and a grade 2B Lachman. Radiographs are shown in Figure A. What is the
likely underlying cause of his current diagnosis? Review Topic
1 Inappropriately early return to play
2 Improper rehabilitation and conditioning
3 Unstable meniscal tear
4 Malpositioned tunnel
5 Inadequate graft sizing
,PREFERRED RESPONSE 4
The most common cause for early failure following ACL reconstruction is a
malpositioned tunnel.
Ideal tunnel placement on the femoral side should be at the approximately 2 o'clock
(for a left knee) or 10 o'clock (for a right knee) position on the lateral wall, which
facilitates a more horizontal, anatomic graft. On the tibial side, the tunnel trajectory in
the coronal plane should be about 60-75 degrees from the horizontal and the tunnel
entrance should be approximately 10-11mm from the anterior border of the PCL.
Noyes et al. emphasize the importance of anatomic reconstruction. They
recommended against using a transtibial tunnel to make the femoral tunnel because it
will result in a vertical orientation. The authors summarized and recommended the
use of individual drilling of each tunnel, and using a anteromedial portal to obtain the
ideal femoral tunnel.
Driscoll et al. compared the rotational properties of a BTB graft placed centrally in
the tibial footprint in both groups, but on the femoral side, placed in the anteromedial
aspect versus central portion of the ACL femoral origin. They noted a significantly
stronger resistance to rotational failure when placed centrally. Thus, noting the
importance of placing the graft anatomically, within the central areas of both the tibial
footprint and femoral origin.
Figure A exhibits malpositioned tunnels, both of which are too vertical. Illustration A
exhibits well-placed tunnels, with the horizontality exhibited on the femoral side and
approximately 75 degrees from the horizontal on the tibial side.
Incorrect answers:
Answer 1: Return to play remains a controversial topic where there is no high-level
evidence to decide the ideal time frame. This patient, however, is seemingly out long
enough to not sustain this tear.
Answer 2: Improper rehabilitation and conditioning may place the patient at risk for
re-injury. However, the most common cause for ACL graft failure is still
malpositioned tunnels, as noted in Figure A.
Answer 3: An unstable meniscal tear, even if it occurred, is not likely the correct
diagnosis simply because of the instability noted on exam.
Answer 5: It is difficult to assess the graft, however, the follow-up is too long for this
to be the cause. Smaller graft sizes would have been evident earlier and likely would
also have shown screw loosening/position change.
, (SAE08OS.199) When comparing gait parameters between a patient with an anterior
cruciate ligament (ACL) deficiency to a patient with a normal knee, the patient with
an ACL deficiency has which of the following? Review Topic
1 An absence of the normal internal rotation of the femur during the terminal swing
phase
2 An absence of the normal external rotation of the femur during the terminal swing
phase
3 Greater posterior translation of the femur during late swing
4 Greater knee flexion during midstance
5 Greater adduction of the hip
PREFERRED RESPONSE 1
During normal gait kinematics, the knee is in near full extension at heel strike with
relative internal rotation of the femur relative to the tibia. During midstance (swing
phase of the contralateral extremity), there is flexion of the knee and external rotation
of the femur relative to the tibia. In addition, in the normal knee there is relative
anterior translation of the tibia during late swing with contraction of the quadriceps.
Between heel strike and midstance there is posterior translation of the tibia relative to
the femur. In an ACL-deficient knee, there is abnormal kinematics characterized by
absence of the normal femoral internal rotation during the terminal swing phase.
Furthermore, there is decreased anterior translation of the tibia in late swing,
presumably an adaptive response with decreased quadriceps contraction and/or
increased hamstring contraction.
(OBQ14.201) The findings from the MRI depicted in Figure A have been shown to
predict which of the following outcomes after anterior cruciate ligament (ACL)
reconstruction? Review Topic
1 Increased risk of re-rupture
2 Higher quality of life scores
3 Increased antero-posterior laxity
4 Delayed recovery of range of motion
5 Increased risk of infection
injuries or "stingers" in younger athletes involved in collision sports? Review Topic
1 C3-4
2 C4-5
3 C5-6
4 C6-7
5 C7-T1
PREFERRED RESPONSE 3
The most commonly involved level for brachial plexus traction injuries in young
athletes is C5-6, ostensibly due to the greater mobility in the midcervical spine.
"Stingers" in older athletes may be due to foraminal stenosis in combination with
extension and nerve root compression.
(SAE08OS.83) A 32-year-old man has groin pain that is aggravated by sitting. A frog
leg lateral and an axial MR arthrogram with gadolinium are shown in Figures 26a and
26b. Nonsurgical management has failed to provide relief and it has been decided to
proceed with surgical intervention. The most appropriate surgical approach should
include Review Topic
1 total hip arthroplasty.
2 arthroscopic labral debridement alone.
3 arthroscopic labral repair alone.
4 posterior hip dislocation with labral repair and femoral osteoplasty.
5 anterior transtrochanteric hip dislocation with labral repair and femoral osteoplasty.
,PREFERRED RESPONSE 5
An anterior labral tear is present in the setting of cam-type acetabulofemoral
impingement. Although labral tears of the hip can occur spontaneously or secondary
to a traumatic episode, many labral tears are related to an underlying predisposing
anatomy such as dysplasia or impingement. Labral tears are often treated successfully
with nonsurgical management. When surgical treatment is indicated, it is generally
recommended to address the predisposing anatomy in addition to management of the
labrum. Cam-type impingement is addressed by removal of the prominent bone at the
junction of the femoral head and neck to prevent abnormal contact between the neck
and the rim of the acetabulum through a normal range of motion. Most of the data
supporting this procedure show that it has been performed with a trochanteric
osteotomy, allowing for an anterior dislocation of the femoral head without
interrupting the blood supply to the femoral head (branches of the medial circumflex
artery). Some authors have reported success with an all-arthroscopic approach. In
general, the outcome of labral repair has been more favorable than labral resection.
(OBQ14.51) A healthy, active collegiate soccer player returns to your office
approximately 10 months after returning to full play and 18 months after undergoing
ACL reconstruction with bone-patellar tendon-bone (BTB) autograft. The patient
reports landing awkwardly after a jumping for a ball and felt his knee give way. He
presents with pain, worse with weight bearing. On physical exam, there is a mild
effusion and a grade 2B Lachman. Radiographs are shown in Figure A. What is the
likely underlying cause of his current diagnosis? Review Topic
1 Inappropriately early return to play
2 Improper rehabilitation and conditioning
3 Unstable meniscal tear
4 Malpositioned tunnel
5 Inadequate graft sizing
,PREFERRED RESPONSE 4
The most common cause for early failure following ACL reconstruction is a
malpositioned tunnel.
Ideal tunnel placement on the femoral side should be at the approximately 2 o'clock
(for a left knee) or 10 o'clock (for a right knee) position on the lateral wall, which
facilitates a more horizontal, anatomic graft. On the tibial side, the tunnel trajectory in
the coronal plane should be about 60-75 degrees from the horizontal and the tunnel
entrance should be approximately 10-11mm from the anterior border of the PCL.
Noyes et al. emphasize the importance of anatomic reconstruction. They
recommended against using a transtibial tunnel to make the femoral tunnel because it
will result in a vertical orientation. The authors summarized and recommended the
use of individual drilling of each tunnel, and using a anteromedial portal to obtain the
ideal femoral tunnel.
Driscoll et al. compared the rotational properties of a BTB graft placed centrally in
the tibial footprint in both groups, but on the femoral side, placed in the anteromedial
aspect versus central portion of the ACL femoral origin. They noted a significantly
stronger resistance to rotational failure when placed centrally. Thus, noting the
importance of placing the graft anatomically, within the central areas of both the tibial
footprint and femoral origin.
Figure A exhibits malpositioned tunnels, both of which are too vertical. Illustration A
exhibits well-placed tunnels, with the horizontality exhibited on the femoral side and
approximately 75 degrees from the horizontal on the tibial side.
Incorrect answers:
Answer 1: Return to play remains a controversial topic where there is no high-level
evidence to decide the ideal time frame. This patient, however, is seemingly out long
enough to not sustain this tear.
Answer 2: Improper rehabilitation and conditioning may place the patient at risk for
re-injury. However, the most common cause for ACL graft failure is still
malpositioned tunnels, as noted in Figure A.
Answer 3: An unstable meniscal tear, even if it occurred, is not likely the correct
diagnosis simply because of the instability noted on exam.
Answer 5: It is difficult to assess the graft, however, the follow-up is too long for this
to be the cause. Smaller graft sizes would have been evident earlier and likely would
also have shown screw loosening/position change.
, (SAE08OS.199) When comparing gait parameters between a patient with an anterior
cruciate ligament (ACL) deficiency to a patient with a normal knee, the patient with
an ACL deficiency has which of the following? Review Topic
1 An absence of the normal internal rotation of the femur during the terminal swing
phase
2 An absence of the normal external rotation of the femur during the terminal swing
phase
3 Greater posterior translation of the femur during late swing
4 Greater knee flexion during midstance
5 Greater adduction of the hip
PREFERRED RESPONSE 1
During normal gait kinematics, the knee is in near full extension at heel strike with
relative internal rotation of the femur relative to the tibia. During midstance (swing
phase of the contralateral extremity), there is flexion of the knee and external rotation
of the femur relative to the tibia. In addition, in the normal knee there is relative
anterior translation of the tibia during late swing with contraction of the quadriceps.
Between heel strike and midstance there is posterior translation of the tibia relative to
the femur. In an ACL-deficient knee, there is abnormal kinematics characterized by
absence of the normal femoral internal rotation during the terminal swing phase.
Furthermore, there is decreased anterior translation of the tibia in late swing,
presumably an adaptive response with decreased quadriceps contraction and/or
increased hamstring contraction.
(OBQ14.201) The findings from the MRI depicted in Figure A have been shown to
predict which of the following outcomes after anterior cruciate ligament (ACL)
reconstruction? Review Topic
1 Increased risk of re-rupture
2 Higher quality of life scores
3 Increased antero-posterior laxity
4 Delayed recovery of range of motion
5 Increased risk of infection
