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Cervical Spine Anatomy

Chapter Preview Chapter Synopsis An expert understanding of cervical anatomy is critical to a spine surgeon operating in this region. An understanding of this anatomy is essential for surgical technique and diagnosis of pathologic processes. This chapter is a review of cervical spine osteology, ligaments, muscles, and neurovascular structures. Important Points The ringlike structures of the atlas (C1) and axis (C2) are unique as compared with…

Biologics and injection therapy for the management of osteoarthritis

OVERVIEW Chapter synopsis Osteoarthritis (OA) is a progressive degenerative joint disease that leads to considerable disability and plagues our aging population with pain and impaired function. There are currently no treatments that reverse or halt the progression of osteoarthritis. Various injection therapies have been developed, and biologic interventions continue to be investigated, showing early promising results. Important points Although there is conflicting evidence whether they are…

Management of proximal tibiofibular joint instability

OVERVIEW Chapter synopsis Proximal tibiofibular joint instability is an uncommon injury that can often be difficult to diagnose. Anterior instability is the most common pattern of instability involving disruption or attenuation of the posterior ligaments. If conservative treatment fails, anatomic reconstruction of the posterior ligaments can restore stability and reduce symptoms. Important points The presentation is often atraumatic or confusing in nature Conservative treatment methods should…

Management of arthrofibrosis of the knee

OVERVIEW Chapter synopsis Arthrofibrosis of the knee is a preventable complication that presents many challenges to the treating physician. Effective treatment involves working closely with rehabilitation staff, with the overall objective being to regain symmetrical knee extension, knee flexion, and strength. A classification system for arthrofibrosis, step-by-step treatment methods, and results of this treatment approach are presented in this chapter. Important points Prevention is the best…

Complex decision-making in patellofemoral surgery and anteromedial tibial tubercle transfer

OVERVIEW Chapter synopsis In patellofemoral surgery, complex decision-making is common, given the variability of anatomic, structural, psychosocial, and functional factors pertaining to patellofemoral disorders. History and physical examination are always important. Listening closely to the patient is essential regarding the patellofemoral joint, as most patients will lead you directly to logical decisions despite previous misdiagnosis or inaccurate surgery. Only precise radiographs are acceptable in defining patellofemoral…

Distal realignment for patellofemoral disease

OVERVIEW Chapter synopsis Tibial tuberosity osteotomy (TTO), often performed in conjunction with other proximal realignment procedures, is an effective treatment to address patellofemoral instability, patellar and trochlear focal chondral defects, and patellofemoral arthritis. TTO is a powerful tool that can normalize patellar tracking, alter patellofemoral forces, and optimize loads across the patellofemoral joint in patients with patellofemoral disease. Patellofemoral pathology is often multifactorial in nature. Proper…

Sulcus deepening trochleoplasty: Open and arthroscopic techniques

OVERVIEW Chapter synopsis Trochlear dysplasia has been recognized as the most common anatomical anomaly associated with recurrent lateral patellar dislocation. A thorough physical exam and imaging evaluation is important to identify the small percentage of patients with high-grade trochlear dysplasia amenable to surgical intervention. Trochleoplasty is a technically challenging procedure and a number of open and arthroscopic techniques have been described. The Dejour sulcus-deepening trochleoplasty is…

Lateral patellofemoral ligament reconstruction for medial patellar iatrogenic instability

OVERVIEW Chapter synopsis Important points Indications Patients with medial patellar subluxation or dislocations Patients with excessive lateral patellar laxity undergoing medial patellofemoral ligament reconstruction Relative contraindications Unaddressed symptomatic patellofemoral chondral damage Surgical technique Soft tissue-based reconstruction with a semi-tendinosis allograft Along the extensor mechanism, the graft is fixated through the distal aspect of the quadriceps tendon and proximal aspect of the patellar tendon The graft is…

Medial patellofemoral ligament reconstruction and repair for lateral patellar instability

OVERVIEW Chapter synopsis The medial patellofemoral ligament (MPFL) is the primary soft tissue restraint to lateral patellar translation. The MPFL is often injured with a first-time lateral patellar dislocation. Rehabilitation is the mainstay of treatment for first-time patellar dislocation; however recurrent patellar instability results in substantial morbidity in active individuals. MPFL reconstruction has become the cornerstone of surgical stabilization of the patella for recurrent lateral patellar…

Managing the lateral side of the patellofemoral joint

OVERVIEW Chapter synopsis Pathologic tightness of the lateral retinaculum can result in maltracking and hypercompression. After clinical assessment of overall bony alignment and integrity of chondral surfaces, the patient may benefit from a procedure addressing the lateral side of the patellofemoral joint. In this chapter, lateral retinacular lengthening and release techniques are described. Based on outcomes, lengthening is strongly recommended over release to decrease the risk…

Multiligament knee reconstruction: Avoiding tunnel convergence and optimal graft fixation order

OVERVIEW Chapter synopsis When reconstructing several knee ligaments, there is an increased risk of reconstruction tunnel convergence on both the tibia and femur; therefore, planning tunnel position and orientation is crucial. Tunnel convergence can compromise ligament reconstructions and fixation, ultimately leading to reconstruction graft failure. The ligament tensioning sequence influences the final tibiofemoral orientation and knee kinematics. Important points A comprehensive physical exam, stress x-rays, and…

Medial collateral ligament and posteromedial corner repair and reconstruction

OVERVIEW Chapter synopsis When the conservative management of medial collateral ligament (MCL) tears fails or, in severe cases, if valgus gapping is present in full extension, an anatomic medial knee reconstruction technique is preferred. This technique provides quality restoration of knee static function, improves overall knee stability, allows for immediate postoperative knee motion during subsequent physical rehabilitation, and reduces the risk of postoperative stiffness complications that…

Posterolateral corner reconstruction: Indications and techniques

OVERVIEW Chapter synopsis Posterolateral corner (PLC) injuries are rare and usually part of a multiligament injury pattern. If left untreated, these injuries may result in chronic pain, instability, failure of cruciate ligament reconstruction grafts, and failure to return to work or sports. The authors’ preferred reconstruction technique utilizes a single Achilles tendon allograft to reconstruct the lateral collateral ligament (LCL), popliteofibular ligament (PFL), and popliteus tendon,…

Arthroscopic posterior cruciate ligament inlay

OVERVIEW Chapter synopsis Several techniques for posterior cruciate ligament reconstruction have been developed. Historically, the arthroscopic approach have been first proposed, then the inlay open approach has been popularized in order to overcome the disavantages of the arthroscopic technique. Hybrid approaches combining the arthroscopic technique with an inlay graft fixation have been recently proposed for achieving the best of the two systems. Important points Indications for…

Posterior cruciate ligament tibial inlay

OVERVIEW Chapter synopsis Posterior cruciate ligament (PCL) injury can occur in isolation or as part of a complex multiligamentous knee injury. The PCL tibial inlay technique avoids the “killer turn” of the transtibial PCL reconstruction. This chapter details PCL reconstruction with an open single-bundle tibial inlay technique using bone–patellar tendon–bone (BPTB) autograft that has been found to have favorable outcomes in the literature. This technique is…

Arthroscopic double-bundle posterior cruciate ligament reconstruction

OVERVIEW Chapter synopsis The goal of this chapter is to provide a review of diagnostic tools, surgical indications, and operative treatment of posterior cruciate ligament (PCL) injuries, focusing on arthroscopic double-bundle PCL reconstruction. Important points Isolated PCL injuries should be suspected in the context of hyperextension and dashboard injuries. However, the majority of PCL injuries occur in the context of multiligament injuries Clinical/surgical pearls Bilateral posterior…

Transtibial tunnel posterior cruciate ligament reconstruction

OVERVIEW Chapter synopsis The keys to successful posterior cruciate ligament (PCL) reconstruction are to identify and treat all pathologies, use strong graft material, accurately place tunnels in anatomic insertion sites, minimize graft bending, use a mechanical graft tensioning device, use primary and backup graft fixation, and employ the appropriate postoperative rehabilitation program. Adherence to these technical principles results in successful single- and double-bundle arthroscopic transtibial tunnel…

Combined anterior cruciate ligament reconstruction and high tibial osteotomy

OVERVIEW Chapter synopsis This chapter describes in detail the indications, surgical planning, and step-by-step procedure for combined anterior cruciate ligament (ACL) reconstruction and open wedge high tibial osteotomy (HTO). Important points All patients undergo preoperative planning, clinical examination, and patient-specific workup. Preoperative measurement of the degree of varus knee alignment is critical, and the correction angle is determined preoperatively for each case. Important factors that could…

Combined anterior cruciate ligament reconstruction and meniscal allograft transplantation

OVERVIEW Chapter synopsis Combined anterior cruciate ligament (ACL) and meniscal deficiency alters knee function and predisposes the patient to accelerated degenerative osteoarthritis. Combined ACL reconstruction (ACLR) with meniscal allograft transplantation (MAT) has been advocated to treat this combined deficiency. During combined MAT and ACLR, a size-matched meniscal allograft is transplanted into the appropriate compartment. With concomitant ACLR, utilize an autograft or allograft depending on patient’s factors…

Lateral extraarticular tenodesis: Techniques and outcomes

OVERVIEW Chapter synopsis Residual anterolateral rotatory laxity after anterior cruciate ligament (ACL) reconstruction (ACLR) has been shown to correlate with inferior outcomes. With further understanding of the importance of the anterolateral complex (ALC) in rotatory control of an ACL deficient knee, various methods of extraarticular augmentation procedures have been re-introduced. We describe our method of lateral extraarticular tenodesis (LET) in addition to a single bundle hamstring…