Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Diagnosis and Treatment of Complex Regional Pain Syndrome

Introduction Complex regional pain syndrome (CRPS) is the term that refers to a painful and disabling disorder that was first described during the United States Civil War. Nomenclature relating to CRPS has varied over the years and has included Sudeck's atrophy, reflex sympathetic dystrophy (RSD), posttraumatic dystrophy, and causalgia. CRPS has a variable presentation, and no single test exists to confirm the diagnosis. The disorder usually…

Knee Pain of Neural Origin

Introduction Critical Points Introduction Nerves are at risk of injury from: Blunt force directed at the knee Stretch/traction injury of the knee joint Inversion sprain to the ankle Open or arthroscopic knee surgery Approach: knee pain that exists after musculoskeletal treatment is of neural origin. Decide whether pain is coming from direct damage to the cutaneous nerves about the knee or from an injury to one…

Prevention and Treatment of Knee Arthrofibrosis

Introduction Critical Points Introduction Arthrofibrosis implies a loss of knee flexion, extension, or both compared with the contralateral normal knee. Primary arthrofibrosis is caused by an exaggerated inflammatory response to an injury or surgical procedure followed by the production of fibroblastic cells and an increase in the deposition of extracellular matrix proteins. Proliferative scar tissue or fibrous adhesions form within the joint, which can be either…

Unicompartmental Patellofemoral Replacement

Indications Patellofemoral arthroplasty (PFA) is a viable option for symptomatic patients in whom severe joint damage and loss of joint space are present in the patellofemoral (PF) compartment but not the tibiofemoral compartments. Although early reports of this procedure were disappointing, improvements in product materials, design, and robotic technology, as well as a better understanding of patient indications, have improved the expected outcome. Critical Points Indications…

Patellofemoral Disorders: Correction of Rotational Malalignment of the Lower Extremity

Introduction What is Rotational Malalignment? The geometry of bones is normally viewed in the three cardinal planes: frontal (coronal), sagittal, and transverse (horizontal, Fig. 36-1 ). The mechanical axis of the lower extremity from the femoral head center to the talus center (sometimes referred to as the hip-knee-ankle [HKA] axis) needs to be viewed in each of the three planes to define alignment. In the frontal…

Operative Options for Extensor Mechanism Malalignment and Patellar Dislocation

Indications Critical Points Indications Majority of patients with patellofemoral disorders respond favorably to conservative measures. Surgery required for recalcitrant cases with specific anatomic abnormalities that require correction. Patellar malalignment: a translational or rotational deviation of the patella relative to any axis. Proximal realignment procedures alter the medial-lateral position of the patella through balancing of soft tissue restraints proximal to its inferior pole. Distal realignment procedures modify…

Aquatic Therapy for the Arthritic Knee

Introduction Water has been used for healing, spiritual, and religious purposes since at least 2400 bc . Water was used by the people of Asia to combat fevers as early as 1500 bc . Hippocrates (460-375 BC) used water for relief of muscle spasms and joint pain. For many years, water exercise was dismissed as a medical intervention and considered to be purely recreational. The advent…

Rehabilitation After Articular Cartilage Procedures

Introduction Articular cartilage defects of the knee appear to be an increasing cause of pain and functional disability in orthopedics and sports medicine. This pathology creates a significant challenge to the health care team, especially the physician who must decide on the appropriate treatment plan (see Chapter 31 ). The avascular nature of articular cartilage predisposes the individual to progressive symptoms and degeneration owing to the…

Osteochondral Grafts: Diagnosis, Operative Techniques, and Clinical Outcomes

Introduction Hyaline articular cartilage is an avascular and insensate tissue that allows low-friction transmission of physiologic loads in diarthrodial joints. Its functional structure ideally is maintained in homeostasis over the lifetime of an individual but remains incapable of mounting an effective repair response when injured in a skeletally mature adult. The treatment threshold for surgical intervention is not unequivocal, but patients with symptomatic lesions are generally…

Knee Articular Cartilage Restoration Procedures

Indications Critical Points Indications and Contraindications Indications Symptomatic full-thickness chondral defect Symptoms such as direct tenderness at lesion, activity-related weight-bearing pain, effusion, and response to injection Treat concomitant pathology (meniscus, alignment, ligament) Patient selection and addressing expectations are critical Contraindications Asymptomatic Patients unwilling or unable to comply with postoperative rehabilitation Uncorrected concomitant pathology (meniscus, alignment, ligament) Osteoarthritis Management of symptomatic focal chondral and osteochondral defects in…

Unicompartmental Knee Replacement for Varus or Valgus Malalignment

The senior author (Frank R. Noyes) has no conflict of interest directly or indirectly with the implant or robotic system mentioned in this chapter. Indications Tibiofemoral unicompartmental knee arthroplasty (UKA) is a viable option for patients in whom severe joint damage and complete loss of joint space is present in one tibiofemoral compartment. Although early reports of this procedure were disappointing, improved product materials and design,…

Correction of Hyperextension Gait Abnormalities: Preoperative and Postoperative Techniques

Introduction and Diagnosis Critical Points Introduction and Diagnosis Patients with chronic insufficiency of the lateral and posterolateral structures may develop a gait abnormality characterized by excessive knee hyperextension during the stance phase of the gait cycle. Gait abnormality is easily identifiable in the clinic: increased extension (>0 degrees) in the sagittal plane, associated varus recurvatum. Patients with knee hyperextension gait problems present with varying amounts of…

Rehabilitation After Tibial and Femoral Osteotomy

Clinical Concepts The protocol described in this chapter was designed for opening-wedge high tibial osteotomy (HTO) and distal femoral osteotomy (DFO). The operative techniques, detailed in Chapter 26 , prevent delayed union or nonunion and collapse at the osteotomy site and allow a rehabilitation program of immediate knee motion and early weight bearing, preventing the complications of arthrofibrosis and patella infera As discussed in Chapter 26…

Valgus Malalignment: Diagnosis, Osteotomy Techniques, and Clinical Outcomes

Introduction The use of osteotomies has decreased, particularly in North America, caused by the advent of more reliable and predictable arthroplasty solutions for younger and middle-aged patients with knee arthrosis. However, interest in osteotomy has recently undergone resurgence with the advent of cartilage repair procedures, increased understanding of multiligament knee instability in the context of malalignment, and loss of meniscal tissue and function. Fewer reports have…

Tibial and Femoral Osteotomy for Varus and Valgus Knee Syndromes: Diagnosis, Osteotomy Techniques, and Clinical Outcomes

Indications Critical Points Indications Varus osseous malalignment: weight-bearing line <50% of tibial width Mild to moderate symptomatic arthrosis medial tibiofemoral compartment Articular cartilage retained in medial tibiofemoral compartment To achieve normal limb alignment before: Medial meniscus transplant Articular cartilage restorative procedures Cruciate ligament or posterolateral reconstruction in double and triple varus knees Patients ≤50 years old, athletically active, wishing to maintain reasonable athletic pursuits High tibial…

Rehabilitation of Meniscus Repair and Transplantation Procedures

Clinical Concepts Critical Points Clinical Concepts Initial rehabilitation goal: prevent excessive compressive and shear forces through limited weight bearing General Postoperative Healing Expectations Rapid healing of peripheral meniscus repairs Delayed healing of complex meniscus repairs in middle third region Further delayed healing of meniscus transplants (1-2 yr) Preoperative patient counseling and education during entire rehabilitation program are paramount. Premature return to high-impact loading activities (jogging, deep knee…

Meniscus Transplantation: Diagnosis, Operative Techniques, and Clinical Outcomes

Indications Critical Points Indications Prior meniscectomy Age ≤50 years Pain in the meniscectomized tibiofemoral compartment No radiographic evidence of advanced joint deterioration; ≥2 mm of tibiofemoral joint space on 45-degree weight-bearing PA radiographs No or only minimal bone exposed on tibiofemoral surfaces Normal axial alignment BMI within normal range The meniscus performs important functions that are vital for the integrity of the articular cartilage of the human…

Meniscus Tears: Diagnosis, Repair Techniques, and Clinical Outcomes

Introduction The crucial roles of the menisci in the human knee are well understood and include load bearing, load transmission, shock absorption, knee joint stability, and lubrication and nutrition of articular cartilage. Meniscectomy frequently leads to irreparable joint damage, including articular cartilage degeneration, flattening of articular surfaces, and subchondral bone sclerosis. Poor long-term clinical results have been reported by many investigators following partial and total meniscectomy.…

Management of Acute Knee Dislocation Before Surgical Intervention

Introduction Knee dislocations are uncommon but serious injuries. These injuries not only pose a potential threat to the limb involved, but often result in long-term pain and functional disability. What was thought to be an injury pattern caused by high-energy collision in motor vehicles or in collision sports, has also emerged as a common diagnosis in the ever-increasing obese population. Although diagnosis and initial management principles…

Classification of Knee Dislocations

Introduction The concept of a dislocated knee has changed markedly over the past few decades. In 1971, Meyers and Harvey predicted that most orthopedists would not see more than one knee dislocation in their entire career. However, evidence indicates that knee dislocations are being seen with increasing frequency for a variety of reasons. Increasing trauma, the growing epidemic of obesity, changes in automotive design, and recognition…