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Meniscus regeneration with biologic or synthetic scaffolds

Overview Chapter synopsis Efforts should be made to preserve the meniscus, but if this is not possible, meniscus regeneration with biologic or synthetic scaffolds may be an option. Multicenter clinical trials and reports have demonstrated new tissue formation and fewer reoperations after collagen scaffold implantation compared with partial meniscectomy alone for greater than 10 years. A synthetic scaffold showed biocompatibility and successful early tissue ingrowth at…

Meniscus substitution: The European perspective on scaffolds, allografts, and prosthetic implants

OVERVIEW Chapter synopsis In this chapter, the different options for meniscus substitution are discussed and elaborated. Specific attention is paid to the important differences in indication and surgical technique. Although a number of these therapeutic options have already proven their clinical benefit in multicenter European trials, many of them have not yet been made available outside of Europe—hence the scope of this chapter. Important points Meniscus…

Arthroscopic meniscal transplantation: Bone plug

OVERVIEW Chapter synopsis Arthroscopic meniscal allograft transplantation (MAT) has the potential to relieve pain and increase knee function within a subset of patients with non-functional menisci or after subtotal or total meniscectomy. The arthroscopic bone plug technique allows a surgeon to match the allograft to the patient’s specific anatomy and to perform concomitant procedures while achieving the benefits of minimally invasive surgery. This chapter outlines the…

Meniscal allograft transplantation: Dovetail technique

OVERVIEW Chapter synopsis Meniscal allografts have been shown to provide subjective benefits in symptomatic patients after meniscectomy. Various surgical techniques have been described, but basic science studies have shown that maintenance of the horn attachments with bone may provide superior biomechanical function. The dovetail technique is a method that provides not only a bone bridge but also a press-fit fixation. Important points Patients should be symptomatic…

Meniscal allograft transplantation: Bridge-in-slot technique

OVERVIEW Chapter synopsis This chapter summarizes the indications, technique, and results of meniscal allograft transplantation with the bridge-in-slot technique for the treatment of symptomatic meniscal deficiency. Important points Meniscal transplants are indicated for symptomatic compartment overload caused by total or subtotal meniscectomy. Osteoarthritis, with the exception of very specific circumstances, is a contraindication. Clinical and surgical pearls Ensure that the graft has been received in an…

Arthroscopic meniscus repair: Meniscal root repair

OVERVIEW Chapter synopsis Meniscal root tears result in a dysfunctional meniscus that is associated with rapid degenerative changes within the compartment due to increased stress on the cartilage and bone. Repair of meniscal root tears in the appropriate clinical setting has been shown to improve functional and radiographic outcomes. Important points Patients who are young or with minimal degenerative changes in the affected compartment should be…

Arthroscopic meniscus repair: All-inside technique

OVERVIEW Chapter synopsis All-inside meniscal repair offers many advantages over traditional inside-out or outside-in meniscal repairs. Benefits include decreased operative times, avoidance of the risks associated with secondary incisions, and ease of use of the implants. Implant designs have evolved since their introduction, which has allowed for safe and reliable all-inside meniscal repairs with results that compare favorably with those of more traditional open methods. Important…

Arthroscopic meniscus repair: Outside-in technique

OVERVIEW Chapter synopsis The outside-in technique of meniscus repair is useful for treating tears amenable to repair within the anterior horn and body. As our understanding of the biomechanical consequences of meniscal deficiency has improved, a detailed understanding of this surgical option is essential to preserve meniscal function. This chapter provides information on treatment indications, preoperative considerations, and surgical techniques that may be used when treating…

Arthroscopic meniscus repair: Inside-out technique

OVERVIEW Chapter synopsis The inside-out technique for meniscus repair is the gold standard against which other repair modalities are compared. It is ideal for bucket handle tears and tears involving the posterior horn through the body of the meniscus. Once the exposure is performed, this technique allows the surgeon to efficiently place multiple sutures in a vertical mattress configuration to create a stable repair. The needles…

Arthroscopic meniscectomy

OVERVIEW Chapter synopsis Meniscal tears are common. Partial meniscectomy is indicated when patients have persistent mechanical symptoms. Proper use of arthroscopic tools and portals allows for a successful meniscectomy. Good to excellent results can be achieved in the appropriately indicated patient. Important points Repair the meniscus if possible Indications Symptomatic meniscal tears that have failed conservative measures Locked knee with an irreparable meniscus tear Acute tears…

Patient positioning, portal placement, and normal arthroscopic anatomy

OVERVIEW Chapter synopsis Prior to any arthroscopic procedure it is necessary to confirm the procedure with the patient and identify and mark the correct side. The chosen method of anesthesia depends on the length and type of procedure. There are a variety of available portals for knee arthroscopy, with most procedures utilizing an anterolateral viewing portal while working through the anteromedial portal. A systematic and efficient…

General principles

OVERVIEW Chapter synopsis The knee is a complex joint and is a common site of musculoskeletal injury. Understanding basic knee anatomy and physiology is key for providing effective treatment and care. Important points Knee anatomy Bony anatomy Ligaments and soft tissues Knee biomechanics Tibiofemoral joint kinematics Patellofemoral joint kinematics Meniscus Biomechanics Physical exam Maneuvers to assess the anterior cruciate ligament Maneuvers to assess the posterior cruciate…

Distal biceps brachii tendon repair

OVERVIEW Chapter synopsis This chapter describes the technique for completing a distal biceps brachii tendon repair and provides an overview of the contemporary results. Important points There are two predominant methods to repair the distal biceps: the one-incision and the two-incision techniques. The one-incision technique is described in detail in this chapter. The theoretical benefit is a less-invasive approach with the added risk of dissection in…

Lateral and medial epicondylitis

OVERVIEW Chapter synopsis Surgical intervention for medial and lateral epicondylitis should be performed only after a year of conservative, nonoperative management that has failed. Methods consist of anti-inflammatories, bracing, injections, and physical therapy. If a patient continues to have pain and loss of function after failing conservative management, open treatment of medial and lateral epicondylitis is appropriate. Debridement of the devitalized tendon to its bony insertion…

Open elbow contracture release

OVERVIEW Chapter synopsis Elbow stiffness is common after injury. A stiff capsule can usually be stretched with confident exercises; patience is warranted because intentionally hurting one’s elbow after injury or surgery can be counterintuitive. Operative treatment is more appealing when heterotopic ossification, implants, malunion, nonunion, or articular damage hinders motion and when there is compression of the ulnar nerve. Knowledge of both the medial and the…

Surgical treatment of posterolateral rotatory instability of the elbow

OVERVIEW Chapter synopsis The lateral collateral ligament (LCL) complex consists of four ligaments: the lateral ulnar collateral ligament (LUCL), the radial collateral ligament (RCL), the annular ligament (AL), and the accessory lateral collateral ligament (ALCL). Injury to the LUCL and the RCL are the primary components in posterolateral rotatory instability (PLRI) of the elbow, as described by O’Driscoll. Important points The typical trauma mechanism: axial compression…

Ulnar collateral ligament repair

OVERVIEW Chapter synopsis Traditional operative treatment of ulnar collateral ligament (UCL) injury in the throwing athlete consists of reconstruction with autogenous graft. However, some athletes can have a UCL injury isolated to either the humeral or ulnar insertion without significant attritional, degenerative changes. Such patients may be candidates for a direct, primary ligament repair, which allows earlier return to competition than a reconstruction with similar high…

Ulnar collateral ligament reconstruction: The DANE technique

Overview Chapter synopsis Elbow ulnar collateral ligament (UCL) injuries are potentially career ending. The DANE technique is an effective way to reconstruct the ligament. It is performed through a muscle splitting approach and employs a combination of interference screw fixation on the ulna and the docking technique on the humerus. Clinical outcomes are excellent in about 90% of patients. Important points Ligament reconstruction can be considered…

Ulnar collateral ligament reconstruction: The modified jobe technique

OVERVIEW Chapter synopsis The Jobe technique was the first technique reported for ulnar collateral ligament (UCL) reconstruction, and several subsequent modifications have been described. The procedure involves passage of a graft, most commonly the palmaris longus tendon, through the ulnar and humeral tunnels in a figure-of-eight fashion. More than 80% of athletes return to their previous level of sport. Important points Accurate diagnosis is paramount. Medial…

Ulnar collateral ligament reconstruction: The docking technique

OVERVIEW Chapter synopsis The docking technique has resulted in excellent outcomes for athletes at all levels of play and has proven to be a less invasive and reliable method of reconstruction of the ulnar collateral ligament (UCL). Important points The palmaris longus and gracilis tendons are ideal grafts for UCL reconstruction. Elbow arthroscopy can be performed before UCL reconstruction to address common pathologies seen in the…