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Anterolateral ligament reconstruction in the setting of anterior cruciate ligament deficiency

OVERVIEW Chapter synopsis Anterolateral ligament reconstruction (ALLR) in the setting of anterior cruciate ligament reconstruction (ACLR) is a subject of debate. Recent studies showed good outcomes and low graft failure rates when ALLR was used in combination with ACLR. This chapter provides an overview of the ALL, its relevant clinical findings, surgical technique and outcomes. Important points Indications: A treatment algorithm recommended by the consensus of…

Primary anterior cruciate ligament repair

OVERVIEW Chapter synopsis Anterior cruciate ligament (ACL) repair is not new. It has mixed short- and long-term results reported. The potential benefit of proprioceptive preservation makes a successful repair very appealing in the treatment of ACL injuries. A number of arthroscopic techniques have recently been described and popularized, but none currently have sufficient clinical or biomechanical data to support widespread use. Important points Isolated ACL repair…

All-inside anterior cruciate ligament reconstruction: Second-generation minimally invasive anterior cruciate ligament reconstruction

OVERVIEW Chapter synopsis Important points An essential advantage of this all-inside GraftLink technique is the ability to retension the graft intraoperatively after final fixation. Specifically, this is done with the shortening strands of the ALD both on the femoral and tibial sides after putting the knee through a full range of motion and stressing the graft. In turn, this eliminates any creep in the construct to…

Anatomic anterior cruciate ligament concept: Single- and double-bundle anterior cruciate ligament reconstruction

OVERVIEW Chapter synopsis The goal of anatomic anterior cruciate ligament (ACL) reconstruction is functional restoration of the ACL to its native dimensions and insertion sites. Patient-specific factors, including age, activity level, and future goals are important considerations during preoperative planning. During image review and arthroscopic evaluation, specific measurements should be performed, including the femoral and tibial insertion sites, the intercondylar notch, and the widths of the…

Revision anterior cruciate ligament reconstruction

OVERVIEW Chapter synopsis Acute failure of an anterior cruciate ligament (ACL) reconstruction is most likely a result of a technical error, whereas failure at over 1 year is more commonly the result of a traumatic event. Regardless, a thorough evaluation of tunnel position, hardware and fixation, and concomitant pathology must be completed before any revision procedure. Important points After failure of an ACL reconstruction: If tunnel…

Allografts for anterior cruciate ligament reconstruction

OVERVIEW Chapter synopsis Anterior cruciate ligament (ACL) reconstruction remains one of the most frequently performed orthopedic procedures, and graft selection remains one of the most crucial preoperative treatment decisions. The use of allograft tissue has increased in the past decade for both primary and revision ACL reconstruction, as these tissues can play a role in the treatment algorithm based on patient age, activity level, and overall…

Quadriceps tendon harvest for anterior cruciate ligament reconstruction

OVERVIEW Chapter synopsis The quadriceps tendon provides a robust, safe, and easy-to-harvest graft for anterior cruciate ligament reconstruction. It may be used as an all-soft-tissue free tendon graft with predictable success and less pain than other autograft alternatives. Important points The quadriceps tendon is twice as thick as the patellar tendon, and therefore the surgeon may harvest a 10-mm-wide graft by carefully defining this desired thickness…

Anterior cruciate ligament reconstruction with hamstring tendon autograft

OVERVIEW Chapter synopsis This chapter details the arthroscopy-assisted technique of anterior cruciate ligament (ACL) reconstruction with a quadrupled hamstring autograft that is performed using independently drilled femoral and tibial tunnels. Specifics of graft harvesting, tunnel positioning, graft fixation, and rehabilitation are covered. Important points Harvest tendons carefully to maximize length. Know how to modify the graft if overall diameter is <8 mm Avoid graft impingement on…

Patellar tendon autograft for anterior cruciate ligament reconstruction

OVERVIEW Chapter synopsis The bone–patellar tendon–bone autograft is the most commonly used graft during the last 20 years and the graft of choice of physicians treating National Collegiate Athletic Association (NCAA) Division 1A and professional athletes. This is because of the graft’s ready accessibility, mechanical strength, and osseous tunnel integration. In this chapter, we highlight the harvesting procedure as well as transtibial and medial portal femoral…

Varus-producing distal femoral osteotomy

OVERVIEW Chapter synopsis This chapter will provide a discussion of varus-producing distal femoral osteotomy (DFO) for the correction of genu valgum. We begin by reviewing key concepts pertaining to clinical assessment of knee alignment. We then discuss indications and contraindications to DFO, followed by a detailed review of the surgical techniques for DFO. We conclude with a brief summary of currently reported clinical outcomes and complications…

Tibial slope modifying osteotomies

OVERVIEW Chapter synopsis This chapter focuses on proximal tibial osteotomies to correct sagittal tibial slope to address not only cruciate ligament (ACL or PCL) pathologies but also meniscal and cartilage deficiencies. Cruciate reconstructions have been shown to fail in patients with greater posterior tibial slope in the case of ACL reconstructed knees and in those with flat or decreased posterior tibial slope in PCL reconstructed knees.…

Lateral closing wedge high tibial osteotomy

OVERVIEW Chapter synopsis This chapter discusses the indications and contraindications for high tibial osteotomy (HTO) and highlights when a lateral closing wedge (LCW) may be preferable over a medial opening wedge (MOW). Our LCWHTO surgical technique is presented as well as a summary of published outcome data. Important points Opening and closing wedge HTOs simultaneously alter coronal and sagittal alignment. LCWHTO has a tendency to reduce…

Opening-wedge high tibial osteotomy

OVERVIEW Chapter synopsis Opening-wedge high tibial osteotomy (HTO) is a valuable technique to address coronal and sagittal malalignment of the lower limb with associated degenerative compartment changes of the knee as well as focal chondral defects. With use of appropriate indications and contraindications, good outcomes have been reported in the literature. In this chapter, we describe the surgical technique for medial opening-wedge high tibial osteotomy. Important…

Emerging techniques in management of cartilage injury of the knee

OVERVIEW Chapter synopsis Knee cartilage injuries present a great challenge for both clinicians in recent decades and may often lead to substantial morbidity, significant time away from work and sport, and possibly permanent disability. This chapter will review the current advanced and emerging strategies and techniques in the field of knee cartilage regeneration and restoration as well as the newest available and soon-to-be available techniques. Important…

Matrix-assisted autologous chondrocyte implantation in the knee

Overview Chapter synopsis MACI (autologous cultured chondrocytes on porcine membrane) is indicated for symptomatic full-thickness chondral defects of the knee in patients 18–55 years of age. Although diagnostic imaging and clinical examination are important, arthroscopic assessment provides the final confirmation of the appropriateness of this two-staged, surface-based treatment for cartilage restoration. A chondral biopsy is performed to obtain healthy autologous cartilage to grow sufficient cells for…

Osteochondral allografting in the knee

OVERVIEW Chapter synopsis This chapter summarizes the indications for, techniques to perform, and results of osteochondral allograft (OCA) transplantation for the treatment of symptomatic cartilage defects of the knee. Important points OCA is indicated for symptomatic, full-thickness chondral or osteochondral defects of the femur, tibia, or patella. The dowel technique is most commonly used. The shell or small fragment technique is useful for complex or large,…

Osteochondral autograft for cartilage lesions of the knee

OVERVIEW Chapter synopsis Osteochondral autograft transplant surgery (OATS) remains an important technique for medium (1 to 3 cm 2 ) chondral and osteochondral defects. When appropriate indications are met, very good success rates can be expected. Meticulous technique for single-plug or multiple-plug (“mosaicplasty”) transplant surgery is imperative to achieve a congruent articulation. Important points Physical examination findings are often unimpressive. Operative decision-making is based more on…

Microfracture and microfracture plus techniques in the knee

OVERVIEW Chapter synopsis Microfracture is a safe, minimally invasive, technically simple, and cost-effective marrow stimulation technique that provides effective short-term functional improvement of small to medium cartilage defects. Appropriate indications, attention to surgical detail, and well-structured rehabilitation help to optimize the outcome from this cartilage repair technique. Shortcomings include limited hyaline repair tissue, variable repair cartilage volume, subchondral bone changes, functional deterioration in some patients, and…

Osteonecrosis of the knee

OVERVIEW Chapter synopsis Osteonecrosis (ON) of the knee is a condition that can rapidly lead to end-stage osteoarthritis. It can be classified as primary, secondary, or post-arthroscopic. Surgical options include arthroscopy, core decompression, osteochondral grafting, re-alignment osteotomies, and prosthetic arthroplasty. While patient selection is critical, favorable outcomes have been reported for both non-surgical and surgical management of ON of the knee. Important points Spontaneous ON of…

Primary repair of osteochondritis dissecans in the knee

OVERVIEW Chapter synopsis Osteochondritis dissecans (OCD) is a pathologic process that results in the detachment of subchondral bone and its overlying articular cartilage from the underlying bone. Several options are available to treat adult OCD, including debridement, drilling, loose body removal, microfracture, various methods of arthroscopic reduction and internal fixation (ARIF), osteochondral autografting, and allografting. Primary repair is described in this chapter. Important points Primary repair…