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Dislocations and Soft Tissue Injuries of the Knee

Pathology Relevant Anatomy Key Points Knee dislocations and knee instabilities are characterized by anterior, posterior, lateral, and medial directions. Combinations of the main components cause rotational instability. The anatomic areas of insertion are of paramount importance for both the reinsertion of a torn ligament and reconstruction. First-line management of knee dislocations is focused on vascular injuries, proper repositioning, and external fixation. Early refixation/reconstruction leads up to…

Patella Fractures and Extensor Mechanism Injuries

Anatomy The extensor mechanism of the lower leg consists of the following: 1. The four muscles of the quadriceps : Muscle Origin Rectus femoris Anterior inferior iliac spine/groove Vastus intermedius Anterior/lateral femur Vastus lateralis Greater trochanter/lateral lip of linea aspera of femur Vastus medialis (longus and obliquus) Intertrochanteric line/medial lip of linea aspera of femur 2. The quadriceps tendon is formed by the convergence of the…

Fractures of the Distal Femur

Pathology Relevant Anatomy The distal end of the femur traditionally encompasses the lower third of this bone. This zone varies greatly in the literature, from the distal 7.6 cm to the distal 15 cm of the femur; another definition is that the distal length is equal to the transverse diameter. This chapter deals only with fractures that involve the supracondylar (metaphyseal) and intercondylar (epiphyseal) areas of the distal…

Outlook for Tissue Engineering Strategies for Anterior Cruciate Ligament Reconstruction

Acknowledgments This chapter is adapted with permission from the following review paper: Leong NL, Petrigliano FA, McAllister DR. Current tissue engineering strategies in anterior cruciate ligament reconstruction. J Biomed Mater Res A . 2014;102:1614–1624. Introduction Anterior cruciate ligament (ACL) rupture is a common injury of the knee. Limitations of allografts and autografts in ACL reconstruction as well as recent advancements in biology and materials science have…

Growth Factors and Other New Methods for Graft-Healing Enhancement

Modern intra-articular anterior cruciate ligament (ACL) reconstructive techniques produce clinically stable ligament reconstruction in the majority of cases. In ACL reconstruction, however, the strength of the grafted tendon is reduced in the early phase after surgery, and then it gradually increases. A problem is that this graft remodeling occurs very slowly. The slow graft maturation may result in graft failure or elongation during the postoperative rehabilitation…

Extra-Articular Tenodesis and Anterior Cruciate Ligament Reconstruction: Techniques and Outcomes

Introduction Historically, anterior laxity in anterior cruciate ligament (ACL) deficient knees was treated surgically by isolated tenodesis, as described by Lemaire or MacIntosh. This procedure was largely abandoned in favor of single-bundle intra-articular ACL reconstruction, because although it effectively limited rotation of the tibial plateau relative to the femur, it only provided moderate control of anterior laxity. Since then, intra-articular ACL reconstruction has been the gold-standard…

Motion Analysis in Anterior Cruciate Ligament Deficient and Reconstructed Knees

Introduction Anterior cruciate ligament (ACL) rupture is a serious injury of the knee joint that results in instability. The stability of the knee thought to have an ACL injury is traditionally evaluated with an arthrometer (i.e., KT-1000) while the patient is relaxed in a supine position. The arthrometer provides the clinician with a quantitative measure of the amount of passive anterior translation between the femur and…

Treatment of Tibial Eminence Fractures

Introduction Tibial eminence fractures are bony avulsions of the anterior cruciate ligament (ACL) from its insertion on the intercondylar eminence of the tibia. The intercondylar eminence is a narrow, raised area between the medial and lateral tibial spines. Tibial eminence fractures, while an intra-articular injury, involve a nonarticular portion of the tibia. The ACL has a broad insertion along the anterolateral aspect of the medial tibial…

Stiffness: Prevention and Treatment

Introduction Motion loss after anterior cruciate ligament (ACL) reconstruction is a devastating complication that can compromise the patient’s ability to return to normal activity. It is a common complication of multiligament knee surgery but can also occur in the setting of isolated ACL reconstruction. An isolated cause of stiffness can sometimes be identified, but in many cases it is a combination of factors both mechanical and…

Anterior Knee Problems after Anterior Cruciate Ligament Reconstruction

Introduction The incidence of anterior knee problems such as pain, tenderness, crepitus, disturbed sensitivity, and inability to kneel or knee-walk after anterior cruciate ligament (ACL) reconstruction has been well documented. The grade of patient satisfaction after the procedure has been associated more strongly with the degree of anterior knee complaints than with any other variable. Pain when kneeling can be disabling for the patient, especially when…

Fracture Complications after Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) reconstruction is one of the most frequently performed operative procedures, with more than 100,000 reconstructions performed annually in the United States alone. Autogenous bone–patellar tendon–bone (BPTB) is one of the most frequently used graft choices by orthopaedic surgeons in the United States, Canada, and Europe. This procedure includes creation of large bony defects in the tibia, femur, and patella for graft harvesting…

Vascular Complications after Anterior Cruciate Ligament Reconstruction and Deep Venous Thrombosis Prophylaxis

Vascular complications after anterior cruciate ligament (ACL) reconstructions cause serious morbidity and potential mortality. Based on a systematic review of the literature, this chapter will present the current knowledge on arterial complications, venous thromboembolism (VTE), and thromboprophylaxis after arthroscopic ACL reconstruction. Arterial Complications Knee arthroscopy is generally a safe procedure with a low incidence of complications. The two largest studies to date report complication rates of…

Hardware Complications after Anterior Cruciate Ligament Reconstruction

Introduction A variety of autograft and allograft tissues can be used for reconstruction of the anterior cruciate ligament (ACL), and a number of different tools and techniques can be used to achieve graft fixation, whether bone to bone or tendon to bone. Commonly used fixation devices include interference screws (metallic and bioabsorbable), suspensory fixation (the Endobutton [Acufex Microsurgical, Mansfield, Massachusetts], RetroButton [Arthrex, Naples, Florida], ACL TightRope…

Numbness/Saphenous Nerve

Introduction Leg numbness due to nerve damage is one of the considerable complications after anterior cruciate ligament (ACL) reconstruction using both bone–patellar tendon–bone (BPTB) and medial hamstring tendons. Such patients especially complain of uncomfortable feelings when falling on their knees. Harvesting a BPTB graft includes risks of damaging nerves and causing sensory disturbance. Pagnani et al. pointed out the risk of saphenous nerve damage by harvesting medial…

Tunnel Widening after Anterior Cruciate Ligament Reconstruction

Introduction Tunnel widening after anterior cruciate ligament reconstruction (ACLR) has been noted for many years. Initially there were concerns that this widening would be progressive. However, it is now clear that tunnel widening only occurs in the first postoperative year and is not progressive after that period. A number of variables have been hypothesized to cause or contribute to tunnel widening. These include the following: 1.…

Osteoporosis after Anterior Cruciate Ligament Reconstruction

Anterior Cruciate Ligament Injuries And Their Treatment Anterior cruciate ligament (ACL) injuries are usually sustained by a young and active population, often under pressure to continue heavy labor or sports activities at a competitive or recreational level. The natural history of an ACL injury still remains unclear. Conservative (nonsurgical) treatment has been reported to produce unsatisfactory results, such as chronic instability, muscle weakness, and osteoarthritis (OA),…

Septic Arthritis in Anterior Cruciate Ligament Surgery

Introduction Septic arthritis (SA) following anterior cruciate ligament (ACL) surgery is an uncommon but serious complication. The infectious process, if not controlled adequately, will jeopardize integrity of the articular cartilage and lead to irreversible damage of the knee joint. The low prevalence of this complication limits the experience of any individual surgeon, and the relevant literature consists of series with relatively small numbers of patients treated…

Return to American Football after Anterior Cruciate Ligament Reconstruction

Introduction Anterior cruciate ligament (ACL) injury is one of the most common knee injuries encountered in sport today. These potentially devastating injuries occur in both contact and noncontact athletes, and can forever change the course of the affected athlete’s career. It is estimated that approximately 200,000 ACL tears occur annually in the United States, with a reported incidence in American football players of approximately 0.07 per…

Performance and Return to Sport after Anterior Cruciate Ligament Reconstruction in Skiers and Snowboarders

Introduction Anterior cruciate ligament (ACL) injuries are common injuries in both skiers and snowboarders. Skiers sustain ACL tears at a significantly greater rate than snowboarders. The incidence of ACL injury is increasing with time in these unique populations. Several mechanisms of ACL tear have been identified, both in the biomechanical laboratory setting and on the slopes via high-definition video analysis. A detailed history and physical examination,…