Day Abos #108 A (11/15 A & B 11/16) Daily Mastery Plan

Front 1

During (ACL) recon divergence b/t the graft & screw fixation w/in the bone tunnel can lead to complications. Which statements re: graft-screw divergence is true? 1-Risk of failure is eliminated using an accessory anteromedial drilling portal; 2-Complications occur > commonly with soft tissue grafts; 3-Loss of fix becomes a > risk if the graft-screw divergence is >30 deg; 4-Excessive graft-screw divergence > during tibial fix; 5-Graft-screw divergence is a CC of late failure of ACL recon

Back 1

divergence greater than 15-30 degrees from the trajectory of the femoral tunnel may lead to failure of fixation and early ACL failure. Technical tips to avoid this complication include: inserting the screw and drill from the same portal (no divergence at all), hyperflexing the knee when inserting the screw if the femoral tunnel was drilled through the tibial tunnel, and using a guide wire to help gauge mismatch,ACL.Ans3

Front 2

Hx:25yoM is s/p 1 yr p/(ACL) recon using (BTB) autograft, c/o persistent instability w/certain activities, operative dictation notes excellent stability intra-op w/ fem fix @ 12 o'clock position. Based on his fem tunnel position, his hx & PE are to reveal which? 1-(+) pivot shift test and instability with cutting activities due to failure to recon the posterolateral bundle of ACL; 2- (+) Lachman's test and instability with forw running activites due to failure to recons the anteromedial bundle -> ACL
3-(+) pivot shift test and instability with cutting activities due to failure to recon the anterolateral bundle of the ACL 4-(+) Lachman's test and instability with forward activites due to failure to recon posteromedial bundle of the ACL; 5-(+)pivot shift test and instability with forward running activities due to failure to recon the posterolateral bundle of the ACL

Back 2

reconstruction with 12 o'clock femoral fixation would lead to a vertically placed graft and result in continued instability with cutting activities, and a positive pivot shift exam due to failure to reconstruct the posterolateral bundle of the ACL. Current standards for anatomic ACL reconstruction stress the importance of more horizontal graft placement (10:30 in a right knee vs 1:30 in the left knee), to try and reconstruct both the anteromedial bundle which provides anterior-posterior stability, and the posterolateral bundle which provides the rotational stability. Improper femoral graft placement is one of the most common reasons for ACL revision surgery.Ans1

Front 3

23yo soccer player suffers an ACL rupture & undergoes recon. Post-op she begins a rehab program and PT develops a series of knee conditioning exercises Which exercises places the lowest strain in this patients properly placed ACL graft? 1-Isometric hamstring contractions @ 60 deg of knee flex; 2-Isolated quad contractions w/ the knee @ 30 deg of flex; 3-Simultaneous quad & hamstring contractions @ 15 deg of knee flex
4-Isolated quad contractions w/ the knee at 15 deg of flex; 5-Active resisted knee motion from terminal exten to 30 deg of flex

Back 3

Isometric hamstring contractions at 60 degrees of knee flexion will produce the lowest strain in this patient's ACL graft. Straight leg raises are also commonly used in post-ACL rehabilitation protocols as this exercise places little stress on an ACL graft.(isometric hamstring contractions at any angle), (isometric quadriceps, simultaneous quadriceps and hamstrings contraction), or involve active knee motion between 35 deg & 90 deg of flex..Ans1

Front 4

Tunnel malposition is 1^etiology for ACL graft failure. All are true of tunnel position EXCEPT: 1- Vertical placement of the fem tunnel can result in rotational instability & impingement against the PCL; 2- Ant placement of the fem tunnel can result in elongation of the graft; 3-Tib tunnel placement should be placed post to a line extending from Blumenstaat's line when the knee is in full ext; 4-Transtibial drilling through a tibia tunnel that is too far ant can result in a vertical (12:00) graft; 5-transtibial drilling through a tibia tunnel that is too far ant can result in an oblique (10:30 or 1:30 position) graft

Back 4

MC error in an ACL recon is to place either the tibial or femoral tunnel too anteriorly, leading to graft impingement and failure, his problem can also be avoided by drilling the femoral tunnel through a medial portal, if the tibial tunnel was placed >50% posteriorly along the length of the anterior tibial plateau, the incidence of rupture was 17% (11 of 66).Ans5

Front 5

Pts c/o numbness over the anterolateral aspect of the knee following ACL recon. This is MCly due to injury of which of the following? 1-Suprapatellar branch of the saphenous; 2-Infrapatellar branch of the saphenous; 3-The common peroneal; 4-The superficial femoral
5. The lateral femoral cutaneous nerve

Back 5

saphenous n arises as a division of the fem N, leaves the add canal b/t the tendons of the gracilis and semiT. It then divides into the main saphenous branch and the infrapatellar branch which crosses the knee below the patella, it can be injured when making the incision for the tibial tunnel or when harvesting hamstring or patellar tendon grafts, anteromedial pain and decreased sensation over the anterolateral infra-patellar area of the knee and leg, IBSN is often injured w/ the traditional vertical incision for central patellar tendon harvest, a horizontal incision may result in a lower injury rate but is technically more challenging.Ans2

Front 6

Incr ACL injury rates in women athletes vs. male athletes may be due to muscular imbalance and relative weakness in which muscle groups? 1- Quad
2-Hamstrings; 3-Gluteus muscles; 4-Adductors
5-Abdominals

Back 6

inc their quadriceps strength > their hamstring strength, putting them at risk for ACL injury, ACL prevention programs based on improving dynamic control of the knee by emphasizing hamstring strengthening should be instituted for girls after menarche, Strengthening and proprioreceptive control of the knee flexors/hamstrings protects against excessive or unopposed knee extensors which protect the ACL, hamstrings are responsive to changes induced by a plyometric jump-training program, but none of the closed chain tests employed in this study identified a meaningful change in performance capabilities..Ans2

Front 7

p/ ACL recon, which tests most closely correlates w/ pt satisfaction w/ their reconstructed knee? 1- KT-1000 manual maximum value; 2-Lachman's test
3-Ant drawer test; 4-Pivot shift test; 5-Cybex testing

Back 7

the pivot shift test was the only test significantly ass w/ pt satisfaction, knee giving away, difficulty cutting and twisting, activity limitation, sports participation, Lysholm score, and overall knee function. KT-1000 is an instrument to measure the anterior translation of the tibia.Ans4