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David Deehan, Philip Dobson and Daniel Hipps
KNEE II STRUCTURED SBA ANSWERS
1. Answer C. Posterolateral aspect of the medial
femoral condyle
Osteochondritis dissecans (OCD) is a condition
for which the aetiology remains unknown. It
affects subchondral bone and secondarily its overlying cartilage and is mostly found in the knee. It
can occur in adults, but is generally identified
when growth remains, when it is referred to as
juvenile OCD. As the condition progresses, the
affected subchondral bone separates from adjacent
healthy bone, and can lead to demarcation and
separation of its associated articular cartilage.
Early disease without separation of the lesion
results in pain. Separation of the lesion leads to
mechanical symptoms and swelling and, in
advanced cases, the formation of loose bodies.
Early identification of OCD is essential as
untreated OCD can lead to the premature degeneration of the joint, whereas appropriate treatment
can halt the disease process and lead to healing.
Establishing the stability of the lesion is a key
part of providing the correct treatment. Stable
lesions, particularly in juvenile patients, have
greater propensity to heal with non-surgical treatment, whereas unstable or displaced lesions usually require surgical management.
Most cases of OCD occur in the posterolateral
aspect of the medial femoral condyle (70%). It
occurs less frequently in other areas such as the
inferior central aspect of the lateral condyle (15%),
the patella (5–10%) and the trochlea (less than 1%)
(Jones & Williams 2016).
Jones MH, Williams AM. Osteochondritis
dissecans of the knee: a practical guide for surgeons. Bone Joint J. 2016;98-B:723– 729.
posterior cortex extension line, 2.5mm distal to
the posterior origin of the medial femoral condyle
and proximal to the level of the posterior point of
the Blumensaat line on a true lateral radiograph
(Stephen et al. 2012).
Stephen JM, Lumpaopong P, Deehan DJ,
Kader D, Amis AA. The medial patellofemoral
ligament: location of femoral attachment and
length change patterns resulting from anatomic
and nonanatomic attachments. Am J Sports Med.
2012;40:1871–1879.
Figure 7.10
Schöttle’s point
3. Answer D. Reduces shear force on the ACL
The larger the posterior slope, the greater the shear
forces on the ACL. Increased slope reduced shear
forces on the PCL. In cases of revision ACL surgery,
the degree ofposterior slope should be consideredto
reduce risk of further failure of reconstruction. An
2. Answer C. 1mm anterior to a line extended from
the posterior cortex, and 2.5mm distal to the
origin of the medial femoral condyle
Medial patellofemoral ligament (MPFL) reconstruction is an accepted treatment for recurrent
patellofemoral instability when patients have
normal alignment and deficient proximal medial
restraints. A malpositioned femoral tunnel will
often lead to poor outcomes.
Schöttle’s point was determined from a cada-
veric study of eight knees as the centre of the
MPFL insertion. It is 1mm anterior to the
144
Figure 7.11 Diagram illustrating an anterior closing-wedge HTO to
reduce the posterior tibial slope in the setting of ACL deficiency. (a)
The red arrows represent the function of the extensor mechanism of
the knee in the setting of ACL deficiency. (b) When the tibial slope is
increased there is an exaggeration of the effect of ACL deficiency. (c)
When the slope is reduced with an osteotomy this effect is
also reduced
Knee II Structured SBA
anteriorclosing wedge osteotomy willhave theeffect
of reducing posterior slope and conferring reduced
shear forces to the ACL graft (Amis 2013; Webb et
al. 2013; Bernhardson et al. 2019).
Amis AA. Biomechanics of high tibial osteotomy.
Knee Surg Sports Trauma Arthrosc. 2013;21:197–205.
Bernhardson AS et al. Tibial slope and its
effect on force in anterior cruciate ligament grafts:
anterior cruciate ligament force increases linearly
as posterior tibial slope increases. Am J Sports
Med. 2019;47:296–302.
Webb JM, Salmon LJ, Leclerc E, Pinczewski
LA, Roe JP. Posterior tibial slope and further
anterior cruciate ligament injuries in the anterior
cruciate ligament-reconstructed patient. Am J
Sports Med. 2013;41:2800–2804.
4. Answer B. Increasing valgus alignment and
increasing posterior tibial slope
Inadvertent increase of the posterior slope can
occur when medial opening wedge osteotomies
are performed on the proximal tibia. The crosssectional shape of the tibia is triangular, narrower
at the anterior aspect. This means that when performing opening wedge osteotomy, the opening
should be trapezoidal and slightly narrower
anteriorly than posteriorly (Weiler et al. 2022).
Figure 7.12 When the slope
is unchanged it should be a
trapezoid opening when seen
from the medial side. That is
your base measurement of
whether to increase or
decrease your slope
Weiler A et al. Significant slope reducti on in ACL
deficiency can be achieved both by anterior
closing-wedge and medial open-wedge high tibial
osteotomies: early experiences in 76 cases. Knee
Surg Sports Trauma Arthrosc. 2022;30:1967–1975.
5. Answer C. Reconstruction reduces risk of sec-
ondary meniscal injuries
The MRI scan demonstrates an ACL disruption.
Episodes of instability in an ACL deficient knee,
predispose the patient to secondary injuries to
chondral surfaces and menisci. A prospective
cohort study of 209 patients comparing ACL
reconstruction for high-risk patients and nonoperative management for low-risk patients
showed increased rates of secondary meniscectomy
in the low-risk patients compared with early ACLR.
Three further cohort studies, including one study
of 6576 active-duty military patients, supported the
principle that ACLR decreases the risk of subsequent meniscus surgeries (Giordano et al. 2023).
Giordano L, Maffulli N, Carimati G,
Morenghi E, Volpi P. Increased time to surgery
after anterior cruciate ligament tear in female
patients results in greater risk of medial meniscus
tear: a study of 489 female patients. Arthroscopy
2023;39:613–622.
6. Answer B. The ALB serves as the primary
restraint to tibial posterior translation at 90°
and the PMB is the primary restraint when the
knee is near to full extension
The two PCL bundles serve different functions
throughout the range of motion. The ALB is the
primary restraint to posterior translation at 90°.
The PMB functions similarly in near full extension
and also resists internal rotation at greater flexion
angles (Apsingi et al. 2008; Wang et al. 2014).
Apsingi S et al. The role of PCL reconstruc-
tion in knees with combined PCL and posterolateral corner deficiency. Knee Surg Sports Trauma
Arthrosc. 2008;16:104–111.
Wang JH et al. Effects of knee flexion angle
and loading conditions on the end-to-end distance
of the posterior cruciate ligament: a comparison of
the roles of the anterolateral and posteromedial
bundles. Am J Sports Med. 2014;42:2972–2978.
7. Answer D. Grade III MCL injury combined with
posterior oblique ligament injury
145
David Deehan, Philip Dobson and Daniel Hipps
In grade I injuries of the MCL, valgus gapping is
not apparent in stress radiography, although tenderness du e to injury is present on clinical exam.
In grade II injuries, increased gapping on valgus
stress may occur but a clear end point will be felt.
In grade III injuries, there is no clear end point on
valgus stressing and the degree of joint opening on
valgus stressing at 30° flexion is graded as 1+
(3–5mm), 2+ (6–10mm), 3+ (>10mm) compared
with the uninjured side. Valgus laxity in full extension can indicate injury to the posteromedial
structures or concurrent cruciate ligament injury
(Rocha de Faria et al. 2020).
Rocha de Faria JL et al. Stress radiography for
multiligament knee injuries: a standardized, stepby-step technique. Arthrosc Tech. 2020;9:e1885–
e1892.
8. Answer C. Combined MCL, posteromedial cap-
sule and posterior oblique ligament injury
Anteromedial instability is caused by injuries to
the posteromedial capsule, posterior oblique ligament and the superficial MCL. The anteromedial
drawer test can demonstrate this injury. The knee
is flexed to 90° and the tibia is externally rotated
10–15° while an anteromedial rotatory force is
applied, causing anterior subluxation of the
medial plateau when the posteromedial structures
are injured significantly. This test is commonly
confused with the posterolateral drawer test so it
is important to actively visualise the amount of
increased rotation and the location of the rotation
while performing this test.
With the posterolateral drawer test a coupled
posterior force and external rotation torque is
applied to the tibia to determine the amount of
rotation of the tibial tubercle that occurs compared with the distal femur. The starting point
for this test is similar to the posterior drawer test,
but the foot is externally rotated about 15°.
Increased external rotation at both 30° and 90°
of knee flexion resulting in a positive dial test is
also indicative of this injury. If the tibial plateau
shifts anteromedially, it is indicative of anteromedial instability, and if posterolateral subluxation
occurs, this is a sign of posterolateral instability
(Larson 1983).
With the dial test approximately 15° of
increased external rotation of a tibia on the femur
with a complete posterolateral corner injury
compared with the contralateral side at 30° of knee
flexion. With an isolated posterolateral corner
injury, when the knee is flexed at 90°, this difference between sides becomes about 5°. However,
when the PCL or the ACL are also injured, there
will be a similar amount of 15° of increased external rotation at 90° of flexion.
One of the important things to recognise with
the dial test, is that it can also be positive for an
isolated or combined medial knee injury. It is
important to concurrently assess for anteromedial
or posterolateral tibial rotation to determine if it is
a posterolateral or posteromedial (medial) knee
injury (Hughston et al. 1976).
Larson RL. Physical examination in the diagnosis of rotatory instability. Clin Orthop Relat Res.
1983;172;38–44.
Hughston JC, Andrews JR, Cross MJ, Moschi
A. Classification of knee ligament instabilities.
Part I. The medial compartment and cruciate ligaments. J Bo ne Joint Surg Am. 1976;58:159–172.
9. Answer B. Early MCL repair/reconstruction and
ACL reconstruction
Grade 3 MCL lesions will often heal successfully
with bracing, assuming they are treated acutely
and there is no Stener type lesion hindering
normal healing. Bracing strategies incl ude
allowing free ROM and restricting movement
within the range of 30–60° flexion. In the context
of a patient who plays sport involving pivoting
such as football and rugby, ACL insufficiency is
unlikely to be tolerated and reconstruction is likely
to required. Although bracing a grade III MCL
injury for 6 weeks is not unreasonable, bracing in
a fixed position, whether in full extension or at 30°
would be inappropriate, leading to stiffness and
muscle wasting. With a multiligament injury such
as this scenario, acute reconstruction of the ACL
and repair/reconstruction of the MCL is a reasonable option, especially in the context of an MCL
avulsion injury (Bollier & Smith 2014; Shultz et al.
2023).
Bollier M, Smith PA. Anterior cruciate liga-
ment and medial collateral ligament injuries. J
Knee Surg. 2014; 27 :359–368.
Shultz CL et al. Nonoperative management,
repair, or reconstruction of the medial collateral
ligament in combined anterior cruciate and
medial collateral ligament injuries – which is best?
146
Knee II Structured SBA
A systematic review and meta-analysis. Am J
Sports Med. 2023;3635465231153157.
10. Answer C. Popliteus tendon, fibular collateral
ligament and posterior cruciate ligament
reconstruction
The clinical findings are indicative of injuries to
the posterolateral corner and the PCL. The PLC
is a restraint to external rotation of the tibia. In
isolated PLC injuries, the dial test will show
significantly increased external rotation at 30°
of knee flexion, but not at 90° flexion when
compared with the uninjured contralateral limb.
In the context of combined PLC and PCL injuries there will also be significantly increased rotation at 90° of knee flexion. Lateral joint opening
on stress radiography of more than 4mm (side to
side difference) is in keeping with a grade III PLC
injury. An isolated PCL injury can produce a side
to side difference of 2m m (Wascher. 2004;
Apsingi et al. 2008).
Apsingi S et al. Control of laxity in knees
with combined posterior cruciate ligament and
posterolateral corner deficiency: comparison of
single-bundle versus double-bundle posterior
cruciate ligament reconstruction combined with
modified Larson posterolateral corner reconstruction. Am J Sports Med. 2008;36:487–494.
Wascher DC. In The Multiple Ligament
Injured Knee: A Practical Guide to Management
(ed. GC Fanelli), pp. 95– 110. New York:
Springer; 2004.
11. Answer C. Fibular collateral ligament and
popliteofibular ligament
This SBA describes the reverse pivot shift test.
When posterolateral corner incompetence is present, holding the knee flexed at 90° with a valgus
and external rotatory force applied will cause the
tibia to sublux posterolaterally. When the knee is
extended in the second part of the examination,
the ITB will pull the tibia forward again as it goes
from being a flexor to an extender of the knee
and a visible reduction of the tibia can occur
(LaPrade & Terry 1997). A positive test can however occur within a proportion of normal physiologically lax knees so it is important to compare
findings with the contralateral knee.
LaPrade RF, Terry GC. Injuries to the pos-
terolateral aspect of the knee: association of
anatomic injury patterns with clinical instability.
Am J Sports Med. 1997;25:433–438.
12. Answer C. Reconstruction of the fibular collat-
eral ligament and popliteus tendon
This represents a grade III PLC injury. Nonoperative management has demonstrated favourable results with minimal radiographic changes
and minimal symptoms at 8-year follow-up in
grade I and grade II PLC injuries. Grade III PLC
injuries managed conservatively have been shown
to have less favourable outcomes (Kannus 1989).
Kannus P. Nonoperative treatment of grade
II and III sprains of the lateral ligament compartment of the knee. Am J Sports Med. 1989;17
(1):83–88.
13. Answer B. ACL reconstruction with hamstring
graft and lateral extra-articular tenodesis
Several pieces of research have shown improved
outcomes of ACL and anterolateral ligament
(ALL) reconstruction compared with isolated
ACL reconstruction, with significantly reduced
risk of graft rupture in young patients.
Persistent anterolateral rotatory laxity following
isolated ACL reconstruction has been correlated
with poor clinical outcomes and graft failure.
Combined reconstruction is also less likely to
result in residual pivot shift.
Patients under the age of 25 with hyperlaxity
or high-grade pivot are reported to have better
outcomes when ACL reconstruction is combined
with lateral extra-articular tenodesis procedures
(Getgood et al. 2020).
The main indication for ALL reconstruction
is patients undergoing ACL reconstruction who
have specific risk factors that predispose them to
an increased risk of ACL graft rupture. These
factors include the following:
Young age (<20 years old).
Participation in pivoting sports or a high-
demand athlete.
Evidence of a high-grade pivot shift on
examination.
Evidence of a lateral femoral notch sign on
pre-operative imaging.
A Segond fracture.
Revision ACL reconstruction.
Chronic (>12 months) ACL injury.
147
David Deehan, Philip Dobson and Daniel Hipps
Getgood AMJ et al. Lateral extra-articul ar tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction:
2-year outcomes from the STABILITY Study
Randomized Clinical Trial. Am J Sports Med.
2020;48:285–297.
14. Answer D. Posterior and lateral to the medial
tibial eminence
The posterior root of the medial meniscus inserts
posterior to the medial tibial eminence. It is
lateral to the articular cartilage margin of the
posteromedial tibial plateau and anterioromedial
to the tibial insertion of the PCL. The insertion is
approximately 1cm posterior and 0.5cm lateral to
the medial tibial eminence (Johannsen et al.
2012).
Johannsen AM et al. Qualitative and quanti tative anatomic analysis of the posterior root
attachments of the medial and lateral menisci.
Am J Sports Med. 2012;40:2342–2347.
15. Answer A. Early surgical repair even if pain is
the only symptom
A full thickness radial root tear, or indeed any
full thickness radial tear affecting the meniscus
will defunction it. Separation of the meniscus at
the tear site relieves the meniscus of the hoop
stresses usually imparted on it and leads to
increased forces or contact pressures through
the articular cartilage on weight bearing
(Tachibana et al. 2017). Because of these factors,
it is important to identify these tears and consider early repair. Non-operative treatment of
Figure 7.13 Anatomy of the anterior and posterior root attachments of the medial and lateral menisci. The anterior lateral (AL) meniscal root
runs deeply beneath and overlap with the anterior cruciate ligament (ACL). The anterior medial (AM) meniscal root is depicted with the
supplemental fibres (SFs) that were observed to be anterior and distal to the central root. Anterior meniscal root structure is also described in
relation to pertinent bony and soft tissue landmarks. AC, articular cartilage; LTE, lateral tibial eminence; MTE, medial tibial eminence; PL root,
posterior lateral meniscal root; PM root, posterior medial meniscal root; TT, tibial tuberosity
148
Knee II Structured SBA
medial meniscus posterior horn root tears has
been shown to result in poor clinical outcomes
and accelerated development of osteoarthritis
(Badlani et al. 2013; Tachiban a et al. 2017).
Badlani JT, Borrero C, Golla S, Harner CD,
Irrgang JJ. The effects of meniscus injury on the
development of knee osteoarthritis: data from
the osteoarthritis initiative. Am J Sports Med.
2013;41:1238–1244.
Tachibana Y et al. Effect of radial meniscal
tear on in situ forces of meniscus and tibiofemoral relationship. Knee Surg Sports Traumat
Arthrosc. 2017;25:355–361.
16. Answer C. Meniscal allograft transplant
Meniscal allograft transplantation (MAT) was
developed for patients with an absence of meniscus to reduce pain, improve function, and potentially slow the rate of osteoarthritis (Smith et al.
2016). MAT can be considered in patients generally under the age of 40 with minimal or no
arthritis.
In 2015 the International Meniscus
Reconstruction Experts Forum (IMREF) produced
a consensus statement recommending the following
indications for MAT: Unicompartmental pain in
the presence of total or subtotal ‘functional’ meniscectomy, as a concomitant procedure to revision
anterior cruciate ligament (ACL) reconstruction to
aid in joint stability when meniscus deficiency is
believed to be a contributing factor to failure, as a
concomitant procedure with articular cartilage
repair in a meniscus-deficient compartment
(Getgood et al. 2017).
Getgood A et al. International Meniscus
Reconstruction Experts Forum (IMREF) 2015
Consensus Statement on the Practice of
Meniscal Allograft Tr ansplantation. Am J Sports
Med. 2017;45:1195–1205.
Smith NA, Parkinson B, Hutchinson CE,
Costa ML, Spalding T. Is meniscal allograft
transplantation chondroprotective? A systematic
review of radiological outcomes. Knee Surg
Sports Trauma Arthrosc. 2016;24:2923–2935.
17. Answer D. One stage revision, changing tibial
slope to 3° and increased femoral component
size
Increased flex ion gap and therefore flexion
instability, can be caused by resecting too much
bone from the posterior femoral condyles. This
could occur if the femur was not measured properly by the surgeon leading them to apply a
smaller cutting block for a smaller femoral component. An increased flexion gap can also occur
if a large posterior slope is cut into the tibia.
Typical cruciate retaining primary knee replacements are designed to be used with a tibial slope
of 0–5°. A larger slope causes the flexion gap to
increase with increasing flexion as femoral roll
back occurs. To restore stability to the patient in
this scenario, the large posterior slope should be
corrected. There is not enough information to
know if the femoral component has been undersized, but upsizing the femoral component in
isolation would not be appropriate in view of
the large posterior slope. Stability can be restored
without resorting to increasing constraint to the
level of a hinged prosthesis (Stambough et al.
2019).
Stambough JB, Edwards PK, Mannen EM,
Barnes CL, Mears SC. Flexion instability after
total knee arthroplasty. J Am Acad Orthop Surg.
2019;27:642–651.
18. Answer A. Isolated MPFL reconstruction
The patient’s Q angle and patella height are
within normal limits in this scenario. The
TTTG is not mentioned, but with a normal Q
angle, it is unlikely to be a significant factor.
Patients with TT-TG >20mm are usually managed with TTO treatment. Isolated MPFL construction for patients with an increased TT-TG
may result in lower post-operative outcomes and
subsequent instability.
Crossing sign is a feature of trochlea dysplasia and this is not present. Dysplasia is more
accurately assessed on an MRI scan. Other things
that can predispose to patella instability such as
valgus coronal alignment or increased femoral
anterversion are not mention ed. Based on the
information and options presented, in the context of recurrent dislocations, an isolated MPFL
reconstruction would be appropriate and this has
been shown to have good outcomes (Schneider et
al. 2016).
Isolated trochleoplasty is indicated for abn ormal patellar tracking with a J sign caused by
femoral trochlear dysplasia and radiographic evidence of trochlear dysplasia.
149
David Deehan, Philip Dobson and Daniel Hipps
Hughston osteotomy transfers the tibial
tubercle distally and medially. This improves
the TT-TG distance and also inferiorises the position of the patella and is a useful surgical procedure for severe patella alta. However, there is a
risk with this procedure of globally increased
patellofemoral contact pressure.
MPFL reconstruction may be indicated as a
treatment for patellar instability in the absence of
osseous abnormality such as patella alta, trochlear dysplasia, or TT-TG more than 15 mm.
Tibial tuberosity transfer is indicated for patellar
instability with abnormalities of patella height or
TT-TG. Where indications for both exist, they
may be combined with the objective of restoring
normal joint kinematics.
Schneider DK et al. Outcomes after isolated
medial patellofemoral ligament reconstruction
for the treatment of recurrent lateral patellar
dislocations: a systematic review and metaanalysis. Am J Sports Med. 2016;44:2993–3005.
19. Answer C. Tibial tuberosity distalisation and
MPFL reconstruction
This is potentially a controversial area. Some surgeons believe in correcting every abnormality present. Most would agree in a stepwise approach
and only employ more complex surgery in the
context of recurrence after reconstruction.
Patella alta is present in this case with a normal
TTTG. A crossing sign on X-ray suggests some
degree of trochlea dysplasia. This would require
further clarification with MRI. Many surgeons
would perform isolated MPFL reconstruction in
this scenario (not an option here) and some would
advocate for combining it with a tibial tubercle
distalisation procedure to correct patella alta (a
risk factor for recurrent dislocation) (SappyMarinier et al. 2019). Tibial tubercle medialisation
is not indicated with a normal TT-TG.
Sappey-Marinier E et al. Clinical outcomes
and predictive factors for failure with isolated
MPFL reconstruction for recurrent patellar
instability: a series of 211 reconstructions with a
minimum follow-up of 3 years. Am J Sports Med.
2019;47:1323–1330.
20. Answer B. Referral to physiotherapy
Despite the increased TTTG and patella alta,
conservative treatment should generally be the
management for first-time patella dislocations
(Vetrano et al. 2017). This can include functional
mobilisation with bracing or application of patellar tape. Immobilisation has been shown to be
associated with increased rates of recurrence and
should be avoided. Studies comparing MPFL
reconstruction and conservative treatment for
first-time patella dislocations have shown conflicting results.
Patella alta, trochlear dysplasia and increased
tibial tuberosity-trochlear grove (TT-TG) distance are major contributors of patella instability, alongside other minor factors, such as medial
patellofemoral ligament (MPFL) injury or dysplasia that impair the restrain forces acting on
the joint. In particular, patella alta, defined by a
Caton–Deschamps index (CDI) >1.2 was found
to be present in 24% of patients who suffered
patellar dislocation and in 3% of normal controls
(Caton et al. 1982).
For patients with recurrent patellar dislocation accompanied by patella alta and increased
TT-TG distance, MPFLR combined with tibial
tubercle transfer is preferred to MPFL reconstruction alone.
Caton J, Deschamps G, Chambat P, Lerat
JL, Dejour H. Les rotules basses. A propos de
128 observations [Patella infera. Apropos of 128
cases]. Rev Chir Orthop Reparatrice Appar Mot.
1982;68:317–325. [In French]
Vetrano M et al. I.S.Mu.L.T. first-time patel-
lar dislocation guidelines. Muscles Ligaments
Tendons J. 2017;7 :1–10.
21. Answer B. Continued conservative management
Surgical procedures that can potentially damage
the physis and lead to growth disturbance
should always be avoided in children if possible.
Therefore, tibial tuberosity transfer options and
MPFL reconstruction that involves drilling
close to the femoral physis should be avoided.
The patient here has slight valgus alignment but
this is unlikely to be contributing to his symptoms and the application of tethering 8 plates
is not indicated. Of the options presented,
continued physiotherapy is the most sensible.
There are soft tissue reconstructive options
available for skeletally immature patients with
recurrent disloca tions such as transfer of a strip
of the patella tendon, VMO advancement and
150
Knee II Structured SBA
lateral release, but these are n ot as effective as
anatomical reconstruction (Nelitz et al. 2013;
Vavken et al. 2013).
Nelitz M, Dreyhaupt J, Reichel H, Woelfle J,
Lippacher S. Anatomic reconstruction of the
medial patellofemoral ligament in children and
adolescents with open growth plates: surgical
technique and clinical outcome. Am J Sports
Med. 2013;41:58–63.
Vavken P et al. Treating patella instability in
skeletally immature patients. Arthroscopy
2013;29:1410–1422.
22. Answer C. Combined MCL and POL recon-
struction
The patient in this scenario displays clinical signs
of incompetence of the superficial MCL and the
posteromedial corner structures. He is 8 weeks
post injury and continued bracing at this stage is
unlikely to lead to healing. To restore knee stability, the sMCL and posterior oblique ligament
(POL) require reconstruction with graft (Cinque
et al. 2017).
Cinque ME et al. Posteromedial corner knee
injuries: diagnosis, management, and outcomes:
a critical analysis review. JBJS Rev. 2017;5:e4.
23. Answer D. Combined PCL and posterolateral
corner reconstruction
The dial test performed on this patient reveals
incompetence of the posterolateral corner of the
knee with increased external rotation at 30° of
knee flexion and combined PCL injury with
increased external rotation at 90° of knee flexion.
The quads active test performed in the scenario
also suggests PCL injury. Missing a PLC injury
or not reconstructing it puts a PCL reconstruction at increased risk of failure, and in an injury
such as this, all injured structures should be
reconstructed either as a one stage or two stage
procedure (Petrillo et al. 2017).
Petrillo S, Volpi P, Papalia R, Maffulli N,
Denaro V. Management of combined injuries of
the posterior cruciate ligament and posterolateral
corner of the knee: a systematic review. Br Med
Bull. 2017;123:47–57.
24. Answer C. Physiotherapy
This patient’ s symptoms have only been present
for 6 weeks. Whilst they may have radiological
signs of severe arthritis, it would not be appropriate to perform an osteotomy or arthroplasty
procedure at this time. Activity modification and
referral to physiotherapy would be the most
appropriate management at this stage (NICE
2022).
National Institute for Health and Care
Excellence (NICE) Osteoarthritis in over 16s:
Diagnosis and Management. PMID: 36745715.
London: NICE; 2022.
25. Answer C. Medial meniscal repair and ACL
reconstruction
The ‘double PCL’ sign as seen here is indi cative
of a bucket handle meniscus tear. In 80% of cases
this is the medial meniscus rather than the lateral. From the sagittal image provided, there is
no evidence of injury to the PCL (seen in this
slice). The ACL is not seen in the slice but of the
options given, medial meniscus repair and ACL
reconstruction is the option most likely to lead to
symptom improvement. Meniscal repair performed in the presence of ACL insufficiency is
more likely to fail, and unless the meniscus is
being resected due to it being irreparable, the
ACL should be reconstructed (when ruptured)
(Barber & Click,1997)(Westermann et al,2014)
Barber FA, Click SD. Meniscus repair
rehabilitation with concurrent anterior cruciate
reconstruction. Arthroscopy 1997;13:433–437.
Westermann RW et al. Meniscal repair with
concurrent anterior cruciate ligament reconstruction: operative success and patient outcomes at 6-year follow-up. Am J Sports Med.
2014;42:2184–
26. Answer D. Medial meniscal injury and ACL
rupture
In this coronal image, meniscal tissue can be seen
sitting in the femoral notch. The medial meniscal
rim is also small compared to the lateral meniscus suggesting medial meniscus injury. A tear
can also be seen in the meniscal rim. The ACL
can also be seen on this slice, although not as
clearly, but it is ruptured, and of the options
presented, there is only one which includes
medial meniscus injury.
27. Answer B. Low levels of vitamin D have been
shown to be associated with this condition
2192.
151
David Deehan, Philip Dobson and Daniel Hipps
Physeal closure is apparent and in skeletally
mature knee, OCDs are unlikely to heal spontaneously in the long term. Studies have also shown
that adults with OCD lesions treated conservatively develop arthritic changes 10 years earlier
than the normal population. A study by Bruns et
al. (2016) showed that 91% of consecutive patients
treated surgically have low levels of vitamin D.
Studies have shown an overall healing rate of over
60% in skeletally immature bone. There are multiple ways to treat such lesions including bone
grafting and fixation, OAT, osteochondral allograft and autologous chondrocyte implantation.
Bruns J, Wer ner M, Soyka M. Is vitamin D
insufficiency or deficiency related to the development of osteochondritis dissecans? Knee Surg
Sports Trauma Arthrosc. 2016;24:1575–1579.
28. Answer A. ACL rupture
The image shows a proximal rupture of the ACL.
There is haemarthrosis present in the knee, but on
this slice, there is no evidence of any other pathology.
29. Answer B. The posterolateral bundle is tight
and the anteromedial bundle is moderately lax
in full extension
The ACL is a primary stabiliser for anterior tibial
translation and a secondary restrain to internal
tibial rotation. It consists of the anteromedial
and posterolateral bundles. The posterolateral
bundle is tight in full extension and the anteromedial bundle is relatively lax. Transection of
either bundle will permit increased anterior tibial
translation, each with different effects at different
angles of knee flexion (Dargel et al. 2007).
Dargel J et al. Biomechanics of the anterior
cruciate ligament and implications for surgical
reconstruction. Strategies Trauma Limb Reconstr.
2007;2:1–12.
30. Answer A. Aggrecan is the primary proteogly-
can in cartilage and contributes to its net negative charge
Isotropic materials are materials whose properties remain the same when tested in different
directions. Cartilage is anisotropic, meaning it
has different mechanical properties depending
on the direc tion in which it is loaded.
Fibrocartilage can form following injury
which consists predominantly of type 1 cartilage.
Chondrocytes are derived from mesenchymal
stem cells. The deep zone contains the lowest
density of cells and the highest proteoglycan
content (Bhosale & Richardson 2008).
Bhosale AM, Richardson JB. Articular car-
tilage: structure, injuries and review of management. Br Med Bull. 2008;87:77–95.
31. Answer B. Bone grafting and fixation
The image shows an osteochondral fragment sitting at the front of the knee. Subchondral bone
and overly ing cartilage can be seen on the
rounded fragment. The source/defect is not seen
on this sagittal slice but it came from the medial
femoral condyle. This is a large fragment and
simply removing it will leave a sizeable defect in
the knee without any additional treatment. This
would potentially lead to ongoing symptoms and
accelerated medial compartment wear. Of the
options presented, debriding the bed of the
defect, bone grafting it and fixing the fragment
back is the most viable option (Makino et al.
2005; Cruz et al. 2016).
Cruz AI Jr, Shea KG, Ganley TJ. Pediatric
knee osteochondritis dissecans lesions. Orthop
Clin North Am. 2016;47:763–775.
Makino A, Muscolo DL, Puigdevall M,
Costa-Paz M, Ayerza M. Arthroscopic fixation
of osteochondritis dissecans of the knee: clinical,
magnetic resonance imaging, and arthroscopic
follow-up. Am J Sports Med. 2005;33:1499–1504.
32. Answer B. ACL reconstruction and MCL repair
The coronal image shows residual bone bruising/
oedema affecting the lateral femoral condyle, the
ACL can also be seen and is ruptured. There is
oedema along the MCL and distally the image is
suggestive of separation of the MCL from the
tibial insertion. Of the options presented, ACL
reconstruction and MCL repair would be most
appropriate (Rao et al. 2022; Shultz et al. 2023).
There is no evidence of malignancy.
Rao R, Bhattacharyya R, Andrews B, Varma
R, Chen A. The management of combined ACL
and MCL injuries: a systematic review. J Orthop.
2022;34,21–30.
Shultz, C. L. et al. Nonoperative management,
repair, or reconstruction of the medial collateral
ligament in combined anterior cruciate and medial
collateral ligament injuries – which is best?
152
(a) (b)
Knee II Structured SBA
Figure 7.14 II images of tibial spine
fixation. (a) anteroposterior; (b) lateral
A systematic review and meta-analysis. Am J Sports
Med. 2023;doi:10.1177/03635465231153157.
33. Answer A. Apply a smaller 4 in 1 femoral cut-
ting block and recut for a smaller femoral
component
A tight flexion gap suggests that not enough bone
has been resected from the posterior femoral condyles. Increasing thedistal femoral cutwill increase
the extension gap but not change the flexion gap.
Resecting more bone from the tibia will increase
both the flexion and extension gap. To resect more
bone from the posterior femoral condyles to
increase the flexion gap, the femoral component
must be downsized, so a smaller femoral cutting
block must be applied and further cuts made.
34. Answer E. Resect more tibia
In order to increase the flexion and extension gap
with one step, more bone should be resected
from the tibia.
35. Answer E. Open reduction and internal fix-
ation, application of cylinder cast
The radiograph demonstrates a displaced tibial
spine avulsion injury. This is completely
displaced and would constitute a type 3 injury
as per the Myers and McKeever classification
in which type 1 fractures are minimally displaced
and type 2 fractures are hinged fragments,
where the anterior portion of the fragment is
displaced but the posterior portion remains
in continuity. Closed management is generally
appropriate for type 1 fractures and some
type 2 injuries. Meniscal entrapment frequently
makes closed reduction impossible in
displaced injuries (Kocher et al. 2003).
Fixation would be appropriate in this case (see
Figure 7.14).
Kocher MS, Micheli LJ, Gerbino P, Hresko
MT. Tibial eminence fractures in children:
prevalence of meniscal entrapment. Am J Sports
Med. 2003;31:404–407.
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