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Tibial Osteotomy

Arthritis and Malalignment The premise of knee osteotomy surgery is to correct malalignment at the site of the deformity and relieve pressure on the overloaded or arthritic compartment. In general, medial compartment osteoarthritis of the knee coexists with a varus knee secondary to deformity in the metaphysis of the tibia. The joint line is generally horizontal to the floor. Femoral varus is unusual but may occur…

Autologous Chondrocyte Implantation

Introduction Historical Perspective Autologous chondrocyte transplantation (ACT) has been known as autologous chondrocyte implantation (ACI) in North America. The technique as described by Peterson and co-workers was adapted by me after several visits to Sweden in the early 1990s ( Fig. 9.1 ). Since March 1995 after institutional review board approval in 1994, the technique of ACI was used to manage large acute and chronic focal…

Use of Fresh Osteochondral Allograft for Chondral and Osteochondral Defects in the Knee

Introduction Fresh osteochondral allografts are composite grafts consisting of a living mature hyaline cartilage portion anchored to a nonliving subchondral bone portion, forming an intact osteochondral functional unit that replaces a damaged corresponding tissue in the recipient joint. Increasing demand for allografts has been met with advancements in tissue procurement and increased availability of fresh donor tissue from commercial entities as opposed to university-based specialized transplantation…

Debridement, Microfracture, and Osteochondral Autograft Transfer for the Treatment of Cartilage Defects

All three techniques discussed in this chapter are treatment options for small articular cartilage defects, predominately because of their low invasiveness. Debridement is mostly indicated for the treatment of (1) incidental lesions discovered during surgery directed at other joint pathology, such as meniscectomy and ACL reconstruction; and (2) lesions in lower demand patients who are reluctant to undergo other cartilage repair procedures that are more invasive…

PRP, BMAC, Stem Cells, and Other Adjuvants and How They Affect Repair: Clinical Outcome Studies

Introduction Biological-based therapies are emerging as a promising alternative for treating articular cartilage degenerative defects and early osteoarthritis (OA). These treatments can reduce symptoms, restore joint function, and possibly prevent the progression of OA by delaying the need for metal resurfacing. Numerous biologic agents are currently used in clinical practice, ranging from platelet concentrates to minimally manipulated mesenchymal stromal cells (MSCs). These have been mostly successful…

Preclinical Evidence for Biologics in Cartilage Repair and Early Osteoarthritis

Introduction Numerous biologics have been investigated in vitro and in preclinical animal models and show significant promise as methods of cartilage repair or as treatments for osteoarthritis (OA). Although there is mounting preclinical and clinical evidence for the use of certain biologics in treating articular disease, data for each biologic should be carefully weighed against where and how the drug has been tested. In the laboratory,…

Patient Evaluation, Cartilage Defect, and Evidence: Putting It All Together

The Decision to Proceed with Joint Preservation The History To have a successful relationship with a patient, the desires, needs, and expectations of the patient must be balanced with what is possible. The surgeon must use his best judgment and draw upon the best available evidence, his own experience, and skills to match these goals. This is sometimes not possible and the patient should be referred…

Imaging: The Basis for a Sound Decision in Joint Preservation

Introduction Radiological assessment of the knee may provide a tremendous amount of information when proper radiographs are performed and a knowledge of patterns of wear are recognized. A standard series of digital radiographs that we perform at our center include a 54-inch anteroposterior (AP) axial alignment x-ray image (with radiographic markers for magnification), standing bilateral AP, 45-degree bent standing posteroanterior (PA) (Rosenberg views ), and a…

Cartilage Repair and Regeneration

Cartilage Structure and Function The Chondrocyte as an Anabolic/Catabolic Cell Chondrocytes are highly specialized cells that differentiate from clusters of mesenchymal cells during skeletal embryogenesis. The chondrocyte synthesizes and secretes the components of the extracellular matrix, primarily proteoglycans and type II collagen. Most of the immature cartilage is temporary and is replaced by bone during epiphyseal development, whereas the regions nearest the synovial cavity remain as…

Chondral Injury and Osteoarthritis: The Impact of Articular Cartilage Lesions

Introduction Damage to the articular cartilage comprises a spectrum of disease entities ranging from single, focal chondral defects to more advanced degenerative disease and end stage osteoarthritis (OA). Long implicated in the subsequent development of osteoarthritis, focal chondral defects result from various causative factors and those factors that may genetically predispose to early breakdown and wear. Genetics may predispose to early cartilage wear and OA in…

Sports Injuries of the Ankle

Participation in sports is associated with foot and ankle injuries; however, one does not need to be an athlete to experience a twisting, impaction, contusive, or repetitive traumatic event. In addition, some conditions are initiated by antecedent trauma; the history of the condition may be nonspecific, and symptoms of injury may have subsided (e.g., chondromalacia or osteochondritis dissecans of the ankle). Other than fractures or dislocations,…

Fractures and Dislocations of the Foot

Fractures of the Calcaneus Intraarticular Fractures Studies in fracture patterns, soft-tissue management, and outcomes of calcaneal fractures have led to debate about the optimal management of calcaneal fractures. Prospective randomized studies have shown equivocal outcomes with operative and nonoperative treatment. However, recent trends in the literature suggest that restoration of physiologic parameters of length, height, and alignment of the calcaneus may lead to better long-term results.…

Disorders of Nails

Deformities and diseases of the toenails are some of the most common and most disabling foot problems. They range from minor annoyances to severe life- or limb-threatening conditions, and abnormalities of the toenails can be a sign of a systemic disease process. Often the pain associated with nail disorders has a marked effect on individuals’ daily lives. A study of 55 patients with nail disorders found…

Neurogenic Disorders

Tarsal Tunnel Syndrome Anatomy and Etiology The tarsal tunnel is a fibroosseous tunnel within the posteromedial ankle and hindfoot in which the tibial nerve, posterior tibial artery, accompanying veins, posterior tibial tendon, flexor digitorum longus, and flexor hallucis longus tendons pass into the foot. The flexor retinaculum acts as the roof of this tunnel and extends from the medial malleolus to the medial side of the…

Diabetic Foot

Diabetic Foot Epidemiology The American Diabetes Association estimates that in 2015, 30.3 million Americans (9.4% of the population) had diabetes, with 84.1 million Americans over the age of 18 with prediabetes. The prevalence of diabetes in Americans aged 65 years and older is 25.2%, and it is the seventh leading cause of death in the United States. The prevalence has been increasing, from 24 million people…

Arthritis of the Foot

Inflammatory and Degenerative Arthritis Arthritis is a term used broadly to refer to joint pain and subsequent joint destruction, and it often is used to describe several different conditions that have the common characteristic of joint pain and destruction but different histopathology and underlying mechanisms. Because of these differences, the pharmaceutical treatment varies dramatically, but surgical treatment is relatively uniform and depends largely on underlying stability,…

Lesser Toe Abnormalities

Metatarsophalangeal Joint Instability Etiology Deformity of the lesser toes, particularly of the second toe, sometimes is related to instability of the metatarsophalangeal joint. This disorder, which ranges in severity from synovitis of the metatarsophalangeal joint to dislocation and chronic deformity (hammer toe, claw toe, or crossover toe), has become a well-recognized problem. Lesser toe deformities are frequent in women older than the age of 50 years…

Disorders of Tendons and Fascia and Adolescent and Adult Pes Planus

Disorders of the Posterior Tibial Tendon Chronic tenosynovitis (either traumatic, degenerative, or secondary to inflammatory arthritis), loss of continuity of the tendon (either complete or incomplete), and loss of the normal anatomic relationships of the tendon to its insertion or insertions (the accessory navicular) may render the posterior tibial tendon insufficient to perform its tasks of plantar-flexion, inversion, and stabilization of the medial longitudinal arch. For…

Disorders of the Hallux

Hallux Valgus (Bunion) Hallux valgus (lateral deviation of the great toe) is not a single disorder, as the name implies, but a complex deformity of the first ray that frequently is accompanied by deformity and symptoms in the lesser toes. Often the angle between the first and second metatarsals is more than the 8 to 9 degrees usually considered to be the upper limits of normal.…

Surgical Techniques

Preoperative Preparation Careful preoperative planning, a thorough knowledge of the pertinent anatomy, good surgical exposure, skill in the use of equipment, and elimination of distraction reduce the likelihood of an undesirable outcome after foot surgery. Careful preoperative planning requires knowledge of the indications and operative techniques, but it also consists of instrument selection, patient positioning, antiseptic preparation, prophylactic antibiotics, tourniquet use, anesthesia, risk factor optimization, and…