SPORT
AAOS 2021
, SPORT – AAOS 2021
Q1 A 38-year-old man has increasing left knee pain and occasional instability. Several years earlier he
sustained a noncontact twisting injury to his knee. He had initial soreness and pain but was able to
resume his normal activities while avoiding sports. On examination, he has medial joint line tenderness,
a grade 2+ Lachman, and a slight varus thrust. His radiographs reveal mild-to-moderate medial
compartment osteoarthritis with varus alignment. In addition to ligament reconstruction, what surgical
treatment strategy is most likely to alleviate his pain and instability?
A. Distal femoral osteotomy
B. Total knee replacement
C. High tibial osteotomy (HTO), lateral closing wedge
D. HTO, medial opening wedge with decreased tibial slope
Correct answer : D
Explanation :
The patient had a previous anterior cruciate ligament (ACL) and posterolateral complex injury. With
chronic instability and osteoarthritis, the best option is HTO with a decrease in the tibial slope to reduce
anterior laxity. Distal femoral osteotomy is better suited to address valgus malalignment. The lateral
closing-wedge osteotomy would not allow for adequate correction of the tibial slope. If the patient
continues to experience instability following correction of the varus malalignment, reconstruction of the
ACL and posterolateral corner would be appropriate at that time.
Recommended Readings :
The patient had a previous anterior cruciate ligament (ACL) and posterolateral complex injury. With
chronic instability and osteoarthritis, the best option is HTO with a decrease in the tibial slope to reduce
anterior laxity. Distal femoral osteotomy is better suited to address valgus malalignment. The lateral
closing-wedge osteotomy would not allow for adequate correction of the tibial slope. If the patient
continues to experience instability following correction of the varus malalignment, reconstruction of the
ACL and posterolateral corner would be appropriate at that time.
Q2. A 14-year-old girl has a head-on-head collision while playing basketball. She had no loss of
consciousness but had persistent headaches for 2 weeks. The patient is now back to school and has no
headaches. What is the best next step?
A. Return to full basketball activity
B. Start light aerobic activity
C. Obtain baseline neuropsychological testing
D. MRI scan of the brain
Correct answer : B
Explanation :
Mild traumatic brain injury is common in the adolescent child. Neuropsychological examination is widely
used but, in this case, the patient is asymptomatic and has no baseline testing. There is a limited role for
MRI in the recovery process of concussions. Furthermore, higher levels of physical/cognitive activity
, SPORT – AAOS 2021
should be avoided due to their potential to increase total recovery time. In this scenario, a graduated
return to activity is most appropriate thus, the next appropriate step is to start light aerobic activity.
Recommended Readings : Shirley E, Hudspeth LJ, Maynard JR. Managing Sports-related Concussions
From Time of Injury Through Return to Play. J Am Acad Orthop Surg. 2018 Jul 1;26(13):e279-e286. doi:
10.5435/JAAOS-D-16-00684. PubMed
Brown NJ, Mannix RC, O'Brien MJ, Gostine D, Collins MW, Meehan WP 3rd. Effect of cognitive activity
level on duration of post-concussion symptoms. Pediatrics. 2014 Feb;133(2):e299-304. doi:
10.1542/peds.2013-2125. Epub 2014 Jan 6. PubMed
Majerske CW, Mihalik JP, Ren D, Collins MW, Reddy CC, Lovell MR, Wagner AK. Concussion in sports:
postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train. 2008 May-
Jun;43(3):265-74. doi: 10.4085/1062-6050-43.3.265. PubMed
Ruff RM. A friendly critique of neuropsychology: facing the challenges of our future. Arch Clin
Neuropsychol. 2003 Dec;18(8):847-64. PubMed
Q3. A 55-year-old woman with degenerative joint disease underwent total shoulder arthroplasty (TSA).
She was doing well without complications at her 2-week visit (Figures 1 and 2). She returned at 6 weeks
with increased pain, shoulder clicking, and difficulty with forward elevation and internal rotation. She
recalls slipping, and to prevent a fall, moved her arm suddenly to grab a rail. New radiographs are shown
in Figures 3 and 4. What is the best next step?
A. Revision to reverse shoulder arthroplasty
B. Electromyography
C. Subscapularis tendon repair
D. Closed reduction
Correct answer : C
Explanation :
The patient underwent TSA. At her regular 2-week follow-up appointment, radiographs show a reduced
glenohumeral joint. She then sustained a traumatic injury and the radiographs at her 6-week appointment
show anterior subluxation of the glenohumeral joint indicative of subscapularis insufficiency.
Subscapularis repair is the next best step in management, especially in this age group, with well-fixed and
well-aligned components.
, SPORT – AAOS 2021
Recommended Readings :
Gerber C, Yian EH, Pfirrmann CA, Zumstein MA, Werner CM. Subscapularis muscle function and structure
after total shoulder replacement with lesser tuberosity osteotomy and repair. J Bone Joint Surg Am.
2005 Aug;87(8):1739-45. PubMed
Caplan JL, Whitfield B, Neviaser RJ. Subscapularis function after primary tendon to tendon repair in
patients after replacement arthroplasty of the shoulder. J Shoulder Elbow Surg. 2009 Mar-Apr;18(2):193-
6; discussion 197-8. doi:10.1016/j.jse.2008.10.019. Epub 2008 Dec 31. PubMed
Buckley T, Miller R, Nicandri G, Lewis R, Voloshin I. Analysis of subscapularis integrity and function after
lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty using
ultrasound and validated clinical outcome measures. J Shoulder Elbow Surg. 2014 Sep;23(9):1309-17.
doi: 10.1016/j.jse.2013.12.009. Epub 2014 Mar 4. PubMed
Q4. Which factor increases the success rate associated with all-inside lateral meniscal repair?
A. Concomitant anterior cruciate ligament (ACL) reconstruction
B. Concomitant medial meniscus repair
C. Older patient age
D. Varus knee alignment
Correct answer : A
Explanation :
Decreased patient age, neutral alignment, and a concomitant ACL tear are associated with improved
success rates of meniscal repair. Meniscus tears on the contralateral side of the knee and articular
cartilage defects are not associated with improved healing rates.
Recommended Readings :
Toman CV, Dunn WR, Spindler KP, Amendola A, Andrish JT, Bergfeld JA, Flanigan D, Jones MH, Kaeding
CC, Marx RG, Matava MJ, McCarty EC, Parker RD, Wolcott M,Vidal A, Wolf BR, Huston LJ, Harrell FE Jr,
Wright RW. Success of meniscal repair at anterior cruciate ligament reconstruction. Am J Sports Med.
2009 Jun;37(6):1111-5. doi: 10.1177/0363546509337010. PubMed
Westermann RW, Wright RW, Spindler KP, Huston LJ; MOON Knee Group, Wolf BR. Meniscal repair with
concurrent anterior cruciate ligament reconstruction: operative success and patient outcomes at 6-year
follow-up. Am J Sports Med. 2014 Sep;42(9):2184-92. doi: 10.1177/0363546514536022. Epub 2014 Jul
14. PubMed
AAOS 2021
, SPORT – AAOS 2021
Q1 A 38-year-old man has increasing left knee pain and occasional instability. Several years earlier he
sustained a noncontact twisting injury to his knee. He had initial soreness and pain but was able to
resume his normal activities while avoiding sports. On examination, he has medial joint line tenderness,
a grade 2+ Lachman, and a slight varus thrust. His radiographs reveal mild-to-moderate medial
compartment osteoarthritis with varus alignment. In addition to ligament reconstruction, what surgical
treatment strategy is most likely to alleviate his pain and instability?
A. Distal femoral osteotomy
B. Total knee replacement
C. High tibial osteotomy (HTO), lateral closing wedge
D. HTO, medial opening wedge with decreased tibial slope
Correct answer : D
Explanation :
The patient had a previous anterior cruciate ligament (ACL) and posterolateral complex injury. With
chronic instability and osteoarthritis, the best option is HTO with a decrease in the tibial slope to reduce
anterior laxity. Distal femoral osteotomy is better suited to address valgus malalignment. The lateral
closing-wedge osteotomy would not allow for adequate correction of the tibial slope. If the patient
continues to experience instability following correction of the varus malalignment, reconstruction of the
ACL and posterolateral corner would be appropriate at that time.
Recommended Readings :
The patient had a previous anterior cruciate ligament (ACL) and posterolateral complex injury. With
chronic instability and osteoarthritis, the best option is HTO with a decrease in the tibial slope to reduce
anterior laxity. Distal femoral osteotomy is better suited to address valgus malalignment. The lateral
closing-wedge osteotomy would not allow for adequate correction of the tibial slope. If the patient
continues to experience instability following correction of the varus malalignment, reconstruction of the
ACL and posterolateral corner would be appropriate at that time.
Q2. A 14-year-old girl has a head-on-head collision while playing basketball. She had no loss of
consciousness but had persistent headaches for 2 weeks. The patient is now back to school and has no
headaches. What is the best next step?
A. Return to full basketball activity
B. Start light aerobic activity
C. Obtain baseline neuropsychological testing
D. MRI scan of the brain
Correct answer : B
Explanation :
Mild traumatic brain injury is common in the adolescent child. Neuropsychological examination is widely
used but, in this case, the patient is asymptomatic and has no baseline testing. There is a limited role for
MRI in the recovery process of concussions. Furthermore, higher levels of physical/cognitive activity
, SPORT – AAOS 2021
should be avoided due to their potential to increase total recovery time. In this scenario, a graduated
return to activity is most appropriate thus, the next appropriate step is to start light aerobic activity.
Recommended Readings : Shirley E, Hudspeth LJ, Maynard JR. Managing Sports-related Concussions
From Time of Injury Through Return to Play. J Am Acad Orthop Surg. 2018 Jul 1;26(13):e279-e286. doi:
10.5435/JAAOS-D-16-00684. PubMed
Brown NJ, Mannix RC, O'Brien MJ, Gostine D, Collins MW, Meehan WP 3rd. Effect of cognitive activity
level on duration of post-concussion symptoms. Pediatrics. 2014 Feb;133(2):e299-304. doi:
10.1542/peds.2013-2125. Epub 2014 Jan 6. PubMed
Majerske CW, Mihalik JP, Ren D, Collins MW, Reddy CC, Lovell MR, Wagner AK. Concussion in sports:
postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train. 2008 May-
Jun;43(3):265-74. doi: 10.4085/1062-6050-43.3.265. PubMed
Ruff RM. A friendly critique of neuropsychology: facing the challenges of our future. Arch Clin
Neuropsychol. 2003 Dec;18(8):847-64. PubMed
Q3. A 55-year-old woman with degenerative joint disease underwent total shoulder arthroplasty (TSA).
She was doing well without complications at her 2-week visit (Figures 1 and 2). She returned at 6 weeks
with increased pain, shoulder clicking, and difficulty with forward elevation and internal rotation. She
recalls slipping, and to prevent a fall, moved her arm suddenly to grab a rail. New radiographs are shown
in Figures 3 and 4. What is the best next step?
A. Revision to reverse shoulder arthroplasty
B. Electromyography
C. Subscapularis tendon repair
D. Closed reduction
Correct answer : C
Explanation :
The patient underwent TSA. At her regular 2-week follow-up appointment, radiographs show a reduced
glenohumeral joint. She then sustained a traumatic injury and the radiographs at her 6-week appointment
show anterior subluxation of the glenohumeral joint indicative of subscapularis insufficiency.
Subscapularis repair is the next best step in management, especially in this age group, with well-fixed and
well-aligned components.
, SPORT – AAOS 2021
Recommended Readings :
Gerber C, Yian EH, Pfirrmann CA, Zumstein MA, Werner CM. Subscapularis muscle function and structure
after total shoulder replacement with lesser tuberosity osteotomy and repair. J Bone Joint Surg Am.
2005 Aug;87(8):1739-45. PubMed
Caplan JL, Whitfield B, Neviaser RJ. Subscapularis function after primary tendon to tendon repair in
patients after replacement arthroplasty of the shoulder. J Shoulder Elbow Surg. 2009 Mar-Apr;18(2):193-
6; discussion 197-8. doi:10.1016/j.jse.2008.10.019. Epub 2008 Dec 31. PubMed
Buckley T, Miller R, Nicandri G, Lewis R, Voloshin I. Analysis of subscapularis integrity and function after
lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty using
ultrasound and validated clinical outcome measures. J Shoulder Elbow Surg. 2014 Sep;23(9):1309-17.
doi: 10.1016/j.jse.2013.12.009. Epub 2014 Mar 4. PubMed
Q4. Which factor increases the success rate associated with all-inside lateral meniscal repair?
A. Concomitant anterior cruciate ligament (ACL) reconstruction
B. Concomitant medial meniscus repair
C. Older patient age
D. Varus knee alignment
Correct answer : A
Explanation :
Decreased patient age, neutral alignment, and a concomitant ACL tear are associated with improved
success rates of meniscal repair. Meniscus tears on the contralateral side of the knee and articular
cartilage defects are not associated with improved healing rates.
Recommended Readings :
Toman CV, Dunn WR, Spindler KP, Amendola A, Andrish JT, Bergfeld JA, Flanigan D, Jones MH, Kaeding
CC, Marx RG, Matava MJ, McCarty EC, Parker RD, Wolcott M,Vidal A, Wolf BR, Huston LJ, Harrell FE Jr,
Wright RW. Success of meniscal repair at anterior cruciate ligament reconstruction. Am J Sports Med.
2009 Jun;37(6):1111-5. doi: 10.1177/0363546509337010. PubMed
Westermann RW, Wright RW, Spindler KP, Huston LJ; MOON Knee Group, Wolf BR. Meniscal repair with
concurrent anterior cruciate ligament reconstruction: operative success and patient outcomes at 6-year
follow-up. Am J Sports Med. 2014 Sep;42(9):2184-92. doi: 10.1177/0363546514536022. Epub 2014 Jul
14. PubMed
