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Multiligament Knee Injuries

Introduction Multiligament knee injuries (MLKIs) are a challenging clinical entity because of the increased number of ligaments involved, associated injuries, diagnosis, decision making about the optimal treatment and rehabilitation. These injuries are not as rare as previously reported; therefore a high level of suspicion and a thorough and systematic evaluation are mandatory to avoid missed or late diagnosis. Furthermore, some injuries may be misdiagnosed because about…

Anterolateral Ligament and the Anterolateral Corner

Introduction After the ‘rediscovery’ of the anterolateral ligament (ALL) by Claes et al. in 2013, there was considerable controversy regarding whether this structure even existed. Several authors reported that they were unable to identify its presence in a proportion of dissection specimens, or even at all. This confusion arose because of the complex anatomy of structures around the lateral epicondyle, inconsistent application of the nomenclature used in…

Posterolateral Corner of the Knee

Anatomy and Function The lateral aspect of the knee is composed of 28 unique structures that act as static and dynamic stabilisers of the knee during varus and rotational motion. To properly appreciate the anatomy and function of these structures, one must first understand the local bony anatomy. The opposing bony surfaces of the lateral femoral condyle and the lateral tibial plateau articulate in a convex…

Repair and Reconstruction of the Superficial Medial Collateral Ligament and the Posteromedial Corner

Introduction This chapter describes the clinical background for medial knee instability and the indications for surgical treatment of medial collateral ligament (MCL) and posteromedial corner injuries. Historically, treatment of acute medial collateral ligament injuries has focused on nonoperative therapies with early controlled motion with relatively good reported patient outcomes. However, more severe acute and symptomatic chronic medial knee injuries may require operative management. Injuries that involve…

Posterior Cruciate Ligament

Introduction The posterior cruciate ligament (PCL) is the largest and strongest ligament in the knee, with a unique innate healing capacity. Therefore, as opposed to other ligaments such as the anterior cruciate ligament (ACL), injuries to the PCL less commonly require surgical intervention. Nevertheless, when PCL tears are suspected, a conscientious clinical approach must be taken to not only diagnose these injuries, but to accurately discriminate…

Anterior Cruciate Ligament

Anatomy Two functional bundles of the anterior cruciate ligament (ACL), the anteromedial (AM) and posterolateral (PL), were first described in 1836 ( Fig. 6.1 ). On the femoral insertion site, two osseous landmarks can be identified. The lateral intercondylar ridge (i.e., ‘resident’s ridge’) is the anterior border of the ACL and runs from proximal to distal. The lateral bifurcate ridge is located between the AM and…

Mechanical Malalignment of the Knee Joint: How and When to Address

Introduction Complex knee injuries are an orthopaedic problem that require knowledge not only of soft tissue anatomy but also lower limb biomechanics and alignment to establish an appropriate management plan and optimal patient outcome. Malalignment of the lower extremities causes eccentric redistribution of normal stresses in the joints. This eccentric stress causes degeneration of cartilage and subchondral bone. Additionally, alignment of the knee has significant long-term…

Computed Tomography of the Knee Joint: Indications and Significance

Three-Dimensional Modelling and Printing in the Complex Knee There is a rapidly growing interest in three-dimensional (3D) modelling and printing in orthopaedic surgery. Advancements in imaging technology with the advent of 3D modelling and 3D printing have revolutionised the medical field and provided physicians with powerful new tools to treat complex injuries and deformities. The knee, being regarded as one of the most complex joints in…

Magnetic Resonance Imaging of the Knee: Conventional and Novel Techniques

MRI Basics Magnetic resonance imaging (MRI) provides a noninvasive means by which to achieve excellent visualisation of soft tissues with additional sensitivity to pathological bone marrow changes within the knee. Exploitation of inherent tissue relaxation characteristics allows for image sets with different contrasts to be generated. Relaxation in this context refers to the process of hydrogen nuclei (spins) returning to their equilibrium status after excitation with…

Plain Radiography of the Knee

Acknowledgement The authors thank Dr John W. Read for his contribution to this chapter in giving permission and rights to many of the images, which are taken from the book Atlas of Imaging in Sports Medicine, second edition, edited by J. Anderson and J. W. Read (McGraw-Hill, 2008). Plain radiography remains an important aspect in the diagnosis and treatment of knee conditions. A thorough understanding of…

Comprehensive Clinical Examination

Introduction Before the incorporation of advanced imaging modalities into routine clinical practice, clinicians were dependent on a detailed clinical history and examination for formulation of a treatment plan. Many examination manoeuvres have been validated clinically or biomechanically and allow the clinician to predict the location and severity of injury to structures and support the selection of imaging studies. Further, the clinician may use this opportunity to…

Surgical Treatment of Hand Infections

Because of their frequency and severity, hand infections are a surgical emergency. Despite being apparently benign, they should not be underestimated; they are the source of significant sequelae if treatment is not adequate and fast. Regular monitoring of the patient is essential to check the evolution towards recovery and to track the development of complications. The purpose of this chapter is not to discuss antibiotic therapy,…

Dressing

The application of a dressing marks the end of surgery and is in itself an art form. The dressing is the only part of surgery that the patient can visualize and immediately appreciate. For the patient it is the immediate benchmark of the quality of surgery received. It serves multiple functions that include support for the operated hand and protection of repairs. Immobilization of the hand…

The Tissue Bank

Multidigit injuries are common. An amputated finger that is not replantable becomes a privileged donor site for harvesting tissue for the reconstruction of neighboring fingers. This is a unique opportunity that must be seized at the time of the emergent procedure. The morbidity of the harvested finger is zero, and all innovative techniques are indicated to allow the salvageable neighboring fingers to benefit from this tissue…

Hand Replantations

Although the replantation of a hand is certainly spectacular, it may seem less demanding technically than a digital replantation. There are, however, many problems that remain to be solved, given the possibility of muscle ischemia, technical choices related to osteosynthesis of the radiocarpal and carpometacarpal skeleton, revascularization requirements, nerve repair and, finally, the treatment of soft tissue defects that accompany this type of trauma. General Principles…

Digital Replantations

Komatsu and Tamai performed the first successful replantation of a fully severed thumb in 1965. Since then, the field of digital replantation has evolved considerably. There has been extensive progress in terms of the development of suture materials, microsurgical instruments and microscopes. There are now organized microsurgical courses to specifically train surgeons to perform this type of surgery. This combined progress in microsurgical training of surgeons…

Nerve Injuries

Open nerve injuries must be viewed as genuine surgical emergencies. In other words, they should be operated on within the initial hours following the accident. First, it is in an emergency setting that the surgeon encounters the best conditions to ensure matched fascicular group alignment. Second, because associated injuries are common, revascularization of the nerve and its surrounding tissues decreases the epi- and perineural sclerosis from…

Nail Trauma

Anatomy and Physiology Physiology Although the nail no longer has a defensive role in humans, it nevertheless retains an important function. It is the only rigid element stabilizing the distal pulp of the fingers beyond the distal phalanx tuft. It limits pulp deformation and thus participates in allowing precise pinch. Certain actions such as picking up very small objects become difficult or impossible in the absence…

Temporary Amputations and Permanent Amputations

Whatever the level of mutilation and finger concerned, carrying out a digital amputation is a significant surgical procedure with functional consequences. We speak of “temporary” amputation when a subsequent reconstruction is planned. This is most often a microsurgical reconstruction by toe transfer. In these circumstances the surgical principles governing fashioning the stump are different from those observed when the digital amputation is permanent. It is therefore…

Injuries of the Extensor Apparatus

Extensor apparatus injuries are too often underestimated, especially in the fingers. Although a cursory clinical examination may give the impression of integrity, it is only a few weeks later that deformity in the digital chain (boutonnière, swan neck, etc.) appears, leading to a delayed diagnosis. This results in secondary surgery that can be more difficult to perform and is less likely to yield a satisfactory outcome.…