5 The Knee PDF
5 The Knee PDF
5 The Knee PDF
Series
James H. Lubowitz, MD
Director, Taos Orthopaedic Institute, Research Foundation, and
Orthopaedic Sportsmedicine Fellowship
Taos, New Mexico
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Dedication
To my loving and wonderful family, for all your patience and support.
I dedicate this work to my beautiful children, Nicholas, Caroline, Jonathan, and Matthew.
And to Ela, for making me smile again.
I honor the life and celebrate the achievements and rich memory of Dr. Leslie Sgaglione; your
balance, unconditional love, and extraordinary existence continue to inspire me every day.
In memory of my close friend and colleague, Benjamin Shaffer, MD; your light shines bright.
Nicholas A. Sgaglione, MD
Thank you to Gina for her inspiration, dedication, patience, and tolerance, and to the Editors,
as well as the AANA Past Presidents, for their mentorship.
James H. Lubowitz, MD
To my incredible family for all of your dedication and steadfast support, and my wonderful
wife, Melissa, and children, Connor, Brody, Caroline, and Catherine. You inspire me every day.
To my dear friend Colonel Warren Kadrmas, whose legacy in the military sports community lives
today.
Matthew T. Provencher, MD, CDR MC USNR
Contents
Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
About the Editors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii
Contributing Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Foreword by John P. Fulkerson, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xxi
Foreword by Lanny L. Johnson, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv
SECTION I GENERAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Chapter 1 Knee Arthroscopy: Setup, Diagnosis, Portals, and Approaches . . . . . . . . . . . . . 3
Vipool K. Goradia, MD
Chapter 2 Arthroscopic Synovectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Jack Anavian, MD; Trevor Born, MD; and Paul Fadale, MD
Chapter 3 Arthroscopic Treatment of Popliteal Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Julie A. Dodds, MD
Chapter 4 Arthroscopic Management of Tibial Plateau Fractures . . . . . . . . . . . . . . . . . . . 53
Brian B. Gilmer, MD and James H. Lubowitz, MD
Chapter 5 Arthroscopic Treatment of Arthrofibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Sanjay Menon, MD and Leon (Lonnie) Paulos, MD
Nicholas A. Sgaglione, MD
James H. Lubowitz, MD
Matthew T. Provencher, MD, CDR MC USNR
About the Editors
Nicholas A. Sgaglione, MD is Professor and Chairman of the North Shore–Long Island Jewish
Medical Center Department of Orthopedic Surgery and at the Hofstra North Shore–Long Island
Jewish School of Medicine. He also serves as the Senior Vice President for Orthopaedics for the
North Shore–Long Island Jewish Health System and Executive Director of the Orthopaedic
Institute. Dr. Sgaglione graduated from the Mount Sinai School of Medicine and completed his
residency in orthopaedic surgery at the Hospital for Special Surgery in New York, followed by a
fellowship in sports medicine at the Southern California Orthopaedic Institute in Los Angeles,
California.
Dr. Sgaglione served as President of the Arthroscopy Association of North America for 2012
to 2013 and also served on its Board of Directors beginning in 2008. He was elected to the
American Orthopaedic Association in 2006 and is a trustee of the AANA Education Foundation
and Association Member Representative for the Orthopaedic Learning Center in Rosemont,
Illinois. He is currently serving on the Arthroscopy: The Journal of Arthroscopic and Related Surgery
Board of Trustees.
Dr. Sgaglione specializes in sports medicine and has served as the Team Orthopaedist for
numerous Long Island High Schools and the US Merchant Marine Academy for the past 24 years
and more recently New York’s professional Major League Lacrosse team, the New York Lizards.
He has also served as an orthopaedic consultant to the US Ski Team and US Professional Golf
Association. Dr. Sgaglione has authored more than 75 peer-reviewed published scientific articles.
He was a co-editor of AANA Advanced Arthroscopy: The Knee and has recently co-edited the Fourth
Edition of the textbook Operative Arthroscopy.
CDR Matthew T. Provencher, MD, MC USN, a native of Barrington, New Hampshire, attended
the US Naval Academy, where he was appointed the Deputy Brigade Commander (Second in
Command), graduated with Distinction with a Major in Electrical Engineering, and was desig-
nated Secretary of the Navy Distinguished Graduate. He was also a 4-year varsity oarsman and
First-Team All-American at Navy, and named Most Valuable Oarsman. He completed his medi-
cal education at Dartmouth Medical School where he graduated with honors and was elected to
the Alpha Omega Alpha Honor Society.
xiv About the Editors
Dr. Provencher completed his orthopaedic residency at the Naval Medical Center San Diego
and his orthopaedic shoulder, knee, and sports surgery fellowship at Rush University. He also
served as an Orthopaedic Surgeon at the Naval Medical Center San Diego from 2004 to 2013,
and was Director of the Sports Division from 2007 to 2013. In addition to his orthopaedic duties,
CDR Provencher performed extensive Humanitarian and Disaster Relief training as the Director
for Surgical Services on the USNS Mercy (TAH-19) during Pacific Partnership 2012.
Currently, Dr. Provencher is the Chief of Sports Medicine and Surgery at Massachusetts
General Hospital, is Visiting Professor of Surgery and Orthopaedics at Harvard Medical School,
and Professor of Surgery and Orthopaedics at the Uniformed Services University of the Health
Sciences. As Chief of Sports Surgery at Massachusetts General Hospital, he is the Head Team
Physician and Medical Director for the New England Patriots, and is a Past-President of the
Society of Military Orthopaedic Surgeons. He was elected into the Herodicus Society, which
identifies excellence in Orthopaedic Sports Surgery as well as was nominated to the Board of
Directors of the American Orthopaedic Society for Sports Medicine. He serves on numerous
national committees and was the Arthroscopy Association of North America 2014 Program
Director and is the Assistant Editor-in-Chief of Arthroscopy: The Journal of Arthroscopic and Related
Surgery. He was recently named one of the Top 20 Shoulder Surgeons in the United States and
Top 28 Knee Surgeons in the United States by Orthopaedics Today. His research includes more than
150 peer-reviewed publications and 150 chapters, and he has written 5 textbooks. Dr. Provencher
resides in Massachusetts with his wife and 4 children.
Contributing Authors
David A. Abrutyn, MD (Chapter 24) Joel Boyd, MD (Chapter 30)
Sports Medicine, Shoulder and Knee Surgery TRIA Orthopaedic Center
Summit Medical Group Bloomington, Minnesota
Bridgewater, New Jersey University of Minnesota
Minneapolis, Minnesota
Annunziato Amendola, MD (Chapter 22)
Professor Joseph Brunkhorst, DO (Chapter 28)
Department of Orthopedic Surgery Department of Orthopaedic Surgery
Chief University of Kentucky School of Medicine
Division of Sports Medicine Lexington, Kentucky
Duke University
Durham, North Carolina William Bugbee, MD (Chapter 18)
Attending Physician
Jack Anavian, MD (Chapter 2) Director
Trauma Fellow Cartilage Transplantation Program
Department of Orthopedic Surgery Division of Orthopaedic Surgery
Warren Alpert Medical School of Scripps Clinic
Brown University La Jolla, California
Providence, Rhode Island
James M. Bullock, MD (Chapter 26)
Jack M. Bert, MD (Chapter 14) Department of Orthopaedic Surgery
Adjunct Clinical Professor University of Pittsburgh
University of Minnesota School of Medicine Pittsburgh, Pennsylvania
Cartilage Restoration Center of Minnesota
Minnesota Bone & Joint Specialists, Ltd Joseph Carney, MD (Chapter 12)
St. Paul, Minnesota Department of Orthopaedic Surgery
Naval Medical Center San Diego
Timothy M. Bert, MD (Chapter 14) San Diego, California
Hedley Orthopedic Institute
Phoenix, Arizona Thomas Carter, MD (Chapter 9)
Emeritus Head of Orthopedic Surgery
Andrew J. Blackman, MD (Chapter 33) Arizona State University
Sports Medicine Fellow Tempe, Arizona
Department of Orthopedic Surgery
Mayo Clinic Sports Medicine Center Brian J. Cole, MD, MBA (Chapters 18, 21)
Rochester, Minnesota Professor and Vice-Chairman
Department of Orthopedics
Trevor Born, MD (Chapter 2) Section Head
Sports Medicine Fellow Rush Cartilage Restoration Center
Department of Orthopedic Surgery Midwest Orthopedics at Rush
Warren Alpert Medical School of Chicago, Illinois
Brown University
Providence, Rhode Island
xvi Contributing Authors
John P. Fulkerson, MD
Orthopedic Associates of Hartford, PC
Clinical Professor of Orthopedic Surgery
University of Connecticut School of Medicine
Farmington, Connecticut
Reference
1. Shahriaree H, ed. O’Connor’s Textbook of Arthroscopic Surgery. Philadelphia, PA: Lippincott; 1984.
Foreword
Why buy The Knee: AANA Advanced Arthroscopic Surgical Techniques? This Foreword is written
from the perspective of a fictitious potential purchaser.
Like most orthopedic surgeons, I like to do knee surgery, especially by arthroscopy. So I looked
beyond the title.
I looked at the list of authors. It was long and has many recognizable names. The latter is
known as the main motivator for a potential purchaser. I should get it for this reason alone. I
then looked at the list of topics. The list includes topics of my interest, but more than that the list
includes topics I rarely see or do. For that reason alone it gives me a ready reference on synovial
chondromatosis or osteotomy, which I have little experience in my residency. I like the list of
authors in the patella section that will serve as a ready referral reference for problem patellar cases
I do not like to get involved with.
The text has really good illustrations of arthroscopy and radiology. I really liked the summation
box of pearls. I will always open the book and read these from time to time. The numerous up-to-
date journal reference citations are important to me, especially in the unfolding area of articular
cartilage treatment methods. The editors sure got it right by making the contributors conform to
the “pertinent” sections.
Will I buy it and not use it? I am pretty experienced in arthroscopy of the knee. I have heard the
many authors’ presentations at AANA, but I would like to see in more depth what Chris Harner
says about meniscus root tears and what Bert and Cole have written about cartilage and arthritis.
This is an area of increasing patient requests.
The bonus is the video where the devil is in the details. Probably a must have. I may not read it
all, but will use it, even right now on those topics of particular interest to my practice.
Lanny L. Johnson, MD
Clinical Professor
Department of Radiology
College of Human Medicine
Michigan State University
East Lansing, Michigan
Introduction
The AANA Advanced Arthroscopic Surgical Techniques Series represents the very best that AANA
has to offer the practicing orthopedic surgeon. With premier arthroscopic surgeons taking the
lead, each book in the series presents the latest diagnostic, therapeutic, and reconstructive tech-
niques available in arthroscopic surgery today.
Each technique-based chapter is consistently organized with a user-friendly interface allowing
for a quick reference or for prolonged study. Bulleted lists of easily accessed, high-yield infor-
mation, including preoperative planning, patient selection, equipment checklists, step-by-step
descriptions of procedures, and essential technical pearls, in addition to indications, contraindica-
tions, postoperative protocols, and potential complications, make this an invaluable resource for
surgeons who want to improve not only their skill level, but also their mastery of the fundamentals
that define arthroscopic surgery. Well-edited videos, accompanied by narration, further serve to
support the materials systematically outlined in each chapter for each volume.
Education and innovation continue to be the top priority for AANA and its leadership. As
such, all proceeds from this Series will be donated to the AANA Education Foundation, which,
among other endeavors, helps support resident education at the Orthopedic Learning Center,
The Traveling Fellowship, the Society of Military Orthopedic Surgeons (SOMOS)–AANA col-
laboration, resident scholarships to the Annual Meeting, as well as numerous research grants and
awards. With the purchase of this book, AANA will also provide free electronic access to the text
and videos from the same book in their initial series, AANA Advanced Arthroscopy (2010).
We believe that this 5-volume series is a “must have” resource for those who rely on their
arthroscopic skills and knowledge to improve patient outcomes. Concise, current, and cogent help
describe the impact that these textbooks will have on your practice and in your clinical successes.
AANA is delighted to have again taken on this critical leadership position in surgeon education,
and is proud of the quality and immediacy of these 5 outstanding volumes.
Richard K. N. Ryu, MD
Jeffrey S. Abrams, MD
Series Co-Editors
SECTION I
General
1
Knee Arthroscopy
Setup, Diagnosis,
Portals, and Approaches
Vipool K. Goradia, MD
Anatomy
The knee joint, as other joints, is composed of a synovial lining within the capsule. Superior to
the patella, the synovium extends to form the suprapatellar pouch (Figure 1-1).1 Superior medial
and superior lateral portals are sometimes placed within this pouch. A layer of fat separates the
pouch from the distal anterior femoral shaft. The pouch extends medially and laterally along the
femoral condyles into the medial and lateral gutters. The suprapatellar pouch and gutters are fre-
quent locations for loose bodies.
Articular cartilage covers the tibial plateau as well as anterior, distal, and posterior condyles of
the femur, along with the patella. Iatrogenic injury to articular cartilage should be avoided at all
times. Forceful insertion and movement of the arthroscopic camera and/or instruments cause most
iatrogenic injuries during arthroscopy. Knowledge of anatomy, portal placement, and constant
visualization of instruments are also required to avoid iatrogenic injury to articular cartilage and
other structures.
The bony anatomy of the knee relevant to arthroscopic knee surgery includes the distal femur,
the proximal tibia, and the patella. With the knee at 60 degrees of flexion, the inferior pole of
the patella is located above the lateral joint line and is an important guide for anterolateral portal
placement (Figure 1-2). Exceptions to using this landmark, however, occur in cases of patellar alta,
baja, dysplasia, or congenital absence. These conditions should be identified preoperatively with
physical examination and standard radiography.
The femoral trochlea consists of medial and lateral trochlear ridges that arise from the cor-
responding femoral condyle.1 The medial femoral condyle is larger than the lateral from proximal
to distal and anterior to posterior. The lateral femoral condyle, however, is wider at the level of
the femoral notch. Distally, the femur opens into a notch that contains the femoral origins of the
anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). The notch serves as a tar-
get for careful, controlled introduction of cannulas and instruments from anterior portals to avoid
injury to articular cartilage (Figure 1-3). When using the scalpel for anterior portal placement, the
Figure 1-4. Posterior aspect of right knee showing the tibial nerve, popliteal artery, and
vein within the popliteal fossa. (This figure was published in Insall & Scott Surgery of the
Knee, 4th ed, Scott WN, Copyright Elsevier 2006.)
blade should be pointed toward the notch, but blind insertion beyond the skin and capsule should
be avoided because this will risk injury to the cruciate ligaments.
The medial tibial plateau is larger than the lateral plateau; the 2 are separated by an intercondy-
lar sulcus or fossa.1 Adjacent to the fossa is a medial and lateral tibial spine that separates the fossa
from the corresponding tibial plateau. The femoral condyles and tibial plateaus are incongruous
without the medial and lateral menisci. The fibula, although extra-articular, has direct relevance
to arthroscopic knee surgery because it serves as a landmark for portals and surgical approaches.
The proximal fibula forms a joint with the proximal posterior surface of the tibia (tibiofibular
joint). It also serves as an insertion for the lateral collateral ligament and biceps femoris tendon.
Knowledge of neurovascular anatomy around the knee joint is important for preventing iatro-
genic injury during portal placement and surgical approaches.2 Posteriorly, in the midthigh, the
sciatic nerve branches into the tibial (or popliteal) and common peroneal nerves. At the posterior
joint line of the knee just posterior to the joint capsule, the tibial nerve passes between the 2 heads
of the gastrocnemius muscles, along with the popliteal artery and vein. From medial to lateral,
the structures include the nerve, artery, and vein (Figure 1-4).1 Makridis et al 3 showed that knee
flexion increases the distance between the tibial insertion of the PCL and the popliteal neurovas-
cular structures.
The common peroneal nerve passes posterior to the biceps femoris tendon and courses between
it and the lateral head of the gastrocnemius toward the fibular head (Figure 1-5).1,2 It then courses
laterally around the fibular neck and into the peroneus longus tendon. In most individuals, the
biceps femoris tendon insertion onto the fibular head can be palpated in 90 degrees of knee flex-
ion. Placing incisions, portals, and retractors anterior to this landmark will help avoid injury the
common peroneal nerve.
6 Chapter 1
On the medial aspect of the knee, the saphenous nerve and its infrapatellar branch are at risk
for injury during placement of medial and posteromedial portals, as well as during all medial
approaches to the knee. The nerve and its branch have a variable course and number of terminal
branches.1,2 In general, the saphenous nerve passes between the gracilis and sartorius muscles
approximately 3 cm posterior to the medial femoral epicondyle. The infrapatellar branch courses
beneath the sartorius (ie, posterior to it) and runs along the anteromedial aspect of the knee, where
it can terminate medially or laterally to the medial border of the patellar tendon (Figure 1-6).
Figure 1-6. Anteromedial superficial structures of right knee showing the saphenous nerve and its
infrapatellar branch. (This figure was published in Insall & Scott Surgery of the Knee, 4th ed, Scott WN,
Copyright Elsevier 2006.)
thrombosis risks should be identified and addressed preoperatively. Details of the history and
examination for specific diagnoses will be covered in the appropriate chapters elsewhere in this
text. On the day of surgery, the surgeon should speak with the patient prior to him or her receiv-
ing sedation. The patient’s history should be reviewed and the appropriate knee marked with the
surgeon’s initials.
Pertinent Imaging
At a minimum, all patients should have preoperative radiography, including a standing pos-
teroanterior view with the knees flexed 45 degrees, a lateral view, and a Merchant or sunrise
view. These x-rays can be useful for identifying degenerative joint disease, osteochondral or other
injuries, tumors, loose bodies, and patellar pathology, such as patella alta or baja, bipartite, or
dysplasia.
The need for magnetic resonance imaging, computed tomography, and other imaging is based
on the initial history, examination, x-rays, and response to prior treatment and will be discussed
in the appropriate chapters.
8 Chapter 1
Equipment
Gravity inflow, in which multiple bags of fluid are raised to 8 to 10 feet, is a common method
for infusing the joint with fluid. Although more popular in the early days of arthroscopy, it con-
tinues to be used today by many surgeons. As technology has improved, the fluid pump has gained
popularity. It provides the advantage of improved hemostasis and higher pressures.2 There are a
variety of different pumps available, so it is important for the surgeon to have a thorough under-
standing of the pump that he or she is using. Each pump has different controls for pressure and
flow maintenance, and the surgeon cannot assume that a set pressure on one pump is equal to the
same pressure on another pump. It is also important to recognize that intra-articular pressures can
be increased by simply manipulating the knee in flexion or extension.4 Muellner et al 5 compared
4 pump systems and concluded that there is a significant difference among pumps in the pressure
that was set and the actual measured intra-articular pressure. They also noted that all pumps were
accurate at pressures below 60 mm Hg but not above this setting.
Selection of outflow methods also plays an important role in distention of the joint and provid-
ing a clear view. The options include suction or gravity outflow through the arthroscope sheath or
through a separate outflow cannula. Continuous outflow, whether gravity or suction, will result
in greater fluid use; therefore, intermittent outflow controlled by the surgeon or an assistant may
be preferable. The author’s preferred technique is presented later in this chapter.
Also, shoulder suction can be connected to the shaver or burr and, similar to another type of
outflow, can be used continuously or intermittently. Again, it is generally preferable to use suction
on an intermittent basis to clear debris; continuous use can make it difficult to maintain joint dis-
tention. Although different manufacturers have small variations in shavers and burrs, they are usu-
ally available in different sizes and levels of aggressiveness. In general, the smallest, least aggres-
sive instrument that can perform the desired task should be used. However, some smaller shavers
and burr tend to become clogged more easily from debris, which can require frequent cleaning.
Regardless of which instrument is selected, it is important for the surgeon to be familiar with
its characteristics. In particular, the surgeon should know which part of the burr or shaver is the
working side and which is the nonworking side. A clear video of the working side should always
be maintained in order to reduce risk of iatrogenic injury (Figure 1-7). The instrument must be
carefully placed (without force) into the joint, moved with the joint, and removed. Minimal, if any,
torque should ever be applied to the shaft, and the surgeon should never shave or burr blindly. The
surgeon also should not select the most aggressive burr just because it will perform faster. Slow,
steady controlled movements are necessary when using a shaver, but especially a burr.
The selection and proper use of an arthroscopic camera allow the surgeon to examine all areas
of the knee joint efficiently. The arthroscope is available in 0, 30, and 70 degrees, although the
0-degree arthroscope is rarely used today because it provides the smallest field of view. As the
light cord is rotated, the end of the arthroscope also rotates, resulting in a wide field of view. Most
surgeons prefer the 30-degree arthroscope for most procedures. The 70-degree arthroscope should
be available if a larger view is needed (looking around a corner), such as in the posterior aspect
of the knee. Although it is important to use rotation of the arthroscopic camera to increase the
field of view, it is also important to maintain the orientation of the arthroscope with the anatomic
position of the joint. For example, with the leg hanging off the end of the bed, the arthroscope
power cord and camera should be maintained in a vertical orientation. This orientation should be
maintained, even as the arthroscope is moved throughout the joint (Video).
Most systems allow the surgeon to document the arthroscopic findings and treatment with
photographs and/or video. Documentation can serve as an important reference for the surgeon,
an educational tool for the patient, and support for the charges to an insurance carrier. However,
surgeons should discuss giving videos to their patients with their malpractice carrier because some
recommend against it for medicolegal reasons.
Knee Arthroscopy: Setup, Diagnosis, Portals, and Approaches 9
Cannulas are not used as frequently in the knee as in other joints, but they can be useful for
posterior portals. Disposable cannulas come in a variety of sizes. You should have several sizes
available and should know in advance the minimum cannula diameter required by various instru-
ments that you plan to use. Metal cannulas are useful for posterior portals because shavers can
screw into the cannula directly and, with the use of an adapter, the camera can also be exchanged
between cannulas.
With repeat use and normal wear, it is common to have to repair or replace cameras and light
cords. It is therefore important to have extra cameras and light cords available during surgery.
Other basic working instruments needed for knee arthroscopy include a probe, spinal needle,
basket punches (narrow, wide, straight, up-biting, up curved, left, right, and back), graspers,
cutters, and varying types of shavers, burrs, and cautery. Basket punches are available in various
shapes, and their selection largely depends on surgeon preference. More important than the shape,
a variety of different angled and curved basket punches should be available so that all areas of the
joint can be accessed.
10 Chapter 1
Treatment
Anesthesia Options
Knee arthroscopy can be performed under general, spinal, or local anesthesia. The choice
primarily depends on surgeon and patient preference but in some cases may be influenced by the
patient’s medical history. In a prospective randomized study of 400 patients, Jacobson et al6 com-
pared 3 anesthesia options and concluded that local anesthesia was technically feasible in 92% of
patients undergoing elective knee arthroscopy. However, when comparing patient satisfaction, the
local anesthetic group had 90% satisfaction vs 97% for the general anesthesia group. Horlocker
and Hebl7 performed an evidence-based review of published studies comparing various anesthetic
methods for knee arthroscopy. They reported that the results of most studies were biased by sur-
geon and patient expectations as well as by differences in postoperative management. They con-
cluded that a single method of anesthesia could not be recommended for all surgeons performing
or patients undergoing knee arthroscopy.
repairs, cartilage restoration, and osteotomies, may be easier to perform with a second surgical
assistant.
Similarly, all members of the operating room team should be informed well in advance of pos-
sible variations in the planned procedure(s) and the instruments required. It is important to discuss
required instruments in advance with the surgical team and/or coordinator. Staff in the room must
also know where instruments are located in case they are requested during the surgery.
Figure 1-10. Different types of leg holders and an example of a lateral post. (A) Leg holder that can accom-
modate both legs. (B) Unilateral leg holder with the tourniquet positioned within holder. (C) Unilateral leg
holder with the tourniquet outside of the holder. (D) Lateral post.
be outside the holder (see Figure 1-10C). If you prefer a unilateral holder or lateral post, it will be
important to determine how to protect the contralateral leg. The use of a leg holder for the non-
operative leg has been shown to increase the risk of compression to the peroneal nerve as it courses
around the fibular neck.2 Nonoperative leg holders can also cause a stretch injury to the femoral
nerve if the hip is held extended. If the foot of the bed is left up for a lateral post, then positioning
the nonoperative leg does not require anything special. If the foot is dropped, it is often easiest
to place a large pad under the nonoperative thigh to keep the hip flexed (Figure 1-11). If there
is concern about pressure on the peroneal nerve, additional foam padding can be applied in this
region, particularly in thin patients.
Other issues related to the leg holder include the position of the foot of the bed and the use
of hip bumps. For lateral post use, the foot of the bed can remain up (see Figure 1-10D) or it can
be lowered. The advantage of the lateral post is faster setup and positioning, ability to move the
leg freely during surgery, ability to hyperflex the knee, and ease of placing the knee in a figure-4
position. The primary disadvantage is that the leg tends to slide over the post when placing valgus
stress on the knee for access to posterior horn of medial meniscus.
This can be prevented, however, by having an assistant place downward pressure on the thigh
(Figure 1-12). The major disadvantage associated with a fixed leg holder is the risk of rupturing
the medial collateral ligament with excess valgus stress2; knee flexion is limited by the lowered
portion table and inability to move the leg freely.
The inability to abduct the leg can sometimes pose difficulties in posteromedial portal place-
ment. If this occurs, you can have an assistant carefully abduct the nonoperative leg or the leg
holder can be loosened or removed beneath the sterile drapes. Femur fractures have also been
Knee Arthroscopy: Setup, Diagnosis, Portals, and Approaches 13
reported with the use of a leg holder, but these are rare.8 Regardless of choice of leg holder, a
small sandbag or other hip bump may be helpful for larger patients who tend to rotate their legs
excessively externally when lying supine.
The next consideration is the decision on tourniquet usage. There are conflicting reports in the
literature as to the usefulness of tourniquets in improving visualization and potential decreased
recovery of muscle strength. Johnson et al,9 in a randomized prospective evaluation of 109 patients
undergoing knee arthroscopy, reported that routine knee arthroscopy could be performed ade-
quately with no tourniquet. Kirkley et al,10 in a similar evaluation of 120 patients, reported no
complications associated with tourniquet use, with a slight trend toward less early postoperative
pain and better isokinetic strength at 2 weeks postoperatively in patients in whom a tourniquet
was not used. Tourniquets with a wide and/or curved cuff have been shown to decrease the risk of
muscle and nerve injury. Rodeo et al11 recommended that tourniquet time less than 2 hours and
pressures less than 350 mm Hg lower the risk of neuropraxia. Several authors have also shown
that a tourniquet should not be reinflated during an operative procedure after it is deflated for a
period of reperfusion.12,13
14 Chapter 1
Portals
Vertical vs horizontal portal incisions are primarily based on surgeon preference. A vertical por-
tal provides greater options for extension in situations in which the pathology cannot be accessed
because the initial portal is too high or low.
High Anterolateral Portal
The high anterolateral portal is the most common initial diagnostic portal. It is located above
the lateral joint line, adjacent to the patellar tendon’s lateral margin.14 The inferior pole of the
patella with the knee in 60 degrees of flexion is a good landmark for the inferior margin of this
portal (Figure 1-13, A and Video). It is important, however, to review the preoperative x-rays to
make certain that the patient does not have patella alta or baja. The anterolateral portal is useful
for examining the medial, lateral, and patellofemoral compartments; visualizing the notch during
ACL reconstruction; and treating medial meniscus pathology.15 In addition to a viewing portal,
it can be also used for fluid inflow.
In general, basic knee arthroscopy can be performed with a 2- or 3-portal technique. The
2-portal technique requires inflow through the arthroscopic camera sheath, whereas the 3-portal
technique requires a separate superior portal for inflow. Most commonly, this superior portal is
placed superolaterally. Stetson and Templin16 have shown faster return to activities and return of
quadriceps strength with the 2-portal technique.
Knee Arthroscopy: Setup, Diagnosis, Portals, and Approaches 15
When pathology is expected in the lateral compartment based on the preoperative diagnosis,
Kim and Kim15 have recommended that the initial portal be placed more laterally and higher
(patellofemoral axillary portal) than a standard high anterolateral portal. The patellofemoral axil-
lary portal is at the junction or axilla of the lateral edge of the patella and the anterior edge of
the lateral femoral condyle (Figure 1-13, B). The authors stated that this portal allows excellent
visualization of the popliteal hiatus, lateral gutter, and lateral compartment.
Anteromedial Portal
A second working portal is created after performing an initial diagnostic examination through
the first portal. Most often, the second portal is the anteromedial portal. The exact position of the
portal is determined by the pathology (Figure 1-13, C and Video). As with all working portals, a
spinal needle is used to determine its precise location. If access to the posterior horn of the medial
meniscus is needed, the portal should be just above the anterior horn of the medial meniscus. If
lateral compartment access is needed, the portal should be high enough to pass over the tibial
spines. Alternatively, if pathology in the posterior horn of the lateral meniscus cannot be accessed
through the anteromedial portal, a low anterolateral portal (Figure 1-13, D) can be placed just
above the anterior horn of the lateral meniscus.15
Accessory and Other Portals
A transpatellar tendon or central portal can be created as an accessory working or viewing por-
tal. The portal must be made vertically in line with the tendon fibers to avoid transecting the ten-
don. The portal is placed at the inferior pole of the patella (Figure 1-13, E). It can be particularly
useful in situations in which the anterolateral portal is too lateral and/or the anteromedial portal is
too medial. In these cases, the transpatellar tendon portal can provide excellent visualization and
access to the notch. Even when the other portals are placed appropriately, the transpatellar portal
can be used as an accessory portal during ACL reconstruction.14
Additional anterior accessory portals can be placed at any location necessary for working or
viewing. Most commonly, they are used to access a torn meniscus, articular cartilage defect, loose
body, or the femoral tunnel placement for ACL or PCL surgery. The landmarks to avoid for
accessory anterior portals are the menisci, articular cartilage, and inferior branch of the saphenous
nerve. An accessory low anteromedial portal (Figure 1-13, F) is often used for placement of a
femoral tunnel during ACL reconstruction.
The superomedial portal is placed 3 to 4 cm superior to the superior pole of the patella (Figure
1-14, A and Video). It should be in line with the medial border of the patella or just posterior to it.
16 Chapter 1
The cannula and obturator should aim toward the suprapatellar pouch, just posterior to the patel-
lar articular cartilage. This is an excellent portal for viewing patellofemoral tracking or the lateral
retinaculum during release. Because the portal violates the vastus medialis obliquus, it can affect
the return of postoperative knee function and quadriceps strength.16 The superolateral portal is
placed 3 to 4 cm superior to the superior pole of the patella and in line with the lateral border of
the patella (Figure 1-15, A and Video). It also provides excellent visualization of patellofemoral
tracking. Either superior portal can also be used for fluid inflow.
All arthroscopic knee surgeons should be comfortable with access to the posterior compart-
ments of the knee via posteromedial and posterolateral portals (Figures 1-14, B and 1-15, B,
respectively, and Video). If unfamiliar with these portals, they should be practiced in the labora-
tory setting prior to attempting them in the operating room. With the arthroscope in the high
anterolateral portal, the camera is advanced into the notch at the interval between the medial
femoral condyle and PCL (Figure 1-16A). Next, the arthroscopic sheath is held in place while the
camera is replaced with a blunt trocar. The sheath and trocar are then gently advanced into the
posteromedial compartment with the knee in 45 to 60 degrees of flexion. It is helpful to have the
index finger of the hand holding the sheath positioned along its shaft. As the sheath is advanced,
the index fingertip can be positioned so that it abuts the outside of the knee prior to penetrating
the posterior capsule with the sheath and trocar. If difficulty is encountered during attempted
passage, a limited inferior medial notchplasty can be performed, taking care to avoid injury to
the PCL. This notchplasty may be required in cases of osteoarthritic spurs or otherwise stenotic
notches.17 Once in the compartment, the trocar is replaced with the camera and the posteromedial
knee is palpated with a gloved finger. This will help in identifying the general area for placement
of a spinal needle. The posteromedial portal is approximately 2 cm superior to the medial femoral
epicondyle and 1 cm posterior (Figure 1-14, B and Video). With the knee in 90 degrees of flexion,
the needle is directed toward the posterior aspect of the intercondylar notch (ie, where the camera
is located; Figures 1-16B and 1-16C). The exact position is dependent on the pathology present.
Care should be taken to avoid injury to the popliteal neurovascular structures with transverse
insertion of the needle posterior to the posterior capsule. A recent cadaver study reported that
90 to 120 degrees of knee flexion are safe for establishing posteromedial portals and 30 degrees is
not recommended.3 Once the correct needle position is attained, a small skin incision is created.
A hemostat is then used for blunt separation of soft tissues. This is helpful to prevent injury to the
saphenous nerve or its branches. Next, a blunt obturator and cannula are inserted along the same
direction as the spinal needle. The entry through the capsule can be directly visualized with the
camera. In some cases, the blunt obturator will slide off the capsule in a posterior direction. If the
Knee Arthroscopy: Setup, Diagnosis, Portals, and Approaches 17
capsule cannot be penetrated after a few careful attempts, the sharp obturator may be needed. This
can be safe if you are confident in the direction required to penetrate the capsule. Once the obtura-
tor is against the capsule, it can be more easily pushed through it. The sharp obturator, however,
increases the risk of injury to neurovascular structures if directed incorrectly.
18 Chapter 1
In a similar fashion, a posterolateral portal can be established with the camera in the anterome-
dial portal. It is advanced through the notch between the ACL and lateral femoral condyle (Figure
1-17A and Video). This can often be done without replacing the camera with a trocar, but do not
use excessive force. If the camera does not pass easily, it is safest to use a blunt trocar. A spinal
needle is again used posterolaterally 2 cm superior to the lateral femoral epicondyle and anterior to
the biceps femoris to avoid injury to the common peroneal nerve (Figures 1-15, B and 1-17B). The
needle is directed toward the tip of the camera (Figure 1-17C), a skin incision is created, and the
cannula is inserted. For posterolateral portals, 90 degrees of knee flexion is safe but 120 degrees
risks injury to common peroneal nerve.3
Author’s Diagnostic Arthroscopy Technique (Video)
A standard leg holder is used for most arthroscopic procedures, and a lateral post is used for
cruciate ligament reconstruction, patellofemoral realignment, and osteochondral autograft trans-
fer procedures requiring extreme knee flexion. If the leg holder is limiting the procedure in any
way, the circulating nurse removes it during surgery beneath the sterile drapes.
Prior to examination under anesthesia, the circulating nurse reads the consent and all staff con-
firm that the correct extremity has the surgeon’s initials. A routine knee examination for range of
motion and ligament stability is performed. The tourniquet is placed over soft cotton roll approxi-
mately one handbreadth above the patella. The extremity is exsanguinated with an Esmarch
bandage, and the tourniquet pressure is set to 300 mm Hg for most patients. For children or those
with very small legs, the tourniquet pressure may be decreased to 250 mm Hg. For obese patients
or those with elevated blood pressure, the tourniquet pressure may be increased to 350 mm Hg.
A large foam pillow is placed beneath the contralateral leg. After sterile prepping and draping,
a time-out is performed to again confirm the correct side. Next, a horizontal high anterolateral
portal is created. The arthroscopic camera sheath and blunt obturator are then carefully inserted
through the capsule. The knee is extended and the sheath is further inserted into the suprapatellar
pouch, just lateral to the patella. Care is taken to avoid injury to the femoral or patellar articular
cartilage. A fluid pump is used for inflow through the arthroscopic sheath. Suction is also con-
nected to the arthroscopic sheath and controlled by the surgeon. Suction is only used to clear
cloudy fluid on an intermittent basis. Routine continuous suction of gravity outflow is not used.
Next, a quick initial diagnostic examination is performed. The sequence of the exam should be
a routine that works for the surgeon. The author’s preference is first to examine the suprapatel-
lar pouch, lateral gutter, patellofemoral joint, and medial gutter. The knee should be flexed and
Knee Arthroscopy: Setup, Diagnosis, Portals, and Approaches 19
extended during examination of the patellofemoral joint. The knee is then flexed with gentle
valgus stress applied as the camera is moved from the medial gutter into the medial compartment.
The camera is then rotated to view the posterior horn, body, and anterior horn of the medial
meniscus. The knee is flexed and extended to view the entire articular cartilage of the medial
femoral condyle.
The camera is then withdrawn slightly as the notch is entered. In some cases, it may be dif-
ficult to visualize the ACL fully because of a thick ligamentum mucosum. In this case, gently
pass the camera over the top of the ligamentum and push it slightly so that there is a close view of
the medial portion of the lateral femoral condyle. The knee is then gently placed into a figure-4
position and rested on the surgeon’s thigh. This provides excellent visualization of the posterior
horn of the lateral meniscus. As the knee is slowly extended, the lateral femoral condyle, body of
the lateral meniscus, and anterior horn can be examined.
At this stage, an anteromedial working portal is created for most pathology. The superior-
inferior position depends on the location of the pathology in the medial vs lateral compartments
(see earlier). A spinal needle is inserted prior to creating a horizontal portal incision under direct
visualization with the camera.
Next, a probe is inserted through the anteromedial working portal into the medial compart-
ment. Although some have suggested that routine examination of the posterior compartment
may be unnecessary,18 result in increased morbidity, and decrease efficiency of the procedure,
the author prefers to examine posteromedially and posterolaterally through the notch in all knee
arthroscopies to avoid missing pathology.19 Usually, this pathology includes a loose body or section
20 Chapter 1
of torn meniscus that is flipped posteriorly and not seen from an anterior view of the meniscus.
The posteromedial compartment is examined while the arthroscope is still in the high antero-
lateral portal. If complete visualization is difficult, a 70-degree arthroscope is used, but this is
extremely rare.
While the arthroscope is in the anteromedial viewing portal, it is passed into the posterolateral
compartment for examination. If any additional pathology is identified from the anteromedial
viewing portal, it is addressed at this time with existing portals or new portals as needed.
Postoperative Protocol
At the end of the arthroscopic procedure, the joint is thoroughly irrigated and fluid is suc-
tioned. The portals are each closed with a nylon suture. The joint is injected for postoperative
pain control with 30 mL of 0.5% bupivacaine (Marcaine). Dressings are applied, the tourniquet is
deflated, and a warm pink foot is confirmed. The postoperative protocol is based on the specific
pathology treated and is discussed in the relevant chapters.
(continued)
Knee Arthroscopy: Setup, Diagnosis, Portals, and Approaches 21
8. The #11 blade is inserted completely through the capsule for greater ease in passing
instruments in and out of the working portal (Figure 1-18 and Video).
9. While viewing from the anterolateral portal, perform any required work through the
anteromedial or other working portals. Once the work is completed, the arthroscope is
moved to the anteromedial portal or other viewing portals. This limits movement of the
arthroscope back and forth and improves efficiency.
Pitfalls
1. Failure to complete a time-out prior to beginning the surgery may lead to wrong-site
surgery.
2. Injury to sensory nerves can result in loss of sensation and painful neuromas.
3. Failure to have the needed instruments during surgery may result in inefficiency, compli-
cations, and potentially poor outcomes.
4. If the orientation of the camera is continuously changed, the surgeon will have difficulty
triangulating instruments.
5. Trying to use an instrument to perform a task for which it is not designed can result in
iatrogenic injury to the joint and/or damage to the instrument.
6. Proceeding immediately to the expected pathology based on the preoperative diagnosis,
treating it, forgetting to examine the rest of the joint, and missing unexpected pathology
should be avoided.
7. The working end of all instruments should remain in view in order to prevent iatrogenic
injury to the joint.
8. The initial quick diagnostic examination may have been limited because of synovitis,
thickened ligamentum, or hypertrophic fat pad. Failure to go back, remove obstructions
as needed, and perform a thorough examination can result in missed pathology.
9. Do not eliminate moving the camera into another portal just to complete the procedure
faster. Complete examination and treatment often require viewing from different portals.
22 Chapter 1
References
1. Clarke HD, Scott WN, Insall JN, et al. Anatomy. In: Scott WN, ed. Insall & Scott Surgery of the Knee.
Vol 1. 5th ed. Philadelphia, PA: Churchill Livingstone; 2011:2-47.
2. Kim TK, Savino RM, McFarland EG, Cosgarea AJ. Neurovascular complications of knee arthroscopy.
Am J Sports Med. 2002;30(4):619-629.
3. Makridis KG, Wajsfisz A, Agrawal N, Basdekis G, Djian P. Neurovascular anatomic relation-
ships to arthroscopic posterior and transeptal portals in different knee positions. Am J Sports Med.
2013;41(7):1559-1564.
4. Funk DA, Noyes FR, Grood ES, Hoffman SD. Effect of flexion angle on the pressure-volume of the
human knee. Arthroscopy. 1991;7(1):86-90.
5. Muellner T, Menth-Chiari WA, Reihsner R, Eberhardsteiner J, Engebretsen L. Accuracy of pressure and
flow capacities of four arthroscopic fluid management systems. Arthroscopy. 2001;17(7):760-764.
6. Jacobson E, Forssblad M, Rosenberg J, Westman L, Weidenhielm L. Can local anesthesia be recom-
mended for routine use in elective knee arthroscopy? A comparison between local, spinal, and general
anesthesia. Arthroscopy. 2000;16(2):183-190.
7. Horlocker TT, Hebl JR. Anesthesia for outpatient knee arthroscopy: is there an optimal technique? Reg
Anesth Pain Med. 2003;28(1):58-63.
8. Cautilli R Jr. Introduction to basics of arthroscopy of the knee. Clin Sports Med. 1997;16(1):1-16.
9. Johnson DS, Stewart H, Hirst P, Harper NJ. Is tourniquet use necessary for knee arthroscopy?
Arthroscopy. 2000;16(6):648-651.
10. Kirkley A, Rampersaud R, Griffin S, Amendola A, Litchfield R, Fowler P. Tourniquet versus no
tourniquet use in routine knee arthroscopy: a prospective, double-blind, randomized clinical trial.
Arthroscopy. 2000;16(2):121-126.
11. Rodeo SA, Forster RA, Weiland AJ. Neurological complications due to arthroscopy. J Bone Joint Surg
Am. 1993;75(6):917-926.
12. Mohler LR, Pedowitz RA, Myers RR, Ohara WM, Lopez MA, Gershuni DH. Intermittent reperfusion
fails to prevent post tourniquet neurapraxia. J Hand Surg Am. 1999;24(4):687-693.
13. Rorabeck CH, Kennedy JC. Tourniquet-induced nerve ischemia complicating knee ligament surgery.
Am J Sports Med. 1980;8(2):98-102.
14. Cohen SB, Fu FH. Three-portal technique for anterior cruciate ligament reconstruction: use of a central
medial portal. Arthroscopy. 2007;23(3):325.e1-325.e5.
15. Kim SJ, Kim HJ. High portal: practical philosophy for positioning portals in knee arthroscopy.
Arthroscopy. 2001;17(3):333-337.
16. Stetson WB, Templin K. Two-versus three-portal technique for routine knee arthroscopy. Am J Sports
Med. 2002;30(1):108-111.
17. León HO, Blanco CE, Guthrie TB, Martínez OJ. Intercondylar notch stenosis in degenerative arthritis
of the knee. Arthroscopy. 2005;21(3):294-302.
18. Lubowitz JH, Rossi MJ, Baker BS, Guttmann D. Arthroscopic visualization of the posterior compart-
ments of the knee. Arthroscopy. 2004;20(7):675-680.
19. Amin KB, Cosgarea AJ, Kaeding CC. The value of intercondylar notch visualization of the posterome-
dial and posterolateral compartments during knee arthroscopy. Arthroscopy. 1999;15(8):813-817.
Introduction
The knee joint has the largest and most extensive synovial membrane compared to any other
joint. Thus, pathologic conditions involving the synovium of the knee can be symptomatic and
debilitating. Benign and malignant processes can involve the synovial membrane. For most con-
ditions that require surgical treatment, arthroscopic synovectomy is a safe and effective method.
Arthroscopic synovectomy of the knee has major potential advantages over open surgical
techniques, including improved visualization of the knee joint, a more complete synovectomy, less
postoperative pain, decreased postoperative knee stiffness/arthrofibrosis, decreased postopera-
tive hemarthrosis, shorter hospitalization, lower surgical site morbidity, the surgery is performed
through arthroscopic portals (thus the division of the quadriceps is avoided), better preservation
of the menisci, and lastly, revision surgery, if required, is less complicated. The major arthroscopic
disadvantage is that it may be a more technically challenging operation to perform, and for some
diffuse and malignant conditions, it is contraindicated.
Indications
▶ Plica syndrome
▶ Pigmented villonodular synovitis (PVNS)
▶ Synovial chondromatosis/osteochondromatosis
▶ Synovial hemangioma
▶ Popliteal (Baker’s) cyst
▶ Hemophilia
▶ Seronegative and seropositive arthropathies
▶ Infection
▶ Arthrofibrosis
Sgaglione NA, Lubowitz JH, Provencher MT, eds. The Knee:
- 23 - AANA Advanced Arthroscopic Surgical Techniques (pp 23-36).
© 2016 AANA.
24 Chapter 2
Arthroscopic synovectomy is indicated for a variety of conditions in patients who have been
disabled for at least 6 months by pain and swelling and have not responded to conservative treat-
ment. An established diagnosis of a synovial disorder is essential. In some instances, a histologic
diagnosis should be made preoperatively.
Plica Syndrome
The medial knee plica can be found in approximately 70% of patients and may become hyper-
sensitive after direct trauma to a flexed knee. It can also be sensitized from overuse. The lateral
knee plica, when it exists, is rarely symptomatic. The clinical presentation is often similar to that
of other conditions of the knee, including meniscal tear and patellar tendinitis, among others.
There may be a snapping sensation along the medial knee during flexion on physical examination.
Therefore, the diagnosis of plica syndrome is often clinical and a diagnosis of exclusion.1 Magnetic
resonance imaging (MRI) has been demonstrated to be of limited value in plica syndrome.2
Arthroscopic resection of a symptomatic plica should be considered after a failed course of anti-
inflammatory medication, consideration of steroids, and physical therapy. Diagnostic arthroscopic
evaluation typically reveals an inflamed or hypertrophied medial plica. Postoperatively, mobiliza-
tion and physical therapy is initiated immediately. In properly selected patients, good-to-excellent
results can be expected after arthroscopic plica resection, with a success rate greater than 80% in
one study.3,4
Clinically, patients often present with symptoms similar to meniscal pathology as the synovium
surrounding the anterior horn of the medial meniscus is most commonly affected. However, other
localized areas of the knee, including the anterior horn of the lateral meniscus, medial/lateral
recess, suprapatellar pouch, intercondylar notch, and suprapatellar fat pad, have been described.
Due to its location, patients often present with symptoms such as pain, swelling, instability, lock-
ing, and catching.5 LPVNS will typically present with more rapid onset of pain and swelling,
which is in contrast to DPVNS, which is characterized by an insidious, slow progression of pain,
swelling, and stiffness of the knee. Plain x-rays may demonstrate findings similar to that of a joint
effusion or soft tissue swelling. These are present in less than 30% of PVNS cases. Thus, plain
x-rays are not sensitive or specific enough to establish a correct diagnosis. On computed tomog-
raphy (CT) scan, PVNS appears as a soft tissue mass with increased density compared to the
muscle, and adjacent bony erosions and subchondral cysts may be seen. MRI currently remains the
most useful diagnostic tool for PVNS (Figure 2-2). It allows the surgeon to better determine the
extent of the lesions, especially in areas that are not easily accessible arthroscopically. High signal
intensity regions may be present on T1 images (corresponding to fat deposition or hemorrhage) or
T2 images (corresponding to joint effusion or synovial inflammation). Synovial fluid aspiration
of the knee is not a reliable diagnostic tool as it typically yields brown or bloody fluid that may be
seen in a variety of conditions and is not specific to PVNS.
Surgical resection is the treatment of choice for both LPVNS and DPVNS. Recurrence
following excision of LPVNS is rare and after total synovectomy of DPVNS can be as low as
9%.6 Malignant transformation and metastasis in patients with PVNS are rare, with a reported
mortality rate of 50%.7 Arthroscopic synovectomy is an effective treatment modality for PVNS,
especially the localized form.8 It has been associated with better functional results and lower rates
of postoperative stiffness than open synovectomy as it allows for optimal visualization of lesions,
especially in areas not easily accessible via an open technique, such as the posterior compartment.
When compared to open synovectomy, arthroscopic synovectomy is associated with a shorter hos-
pital stay and a shorter rehabilitation period. Flandry et al6 demonstrated that rates of postopera-
tive stiffness following open synovectomy were as high as 24% with the need for further manipu-
lation. Nevertheless, improper use of this arthroscopic technique and an incomplete synovectomy
may result in unacceptable recurrence rates. Arthroscopic synovectomy carries a risk of incomplete
resection in DPVNS, as well as the theoretical risk of portal/joint seeding. In DPVNS, complete
26 Chapter 2
A B
synovectomy is associated with better results and a substantially lower recurrence rate than partial
excision.9 However, complete arthroscopic synovectomy is technically demanding as the posterior
compartment is almost always affected in DPVNS and recurrence rates are still significant.8,10
Therefore, the surgeon must be comfortable working through posteromedial and posterolateral
portals. With regard to the treatment of PVNS with invasion into the subchondral bone, open
and arthroscopic techniques are reported to have a poor prognosis. Although radiation therapy
has been used as an alternative treatment modality for invasive PVNS, results are mixed.11,12 The
combination of arthroscopic and open synovectomy for DPVNS shows promise and showed good
results in recent studies with lower recurrence rates when compared to either modality alone.11,13
Synovial Chondromatosis/Osteochondromatosis
Synovial chondromatosis is a rare and benign metaplasia of the synovium in which numerous
clusters of intra-articular cartilaginous and/or osteocartilaginous bodies are formed (Figure 2-3A).
This condition most commonly occurs in middle-aged men and is often a monoarticular process,
with more than 50% of cases presenting in the knee joint. It occurs in a primary or secondary
form. Primary synovial chondromatosis occurs spontaneously with no preexisting identifiable joint
pathology, whereas the secondary form presents in the setting of a preexistent, underlying disease,
such as osteoarthritis, rheumatoid arthritis (RA), osteochondritis dissecans, etc. On presentation,
patients will have pain, swelling, and possibly mechanical symptoms. The loose bodies are not
typically revealed on plain x-rays in the absence of calcification. Therefore, CT scan is only useful
for identifying calcified loose bodies. The usefulness of MRI depends on the degree of synovial
proliferation and amount of calcification within these bodies. The cartilaginous nodules have
intermediate signal intensity on T1-weighted images and high signal intensity on T2-weighted
images (Figure 2-3B). MRI with intra-articular gadolinium contrast increases the sensitivity for
detecting lesions.
Operative intervention is indicated for patients with recurrent painful effusions or mechanical
symptoms. Although open treatment has been long described, arthroscopic synovectomy with
removal of loose bodies has proven to be a safe and effective treatment for this disease.14 The
postoperative prognosis after excision is generally good, with low rates of recurrence and malig-
nant transformation. Recurrence rates between arthroscopic and open synovectomy are equivalent,
Arthroscopic Synovectomy 27
ranging from 0% to 31%. However, open treatment is associated with a higher incidence of pro-
longed rehabilitation and increased postoperative knee stiffness.
Synovial Hemangioma
Synovial hemangioma is a benign, vascular tumor that typically occurs in the knee. It is a rare
condition and is more frequently seen in children and young adults. It presents as a recurrent,
painful, monoarticular hemarthrosis. Patients will complain of pain, limited range of motion
(ROM), and stiffness, with no history of prior trauma. An associated cutaneous hemangioma is
seen in 40% of patients with a synovial hemangioma. On physical examination, a palpable, spongy,
compressible mass may be present. Hemangiomas of the knee have been described in the following
3 forms: synovial, juxta-articular, or intermediate (containing both synovial and juxta-articular
components). The intermediate form is often diffuse and considered unresectable. X-rays may
reveal a soft tissue mass, calcified phleboliths, and/or hemophilia-like arthropathy with epiphyseal
enlargement. On MRI, there is typically a lobulated, intra-articular mass with intermediate signal
intensity on T1-weighted images and both high and low intensity areas on T2-weighted images.
On the T2-weighted images, the high intensity areas represent pooling of blood in vascular spaces
and the low intensity areas represent the fibrous septae of the vascular channel. MRI is essential to
determine the location and extent of the lesion, thereby aiding in preoperative planning.15
Complete surgical excision of the mass is the definitive treatment, with preoperative embo-
lization of the lesion often necessary to help reduce intra- and postoperative bleeding. Use of
intraoperative coagulation/ablation during resection has also been shown to help reduce surgical
bleeding.16 For localized lesions, resection of the lesion with partial arthroscopic synovectomy is
effective. For diffuse lesions, a complete synovectomy is required. Complete synovectomy is the
only proven definitive treatment and is associated with a low recurrence rate. Successful complete
arthroscopic synovectomy has been reported.
Hemophilia
Hemophilia is a group of genetic bleeding disorders characterized by a deficiency of factor VIII
(hemophilia A) or factor IX (hemophilia B). Hemarthrosis is the most common and most dis-
abling musculoskeletal manifestation of the disease, leading to arthropathy, capsular fibrosis, and
joint contracture. Arthroscopic synovectomy is indicated in patients with recurrent hemarthroses
28 Chapter 2
that have failed conservative treatment for at least 6 months. Nevertheless, the presence of bony
deformities, osteophytes, and joint destruction makes this procedure technically demanding. It has
been shown to decrease the frequency of hemarthrosis, decrease the need for factor replacement,
and improve pain and ROM.22-24 The outcome following treatment is often correlated with the
degree of joint destruction seen arthroscopically and on imaging.
An emphasis on maximizing factor replacement preoperatively is critical to prevent periop-
erative bleeding. Coordination with a hematologist is recommended for managing perioperative
coagulation factor levels. Placement of a monitored drain and use of a compressive dressing post-
operatively is recommended. Patients are typically admitted to the hospital for physical therapy,
factor replacement, and monitoring. Postoperatively, use of a continuous passive motion machine
will help facilitate early motion, and cryotherapy with ice packs can be used to improve pain and
reduce swelling.
Seropositive Arthropathy
RA affects people predominantly between the ages of 35 and 50 years, with a 75% female
predominance. Patients will present with pain and stiffness due to inflammation and, in severe
cases, with hemorrhage and effusions, resulting in joint destruction over time. MRI will show
enhancement in areas of bony erosion and cartilage loss.
New disease-modifying antirheumatic drugs (DMARDs) have revolutionized the treatment
for RA. However, evidence supports that arthroscopic synovectomy can reduce joint destruction
in younger patients who do not respond adequately to DMARDs, with the theoretical benefit
of eliminating a major source of inflammatory chemokines and cytokines.25 Although more
technically demanding, complete arthroscopic synovectomy has advantages over conventional
open synovectomy in that it is less invasive and, therefore, the preferred treatment in rheumatoid
patients, who are at increased risk for postoperative infection and often have friable skin.26 When
compared to open treatment, complete arthroscopic synovectomy has also been shown to reduce
intraoperative blood loss, hospital stay, and return to function.27 However, one study showed a
high recurrence rate when compared with open synovectomy.28
Seronegative Arthropathy
Seronegative arthropathy is a term used to describe a broad array of musculoskeletal conditions
that share similar clinical and immunologic characteristics, including juvenile idiopathic arthritis,
ankylosing spondylitis, psoriatic arthritis, and Reiter’s syndrome. There is a genetic predisposi-
tion linked to the human leukocyte antigen genes, such as HLA-B27; therefore, it tends to run
in families. Early in the disease process, patients typically present with generalized myalgia. As
the disease progresses, patients go on to develop asymmetric joint pain and stiffness that worsens
with inactivity and low back pain in addition to various nonmusculoskeletal symptoms, includ-
ing constitutional symptoms, uveitis, urethritis, and gastrointestinal symptoms. Plain x-rays may
show no abnormalities early in the disease, followed by progressive asymmetric oligoarticular joint
involvement, juxta-articular osteoporosis, and a distinctive spinal pattern in the case of sacroiliitis
and ankylosing spondylitis.
Treatment for seronegative arthritis starts with medication and physical therapy. In older
patients with advanced disease and joint destruction, arthroplasty is the preferred definitive treat-
ment, whereas synovectomy may serve as a prophylactic treatment measure in the growing child.
Dell’Era et al reported results after synovectomy in children with juvenile idiopathic arthritis and
found that arthroscopic synovectomy results in adequate postoperative knee ROM with shorter
hospital stay when compared to open synovectomy.29
Arthroscopic Synovectomy 29
Contraindications/Controversial Indications
Absolute
▶ Intra-articular malignant conditions (eg, synovial sarcoma)
▷ Treatment for such conditions is often radical excision with chemotherapy and/or radiation
Relative
▶ Surgeon lack of experience/proficiency
▷ Performing a thorough synovectomy requires excellent technical skills and proficiency in
arthroscopy. Inadequate/incomplete performance may lead to local recurrence and/or poor
outcomes. Therefore, arthroscopic synovectomy is not recommended if the surgeon does
not feel confident in his or her ability to perform a complete and adequate arthroscopic
synovectomy. If this is the case, a traditional open approach should be utilized or the
patient should be referred to an experienced arthroscopist.
▶ Severe arthritic changes/deformity/contractures
▷ Such conditions may include advanced osteoarthritis, RA, seronegative arthritis, and
hemophilia. In such cases, total knee arthroplasty is the definitive treatment of choice.
Operative Planning
X-rays and MRI images should be reviewed and accessible in the operating room prior to the
start of the procedure. The authors recommend the use of a light general anesthetic. Consideration
of local or regional nerve blocks may aid in the reduction of postoperative pain if needed. After the
induction of general anesthesia, an examination under anesthesia should be performed, evaluating
both the ROM and stability of the knee and compared to the contralateral knee. The incidence
of infections with arthroscopy is very low. Nevertheless, the authors agree with the recent recom-
mendations for patient weight-based dosing of cefazolin or clindamycin for true penicillin aller-
gies, within 1 hour of incision or tourniquet inflation.
Equipment
The use of a well-padded thigh tourniquet may be considered as a more complete synovectomy
may result in increased bleeding that can make visibility during arthroscopy difficult. In most
cases, a 30-degree arthroscope is used for the majority of the procedure. Nevertheless, for adequate
visualization of the posterior compartment, a 70-degree arthroscope is often necessary and should
be available for the entire procedure. Initially, the inflow pump should be set at a low setting to
reduce knee distention and fluid extravasation intraoperatively. It can be adjusted throughout the
procedure accordingly. Although choice of shaver depends on the anatomy of the patient and the
location of the synovectomy, a variety of shaver sizes should also be available. A 5.5-mm full-radi-
us synovectomy blade is effective in the anterior compartment. A 3.5-mm full-radius synovectomy
blade or a 4.5-mm curved synovial resector can be used in smaller knees or hard to reach areas,
such as the posterior compartment and under the menisci.
Figure 2-4. Illustration of the 6 arthroscopic portals used in a complete arthroscopic synovectomy of the
knee.
the posteromedial knee is performed under visualization to better localize portal placement. At
this time, a spinal needle is introduced into the posteromedial corner of the knee joint aiming
anteriorly (Figure 2-6). Dimming of the overhead and room lights and transillumination using
the arthroscopy may also aid in introduction of the spinal needle. The posteromedial portal is the
then established, and a blunt cannula is introduced via this portal. The cannula is best introduced
over a switching stick to allow for easier and more accurate cannula placement. Caution must be
exercised when introducing any instrument into the joint in this location with an emphasis on
aiming slightly anteriorly to avoid iatrogenic injury to the posterior neurovascular bundle. The
posteromedial portal is typically placed 16 to 35 mm from the saphenous vein.30 Synovectomy of
the posteromedial knee is then performed through this portal with a 4.5-mm shaver systematically
from the periphery to the center. One must be mindful of the suction during this part of the pro-
cedure to avoid drawing the posterior capsule into the shaver, thereby risking accidental iatrogenic
injury to vital posterior structures.
Lastly, the lateral portion of the posterior compartment is then accessed similarly by switch-
ing the arthroscope to the anteromedial portal. Holding the knee flexed at 90 degrees will allow
the common peroneal nerve to fall further posteriorly behind the biceps femoris tendon. A spinal
needle is introduced anterior to the biceps femoris tendon, 1 cm above the joint line and 1 cm pos-
terior to the femoral condyle. The posterolateral portal is established and then cannulated like the
posteromedial portal. The posterolateral portal is typically placed 40 to 52 mm from the peroneal
nerve.30 Synovectomy of the posterolateral knee is then performed similar to the posteromedial
side in a systematic fashion.
Postoperative Protocol
Depending on the extent of synovectomy performed, a drain may be placed and monitored for
at least 1 day prior to removal to reduce postoperative hemarthrosis. Nevertheless, this may not be
needed if the bleeding is not significant at the conclusion of the case. A compressive dressing is
34 Chapter 2
applied to the knee. Patients can be made partial weightbearing with crutches for assistance and are
typically discharged the same day or on the first postoperative day. Cryotherapy with ice packs can
aid in postoperative reduction in pain and swelling. Oral pain medication should be prescribed, and
physical therapy should start early to ensure rapid restoration of normal gait, ROM, and strength.
Patients should be provided with written home instructions to begin immediate postoperative home
therapy with a focus on active ROM and quadriceps strengthening. Although not critical, the use of
a continuous passive motion machine to facilitate early motion is reasonable. The majority of patients
approach near normal activity level by the fourth postoperative week.
Potential Complications
Complications resulting from arthroscopic synovectomy are similar to those of any arthroscopic
procedure, including anesthesia concerns, infection, bleeding, deep venous thrombosis, arthro-
fibrosis, and iatrogenic injury to articular cartilage or neurovascular structures. Caution must
be taken during the procedure to maneuver the arthroscope or instruments to avoid excessive
pressure on the articular cartilage and to direct instruments away from vulnerable posterior
structures when using the posterolateral and posteromedial portals, namely the neurovascular
bundle, saphenous vein and nerve, and the common peroneal nerve. Other complications specific
to arthroscopic synovectomy include hemarthrosis resulting in pain and stiffness, postoperative
arthrofibrosis requiring a manipulation or arthroscopic lysis of adhesions, reflex sympathetic dys-
trophy, or incomplete resection resulting in recurrence or persistence of the synovial pathology,
thereby requiring additional surgery.
References
1. Shetty VD, Vowler SL, Krishnamurthy S, Halliday AE. Clinical diagnosis of medial plica syndrome of
the knee: a prospective study. J Knee Surg. 2007;20(4):277-280.
2. Monabang CZ, De Maeseneer M, Shahabpour M, Lenchik L, Pouliart N. MR imaging findings in
patients with a surgically significant mediopatellar plica. JBR-BRT. 2007;90(5):384-387.
3. Weckström M, Niva MH, Lamminen A, Mattila VM, Pihlajamäki KH. Arthroscopic resection of medial
plica of the knee in young adults. Knee. 2010;17(2):103-107.
4. Muse GL, Grana WA, Hollingsworth S. Arthroscopic treatment of medial shelf syndrome. Arthroscopy.
2010;26(3):391-392.
5. Dines JS, Bernadino TM, Wells JL, et al. Long-term follow-up of surgically treated localized pigmented
villonodular synovitis of the knee. Arthroscopy. 2007;23(9):930-937.
6. Flandry FC, Hughston JC, Jacobson KE, Barrack RL, McCann SB, Kurtz DM. Surgical treatment of dif-
fuse pigmented villonodular synovitis of the knee. Clin Orthop Relat Res. 1994;(300):183-192.
7. Bertoni F, Unni K, Beabout JW, Sim FH. Malignant giant cell tumor of the tendon sheaths and joints
(malignant pigmented vilonodular synovitis). Am J Surg Pathol. 1997;21(2):153-163.
8. Jain JK, Vidyasagar JV, Sagar R, Patel H, Chetan ML, Bajaj A. Arthroscopic synovectomy in pigmented
villonodular synovitis of the knee: clinical series and outcome. Int Orthop. 2013;37(12):2363-2369.
9. De Ponti A, Sansone V, Malcherè M. Result of arthroscopic treatment of pigmented villonodular syno-
vitis of the knee. Arthroscopy. 2003;19(6):602-607.
10. Sharma V, Cheng EY. Outcomes after excision of pigmented villonodular synovitis of the knee. Clin
Orthop Relat Res. 2009;467(11):2852-2858.
11. de Carvalho LH Jr, Soares LF, Goncalves MB, Temponi EF, de Melo Silva O Jr. Long-term success in
the treatment of diffuse pigmented villonodular synovitis of the knee with subtotal synovectomy and
radiotherapy. Arthroscopy. 2012;28(9):1271-1274.
12. Park G, Kim YS, Kim JH, et al. Low-dose external beam radiotherapy as a postoperative treatment for
patients with diffuse pigmented villonodular synovitis of the knee: 4 recurrences in 23 patients followed
for mean 9 years. Acta Orthop. 2012;83(3):256-260.
13. Colman MW, Ye J, Weiss KR, Goodman MA, McGough RL III. Does combined open and arthroscop-
ic synovectomy for diffuse PVNS of the knee improve recurrence rates? Clin Orthop Relat Res.
2013;471(3):883-890.
14. Samson L, Mazurkiewicz S, Treder M, Wiśniewski P. Outcome in the arthroscopic treatment of synovial
chondromatosis of the knee. Orthop Traumatol Rehabil. 2005;7(4):391-396.
15. Winzenberg T, Ma D, Taplin P, Parker A, Jones G. Synovial haemangioma of the knee: a case report.
Clin Rheumatol. 2006;25(5):753-755.
16. Barakat MJ, Hirehal K, Hopkins JR, Gosal HS. Synovial hemangioma of the knee. J Knee Surg.
2007;20(4):296-298.
17. Lindgren PG: Gastrocnemio-semimembranosus bursa and its relation to the knee joint. III. Pressure
measurements in joint and bursa. Acta Radiol Diagn (Stockh). 1978;19(2):377-388.
18. Akagi R, Saisu T, Segawa Y, et al. Natural history of popliteal cysts in the pediatric population. J Pediatr
Orthop. 2013;33(3):262-268.
19. Takahashi M, Nagano A. Arthroscopic treatment of popliteal cyst and visualization of its cavity through
the posterior portal of the knee. Arthroscopy. 2005;21(5):638.
20. Sansone V, DePonti A. Arthroscopic treatment of popliteal cyst and associated intra-articular knee
disorders in adults. Arthroscopy. 1999;15(4):368-372.
21. Calvisi V, Lupparelli S, Giuliani P. Arthroscopic all-inside suture of symptomatic Baker’s cysts: a techni-
cal option for surgical treatment in adults. Knee Surg Sports Traumatol Arthrosc. 2007;15(12):1452-1460.
22. Yoon KH, Bae DK, Kim HS, Song SJ. Arthroscopic synovectomy in haemophilic arthropathy of the
knee. Int Orthop. 2005;29(5):296-300.
23. Verma N, Valentino LA, Chawla A. Arthroscopic synovectomy in haemophilia: indications, technique
and results. Haemophilia. 2007;13(suppl 3):38-44.
24. de Almeida AM, de Rezende MU, Cordeiro FG, et al. Arthroscopic partial anterior synovectomy of the
knee on patients with haemophilia [published online ahead of print October 12, 2013]. Knee Surg Sport
Traumatol Arthrosc.
36 Chapter 2
25. Ogawa H, Itokazu I, Ito Y, Fukata M, Shimizu K. The therapeutic outcome of minimally invasive syno-
vectomy assisted with arthroscopy in the rheumatoid knee. Mod Rheumatol. 2006;16(6):360-363.
26. Kim SJ, Jung KA, Kwun JD, Kim JM. Arthroscopic synovectomy of the knee joint in rheumatoid arthri-
tis: surgical steps for complete synovectomy. Arthroscopy. 2006;22(4)461.e1-461.e4.
27. Masłoń A, Witoński D, Pieszyński I, Grzegorzewski A, Snyder M. Early clinical results of open and
arthroscopic synovectomy in knee inflammation. Orthop Traumatol Rehabil. 2007;9(5):520-526.
28. Chalmers PN, Sherman SL, Raphael BS, Su EP. Rheumatoid synovectomy: does the surgical approach
matter? Clin Orthop Relat Res. 2011;469(7):2062-2071.
29. Dell’Era L, Facchini R, Corona F. Knee synovectomy in children with juvenile idiopathic arthritis.
J Pediatr Orthop B. 2008;17(3):128-130.
30. Pace JL, Wahl CJ. Arthroscopy of the posterior knee compartments: neurovascular anatomic relation-
ships during arthroscopic transverse capsulotomy. Arthroscopy. 2010;26(5):637-642.
Introduction
Popliteal cysts occur relatively commonly in patients older than 50 years. Anatomists have been
aware of the presence of popliteal cysts for more than 150 years. Adams1 first described popliteal
cysts in 1840 as an “enlarged bursa that is normally situated beneath the inner head of the gas-
trocnemius and communicates with the joint by a species of valvular opening.” In 1897, Baker2
described the association of the cyst with the semimembranosus bursa and with this, his name
became associated with the cyst, frequently now called “Baker’s cyst.” Most of the popliteal cysts
occurring at the time of Adams and Baker were due to the inflammation and swelling associated
with tuberculosis of the knee. Although there have been a few modifications to the descrip-
tions of these cysts, the popliteal cyst is best defined as an enlargement of the gastrocnemius-
semimembranosus bursa, which communicates with the knee joint via a valve-like structure.3-6
It is the presence of this valve-like structure that allows the cysts to be successfully treated via
arthroscopic surgery.
Previous surgical treatment of popliteal cysts via the open approach has been described by
multiple authors.6-8 Complications have included fistula formation, recurrence, abscess, and
saphenous nerve injury.6,8 Many of these complications can be avoided by using an arthroscopic
approach. Arthroscopic treatment of popliteal cysts was first described by Sansone and De Ponti.9
Their treatment consisted mainly of decompression of the cyst through a hole in the posterior
capsule. With this, at 1 year, all patients showed reduction in the size of the cyst, with 95% of
patients displaying “optimal or good clinical results” at 2 years postoperatively. This technique has
been further refined10-12 by taking down the capsular fold that has been consistently identified
in nearly all patients with popliteal cysts.13 Ahn et al defined clearly the location of the valvular
capsular fold at the medial aspect of the medial head of the gastrocnemius and described the tech-
nique they used to resect the fold.11 Also described by Ahn et al was a posteromedial cystic portal,
which provides access to the cyst itself. This portal is located just superior to the posteromedial
portal and is used for resection of cyst walls if indicated. Follow-up magnetic resonance imaging
(MRI) at a minimum of 6 months showed complete disappearance or significant decrease in size
in all cysts and improved clinical outcomes in 94% of patients,12 thus confirming the viability and
value of arthroscopic treatment of popliteal cysts.
Popliteal cysts can be noted as incidental findings on MRI scan or can be severe enough to
cause nerve and/or vascular complications. They have been noted in 30% of cadaver specimens14
and have been identified on 5% of knee MRIs.15 It is essential that the surgeon perform a pre-
cise history and physical examination to discern which popliteal cysts warrant treatment, surgi-
cal or nonsurgical. Pediatric popliteal cysts are usually asymptomatic and often resolve without
treatment.16
Posteromedial knee mass and/or pain are the most common presenting symptoms of popliteal
cysts. Cysts that exceed 5 cm are more likely to be symptomatic. Pain arising from the cyst itself
is often difficult to discern from the posterior knee pain arising from associated intra-articular
pathology, such as posterior horn medial meniscal tears. A sensation of fullness and the intermit-
tent nature of the posteromedial pain as effusions and cyst distension occur tend to point toward
a symptomatic cyst. Neurovascular compromise can also cause symptoms. Because of the more
medial position of the nerve, most commonly seen are tibial nerve compression symptoms, includ-
ing pain, gastrocnemius weakness and atrophy, burning sensations, and parasthesias. Tibial vein
compromise can lead to pseudothrombophlebitic symptoms, including pain, swelling, and lymph-
edema. Arterial compromise is rare due to the medial and deep position of the tibial artery and its
stiff walls (Figure 3-1). Rupture of a popliteal cyst has been known to cause acute compartment
syndrome, necessitating acute fasciotomy.17
The accumulation and persistence of fluid within a popliteal cyst is proposed to be caused by
2 factors. The first is the overproduction of synovial fluid within the joint because of intra-artic-
ular pathology, synovitis, or both. Common intra-articular pathologies include chondromalacia,
chondral debris, or meniscal tears. Systemic arthropathies, such as rheumatoid arthritis, gout, or
chondrocalcinosis, can also cause persistent effusions. Increased synovial fluid within the joint
is forced out through the posteromedial opening into the popliteal cyst, when present, and then
becomes trapped within the cyst because of the 1-directional flow between the intra-articular
cavity and the cyst due to the valvular mechanism.
Nonsurgical treatment has consisted of nonsteroidal anti-inflammatory drugs (NSAIDs),
intra-articular corticosteroid injection,18 and direct cyst aspiration with steroid injection.
Aspiration of the cyst and injection with corticosteroid is felt to yield similar results to intra-
articular corticosteroid injection.19 NSAIDs may be effective if the knee effusion is caused by
systemic arthropathy, such as rheumatoid arthritis. If intra-articular pathology exists, complete
nonsurgical treatment may be less effective. Medial meniscal tears have been noted to be the most
common pathology associated with popliteal cysts.20 Addressing the intra-articular pathology,
Arthroscopic Treatment of Popliteal Cysts 39
such as performing meniscectomy, may be adequate to allow the joint effusion to dissipate and the
cyst may resolve on its own.21 However, in patients with intra-articular pathology that cannot be
corrected by arthroscopic means, such as high-grade chondral lesions (grades III and IV), the cyst
often remains following arthroscopy, leading to poor patient satisfaction.21 Symptomatic popliteal
cysts in these patients are amenable to arthroscopic decompression of the cyst.
Indications
▶ Painful cyst (usually larger than 5 cm)
▶ Cyst causing neurovascular compromise
▶ Cyst occurring in the presence of grade III or IV chondromalacia or synovial disease
▶ Cyst not responding to conservative treatment
The most logical indication for arthroscopic treatment of popliteal cysts is a symptomatic cyst
(usually larger than 5 cm), which occurs in a knee in which at least a portion of the intra-articular
pathology will not be corrected by arthroscopic treatment (eg, grade III or IV chondromalacia).
Also, arthroscopic treatment of the symptomatic cyst is indicated in knees without intra-articular
pathology other than synovitis, such as seen in chondrocalcinosis or rheumatoid disease, in which
conservative treatment (steroid injections, NSAIDs) has failed.
Loose bodies may also be present in popliteal cysts. These may cause continued fluid accu-
mulation within the cyst, contributing to its inability to resorb, again necessitating arthroscopic
treatment of the cyst itself.
Pertinent Imaging
▶ MRI is essential for preoperative planning prior to arthroscopic treatment of the cyst.
Identifying the fluid collection as a true popliteal (Baker’s) cyst can be best done by noting
the surrounding structures on the MRI (Figure 3-2). The neck of the fluid collection must
be present between the medial head of the gastrocnemius and the semimembranosus tendon
for the pathology to be present, which is amenable to arthroscopic treatment. The valvular
communication between the cyst and the joint is always present in this location. This is best
identified on the axial sections. The cyst itself usually lies medial to the medial head of the
40 Chapter 3
gastrocnemius. Locating the most superficial portion of the cyst on MRI is also important
if cyst excision or loose body excision is to be performed. This can be best identified on the
sagittal and coronal sections. If the cyst extends proximal to the joint line, it often follows the
course of the semimembranosus tendon proximally, toward the midline of the popliteal fossa,
often abutting the neurovascular bundle (Figure 3-3). This is essential to note if considering
cystectomy. MRI may also help define other pathology that is to be addressed at the time of
arthroscopy, such as meniscal tears and chondral injury, which are commonly associated with
popliteal cysts.20,21 MRI will also assist in diagnosing other popliteal masses that can present
in a similar fashion. Although rare, popliteal artery aneurysms, synovial cell sarcomas, and
Arthroscopic Treatment of Popliteal Cysts 41
Figure 3-3. Axial MRI of a large popliteal cyst extending proximal to the joint line. Note the proximity of
the cyst to the tibial nerve, vein (V), and artery (A).
hemangiomas can be mistaken for popliteal cysts on initial presentation. MRI findings for
these entities differ greatly from popliteal cysts.
▶ Although ultrasound can also be used to diagnose and define a popliteal cyst, the surgeon
must have an excellent understanding of the images and have the ability to identify surround-
ing structures. It is essential to have knowledge of the actual shape and position of the cyst.
Equipment
Standard arthroscopic equipment is required for arthroscopic decompression of popliteal cysts.
In order to easily obtain access to the posteromedial aspect of the knee, a second arthroscopic
sheath is recommended. An 18-gauge spinal needle is used for localization of portals. An
arthroscopic shaver and biting baskets are often required for resection of the valvular mechanism,
and arthroscopic graspers need to be available for loose bodies that may be encountered within the
cyst. A 70-degree arthroscope is occasionally used to assist in visualization.
B
Arthroscopic Treatment of Popliteal Cysts 45
lesion and/or the opening into the cyst is not easily identified, pressure on the posteromedial knee
directly over the cyst can sometimes elicit a puff of fluid from the cyst through the opening into
the knee. This fluid is usually more viscous and more yellowish than the synovial fluid and can
be easily identified. Injection of the cyst with methylene blue pre- or intraoperatively can also help
identify the opening, again with direct pressure on the cyst and intra-articular visualization. The
preoperative MRI scan is helpful to identify the most superficial location of the cyst posteriorly
to inject the dye.
Once the proper position for the posteromedial portal has been ascertained, a small longitudi-
nal nick is created in the skin, and a cannula with a blunt trocar is passed under direct visualization
into the posterior aspect of the knee. The PoTSI lesion is taken down with baskets and/or a shaver
at the medial edge of the tendon of the medial head of the gastrocnemius, further revealing the
opening into the popliteal cyst (Figure 3-9). An 8- to 10-mm opening is created in the PoTSI
lesion to allow free flow of synovial fluid out of the cyst into the knee (Figure 3-10). The arthro-
scope is then transferred into the posteromedial portal to allow visualization of the interior of the
cyst. Cyst walls are identified and often noted to be incompletely septated (Figure 3-11). Chondral
or bony loose bodies are frequently encountered (Figure 3-12). These can sometimes be irrigated
out or occasionally require a transcystic portal for removal. To irrigate the cyst, the arthroscopic
sheath originally placed in the anteromedial or anterolateral portal is left in place in the postero-
medial compartment while the arthroscope remains in the popliteal cyst via the posteromedial
portal, allowing free flow of fluid out of the cyst into the sheath and out of the knee. Suction can
also be placed on the anterior cannula while visualizing through the posteromedial portal to assist
in irrigating out loose bodies.
In order to remove larger loose bodies from the cyst or resect the popliteal cyst, it is necessary
to gain a working portal into the cyst. Prior to creating a transcystic portal, the MRI must be
studied to assess the most subcutaneous location of the cyst (Figure 3-13). This is usually posterior,
just medial to the midline, and below the joint line. The MRI will also be helpful to visualize any
large subcutaneous veins that may lie between the cyst and the skin. Using transillumination from
the arthroscope in the posteromedial portal, the planned location for the transcystic portal is first
marked with a needle. Transillumination will often also outline any crossing veins. The needle is
visualized in the cyst to ensure adequate access to the loose body or the cyst walls. A small nick is
46 Chapter 3
*
Arthroscopic Treatment of Popliteal Cysts 47
created in the skin, and a blunt trocar and cannula are introduced into the cyst. Through this can-
nula, loose bodies can be removed or the cyst may be resected. Cyst resection is often not necessary
as decompression of the cyst alone often leads to its resolution. Cyst excision can be performed
similarly to a standard synovectomy, with extreme care to remove only the cyst lining and not
wander lateral into the neurovascular structures. Cystectomy is performed in the case of recurrent
cysts or if the cyst lining appears to consist of diseased synovium, such as that occasionally seen in
rheumatoid or other systemic arthropathies.
Portals are closed with nonabsorbable sutures. It is important to close the posteromedial and
transcystic portals as these may lead to cutaneous fistulas if they do not properly heal. These
portals also tend to gap open more than the standard anterior arthroscopic portals. A compression
dressing is placed over the posteromedial knee, with care not to compromise the mid portion of
the popliteal fossa, in addition to the standard arthroscopic dressing. If cyst excision is performed,
the patient is placed in intermittent pneumatic compression socks for 2 weeks to add additional
compression to the proximal calf.
Postoperative Protocol
Full range of motion is allowed postoperatively. Leg elevation is essential to avoid knee and
lower leg swelling. The patient is encouraged to bear weight as tolerated; discontinuing crutches
as able and the performance of ankle pumps are advised to minimize risk of venous thrombosis.
Gradual return to activities of daily living and sports activities, if applicable, is allowed. Patients
usually return to all activities by 4 to 6 weeks postoperatively.
Recurrence rates, even with PoTSI flap excision only, have been rare in the literature and in the
author’s practice (Figure 3-14).10,12
48 Chapter 3
Potential Complications
Although minimal complications are usually associated with arthroscopic surgery, there are
some circumstances with arthroscopic treatment of popliteal cysts that require special attention
to avoid complications.
Popliteal cyst excision requires the creation of a posteromedial portal. This portal is placed
along the medial joint line after localization with a spinal needle under direct arthroscopic visual-
ization. Structures at risk when creating this portal include the saphenous nerve and the saphenous
Arthroscopic Treatment of Popliteal Cysts 49
Figure 3-13. Axial MRI of a popliteal cyst demonstrating the most superficial position
for the transcystic portal (arrow).
vein. Although these structures can sometimes be identified by transillumination prior to needle
localization, this is not always possible due to the thickness of the subcutaneous tissue. After
needle localization, a longitudinal nick is created in the skin only. Only blunt trocars should be
used to introduce the posteromedial cannula. The smallest cannula possible should be used in this
portal to minimize risk to the surrounding structures. A smooth cannula may also reduce this risk.
Also, when placing the posteromedial or anterior cannula into the posteromedial compartment,
care must be taken not to plunge into the compartment. The popliteal artery, vein, and nerve can
lie directly in the path of the cannula if placed too deep. Again, only blunt cannulas should be used
when going into the posteromedial compartment.
The popliteal nerve, artery, and vein can also be at risk during the resection of the PoTSI lesion
or of resection of the cyst itself. Resection of the PoTSI lesion should cause minimal risk as the
lesion is located medial to the medial edge of the gastrocnemius tendon, with the neurovascular
structures lying far more lateral between the 2 heads of the gastrocnemius. However, if one does
not identify the medial head of the gastrocnemius upon entering the posterior compartment,
the resection can be begun too laterally, putting the popliteal structures at risk. Upon resecting
the cyst, if necessary, care must be taken to resect only the cyst lining. This plane can usually
be easily identified. However, if the plane is not easily identified, especially when taking down
the anterolateral portion of the cyst, it is better to leave this portion of the cyst in situ. In the
author’s experience, leaving a portion of the cyst in place does not necessarily lead to recurrence.
Preoperative planning with the MRI scan will also help identify the proximity of the popliteal
structures to the cyst as they are often completely shielded from the resection by the medial head
of the gastrocnemius. Popliteal artery pseudoaneurysm after arthroscopic cystectomy has been
reported.22 Preoperative imaging confirmed the proximity of the cyst to the popliteal artery, with
the concerning cysts often extending proximal and lateral to the usual cyst location.
50 Chapter 3
B
Arthroscopic Treatment of Popliteal Cysts 51
Conclusion
Arthroscopic treatment of popliteal cysts is a relatively straightforward procedure for treat-
ment of symptomatic popliteal cysts. Cyst removal or decompression first requires location of the
valve-like mechanism or PoTSI lesion at the medial edge of the medial head of the gastrocnemius
tendon. The valve-like fold is then taken down through a posteromedial portal to allow free flow
of fluid between the cyst and the intra-articular environment of the knee. Further work within the
cyst requires placement of the arthroscope into the posteromedial portal and creation of a tran-
scystic portal. Careful attention to the preoperative MRI and knowledge of anatomy can create a
reproducible result with excellent patient satisfaction and low incidence of reoccurrence.
References
1. Adams R. Chronic rheumatic arthritis of the knee joint. Dublin J Med Sci. 1840;17:520-522.
2. Baker WM. On the formation of the synovial cysts in the leg in connection with disease of the knee
joint. St Barth Hosp Rep. 1877;13:245-261.
3. Gristina AG, Wilson PD. Popliteal cysts in adults and children. A review of 90 cases. Arch Surg.
1964;88:357-363.
4. Goldstein LA, Dickerson RC. Atlas of Orthopedic Surgery. Vol 2. St. Louis, MO: CV Mosby Co;
1974:762-763.
5. Lindgren PG, Willén R. Gastrocnemio-semimembranosus bursa and its relations to the knee joint. Acta
Radiol Diagn (Stockh). 1977;18(5):497-512.
6. Rauschning W, Lindgren PG. Popliteal cysts (Baker’s cysts) in adults. I: clinical and roentgenological
results of operative excision. Acta Orthop Scand. 1979;50(5):583-591.
7. Hughston JC, Baker CL, Mello W. Popliteal cyst: a surgical approach. Orthopedics. 1991;14(2):147-150.
8. Vahvanen V. Popliteal cysts. A follow-up study on 42 operatively treated patients. Acta Orthop Scand.
1973;44(3):303-310.
9. Sansone V, De Ponti A. Arthrosopic treatment of popliteal cyst and associated intra-articular knee
disorders in adults. Arthroscopy. 1999;15(4):368-372.
10. Ko S, Ahn J. Popliteal cystoscopic excisional debridement and removal of capsular fold of valvular
mechanism of large recurrent popliteal cyst. Arthroscopy. 2004;20(1):37-44.
11. Ahn JH, Yoo JC, Lee SH, Lee YS. Arthroscopic cystectomy for popliteal cysts through the posteromedial
cystic portal. Arthroscopy. 2007;23(5):559.e1-559.e4.
12. Ahn JH, Lee SH, Yoo JC, Chang MJ, Park YS. Arthroscopic treatment of popliteal cysts: clinical and
magnetic resonance imaging results. Arthroscopy. 2010;26(10):1340-1347.
13. Kim KI, Lee SH, Ahn JH, Kim JS. Arthroscopic anatomic study of posteromedial joint capsule in knee
joint associated with popliteal cyst. Arch Orthop Trauma Surg. 2014;134(7):979-984.
14. Guerra J Jr, Newell JD, Resnick D, Danzig LA. Pictorial essay: gastrocnemio-semimembranosus bursal
region of the knee. AJR Am J Roentgenol. 1981;136(3):593-596.
15. Fielding JR, Franklin PD, Kustan J. Popliteal cysts: a reassessment using magnetic resonance imaging.
Skeletal Radiol. 1991;20(6):433-435.
16. Akagi R, Saisu T, Segawa Y, et al. Natural history of popliteal cysts in the pediatric population. J Pediatr
Orthop. 2013;33(3):262-268.
17. Sanchez JE, Conkling N, Labropoulos N. Compression syndromes of the popliteal neurovascular
bundle due to Baker cyst. J Vasc Surg. 2011;54(6):1821-1829.
18. Acebes JC, Sánchez-Pernaute O, Díaz-Oca A, Herrero-Beaumont G. Ultrasonographic assessment of
Baker’s cysts after intra-articular corticosteroid injection in knee osteoarthritis. J Clin Ultrasound.
2006;34(3):113-117.
19. Di Sante L, Paoloni M, Ioppolo F, Dimaggio M, Di Renzo S, Santilli V. Ultrasound-guided aspiration
and corticosteroid injection of Baker’s cysts in knee osteoarthritis: a prospective observational study.
Am J Phys Med Rehabil. 2010;89(12):970-975.
20. Stone KR, Stoller D, De Carli A, Day R, Richnak J. The frequency of Baker’s cysts associated with menis-
cal tears. Am J Sports Med. 1996;24(5):670-671.
21. Rupp S, Seil R, Jochum P, Kohn D. Popliteal cysts in adults. Prevalence, associated intraarticular lesions,
and results after arthroscopic treatment. Am J Sports Med. 2002;30(1):112-115.
22. Kp V, Yoon JR, Nha KW, Yang JH, Lee JH, Jegal H. Popliteal artery pseudoaneurysm after arthroscopic
cystectomy of a popliteal cyst. Arthroscopy. 2009;25(9):1054-1057.
23. Cho JH. Clinical results of direct arthroscopic excision of popliteal cyst using a posteromedial portal.
Knee Surg Relat Res. 2012;24(4):235-240.
Introduction
Tibial plateau fractures typically present as a high-mechanism injury in a young patient, such as
a car vs pedestrian or fall from height, or a low-energy fracture in elderly patients. Among athletes,
they are common in skiers.1,2
The mechanism of injury is a combination of a varus or valgus deforming force and axial load
resulting in a spectrum of shear and depression fracture patterns. The most common classification
is the Schatzker system (Figure 4-1).
Several features of tibial plateau bony anatomy are critical for understanding and treating these
injuries.1
▶ The lateral tibial plateau is convex and lies 2 to 3 mm proximal to the medial plateau. Raising
depressed fragments of the lateral tibial plateau only to the level of the medial plateau will not
result in anatomic restoration of the articular surface.
▶ Normally, the lateral condyle of the femur lies directly in line with the lateral rim of the tibial
plateau and the medial condyle with the medial rim of the tibial plateau. Widening of the
tibial plateau is a common feature of tibial plateau fractures, and failure to reduce the condylar
width results in abnormal articular contact with the femoral condyles.
▶ On average, the proximal tibia has a posterior slope of 9 degrees. This observation is critical
in obtaining proper fluoroscopic imaging during fixation to evaluate articular reduction.
Associated soft tissue injury with tibial plateau fracture is common. Frequency of lateral menis-
cal injury is frequently quoted as present in 42% to 45% of plateau fractures3,4; however, in one
series, 91% of patients had evidence of lateral meniscal pathology and 77% had tear or avulsion
of a cruciate or collateral ligament.5 The menisci function as significant secondary stabilizers of
the knee joint, and their treatment is related to outcomes. The clinical implications of associated
cruciate and collateral ligament injury remain incompletely defined.
Arthroscopy has emerged as a useful tool for evaluating articular reduction and treating
associated soft tissue pathology. Short-term results of arthroscopic reduction internal fixation
(ARIF) have been promising, with good and excellent results in greater than 90% of patients.6-10
Medium-term results appear comparable to short-term results.11,12 Not surprisingly, results of
ARIF for more complex type V and VI fractures are less satisfactory but still approach 90% good
and excellent.13
Tibial eminence avulsion fractures commonly occur in children and adolescents.14 However, it
is sometimes misunderstood that this condition occurs only in the young. Although less common,
anterior cruciate ligament (ACL) avulsion also occurs in adults.15,16
Isolated intercondylar eminence fractures are avulsion fractures of the tibial insertion of the
ACL. The most common classification system was initially described by Meyers and McKeever17
(Figure 4-2). It is critical to understand that failure to completely reduce the displaced frag-
ment alters the length-tension relationship of the ACL and results in functional cruciate insta-
bility. Several techniques have been described for fixation, and excellent outcomes have been
reported.18-22
Indications
▶ Tibial plateau fractures
▷ Articular depression and/or incongruity greater than 4 mm1
▷ Schatzker type III and selected types I, II, and IV fractures
▶ Tibial eminence fractures
▷ Meyers and McKeever type I fractures if associated with meniscal tears or concomitant
pathology requiring arthroscopic treatment
▷ Meyers and McKeever type II fractures typically require ARIF because of the high rate of
incarceration of the anterior horn of the medial meniscus.
▷ Most displaced Meyers and McKeever type III fractures
Controversial Indications
▶ Tibial plateau fractures
▷ ARIF may be appropriate for types I, II, and IV, in which displacement of the split frag-
ment is minimal
Arthroscopic Management of Tibial Plateau Fractures 55
▷ Arthroscopically assisted open reduction and internal fixation is indicated for deformity
effecting the mechanical axis of the limb.
▷ Schatzker type V and VI fractures are best treated with arthroscopically assisted open
reduction and internal fixation.
▶ Tibial eminence fractures
▷ Some type IIIB fractures may be amenable to closed reduction because the large bony frag-
ment can be reduced by the femoral condyles and soft tissue incarceration is less common.14
Pertinent Imaging
▶ Tibial plateau fractures
▷ Anteroposterior, lateral, and oblique x-rays reveal most tibial plateau fractures but can miss
minimally displaced and joint depression fractures.
▷ Noncontrast computed tomography (CT) scan is indicated for preoperative planning to
evaluate fragment morphology, fracture pattern, and articular depression
▷ Magnetic resonance imaging (MRI) is a useful adjunct to identify occult fractures and
associated soft tissue pathology.5,23
▶ Tibial eminence fractures
▷ Tibial eminence fractures are most frequently diagnosed with standard anteroposterior,
lateral, and oblique knee x-rays.
▷ Advanced imaging (CT or MRI) may be indicated when the classification or the size of the
bony avulsion is uncertain and nonoperative treatment is being considered.14
Equipment
Equipment for ARIF of tibial plateau fractures includes standard arthroscopy equipment, ACL
drill guide, guide wires, cannulated drill bits, and coring reamer, cannulated tamp, and large-
diameter screws (Figure 4-3). Special equipment for tibial eminence fracture fixation includes
standard arthroscopy equipment, ACL drill guide, guide wires, suture hook, nitinol wire loop,
and high-strength suture material.
Arthroscopic Management of Tibial Plateau Fractures 57
Figure 4-5. (A) Prereduction view of a Schatzker type III (lateral central compression)
fracture viewed from an anterolateral portal in a left knee. The depressed articular
surface results in widening of the lateral compartment. (B) Postreduction view of
Schatzker type III fracture. A cannulated tamp is used to elevate the fracture site under
arthroscopic visualization.
while removing as little bone as possible. The cannulated tamp is used to elevate the fracture site
under arthroscopic visualization (Figure 4-5). The underlying metaphyseal bone and cortical disk
serve as autograft. A calcium or hydroxyapatite-impregnated bioabsorbable cannulated interfer-
ence screw of large diameter is then advanced through the cortical window to further elevate the
fracture under direct arthroscopic visualization (Figure 4-6). The screw provides elevation of the
fragment and rigid internal fixation of the fracture.
Arthroscopic Management of Tibial Plateau Fractures 59
For isolated or predominantly depression (type III) fractures, the screw obviates the need for
percutaneous placement of subchondral, metal, cannulated buttress screws. For split depression
(types II and IV) with significant metaphyseal displacement and more complex patterns (types V
and VI) requiring open plating, major split fragments are reduced first, articular reduction is opti-
mized and provisionally fixed with smooth K-wires. Finally, plate application can then compress
the reduced articular surface, reduce condylar widening, and rigidly fix the fracture fragments.
Techniques for tibial plateau ARIF are demonstrated in the Video.
Figure 4-8. Arthroscopic view of a right knee from an anterolateral portal. (A) Preoperative view dem-
onstrating elevated eminence avulsion fracture. (B) Drill enters lateral to the fragment, previously passed
suture is visible medial to fragment. (C) Downward traction on suture limbs after final passing reduces
elevated fracture fragment. (Reprinted with permission from Gregory Schmale, MD.)
An ACL guide is used to place medial and lateral drill holes on either side of the fragment
through the intact bone adjacent to the fracture under arthroscopic visualization. A longitudinal
incision is centered over the tibial tubercle, which allows subcutaneous access to the medial and
lateral entry points. The medial pin enters the tibia just medial to the tubercle and the lateral pin
just lateral.
A nitinol wire loop is passed up through the drill holes medially and laterally. Routine suture
passage brings the suture ends out the medial and lateral drill holes. Distal traction on the suture
ends reduces the fracture (Figure 4-8). The sutures are tied under tension while an assistant per-
forms a reverse Lachman maneuver (Figure 4-9). Only one suture is required in most cases, but
additional sutures can be added as described above.
Tibial eminence fractures, even after complete reduction and fixation, may demonstrate a few
millimeters of superior displacement. Functional outcome remains excellent.14
Techniques for tibial eminence avulsion ARIF are demonstrated in the Video.
Arthroscopic Management of Tibial Plateau Fractures 61
Postoperative Protocol
Patients are initially admitted for observation and pain control. ARIF provides rigid fixation
and allows immediate early motion. Continuous passive motion can be a useful adjunct in the early
postoperative period. Zero to 90 degrees of motion at 2 weeks and full ROM at 6 weeks is the goal.
Weightbearing is delayed, generally for 12 weeks or until radiographic evidence of healing is present.
Partial weightbearing is initiated and gradually advanced to full weightbearing over 4 weeks. A hinged
knee bracing for 6 weeks is recommended for patients with associated collateral ligament injuries.
For intercondylar eminence avulsion fractures, the patient can be discharged on the day of sur-
gery. Crutches are recommended, but patients are permitted to bear full weight with the knee locked
in a brace in full extension. The brace is unlocked or removed for continuous passive motion. Early
outpatient physical therapy is recommended to achieve 0 to 90 degrees of knee flexion at 2 weeks and
full ROM by 6 weeks. Isometric quadriceps and hamstring strengthening with the knee locked in
the brace is permitted during the first 6 weeks. After 6 weeks, the brace is discontinued and resistive
exercises are introduced; however, terminal resisted extension is not allowed for 12 weeks.
Potential Complications
For ARIF, it is critical that calf compartments are continually palpated to ensure that fluid
extravasation does not cause iatrogenic compartment syndrome.28 Although intercondylar eminence
avulsion fractures are contained injuries, they may be associated with capsular disruption and, thus,
are not immune to this devastating complication. Dry arthroscopy whenever possible decreases fluid
extravasation and risk of increased compartment pressure. Inadequate preoperative planning can
result in unappreciated fracture lines that will displace if not appropriately reduced and rigidly fixed.
References
1. Browner BD. Skeletal Trauma. 4th ed. Philadelphia, PA: Saunders; 2009.
2. Lubowitz JH, Elson WS, Guttmann D. Part I: arthroscopic management of tibial plateau fractures.
Arthroscopy. 2004;20(10):1063-1070.
3. Mustonen AO, Koivikko MP, Lindahl J, Koskinen SK. MRI of acute meniscal injury associated with
tibial plateau fractures: prevalence, type, and location. AJR Am J Roentgenol. 2008;191(4):1002-1009.
62 Chapter 4
4. Colletti P, Greenberg H, Terk MR. MR findings in patients with acute tibial plateau fractures. Comput
Med Imaging Graph. 1996;20(5):389-394.
5. Gardner MJ, Yacoubian S, Geller D, et al. The incidence of soft tissue injury in operative tibial plateau
fractures: a magnetic resonance imaging analysis of 103 patients. J Orthop Trauma. 2005;19(2):79-84.
6. Tian M, Wang L, Zhang Y, Liu J. Curative effect of minimally invasive percutaneous plate osteosynthe-
sis assisted by arthroscopy on 29 cases of tibial plateau fractures [in Chinese]. Zhongguo Xiu Fu Chong
Jian Wai Ke Za Zhi. 2009;23(8):921-924.
7. Duan XJ, Yang L, Guo L, Chen GX, Dai G. Arthroscopically assisted treatment for Schatzker type I-V
tibial plateau fractures. Chin J Traumatol. 2008;11(5):288-292.
8. Hung SS, Chao EK, Chan YS, et al. Arthroscopically assisted osteosynthesis for tibial plateau fractures.
J Trauma. 2003;54(2):356-363.
9. Asik M, Cetik O, Talu U, Sozen YV. Arthroscopy-assisted operative management of tibial plateau frac-
tures. Knee Surg Sports Traumatol Arthrosc. 2002;10(6):364-370.
10. Roerdink WH, Oskam J, Vierhout PA. Arthroscopically assisted osteosynthesis of tibial plateau frac-
tures in patients older than 55 years. Arthroscopy. 2001;17(8):826-831.
11. Siegler J, Galissier B, Marcheix PS, Charissoux JL, Mabit C, Arnaud JP. Percutaneous fixation of tibial plateau
fractures under arthroscopy: a medium term perspective. Orthop Traumatol Surg Res. 2011;97(1):44-50.
12. Scheerlinck T, Ng CS, Handelberg F, Casteleyn PP. Medium-term results of percutaneous, arthroscop-
ically-assisted osteosynthesis of fractures of the tibial plateau. J Bone Joint Surg Br. 1998;80(6):959-964.
13. Chan YS. Arthroscopy- assisted surgery for tibial plateau fractures. Chang Gung Med J. 2011;34(3):239-247.
14. Lubowitz JH, Elson WS, Guttmann D. Part II: arthroscopic treatment of tibial plateau fractures: inter-
condylar eminence avulsion fractures. Arthroscopy. 2005;21(1)86-92.
15. Toye LR, Cummings DP, Armendariz G. Adult tibial intercondylar eminence fracture: evaluation with
MR imaging. Skeletal Radiol. 2002;31(1):46-48.
16. Bonin N, Jeunet L, Obert L, Dejour D. Adult tibial eminence fracture fixation: arthroscopic procedure
using K-wire folded fixation. Knee Surg Sports Traumatol Arthrosc. 2007;15(7):857-862.
17. Bucholz RW, Heckman JD, Court-Brown C, et al. Rockwood and Green’s Fractures in Adults. 6th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
18. Parr RR. Arthroscopic reduction and headless cannulated compression screw fixation of adults’ tibial
eminence fractures. Am J Orthop (Belle Mead NJ). 2006;35(12):558-561.
19. Lehman RA Jr, Murphy KP, Machen MS, Kuklo TR. Modified arthroscopic suture fixation of a dis-
placed tibial eminence fracture. Arthroscopy. 2003;19(2):E6.
20. Hapa O, Barber FA, Süner G, et al. Biomechanical comparison of tibial eminence fracture fixation with
high-strength suture, EndoButton, and suture anchor. Arthroscopy. 2012;28(5):681-687.
21. Senekovic V, Veselko M. Anterograde arthroscopic fixation of avulsion fractures of the tibial eminence
with a cannulated screw: five-year results. Arthroscopy. 2003;19(1):54-61.
22. Kogan MG, Marks P, Amendola A. Technique for arthroscopic suture fixation of displaced tibial inter-
condylar eminence fractures. Arthroscopy. 1997;13(3):301-306.
23. Markhardt BK, Gross JM, Monu JU. Schatzker classification of tibial plateau fractures: use of CT and
MR imaging improves assessment. Radiographics. 2009;29(2):585-597.
24. Caspari RB, Hutton PM, Whipple TL, Meyers JF. The role of arthroscopy in the management of tibial
plateau fractures. Arthroscopy. 1985;1(2):76-82.
25. Jennings JE. Arthroscopic management of tibial plateau fractures. Arthroscopy. 1985;1(3):160-168.
26. Buchko GM, Johnson DH. Arthroscopy assisted operative management of tibial plateau fractures. Clin
Orthop Relat Res. 1996;(332):29-36.
27. Lubowitz JH, Grauer JD. Arthroscopic treatment of anterior cruciate ligament avulsion. Clin Orthop
Relat Res. 1993;(294):242-246.
28. Belanger M, Fadale P. Compartment syndrome of the leg after arthroscopic examination of a tibial
plateau fracture. Case report and review of the literature. Arthroscopy. 1997;13(5):646-651.
Introduction
Arthrofibrosis was described as the fibroplastic response of the joint to trauma in 1951.1 In
1973, Enneking and Horowitz2 demonstrated the intra-articular effects of immobilization in
the knee, including progressive contracture of the capsule and pericapsular structures, encroach-
ment of the joint by fibro-fatty connective tissue, and joint cavity obliteration. Further study
yielded open techniques to manage the disorder and, in 1982, Sprague et al 3 described the first
arthroscopic approach to the treatment of the stiff knee.
The physical changes noted by Enneking and Horowitz’s classic article are identical to those
observed with any kind of prolonged motion loss and must be addressed along with the underlying
cause of the motion loss.
In general, a knee that has suffered hemarthrosis as a result of injury or surgery, which dem-
onstrates persistent inflammation, decreased range of motion (ROM), and patella tightness, is
indicated for intervention. However, the knee must be “cool” before any surgical intervention.
Indications
▶ Decreased ROM: Pain and decreased ROM after ligament reconstruction surgery, especially
when performed during the acute phase and in combination with extra-articular procedures4
▶ Failure of nonoperative treatment or manipulation alone: Patients who have failed to regain
full ROM within 4 to 6 weeks after surgery should be counseled regarding possible interven-
tion for arthrofibrosis. If manipulation followed by judicious physical therapy, anti-inflam-
matory drugs, and hamstring stretching exercises between weeks 6 and 12 fails to bring about
progress, then arthroscopic management is indicated typically between weeks 10 and 12.5
Controversial Indications
▶ Active inflammation: Surgical intervention should not be considered if the knee is still
actively inflamed.
▶ Extensor lag: Surgery should be delayed when there is an extensor lag.6 There should be full
quad activation and strength prior to consideration of arthroscopic lysis of adhesions in the
joint so as to maintain extension gains.
In summary, presurgical goals should include good quadriceps strength without lag and mini-
mal swelling, warmth, and pain.
It is also imperative to consider the cause of the stiffness. Acute surgical intervention less than
21 days after injury 7,8 or prior to return of ROM and quad control9 has been associated with
development of arthrofibrosis. Prolonged postoperative immobilization, particularly in flexion,
has also been implicated as a cause of chronic loss of motion.10-12 Bleeding and inflammation can
result in inability to regain ROM early.13 Malposition of osseous elements, anterior placement of
the tibial tunnel,14,15 or overtensioning of ligamentous structures can cause disordered joint kinet-
ics. Excessively aggressive physical therapy can potentially increase joint inflammation. Finally,
patient factors, such as exuberant scar formation, can play a role.
In knee ligament surgery, there is potential for many of the above issues to occur as there can
be nonisometric placement of grafts, fat pad trauma, notch impingement, and bleeding. These
procedures are also typically followed by extensive and frequently aggressive physical therapy.
Infrapatellar entrapment may be associated with atypical pain, loss of extension and flexion,
and sometimes patella infera (Video).18 It can be classified as primary or secondary, such as entrap-
ment caused by nonisometric graft placement. It can also be divided into 3 distinct stages. In stage
I, the prodromal stage, there is periarticular inflammation and swelling combined with immobil-
ity and quadriceps weakness as demonstrated by an extension lag. Tenderness is noted about the
patellar tendon and active ROM is painful. There is decreased excursion of patellar glide tests
and patellar tilt, although not rigidly fixed in the early stage. In stage II, the active stage, there is
essentially no patellar tilt, decreased medial to lateral glide, and loss of anterior tilt. There may be a
positive shelf sign. A positive shelf sign is characterized by an increased slope between the inferior
pole of the patella and the proximal tibia with the knee in extension (Figure 5-2). A positive shelf
sign is typically a late finding that indicates significant chronicity and possible patella infera. Its
appearance is due to the adhesion of the patella tendon to the anterior tibia. Stage III, the residual
stage, is characterized by slightly more supple peripatellar and retinacular tissues but with more
significant patellofemoral arthrosis as demonstrated by patellofemoral crepitation on examination
and decreased joint space seen on x-rays. Patella infera is usually present.19
Infrapatellar entrapment combined with suprapatellar entrapment results in loss of extension
and flexion. It is our opinion that loss of patellar mobility from cranially to caudally represents the
most telling indicator on physical examination for recalcitrant arthrofibrosis.
Pertinent Imaging
Standard x-rays: Anteroposterior, bent knee posteroanterior, and Merchant view x-rays
should be obtained, in addition to an excellent lateral image of the knee in 30 degrees of f lex-
ion. The lateral image is crucial to evaluate for patella infera, which can be measured using the
modified Insall-Salvati method. 20 The length of the patella tendon is measured from its origin
66 Chapter 5
from the inferior pole of the patella to its insertion at the proximal pole of the tibial tubercle.
The length of the patella is then measured at its greatest diagonal length from its superior to
inferior pole. The normal ratio of length of the patellar tendon:length of the patella should be
approximately 1:1, with some minor gender variation. A ratio of less than 0.8 indicates patella
infera (Figure 5-3).
Magnetic resonance imaging (MRI): MRI can be helpful to evaluate for causes of anterior
impingement, including improper graft placement and exuberant scar formation anteriorly as well
as the presence of a “pseudopatella tendon” (Figure 5-4).
Decision Making
Manipulation under anesthesia and manipulation under anesthesia with arthroscopic fibrino-
lysis have been shown to be effective treatments for postoperative motion loss.15,21-23 In patients
with arthrofibrosis who have good quadriceps strength with minimal pain, swelling, and warmth,
the first question to be addressed is whether there is isolated flexion or extension loss or a com-
bined problem (Figure 5-5).
In isolated contractures with positive inferior patellar tilt, manipulation alone should be per-
formed prior to 4 months postoperatively. In more chronic situations, manipulation under anes-
thesia with arthroscopic lysis of adhesions is indicated to reduce risk of cartilage damage during
manipulation. When inferior patellar tilt is obliterated, arthroscopic lysis of adhesions in addition
to manipulation under anesthesia is indicated regardless of acuity or chronicity. If loss of patel-
lar tilt persists, open treatment with possible interposition graft between the patella tendon and
anterior tibia or correction of other anatomic issues must be considered (Figure 5-6).
Arthroscopic Treatment of Arthrofibrosis 67
Figure 5-4. Sagittal MRI of a patient with advanced infrapatellar contraction syndrome. A
prominent pseudotendon can be seen posterior to the patellar tendon. This represents fibrosis
and remodeling of the fat pad.
68 Chapter 5
Figure 5-5. Algorithm for the management of knee stiffness. If extensor lag or signs of inflammation are
present, discontinue aggressive ROM exercises and treat with quadriceps strengthening and anti-inflam-
matory drugs. When inflammation and strength improve, determine whether there is loss of flexion,
extension, or both and then proceed accordingly.
In combined cases in which there is loss of flexion and extension, the height of the patella
with respect to the joint line must be assessed. If there is loss of inferior patellar tilt and patella
infera, a Delee osteotomy or other patella-lengthening procedure must be performed in addition
to arthroscopic lysis of adhesions and manipulation under anesthesia (Figure 5-7). If the patellar
height is normal in a combined contracture with loss of inferior patellar tilt, then arthroscopic
lysis of adhesions should be performed with specific release of the distal patella and meniscal tibial
interval.24,25
Equipment
Standard arthroscopy instruments are used. A 4.0- to 4.5-mm aggressive shaver can be used,
but a radiofrequency ablation or other electrocautery-type device is preferred to maintain hemo-
stasis while allowing for deliberate tissue dissection. Curved instruments, particularly a curved
shaver, can also be helpful in order to address dense infrapatellar pathology when working toward
the anterior portals. If an interposition graft is to be used, the authors typically use a Ventrio
Hernia Patch (Bard) and have it available in the room for use. A pump should be used for fluid
management, and an outflow cannula can be used at the surgeon’s discretion. The arthroscopic
fluid can be augmented with epinephrine to aid with visualization.
Arthroscopic Treatment of Arthrofibrosis 69
Figure 5-6. Illustration demonstrating placement Figure 5-7. A Delee osteotomy can be performed
of an interposition graft for severe infrapatellar in addition to arthroscopic lysis of adhesions in
contraction syndrome. The graft is placed to pre- cases of patella infera with loss of inferior tilt. By
vent adhesions between the patellar tendon and moving the tubercle superiorly and anteriorly, the
the anterior tibia. A nonreactive barrier is utilized or anterior interval and the normal patella position
a hernia patch (Bard type) is used and cut to shape. are restored.
arthroscopic shaver is introduced to clear the contents of the suprapatellar pouch until reasonable
visualization can be obtained. The shaver is then substituted with a radiofrequency ablation device
used to further expand and clear the suprapatellar pouch underneath the quadriceps tendon.
Looking medially from the anterolateral portal, a thickened plica may be identified and can
be addressed with the ablation device from the superolateral portal. The entire medial gutter can
then be released while viewing from this position. The ablation device can then be used from the
superolateral portal to release the lateral gutter while viewing from the anterolateral portal.
The patella should then be reexamined. Medial and lateral glides should be improved, oth-
erwise further release in the above manner is warranted. If the medial and lateral glides have
improved but there is still restricted anterior tilt, the lateral compartment should be visualized
to the intercondylar notch by bringing the scope from the lateral gutter into the compartment.
There may be significant adhesions between the distal tip of the patella and the anterior tibia
and intercondylar notch. Establish an anteromedial portal using a spinal needle with the knee in
approximately 30 degrees of flexion to increase your working space anteriorly. It may be necessary
to expand it sharply secondary to dense fibrotic tissue at the prior portal site. Gently debride the
adhesions in the notch, taking care to avoid injury to the cruciate ligaments or cruciate grafts.
After opening the notch, use the ablation device to further release the area behind the patellar
tendon and release all tissue from the distal tip of the patella. Care should be taken to avoid injury
to the patellar tendon and to avoid resection of the fat pad. Adhesions from the fat pad to the
patella must be released, but the fat pad should be preserved. The fat pad should then be released
from the tibia to allow exposure of the intermeniscal ligament. Again, using bipolar electrocautery,
the interval between the tibia and anterior retinaculum of the knee is then resected, opening the
interval and allowing more meniscal mobility.
At the completion of this step, the patella should be reevaluated. Medial and lateral glides
and now anterior tilt of the patella should be improved. The remainder of the joint, including
the menisci and any ligament grafts, should be visualized. There may be hypertrophic scar of
the meniscus, which can be debrided with the shaver or radiofrequency device. The graft should
be evaluated for a prominent bone block or for anterior impingement. If there is bone or fibrotic
scar tissue from anterior impingement, it should be excised in its entirety and then the graft itself
should be reevaluated. It can be thinned or lengthened by making small perpendicular incisions
using a meniscal knife through the graft substance at multiple levels.
A final manipulation can then be performed, and then ROM, patellar glides, and patellar tilt
can be retested. The instruments should be placed back into the joint after manipulation to evalu-
ate the cruciate ligaments, as there can be partial or complete rupture of a fibrotic ligament with
manipulation. Any torn tissue can be debrided at this time.
At the completion of the procedure, the fat pad and any ligament grafts should remain intact
without excision. The patella should be mobile, and full ROM can be obtained. The knee is irri-
gated to remove any loose debris, the portals are closed using a nylon suture, and a soft, compres-
sive dressing is applied. The tourniquet may be lowered prior to closure to evaluate hemostasis
and/or a drain may be used at the surgeon’s discretion.
Postoperative Protocol
The postoperative management of the patient must be criteria based, low force, essentially
painless, and patient controlled. One must read the tissues and consider overall tissue injury,
inflammation, and weakness, among other factors. Use of liberal analgesics as well as strong anti-
inflammatory drugs, such as one or more Medrol (methylprednisolone) dose packs, can be used to
aid with rehabilitation. Rest days must be allowed, and there should be no excessive manual push-
ing. The patient must actively perform ROM exercises. Rehabilitation should be directed toward
regaining extension and quadriceps strength first, followed by flexion. After full passive and active
72 Chapter 5
extension are regained, arthroscopic lysis of adhesions with manipulation under anesthesia may be
necessary to regain full flexion between 4 and 6 months postintervention.
Potential Complications
The most common complication after surgery for arthrofibrosis is inability to regain and main-
tain full joint ROM. Other reported complications have included skin tearing, unicortical fracture
of the femoral condyle, superficial wound infection, deep wound infection, septic arthritis, pero-
neal nerve palsy, partial patellar ligament rupture, patellofemoral pain syndrome, and postopera-
tive bleeding requiring reoperation. There is also a risk of recurrent patholaxity if ligament grafts
or repairs are released during the procedure. Deep venous thrombosis is also a significant potential
complication; therefore, these patients should be treated with mechanical and pharmacologic pro-
phylaxis at the surgeon’s discretion.
References
1. Luck JV. Traumatic arthrofibrosis; the fibroplastic response of joints to trauma. Bull Hosp Jt Dis.
1951;12(2):394-403.
2. Enneking WF, Horowitz M. The intra-articular effects of immobilization on the human knee. J Bone
Joint Surg Am. 1972;54(5):973-985.
3. Sprague NF III, O’Connor RL, Fox JM. Arthroscopic treatment of postoperative knee fibroarthrosis.
Clin Orthop Relat Res. 1982;(166):165-172.
4. Harner CD, Irrgang JJ, Paul J, Dearwater S, Fu FH. Loss of motion after anterior cruciate ligament
reconstruction. Am J Sports Med. 1992;20(5):499-506.
Arthroscopic Treatment of Arthrofibrosis 73
5. Cosgarea AJ, DeHaven KE, Lovelock JE. The surgical treatment of arthrofibrosis of the knee. Am J
Sports Med. 1994;22(2):184-191.
6. Shelbourne KD, Patel DV. Treatment of limited motion after anterior cruciate ligament reconstruction.
Knee Surg Sports Traumatol Arthrosc. 1999;7(2):85-92.
7. Shelbourne KD, Wilckens JH, Mollabashy A, DeCarlo M. Arthrofibrosis in acute anterior cruciate
ligament reconstruction. The effect of timing of reconstruction and rehabilitation. Am J Sports Med.
1991;19(4):332-336.
8. Cosgarea AJ, Sebastianelli WJ, DeHaven KE. Prevention of arthrofibrosis after anterior cruciate liga-
ment reconstruction using the central third patellar tendon autograft. Am J Sports Med. 1995;23(1):87-92.
9. Sterett WI, Hutton KS, Briggs KK, Steadman JR. Decreased range of motion following acute versus
chronic anterior cruciate ligament reconstruction. Orthopedics. 2003;26(2):151-154.
10. Shelbourne KD, Johnson GE. Outpatient surgical management of arthrofibrosis after anterior cruciate
ligament surgery. Am J Sports Med. 1994;22(2):192-197.
11. Noyes FR, Mangine RE, Barber SD. The early treatment of motion complications after reconstruction
of the anterior cruciate ligament. Clin Orthop Relat Res. 1992;(277):217-228.
12. Noyes FR, Berrios-Torres S, Barber-Westin SD, Heckmann TP. Prevention of permanent arthrofibrosis
after anterior cruciate ligament reconstruction alone or combined with associated procedures: a pro-
spective study in 443 knees. Knee Surg Sports Traumatol Arthrosc. 2000;8(4):196-206.
13. Magit D, Wolff A, Sutton K, Medvecky MJ. Arthrofibrosis of the knee. J Am Acad Orthop Surg.
2007;15(11):682-694.
14. Yaru NC, Daniel DM, Penner D. The effect of tibial attachment site on graft impingement in an anterior
cruciate ligament reconstruction. Am J Sports Med. 1992;20(2):217-220.
15. Romano VM, Graf BK, Keene JS, Lange RH. Anterior cruciate ligament reconstruction. The effect of
tibial tunnel placement on range of motion. Am J Sports Med. 1993;21(3):415-418.
16. Shelbourne KD, Patel DV, Martini DJ. Classification and management of arthrofibrosis of the knee after
anterior cruciate ligament reconstruction. Am J Sports Med. 1996;24(6):857-862.
17. Del Pizzo W, Fox JM, Friedman ML, et al. Operative arthroscopy for the treatment of arthrofibrosis of
the knee. Contemp Orthop. 1985;10:67-72.
18. Paulos LE, Rosenberg TD, Drawbert J, Manning J, Abbott P. Infrapatellar contracture syndrome. An
unrecognized cause of knee stiffness with patella entrapment and patella infera. Am J Sports Med.
1987;15(4):331-341.
19. Paulos LE, Wnorowski DC, Greenwald AE. Infrapatellar contracture syndrome. Diagnosis, treatment,
and long term followup. Am J Sports Med. 1994;22(4):440-449.
20. Grelsamer RP, Meadows S. The modified Insall-Salvati ratio for assessment of patellar height. Clin
Orthop Relat Res. 1992;(282):170-176.
21. Dodds JA, Keene JS, Graf BK, Lange RH. Results of knee manipulations after anterior cruciate ligament
reconstructions. Am J Sports Med. 1991;19(3):283-287.
22. Fisher SE, Shelbourne KD. Arthroscopic treatment of symptomatic extension block complicating ante-
rior cruciate ligament reconstruction. Am J Sports Med. 1993;21(4):558-564.
23. Klein W, Shah N, Gassen A. Arthroscopic management of postoperative arthrofibrosis of the knee joint:
indication, technique, and results. Arthroscopy. 1994;10(6):591-597.
24. Steadman JR, Dragoo JL, Hines SL, Briggs KK. Arthroscopic release for symptomatic scarring of the
anterior interval of the knee. Am J Sports Med. 2008;36(9):1763-1769.
25. Chen MR, Dragoo JL. Arthroscopic releases for arthrofibrosis of the knee. J Am Acad Orthop Surg.
2011;19(11):709-716.
Introduction
As the role of the arthroscope evolved in the 1970s, so did the diagnosis and treatment of
meniscal tears. Whereas total meniscectomy was the norm in the era of open meniscal resection,
the evolution to arthroscopic techniques demonstrated that partial meniscectomy was better than
total meniscectomy. Despite these advances, meniscectomy, even partial, is associated with an
increased risk of osteoarthritis.1-3 Meniscal repair techniques have evolved over the past several
decades in an attempt to improve outcomes. Unfortunately, the vast majority of meniscus tears
cannot be treated with repair, and arthroscopic partial meniscectomy remains the best procedure
in patients with symptomatic meniscal tears.
Arthroscopic partial meniscectomy is an outpatient procedure that can be done under a variety
of anesthetic techniques (general, spinal, or regional with or without sedation). Prior to surgical
intervention, nonoperative management is the mainstay of initial treatment in the majority of
cases. Nonoperative management consists of ice, nonsteroidal anti-inflammatory drugs in patients
in whom they are not contraindicated, physical therapy, activity modification, with the possible
addition of intra-articular injection of steroids.
Indications
▶ Persistent pain despite conservative treatment
▶ Presence of mechanical symptoms
▶ Younger physiologic age
▶ Increased activity demands
▶ Failure of previous meniscal repair
Controversial Indications
▶ Tear amendable to repair
▶ Asymptomatic tear
▶ Stable tear (typically < 1.5 cm in length and incomplete, particularly in a patient with an ante-
rior cruciate ligament [ACL]-deficient knee4,5)
▶ Degenerative tear in patients with evidence of osteoarthritis (30% nonoperative failure rate
requiring conversion to surgery6)
Pertinent Imaging
▶ Plain x-rays: Weightbearing anteroposterior and posteroanterior, lateral, and sunrise
▶ Magnetic resonance imaging (MRI)
▶ Ultrasound
Arthroscopic Meniscal Resection 79
A B
Figure 6-2. (A) Sagittal and (B) coronal MRIs of a complex, degenerative medial meniscal tear.
Plain x-rays, including bent knee posteroanterior (Rosenberg views),10 are indicated to rule out
other potential causes of a patient’s symptoms (eg, loose body, osteoarthritis, osteochondritis des-
sicans). MRI is the gold standard for diagnostic imaging of meniscal tears (Figure 6-2). Diagnostic
accuracy of MRI scanning for medial meniscal tears exceeds 90%11; due to the popliteal hiatus, it
is somewhat less accurate for the lateral meniscus. Ultrasound has a sensitivity of 86.4%, a speci-
ficity of 69.2%, a positive predictive value of 82.6%, and a negative predictive value of 75% for
detecting meniscal tears.12 Use of ultrasound is limited due to a high level of operator dependence
and low specificity.
Equipment
▶ Arthroscopic pump
▶ 30-degree arthroscope
▶ 70-degree arthroscope available
▶ Arthroscopic probe
▶ Array of arthroscopic punches (often termed biters; Figure 6-3)
▶ Motorized shaver 4.0 mm (3.5 or 3.0 mm for smaller or tighter knees)
▶ Arthroscopic knives (straight, banana, and back-cutting) may assist with meniscal resection
Figure 6-4. Photograph of the leg in a leg holder with the foot of the operating room table
extended and the hip flexed 30 degrees to allow access to the knee.
Routine knee arthroscopy can be performed without the use of a tourniquet. This is facilitated
by distending the joint prior to portal placement with a local anesthetic with epinephrine. (The
senior author uses 50 cc of 1% Xylocaine (lidocaine) with epinephrine 1:100,000 sterilely injected
prior to prepping and draping the leg.) Infiltration of the sites for portal placement with local
Arthroscopic Meniscal Resection 81
anesthetic with epinephrine also facilitates knee arthroscopy without the use of a tourniquet. The
senior author’s preferred local anesthetic is 0.25% bupivacaine with epinephrine (1:200,000) for
the portal sites.
There are multiple possible portals for arthroscopic meniscectomy. The senior author prefers a
vertical portal just lateral to the proximal patellar tendon for the arthroscope and a relatively low
oblique portal anteromedially for instrumentation (Figure 6-5).
The anterolateral portal should be developed with the knee flexed at least 50 degrees to protect
the articular surfaces. Once the capsule and synovium have been penetrated using a blunt obtura-
tor, the knee is extended to facilitate positioning of the sheath in the suprapatellar pouch. The use
of a spinal needle for localization of the anteromedial portal while visualizing from the anterolat-
eral portal is often beneficial to optimize portal placement.
The surgeon should be prepared to use multiple other portals if necessary; specifically, the
posteromedial or posterolateral portals may be helpful to remove a retained meniscal fragment that
gets into the posterior compartment. These must be developed with the knee flexed to 90 degrees.
Protection of the neurovascular structures when one of these portals is being established and
used is paramount. The posterolateral portal must always be developed well anterior to the biceps
tendon to avoid the peroneal nerve. These portals are most safely developed by initially using a
spinal needle for localization. Placement of the cannula with a blunt obturator through the capsule
should be done while directly visualizing the capsule.
82 Chapter 6
initial cut. Using scissors or a punch, the far lateral attachment of the unstable segment is cut such
that there are only a few remaining fibers. Attention is then focused on the most medial or anterior
locus of the tear, which should be completely released using a biter tapered into the axilla of the
tear. The released portion of the meniscus can then be grasped and avulsed, typically by repetitive
rolling motions. A small motorized shaver (3 to 4 mm) is then used to suction any debris from
the release and then to smooth and balance the residual meniscus. If the vertical longitudinal tear
extends too far anteriorly to be able to adequately begin the taper from the anteromedial portal,
the anterior release is more easily fashioned with the arthroscope in the anteromedial portal and
the cutting instrumented in the anterolateral portal (Video).
If a vertical longitudinal tear extends from the posterior horn anterior to the mid or anterior
portion of the meniscus, it can be termed a bucket handle tear and may displace to lock the knee
(Figure 6-6). The easiest way to resect a locked bucket handle tear is to reduce it by using valgus
stress and a blunt obturator to manipulate it back into a reduced position. The authors recommend
inspecting the peripheral rim to ascertain whether meniscal repair is an option prior to reducing
the locked bucket handle tear. In a tight joint with a long-standing displaced segment, reduction
of the displaced segment may not be possible. Using the needling technique described to relax the
MCL can facilitate the reduction.
Flap tears of the posterior and mid portion of the medial meniscus are relatively common. They
can result from a small vertical longitudinal tear that has propagated out through the free border
of the meniscus. The resection technique for flap tears is identical to that of a vertical longitudinal
tear, except if one is preferentially using the cut and avulse technique, there is only one attachment
site and that should not be cut through completely. Tapering of the resection margins is crucial.
Flap tears tend to occur more centrally located than the vertical longitudinal tears and are, there-
fore, in relatively softer, less dense meniscus tissue, which means they may often be readily resected
by just the use of a shaver.
Horizontal cleavage tears typically occur in the older population and are more of a degenera-
tive tear pattern. They can typically be thought of with central degeneration within the menis-
cus that propagates through to the undersurface through a rotation shear. They often cause
pain but rarely mechanical symptoms. Typically, these tears are resected using a punch. Since
the smaller leaf let is usually the inferior leaf let, that is the preferential one to remove. It is also
technically more easily reached because the superior surface of the meniscus tends to ride up
behind the condyle when there is a horizontal split. The leaf let that is selected to be removed
should be resected back to the level such that there is no longer any pathologic motion between
it and the remaining leaf let.
Complex tears are a result of a tear pattern that includes multiple planes (Figure 6-7). They
are more common in older patients in whom the meniscus tissue is somewhat abnormal already.
The meniscus should be probed and evaluated to identify the tear pattern as closely as possible
prior to resection. Flap tears and vertical longitudinal tears are resected using the techniques
previously identified. It is important to be certain that a f lap is not left folded under the menis-
cus. This is typically the case if there is an undersurface f lap that is located at the mid portion
of the meniscus.
C
Arthroscopic Meniscal Resection 85
bony attachment of the remaining meniscus stays intact. If these tears are small, resection is not
necessary. If they are large and could potentially cause mechanical symptoms, resection should be
accomplished.
Horizontal tears are less common in the lateral meniscus than on the medial side. This is a
degenerative tear pattern, and resection should be based on removing the smaller leaflet as is done
on the medial side.
Radial tears are common in the lateral meniscus. They are typically in the mid portion or
slightly anterior to mid. If they extend out to the meniscosynovial junction in the vascular area
of the meniscus, the deeper portions of these can be repaired with a complex repair. If they are
entirely within the thin central portion of the meniscus, resection should be accomplished. The
anterior leaflet can be done with the instruments brought in from the anteromedial portal using a
side biter. The posterior leaflet can be accomplished through the same portal using a regular biter.
Shaving to remove any site that may propagate is appropriate.
Postoperative Protocol
With the use of supplementary local anesthesia into the portal sites and potentially into the joint,
immediate postoperative pain from a partial meniscectomy is minimal. Closure of the incisions can
be accomplished in several ways. The senior author’s protocol is to use subcuticular sutures and adhe-
sive strips followed by a bulky, gently wrapped, compressive dressing to help to minimize postopera-
tive swelling. Cryotherapy can be of benefit in reducing the swelling during the postoperative period.
The authors routinely instruct patients to use crutches until they can bear weight comfortably with
a minimal limp. This is typically after several days. Range of motion exercises, quadriceps setting
exercises, and straight leg lifts are appropriate early on to try to maintain quadriceps tone.
Deep vein thrombophlebitis (DVT), although uncommon after a routine meniscectomy, can
occur. It is appropriate to take steps to minimize the chance of this. At the authors’ institution,
they routinely use elastic compression stockings as a mechanical means to reduce the risk of DVT.
Chemoprophylaxis with 325 mg of aspirin once or twice a day for several weeks post knee arthros-
copy is also reasonable.
At the first postoperative visit, one should be careful to assess for any signs of DVT. The
authors consider referral to a physical therapist to regain strength and function in select patients.
If they are capable of accomplishing this on their own, physical therapy is not a necessity following
arthroscopic meniscectomy.14
Arthroscopic Meniscal Resection 87
Potential Complications
Iatrogenic injury to the articular surface is perhaps the most likely complication of menis-
cal surgery. Although not routinely reported, the surgeon must be vigilant in avoiding injury
to the articular cartilage during instrumentation. Preventative measures, such as MCL relation
technique, are important to limit damage. The risk of infection after arthroscopic partial menis-
cectomy is low; however, consequence of an infection can be devastating. The use of prophylactic
antibiotics preoperatively is encouraged as a prophylactic measure. Serious neurovascular injuries,
although rare, have been reported post meniscectomy. Vigilance must be maintained to avoid
injury to the popliteal artery and tibial and peroneal nerves. Injury to the infrapatellar branch of
the saphenous nerve during creation of the anterior arthroscopy portals is the most common neu-
rologic injury. Sherman et al15 reported a 22.2% incidence of sensory changes in this distribution
after standard portals had been made. In some instances, injury can result in a painful neuroma in
continuity or at the end of the transsection. This may be a significant problem and can result in
complex regional pain syndrome in the rare patient. If a neuroma is encountered, desensitization
massage is recommended.
Although injury to the MCL has been reported as a complication of knee arthroscopy due to
the stress of trying to open a tight joint, the authors are strong advocates for the release of the
MCL through needling techniques if the joint is at risk for significant articular surface injury.
MCL injuries can be treated with brace protection against valgus stress in the immediate postop-
erative period.
Spontaneous osteonecrosis of the femoral condyle has been reported post meniscectomy with
a variety of surgical techniques, including the use of laser, radiofrequency or plain electrocautery,
and cold resections with the punch and shaver.16 It is felt that this risk is higher with the use of
laser or thermal devices; therefore, their use has been curtailed by many in routine meniscectomy.
Spontaneous osteonecrosis post meniscectomy is an exceedingly uncommon event and typically
occurs in middle-aged patients with early findings of osteoarthritis. It may relate to increased
pressure upon an already damaged articular surface potentially exacerbated by the heat generated
by the use of thermal devices.
References
1. Englund M, Roos EM, Lohmander LS. Impact of type of meniscal tear on radiographic and symp-
tomatic knee osteoarthritis: a sixteen‐year followup of meniscectomy with matched controls. Arthritis
Rheum. 2003;48(8):2178-2187.
2. Englund M, Lohmander LS. Risk factors for symptomatic knee osteoarthritis fifteen to twenty‐two
years after meniscectomy. Arthritis Rheum. 2004;50(9):2811-2819.
3. Roos H, Laurén M, Adalberth T, Roos EM, Jonsson K, Lohmander LS. Knee osteoarthritis after menis-
cectomy: prevalence of radiographic changes after twenty‐one years, compared with matched controls.
Arthritis Rheum. 1998;41(4):687-693.
4. Neyret P, Donell ST, Dejour H. Results of partial meniscectomy related to the state of the anterior cruci-
ate ligament. Review at 20 to 35 years. J Bone Joint Surg Br. 1993;75(1):36-40.
5. Allen CR, Wong EK, Livesay GA, Sakane M, Fu FH, Woo SL. Importance of the medial meniscus in the
anterior cruciate ligament‐deficient knee. J Orthop Res. 2000;18(1):109-115.
6. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteo-
arthritis. N Engl J Med. 2013;368(18):1675-1684.
7. Terry GC, Tagert BE, Young MJ. Reliability of the clinical assessment in predicting the cause of internal
derangements of the knee. Arthroscopy. 1995;11(5):568-576.
8. Eren OT. The accuracy of joint line tenderness by physical examination in the diagnosis of meniscal
tears. Arthroscopy. 2003;19(8):850-854.
9. Evans PJ, Bell GD, Frank C. Prospective evaluation of the McMurray test. Am J Sports Med.
1993;21(4):604-608.
10. Rosenberg TD, Paulos LE, Parker RD, Coward DB, Scott SM. The forty-five-degree posteroanterior
flexion weight-bearing radiograph of the knee. J Bone Joint Surg Am. 1988;70(10):1479-1483.
11. Konan S, Rayan F, Haddad FS. Do physical diagnostic tests accurately detect meniscal tears? Knee Surg
Sports Traumatol Arthrosc. 2009;17(7):806-811.
12. Shetty AA, Tindall AJ, James KD, Relwani J, Fernando KW. Accuracy of hand-held ultrasound scan-
ning in detecting meniscal tears. J Bone Joint Surg Br. 2008;90(8):1045-1048.
13. Shelbourne KD, Heinrich J. The long-term evaluation of lateral meniscus tears left in situ at the time of
anterior cruciate ligament reconstruction. Arthroscopy. 2004;20(4):346-351.
14. Goodwin PC, Morrissey MC, Omar RZ, Brown M, Southall K, McAuliffe TB. Effectiveness of
supervised physical therapy in the early period after arthroscopic partial meniscectomy. Phys Ther.
2003;83(6):520-535.
15. Sherman OH, Fox JM, Snyder SJ, et al. Arthroscopy—“no-problem surgery.” An analysis of complica-
tions in two thousand six hundred and 40 cases. J Bone Joint Surg Am. 1986;68(2):256-265.
16. Son IJ, Kim MK, Kim JY, Kim JG. Osteonecrosis of the knee after arthroscopic partial meniscectomy.
Knee Surg Relat Res. 2013;25(3):150-154.
Introduction
Acute meniscal injury tends to occur following a traumatic compression-rotational injury of the
knee as it moves from flexion into extension. Tears can be described by anatomic location within
the knee (ie, posterior horn, body, anterior horn) or by the tear pattern (ie, horizontal, radial,
longitudinal, bucket handle, oblique, or complex). Simple tear patterns tend to occur in younger
patients following traumatic injury, whereas more complex tears involving multiple planes tend to
occur in older individuals and are typically degenerative in nature. Complex degenerative tears
may be acute or chronic in nature and tend to be irreparable.
Historically, the understanding of meniscal anatomy and its vascularity provided by the peri-
meniscal capillary plexus has dictated meniscal repair strategies. Cooper et al1 divided the menis-
cus into 3 zones according to its vascularity, which was subsequently thought to correlate with the
meniscus’s intrinsic ability to heal. Meniscal repair was subsequently limited to peripheral tears
within the red-red zone of the meniscus. However, there has been increased interest in the heal-
ing potential of tear patterns that were regarded by many as irreparable, including vertical tears
within the red-white zone, 2 radial tears (Figure 7-1),3 and horizontal cleavage tears (Figure 7-2).4
Moreover, the improved ease of all-inside meniscal repair techniques outlined in this chapter have
allowed surgeons to continue to push the boundaries of meniscal repair indications, especially for
tears found in young adolescent athletes.5 In addition, understanding the biology of the improved
meniscal healing potential with concurrent anterior cruciate ligament (ACL) reconstruction has
proposed the use of biologic augmentation to improve outcomes in isolated meniscal repairs.6,7
The reason to broaden the indications for surgical meniscus repair rests on the long-term out-
comes of meniscectomized patients. The degree of meniscal resection has long been correlated
with the increase of mean and peak contact stresses within the tibiofemoral compartment.8 Long-
term consequences of this include articular cartilage degeneration and risk of osteoarthrosis. For
example, in a completely meniscectomized knee, tibiofemoral contact areas decrease 40% to 75%
and peak local contact stresses can increase up to 235% of normal.8 The importance of meniscal
conservation cannot be overemphasized and provides a means to restore normal tibiofemoral con-
tact pressures and limit the risk of osteoarthritis.5,9
Sgaglione NA, Lubowitz JH, Provencher MT, eds. The Knee:
- 89 - AANA Advanced Arthroscopic Surgical Techniques (pp 89-102).
© 2016 AANA.
90 Chapter 7
A B
Figure 7-1. (A) Axial proton dense MRI sequences showing full-thickness radial tear
anterior horn lateral meniscus in a 29-year-old athlete, and (B) evidence of healing after
radial meniscal repair at 9 months postoperatively.
Figure 7-2. (A) Horizontal cleavage tear of the anterior horn-body lateral menis-
cus. (B) Cleavage tear following debridement and resection of a white-white zone.
(C) Horizontal cleavage tear flowing repair with 3 all-inside vertical mattress sutures.
Indications
When indicating a patient for meniscal repair, tear location, pattern, vascularity, tissue viabil-
ity, ability to hold repair sutures, and associated pathology should be evaluated. In addition, the
surgeon should consider the patient’s age, activity level, overall health, occupation, goals, expecta-
tions, and ability to comply with a strict postoperative rehabilitation protocol. A thorough history,
including injury mechanism, activity-related pain, and the presence of mechanical symptoms
(acute loss of motion, locking, catching, or instability), should also be obtained. After indication,
a frank discussion should be had with the patient preoperatively outlining the long-term implica-
tions of an attempted repair over meniscectomy, including the potential risk of repair failure and
the potential need for future surgical resection.
Acute surgical repair should be considered for any meniscus that is determined to be repairable
at the time of diagnosis. If left untreated, a displaced tear can cause significant articular carti-
lage damage. In particular, any unstable tear that produces mechanical symptoms of locking or
instability or a tear that is displaced or incarcerated within the joint should be repaired urgently.
Repairable meniscal injuries in younger patients should also be considered for expeditious surgical
repair. However, what constitutes a young patient can be hard to determine as there is currently no
consensus regarding an age limit for attempted meniscal repair. What is known, however, is that
the meniscal healing response and meniscal cellularity decrease with age.10 However, successful
repairs have been shown to be more than 85% in patients older than 40 years in medium-term
follow-up studies.11,12
Arthroscopic Meniscal Repair 91
▶ Patient characteristics
▷ Young athletic patients (younger than 40 years)
▷ Acute traumatic meniscal injury with mechanical symptoms
▷ Concomitant ACL reconstruction
▷ Those willing to undergo postoperative rehabilitation
▶ Tear configuration
▷ Unstable longitudinal/vertical tears longer than 1 cm
▷ Bucket handle tears
▶ Tear location
▷ Peripheral third red-red zone
▷ Meniscal root injuries
Controversial Indications
▶ Patient characteristics
▷ Older athletic patients (older than 40 years)
▷ Chronic displaced tears with plastic deformity
▶ Tear configuration
▷ Radial tears in young athletic patients
▷ Horizontal cleavage tears in young athletic patients
▶ Tear location
▷ Central red-white zone tears
Examination Techniques
▶ Inspection of the joint visualizing effusion/localized joint line swelling
▶ Palpation of the joint line for focal medial or lateral joint line tenderness/parameniscal cyst
formation
▶ Loss of full extension/flexion of the knee (ie, locking)
▶ Pain with ROM
▷ Pain with deep knee flexion suggestive of posterior horn meniscal pathology
▷ Pain with extension suggestive of anterior horn pathology
▷ Reproducible catching during ROM with localized pain
92 Chapter 7
Pertinent Imaging
Radiographic imaging is obtained in any patient presenting with possible meniscal pathology
and includes 4 standard x-ray views. Plain x-rays are used to evaluate for any concomitant bony
pathology, extremity malalignment, arthritis, chondrocalcinosis, or findings consistent with any
potential associated injuries (eg, loose bodies, osteochondral fractures/defects, osteochondritis dis-
secans lesions, Pellegrini-Stieda sign, and Segond sign).
Magnetic resonance imaging (MRI) is typically described as the gold standard in the diagnosis
of meniscal pathology; however, it may not always be necessary. Its high sensitivity and specificity
(96% and 97%, respectively)13 typically confirms clinical suspicion of meniscal injury, delineates
meniscal tear morphology, and evaluates for any additional articular cartilage or ligamentous
injury. Contrast is not required for the diagnosis of meniscal pathology, although in the setting of
prior meniscectomy, intra-articular gadolinium improves diagnostic sensitivity for new pathology.
▶ X-rays
▷ 30- to 45-degree posteroanterior weightbearing flexion view
▷ True lateral view
▷ Notch view
▷ Patella skyline view
▶ MRI without gadolinium
▷ Increased signal intensity on T1- and intermediate-weighted images
▷ Sequences include fast spin-echo proton density, fat-saturated fast-spin-echo T2, and T1
Equipment
▶ Arthroscopy tower
▷ Light source
▷ Monitor and recording device
▷ 4-mm, 30-degree arthroscope with cannula (recommend having a 70-degree arthroscope
available)
▶ Irrigation system
▷ Inflow: Gravity inflow of lactated ringers solution vs high-pressure pump system
▷ Outflow: To suction/pump
Arthroscopic Meniscal Repair 93
▶ Although still debated within the literature, in the authors’ practice, a weight-based dose of a
third-generation cephalosporin is given prior to anesthesia for preoperative antibiotics.
▶ Patients are also typically risk stratified for perioperative anticoagulation.
▷ The authors’ philosophy is that after risk stratification of the individual patient, if the
patient is deemed high risk (prior history of deep vein thrombosis, clotting disorder etc),
then the patient is given appropriate anticoagulation postoperatively.
Diagnostic Arthroscopy
▶ A time-out is performed, with the operative staff confirming that the surgical procedure and
all surgical imaging/equipment has been made available and verified.
▶ With a #11 blade, an anterolateral viewing portal is created within the soft spot 1 cm lateral
to the patellar tendon and adjacent to the inferior pole of the patella.
▶ With a valgus force directed on the knee, a working anteromedial portal is created under
direct visualization within the medial soft spot 1 cm medial to the patellar tendon and 1 cm
proximal to the joint line.
The working portal is localized arthroscopically with a spinal needle prior to portal placement.
▷ When positioning the spinal needle anteromedially, confirm that the needle passes easily
to the posterior horn of the medial meniscus without touching the medial femoral condyle.
This ensures correct placement of the portal.
▷ You may also use the concavity of the medial tibial plateau to ensure easy passage to the
posterior horn of the meniscus.
▷ Pie-crusting of the medial collateral ligament (MCL) using a 14-gauge needle can improve
access to the medial compartment in overly tight knees (Figure 7-4).
▶ An optional accessory superomedial outflow portal can be made medial to the quadriceps at
the superior pole of the patella directed obliquely into the joint.
▶ Perform a full diagnostic arthroscopy and evaluate the meniscal tear characteristics with the
use of an arthroscopic probe.
▷ Document the location, morphology, length, and tissue quality of the tear.
▷ Document any chondral wear seen throughout the knee.
Arthroscopic Meniscal Repair 95
Meniscal Preparation
▶ If amenable to repair, stimulate vascular in-growth at the edge of the tear with rasping or
trephination.
▷ Rasping may be performed by lightly abrading the fibrous tissue at the meniscal edges
and the meniscosynovial junction with an arthroscopic shaver (with minimal suction) or
meniscal rasp.
▷ Trephination is performed by inserting a long 18- or 20-gauge needle percutaneously or
through the arthroscopic portals across the meniscus tear to create vascular channels.
▶ Hold the meniscus reduced with use of a Mulberry knot (optional).
▷ Pass a 0-Prolene suture through an 18-gauge needle passed from an outside-in technique
and retrieve it arthroscopically from the working portal.
▷ Tie multiple knots in the retrieved end of the suture and pull back into the joint; the menis-
cus will reduce to the periphery with continued traction.
Repair Techniques
Multiple techniques for meniscal repair have been described. Open repair techniques have
been primarily replaced with inside-out, outside-in, and all-side techniques. Each arthroscopic
technique is described in a stepwise fashion. Inside-out techniques are best used for middle or
posterior horn tears. Outside-in techniques are typically used for tears of the anterior and middle
third, as well as radial tears. All-inside techniques are used for most tear configurations and have
evolved from nonsuture fixation that relied on reverse barbed fishhook designs (eg, Meniscus
Arrow; ConMed Linvatec) to all-suture fixation techniques that have consistently shown to have
superior results.14-16
Regardless of the technique chosen, the key to fixation is to achieve perpendicular compressive
forces at the meniscocapsular junction. This may require the use of additional portals depending
upon tear characteristics and may include the use of a superolateral, posteromedial, posterolateral,
mid-patella, central, far medial, or far lateral portal. Slight elevation of the standard anterolateral
or anteromedial portal may also provide improved access to the contralateral compartment for
meniscal fixation.
Inside-Out Technique (Video)
▶ Posteromedial tears
▷ Place the knee in 20 to 30 degrees of flexion to avoid tethering the capsule and avoid the
saphenous nerve.
▷ Make a 4- to 6-cm longitudinal incision along the posterior edge of the MCL, centered
one-third above and two-thirds below the joint line (Figure 7-5A).
96 Chapter 7
▷ Dissect anterior to the sartorius and semimembranosus musculature and retract posteriorly,
exposing the medial head of the gastrocnemius that is retracted to expose the underlying
capsule.
▶ Posterolateral tears
▷ Place the knee in 90 degrees of flexion to allow the peroneal nerve, popliteus, and lateral
inferior geniculate artery to fall posteriorly.
▷ Make a 4- to 6-cm longitudinal incision at the posterior edge of the lateral collateral liga-
ment and anterior to the biceps femoris tendon, centered one-third above and two-thirds
below the joint line (Figure 7-5B).
▷ Sharply dissect the fascial plane between the iliotibial band and the biceps tendon to
expose the lateral head of the gastrocnemius.
▷ Dissect deep and anterior to the lateral head of the gastrocnemius to expose the lateral
capsule.
▷ Place a popliteal retractor against the capsule to retract the gastrocnemius posteriorly to
safely visualize, deflect, and capture the exiting repair needles.
▶ Pass a single- or double-lumen cannula arthroscopically through a working portal perpen-
dicular to the tear.
▶ Pierce the meniscus above and below the tear site in a vertical mattress suture fashion with
long flexible needles with high-strength, nonabsorbable 0 or 2-0 suture material by passing
the needles through the cannula.
▶ Capture the needles separately through a posteromedial or posterolateral incision as previously
described. Do not to pull either suture all the way through until both needles are passed.
▶ Tension each suture and tie down to the capsule while viewing the repair arthroscopically and
confirming reduction and fixation of the meniscus.
Outside-In Technique
▶ Palpate the joint line and then pierce the joint line with an 18-gauge spinal needle, passing
through the meniscocapsular junction, meniscal rim, and the torn fragment.
Arthroscopic Meniscal Repair 97
Figure 7-6. (A) Vertical tear of the posterior horn lateral meniscus. (B) Meniscal bed
preparation with an arthroscopic shaver. (C) Vertical mattress suture configuration with
reduction of a meniscal tear.
▶ Repierce the meniscus with another 18-gauge needle through the tear and pass a 0-Prolene
suture through the working portal. Tie a 0 or 2-0 nonabsorbable, high-strength suture to the
Prolene and shuttle through the meniscus.
▶ Repeat this procedure again through the meniscal tear to produce a vertical or horizontal
mattress suture configuration by tying the free end of the 0 or 2-0 suture to the second pass
of the Prolene suture. The needles should be spaced about 3 to 5 mm apart.
▶ A second outside-in technique is to use a proprietary meniscal device (ie, Meniscal Mender;
Smith & Nephew) that includes a preloaded nitinol wire to allow easy passage of suture mate-
rial without having to exit the joint (Video).
▶ After tensioning of the mattress suture, a small 1-cm skin incision is made between the suture
strands, and blunt dissection is carried down to the capsule. An arthroscopic probe may be
used to retrieve the sutures from within the incision, and the sutures are sequentially tied
down to the capsule under direct visualization, taking care to avoid incarceration of any soft
tissue (Video).
Augmentation Techniques
Considering the poor vascularity of meniscal tissue, adjunct techniques can assist menis-
cal healing and improve clinical results.7 Attempts to improve vascularity at the repair site are
performed by the creation of vascular access channels through the use of meniscal debridement,
rasping, excoriation, and trephination as previously described.18 Newer biologic augmentation
techniques have evolved in an attempt to recreate the enhanced meniscal healing seen during
concomitant ACL reconstruction.19
Various arthroscopic techniques try to recreate this biologic advantage. Shaving or perforating
the bone surface of the notch using a microfracture technique has been described as a practical
and cost-effective method for creating a hemarthrosis and releasing growth factors and cytokines
(Figure 7-8).20 More recent technologies have promoted the use of a fibrin clot 21 or platelet-rich
fibrin matrix 22 in an attempt to deliver biologically active factors directly to a meniscal repair site.
The fibrin clot provides a chemotactic and mitogenic stimulus to the reparative process as well as
a scaffold where fibrous tissue may form (Figure 7-9).19 Platelet-rich fibrin matrix technique is a
variant of platelet-rich plasma (PRP) delivery. The technique is performed by obtaining a sample
of autologous blood intraoperatively (about 10 mL) and placing it in a centrifuge. After centrifuga-
tion is completed, the fibrin clotting cascade is activated with an agent such as calcium chloride,
and the sample is placed through a second centrifuge step. This process minimizes platelet activa-
tion and traps inactivated platelets in the fibrin matrix, allowing sustained release of cytokines.23
The matrix is then placed into the meniscal repair site. Proprietary technology is available to
perform this method.
PRP has yet to be fully understood with meniscal repair techniques, and there are currently
no randomized controlled trials investigating PRP usage and meniscal repair. Yet, the theoretical
advantage of growth factors within platelets (transforming growth factor beta and platelet-derived,
vascular endothelial, fibroblast, and epidermal growth factors) still exists. More information is
required before they can be routinely used in meniscal repair surgery.
Arthroscopic Meniscal Repair 99
Postoperative Protocol
Postoperative care is individualized based on tear geometry, repair construct strength, associ-
ated surgical procedures, and surgeon preference. The authors prefer that the patient is placed
into a hinged knee brace in the operating room locked in extension. Early passive ROM and early
weightbearing with crutches is promoted; however, in the case of a radial repair, weightbearing is
restricted for 6 to 8 weeks. Weightbearing ROM is restricted to 90 degrees for the first 3 weeks for
nondisplaced meniscal tears and 4 to 6 weeks for displaced bucket handle tears. Bracing and crutch
use are discontinued when the patient shows good quadriceps control and no antalgia. Return to
pivoting sports ranges from 4 to 6 months or when the patient has no point tenderness or effusion
and can show full extension and painless terminal flexion.
100 Chapter 7
Potential Complications
Arthroscopic knee surgery has consistently been found to be a safe procedure. The overall
incidence of complication has ranged from 0.56% to 8.2%.24 Meniscus repair surgery is associ-
ated with a higher complication rate than meniscus resection, with reports as high as 18%. 25 The
complications associated with meniscal repair and their incidence include infection (0.23% to
0.42%), 26 deep vein thrombosis (1.8% to 41.2%; average 6.8%),27 and vascular (0.54% to 1.0%)28
and neurologic complications (0.06% to 2.0%).29
The rate of infection is related to operative time, use of intraoperative corticosteroid injection,
extended tourniquet use, medical comorbidities, and a history of prior surgery.30 If a postopera-
tive infection is suspected or diagnosed following a repair, it is appropriate to leave the implant or
sutures in place during an urgent irrigation and debridement of the joint. However, the associated
failure rate is higher.
Neurovascular injury, although rare, can be devastating for the patient. Vascular complica-
tions can include popliteal artery injury, pseudoaneurysm, and arteriovenous fistula formation.
Neurologic injury can include direct or indirect nerve injury or complex regional pain syndrome.
A systematic review by Grant et al 31 reported a 9% incidence of nerve irritation/injury with the
inside-out technique vs 2% for all-inside techniques, including first-generation devices.
The most common pitfall in arthroscopic meniscal repair procedures is implant-related compli-
cations. Even newest-generation, all-inside fixators have all been associated with chondral dam-
age secondary to implant abrasion.31 If not used properly, the devices have a tendency to misfire,
launch inaccurately, or break. This may lead to excessive chondral loss or a loose body/fragment
within the joint. Other implant complications include inflammation superficial to the subcutane-
ous anchor, especially medially overlying the MCL, and cyst formation.
References
1. Cooper DE, Arnoczky SP, Warren RF. Arthroscopic meniscal repair. Clin Sports Med. 1990;9(3):589-607.
2. Barber-Westin SD, Noyes FR. Clinical healing rates of meniscus repairs of tears in the central-third
(red-white) zone. Arthroscopy. 2014;30(1):134-146.
3. Ra HJ, Ha JK, Jang SH, Lee DW, Kim JG. Arthroscopic inside-out repair of complete radial tears of the
meniscus with a fibrin clot. Knee Surg Sports Traumatol Arthrosc. 2013;21(9):2126-2130.
4. Pujol N, Bohu Y, Boisrenoult P, Macdes A, Beaufils P. Clinical outcomes of open meniscal repair of
horizontal meniscal tears in young patients. Knee Surg Sports Traumatol Arthrosc. 2013;21(7):1530-1533.
5. Vanderhave KL, Moravek JE, Sekiya JK, Wojtys EM. Meniscus tears in the young athlete: results of
arthroscopic repair. J Pediatr Orthop. 2011;31(5):496-500.
Arthroscopic Meniscal Repair 101
30. Montgomery SC, Campbell J. Septic arthritis following arthroscopy and intra-articular steroids. J Bone
Joint Surg Br. 1989;71(3):540.
31. Grant JA, Wilde J, Miller BS, Bedi A. Comparison of inside-out and all-inside techniques for the repair
of isolated meniscal tears: a systematic review. Am J Sports Med. 2012;40(2):459-468.
Introduction
The importance of the meniscal roots has been thoroughly described in the orthopedic lit-
erature. An injury to the lateral or medial posterior roots results in a loss of hoop stresses in the
medial and lateral compartments, abnormal contact forces, a significant increase in tibiofemoral
contact pressures, altered knee joint kinematics, and resultant degenerative joint disease.1-11 On
the medial side, a meniscal root tear has similar biomechanical consequences as a total medial
meniscectomy.1,2,6,12 Laterally, the effects of a root tear are significant but not as extreme.10,13
Properly diagnosing and treating these injuries is critical to the health and integrity of knee
articular cartilage.
In the past, these injuries have been difficult to consistently diagnose, especially on the medial
side.14-16 Advanced imaging and the identification of certain risk factors for the development of
root tears have allowed surgeons and radiologists to better delineate patients with this detrimen-
tal injury. Risk factors for posterior medial root tears include increased age, female sex, varus
mechanical axis, increased body mass index, higher Kellgren-Lawrence grade, and decreased
sports activity.2,4,9,16,17 The most common risk factor for a posterior lateral meniscal root tear is
a concurrent anterior cruciate ligament (ACL) tear.10 Because of the serious biomechanical con-
sequences of root tears, these injuries must be addressed timely and appropriately. This chapter
focuses primarily on the technique involved in the repair of medial and lateral root avulsions off
of their bony insertions.
Indications
Posterior Medial Meniscal Root Tear
▶ Failure of nonoperative treatment, including nonsteroidal anti-inflammatory drugs, physical
therapy, bracing, activity modifications, and injections1,2,7,18
Contraindications
Contraindications for meniscal root repair include greater than or equal to grade 3 articular
cartilage changes, poor root tissue quality (ie, cannot hold a suture), and/or irreducible root to the
insertion site. In this setting, arthroscopic debridement may give temporary benefit.
Lateral
▶ Usually (90% or greater) associated with an ACL tear and in the multiple-ligament–injured
knee5
▶ Very rarely occurs as an isolated tear
▶ High-grade pivot shift (grade 3 or higher) in the setting of ACL tear19
Pertinent Imaging
▶ X-rays: Bilateral posteroanterior flexion weightbearing, lateral, and Merchant views (look
carefully on the full weightbearing views for joint space narrowing and lateral tibial femoral
subluxation)
▶ Long-leg cassette (medial meniscal root tear)
▶ Magnetic resonance imaging (MRI)2,5,18,19,21-24: “Ghost sign” (sagittal), vertical linear
defect (coronal), radial linear defect (axial), meniscal extrusion greater than 3 mm (coronal)
▶ Assess articular cartilage changes in all 3 compartments (greater than grade 3 changes and/
or tricompartmental changes should be documented and are contraindications to root repair)
Arthroscopic Repair of Meniscal Root Avulsions 105
Equipment
▶ 30- and 70-degree arthroscopes
▶ 4.5-mm full-radius resector (straight and curved)
▶ ACL drill guide with guide pin (3/32-in K-wire)
▶ Meniscal rasp (used to roughen bony insertion)
▶ 70-degree upbend suture shuttle device
▶ Arthroscopic knot pusher
▶ Hewson suture passer
▶ 8-mm clear cannula
▶ #2 nonabsorbable braided suture
▶ 4.5-mm cancellous screw with washer
An 8-mm clear cannula is placed in the anterolateral portal in preparation for suture passage.
With the scope in the posteromedial portal, a suture shuttle device is used through the antero-
lateral portal to pierce the meniscal root in an inferior to superior direction (Figure 8-3). The
monofilament loop is then passed and retrieved through the anterolateral portal. A braided suture
loop is shuttled through the meniscus and out of the anterolateral portal so the free ends of the
suture can be pulled through the loop, creating a loop stitch around the meniscus once the suture
is cinched down through the anterolateral portal (Figure 8-4). This can be done by using an
arthroscopic knot pusher. A second loop stitch should be attempted if possible for added strength.
To establish the tunnel for the sutures, an ACL drill tip guide is inserted through the anterolat-
eral portal through the intercondylar notch and placed at the anatomic root insertion site. The drill
sleeve is used to localize an incision site over the anterolateral tibia. This is a 3- to 4-cm oblique
incision typically located at the anterolateral flare of the proximal tibia, distal to Gerdy’s tubercle
but overlying the very proximal extent of the tibialis anterior. The fascia of the tibialis anterior is
incised and the muscle is gently elevated off the bone using a lap sponge and elevator or osteotome.
The drill sleeve is then placed onto the tibia once the tip position is confirmed to be on the root
insertion site. A 3/32-in guide pin is then drilled just to the tip of the ACL drill guide but not
completely through the posterior cortex of the tibia. The tunnel is completed by gently tapping the
pin through the posterior cortex with a mallet under direct visualization to avoid injury to the pop-
liteal neurovascular bundle. The guide pin is then removed, and a Hewson suture passer is inserted
into the tunnel in its place. The Hewson loop is removed through the anterolateral portal, and the
suture ends are passed through the loop (Figure 8-5). The suture is then shuttled down through
the tunnel. Suture passage is facilitated by using the ice tongs to create a pulley at the tunnel apex,
thereby improving the angle of suture entry into the tunnel. The sutures are tied over a 4.5-mm
cancellous screw with washer inserted into the anterolateral tibia. The sutures are tensioned with
the knee in 30 degrees of flexion, and reduction of the root is visualized arthroscopically (Figure
8-6). After the sutures are secured, the tibialis anterior fascia is repaired using a 0-Vicryl suture,
and the skin is closed in a layered fashion using 2-0 Vicryl and 4-0 Caprosyn sutures.
108 Chapter 8
Postoperative Protocol
In the immediate postoperative period, the knee is placed in a hinged brace locked at 20 degrees
of flexion and the patient is made nonweightbearing. The patient is progressed to full weightbear-
ing over the following 8 weeks. Initially, range of motion is restricted from 0 to 90 degrees and
achieved using a continuous passive motion machine. The patient is allowed to perform quadriceps
sets, calf pumps, straight leg raises, and heel slides in the immediate postoperative period. He or
she is advanced to supervised physical therapy and more functional exercises once full weightbear-
ing is allowed and achieved. Full return to activity can typically be achieved by 4 months in an
isolated meniscal root repair.
Potential Complications
Complications include iatrogenic damage to the meniscus due to multiple passes of the suture
shuttle device as well as iatrogenic damage to the cruciate ligaments from passage of instru-
ments through the intercondylar notch. Nonanatomic repair, especially of the medial meniscus
root, can lead to progression of osteoarthritic changes.25 Damage to the popliteal neurovascular
structures is possible with careless passage of the guide pin. Specific complications related to
the above technique include interfering with tunnel placement for concurrent ACL reconstruc-
tion, suture abrasion in the bone tunnel, and suture creep. 2 Complications associated with knee
arthroscopy but not specifically with root repair include deep vein thrombosis, infection, and
arthrofibrosis.
112 Chapter 8
References
1. Vyas D, Harner CD. Meniscus root repair. Sports Med Arthrosc. 2012;20(2):86-94.
2. Bhatia S, LaPrade CM, Ellman MB, LaPrade RF. Meniscal root tears: significance, diagnosis, and treat-
ment. Am J Sports Med. 2014;42(12):3016-3030.
3. Henry S, Mascarenhas R, Kowalchuk D, Forsythe B, Irrgang JJ, Harner CD. Medial meniscus tear mor-
phology and chondral degeneration of the knee: is there a relationship? Arthroscopy. 2012;28(8):1124.
e2-1134.e2.
4. Guermazi A, Hayashi D, Jarraya M, et al. Medial posterior meniscal root tears are associated with devel-
opment or worsening of medial tibiofemoral cartilage damage: the multicenter osteoarthritis study.
Radiology. 2013;268(3):814-821.
5. Koenig JH, Ranawat AS, Umans HR, DiFelice GS. Meniscal root tears: diagnosis and treatment.
Arthroscopy. 2009;25(9):1025-1032.
6. Wang KH, Hwang DH, Cho JH, Changale SD, Woo SJ, Nha KW. Arthroscopic direct repair for a com-
plete radial tear of the posterior root of the medial meniscus. Clin Orthop Surg. 2011;3(4):332-335.
7. Jung YH, Choi NH, Oh JS, Victoroff BN. All-inside repair for a root tear of the medial meniscus using
a suture anchor. Am J Sports Med. 2012;40(6):1406-1411.
8. Seo JH, Li G, Shetty GM, et al. Effect of repair of radial tears at the root of the posterior horn of the
medial meniscus with the pullout suture technique: a biomechanical study using porcine knees.
Arthroscopy. 2009;25(11):1281-1287.
9. Ozkoc G, Circi E, Gonc U, Irgit K, Pourbagher A, Tandogan RN. Radial tears in the root of the posterior
horn of the medial meniscus. Knee Surg Sports Traumatol Arthrosc. 2008;16(9):849-854.
10. Bao HR, Zhu D, Gong H, Gu GS. The effect of complete radial lateral meniscus posterior root tear on
the knee contact mechanics: a finite element analysis. J Orthop Sci. 2013;18(2):256-263.
11. Stärke C, Kopf S, Lippisch R, Lohmann C, Becker R. Tensile forces on repaired meniscal root tears.
Arthroscopy. 2013;29(2):205-212.
12. Allaire R, Muriuki M, Gilbertson L, Harner CD. Biomechanical consequences of a tear of the posterior
root of the medial meniscus. Similar to total meniscectomy. J Bone Joint Surg Am. 2008;90(9):1922-1931.
13. Forkel P, Herbort M, Schulze M, et al. Biomechanical consequences of a posterior root tear of the
lateral meniscus: stabilizing effect of the meniscofemoral ligament. Arch Orthop Trauma Surg.
2013;133(5):621-626.
14. Casagranda BU, Leeman J, Costello JM, Rafiee B, Harner CD. Coronal oblique imaging of the knee:
can it increase radiologists’ confidence in diagnosing posterior root meniscal tears? Clin Radiol.
2013;68(6):e316-e322.
15. Wilson BF, Johnson DL. Posterior horn medial meniscal root repair with cruciate ligament/medial col-
lateral ligament combined injuries. Orthopedics. 2011;34(12):986-988.
Arthroscopic Repair of Meniscal Root Avulsions 113
16. Matheny LM, Ockuly AC, Steadman JR, LaPrade RF. Posterior meniscus root tears: associated patholo-
gies to assist as diagnostic tools [published online ahead of pring May 28, 2014]. Knee Surg Sports
Traumatol Arthrosc.
17. Hwang BY, Kim SJ, Lee SW, et al. Risk factors for medial meniscus posterior root tear. Am J Sports Med.
2012;40(7):1606-1610.
18. Lee JH, Lim YJ, Kim KB, Kim KH, Song JH. Arthroscopic pullout suture repair of posterior root
tear of the medial meniscus: radiographic and clinical results with a 2-year follow-up. Arthroscopy.
2009;25(9):951-958.
19. Peterson W, Forkel P, Feucht MJ, Zantop T, Imhoff AB, Brucker PU. Posterior root tear of the medial
and lateral meniscus. Arch Orthop Trauma Surg. 2014;134(2):237-255.
20. Shelbourne KD, Roberson TA, Gray T. Long-term evaluation of posterior lateral meniscus root tears left
in situ at the time of anterior cruciate ligament reconstruction. Am J Sports Med. 2011;39(7):1439-1443.
21. Lee YG, Shim JC, Choi YS, Kim JG, Lee GJ, Kim HK. Magnetic resonance imaging findings of surgi-
cally proven medial meniscus root tear: tear configuration and associated knee abnormalities. J Comput
Assist Tomogr. 2008;32(3):452-457.
22. Lee SY, Jee WH, Kim JM. Radial tear of the medial meniscal root: reliability and accuracy of MRI for
diagnosis. AJR Am J Roentgenol. 2008;191(1):81-85.
23. Choi SH, Bae S, Ji SK, Chang MJ. The MRI findings of meniscal root tear of the medial meniscus: empha-
sis on coronal, sagittal and axial images. Knee Surg Sports Traumatol Arthrosc. 2012;20(10):2098-2103.
24. Kim SB, Ha KJ, Lee SW, et al. Medial meniscus root tear refixation: comparison of clinical, radiologic,
and arthroscopic findings with medial meniscectomy. Arthroscopy. 2011;27(3):346-354.
25. Stärke C, Kopf S, Gröbel KH, Becker R. The effect of nonanatomic repair of the meniscal horn attach-
ment on meniscal tension: a biomechanical study. Arthroscopy. 2010;26(3):358-365.
Introduction
The meniscus plays a vital role in preserving normal knee function, including shock absorp-
tion, load transmission, stability, joint lubrication, and nutrition.1,2 Thus, subtotal removal of
the meniscus enhances the rate of degenerative arthritis in the knee.3 Although preservation of
the meniscus should be the standard of care, most tears are treated with excision. To recreate the
function of the meniscus, many methods and materials have been explored. Meniscal allograft
transplantation is the one proven option to treat those who have become symptomatic from exci-
sion of the meniscus (Figure 9-1).4
Since the first isolated meniscal transplant was performed in 1984, surgical techniques have
continued to improve and have transitioned from open procedures to arthroscopic-assisted pro-
cedures.5,6 Although some authors have reported good outcomes with only soft tissue fixation of
the meniscus to the host, biomechanical studies show that if the horn attachments are secured
with bone, the allograft more closely replicates the normal meniscus.7 Thus, although it may be
technically more difficult, it is currently recommended to use bone graft to bone tunnel fixation.
The most commonly performed techniques to secure the horns through bone fixation are the bone
bridge and bone plug methods.
Although several bone bridge variations have been described, the dovetail technique is the
author’s procedure of choice. It has the advantage of providing a bone slot that provides press-fit
fixation and, therefore, does not require additional screws or sutures, as do the other bone bridge
techniques. Although the bone bridge methods can be used for lateral and medial grafts, it is the
author’s preference to use the dovetail for lateral grafts and the double-bone plugs for the medial
side. The distance between the lateral horn attachments is only a centimeter, whereas on the medi-
al side, the distance is 2.5 cm or greater. In addition, the anterior horn attachment of the medial
meniscus has been found to be of great variation.8 By having the horns separate, one can modify
the attachments to accommodate any graft-host mismatch. Conversely, the bone plug technique
is not recommended on the lateral side. With the close proximity of the horn attachments, the
2 drill holes carry a significant risk of disrupting the bone between the holes and losing fixation.
Indications
A thorough history is of vital importance and should include information regarding previous
knee injuries, specific symptoms, and prior treatments and surgical procedures. For consideration
of meniscal allograft transplantation, the patient should have pain localized to the meniscus-defi-
cient compartment, although joint effusions can result in some generalized discomfort. Particular
emphasis should also be paid to any chondral lesions, limb alignment, and ligament stability.
An effort should be made to obtain operative reports and intraoperative photographs, which can
be useful in determining the amount of meniscus remaining and the condition of the articular
cartilage.
Meniscal transplant should be performed with the goal of reducing pain with the ability to
increase activity level secondary.9,10 Because of the lack of evidence, patients should not be told to
expect the procedure to delay or prevent the progression of osteoarthritis.11,12 Meniscal transplan-
tation should be considered only when nonsurgical measures to control pain have been exhausted
and/or there is evidence that the involved compartment is degenerating. In general, a patient
should have a history of symptoms localized to the meniscus-deficient compartment and not have
advanced arthritic changes. Grade IV chondromalacia is a contraindication unless a defect is focal
and can be treated with a cartilage repair/replacement method. It is commonly recommended that
patients should be younger than 50 to 55 years; however, this is controversial, and age restrictions
should also be based on a patient’s physiologic age.
▶ Majority of meniscus excised
▶ Pain in the meniscus-deficient compartment
▶ Chondromalacia no greater than grade III
▶ Knee without ligament laxity
▶ Age typically younger than 55 years
Controversial Indications
Although not absolute contraindications, patients with ligament laxity, limb malalignment, and
full-thickness chondral defects need to have these addressed to be considered. It is well known
that the medial meniscus is an important secondary stabilizer in patients with an anterior cruciate
ligament (ACL)-deficient knee. In addition, chronically ACL-deficient knees have been shown
to be associated with increased rates of meniscal tears. Thus, patients with ACL-deficient knees
Arthroscopically Assisted Meniscal Transplantation 117
require reconstruction before the meniscus is replaced or, more commonly, at the same time as
the meniscus.
Limb alignment is another circumstance that can substantially affect the outcome of meniscal
allograft transplantation. Although it is not uniformly agreed upon, many surgeons will perform
an osteotomy to unload the involved compartment if the mechanical axis is a few degrees greater
than the contralateral knee. The extent of the correction is typically to have the mechanical axis
pass through the contralateral tibial spine rather than the more extensive correction recommended
for arthritic knees. The procedure can be staged or performed at the same time as the meniscus,
which is what the author prefers.
Full-thickness cartilage defects have previously been considered to be a contraindication for
meniscal allograft transplantation. However, if the defect is isolated and can be corrected with a
cartilage repair or restoration procedure, it is not contraindicated. A systematic review of studies
that reported the results of meniscus alone or combined meniscal allograft transplantation with
cartilage repair procedures found similar results in 4 of the 6 studies.13 Noyes et al14 examined
concomitant procedures, such as osteochondral autograft and ACL reconstruction in 40 meniscal
transplantations and reported no increase in complications among patients who received concomi-
tant procedures.
▶ Isolated full-thickness chondral defect
▶ Limb malalignment
▶ Age older than 55 years
The primary contraindication to meniscal allograft transplantation is advanced arthritis. A his-
tory of infection, inflammatory arthropathy, synovial disease, and morbid obesity represent other
contraindications.
Pertinent Imaging
A complete set of x-rays must be obtained for full evaluation of the knee. Not only should the
joint space be assessed, but also spurring and flattening of the condyles, which may indicate that
the knee is more arthritic than the joint space alone would indicate.
Views to obtain include the following:
▶ Weightbearing anteroposterior (AP) in full extension
▶ Weightbearing posteroanterior in 45 degrees of flexion, lateral with no rotation, and axial
view of the patellofemoral joint
118 Chapter 9
If x-rays are to be used for meniscal allograft sizing, a magnification marker should be placed
on the cassette for 2 orthogonal views of the joint line. Any question of limb malalignment or gait
abnormalities should necessitate long-leg alignment films.
▶ Magnetic resonance imaging (MRI) scans are typically obtained to determine if other pathol-
ogy is present and is useful to evaluate for stress reaction in the bone.
Equipment
▶ Meniscal allograft
▷ Sized match graft (plain x-rays are typically sufficient)
▷ Fresh-frozen allograft preferred
▶ Arthroscopy tower and equipment for standard knee arthroscopy
▶ Meniscus repair devices (surgeon’s preference)
▶ Long-length, open-ended meniscus suturing needles
▶ Lateral meniscal allograft
▷ Dovetail instrumentation
▷ Oscillating saw
▶ Medial meniscal allograft
▷ ACL guide and drill system
▷ 0.062 K-wire
▷ Coring reamer (8 mm)
▷ Small motorized burr
▷ Polyethylene button or low-profile screw
Thus, fresh-frozen grafts are the most commonly used allograft preservation method today. It is
vital that the allografts are obtained from American Association of Tissue Banks–certified tissue
banks, which require stringent procurement and processing methods to prevent contamination
and infection of the grafts.
Additional concerns have been raised regarding the age of donors for meniscal allografts and
the viability and tensile strength of the grafts. Current recommendations are for the transplanta-
tion of meniscal allografts from donors younger than 45 years. The tensile strength of meniscal
tissue and the proteoglycan and collagen content have been shown to not vary with age among
grafts examined from donors aged 15 to 44 years.21
is used to make a shallow (1- to 2-mm) trough directly in line with the anterior and posterior
horns of the meniscus. This initial trough functions as a path for placement of an osteotome in
the sagittal plane. A referencing depth line on the osteotome helps to maintain proper orienta-
tion as the tibial plateau slopes inferiorly when advancing from anterior to posterior. The osteo-
tome should be advanced under direct visualization until it contacts the posterior tibial cortex.
A 6-mm drill guide is fit over the osteotome, and the drill advanced. The guide enables the drill
to be seen arthroscopically at all times, which helps maintain proper height and avoid breaking
through the distal cortex (Figure 9-3). A second jig to accommodate a 7-mm drill at a height of
3 mm lower than the initial jig is then attached. The second drill is also seen at all times and is
used to deepen the channel to 10 mm and expand the inferior aspect. A semitrapezoidal rasp is
used to complete the dovetail slot (Figure 9-4). It is important that the rasp should follow the
AP slope of the tibia, and the top of the rasps should remain f lush with articular surface. The
channel should be cleared of all remaining bone debris, and the channel sizer should be used to
ensure the channel preparation is complete (Figure 9-5). A posterolateral incision should then
be made using the interval between the iliotibial band and the anterior margin of the biceps
femoris tendon for access to the capsule. Although staying in front of the biceps femoris should
prevent injury to the peroneal nerve, formal exposure of the nerve can always been made.
Allograft Preparation
The meniscal allograft is typically sent by the tissue bank as a hemitibial plateau with the
meniscus. It is imperative to see the entire horn attachments for proper bone cuts; thus, any excess
soft tissue should be removed. The allograft bone should then be cut in an AP plane to the ends
of the attachments. The end of the channel rasp is used to mark an outline of the desired dovetail
design onto the ends of the bone as a reference for placing the graft in an upside-down position in
the holding device (Figure 9-6). Three cutting jigs and an oscillating saw are used to complete the
graft preparation. The first is a vertical cut on the medial aspect of the graft (Figure 9-7A). Often,
this is already precut during the meniscal allograft processing. Next, the inferior cut is made in
orientation to match the depth of the slot (Figure 9-7B). Finally, the third cutting guide is used to
Arthroscopically Assisted Meniscal Transplantation 121
Figure 9-7. (A) Meniscus in a cutting jig with vertical cuts for dovetail preparation. (continued)
124 Chapter 9
Figure 9-7 (continued). Meniscus in a cutting jig with (B) horizontal and (C) oblique cuts for
dovetail preparation.
make the angled cut on the lateral aspect of the graft (Figure 9-7C). Once all cuts are complete,
the sizing block is used to confirm it will allow a press fit, but the graft should also slide through
smoothly (Figure 9-8). Any adjustments should be made at this time rather than trying to force
the graft into the prepared channel. A 2-0 polydioxanone suture to be used as a reduction suture
is placed through the posterior segment to complete the graft preparation.
Arthroscopically Assisted Meniscal Transplantation 125
Figure 9-8. Completed graft in sizing block to confirm proper size and press-fit.
Meniscus Implantation
The reduction suture is passed out through the posterolateral incision for application of gentle
traction once the graft is inserted into the tibial channel. If needed, a bone tamp can be used to
gently push the bone block further into the knee until contact with the posterior wall of the tibia
(Figure 9-9). At this point, the anterior arthrotomy is closed to prevent fluid extravasation, and
126 Chapter 9
the rest of the meniscus sutured. Various techniques can be used, but the surgeon’s preference for
repairing a bucket handle meniscus tear is common. If only all-inside technique is used, special
attention needs to be made to ensure that the graft is not extruded outward when tightening the
fixation device. The author’s preference is inside-out sutures for the posterior and middle horns
and outside-in for the anterior horn. All-inside sutures will be used at the most posterior aspect if
additional fixation near the root is needed. Absorbable and nonabsorbable sutures can be used, as
second-look arthroscopies have shown that healing of the graft has not been a common problem.
Usually, 8 to 10 sutures are required to completely secure the graft.
Medial: Double Bone Plug Technique (Video)
Recipient Bed Preparation
An ACL guide set at 60 degrees is used to place a guide pin into the anatomic posterior horn
insertion of the old meniscus. A steep angle is selected to assist in reducing the plug, similar in
reason to the tibial tunnel during posterior cruciate ligament surgery. The tibial tunnel is then
drilled to a diameter of 7 mm, with the 1-mm difference allowing easy placement of the bone plug.
A shuttle suture is passed up the tibial tunnel, retrieved, and brought out of the knee. Although
the suture can be removed through the scope portal, the author has found it easy to make the ante-
rior arthrotomy prior to bringing the suture out. Often, soft tissue can be entrapped between the
suture and a subsequent arthrotomy incision, which may impede bringing the graft into the knee.
A posteromedial incision is then made and dissected down to the capsule in the same manner as
one would for a medial meniscus repair using inside-out sutures.
Allograft Preparation
Initial graft preparation is similar to that of the lateral side, with any remaining capsular tissue
attached to the meniscus removed to ensure complete visualization of the horn attachments. They
are then marked for size and planned orientation. Typically, an 8-mm coring reamer will encom-
pass the horn attachment. The posterior bone plug is performed first, with a 0.062-in K-wire
passed to enter the center of the attachment at a roughly a 60-degree angle to mimic the angle
of the tibial tunnel. A collared pin is placed into the pilot hole, and the 8-mm coring reamer is
used to create a bone plug. The bone plug end is then trimmed to be 6 mm in diameter and 8 mm
in length. The size has been found to sufficiently secure the attachment but not be too large to
impede reduction of the plug. Although a 6-mm coring reamer can be used, the author has found it
easier to use the slightly larger corer to ensure fully encompassing the attachment and that it is less
likely to damage the plug during harvest. The anterior horn is obtained in a similar fashion, but
the plug is maintained at an 8-mm diameter and 10-mm length because reduction is not difficult.
To insert and secure the posterior bone plug, a 2-0 nonabsorbable suture is passed up through the
bone plug, sutured through the meniscal horn attachment, and brought back down the plug. It
is imperative to include the edge of the meniscus during the suturing to add additional strength
to the suture because the bone plug can be disrupted if pulled forcefully by itself. The anterior
bone plug can be secured using the same suturing technique or placed in press-fit means, which
are described later. As with the dovetail technique, a polydioxanone suture is placed through the
meniscus to function as a reduction suture (Figure 9-10).
Meniscus Implantation
The meniscus reduction sutures are passed into the knee and retrieved through the posterome-
dial incision using open-ended needles and inside-out technique. The posterior bone plug suture
is placed through the tibial tunnel suture and subsequently brings the bone plug suture out the
tibial tunnel entrance. The surgeon applies gently on the bone plug suture and uses his or her
index finger to carefully reduce the plug and bring the meniscus into the knee. At the same time,
an assistant uses light tension on the reduction suture to help bring the meniscus into the knee,
which also prevents the graft from flipping over.
Arthroscopically Assisted Meniscal Transplantation 127
Although the anterior plug can be placed right after the posterior plug, it is the author’s prefer-
ence to place a posterior then medial suture for initial fixation before securing the anterior horn.
The author has found that by suturing the graft in this manner, the graft position is more adapt-
able to any differences between the graft and host (Figure 9-11). For example, if the anterior plug
is secured first and the placement is incorrect, the difference needs to be made when suturing the
remaining meniscus. It can thus result in a graft that is extruded outward or one in which there
may be excess tension on the repair. If the preliminary fixation is done posterior then middle, it is
much easier to make adjustments for the anterior bone plug placement.
Once the anterior bone plug site is determined, a guide pin is placed and overreamed with an
8-mm drill to a depth of 1 cm. The anterior bone plug can be secured with a suture or can be
press-fit. Until experience is gained, it is wise to use a suture because ensuring a secure press-fit
has a learning curve. If the graft is to be secured with a bone plug stitch, a small hole to accom-
modate a suture-passing device is made in the anterior tibia and the plug sutures brought down
reducing the plug into the socket. The sutures from the 2 plugs are then tied to one another for
fixation. With the press-fit method, the tibia socket is made 1 to 2 mm less deep, and a tamp is
used to compress the plug into the socket. The suture for the posterior plug is tied down at tibia
opening once it has been reduced. The author has found that a simple, inexpensive polyethylene
button serves just as well as a more expensive fixation device. Subsequent suturing of the meniscus
is the same as previously described for the dovetail method.
Concomitant Procedures
Combined Anterior Cruciate Ligament Reconstruction and
Meniscal Transplantation
The main concern when reconstructing an ACL in conjunction with a meniscal allograft is
the tibial tunnels/channel preparation. If a bone bridge technique is used on the medial side,
there can be a small area of overlap with the channel and the tibial ACL tunnel. Therefore, all
bone preparation should be completed prior to either graft placement. If there is any overlap, the
128 Chapter 9
Figure 9-11. Tibial plateau demonstrating placement of bone plugs and initial fixation of a
medial graft. Note the significant difference in distance between the medial and lateral horn
attachments.
meniscal allograft is placed first. The drill can then be inserted up the ACL tunnel and carefully
used to remove bone that would prevent the ACL from passing. Conversely, if one tried to place
the ACL graft first, it would prevent reduction of the bone bridge into the slot or cause damage
to the ACL graft.
If the double bone plug technique is used in conjunction with an ACL, overlap of tunnels
should not occur if proper technique is used. Some tips can help to further limit the risk. If the
tibia is small, then the meniscus tunnel is drilled more midline and the ACL slightly more medial
than usual to enable more cortical bone between the drill holes. If the ACL tunnel appears to be
in close proximity to the anterior horn attachment, the plug socket can be drilled at a slight lateral
angle to have it directed away from the tibia tunnel.
For lateral meniscal allografts, overlap of the ACL tunnel of bone channel should not occur if
placed properly. In the event an error occurs, it should be addressed in the same manner as noted
for a bone bridge graft placed on the medial side.
High Tibial Osteotomy and Meniscal Transplantation
Osteotomies are typically performed when the mechanical alignment is toward the involved
compartment by more than a few degrees greater than the contralateral knee. All aspects of the
meniscal portion of the procedure, except placement of the graft, are completed prior to the
osteotomy and its fixation. When performing a bone bridge allograft, if the osteotomy is made
as inferior on the tibia as possible, the plate and screws should be distal enough to not have
overlap with the channel. If the bone plug technique is used, the posterior tunnel should be
drilled as steep of an angle on the tibia as possible. It helps keep the tunnel more posterior and
decreases the risk of overlap with the osteotomy screws. If there is a concern of overlap, keep
the drill for the meniscus inserted in the bone tunnel to identify its location when the osteotomy
screws are placed.
Arthroscopically Assisted Meniscal Transplantation 129
Postoperative Protocol
The initial postoperative care is to control pain, limit swelling, and obtain full extension.
Weightbearing is limited for the initial 4 weeks. A postoperative ROM brace is worn during this
period, with flexion limited to 90 degrees to minimize the meniscus translation and subsequent
stress on the posterior repair.
At 4 weeks, patients are allowed full weightbearing and unrestricted ROM. Stationary bik-
ing with low resistance and straight leg swimming are also started at that time. Progressive,
low-impact strengthening is implemented when the gait pattern has returned to normal. Most
surgeons recommend waiting until 4 months to allow jogging, although the author has found
no detriment if it is allowed as early as 12 weeks. Regardless of the time, patients with moderate
arthritis are strongly discouraged to avoid high impact activities permanently.
From 4 to 6 months, leg strengthening is progressed as comfortable, with core and balance
exercises stressed. Patients are released at 6 months if strength and endurance are comparable to
the contralateral leg and agility testing is normal. Regardless of the degree of chondromalacia,
patients’ expectations should not be to return to unlimited high-impact or contact sports.
Potential Complications
The reported complication rates vary widely, with initial series as high as 50%. However,
as experience and indications have been refined, the rates have dropped significantly (Figure
9-12).23,24 In a meta-analysis of 44 studies, Elattar et al 25 found an overall complication rate of
21.3%. The most common complication was tearing of the graft. In a systematic review of the
literature on meniscal transplantation, Matava 26 noted 45 tears in 547 patients for a tear rate
of 8.2%. The mean follow-up of the 15 studies reviewed was 55 months (range, 6 months to
14.5 years). In a long-term series of 100 patients, Verdonk et al 27 reported that the cumulative
survival rates following transplantation at 10 years for medial meniscal allografts were 74.2% and
69.8% for the lateral meniscus.
Whenever discussing allografts, infection and immune reaction are expressed as a concern.
Because fresh-frozen meniscal grafts are acellular, significant immune reactions are rare, with
review articles typically stating an occurrence of 1%. To date, no reports of HIV transmission have
been described from the use of meniscal allografts. The prevalence of infection is no higher than
standard meniscus repair procedures.
As with any meniscal repair method, a major concern for complication is neurovascular injury.
Arthrofibrosis is another possible complication that may be overlooked. If only the capsule is
remaining to suture the graft, the capsule can become entrapped if care is not taken to ensure the
posterior sutures are not overtightened. In addition, arthrofibrosis is of greater concern for menis-
cal allografts than standard meniscus repairs because the arthrotomy and extensive anterior horn
suturing can result in more anterior compartment scarring.
130 Chapter 9
References
1. Renström P, Johnson RJ. Anatomy and biomechanics of the menisci. Clin Sports Med. 1990;9(3):523-538.
2. Baratz ME, Fu FH, Mengato R. Mensical tears: the effect of meniscectomy and of repair on intraarticular
contact areas and stress in the human knee. A preliminary report. Am J Sports Med. 1986;14(4):270-275.
3. Allen PR, Denham RA, Swan AV. Late degenerative changes after meniscectomy. Factors affecting the
knee after operation. J Bone Joint Sur Br. 1984;66(5):666-671.
4. Brophy RH, Matava MJ. Surgical options for meniscal replacement. J Am Acad Orthop Surg.
2012;20(5):265-272.
5. Garrett JC. Meniscal transplantation: a review of 43 cases with two to seven year follow-up. Sports Med
Arthrosc Rev. 1993;2:164-167.
6. Cole BJ, Carter TR, Rodeo SA. Allograft meniscal transplantation: background, techniques, and results.
Instr Course Lect. 2003;52:383-396.
Arthroscopically Assisted Meniscal Transplantation 131
7. Abat F, Gelber PE, Erquicia JI, Pelfort X, Gonzalez-Lucena G, Monllau JC. Suture-only fixation tech-
nique leads to a higher degree of extrusion than bony fixation in meniscal allograft transplantation. Am
J Sports Med. 2012;40(7):1591-1596.
8. Berlet GC, Fowler PJ. The anterior horn of the medial meniscus. An anatomic study of its insertion. Am
J Sports Med. 1998;26(4):540-543.
9. Carter TR, Rabago M. Meniscal allograft transplantation: ten-year follow-up. Arthroscopy. 2012;28(suppl
1);e17-e18.
10. LaPrade RF, Willis NJ, Spiridonov SI, Perkinson S. A prospective outcomes study of meniscal allograft
transplantation. Am J Sports Med. 2010;38(9):1804-1812.
11. Kim JG, Lee YS, Bae TS, et al. Tibiofemoral contact mechanics following posterior root of the medial
meniscus tear, repair, meniscectomy, and allograft transplantation. Knee Surg Traumatol Arthrosc.
2013;21(9):2121-2125.
12. Vundelinckx B, Vanlauwe J, Bellemans J. Long-term subjective, clinical, and radiographic outcome
evaluation of meniscal allograft transplantation in the knee. Am J Sports Med. 2014;42(7):1592-1599.
13. Harris JD, Cavo M, Brophy R, Siston R, Flanigan D. Biological knee reconstruction: a systematic
review of combined meniscal allograft transplantation and cartilage repair or restoration. Arthroscopy.
2011;27(3):409-418.
14. Noyes FR, Barber-Westin SD, Rankin M. Meniscal transplantation in symptomatic patients less than
fifty years old. J Bone Joint Surg Am. 2004;86(7):1392-1404.
15. Huang A, Hull ML, Howell SM. The level of compressive load affects conclusions from statistical analy-
ses to determine whether a lateral meniscus allograft restores tibial contact pressure to normal: a study
in human cadaveric knees. J Orthop Res. 2003;21(3):459-464.
16. Pollard ME, Kang Q, Berg EE. Radiographic sizing for meniscal transplantation. Arthroscopy.
1995;11(6):684-687.
17. Yoon YR, Kim TS, Lim HC, Lim HT, Yang JH. Is radiographic measurement of bony landmarks reliable
for lateral meniscal sizing? Am J Sports Med. 2011;39(3):582-589.
18. McDermott ID, Sharifi F, Bull AM, Gupte CM, Thomas RW, Amis AA. An anatomical study of menis-
cal allograft sizing. Knee Surg Sports Traumatol Arthrosc. 2004;12(2):130-135.
19. Carter T, Economopoulos KJ. Meniscal allograft shrinkage—MRI evaluation. J Knee Surg.
2013;26(3):167-171.
20. Rijk PC. Menisal allograft transplantation—part I: background, results, graft selection and preserva-
tion, and surgical considerations. Arthroscopy. 2004;20(7):728-743.
21. Bursac P, York A, Kuznia P, Brown LM, Arnoczky SP. Influence of donor age on the biomechanical and
biochemical properties of human meniscal allografts. Am J Sports Med. 2009;37(5):884-889.
22. Choi NH, Yoo SY, Victoroff BN. Position of the bony bridge of lateral meniscal transplants can affect
meniscal extrusion. Am J Sports Med. 2011;39(9):1955-1959.
23. Hutchinson ID, Moran CJ, Potter HG, Warren RF, Rodeo SA. Restoration of the meniscus: form and
function. Am J Sports Med. 2014;42(4):987-998.
24. Wirth CJ, Peters G, Milachowski KA, Weismeier KG, Kohn D. Long-term results of meniscal allograft
transplantation. Am J Sports Med. 2002;30(2):174-181.
25. Elattar M, Dhollander A, Verdonk R, Almqvist KF, Verdonk P. Twenty-six years of meniscal allograft
transplantation: is it still experimental? A meta-analysis of 44 trials. Knee Surg Sports Traumatol
Arthrosc. 2011;19(12):147-157.
26. Matava MJ. Meniscal allograft transplantation: a systematic review. Clin Orthop Relat Res.
2007;(455):142-157.
27. Verdonk PC, Demurie A, Almqvist KF, Veys EM, Verbruggen G, Verdonk R. Transplantation of viable
meniscal allograft. Survivorship analysis and clinical outcome of one hundred cases. J Bone Joint Surg
Am. 2005;87(4):715-724.
Introduction
Patellar tendinopathy is widely recognized as a degenerative process of the patellar tendon,
occurring with increased frequency in jumping athletes. In 1973, Blazina et al1 coined the term
jumper’s knee to describe the condition, which has a strong predilection for affecting athletes
involved in intense repetitive jumping activity, such as basketball and volleyball. Lian et al 2
showed an overall prevalence of jumper’s knee in 613 elite athletes of 14.2%, with the highest
prevalence in volleyball (44.6%) and basketball (31.9%) players.
Although first viewed as an inflammatory condition and often referred to as patellar tendinitis,
it is now understood from histopathological study that the condition is mostly degenerative and
multifactorial, likely involving a complex cascade of events resulting in damaged, painful tissue.
Excessive or repetitive loading during jumping has been implicated as a cause.3-5 Some evidence
has found a longer distal nonarticular facet in patients with patellar tendinopathy,6 but others have
not identified significant differences that could contribute to impingement as a cause of patellar
tendinopathy.7 The proximal posterior degenerated tendon tissue has shown evidence of neoin-
nervation and neovascularity in addition to collagenous disorganization.8,9 In addition, Hoffa’s fat
pad has been implicated for impinging on a protruded inferior pole of the patella and developing
sensitive pain receptors as part of the disease process.10
Treatments have varied greatly in nature and success. A trial of nonoperative treatment is well
supported in the literature, with most authors recommending at least 3 to 6 months of conservative
measures prior to considering surgical intervention.11-13 Most clinicians advocate a short period of
discontinuation from the offending activity and a structured physical therapy program focusing on
eccentric quadriceps strengthening exercises and knee range of motion (ROM). Other nonopera-
tive measures have included a short course of nonsteroidal anti-inflammatory drugs, cryotherapy,
platelet-rich plasma injections, and low-energy radial extracorporeal shock wave therapy.14-16
When conservative measures fail to provide adequate relief of symptoms, surgical management
is considered. Traditionally, open surgical methods have been applied with success, with the goal
of removing the degenerated area of patellar tendon while often excising the protruded inferior
pole of the patella.17-19 In recent years, open surgery has increasingly been replaced by arthroscopic
techniques. Support for arthroscopy comes not only from its minimally invasive nature but also its
proposed ability to address the complex nature of the degenerative process in a more reliable and
complete manner, including excision of the protruded inferior pole of the patella without harming
intact tendon tissue, resection of the proximal posterior painful fat pad, direct resection of affected
tendon tissue, cauterization of tendon neovasculature, and the possible use of more accelerated
rehabilitation.20-26
Multiple studies support open and arthroscopic procedures as successful management strate-
gies for chronic patellar tendinopathy unresponsive to conservative treatment, 21 with a recent
trend favoring arthroscopy. In a recent systematic review, Marcheggiani Muccioli et al 20 found
that satisfactory results were achieved in 92.4% of arthroscopically treated patients and in 87.2%
of patients treated with open surgery. Return to sport rates also favored arthroscopy (84.2% vs
76.6%).20 However, evidence is limited, and no randomized controlled prospective trials have
compared open vs arthroscopic treatment. Arthroscopic treatment has been demonstrated to be
superior to sclerosing injections in one randomized trial.27
Indications
Arthroscopic debridement is indicated for the treatment of an established, chronic patellar ten-
dinopathy that has failed at least 3 to 6 months of nonsurgical management that includes eccentric
strengthening exercises for the knee extensor mechanism.12,22 It has been described for the treat-
ment of proximal to mid-tendon lesions; arthroscopic debridement of patella tendinopathy at the
insertion of the tendon to the tibial tubercle is technically difficult to perform due to challenges
in the visualization of this area.
▶ Chronic patellar tendinopathy
▶ Failed 3 to 6 months of nonsurgical treatment, including eccentric strengthening
▶ Proximal to mid-tendon lesions
Controversial Indications
No significant controversy exists with regard to proceeding to surgical management after fail-
ure of nonsurgical treatment. No clear data support arthroscopic compared to open surgical treat-
ment 20 or distal pole resection of the patella in addition to tendon debridement alone.12
▶ Has not failed eccentric strengthening of the extensor mechanism
▶ Distal lesion
Pertinent Imaging
▶ X-rays: Anteroposterior, lateral, and sunrise views; usually normal but may show enthesophyte
(traction spur) at the inferior patella
▶ Ultrasound: May show a hypoechoic region in the patellar tendon or a thickened tendon in
areas of degeneration. Color Doppler ultrasound may show increased vascularity 23
▶ Magnetic resonance imaging ([MRI] T1 and T2): May show increased signal in areas of
degeneration; may show tendon thickening
Equipment
The following are required to perform this procedure: standard arthroscopy equipment; a spinal
needle for portal localization; a 4-mm, high-definition, 30-degree arthroscope; an arthroscopic
shaver; an arthroscopic burr; and a 90-degree arthroscopic radiofrequency ablation device.
The patellar tendon should be inspected completely to identify areas of mucoid degeneration or
hypervascularity characteristic of chronic patellar tendinopathy. These degenerated areas should
be resected with the arthroscopic shaver. Debridement of the damaged tissue can also be guided by
preoperative imaging. Viewing from multiple portals is recommended to ensure thorough removal
of degenerated tissue. Typically, an 8- to 10-mm wide segment of degenerative tendon at the cen-
tral inferior pole of the patella is removed (Figure 10-9). Intact tendon tissue should be carefully
protected and preserved. The adequacy of the debridement of degenerative tissue can be confirmed
by placing the arthroscope into the central portal and inspecting the margins of the resection. Any
neovessels found within the tendon should be cauterized. If felt necessary, an osteoplasty of the
inferior patella is performed with an arthroscopic burr or bone-cutting shaver, to both enhance a
healing response within the tendon and remove a potential source of painful impingement.
Postoperative Protocol
Postoperatively, early ROM and immediate weightbearing are encouraged to avoid stiffness
and accelerate recovery of function. Eccentric strengthening closed chain exercises are initiated as
quadriceps function returns. Running typically is allowed by 5 to 6 weeks postoperatively. Return
to sport is guided by collaboration of the patient, the physician, and the physical therapist.
Return to sport is often accomplished by 10 to 12 weeks postoperatively.24
Arthroscopic Treatment of Patellar Tendinopathy (Jumper’s Knee) 141
Potential Complications
Although rare, vigorous resection of the patellar tendon can lead to partial or complete patellar
tendon rupture. Inability to cauterize neovessels can theoretically lead to hematoma. Osteophytes
at the site of the inferior patellar osteoplasty are occasionally found postoperatively but are often
asymptomatic.
References
1. Blazina ME, Kerlan RK, Jobe FW, Carter VS, Carlson GJ. Jumper’s knee. Orthop Clin North Am.
1973;4(3):665-678.
2. Lian OB, Engebretsen L, Bahr R. Prevalence of jumper’s knee among elite athletes from different sports:
a cross-sectional study. Am J Sports Med. 2005;33(4):561-567.
3. Dillon EM, Erasmus PJ, Müller JH, Scheffer C, de Villiers RV. Differential forces within the proximal
patellar tendon as an explanation for the characteristic lesion of patellar tendinopathy: an in vivo
descriptive experimental study. Am J Sports Med. 2008;36(11):2119-2127.
142 Chapter 10
4. Lavagnino M, Arnoczky SP, Elvin N, Dodds J. Patellar tendon strain is increased at the site of the jump-
er’s knee lesion during knee flexion and tendon loading: results and cadaveric testing of a computational
model. Am J Sports Med. 2008;36(11):2110-2118.
5. Bahr MA, Bahr R. Jump frequency may contribute to risk of jumper’s knee: a study of interindividual
and sex differences in a total of 11,943 jumps video recorded during training and matches in young elite
volleyball players. Br J Sports Med. 2014;48(17):1322-1326.
6. Lorbach O, Diamantopoulos A, Kammerer KP, Paessler HH. The influence of the lower patellar
pole in the pathogenesis of chronic patellar tendinopathy. Knee Surg Sports Traumatol Arthrosc.
2008;16(4):348-352.
7. Schmid MR, Hodler J, Cathrein P, Duewell S, Jacob HA, Romero J. Is impingement the cause of jumper’s
knee? Dynamic and static magnetic resonance imaging of patellar tendinitis in an open-configuration
system. Am J Sports Med. 2002;30(3):388-395.
8. Maffulli N, Testa V, Capasso G, et al. Similar histopathological picture in males with Achilles and patel-
lar tendinopathy. Med Sci Sports Exerc. 2004;36(9):1470-1475.
9. Khan KM, Bonar F, Desmond PM, et al. Patellar tendinosis (jumper’s knee): findings at histopatho-
logic examination, US, and MR imaging. Victorian Institute of Sport Tendon Study Group. Radiology.
1996;200(3):821-827.
10. Fredberg U. Tendinopathy—tendinitis or tendinosis? The question is still open. Scand J Med Sci Sports.
2004;14(4):270-272.
11. Bahr R, Fossan B, Løken S, Engebretsen L. Surgical treatment compared with eccentric training
for patellar tendinopathy (jumper’s knee). A randomized, controlled trial. J Bone Joint Surg Am.
2006;88(8):1689-1698.
12. Cucurulo T, Louis ML, Thaunat M, Franceschi JP. Surgical treatment of patellar tendinopathy in ath-
letes. A retrospective multicentric study. Orthop Traumatol Surg Res. 2009;95(8 suppl 1):S78-S84.
13. Ferretti A, Conteduca F, Camerucci E, Morelli F. Patellar tendinosis: a follow-up study of surgical treat-
ment. J Bone Joint Surg Am. 2002;84(12):2179-2185.
14. Larsson ME, Käll I, Nilsson-Helander K. Treatment of patellar tendinopathy—a systematic review of
randomized controlled trials. Knee Surg Sports Traumatol Arthrosc. 2012;20(8):1632-1646.
15. Furia JP, Rompe JD, Cacchio A, Del Buono A, Maffulli N. A single application of low-energy radial
extracorporeal shock wave therapy is effective for the management of chronic patellar tendinopathy.
Knee Surg Sports Traumatol Arthrosc. 2012;21(2):346-350.
16. Charousset C, Zaoui A, Bellaiche L, Bouyer B. Are multiple platelet-rich plasma injections useful
for treatment of chronic patellar tendinopathy in athletes? A prospective study. Am J Sports Med.
2014;42(4):906-911.
17. Kaeding CC, Pedroza AD, Powers BC. Surgical treatment of chronic patellar tendinosis: a systematic
review. Clin Orthop Relat Res. 2007;(455):102-106.
18. Gill TJ, Carroll KM, Hariri S. Open patellar tendon debridement for treatment of recalcitrant patellar
tendinopathy: indications, technique, and clinical outcomes after a 2-year minimum follow-up. Sports
Health. 2013;5:276-280.
19. Shelbourne KD, Henne TD, Gray T. Recalcitrant patellar tendinosis in elite athletes: surgical treatment
in conjunction with aggressive postoperative rehabilitation. Am J Sports Med. 2006;34(7):1141-1146.
20. Marcheggiani Muccioli GM, Zaffagnini S, Tsapralis K, et al. Open versus arthroscopic surgical treat-
ment of chronic proximal patellar tendinopathy. A systematic review. Knee Surg Sports Traumatol
Arthrosc. 2013;21(2):351-357.
21. Coleman BD, Khan KM, Kiss ZS, Bartlett J, Young DA, Wark JD. Open and arthroscopic patellar
tenotomy for chronic patellar tendinopathy. A retrospective outcome study. Victorian Institute of Sport
Tendon Study Group. Am J Sports Med. 2000;28(2):183-190.
22. Pascarella A, Alam M, Pascarella F, Latte C, Di Salvatore MG, Maffulli N. Arthroscopic management of
chronic patellar tendinopathy. Am J Sports Med. 2011;39(9):1975-1983.
23. Willberg L, Sunding K, Ohberg L, Forssblad M, Alfredson H. Treatment of jumper’s knee: promising
short-term results in a pilot study using a new arthroscopic approach based on imaging findings. Knee
Surg Sports Traumatol Arthrosc. 2007;15(5):676-681.
24. Alaseirlis DA, Konstantinidis GA, Malliaropoulos N, Nakou LS, Korompilias A, Maffulli N.
Arthroscopic treatment of chronic patellar tendinopathy in high-level athletes. Muscles Ligaments
Tendons J. 2013;2(4):267-272.
Arthroscopic Treatment of Patellar Tendinopathy (Jumper’s Knee) 143
25. Lorbach O, Diamantopoulos A, Paessler HH. Arthroscopic resection of the lower patellar pole in
patients with chronic patellar tendinosis. Arthroscopy. 2008;24(2):167-173.
26. Romeo AA, Larson RV. Arthroscopic treatment of infrapatellar tendonitis. Arthroscopy.
1999;15(3):341-345.
27. Willberg L, Sunding K, Forssblad M, Fahlström M, Alfredson H. Sclerosing polidocanol injections or
arthroscopic shaving to treat patellar tendinopathy/jumper’s knee? A randomised controlled study. Br J
Sports Med. 2011;45(5):411-415.
Introduction
There has been great emphasis recently on invasive methods of medial patellofemoral ligament
(MPFL) reconstruction for patellar instability.1-6 Although these techniques can be effective and
appropriate for severe cases of instability caused by MPFL insufficiency, it is important to keep
perspective on the appropriate indications for these techniques. MPFL reconstruction with a graft
is indicated when the native MPFL is incompetent and the remaining native tissue is inadequate
to be repaired or reefed primarily. A graft may also be considered in severe cases of trochlear dys-
plasia. However, in the great majority of cases with mild or moderate instability, a simple reefing
of the MPFL is a highly successful procedure, whether done arthroscopically or by mini-open
techniques, and is a less-invasive and less-expensive procedure.7,8
Numerous studies have been published documenting the effectiveness of arthroscopic patellar
realignment (APR) for patellar instability, with success rates greater than 90% and no or minimal
complications.9-16 MPFL reconstruction, although effective, is an open invasive procedure fraught
with potential complications in up to 26% of patients,17,18 including patellar fracture, overtighten-
ing, and nonisometric placement of the graft resulting in pain, stiffness, and medial tracking.17,18
These complications have not been reported with arthroscopic realignment.
Anatomic studies and clinical experience have shown that the MPFL heals in an elongated
fashion following subluxation or dislocation.19 Reefing of this lax MPFL is possible in a procedure
similar to capsulorrhaphy of the shoulder for laxity of the glenohumeral ligaments and results in
effective tightening of the native tissue.7,8
Indications
▶ Mild to moderate patella instability
▶ Lateral patella subluxation
▶ Pediatric patients with open growth plates
Sgaglione NA, Lubowitz JH, Provencher MT, eds. The Knee:
- 145 - AANA Advanced Arthroscopic Surgical Techniques (pp 145-160).
© 2016 AANA.
146 Chapter 11
Candidates for isolated arthroscopic reefing include patients with lateral patellar subluxation or
lateral dislocation with mild to moderate instability. These patients typically have good integrity
of their native tissues and are amenable to reefing of this native tissue. In a typical community
orthopedic practice, this represents the majority of patients with patellar instability. In addition,
APR is an excellent choice for pediatric patients with open growth plates, whereas MPFL recon-
struction with drill holes has increased risks.
In contrast, MPFL reconstruction with a graft would be recommended for patients with
severe instability, which is often associated with significant underlying dysplasia and would have
a higher risk for failure with an arthroscopic realignment. On physical examination, these more
severe cases often have a severe J sign with 3- to 4-quadrant lateral translation of their patella eas-
ily demonstrated. In particular, patients with severe trochlear dysplasia place higher-than-normal
forces on their MPFL due to the lack of bony constraint to the patella. For these patients, a formal
MPFL reconstruction with a graft (possibly in conjunction with a tubercle osteotomy) is more
appropriate because these patients require an extra strong MPFL in order to overcome the under-
lying dysplasia.20 Finally, APR is contraindicated for patients with a previously failed reefing or
poor native tissue for any reason, including old scarring, radiation, or collagen disorders, such as
Ehlers-Danlos syndrome.
Controversial Indications
▶ Lateral patellofemoral compression syndrome
▶ Lateral patellofemoral arthritis
Contraindications
▶ Poor quality native tissue
▶ Revision surgery
▶ Severe trochlea dysplasia
▶ Acute MPFL avulsion
APR is contraindicated in patients with poor-quality native tissue. This will typically be in
patients with severe recurring instability over many years, revision cases, or in patients with under-
lying collagen disease. APR is also contraindicated in patients with severe trochlear dysplasia,
where an extra-strong MPFL is necessary to overcome extreme lateral translation forces caused by
lack of bony congruity. Finally, patients with an acute avulsion of the MPFL following a recent
dislocation that is clearly demonstrated on magnetic resonance imaging (MRI) will need an open
reattachment of the MPFL if surgery is to performed within the first 6 weeks post injury. After
6 weeks, the MPFL is usually adequately reattached and, at this point, an APR may be undertaken
if instability persists.
Relative Contraindications
▶ Inadequate arthroscopic skills
▶ Fluid extravasation
▶ Open procedure already being performed
Arthroscopic Treatment of Patellar Instability 147
Relative contraindications include lack of arthroscopic surgical skills to perform the procedure,
fluid extravasation limiting the ability to complete the procedure, or in patients who may already
require an open procedure for other reasons (eg, cartilage resurfacing).
Combination Procedures
Arthroscopic realignment can be effective in conjunction with other patellar instability pro-
cedures. In a patient undergoing a tibial tubercle realignment, who has associated mild MPFL
laxity, the author has found the addition of APR an effective and less invasive method to supple-
ment this procedure.
Pertinent Imaging
▶ X-ray Merchant view (congruity, tilt)
▶ X-ray lateral (alta, trochlea dysplasia)
▶ MRI (TT-TG distance, chondral defects, MPFL status)
148 Chapter 11
All patients should have preoperative Merchant and true lateral x-rays. The Merchant view is
useful for assessing the amount of patellar tilt, patellar translation, and trochlear dysplasia and
narrowing of the patellofemoral joint space from arthrosis. Medial bony avulsion fragments and
marginal osteophytes can also be seen. The presence of an acute avulsion fracture of the MPFL
would indicate the need for an open repair of this fragment or direct repair of the MPFL back to
the patella. The presence of arthrosis would affect the outcome and treatment recommendations.
If lateral arthrosis is present, arthroscopic stabilization is a viable option. If medial facet arthrosis
is present, any medial tightening procedure, whether arthroscopic or open, may be contraindicated
because this would compress the medial facet and likely increase pain and the progression of the
arthrosis.
A true lateral view is useful for evaluating trochlear dysplasia. A crossing sign, supratrochlear
spur, or a double contour of the anterior cortex indicates the presence of a shallow, dysplastic
trochlea (Figure 11-1).23 If these findings are present, a formal MPFL reconstruction with a graft
Arthroscopic Treatment of Patellar Instability 149
is often indicated. Rarely, in patients with extreme trochlear dysplasia, particularly for revision
surgery, a trochleoplasty may also be considered.
Patellar height should also be measured on the preoperative lateral view. Significant patella alta
is an additional contributing factor for patellar instability.
Although various measurements have been described for this measurement, the author prefers
the Caton-Deschamps ratio, which measures from the anterosuperior angle of the proximal tibia
to the inferior pole of the patellar articular surface, divided by the articular length of the patella
(Figure 11-2).24 If this measurement is greater than 1.2, a distalization osteotomy of the patella
may need to be considered as part of the operative procedure.
MRI is an essential part of the author’s preoperative planning and can be used to measure
the TT-TG.22 This measurement is the accepted method for determining if the tubercle is
malaligned. If the distance is greater than 20 mm, the addition of a distal realignment (tibial
tubercle osteotomy) should be considered (Figure 11-3).22,25,26
150 Chapter 11
MRI is also useful for the evaluation of chondral injuries. Acute chondral fractures and loose
bodies are common with patellar dislocation, and one should look for them. Acute patellar dislo-
cations often cause chondral fractures of the medial facet of the patella or the lateral aspect of the
distal lateral trochlea. Chronic lateral patellar tracking can lead to degenerative chondral wear of
the lateral facet of the patella or trochlea. The presence of a large chondral defect or significant
arthrosis may affect surgical planning. For small grade 4 chondral defects, a microfracture is usu-
ally planned as part of the arthroscopic procedure. For large defects (> 2 cm), patients may require
a 2-stage procedure, including an open implantation of cartilage (chondrocyte implantation or
cartilage graft) that would preclude the sensibility of an arthroscopic realignment procedure. In
rare cases of acute patellar dislocation, if a large osteochondral fragment is present, direct repair
of the fragment using chondral darts or screws may be an option.
Equipment
This procedure can be performed with routine instruments typically found in most operating
rooms and is inexpensive. The following items are necessary:
▶ 4.0-mm arthroscope
▶ 5.0-mm cannula
▶ A Touhy (epidural) needle (17- or 18-gauge) for suture passing (BD Perisafe Modified Tuohy
Point Epidural Needle 17 G x 3 ½ in; Becton Dickinson)
▶ Arthroscopic knot pusher
▶ Arthroscopic suture retriever
▶ Arthroscopic suture cutter
▶ Ball tip rasp
Figure 11-4. The leg holder should be placed high on the thigh to avoid interference with suture tying
from the supralateral portal.
Diagnostic Arthroscopy
A diagnostic arthroscopy is performed. Evaluate the integrity of the articular cartilage and
look for loose bodies, which are removed or fixed in rare cases. Acute chondral fractures are com-
mon with patellar dislocation. Treatment of chondral injuries should be performed prior to the
stabilization procedure. Grade 4 chondral defects are typically treated with microfracture. Lesser
degrees of chondromalacia should be debrided. Lateral facet osteophytes should be removed.
The remainder of the knee is evaluated for any additional pathology that may require treatment.
Patellar tracking is evaluated under direct visualization. Confirmation is made of patellar tilt and
translation (Figure 11-5).
B
Arthroscopic Treatment of Patellar Instability 153
Figure 11-6. A healing response is created along the medial retinaculum with a ball tip rasp by abrading
the synovium and capsule.
Figure 11-8. (A) Outside view of the suture being passed through a Tuohy epidural needle.
(continued)
A B
Knot Tying
The arthroscope is in the anterolateral portal. All sutures are currently located in the supero-
lateral cannula. The author then retrieves the most inferior sets of sutures out through the antero-
medial portal to get them out of the way, leaving just the most proximal of the sutures in the
superolateral cannula. Arthroscopic knot tying is then performed of this suture. Simple sutures or
a sliding knot (Duncan loop) may be used. The next most proximal suture is then retrieved back
through the cannula and tied (Figure 11-11). This process is repeated until all sutures are tied.
Assessment
The knee is then flexed, and patellar tracking and stability are evaluated. The goal is to have
the patella centered in the trochlear groove at 20 to 25 degrees of knee flexion (Figure 11-12).
Verification is also made that lateral patella overhang has been eliminated (Figure 11-13). Gentle
manual translation can also be checked to verify that the MPFL is snug and that all excess lat-
eral translation has been eliminated. If necessary, additional sutures may be added at this time.
One of the major advantages of this technique is that the medial reefing is titrated under direct
arthroscopic vision. Only the necessary number of sutures are placed to achieve neutral tracking,
which eliminates any risk of overcorrection.
Arthroscopic Treatment of Patellar Instability 157
Figure 11-11. Outside view of arthroscopic knot tying of the most superior stitch performed through the
supralateral cannula while the more inferior stitches are parked in the anteromedial portal for subsequent
tying.
Postoperative Protocol
The patient is placed in a hinged-knee brace that is locked in full extension. Partial weightbear-
ing is permitted with crutches. Ankle ROM and isometric quadriceps contractions are allowed
immediately. At 1 week, the patient returns for suture removal and is instructed in heel slides from
0 to 30 degrees. ROM is gradually increased to 90 degrees over the first 3 to 4 weeks. The brace
is discontinued at 4 weeks, and ROM is increased to full. Patients can usually return to full sports
participation at 4 months.
Potential Complications
One of the advantages of arthroscopic patellar stabilization is that complications are rare.
Postoperative stiffness is possible but has not been seen in the author’s patient population using
the rehabilitation protocol described. Early on in the development of this procedure, the author
immobilized the patients for 4 weeks before beginning ROM and had several patients with post-
operative stiffness. The author advises beginning ROM early as described.
The author has experienced no cases of overcorrection using this technique. He thinks this is
unlikely because the procedure is performed under direct visualization and the patella position can
be titrated based on the number of sutures and the size of the tissue bite taken.
Recurring instability is possible with this procedure as with any other, although the incidence
has been low.9-16 Risk of recurrence can be minimized by proper patient selection and adherence
to the technical details as outlined.
This procedure will not be effective if it is performed on a patient who needs bony realignment
surgery for severe dysplasia or has inadequate integrity of his or her native MPFL tissue.
Arthroscopic Treatment of Patellar Instability 159
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2. Buckens CF, Saris DB. Reconstruction of the medial patellofemoral ligament for treatment of patello-
femoral instability: a systematic review. Am J Sports Med. 2010;38(1):181-188.
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4. Christiansen SE, Jacobsen BW, Lund B, Lind M. Reconstruction of the medial patellofemoral ligament
with gracilis tendon autograft in transverse patellar drill holes. Arthroscopy. 2008;24(1):82-87.
5. Drez DJ Jr, Edwards TB, Williams CS. Results of medial patellofemoral ligament reconstruction in the
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6. Steiner TM, Torga-Spak R, Teitge RA. Medial patellofemoral ligament reconstruction in patients with
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7. Ma LF, Wang F, Chen BC, Wang CH, Zhou JW, Wang HY. Medial retinaculum plasty versus medial
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8. Harle D, Smith T, Loveday DT. Medial reefing versus medial patellofermoral ligament reconstruction
for patellar instability. Eur J Orthop Surg Traumatol. 2010;20(7):547-551.
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10. Small NC. Arthroscopically assisted proximal extensor mechanism realignment of the knee. Arthroscopy.
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Arthroscopy. 2001;17(5):555-557.
13. Halbrecht JL. Arthroscopic patella realignment: an all-inside technique. Arthroscopy. 2001;17(9):940-945.
14. Halbrecht JL. Arthroscopic management of patella instability. Oper Tech Orthop. 2007;17(4):211-215.
15. Haspl M, Cicak N, Klobucar H, Pecina M. Fully arthroscopic stabilization of the patella. Arthroscopy.
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patellar stabilization with anchor sutures. Arthroscopy. 2004;20(7):761-764.
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Introduction
Patellofemoral instability as a clinical entity depends on factors of constraint, such as the abil-
ity of the patella to engage in the trochlea as well as the soft tissue restraints to patellar mobility.
The medial patellofemoral ligament (MPFL) is the primary ligamentous restraint against lateral
patellar displacement with the MPFL reported to provide between 50% and 60% of the medial
soft tissue resistance to lateral dislocation of the patella.1-3 Consequently, patellar dislocation often
results in injury to the medial retinacular ligaments, including the MPFL, leading to increased
lateral patellar mobility. Competency of the MPFL is necessary and sufficient to restore lateral
patellar mobility to a normal range; consequently, surgical treatment should aim for restoration of
a functional MPFL.4
Indications
Nonoperative treatment is typically indicated for acute, first-time dislocators without associated
osteochondral fracture or loose bodies.
Surgical management is indicated for the following:
▶ Recurrent patellar instability (at least 2 documented instability events) and a confirmatory
physical examination demonstrating excessive lateral patellar laxity4-7: For these recurrent
dislocators, MPFL reconstruction is the current procedure of choice.
▶ Osteochondral fracture or a loose body that is potentially repairable or causing mechanical
symptoms: Consideration must be given to the size and location of the donor fragment and
the presence of adequate subchondral bone when considering fragment repair. In the pres-
ence of osteochondral injury being addressed surgically, one can perform concomitant MPFL
reconstruction.
▶ Smaller, isolated chondral injuries: Surgery may be indicated if mechanical symptoms are
present. Nonoperative treatment is appropriate in the absence of mechanical symptoms.
Sgaglione NA, Lubowitz JH, Provencher MT, eds. The Knee:
- 161 - AANA Advanced Arthroscopic Surgical Techniques (pp 161-172).
© 2016 AANA.
162 Chapter 12
Physical Examination
General
▶ Range of motion (ROM): Block to motion could indicate symptomatic loose body
▶ Size of effusion: Acute, traumatic instability events tend to lead to moderate/severe effusions,
but consider osteochondral fracture if a large, tense effusion is present.
▶ A comprehensive physical examination is needed to assess for cruciate/collateral injury.
Important Considerations
▶ Patient guarding can lead to a false-negative result.
▶ Intra-articular anesthetic can be used to assist with patient evaluation.
▶ If gross hemarthrosis is present on joint aspiration, consider magnetic resonance imaging
(MRI) to evaluate for an osteochondral fracture/loose body.
Reconstruction of the Medial Patellofemoral Ligament for Instability 163
Pertinent Imaging
▶ Plain x-rays: Important for identifying avulsion fractures, loose bodies, patella alta, and
trochlear dysplasia
▷ Standing anteroposterior view
▷ True lateral view with the knee flexed 30 degrees: Allows for measurement of patellar
height and assessment of trochlear dysplasia
▷ Axial patellar view at 30 or 45 degrees of flexion: Important for finding subluxation, dis-
location, or avulsion fractures
▶ Computed tomography (CT): Can further identify and characterize avulsion or osteochon-
dral fractures/loose bodies; evaluates trochlear dysplasia
▶ Stress radiography: With the knee flexed to 30 degrees, obtain an axial patellar view bilaterally
with laterally directed force to the medial aspect of the patella. A side-to-side increase of 3.7 mm
or more of lateral translation on the symptomatic vs asymptomatic side is considered abnormal.9
▶ MRI
▷ Identifies the location and degree of medial soft tissue injury
▷ Reported to be more accurate than arthroscopy in identifying MPFL injuries10
▷ MPFL injuries occur commonly in the form of tears near the femoral attachment or avul-
sions off the femur but may also occur as midsubstance tears or avulsions off the patella.
Injuries to multiple sites in the medial ligamentous complex can occur.11
▷ Can identify osteochondral injuries on the patella and femur as well as loose bodies that
may be missed on plain x-rays (Figure 12-1)
164 Chapter 12
Equipment
The following equipment is recommended in addition to standard soft tissue retractors for the
authors’ preferred method of MPFL reconstruction:
▶ Knee arthroscopy equipment if knee arthroscopy is to be performed prior to MPFL
reconstruction
▶ Soft tissue tendon stripper for the harvest of semitendinosus graft (the authors prefer a closed
tendon stripper)
▶ 4.5-mm drill with guide for drilling tunnels in the patella for each end of the semitendinosus
tendon graft
▶ Small curved curette to clear the patellar tunnels of debris for graft passage
▶ 18-gauge steel wire to be fashioned to retrieve suture through the patellar tunnels. Alternative
options include commercially produced curved suture passer devices.
Reconstruction of the Medial Patellofemoral Ligament for Instability 165
▶ Smooth 2.4-mm guide wire pin (Beath pin equivalent) diameter, and if applicable, with eyelet
for suture. This pin is used to drill into the center of the femoral MPFL footprint and guide
the reamer for MPFL femoral tunnel creation. If the pin is too long, it can interfere with
obtaining fluoroscopy to confirm anatomic positioning of the pin in the MPFL origin.
▶ Fluoroscopy for checking the position of the guide pin in the femoral footprint of the MPFL.
The authors prefer to use a Mini-C arm equivalent.
▶ Cannulated reamers of various diameters from 5 to 8 mm for drilling the femoral tunnel
▶ Interference screws for fixation of grafts in the femoral tunnel. Typically, screws run from
lengths of 20 to 25 mm and diameters of 5 to 8 mm.
▶ #0 or #1 absorbable suture
▶ #5 braided polyethylene suture
▶ #2 nonabsorbable sutures
▶ Once all tendinous slips have been freed, harvest the semitendinosus tendon using a closed
(preferred) or open tendon stripper.
▶ Baseball stitches are placed on both free ends with #2 nonabsorbable suture for later graft
passage through the 2 patellar tunnels.
▶ The graft is prepared on the back table by first sizing the graft to 240 mm and then folding
it in half, leaving a doubled graft of 120 mm. It is recommended to make the doubled graft
length no less than 120 mm to ensure adequate graft length.
▶ A #5 polyethylene suture is placed through the loop to be used for pulling the doubled graft
into the blind femoral tunnel.
▶ A baseball stitch 25 mm in length with #0 or #1 absorbable suture is placed in the looped end
of the graft to sew together the 2 graft strands that will be in the femoral tunnel.
▶ A second 4.5-mm drill hole is placed on the medial side of the patella at a point two-thirds
down the length of the patella.
▷ A corresponding drill hole is placed on the anterior surface of the patella about 8 mm from
the medial border, and the 2 holes are connected with a curved curette.
▶ If the semitendinosus graft is more than 4.5 mm in diameter, the drill holes are enlarged
slightly to facilitate graft passage.
▶ It is important to avoid placing the distal patellar tunnel distal to the native insertion of the
MPFL to avoid constraining the distal pole of the patella.
posterior origin of the medial femoral condyle, and proximal to the level of the posterior point
of the Blumensaat line on a lateral x-ray with both posterior condyles projected in the same
plane (Figure 12-5).16
▶ A loop of #5 braided polyethylene suture is passed around the Beath pin, through the dis-
sected retinacular tunnel, and then through one of the patellar tunnels.
▶ The knee is taken through ROM to evaluate isometry while holding the suture at the anterior
aspect of the patellar tunnel to evaluate for length changes of the suture during ROM (Figure
12-6).
▷ If lengthening occurs in flexion, a second Beath pin is placed more distally toward the
medial epicondyle. The first pin is left in place to facilitate repositioning while drilling the
second Beath pin. The loop of #5 suture is passed around the second Beath pin, and the
knee is put through ROM again. If isometry is acceptable, the first Beath pin is removed.
▷ If lengthening occurs in extension, a second Beath pin is placed more proximally toward
the adductor tubercle. The first pin is left in place to facilitate repositioning while drilling
the second Beath pin. The loop of #5 suture is passed around the second Beath pin, and the
knee is put through ROM again. If isometry is acceptable, the first Beath pin is removed.
Reconstruction of the Medial Patellofemoral Ligament for Instability 169
▶ Once the femoral pin site is accepted, a blind tunnel is reamed into the femur the size of the
doubled graft. For a semitendinosus graft, this usually is 6 to 7 mm in diameter.
▶ The femur is reamed to a depth of at least 20 mm, with a preferred depth of 25 mm.
▶ The free graft arms are doubled back and sutured on themselves just medial to the patella
using 2 figure-8 mattress sutures of #2 nonabsorbable suture on a tapered needle.
▶ Patellar mobility is checked after the first suture is placed. There should be a good endpoint,
or checkrein, with the knee in full extension and at 30 degrees of flexion, full knee ROM, and
7 to 9 mm of lateral patellar displacement from the centered position at 30 degrees of flexion.
▶ Excess graft is sharply removed.
▶ The native MPFL is sutured to the graft, and then the retinaculum is closed over the graft.
▶ The wounds are closed in standard fashion.
Postoperative Protocol
▶ Weightbearing as tolerated is allowed immediately postoperatively in a drop-lock or knee
extension brace.
▶ Passive ROM and resisted closed chain exercises are started as soon as possible to restore
ROM and quadriceps control. Preserving motion is key after MPFL surgery.
▶ Bracing may be continued for up to 6 weeks during ambulation to prevent falls until quadri-
ceps control is restored. Circumferential measurement of quadriceps 10 cm above the superior
pole of the patella can aid in evaluating restoration of the quadriceps.
▶ Patients are allowed to return to stressful activities, including sports, when they attain full
ROM and have regained at least 80% of their quadriceps strength compared to the noninjured
limb.
▶ If at least 90 degrees of flexion is not achieved by 6 postoperative weeks, then the intensity
of the therapy program must be increased. Manipulation under anesthesia may be needed
between 9 and 12 weeks postoperatively if stiffness does not resolve with therapy alone.
Potential Complications
▶ Inadequate graft length can occur if the total tendon length is less than 240 mm or in very
large patients. Subsequently, the authors recommend getting consent from patients for poten-
tial allograft tendon use with an appropriately sized allograft on standby.
▶ Breakage of the patella bone bridge may occur during preparation of the 2 patellar tunnels or
during passage of an oversized graft through a tight patellar tunnel. If this occurs, a second
exit hole can be drilled more laterally on the anterior patellar surface. Another option is to
drill the tunnel transversely across the patella, exiting at the lateral patellar margin. The graft
can be secured by tying the sutures over a button or suturing the graft to the soft tissues on
the lateral patellar border.
▶ Nonanatomic femoral tunnel placement will result in inappropriate graft behavior during
ROM and reliably produce inadequate results.
▶ Excessive medial patellar constraint results in a painful, overconstrained patella.17-19
▶ It is imperative not to set the graft in tension but to instead ensure the MPFL graft is lax
throughout a ROM becoming tight only when the patella is displaced laterally from its cen-
tered position.
▶ Symptomatic hardware can occur when the femoral tunnel interference screw is left proud
outside of the femoral tunnel. Ensuring the screw is buried in the femoral tunnel can avoid
this complication. Screw removal is acceptable, but it is recommended that the patient be fully
Reconstruction of the Medial Patellofemoral Ligament for Instability 171
rehabilitated and back to unrestricted activities prior to this. Avoiding screw removal within
6 months after surgery is recommended. When removing the interference screw, careful
attention should be paid to avoid violating the MPFL graft.
▶ Patellar fracture can occur after MPFL reconstruction, but it is the authors’ opinion that
patellar fracture is less likely using this technique because large implants and transverse bone
tunnels are avoided. If patellar fracture occurs, treatment using standard AO techniques is
recommended.
▶ Postoperative stiffness can occur if motion is not encouraged after MPFL reconstruction sur-
gery. It is recommended that MPFL reconstruction be avoided with concomitant procedures
that have competing postoperative rehabilitation protocols that require motion protection.
References
1. Conlan T, Garth WP Jr, Lemons JE. Evaluation of the medial soft-tissue restraints of the extensor
mechanism of the knee. J Bone Joint Surg Am. 1993;75(5):682-693.
2. Panagiotopoulos E, Strzelczyk P, Herrmann M, Scuderi G. Cadaveric study on static medial patellar
stabilizers: the dynamizing role of the vastus medialis obliquus on medial patellofemoral ligament. Knee
Surg Sports Traumatol Arthrosc. 2006;14(1):7-12.
3. Hautamaa PV, Fithian DC, Kaufman KR, Daniel DM, Pohlmeyer AM. Medial soft tissue restraints in
lateral patellar instability and repair. Clin Orthop Rel Res. 1998;(349):174-182.
4. Fithian DC, Gupta N. Patellar instability: principals of soft tissue repair and reconstruction. Tech Knee
Surg. 2006;5:19-26.
5. Mäenpää H, Lehto MU. Patellar dislocation. The long-term results of nonoperative management in
100 patients. Am J Sports Med. 1997;25(2):213-217.
6. Nikku R, Nietosvaara Y, Aalto K, Kallio PE. Operative treatment of primary patellar dislocation does
not improve medium-term outcome: a 7-year follow-up report and risk analysis of 127 randomized
patients. Acta Orthop. 2005;76(5):699-704.
7. Nikku R, Nietosvaara Y, Kallio PE, Aalto K, Michelsson JE. Operative versus closed treatment of pri-
mary dislocation of the patella: similar 2-year results in 125 randomized patients. Acta Orthop Scand.
1997;68(5):419-423.
8. Fithian DC, Paxton WE, Stone ML, et al. Epidemiology and natural history of acute patellar dislocation.
Am J Sports Med. 2004;32(5):1114-1121.
9. Teitge RA, Faerber WW, Des Madryl P, Matelic TM. Stress radiographs of the patellofemoral joint.
J Bone Joint Surg Am. 1996;78(2):193-203.
10. Panagiotopoulos E, Strzelczyk P, Herrmann M, Scuderi G. Cadaveric study on static medial patellar
stabilizers: the dynamizing role of the vastus medialis obliquus on medial patellofemoral ligament. Knee
Surg Sports Traumatol Arthrosc. 2006;14(1):7-12.
11. Elias DA, White LM, Fithian DC. Acute lateral patellar dislocation at MR imaging: injury patterns of
medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella. Radiology.
2002;225(3):736-743.
12. Caton J, Deschamps G, Chambat P, Lerat JL, Dejour H. Patella infera. Apropos of 128 cases [in French].
Rev Chir Orthop Reparatrice Appar Mot. 1982;68(5):317-325.
13. Dejour H, Walch G, Nove-Josserand L, Guier C. Factors of patellar instability: an anatomic radiographic
study. Knee Surg Sports Traumatol Arthrosc. 1994;2(1):19-26.
14. Camp CL, Stuart MJ, Krych AJ, et al. CT and MRI measurements of tibial tubercle-trochlear groove
distances are not equivalent in patients with patellar instability. Am J Sports Med. 2013;41(8):1835-1840.
15. Salzmann GM, Weber TS, Spang JT, Imhoff AB, Schöttle PB. Comparison of native axial radiographs
with axial MR imaging for determination of the trochlear morphology in patients with trochlear dys-
plasia. Arch Orthop Trauma Surg. 2010;130(3):335-340.
16. Schöttle PB, Schmeling A, Rosenstiel N, Weiler A. Radiographic landmarks for femoral tunnel place-
ment in medial patellofemoral ligament reconstruction. Am J Sports Med. 2007;35(5):801-804.
17. Elias JJ, Cosgarea AJ. Technical errors during medial patellofemoral ligament reconstruction could over-
load medial patellofemoral cartilage: a computational analysis. Am J Sports Med. 2006;34(9):1478-1485.
18. Muneta T, Sekiya I, Tsuchiya M, Shinomiya K. A technique for reconstruction of the medial patello-
femoral ligament. Clin Orthop Rel Res. 1999;(359):151-155.
19. Nomura E, Horiuchi Y, Kihara M. Medial patellofemoral ligament restraint in lateral patellar transla-
tion and reconstruction. Knee. 2000;7(2):121-127.
Introduction
Patellofemoral pain and dysfunction is often caused by improper tracking and concomitant
maldistribution of forces between the patella and the trochlear groove. In addition, patellar insta-
bility is a common problem that often requires surgical intervention. When performed on the
appropriately selected patient, tibial tubercle transfer (TTT) is a powerful surgical technique for
altering mechanical alignment, allowing redistribution of loads within the articular cartilage, and
promoting patellar stability. Medialization and anteromedialization of the tibial tubercle are effec-
tive ways to dissipate loads on the lateral patellofemoral compartment.1,2 The surgical procedure
is clinically successful and allows patients to resume increasing levels of activity.3
Indications
▶ Patellofemoral instability, patellar and trochlear focal chondral lesions
▶ Lateral patellar compression syndrome and patellofemoral articular degeneration
▶ Procedure in conjunction with soft tissue patellar stabilization, chondral replacement thera-
pies, and patellofemoral resurfacing
▶ Patellofemoral pain and/or instability associated with a poorly balanced patellar-trochlear
articulation4,5
▶ Medialization with minimal anteriorization in patients for whom the major pathology is
patellar instability6
▶ Patients with significant patellar tilt and significant articular degeneration in the lateral and
inferior patellofemoral joint
Controversial Indications
▶ TTT-anteromedialize the tibial tubercle as an adjunct to autologous chondrocyte implanta-
tion procedures in the patellofemoral joint in an effort to redistribute the joint forces to protect
the cartilage implantation.7
▶ Distalization procedures in patients with recurrent instability in the setting of patella alta.
Distalization can be added in conjunction with a TTT.6,8
Contraindications
▶ Significant proximal pole arthritis or cartilage disease
▶ Significant medial trochlear cartilage disease
▶ Complex regional pain syndrome
▶ Medical or psychiatric disorders prohibiting surgical intervention4,5
Best Test
▶ The best test for determining an optimal candidate for anteromedialization is the step down
test (to establish that a distal patella articular lesion is likely causing pain) in which the patient
has subpatellar pain upon stepping down with the contralateral leg. If this test reproduces the
patient’s symptom, and imaging and/or arthroscopic evidence documents tilt with a distal/
lateral patella articular lesion, the patient is likely a candidate for anteromedialization once
nonoperative measures have failed.
Tibial Tubercle Transfer 175
Pertinent Imaging
▶ Computed tomography and magnetic resonance imaging (MRI) examination are useful tools
in evaluating the mechanical anatomy of the relationship of the patella to the trochlear groove
(tibial tubercle to trochlear groove).12-15
▶ Standard anteroposterior, lateral, and axial views of the patella, in addition to full-length
standing films, can give insight into overall alignment and articulation variations within the
knee. Patellar height (Insall-Salvati ratio) can be assessed using the lateral position.
Equipment
Various guide systems are currently on the market for tibial tuberosity osteotomies. The
Arthrex T3 AMZ system and DePuy Synthes Tracker AMZ Guide provide a guided system for
creating a controlled osteotomy on the tibia while protecting soft tissue structures and controlling
the degree of realignment of the extensor mechanism. Some surgeons, with experience and train-
ing, may be able to perform most tubercle transfer osteotomies without using a guide.
▶ Arthroscopy equipment
▶ Intraoperative fluoroscopy
▶ Sharp and dull soft tissue retractors
▶ Dissection scissors
▶ Wide and narrow sagittal bone cutting blades (osteotomes; one-half and one-quarter in)
▶ K-wires (2.1 and 2.4 mm)
▶ Small fragment or large fragment fixation sets (Synthes or Stryker)
Figure 13-1. Arthroscopic views of the patellofemoral joint prior to procedure throughout the ROM. The
patella has significant contact forces on the lateral trochlea, and there is significant patellar tilt secondary
to weak medial soft tissues. (Reprinted with permission from Ganesh Kamath, MD.)
Figure 13-2. Arthroscopic view of the patellofemoral joint postoperatively throughout the ROM. The
patella now reengages the trochlea in uniform alignment. (Reprinted with permission from Ganesh
Kamath, MD.)
tubercle and carrying the incision approximately 6 cm distal to the tibial tubercle. Careful soft
tissue dissection of the patellar tendon along its lateral and medial borders should increase mobili-
zation (Figure 13-2). Often, the fat pad must be released from the posterior of the patellar tendon
to allow sufficient mobilization and appropriate visualization (Figure 13-3). The tibialis anterior
origin muscle fascia is released and reflected posteriorly using electrocautery and/or a Cobb eleva-
tor. The medial and lateral borders of the patellar tendon are clearly defined using blunt dissection
and a retractor or a vessel loop is placed around the tendon (Figure 13-4).
Depending on surgeon preference, the osteotomy can begin with a cut transverse to the long
axis of the tibia just proximal to the patellar tendon insertion. This can be done with small osteo-
tomes or a small fine oscillating saw while protecting the patellar tendon. This transverse proximal
cut may also be performed after the long sloping longitudinal cut (Figure 13-5).
With the patella oriented anteriorly, protective retractors are used retract the tibialis anterior
and expose the entire proximal anterior tibia for the extent of the incision. A fine tooth oscillat-
ing saw blade is used to create an approximately 5- to 7-cm longitudinal osteotomy (Figure 13-6).
Tibial Tubercle Transfer 177
Figure 13-4. Lateral tibial exposure with appropriate identification and exposure of the patellar tendon.
This is important for avoiding iatrogenic injury. (Reprinted with permission from Ganesh Kamath, MD.)
178 Chapter 13
Figure 13-5. With the patellar tendon retracted, an osteotome is safely used to make a transverse cut
through the tibia. (Reprinted with permission from Ganesh Kamath, MD.)
Figure 13-6. Once the exposure is complete, the AMZ Guide can be placed to reference the bone cut.
(Reprinted with permission from Ganesh Kamath, MD.)
With the knee held in a straight anteroposterior orientation, the saw blade is placed about
5 mm behind the insertion of the medial patellar tendon into the tibial tuberosity, oriented in a
transverse plane, and then rotated slightly such that the blade, upon making the cut, will move
anteriorly as it proceeds distally. Place a target point approximately 5 cm distal to the tibial
tuberosity directly at the anterior crest of the tibia. By raising the saw anteriorly, the steepness
Tibial Tubercle Transfer 179
Figure 13-7. Lateral connecting osteotomy. An osteotome is used to connect the transverse tibial oste-
otomy to the main osteotomy. (Reprinted with permission from Ganesh Kamath, MD.)
(and thus the desired anteriorization of the tibial tubercle) can be adjusted. It is important to
create the angle of the osteotomy anteriorly at its distal aspect to avoid creating an unnecessary
stress fracture in the tibia by notching the tibia. The osteotomy should exit the tibia smoothly,
leaving a small bone bridge (such that a simple greenstick fracture over the distal end is all that
is needed to release the osteotomized fragment in a straight medial direction once all cuts are
completed).
An oblique connecting cut is needed on the lateral side to connect the longitudinal and
the transverse cuts to allow release of the osteotomized tubercle (Figure 13-7). The proximal
cut above the patellar tendon insertion provides a shelf upon which the transferred osteotomy
fragment may rest securely after transfer in the medial direction, supplementing screw fixation
(Figure 13-8).
In many cases, the tibial tuberosity will be moved about 1 cm medially. The tibial tuberosity
should be moved only as far medially as is necessary to create better tracking of the patella into
the trochlea, avoiding excessive medialization (Figure 13-9).
Excessive medialization may lead to medial patellar instability, which is a serious postopera-
tive complication. The goal is to recreate a more normal tracking pattern in which the patella
goes slightly laterally in extension and then moves proximally into the center of the trochlea
with knee f lexion. A K-wire can be used to hold the osteotomy in place as patellar tracking
is evaluated. Arthroscopic and open evaluation of patellar tracking can be used to evaluate
dynamic patellar tracking (Figures 13-2, 13-9, and 13-10). Once proper tracking of the patella
is established, two 4.5 screws or three 3.5 screws should be used to stabilize the transferred
tibial tubercle. The screws are placed through the osteotomy fragment and countersunk, and
then appropriately sized drill holes are made into the posterior cortex to create lag fixation. In
many cases, a small amount of bone may be removed from the medial aspect of the transferred
bone fragment if overly prominent.
In patients with instability who have insufficient medial retinacular anatomy, some
arthroscopic or open imbrication may be appropriate to reestablish normal length of medial
patellofemoral and medial quadriceps femoral restraints. For proper restoration of patellofemo-
ral stability in the presence of lateral patellar tracking, it is important to correct the alignment
of the patellofemoral joint by TTT before doing any medial reconstruction.
180 Chapter 13
Figure 13-9. K-wire placement into the tibial tuberosity. Measurements can be used to estimate the
amount of anteromedialization to be obtained by the tibial tubercle osteotomy. (Reprinted with permis-
sion from Ganesh Kamath, MD.)
Tibial Tubercle Transfer 181
Figure 13-10. K-wire placement into the tibial tuberosity. A K-wire can be placed after the tuberosity is
anteromedialized, and arthroscopic evaluation can be used to assess patellar tracking. (Reprinted with
permission from Ganesh Kamath, MD.)
Anteromedialization
Exposure is the same as for medial TTT. To perform anteromedial TTT, the entire lateral
tibia must be exposed by elevating the tibialis anterior. This becomes particularly important with
anteromedial TTT because of the obliquity of the cut, which determines the amount of anterior-
ization. In order to perform a steep anteromedial TTT, the saw blade is placed immediately adja-
cent to the medial patellar tendon and then angled posterolaterally such that the saw blade will exit
the lateral tibial cortex. Again, the osteotomy is tapered toward the anterior tibial crest distally.
In many cases, a 6- to 8-cm longitudinal cut is created. The length is determined by marking the
periosteum, starting at the medial patellar tendon insertion and creating a straight line exiting at
the anterior tibial crest distally with the desired distance from the proximal tibial tubercle.
When unloading of the distal and lateral patella is of utmost importance, a steeper osteotomy
is created. The saw blade must be watched carefully as it exits the lateral tibia cortex, first at the
distal aspect and then followed as the cut is brought anteriorly and distally. The saw blade must
never exit posteriorly or be out of direct vision of the surgeon. Osteotomes may be used to fine-
tune the osteotomy distally to ensure sufficient release while maintaining distal bone continuity.
Distalization
One technique is to bevel the most distal transverse osteotomy so as to lock in the tibial tubercle
after the transfer. Finally, the tuberosity is mobilized by making a coronal plane cut and freeing
the tibial tubercle fragment with an osteotome. The patellar tendon is dissected in order to allow
distal excursion of the tibial tubercle.
Next, the tuberosity is shifted distally and locked into the most distal transverse tibial cut.
The tuberosity is then fixed in a lag-time fashion as previously noted.6,8 Little clinical outcome
data exist to support distalization, and some increasing evidence shows that the loads created by
altering the Blix curve and retinacular alignment with tubercle distalization can lead to failure of
fixation and/or patellofemoral overload and result articular cartilage damage. The best place for
tubercle distalization remains to be determined.
182 Chapter 13
Postoperative Protocol
Following TTT, the patient should be anticoagulated. Foot and ankle pumps, ice, elevation,
and rest are important for the first 5 days, but the patient may ambulate with crutches for short
distances in a protective brace.
After the first few days, the patient should begin daily work on ROM, sitting in a chair, remov-
ing the knee immobilizer, and progressing toward a 90-degree bend by 4 weeks postoperatively.
Quad sets should be done starting on the first postoperative day. Most patients should be able
to bend the knee to 100 to 120 degrees by 6 weeks postoperatively. Physical therapy may start at
the discretion of the surgeon, taking care to respect the soft tissue healing of the anterior wound.
High-level activity and running should not be performed until at least 6 months postoperatively
(Table 13-1). Radiographic evidence of complete healing should be established before any vigorous
activities.
Potential Complications
Problems or need for additional surgery after a TTT have been reported to be up to 37% when
postoperative hardware removal is considered. The most common complications are listed in Table
13-2.16
The prevalence of metaphyseal fractures ranges from 0% to 9.5% in small case series and case
reports.16 Fracture can be prevented by avoiding a notched tibia distally. Careful attention should
be made to the thickness of the distal edge of the osteotomy. If it is too large, the fragment will
not appropriately hinge during the transfer, and a stress fracture may occur at the level or distal
to the osteotomy site. Protected weightbearing postoperatively is also crucial to preventing further
propagation of these types of fractures.17
Nonunion is a rare complication that may be attributed to heat necrosis from saw use, uneven
osteotomy, improper screw placement techniques, and excessive periosteal stripping. Osteotomes
may be used to complete the osteotomy so as to avoid necrosis at the cortical edges. A minimal-
istic approach should also be considered when making the exposure to the anterior tibia, and an
attempt to preserve bony blood supply should be paramount.18
Hardware irritation has been reported as a common postoperative complaint. Countersinking
the traditional 2-by-4.5-mm screws is important to avoid hardware irritation. In biomechanical
cadaver studies, 3-by-3.5-mm screws have been proven to withstand similar maximal loads. The
lesser prominence of the 3.5-mm screw heads may be a way to avoid hardware irritation.19
Vascular injury is a potential catastrophic complication of the tibial tubercle osteotomy. Bifurcation
of the popliteal artery has been found to be 8.3 mm from the exit point of the superior screw, and the
tibial artery has been found to be 9.0 mm from the inferior screw. Because of the proximity of these
large vessels, care should be taken not to plunge past the posterior cortex of the tibia and to always
visualize the most posterior saw cut exiting the posterolateral cortex. Tissue protectors should also
always be in place to avoid damage to the skin.20 The lateral tissue protector also must protect the
peroneal nerve, which is at risk if the saw or osteotomes are uncontained laterally.
It is important to maintain full-thickness skin flaps during the dissection to prevent wound
complications. An appropriate closure of soft tissues may prevent the formation of dead space sero-
mas/hematomas that may lead to secondary infection. Drains may be used at the discretion of the
surgeon. Osteomyelitis can occur about 5.8% of the time if there are serious wound complications.
Other rare but important complications include arthrofibrosis, compartment syndrome, and
deep venous thrombosis. Arthrofibrosis has a prevalence of about 8.5% but is uncommon by
starting early postoperative ROM. Postoperative protocols with use of a hinged knee brace can
help allow early ROM and prevent this complication. Compartment syndrome can be prevented
Tibial Tubercle Transfer 183
by creating a rent in the tibialis anterior fascia prior to elevating the subperiosteal flap laterally.
In addition, the opened anterior-lateral compartment fascia should not be repaired, allowing any
potential bleeding a course of egress. Care should be taken to avoid complete anesthetic blocks of
the legs (femoral and sciatic combined blocks) as latent compartment syndrome is a recognized
(but uncommon) complication associated with lower extremity surgery. In addition, drains may
184 Chapter 13
References
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2. Beck PR, Thomas AL, Farr J, Lewis PB, Cole BJ. Trochlear contact pressures after anteromedialization
of the tibial tubercle. Am J Sports Med. 2005;33(11):1710-1715.
3. Katchburian MV, Bull AM, Shih YF, Heatley FW, Amis AA. Measurement of patellar tracking: assess-
ment and analysis of the literature. Clin Orthop Relat Res. 2003;(412):241-259.
4. Sherman SL, Erickson BJ, Cvetanovich GL, et al. Tibial tuberosity osteotomy: indications, techniques,
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6. Feller JA. Distal realignment (tibial tuberosity transfer). Sports Med Arthrosc. 2012;20(3):152-161.
7. Trinh TQ, Harris JD, Siston RA, Flanigan DC. Improved outcomes with combined autologous chondro-
cyte implantation and patellofemoral osteotomy versus isolated autologous chondrocyte implantation.
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8. Duchman K, Bollier M. Distal realignment: indications, technique, and results. Clin Sports Med.
2014;33(3):517-530.
9. Mihalko WM, Boachie-Adjei Y, Spang JT, Fulkerson JP, Arendt EA, Saleh KJ. Controversies and tech-
niques in the surgical management of patellofemoral arthritis. Instr Course Lect. 2008;57:365-380.
10. Crossley K, Bennell K, Green S, Cowan S, McConnell J. Physical therapy for patellofemoral pain: a ran-
domized, double-blinded, placebo-controlled trial. Am J Sports Med. 2002;30(6):857-865.
11. Doberstein ST, Romeyn RL, Reineke DM. The diagnostic value of the Clarke sign in assessing chondro-
malacia patella. J Athl Train. 2008;43(2):190-196.
12. Salzmann GM, Weber TS, Spang JT, Imhoff AB, Schöttle PB. Comparison of native axial radiographs
with axial MR imaging for determination of the trochlear morphology in patients with trochlear dys-
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study. Knee Surg Sports Traumatol Arthrosc. 1994;2(1):19-26.
14. Goutallier D, Bernageau J, Lecudonnec B. The measurement of the tibial tuberosity. Patella groove
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1978;64(5):423-428.
15. Camp CL, Stuart MJ, Krych AJ, et al. CT and MRI measurements of tibial tubercle-trochlear groove
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16. Harrison RK, Magnussen RA, Flanigan DC. Avoiding complications in patellofemoral surgery. Sports
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17. Luhmann SJ, Fuhrhop S, O’Donnell JC, Gordon JE. Tibial fractures after tibial tubercle osteotomies for
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18. Cosgarea AJ, Freedman JA, McFarland EG. Nonunion of the tibial tubercle shingle following Fulkerson
osteotomy. Am J Knee Surg. 2001;14(1):51-54.
19. Warner BT, Kamath GV, Spang JT, Weinhold PS, Creighton RA. Comparison of fixation meth-
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20. Kline AJ, Gonzales J, Beach WR, Miller MD. Vascular risk associated with bicortical tibial drilling dur-
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Introduction
Osteoarthritis is a common condition treated by a range of nonoperative modalities, includ-
ing nonsteroidal anti-inflammatory drugs, analgesics, weight loss, activity modification, intra-
articular injections of steroids or hyaluronic acid, muscle strengthening, and off-loading the
affected compartment with unloader bracing or a heel wedge.1 When nonoperative measures
fail, arthroscopic intervention may be considered. Arthroscopic surgery as a possible intervention
to osteoarthritis has been commonly performed to alleviate symptoms and possibly delay future
arthroplasty. As the prevalence of arthroscopy has increased, so has the interest in outcomes
because there is currently no conclusive evidence that arthroscopy delays or arrests the progression
of osteoarthritis.2
Conflicting opinions based on the current literature regarding arthroscopic debridement in
knee osteoarthritis are explained by the wide range of inclusion criteria, surgical procedures, and
outcome measures used in different studies.3 Arthroscopic debridement comprises a variety of
procedures combined into a single operation. Lavage removes the mechanical irritating products
and evacuates degradative enzymes potentially contributing to joint degeneration. Partial men-
iscectomy, articular cartilage shaving, and loose body removal are also commonly performed to
improve mechanical symptomatology. On occasion, surgeons also perform a limited synovectomy
or osteophyte excision. As a result, the literature has become somewhat confusing and discordant.
This controversy has been highlighted in several randomized controlled trials.4
Since 2002, there have been 6 randomized controlled trials of arthroscopic management of
knee osteoarthritis published, including 2 focusing on the efficacy of arthroscopic debridement
and lavage on pain and function5,6 and 4 on the efficacy of arthroscopic partial meniscectomy in
patients with symptomatic meniscal tears and underlying mild to moderate knee osteoarthritis.7-9
In a study comparing arthroscopic debridement, arthroscopic lavage, and a placebo group
who had skin incisions only, Moseley et al 5 showed no difference at 2-year follow-up between
the 3 treatment groups. The conclusion was that the results were similar for the lavage and
debridement group compared to the placebo group.5 Multiple potential biases to this study were
identified. Of the veterans, 44% declined to participate, all procedures were performed by a single
surgeon (performance bias), outcomes were self-reported with an invalidated knee score (detec-
tion bias), and no patients with positive magnetic resonance imaging (MRI) findings for internal
derangement were included in this study.4,10
Kirkley et al6 published a study in 2008 in which patients with moderate to severe osteoarthritis
were randomized into the following 2 groups: surgical lavage and arthroscopic debridement with
physical and medical therapy vs nonoperative treatment, including physical and medical therapy
only. The arthroscopic group had better outcomes at 3 months, but no difference existed at 2 years
between the groups.6 Patients with large symptomatic meniscal tears were excluded from the
study. This inclusion bias was the largest flaw in the study because these patients typically benefit
from arthroscopic debridement in association with knee osteoarthritis.4
Despite Moseley et al’s5 and Kirkley et al’s6 studies, the question of whether surgery is more
effective than a standardized nonoperative regimen in patients with symptomatic meniscal tear
and concomitant knee osteoarthritis remains unanswered. Four studies have been published in the
past several years that begin to address these questions about the role of surgery in patients with
meniscal tears and concomitant osteoarthritis.
Herrlin et al7 evaluated patients with knee pain, meniscal tears on MRI, and radiographic
osteoarthritis. They compared 2 groups treated with arthroscopic partial meniscectomy and those
treated with exercise alone using multiple functional outcome scores at 6-month and 5-year follow-
up. The results were similar at both points of follow-up between patients treated with arthroscopy
and those treated with exercise. However, 30% of patients from the nonoperative group did not
have satisfactory pain relief and received an arthroscopic partial meniscectomy, noting significant
improvement after the procedure.7
The Meniscal Tear in Osteoarthritis Research (MeTeOR) Trial shared many design similari-
ties to the study by Herrlin et al7 but was considerably larger, with 351 subjects from 7 centers.
Patients with MRI-documented meniscal tears with radiographic osteoarthritis were randomized
to a standardized physical therapy regimen or arthroscopic partial meniscectomy with postopera-
tive physical therapy. Functional outcomes were measured at 6 and 12 months and showed no
differences between the groups. Similar to the Herrlin et al7 study, 30% of the subjects crossed
over from nonoperative therapy to surgery.8
Yim et al9 published a randomized controlled trial of arthroscopic partial meniscectomy vs
nonoperative regimen focused on strengthening on 102 subjects with symptomatic meniscal tears.
They found no significant difference in outcomes at 2-year follow-up. However, unlike Herrlin
et al7 and the MeTeOR trials, only 1 patient crossed over from the nonoperative arm to surgery.9
Sihvonen et al11 reported on a randomized controlled trial of arthroscopic partial meniscecto-
my vs sham surgery for symptomatic degenerative medial meniscal tear without knee osteoarthritis
in 146 patients. Like those of Moseley et al 5 and Kirkley et al,6 Sihvonen et al’s subjects showed
no difference in outcomes at 12 months.11
Given that the current literature has not been conclusive in showing a clear benefit, arthros-
copy continues to be used for patients with arthropathy. Fedorka et al12 examined the incidence
and rates of knee arthroscopy in patients younger than 65 years and the subsequent risk of knee
arthroplasty. They found that the conversion rate to arthroplasty was dependent on the age of
the patient. Patients in the younger than 65 years age group had a conversion rate of 4.1% within
5 years of arthroscopy for all patients. Patients older than 65 years had a higher conversion rate of
10.2% undergoing arthroplasty within 1 year of arthroscopy. The age of the patient and extent of
arthritis play a role in who benefits from an arthroscopy in the presence of arthropathy.12
Arthroscopic Approach to Knee Osteoarthritis 191
Indications
Regardless of the controversy, arthroscopic surgery is an effective procedure in young and select
middle-aged patients with knee osteoarthritis. Patients with severe osteoarthritis do not seem to
benefit from arthroscopy.2 However, some patients with mild to moderate osteoarthritis may have
the following:
▶ Symptomatic meniscus pathology
▶ Impinging osteophytes
▶ Loose bodies
Patients with these findings may benefit greatly from arthroscopic treatment. The goal of
arthroscopy in this setting is to reduce mechanical irritation and thus reduce symptomatic synovi-
tis. Removal of loose bodies and debridement of unstable cartilage can be performed. The indica-
tions for arthroscopic debridement, partial meniscectomy, and/or loose body removal include the
discrete chief complaints of the following:
▶ Acute onset of well-localized joint line pain
▶ Mechanical symptoms, such as catching or locking13
The x-rays should demonstrate normal or near normal alignment, mild to moderate degenera-
tive changes, and a large meniscal tear confirmed by MRI.
Occasionally, an athlete with advanced arthritis may be a candidate for arthroscopy to relieve
acute pain and mechanical symptoms. Symptoms typically present as the abrupt onset of a severe,
sharp pain in the involved compartment along with catching or locking. The goals of surgery need
to be limited to relieve the mechanical symptoms but not the arthritic pain.
Controversial Indications
▶ Persistent pain with mild to moderate osteoarthritis without specific mechanical symptoms.
In at least one study, there appears to some benefit in postponing total knee arthroplasty
(TKA) by several years subsequent to arthroscopic debridement.12
90 degrees of flexion medially or laterally in internal and external rotation), pain with hyperexten-
sion, and effusion almost always confirm a symptomatic torn meniscus. Improved outcomes from
arthroscopic debridement are a reduction in pain and mechanical symptoms resulting from loose
bodies, displaced articular chondral lesions, and meniscal tears.2-4
Pertinent Imaging
Preoperative radiography should consist of the following:
▶ Standing schuss or Rosenberg view (posteroanterior film of both knees flexed at 30 degrees)
▶ Lateral view
▶ Merchant view
Best Test
The schuss view is suggested as the most accurate method for the evaluation of joint-space nar-
rowing in knee osteoarthritis.15 A standard anteroposterior view may underestimate the amount
of osteoarthritis present.
The need for MRI is based on the initial history, examination, x-rays, and response to prior
treatment. MRI typically is obtained in patients considered candidates for arthroscopic interven-
tion to assess for loose bodies not visualized on x-rays, meniscal pathology, and potential unstable
chondral flaps.3,4
Equipment
▶ Gravity inflow is a common method for infusing the joint. As technology has improved, the
fluid pump has gained popularity. It has the advantage of improved hemostasis and higher
pressures. Selection of outflow also plays an important role in distention of the joint and
providing a clear view. Continuous outflow, whether gravity or suction, will result in greater
fluid use; therefore, intermittent outflow controlled by the surgeon or an assistant may be
preferable.
▶ Shavers and occasionally burrs are used during arthroscopy to debride chondral flaps, perform
meniscectomies, and shave osteophytes. Shavers are typically available in different sizes and
levels of aggressiveness. In general, the smallest and least aggressive shaver should be used.
▶ The selection and proper use of an arthroscopic camera allows the surgeon to examine all
areas of the knee joint efficiently. Most surgeons prefer the 30-degree arthroscope for most
procedures. The 70-degree arthroscope is used if a larger view is needed, such as in the pos-
terior aspect of the knee.
▶ Cannulas are not used frequently in the knee but can be useful for posterior portals. Metal
cannulas are useful for posterior portals because shavers can screw into the cannula directly
and, with the use of an adapter, the camera can be exchanged between cannulas.
▶ Other basic working instruments needed for knee arthroscopy include a probe, spinal needle,
basket punches (narrow, wide, straight, upbiting, curved, left, right, and back), graspers, cut-
ters, and varying types of shavers, burrs, and cautery. Basket punches are available in various
shapes and selection should be based on surgeon preference. More important than the shape,
a variety of different angled and curved basket punches should be available so that all areas
of the joint can be accessed.
Arthroscopic Approach to Knee Osteoarthritis 193
Postoperative Protocol
The postoperative protocol is based on the specific pathology treated. For loose body removal,
chondroplasty, and meniscectomies, rehabilitation may progress aggressively because there is no
anatomic structure that requires protection. The protocol should involve 3 phases. Progression
to the next phase should be based on clinical criteria and meeting the established goals for each
194 Chapter 14
phase. Phase 1 is the acute phase and consists of diminishing pain and edema, restoring knee
ROM, reestablishing quadriceps muscle activity, and educating the patient on weightbearing as
tolerated, use of crutches, icing, elevation, and the rehabilitation process. Phase 2 goals are to
restore and improve muscle strength and endurance; reestablish full, pain-free ROM; a gradual
return to functional activities; restore normal gait without an assistive device; and improve balance
and proprioception. Phase 3 goals include enhancing muscular strength and endurance, maintain-
ing full ROM, and returning to sports, functional activities, and work tasks.2-4
Potential Complications
Doing knee arthroscopy for any reason results in overall complication rates ranging from
0.8% to 1.8%. Intraoperative complications include further articular cartilage damage (scuffing),
Arthroscopic Approach to Knee Osteoarthritis 195
instrument breakage, and neurological and vascular injury. The senior author uses a technique of
partial release of the MCL with an arthroscopic electrocautery intra-articularly, or a motorized
shaver if the joint is tight medially. Creating a Type II MCL tear should have no effect on the
patient long term as opposed to an injury to the articular surface, which will cause permanent
damage to the articular surface. Capsular herniation can occur when a portion of the capsule is
excised near the portal, causing free communication between the joint and subcutaneous tissue.
This can be painful and cosmetically displeasing. Postoperative complications can also include
thromboembolism, worsening pain, hemarthrosis, infection, effusion and synovitis, complex
regional pain syndrome, and infrapatellar contracture.16-19 It is important to have a thorough
medical preoperative assessment, diligent arthroscopic procedure, and careful postoperative man-
agement as well.
Conclusion
Arthroscopic debridement can benefit patients with mild to moderate arthritis and mechanical
complaints of pain. It can postpone the need for unicompartmental and TKA and is particularly
beneficial in younger patients who wish to remain physically active and in patients with significant
comorbidities that would make undertaking TKA medically undesirable. The surgeon and the
patient must understand that the results of the operation will not completely alleviate the patient’s
complaints of pain but will afford him or her partial relief and hopefully prevent the necessity of
TKA for several years.
References
1. Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (nonarthroplasty). J Am
Acad Orthop Surg. 2009;17(9):591-600.
2. Dervin GF, Stiell IG, Rody K, Grabowski J. Effect of arthroscopic débridement for osteoarthritis of the
knee on health-related quality of life. J Bone Joint Surg Am. 2003;85(1):10-19.
3. Bert J. Arthroscopic treatment of degenerative arthritis of the knee. In: Scott WN, Scuderi G, eds. Insall
& Scott Surgery of the Knee. 5th ed. Philadelphia, PA: Churchill Livingstone; 2012:229-234.
4. Krych AJ, Bert JM, Levy BA. Treatment of OA of the knee in the middle-aged athlete: the role of arthros-
copy. Sports Med Arthrosc. 2013;21(1):23-30.
5. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis
of the knee. N Engl J Med. 2002;347(2):81-88.
6. Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteo-
arthritis of the knee. N Engl J Med. 2008;359(11):1097-1107.
7. Herrlin S, Hållander M, Wange P, Weidenhielm L, Werner S. Arthroscopic or conservative treatment
of degenerative medial meniscal tears: a prospective randomised trial. Knee Surg Sports Traumatol
Arthrosc. 2007;15(4):393-401.
8. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteo-
arthritis. N Engl J Med. 2013;368(18):1675-1684.
9. Yim JH, Seon JK, Song EK, et al. A comparative study of meniscectomy and nonoperative treatment for
degenerative horizontal tears of the medial meniscus. Am J Sports Med. 2013;41(7):1565-1570.
10. Horng S, Miller FG. Is placebo surgery unethical? N Engl J Med. 2002;347(2):137-139.
11. Sihvonen R, Paavola N, Malmivaara A, et al. Arthroscopic partial meniscectomy versus sham surgery
for a degenerative meniscal tear. N Engl J Med. 2013;369(26):2515-2524.
12. Fedorka CJ, Cerynik DL, Tauberg B, Toossi N, Johanson NA. The relationship between knee arthros-
copy and arthroplasty in patients under 65 years of age. J Arthroplasty. 2014;29(2):335-338.
13. Marx RG. Arthroscopic surgery for osteoarthritis of the knee? N Engl J Med. 2008;359(11):1169-1170.
14. Fond J, Rodin D, Ahmad S, Nirschl RP. Arthroscopic debridement for the treatment of osteoarthritis of
the knee: 2 -and 5-year results. Arthroscopy. 2002;18(8):829-834.
15. Piperno M, Hellio Le Graverand MP, Conrozier T, Bochu M, Mathieu P, Vignon E. Quantitative
evaluation of joint space width in femorotibial osteoarthritis: comparison of three radiographic views.
Osteoarthritis Cartilage. 1998;6(4):252-259.
16. Bert J, Bert T. Complications of knee arthroscopy. In: AANA Advanced Arthroscopy: The Knee.
Philadelphia, PA: Saunders Elsevier; 2010:5:37-44.
17. DeLee JC. Complications of arthroscopy and arthroscopic surgery: results of a national survey.
Arthroscopy. 1985;1:214-220.
18. Small NC. Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy.
1998;4:215-221.
19. Rodeo S, Forster R, Weiland A. Current concepts review: neurological complications due to arthros-
copy. J Bone Joint Surg Am. 1993;75:917-926.
Introduction
Osteochondritis dissecans (OCD) is described as a focal, idiopathic alteration of subchondral
bone with risk for instability and disruption of adjacent articular cartilage that may result in
premature osteoarthritis.1 When describing OCD lesions, the parent bone refers to the normal
bone structure surrounding the abnormal progeny bone. The cartilage over the progeny bone is
part of the OCD lesion, with a well-defined bone margin apparent on imaging.
OCD lesions can be found in the shoulder, elbow, hip, ankle, and foot, but they are most
common in the knee. Approximately 60% to 70% occur at the medial femoral condyle and about
20% to 30% at the lateral femoral condyle, with rare cases in the trochlea, patella, and tibial
plateau. 2,3 Few higher level of evidence studies have been reported on OCD of the knee, such
as randomized clinical trials and prospective cohort studies. Thus, the strength of recommen-
dations for treatment options is limited. The recent 2010 American Academy of Orthopaedic
Surgeons Guideline for treatment of OCD of the knee revealed a paucity of high-level research
in this area.4
In skeletally immature patients, stable OCD lesions (those with intact overlying cartilage)
may progress toward healing in the majority of patients, with appropriate activity restrictions,
including activity and motion limitations.5 The specific restrictions and length of nonoperative
treatment vary. Different healing rates have been described, with success rates of 60% to 90% 6,7
to less than 60%.5,8-10 Significant healing may take 6 to 18 months, and prolonged activity
restrictions may lead to loss of motion, muscle atrophy, poor treatment compliance, family frus-
tration, and psychosocial impact of prolonged absence from sports participation.8,11-13
Indications
▶ Failure of nonoperative treatment
▶ Failure of a stable lesion to demonstrate radiographic healing with persistence of clinical
symptoms longer than 3 to 6 months14
▶ Arthroscopic demonstration of unstable lesion surface, margins, and fragmentation
Cartilage lesion stability is an important consideration when evaluating OCD lesions.
Instability may be assessed by magnetic resonance imaging (MRI) evaluation. Kijowski et al15
defined criteria for stability in those with open physes based upon the following MRI findings.
Figure 15-2. MRI findings (A) before and (B) 3 months after drilling in a 13-year-old female soccer player.
and the use of significantly more radiation. The longer radiation exposure has implications for
the patient and the operating room team. Surgical technique that consistently produces adequate
drilling into the lesion/progeny bone can be challenging; whether this technique can be accurately
reproduced in general use is a concern.18
Trans- and retroarticular techniques have excellent outcomes at short-term follow-up. Healing
rates for transarticular drilling have been reported at 70% to 90% or greater.12,18,19 Healing rates
for retroarticular drilling have been reported at 75% or greater (Figure 15-2).17,20-22
Controversial Indications
▶ OCD lesions with instability should not be treated with isolated subchondral bone drilling.
Although this technique may supplement the treatment for more advanced lesions, adjuvant
Arthroscopic Approaches to Osteochondritis Dissecans 201
procedures may be required to obtain lesion stability and a healthy subchondral bone environ-
ment that promotes healing between the parent and progeny bone.
▶ Older patients, including those with fusing (closing) or fused (closed) physes, and some larger
lesions, are usually not candidates for isolated subchondral bone healing.
▶ Children with a history of malignancy, autoimmune disease, or other conditions requiring
steroid use may develop lesions similar to OCD. These lesions are difficult to treat, and the
treatment principles of OCD may not apply.
Pertinent Imaging
Four-view series knee x-rays are valuable in the first stage of evaluation. A notch view will
frequently reveal lesions that are located more posteriorly on the condyles, making them difficult
to visualize on an anteroposterior (AP) view (Figure 15-3). The lateral view should be evaluated
closely because the lesions may not be readily apparent without close inspection of the condyles
and the trochlea. Merchant and trochlear views will reveal the rare trochlear groove lesions, more
commonly seen in the lateral aspect.
In younger patients with smaller and stable lesions, MRI may not be necessary at the first
stage of evaluation. Radiographic evaluation may be limited in the ability to detect subtle signs of
lesion instability, and MRI is a valuable tool for more comprehensive evaluation of size, location,
subchondral changes suggestive of lesion instability, or frank cartilage breach. The authors’ usual
practice is to obtain an MRI in most patients with an OCD. In addition to the findings described
by Kijowski et al,15 findings on the MRI that suggest instability include the following:
▶ A clear break/breach in the articular cartilage
▶ Radially oriented linear markings in the articular cartilage
▶ Disruption of normal cartilage contour in the progeny region compared with the surrounding
bone and cartilage
▶ Significant T2 sequence signal changes within and/or behind the progeny bone. Signal
changes in these regions that mimic the intra-articular fluid are suggestive of a breach in the
cartilage surface.15
202 Chapter 15
Equipment
The equipment necessary for the procedure includes the following:
▶ Routine knee arthroscopy equipment
▶ K-wires of 4 or 9 inches in length. Longer K-wires may be better for retroarticular drilling,
but both lengths work well for transarticular drilling.
▶ K-wire driver. Drivers with an adjustable wire collet are superior to those that use a Jacob’s
chuck.
Arthroscopic Approaches to Osteochondritis Dissecans 203
Figure 15-4. Leg position with the end of the table in full extension.
Figure 15-5. Thigh position with mini C-arm use. The thigh can be flexed and externally rotated to allow
for visualization of the OCD lesion and K-wire drilling.
Arthroscopic Approaches to Osteochondritis Dissecans 205
▶ Perform a routine diagnostic arthroscopy to confirm the absence of other joint pathology,
including chondral free bodies, significant plica bands, etc. Routine anterolateral and antero-
medial portals are used. In some cases, the OCD lesion may be better seen by using the light
source on a lower setting to reduce the reflected light form the hyaline cartilage surfaces. This
can be especially helpful if the overlying cartilage is completely normal.
▶ The K-wires should be positioned as perpendicular as possible to the lesion. Changing the
degree of knee flexion/extension can help with wire placement. K-wire drilling may be done
through the portals or directly through the skin.
▶ Avoid bending the wires during placement. If this occurs, it is safer to remove the wires
without the K-wire driver. If the driver is used on a bent pin, the pin may shear off at the
bend due to the relatively high torque applied to the pin. A stout needle driver can be used to
gently remove a bent pin and avoid breaking the pin off in the bone or at the cartilage surface.
▶ Carefully monitor the depth of K-wire penetration. For transarticular drilling, penetration
into the parent bone beyond a few centimeters may not be necessary (Figure 15-6). Place the
K-wire on the surface of the cartilage and then grasp the collet driver away from the skin
surface. The distance from the skin surface and the collet driver should equal the desired
depth of penetration. The K-wire is advanced until the collet tip contacts that skin, ensuring
an appropriate depth of drilling into the lesion and normal bone.
▶ In most cases, the K-wire orientation will be perpendicular to the cartilage and/or the lesion/
progeny bone. In some cases, orientation may be less than perpendicular due to lesion location.
Transarticular Drilling
▶ K-wire selection: Historically, 0.0625-in wires have been used in previous publications. To
minimize the trauma to the articular hyaline cartilage, the use of 0.045- or 0.054-in wires
may be selected. These wires have sufficient stiffness for transarticular drilling.
▶ Drill hole density: Typically, 4 to 5 drill holes are passed per square centimeter.
206 Chapter 15
▶ Drill hole depth: The use of imaging can help guide this. Ideally, the drill holes will cross the
progeny bone and enter the parent bone by about a 1 to 2 cm or slightly more. The K-wire can
be grasped outside of the knee with a gap between the tip of the driver and the patient’s skin
surface. This gap can approximate the depth of penetration desires, and when the tip of the
driver contacts the skin, no further advancement of the wire is necessary. In all cases, be aware
of the potential for injury to neurovascular structures about the knee. It is also important to
be aware of the physis because drilling should not penetrate the physis.
▶ When the surface cartilage is entirely normal, use of the C-arm may be necessary to identify
the appropriate drilling location. The use of AP, lateral, and oblique imaging may be advanta-
geous in this situation.
Retroarticular Drilling
▶ Drilling must be performed under AP and lateral fluoroscopic guidance, as described by
Edmonds et al,17 Kocher et al,18 and Boughanem et al.20
▶ The entrance point of the K-wires is distal to the femoral physis, traversing the epiphysis,
directed toward the OCD progeny bone. Review of x-ray and MRI sequences can help
determine the optimal starting point for drilling. C-arm images should be used to ensure
that these pins are not crossing the physis (Figure 15-7).
▶ The larger-diameter K-wire of 0.0625 in may be a better choice than the 0.054- or 0.045-in
K-wire. This larger diameter wire is stiffer and may be easier to orient the K-wire in the opti-
mal drilling position for drilling. Remember, this K-wire will traverse a longer region of bone
prior to entering the progeny bone of the OCD lesion.
▶ The first K-wire should aim to enter the more central region of the OCD lesion. After drill-
ing is complete with this wire, this can act as a guide for secondary drilling. The use of a small
drill guide with multiple drill hole options can help with secondary drilling. Place the drill
guide over the K-wire that is in a near central location of the OCD lesion. This drill guide
can now rotate around this centrally placed wire to facilitate the placement of appropriately
spaced but nearly parallel drill holes (Figure 15-8).
Arthroscopic Approaches to Osteochondritis Dissecans 207
▶ To provide the patient with a less noticeable scar, a small incision about 5 to 8 mm can be
used. This incision is centered around the first pin, and subsequent K-wire passes can per-
formed through the incision. This single incision may cause less of a scar compared to multiple
K-wire marks through the skin.
▶ Perform a minimum of 4 to 8 wire passes per square centimeter (to ensure adequate disruption
of sclerotic bone margin of the OCD lesion). Additional wire passes may be advantageous
(because additional wire passes are theorized to not be disruptive to the health of the articular
cartilage) as described in published techniques.18,20
Avoid crossing the progeny bone into the hyaline articular cartilage. If the K-wire is advanced
slowly, you may see the vibration and movement of the cartilage above the progeny bone without
penetrating the articular cartilage and entering the joint.
Postoperative Protocol
All patients will be prescribed formal outpatient physical therapy, beginning within 1 week of
surgery, to include the following features:
▶ Weeks 0 to 6: Nonweightbearing with crutches
▶ After 6 weeks: Weightbearing as tolerated
▶ Continuous passive motion machines are not used routinely due to variation in insurance
coverage, family, and institutional resources.
208 Chapter 15
▶ Prescribed aquatic therapy is not used routinely due to insurance coverage limitations.
▶ During the nonweightbearing phase, patients will be allowed the following:
▷ Full range of motion of the affected knee
▷ Strength training will be allowed within the weightbearing guidelines, including isometric
thigh and leg activity
▷ Stationary bike with zero or minimal resistance
▶ Recreational swimming following confirmation of wound healing (minimum 2 weeks postop-
eratively) will be allowed, but breaststroke and whip kicks will not be permitted.
Potential Complications
Fortunately, acute surgical complications for retro- and transarticular drilling are rare. Most
studies have reported no or rare perioperative complications.12,17-19,21,23,25-31 Most of these
studies lacked significant follow-up beyond the phase of subchondral bone healing, and thus, the
long-term impact on joint health and articular cartilage is unknown. The main complication from
this surgery may be failure to obtain adequate healing. This may be more likely with larger lesions,
lesions in older patients, or lateral femoral condyle lesions. Counseling the patient and family
about the possibility of incomplete healing, as well as the need for future surgery, is important.
Pins may break off during drilling, and the techniques to avoid this, or to avoid shearing off
the pins in the joint, are described in the surgical technique.
Indications
When the lesion has some instability, the placement of arthroscopic fixation may be indicated.
If the instability is minimal and the cartilage surface is predominantly intact, arthroscopic screw
or pin fixation may be used for lesion stabilization, in combination with subchondral bone drilling.
Fixation options include metallic screws and/or bioabsorbable screws or pins.
Controversial Indications
▶ In cases of significant instability, such as trap door lesions or those with significant or
complete detachment (trap door lesion or completely detached fragment), more advanced
arthroscopic or mini open procedures may be necessary. These lesions are more common in
skeletally mature patients but can be seen in skeletally immature patients. In addition to drill-
ing and fixation, debridement of necrotic bone from the lesion/progeny bone and abnormal
subchondral bone may be necessary, along with supplemental autogenous bone grafting.
▶ In some cases, cartilage salvage of the progeny fragment may not be possible; in these cases,
a cartilage implantation technique may be necessary. These techniques are beyond the scope
of this chapter.
Pertinent Imaging
MRI is indicated for preoperative evaluation and planning for these patients. Signs of instabil-
ity on MRI have been described previously.
Equipment
▶ The equipment used for this procedure is similar to that described for subchondral bone drill-
ing. The choice of fixation devices will be at the discretion of the surgeon.
210 Chapter 15
A B
Figure 15-10. (A, B) Countersunk screws within the cartilage.
▷ In all cases, screw backout or prominence are concerns because this can cause damage to
the opposite cartilage surfaces. In some cases, second-look arthroscopy and early screw
removal may be necessary to avoid these types of complications. In all cases in which
screws are not fully recessed in the subchondral bone, the authors routinely remove these
about 4 to 6 weeks after placement.
▶ Bioabsorbable screw and pin options include the following.
▷ Pins: These can be placed with relative ease. The ability to obtain compression with these
devices is limited. In some cases, the portion of the pin within the articular cartilage may
not dissolve adequately. This lack of absorption can lead to problems with the following:
• Scoring of the articular cartilage on the opposite joint surface
• A portion of the pin becomes a free body in the joint, leading to some symptoms.
• In some cases, the pins may start to back out of the bone.
• In the authors’ experience, there is a tendency for the surgeon to leave the pins too proud
within the cartilage. These pins should be countersunk in the cartilage to avoid backout
and damage to other cartilage surfaces.
▷ Screws: The size of the bioabsorbable screw head may be larger than comparable shaft
diameter metallic screws. Although these may work well in lesions with adequate bone for
subchondral bone fixation, the size of the screw head may leave a larger cartilage entry
track than metallic screws. The heads of these screws may not adequately absorb and can
become free bodies within the joint. In lesions with inadequate subchondral bone sub-
stance, these screws may be limited in the ability to obtain adequate cartilage purchase or
may cut through the cartilage. These screws may also form expanding cysts around the
screws, during screw absorption.
▶ Cannulated screw options may be placed arthroscopically, but noncannulated options may
require a small arthrotomy in some cases. Titanium screw options also exist for recessed and
superficial fixation and may allow for better MRI evaluation postoperatively when compared
with stainless screw options (see Figure 15-9).
▶ If adequate subchondral lesion/progeny bone exists for fixation, a screw option with a low
profile, fully recessed device may be selected. This screw will be placed below the level of the
cartilage, with all fixations depending upon the surrounding bone of the lesion (see Figure
15-9). The depth of penetration can be verified in the following 2 ways.
▷ After the screw is placed, look down the screw hole through the layer of cartilage and bone.
The head of the screw should be fully recessed in the bone, not within the articular cartilage.
▷ The C-arm can be used, and multiple oblique angles may be necessary to ensure that the
screw head is completely recessed in the bone (Figure 15-11).
▶ If the subchondral bone is inadequate for recessed screw fixation in the bone, a device that
obtains fixation in the cartilage may be used. This includes bioabsorbable pins and some
screw options. Screw options with a very low profile screw head are probably ideal for this, to
avoid screw prominence and contact with the opposite joint surface, and loss of fixation if the
device descends too far into the cartilage substance. Screws that are not fully recessed into the
subchondral bone will need to be removed early.
Postoperative Protocol
During clinical follow-up visits, x-rays are used to confirm that the fixation is still in place and
not migrating or backing out. These films can be compared with the intraoperative C-arm images.
The rehabilitation protocol is similar to the protocol for subchondral bone drilling. In cases in
which surface fixation is used, the authors routinely perform a second-look arthroscopy and per-
form implant removal. The time for removal varies but typically occurs between 4 and 8 weeks.
In cases in which the screw heads are not fully recessed into the subchondral bone, the authors
limit impact activities until the hardware has been removed. Early full knee range of motion is
encouraged in most cases.
Arthroscopic Approaches to Osteochondritis Dissecans 213
Potential Complications
Routine complications described previously with subchondral bone drilling are applicable here.
Failure of fixation, which leads to pins and/or screws backing out, are of concern, and this needs
to be monitored closely by imaging and patient evaluation. Fracture of a portion of the bioabsorb-
able fixation devices can occur and lead to development of symptoms. In rare cases, reactions to
the biocomposite material can also produce synovitis and cystic lesions in the subchondral bone.
Conclusion
Treating young patients with OCD can be some of the most satisfying work, and OCD lesions
are also some of the most challenging cartilage conditions that are treated by sports/arthroscopy
surgeons. The prognosis for younger patients is overall good, but older patients are less likely to
heal with observation or minimally invasive procedures. Future multicenter research on this condi-
tion will be necessary to determine optimum treatment protocols.
Acknowledgments
The authors would like to thank Benton Heyworth, MD, and Jake Jacobs for their feedback
on this chapter.
214 Chapter 15
References
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4. Chambers HG, Shea KG, Anderson AF, et al. Diagnosis and treatment of osteochondritis dissecans.
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6. Linden B. Osteochondritis dissecans of the femoral condyles: a long-term follow-up study. J Bone Joint
Surg Am. 1977;59(6):769-776.
7. Sales de Gauzy J, Mansat C, Darodes PH, Cahuzac JP. Natural course of osteochondritis dissecans in
children. J Pediatr Orthop B. 1999;8(1):26-28.
8. Cahill BR, Phillips MR, Navarro R. The results of conservative management of juvenile osteochondritis
dissecans using joint scintigraphy: a prospective study. Am J Sports Med. 1989;17(5):601-606.
9. Cepero S, Ullot R, Sastre S. Osteochondritis of the femoral condyles in children and adolescents: our
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10. Pill SG, Ganley TJ, Milam RA, Lou JE, Meyer JS, Flynn JM. Role of magnetic resonance imaging and
clinical criteria in predicting successful nonoperative treatment of osteochondritis dissecans in chil-
dren. J Pediatr Orthop. 2003;23(1):102-108.
11. Hughston JC, Hergenroeder PT, Courtenay BG. Osteochondritis dissecans of the femoral condyles.
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the medial femoral condyle. Arthroscopy. 1994;10(3):286-291.
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Arthroscopic Approaches to Osteochondritis Dissecans 215
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tis dissecans of the knee. Skeletal Radiol. 2011;40(6):765-770.
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Am. 1979;10(3):671-683.
30. Lee CK, Mercurio C. Operative treatment of osteochondritis dissecans in situ by retrograde drilling and
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31. Louisia S, Beaufils P, Katabi M, Robert H; French Society of Arthroscopy. Transchondral drilling for
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2003;11(1):33-39.
Introduction
Articular cartilage injuries affect an estimated 900,000 individuals in the United States every
year and result in considerable morbidity and disability for affected individuals, with a substan-
tial associated burden on the health care system.1 It has been well established that injury to the
chondral surface does not readily repair itself. However, previous experience has shown that this
limited spontaneous repair capacity of articular cartilage can be overcome if there is access to the
mesenchymal stem cells (MSCs) in the subchondral bone marrow, which can be achieved with
different so-called marrow stimulation techniques. Penetration of the subchondral bone plate
leads to outflow of growth factors, cytokines, and bone marrow-derived MSCs from the subchon-
dral bone marrow, with formation of a pluripotent clot in the chondral defect that stimulates the
formation of fibrohyaline repair cartilage.
holes allow bone marrow contents, including MSCs, to flow out into the defect and form a super
clot that promotes development of fibrohyaline cartilage repair tissue.8-10 Experimental studies by
Chen et al11-13 reported that the use of the conical microfracture awls can lead to compaction of
the subchondral bone with subchondral fracture and osteocyte necrosis. Moreover, they found that
the microfracture may result in a sealing effect from the subchondral bone marrow. In contrast in
their rabbit model, they found that cooled drilling allowed better egress of marrow content than
microfracture and potential for improved repair cartilage tissue volume and quality. These find-
ings have stimulated a renaissance of subchondral drilling and have led to the development of a
modified drilling technique (Powerpick, Arthrex) that limits the risk of thermal necrosis and the
reported adverse subchondral bone effects of microfracture. Another approach to reducing the
reported deleterious effect of microfracture on the subchondral bone and to optimize bone mar-
row access has been described by Benthien and Behrens.14 This so-called nanofracture technique
(Arthrosurface) involves the use of a cannulated aiming device with a 1-mm diameter needle that
is penetrated 9 mm deep into the subchondral marrow. It has been proposed that this technique
generates a “smaller, deeper, better” solution with more hyaline character of the repair cartilage
compared to traditional microfracture technique. However, prospective studies have not yet dem-
onstrated the clinical superiority of modified drilling techniques and nanofracture compared to
the original awl microfracture technique.
Indications
Microfracture, MASS, drilling, or nanofracture are indicated for symptomatic, high-grade
(grade III to IV) chondral defects of the knee in active patients who are physiologically too young
for arthroplasty. This technique is most successfully used as a first-line treatment of isolated
lesions up to 4 cm 2 involving the femoral condyles, trochlea, and patella. Prerequisites for success-
ful microfracture include adequate range of motion (ROM), appropriate axial alignment or patel-
lar tracking, ligamentous stability, and the ability to comply with the postoperative rehabilitation.
Adjuvant procedures may be performed simultaneously to address coexisting pathology without
negative effects of the complex procedures on the postoperative functional outcome and activity
level. Detailed indications and contraindications for microfracture are as follows:
▶ Symptomatic cartilage lesions of the femur, patella, or tibia (including incidental defects)
▶ Defect size smaller than 4 cm 2
▶ Short preoperative duration of symptoms (optimally < 12 months)
▶ Patient age (optimally < 45 years)
Arthroscopic Marrow Stimulation 219
Contraindications
▶ Generalized degenerative joint changes
▶ Limited patient compliance
▶ Uncontained chondral lesions
▶ Severe axial malalignment greater than 5 degrees for femoral condyle lesions (surgical realign-
ment required)
▶ Patellar maltracking or instability for patellofemoral lesions
▶ High-grade ligamentous instability (surgical stabilization required for translation > 10 mm)
▶ Tumor
▶ Infection
▶ Inflammatory arthropathy
▶ Systemic cartilage disorder
Controversial Indications
▶ Preoperative duration of symptoms greater than 12 months
▶ Body mass index (BMI) greater than 30 kg/m 2
▶ Meniscal deficiency
▶ Moderate to advanced chondropenia
▶ Defect size greater than 4 cm 2
▶ Patient age older than 60 years
Patient History
Obtaining a thorough history in patients with knee cartilage defects is a critical first step in
selecting appropriate candidates for microfracture. Symptoms from cartilage defects are usually
nonspecific and can mimic other knee pathology, such as meniscal tears. Pain with weightbearing
is often present with impact activities. Catching and locking sensation can occur from cartilage
flaps of larger defects. Joint effusion is frequently reported, particularly after demanding impact
activities. Defects of the femoral condyles often produce focal tenderness over the condyle rather
than the joint line. Patellar or trochlear lesions usually lead to pain when ambulating stairs, driv-
ing a car, getting out of a chair, or in a squatting position. Symptoms of patellar instability may
be reported. Articular cartilage defects may present acutely (eg, joint trauma, such as knee liga-
ment tears) or chronically. Any history of previous knee surgeries should be noted because marrow
stimulation techniques are most effective as a first-line treatment.
Pertinent Imaging
Plain x-rays, including weightbearing anteroposterior, lateral, Rosenberg, long-leg, and
Merchant views, can help identify osteochondral lesions, joint space narrowing, patellar maltrack-
ing, or lower-extremity malalignment. Cartilage-sensitive magnetic resonance imaging (MRI)
presents a sensitive, specific, and accurate tool for noninvasive diagnosis of articular cartilage
injury.18 It provides useful information about meniscal and ligamentous status, subchondral bone,
lesion size, and depth. Due to the pathologic changes in the surrounding cartilage, the final size
of the defect usually is larger than the defect size measured on preoperative MRI.1
Equipment
▶ 30-degree arthroscope
▶ Graspers
▶ Small (3.5-mm) arthroscopic shaver
▶ Sharp ring curette
▶ Microfracture awls (30 to 90 degrees)
▶ Nanofracture guide (15 degrees)
▶ Nanofracture needles
▶ Powerpick system (30- or 45-degree tips with a top length of 4 mm [regular] and 6 mm
[Powerpick Extend; Arthrex])
cannot be used because sufficient pooling of the marrow clot cannot be achieved. The ROM in
which the lesion articulates with the opposing joint surface is carefully recorded. Knowledge of
this range of contact has important implications for postoperative rehabilitation.
Step 2
A curette is used to carefully remove the calcified cartilage layer from the base of the lesion
(Figure 16-2). The calcified cartilage layer is a thin layer between the deep zone of the cartilage
and subchondral bone and can increase in thickness with age. Removal of the calcified cartilage
has been shown to improve bonding of the repair tissue to the subchondral bone after microfrac-
ture. 20 The calcified cartilage can be difficult to differentiate visually but can be distinguished
more easily from the hard underlying subchondral bone plate by tactile feedback. Use of a
curette provides better manual feedback than use of an arthroscopic shaver and avoids exces-
sive debridement with thinning of the subchondral bone. Excessive removal of the subchondral
bone may stimulate subchondral bone overgrowth and should be avoided. This phenomenon
is observed in 25% to 49% of patients after microfracture and leads to relative thinning of the
overlying repair cartilage layer with resultant biologic and biomechanical implications for the
repair tissue quality.
222 Chapter 16
Step 3
Following appropriate removal of the calcified cartilage layer, subchondral bone penetrations
are created using commercially available microfracture awls, nanofracture needles (1-mm diam-
eter), or microdrills (1.5-mm diameter). The shape of the instruments is designed for controlled-
depth penetration of the instrument tip. Penetration of the subchondral bone is performed with
the instrument tip perpendicular to the subchondral bone plate. Perpendicular alignment ensures
appropriate depth of penetration into the subchondral bone marrow and avoids skiving of the
microfracture awl tip during impact with the mallet. Skiving of the microfracture awls can cre-
ate large longitudinal disruptions of the subchondral bone plate and may affect its biomechanical
integrity. Skiving can also be avoided by gently toeing in the tip of the instrument. The risk for
skiving is reduced significantly with the nanofracture and microdrilling techniques.
Microfracture awls are available with tip angulations of 30, 45, 60, and 90 degrees and
facilitate access to cartilage lesions in all areas of the knee joint. For femoral condyle or trochlear
lesions, the 30- or 45-degree awls readily provide perpendicular alignment of the instrumentation
(Figure 16-3). Knee motion can also help to optimize instrument positioning. The 90-degree awl
is frequently used for patellar defects. Perpendicular penetration of the 90-degree awl through
the patellar subchondral bone plate is facilitated by impacting the grip of the instrument rather
than its end. This technique in combination with manual stabilization and counterpressure on
the patella will help to prevent skiving of the instrument (Figure 16-4). Nanofracture guides
(Arthrosurface) are available at a 15-degree angle, and microdrills (Powerpick) are available with
30- and 45-degree tip angles allowing for depth of penetration from 4 to 6 mm. Nanofracture and
microdrilling allow for technically easier penetration of the subchondral bone plate.
Subchondral bone penetrations are created on the periphery of the defect first and are then
continued toward the center of the lesion using a systematic spiral pattern (Figure 16-5). This
systematic approach provides homogeneous distribution of the holes throughout the entire carti-
lage defect and maximizes adherence of the mesenchymal clot at the base (Figure 16-6). Three-
to 4-mm-wide bone bridges are carefully maintained between the individual holes to preserve
subchondral bone plate integrity and function. Release of fatty droplets from the subchondral
bone holes indicates adequate depth of the penetration. Once the entire defect has been treated,
any bony debris on the rim of the holes is removed by curettage or arthroscopic shaver. Adequate
release of blood and marrow fat droplets from the holes can also be confirmed by eliminating
arthroscopic pump pressure. Once adequate access to the subchondral bone marrow has been
ensured, the arthroscope is removed from the joint. No drains are used to avoid removal of the
pluripotent mesenchymal clot from the cartilage defect by suction or direct abrasion by the drain
Arthroscopic Marrow Stimulation 223
MASS
MASS techniques have the same indications/contraindications as microfracture-alone tech-
niques. Lesion preparation is identical as for microfracture techniques; care should be taken to
remove the calcified cartilage without disrupting the subchondral bone and create stable vertical
walls of the lesion. Each technique has nuances to the procedure, but each mainly includes lesion
preparation, microfracture/nanofracture, product mixture, and product delivery.
Following lesion preparation and microfracture, the AMIC technique (Geistlich) uses a slightly
undersized porcine collagen membrane (type I or III) that is formed by a template (aluminum). The
membrane is placed into the lesion and secured with a fibrin clot created from the patient’s own
blood after undergoing centrifuging or with commercially available fibrin glue.21
The BioCartilage technique provides a 1-step, off-the-shelf, MASS technology that can be used
with microfracture, nanofracture, or microdrilling (Powerpick). Following preparation of the defect,
the patient’s blood is drawn and prepared into autologous conditioned plasma by defined centrifu-
gation. The autologous conditioned plasma is then mixed with a micronized extracellular allograft
cartilage matrix containing type II collagen and proteoglycans to form a thick but fluid paste that is
then injected into the cartilage defect, filling the defect up to 1 mm below the level of the surrounding
native articular cartilage. Fibrin glue is then applied over the implanted BioCartilage paste to seal the
lesion flush with the surrounding cartilage and is allowed to cure for 5 to 10 minutes.22 The technique
is traditionally done with mini-arthrotomy but can also be performed arthroscopically (Figure 16-7).
The BST-CarGel technique is also designed to promote hyaline cartilage regeneration in conjunc-
tion with bone marrow stimulation technique for the repair of articular cartilage. BST-CarGel uses
an off-the-shelf, minimally invasive, 1-step procedure. BST-CarGel uses a scaffold augmentation
with chitosan, a natural glucosamine polysaccharide derived from the exoskeleton of crustaceans with
proven biocompatibility, biodegradability, and natural adhesiveness. Following the marrow stimula-
tion of the cartilage defect, BST-CarGel is mixed with whole blood drawn from the patient, and the
liquid gel is then applied into the defect, filling it flush with the surrounding cartilage. Depending
on the lesion location, patient positioning should be designed to allow for gravity to optimize lesion
fill with the gel. The mixture is allowed to set in the lesion for approximately 15 minutes.23
Specific Steps
1. Perform a complete arthroscopic joint survey to identify associated pathology and assess
joint cartilage status.
2. Debride the chondral defect to stable and healthy surrounding cartilage margins and
determine the final defect size.
3. Gently but thoroughly remove the calcified cartilage layer, avoiding bleeding from the
subchondral bone.
4. Start subchondral bone penetrations in the periphery of the defect with perpendicular
access of the instrument tip to the defect base.
5. Systematically penetrate the subchondral bone plate using a spiral pattern, leaving 3 to
4 mm between individual subchondral bone holes.
6. Ensure appropriate depth of the penetration to the subchondral bone marrow by visual-
ization of fat droplets or bleeding from the individual subchondral bone holes.
7. Close the portal incisions tightly and avoid drain placement.
Arthroscopic Marrow Stimulation 225
A B
C D
Postoperative Protocol
Appropriate rehabilitation following treatment of articular cartilage defects of the knee with
marrow stimulation helps MSC differentiation in the clot while avoiding detrimental compression
and shear forces on the developing repair cartilage tissue. Rehabilitation presents a critical compo-
nent for successful treatment outcome and follows different guidelines for femorotibial lesions and
patellofemoral defects (Table 16-1). Although general timelines can be useful, progression through
rehabilitation should be done individually based on the lesion characteristics, surgical details, and
patient symptoms. Concomitant procedures, such as ligament reconstruction, meniscal surgery, or
osteotomy, may alter the postoperative rehabilitation protocol.
226 Chapter 16
FEMORAL DEFECTS
▶ Touchdown weightbearing for 2 weeks then progress 25% per week
▶ Continuous passive motion 6 to 8 hours/day for 6 weeks
▶ Closed kinetic chain exercises (biking) without resistance at 2 weeks
▶ Start limited-arc open kinetic chain exercises at 6 to 8 weeks
▶ Initiate impact exercises (jogging) at 4 months if no pain/effusion
▶ Start plyometric drills at 5 months
▶ Return to cutting, jumping activities at 5 to 6 months
▶ Sport-specific skill program and functional progression at 6 months
▶ Gradual return to high-impact athletics by 6 to 8 months
PATELLAR/TROCHLEAR DEFECTS
▶ Weightbearing as tolerated for 8 weeks with brace locked at 0 to 20 degrees
▶ Continuous passive motion 6 hours/day for 6 to 8 weeks at 0 to 45 degrees
▶ Start closed kinetic chain exercises without resistance at 2 to 4 weeks
▶ Limited-arc range of motion exercises until 12 weeks
▶ Start open kinetic chain exercises after 12 to 16 weeks
▶ Initiate impact activities at 6 to 7 months
▶ Return to high-impact athletics at 8 to 12 months
*Individualized progression is recommended based on patient’s lesion characteristics and symptoms rather
than fixed timelines.
Potential Complications
▶ Insufficient debridement to a stable peripheral cartilage margin and failure to remove the
calcified cartilage layer can limit attachment of the repair tissue to the subchondral bone and
surrounding intact cartilage.
▶ Compromise of subchondral bone plate integrity from limited distance between subchondral
holes, skiving of instruments, or excessive calcified cartilage debridement
▶ Insufficient depth penetration of the subchondral bone and the low density of the penetra-
tions may reduce the quality and quantity of the repair cartilage tissue.
▶ Premature weightbearing can lead to clot displacement or limit attachment to the surrounding
cartilage or base.
▶ Aggressive removal of the calcified cartilage layer can promote subchondral bone overgrowth.
Arthroscopic Marrow Stimulation 227
Results
Over the past 2 decades, many studies have shown good short-term follow-up results after
microfracture.24-28 Several factors were identified that affected the clinical outcome after micro-
fracture and included age (better results with age older than < 40 years), lesion location, duration
of symptoms (< 12 months), lesion size (< 4 cm 2), preoperative activity level (Tegner score > 4),
BMI (< 30 kg/m 2), and competitive level for athletes (better return to sport in competitive ath-
letes).1,18,19,24,25,29 Microfracture effectively improved knee function in many studies during the
first 24 months postoperatively, but the reports on durability of the initial functional improvement
conflicted with several studies that reported decreases from the initial improvement and higher
failure rates after 2 years.18,19,30 Two studies in professional athletes document the decline in per-
formance in the short term.30,31 Eighty-three percent of National Basketball Association players
returned to sport, although they had fewer games played, points per game, and steals per game.32
Long-term follow-up has demonstrated that gradual functional decline can occur after the initial
functional improvement observed in the first 2 years after microfracture. Systematic review of
6 long and 9 short-term studies suggested functional results may be limited beyond 5 years after
microfracture. However, average functional improvement after microfracture remained higher
than preoperative levels even beyond 10 years after microfracture, and similar gradual functional
decrease has been observed for other cartilage repair techniques over time, demonstrating the
common need for further scientific and technical advances to optimize the outcome from articular
cartilage repair despite the promising results from first-generation technologies.8,10,18,19,27,29,31,33
New technologies, such as nanofracture and microdrilling, may help to overcome some of the
technical and outcome limitations associated with microfracture, but more scientific studies are
needed to systematically evaluate the clinical efficacy of these promising new techniques.
Most recently, the outcome of MASS techniques has been studied. The data are currently
limited to short-/medium-term data, and long-term studies need to be completed. Gille et al 34
showed a significant improvement in Lysholm and visual analog scale scores of 57 patients at
2 years undergoing AMIC. When compared to microfracture alone, AMIC shows no significant
improvement of clinical scores or MRI defect filling at 1 and 2 years.35 Although BST-CarGel
treatment compared to microfracture alone showed a significantly greater defect filling and more
hyaline cartilage-like T2 values, it did not show a greater clinical benefit.23
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necrosis during bone-marrow stimulation for cartilage repair. J Orthop Res. 2009;27(11):1432-1438.
13. Chen H, Chevrier A, Hoemann CD, Sun J, Ouyang W, Buschmann MD. Characterization of subchon-
dral bone repair for marrow-stimulated chondral defects and its relationship to articular cartilage
resurfacing. Am J Sports Med. 2011;39(8):1731-1740.
14. Benthien JP, Behrens P. Reviewing subchondral cartilage surgery: considerations for standardized and
outcome predictable cartilage remodeling. Int Orthop. 2013;37(11):2139-2145.
15. Gudas R, Gudaitė A, Pocius A, et al. Ten-year follow-up of a prospective, randomized clinical study of
mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochon-
dral defects in the knee joint of athletes. Am J Sports Med. 2012;40(11):2499-2508.
16. Knutsen G, Drogset JO, Engebertson L, et al. A randomized trial comparing autologous chondrocyte
implantation with microfracture. Findings at five years. J Bone Joint Surg Am. 2007;89(10):2105-2112.
17. Saris DB, Vanlauwe J, Victor J, et al. Treatment of symptomatic cartilage defects of the knee: character-
ized chondrocyte implantation results in better clinical outcome at 36 months in a randomized trial
compared to microfracture. Am J Sports Med. 2009;37(suppl 1):10S-19S.
18. Mithoefer K, Williams RJ III, Warren RF, et al. The microfracture technique for the treatment of articu-
lar cartilage lesions in the knee. A prospective cohort study. J Bone Joint Surg Am. 2005;87(9):1911-1920.
19. Mithoefer K, Williams RJ III, Warren RF, et al. High-impact athletics after knee articular cartilage
repair: a prospective evaluation of the microfracture technique. Am J Sports Med. 2006;34(9):1413-1418.
20. Frisbie DD, Morisset S, Rodkey WG, Steadman JR, McIlwraith CW. Effects of calcified cartilage on heal-
ing of chondral defects treated with microfracture in horses. Am J Sports Med. 2006;34(11):1824-1831.
21. Benthien JP, Behrens P. The treatment of chondral and osteochondral defects of the knee with autolo-
gous matrix-induced chondrogenesis (AMIC): method description and recent developments. Knee Surg
Sports Traumatol Arthrosc. 2011;19(8):1316-1319.
22. Abrams GD, Mall NA, Fortier LA, Roller BL, Cole BJ. BioCartilage: background and operative tech-
nique. Oper Tech Sports Med. 2013;21(2):116-124.
Arthroscopic Marrow Stimulation 229
23. Stanish WD, McCormack R, Forriol F, et al. Novel scaffold-based BST-CarGel treatment results in
superior cartilage repair compared with microfracture in a randomized controlled trial. J Bone Joint
Surg Am. 2013;95(18):1640-1650.
24. Kreuz PC, Erggelet C, Steinwachs MR, et al. Is microfracture of chondral defects in the knee associated
with different results in patients aged 40 years or younger? Arthroscopy. 2006;22(11):1180-1186.
25. Kreuz PC, Steinwachs MR, Erggelet C, et al. Results after microfracture of full-thickness chondral
defects in different compartments in the knee. Osteoarthritis Cartilage. 2006;14(11):1119-1125.
26. Miller BS, Steadman JR, Briggs KK, Rodrigo JJ, Rodkey WG. Patient satisfaction and outcome after
microfracture of the degenerative knee. J Knee Surg. 2004;17(1):13-17.
27. Miller BS, Briggs KK, Downie B, et al. Clinical outcomes following the microfracture procedure for
chondral defects in the knee: a longitudinal data analysis. Cartilage. 2010;1:108-112.
28. Salzmann GM, Sah B, Südkamp NP, Niemyer P. Clinical outcome following the first line, single lesion
microfracture at the knee joint. Arch Orthop Trauma Surg. 2013;133(3):303-310.
29. Blevins FT, Steadman JR, Rodrigo JJ, Silliman J. Treatment of articular cartilage defects in athletes: an
analysis of functional outcome and lesion appearance. Orthopedics. 1998;21(7):761-768.
30. Gobbi A, Nunag P, Malinowski K. Treatment of chondral lesions of the knee with microfracture in a
group of athletes. Knee Surg Sports Traumatol Arthrosc. 2005;13(3):213-221.
31. Gobbi A, Karnatzikos G, Kumar A. Long-term results after microfracture treatment for full-thickness
knee chondral lesions in athletes. Knee Surg Sports Traumatol Arthrosc. 2014;22(9):1986-1996.
32. Harris JD, Walton DM, Erickson, BJ, et al. Return to sport and performance after microfracture in the
knees of National Basketball Association players. Orthop J Sports Med. 2013;1(6):1-7.
33. Goyal D, Keyhani S, Lee EH, Hui JH. Evidence-based status of microfracture technique: a systematic
review of level I and II studies. Arthroscopy. 2013;29(9):1579-1588.
34. Gille J, Behrens P, Volpi P, et al. Outcome of autologous matrix induced chondrogenesis (AMIC) in
cartilage knee surgery: data of the AMIC Registry. Arch Orthop Trauma Surg. 2013;133(1):87-93.
35. Anders S, Volz M, Frick H, Gellissen J. A randomized, controlled trial comparing autologous matrix-
induced chondrogenesis (AMIC®) to microfracture: analysis of 1- and 2-year follow-up data of 2 centers.
Open Orthop J. 2013;7:133-143.
Introduction
Symptomatic focal advanced grade III/IV osteochondral defects in the knee present a unique
treatment dilemma for clinicians. It is well known that damaged cartilage lacks the ability to
heal with restorative type II hyaline tissue. Autogenous osteochondral transplantation (AOT) is a
viable treatment option in the properly selected patient. D’Aubigné first described AOT in 1945
as a pedunculated patellar graft. Campanacci used a similar procedure for patients with osteo-
articular defects from giant cell tumor resections.1 Later press-fit technology was pioneered by
Outerbridge and reported in 1995. This technique resulted in improved knee scores and demon-
strated well-fixed integrated grafts on second-look arthroscopy.2 In an effort to eliminate the need
for an invasive arthrotomy, all-arthroscopic techniques have been described, with optimal results.
The main advantage of AOT over other articular cartilage biological resurfacing methodolo-
gies (ie microfracture) is the predictable restoration of viable hyaline cartilage and bone-to-bone
autogenous graft healing. A histologic analysis of 7 patients after AOT showed viability of hya-
line cartilage structure and healing of subchondral bone at 2 to 12 months.3 This restoration is
thought to be the key to the success of AOT procedures. Gudas et al4,5 published a randomized
trial of 60 young athletes demonstrating the success of AOT over microfracture. They reported
higher return to sport and higher knee scores at 3- to 10-year follow-up. More recently, Krych et
al6 reported higher activity levels following AOT compared to microfracture procedures. Marcacci
reported7 76.7% good or excellent results at 7-year follow-up with an all-arthroscopic approach in
a prospective study of 30 patients. Barber et al8 reported an improvement of Lysholm score from
44 preoperatively to 84 at 2-year follow-up.
The term mosaicplasty, originally described by Hangody et al,9 refers to the use of smaller,
3- to 5-mm-diameter autologous grafts. This allows for less potential donor site morbidity and
more available graft tissue in the native knee. It is possible to fill one large defect with several
small plugs to restore the native contour of the condyle.9 The advantage of using multiple smaller
grafts is greater potential to restore complex surface topography of certain lesions. The disadvan-
tages include less potential hyaline and more intergraft clefting. Treatment results confirming
the advantages of smaller grafts have been reported by Filardo et al,10 who found a significant
number of patients complaining of pain attributed to donor site morbidity in a study of 31 patients
after femoral condyle AOT. In a large multicenter trial including 383 patients with 2- to 17-year
follow-ups, Hangody et al11 demonstrated 91% good to excellent results with femoral AOT and
74% good to excellent results with patellofemoral AOT. More recently, in a prospective study of
33 patients, Astur et al12 reported significant improvement of knee scores and osseous integration
on magnetic resonance imaging (MRI) after patellofemoral AOT.
Advantages13
▶ Arthroscopic outpatient procedure/minimally invasive techniques
▶ Single point of service index cost-effective procedure
▶ Hyaline cartilage and subchondral bone full tissue restoration
▶ Long-term outcome data results at 7 to 10 years demonstrate success
Disadvantages13
▶ Donor site morbidity
▶ Limited donor site availability
▶ Technically challenging procedure
▶ Areas of intergraft fibrocartilage due to incongruent geometric configuration of grafts
Indications
▶ Symptomatic and active patient with focal osteochondral pathology
▶ Focal articular cartilage lesions on the medial or lateral femoral condyles, patella, and central
trochlea
▶ Defect size of 10 to 25 mm in diameter or 15 to 250 mm 2 in area
▶ Patient age younger than 50 years
▶ Rehabilitation compliant
▶ Ligamentous stability
▶ Lack of significant degenerative changes
▶ Lack of significant varus/valgus deformity
▶ Lack of significant patellofemoral joint deformity
▶ Lack of rheumatoid disease or crystal arthropathy
Controversial Indications
▶ Lesions smaller than 10 mm
▶ Lesions larger than 400 mm 2
▶ History of patellofemoral pain syndrome
Autogenous Osteochondral Transplantation 233
Pertinent Imaging
▶ Anteroposterior and 45-degree posteroanterior standing x-rays, including lateral, notch, and
sunrise/Merchant views
▶ Full-length hip-to-ankle standing x-rays to calculate the lower-extremity mechanical axis
▶ High-resolution MRI improves the accuracy of assessment of the cartilaginous defect, includ-
ing width, length, and depth and which can also be used to measure tibial tuberosity to
trochlear groove distance
▶ Computed tomography arthrogram if MRI is contraindicated (can also measure tibial tuber-
osity to trochlear groove distance)
Equipment
▶ Standard arthroscopy equipment
▷ Fluid pump
▷ Radiofrequency ablation tool
▷ Oscillating shaver
▷ Calibrated defect measuring probe/ruler
▶ Sharp ring curettes
▶ Proprietary disposable harvesting/trephine system, including the following:
▷ Donor site harvester trephine/tubed cutter device
234 Chapter 17
▷ Defect recipient site preparation harvester trephine/tubed cutter device (with 1-mm offset
smaller diameter than donor harvester to ensure press-fit)
▷ Calibrated alignment rod
▷ Insertion tamp
Figure 17-2. Proprietary knee positioner that uses Velcro to maintain the knee flexion angle
to ensure perpendicular harvesting and grafting.
Harvest Technique
Debridement of the fat pad is helpful and necessary for appropriate visualization. Standard
medial and lateral peripatellar tendon portals are made. It is important to position the portals close
to and adjacent to the patellar tendon.
Once the area of harvest has been selected, it is useful to create a satellite portal such that the
donor harvester device can be applied perpendicular to the chondral surface (Figure 17-5). These
portals should be vertically oriented and extensile. Extending the portal sites for harvesting can
facilitate harvesting an osteochondral graft with a perpendicular cartilage surface (Figure 17-6).
An extended portal incision may require closure to maintain fluid pressure in the knee for the
remaining steps of the procedure. If necessary, a transpatellar tendon portal can be used for har-
vesting trochlear cartilage. The standard graft plug diameter used is typically 4 to 10 mm.17 The
donor site harvester is placed against the surface of the cartilage and is gently impacted with a
mallet to a depth of 13 to 15 mm.13 Once the donor harvester is inserted to the appropriate depth,
rotation is performed to cut and disengage the graft from the subchondral bone. Special care must
be taken to avoid levering and/or toggling of the harvester devices as this will decrease the stability
of the press-fit.18
The same portal can be used for adjacent harvesting if acceptable perpendicularity is achieved.
Separation of each harvest site by 2 mm of bone is important, as is care taken to address the
underlying curvature of the harvest site to avoid convergence of the graft harvest site base, which
Autogenous Osteochondral Transplantation 237
can result in iatrogenic fracture (Figure 17-7). Small adjustments in the flexion of the knee can aid
in this. Once removed, the donor graft plug must be inspected for its integrity, size, and chondral
cap thickness.
Graft Insertion
Graft position is critical to the success of plug implantation. The cartilaginous surface of the
graft must be flush with the surrounding native cartilage. A height mismatch can cause early
failure of the graft. Countersunk grafts lead to cartilage thickening, fibrous overgrowth, or even
cartilage necrosis. Proud grafts also lead to failure via surface shear and toggling, which can result
in graft fissuring and underlying clefting. Combination of small and large graft plugs can lead
Autogenous Osteochondral Transplantation 239
to near 100% defect coverage with congruent a surface.9,19,20 The graft should be gently manu-
ally impacted (Figure 17-8). Use of a mallet can result in graft chondrocyte injury or fissuring
of the plug.13 Once all plugs have been placed, carefully assess the congruency of the surface
(Figure 17-9). Proud plugs will be subject to compression fissuring and potential breakdown with
weightbearing, and incongruent plugs significantly alter the biomechanics of the cartilaginous
surface.19,21
Postoperative Protocol
Limiting weightbearing until bone-to-bone graft healing occurs is important to avoid graft
subsidence. Early ROM to avoid stiffness is important.9 Protocols typically commence with
immediate motion and nonweightbearing limitations for 1 to 3 weeks. Progressive weightbearing
begins at 2 to 6 weeks and full weightbearing at 6 weeks. Patients are typically withheld from
sports for 3 to 6 months.9,13
Potential Complications
Chondrocyte viability in graft plugs is a concern for AOT procedures. Huntley et al 22 dem-
onstrated chondrocyte death in human tissue from arthroplasty resections at the periphery or the
graft plugs that had been harvested with standard techniques. The zone of death of chondrocytes
they describe suggests that the border of the plugs will heal to fibrocartilage rather than a hya-
line structure, although this has not been shown in vivo. The plugs can fracture during harvest,
decreasing the number of available plugs. The necessity for perpendicular articular surface leads
to converging plug bases. This can alter the depth of the plug.
240 Chapter 17
Immediate perioperative complications can include painful hemarthrosis, infection, and venous
thromboembolism. Complications that may require a revision procedure include harvest site frac-
ture, arthrofibrosis, patellofemoral pain, clefting, cavitation, and subchondral cyst formation.6
Clinical outcomes include subjective, objective, functional, radiologic, and histologic parameters.
Tetta et al 23 described MRI evaluation of postoperative AOT patients. They reported that clinical
results are correlated to postoperative imaging.23
References
1. Chen E, Sgaglione NA. Osteochondral autograft plug transfer. In: Scott WN, ed. Insall & Scott Surgery
of the Knee. 5th ed. Philadelphia, PA: Churchill Livingstone; 2012:178-194.
2. Outerbridge HK, Outerbridge AR, Outerbridge RE. The use of a lateral patellar autologous graft for the
repair of a large osteochondral defect in the knee. J Bone Joint Surg Am. 1995;77(1):65-72.
3. Barber FA, Chow JC. Arthroscopic osteochondral transplantation: histologic results. Arthroscopy.
2001;17(8):832-835.
4. Gudas R, Gudaitė A, Pocius A, et al. Ten-year follow-up of a prospective, randomized clinical study of
mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochon-
dral defects in the knee joint of athletes. Am J Sports Med. 2012;40(11):2499-2508.
5. Gudas R, Gudaitė A, Mickevičius T, et al. Comparison of osteochondral autologous transplantation,
microfracture, or debridement techniques in articular cartilage lesions associated with anterior cruciate
ligament injury: a prospective study with a 3-year follow-up. Arthroscopy. 2013;29(1):89-97.
6. Krych AJ, Harnly HW, Rodeo SA, Williams RJ III. Activity levels are higher after osteochondral auto-
graft transfer mosaicplasty than after microfracture for articular cartilage defects of the knee: a retro-
spective comparative study. J Bone Joint Surg Am. 2012;94(11):971-978.
7. Marcacci M, Kon E, Delcogliano M, Filardo G, Busacca M, Zaffagnini S. Arthroscopic autologous
osteochondral grafting for cartilage defects of the knee: prospective study results at a minimum 7-year
follow-up. Am J Sports Med. 2007;35(12):2014-2021.
8. Barber FA, Chow JC. Arthroscopic chondral osseous autograft transplantation (COR procedure) for
femoral defects. Arthroscopy. 2006;22(1):10-16.
9. Hangody L, Vásárhelyi G, Hangody LR, et al. Autologous osteochondral grafting—technique and long-
term results. Injury. 2008;39(suppl 1):S32-S39.
10. Filardo G, Kon E, Perdisa F, Balboni F, Marcacci M. Autologous osteochondral transplanta-
tion for the treatment of knee lesions: results and limitations at two years’ follow-up. Int Orthop.
2014;38(9):1905-1912.
11. Hangody L, Dobos J, Baló E, Pánics G, Hangody LR, Berkes I. Clinical experiences with autologous
osteochondral mosaicplasty in an athletic population: a 17-year prospective multicenter study. Am J
Sports Med. 2010;38(6):1125-1133.
12. Astur DC, Arliani GG, Binz M, et al. Autologous osteochondral transplantation for treating patellar
chondral injuries: evaluation, treatment, and outcomes of a two-year follow-up study. J Bone Joint Surg
Am. 2014;96(10):816-823.
13. Sgaglione NA, Chen E, Bert JM, Amendola A, Bugbee WD. Current strategies for nonsurgical,
arthroscopic, and minimally invasive surgical treatment of knee cartilage pathology. Instr Course Lect.
2010;59:157-180.
14. Ahmad CS, Cohen ZA, Levine WN, Ateshian GA, Mow VC. Biomechanical and topographic consider-
ations for autologous osteochondral grafting in the knee. Am J Sports Med. 2001;29(2):201-206.
15. Garretson RB III, Katolik LI, Verma N, Beck PR, Bach BR, Cole BJ. Contact pressure at osteochondral
donor sites in the patellofemoral joint. Am J Sports Med. 2004;32(4):967-974.
16. Bartz RL, Kamaric E, Noble PC, Lintner D, Bocell J. Topographic matching of selected donor and recipi-
ent sites for osteochondral autografting of the articular surface of the femoral condyles. Am J Sports
Med. 2001;29(2):207-212.
17. Keeling JJ, Gwinn DE, McGuigan FX. A comparison of open versus arthroscopic harvesting of osteo-
chondral autografts. Knee. 2009;16(6):458-462.
18. Duchow J, Hess T, Kohn D. Primary stability of press-fit-implanted osteochondral grafts. Influence of
graft size, repeated insertion, and harvesting technique. Am J Sports Med. 2000;28(1):24-27.
19. Pearce SG, Hurtig MB, Clarnette R, Kalra M, Cowan B, Miniaci A. An investigation of 2 techniques for
optimizing joint surface congruency using multiple cylindrical osteochondral autografts. Arthroscopy.
2001;17(1):50-55.
20. Huang FS, Simonian PT, Norman AG, Clark JM. Effects of small incongruities in a sheep model of
osteochondral autografting. Am J Sports Med. 2004;32(8):1842-1848.
21. Koh JL, Wirsing K, Lautenschlager E, Zhang LO. The effect of graft height mismatch on contact pres-
sure following osteochondral grafting: a biomechanical study. Am J Sports Med. 2004;32(2):317-320.
242 Chapter 17
22. Huntley JS, Bush PG, McBirnie JM, Simpson AH, Hall AC. Chondrocyte death associated with human
femoral osteochondral harvest as performed for mosaicplasty. J Bone Joint Surg Am. 2005;87(2):351-360.
23. Tetta C, Busacca M, Moio A, et al. Knee osteochondral autologous transplantation: long-term MR find-
ings and clinical correlations. Eur J Radiol. 2010;76(1):117-123.
Introduction
Patients with symptomatic chondral and osteochondral defects of the knee are commonly
encountered in orthopedic practice. Left untreated, cartilage lesions may contribute to chronic
joint irritation and inflammation resulting in early progression of osteoarthritis.1 This increasingly
common clinical problem has led surgeons and scientists to pursue and refine biologic solutions
for joint restoration.2 Fresh osteochondral allograft (OCA) transplantation is a technique that has
been successfully used for primary treatment of a wide spectrum of articular injuries and joint
diseases as well as for the salvage of failed cartilage repair. For the surgeon, use of fresh OCA pro-
vides an opportunity to achieve durable biological joint restoration. For the patient, this procedure
provides predictable symptomatic relief and lasting functional improvement with the possibility of
delaying or eliminating the need for arthroplasty.3
Indications
▶ Diagnosis
▷ In general, conditions of the knee indicated for treatment with fresh OCA include large
chondral and osteochondral lesions secondary to the following:
• Osteochondritis dissecans (Figure 18-1)
• Focal avascular necrosis
• Other conditions involving cartilage disease or absence of subchondral bone (ie, frac-
ture malunion)
• Failed cartilage repair procedures (ie, microfracture, osteochondral autologous transfer,
autologous chondrocyte implantation)
• Degenerative knee conditions (select cases) in which arthroplasty is relatively
contraindicated4
Sgaglione NA, Lubowitz JH, Provencher MT, eds. The Knee:
- 243 - AANA Advanced Arthroscopic Surgical Techniques (pp 243-255).
© 2016 AANA.
244 Chapter 18
Relative Contraindications
▶ Age
▷ No absolute age limitations
▷ Inferior outcomes have been reported in older patients (ie, age > 40 years)6
Osteochondral Allograft Transplantation 245
▶ Comorbid conditions
▷ Uncorrected joint malalignment and/or ligamentous instability
▷ Meniscal insufficiency
▷ Inflammatory arthropathy
▷ Diffuse degenerative arthrosis
▷ Morbid obesity, body mass index (BMI) > 30 kg/m 2
Pertinent Imaging
▶ X-rays
▷ Standing anteroposterior view with the knee in full extension (weightbearing) to assess
anterior joint space narrowing and to allow tissue banks to size-match allografts
• Use a marker to correct for magnification8
◊ Femoral lesions: Width of the affected condyle is measured, with an acceptable
match considered as allograft condyle within ± 2 mm9
◊ Tibial lesions: Width of the affected tibial plateau is measured from the medial to
lateral cortex just distal to the articular surface.
246 Chapter 18
▷ Standing posteroanterior view with the knee flexed 45 degrees (weightbearing) to assess
posterior joint space narrowing
▷ Lateral view to assess patellofemoral relationship (ie, alta or baja)
▷ Patellar view to assess the presence of trochlear or patellar dysplasia, patellar tilt, and/or
maltracking
▷ Standing bilateral long-leg alignment view to measure the mechanical axis through the
knee
▶ Magnetic resonance imaging (MRI)
▷ To assess cartilage integrity and bone quality of/adjacent to articular lesion as well as con-
comitant ligamentous and/or meniscal pathology
▷ The true size of the articular lesion may be underestimated.10
▶ Conventional computed tomography (CT)
▷ To quantify the extent of bone involvement, bone quality, and/or evaluate patellofemoral
relationship (ie, tibial tubercle to trochlear groove distance)
▶ Single-photon emission CT
▷ A hybrid imaging technique that combines bone scintigraphy with high-resolution CT
images is useful in patients for whom MRI is contraindicated and/or when image quality
is impaired by retained metallic implants.11
▶ Arthroscopic images
▷ Photographic images recorded during previous surgical procedures provide insight into
defect dimensions, degree of containment, and associated pathology.
▷ They may obviate the need for another diagnostic knee arthroscopy.
Equipment
The equipment required depends on the surface to be grafted and the surgical technique used.
For most contained defects of the femoral condyles, a press-fit technique can be performed using
commercially available systems (Arthrex) that simplifies site preparation, donor harvesting, and
graft insertion (Figure 18-2).12 However, if the size or location of the lesion does not permit use of
a dowel-type press-fit system, the surgeon should be prepared to perform the shell graft technique.
Because shell grafts require measured resection and sculpting of bone and cartilage, additional
surgical equipment on hand should include calipers, depth-gauge, high-speed burr, reciprocating
and oscillating saws, bone files, and/or rasps. In addition, use of fluoroscopy is critical for the
treatment of certain large knee defects (ie, tibial plateau) and may enhance accuracy when treating
other anatomic locations as well. For either technique, the allograft is opened and inspected prior
to surgical incision to ensure it is acceptable for implantation. Although most grafts can be press-
fit without fixation, multiple options for graft fixation should be available, including bioabsorbable
pins and/or low-profile interfragmentary screws 3 mm in diameter or less.
Figure 18-2. Typical instruments used to prepare and insert a plug-type allograft.
Figure 18-3. Stable limb positioning that allows for various degrees of knee flexion facilitates exposure
of the lesion.
248 Chapter 18
osteotomy is planned, it may be advantageous to have access to the ipsilateral anterior superior
iliac spine as a source of autograft bone and as a reference to evaluate alignment. A diagnostic
arthroscopy may be performed before the OCA transplantation to confirm lesion size and/or to
treat coexisting pathology.
Surgical Exposure
A standard midline incision is made. Depending on lesion location, a medial or lateral arthrot-
omy may be used. Once the joint capsule has been incised and the retractors have been placed,
the knee is brought into the degree of flexion that presents the lesion into the arthrotomy site. In
some cases, when the lesion is posterior, detachment and reflection of the meniscus may aid expo-
sure. Angled retractors are placed medially and laterally to expose the condyle. A carefully placed
retractor into the notch is useful to aid in patellar retraction (Figure 18-4). Extension of the deep
incision proximally and distally aids in patellar mobilization.
Figure 18-4. Exposure of the lesion with small arthrotomy and retractor placement. This patient has a
failed microfracture of the medial femoral condyle.
is too narrow to harvest a 30-mm diameter graft). Recipient site preparation begins with place-
ment of a guide wire through the cylindrical sizing guide into the center of the lesion, perpendicu-
lar to the articular surface. The cartilage surface is scored, and a cannulated counter bore reamer
is used to remove the articular cartilage and 3 to 4 mm of subchondral bone. In deeper lesions,
the pathologic bone is removed until there is healthy, bleeding bone. Generally, for treatment of
chondral defects, depth does not exceed 6 to 8 mm (Figure 18-5). For treatment of osteochondral
lesions, depth may reach up to 10 mm. The authors rarely find it necessary or appropriate to ream
more than 8 mm total depth. The reamings are collected and may be used to graft osseous defects
(cysts) or to optimize the position of the graft. At this point, the guide pin can be removed. If
necessary, multiple perforations can be made in the base of the defect using a K-wire to promote
vascular inflow. A skin marker is used to mark the 12 o’clock position for reference, and depth
measurements are made and recorded in the 4 quadrants of the recipient site. A ruler or depth
gauge is used to measure and record the socket depth at the 3, 6, 9, and 12 o’clock positions. The
recipient socket is now complete and ready for the press-fit OCA.
The corresponding anatomic location of the recipient site is identified on the donor allograft.
The allograft is then secured to the allograft workstation platform or held with clamps and posi-
tioned such that the appropriate diameter bushing may be positioned perpendicular to the articu-
lar surface, matching the orientation used to create the recipient site. The cylindrical sizing tube
is used to confirm that the selected angle will match the contour of the defect, and the 12 o’clock
position is marked with a surgical marker. The appropriate size-coring reamer is passed through
the bushing and advanced through the entire depth. Once harvested from the donor condyle, the
graft is removed as a long cylindrical plug. An oscillating saw can be used to release the graft from
the donor condyle. The depths for the 4 quadrants of the recipient site are transferred to the graft,
and the allograft plug thickness is customized using a microsagittal saw to trim excess bone to the
thickness matching the recipient site. Just before insertion, it is beneficial to bevel the edges of
the osseous portion with a small rongeur or rasp to facilitate the initial press-fit into the recipient
socket. The donor graft should be irrigated copiously with a pulsatile lavage to remove blood and
marrow cells to decrease the risk of a host immune response.16 The donor graft is positioned by
250 Chapter 18
Figure 18-5. Preparation of the defect site is complete. Note the relatively shallow depth of the site.
aligning the markings and is pressed into place by hand. The authors prefer to use passive knee
ROM to initially seat the graft, and then gentle tamping can be performed to fully seat the graft,
but excessive impact loading with a mallet during allograft insertion may damage the extracellular
matrix and/or result in chondrocyte death. If the graft does not fit, dilating the recipient site with
a slightly oversized tamp or reinserting the guide wire and reaming deeper may be considered
or the graft can be further trimmed or beveled. The final resting position of the graft should be
flush relative to the surrounding articular surface, although the authors accept stepoffs of less
than 1 mm (Figure 18-6).17 If the graft is unstable or has an exposed edge, absorbable pins or
biocompression screws are used. For large femoral defects, more than 1 press-fit OCA plug may be
required. The “snowman technique” facilitates coverage of a greater condylar area using a second
press-fit plug (Figure 18-7). In this technique, the first graft is secured with a small K-wire or, if
necessary, definitively fixed with biocompression screws to prevent dislodgement during prepara-
tion of the second overlapping site. Care is taken to minimize space between multiple grafts as this
may lead to formation of biomechanically inferior fibrocartilage and/or lack of articular congruity
(ie, cobble stoning) which may alter biomechanics and negatively affect clinical outcome.
Shell Technique
For uncontained or asymmetric lesions or for lesions in locations that are difficult to access
on the femur, a free-hand technique is required to match donor tissue to the recipient defect. A
skin marker is used to outline the shape of the defect, and a 15-blade scalpel is used to incise the
remaining cartilage, which is then removed using sharp curettes. A high-speed burr is then used
to remove the underlying pathologic bone to expose healthy bleeding bone. Creation of a simple
recipient site geometry (ie, rectangle or trapezoid) simplifies subsequent freehand sizing of the
OCA. After the recipient site is prepared, the donor graft is roughly fashioned with a microsagit-
tal saw. It is best to make the initial cuts slightly wider than measured to oversize the donor graft.
A series of trial fittings and repeated measurement guide sculpting of the donor tissue to achieve
a precise fit.
Osteochondral Allograft Transplantation 251
Figure 18-6. The graft has been inserted in appropriate orientation, and a flush press-fit has been
obtained.
Figure 18-7. In this patient, 2 overlapping grafts have been used in the “snowman” configuration.
252 Chapter 18
For the patella, although smaller lesions may be successfully managed with press-fit circular
grafts, larger lesions are managed with a technique similar to that used in total knee arthro-
plasty. Patellar thickness is measured with calipers and resection of the articular surface is
performed, maintaining at least 12 mm of residual bone. The donor graft is then resected in a
similar fashion. The allograft is then lavaged and seated in the appropriate position. The graft
is then secured with interfragmentary screw fixation from the anterior surface of the patella
into the subchondral bone beneath the median ridge of the graft. Afterward, an assessment
of patellar tracking will determine the need for any additional soft tissue or bony realignment
procedures.
Large post-traumatic tibial plateau lesions are managed with a technique similar to that
used in unicompartmental knee arthroplasty. Under f luoroscopic guidance, en bloc resection
of the meniscotibial unit with an “L-cut” is performed. Two freehand cuts are made to resect
a minimal amount of subchondral bone. K-wires or arthroplasty jigs may be used to assist the
surgeon with these cuts. Measurements of the length and width of the resected surface and the
joint space gap allow estimation of the required allograft dimensions. Next, the donor graft is
secured in the graft holder, and the desired dimensions are marked. Ideally, tibial plateau grafts
are 8 to 12 mm thick, which is typical for restoring plateau height after fracture malunion. A
reciprocating saw is used to make the vertical cut, and an oscillating saw is used to make the
horizontal cut referencing off the marks placed on the graft margins. Once sculpted to the
optimal size and shape, the graft is lavaged and carefully inserted in the anatomic position
adjacent to the femoral condyle. The knee is taken through a ROM, and the graft is inspected
visually and under f luoroscopy to assess graft position and restoration of the joint line and tibial
slope. Revisions are made as necessary to optimize graft fit and position as well as overall joint
alignment and mechanics. The graft is then fixed with 2 interfragmentary screws placed from
the submeniscal articular margin at the midcoronal and anterior positions. After fixation of the
bone, the meniscus is repaired in the standard fashion.
Postoperative Protocol
Phase I: 0 to 4 Weeks
In the first phase of rehabilitation, patient goals are to control pain and swelling, restore
muscle control, improve knee ROM, and protect the allograft. Patients are allowed unre-
stricted early nonweightbearing motion unless a concurrent procedure dictates otherwise.
Weightbearing status varies based on lesion location, but the general goal is to avoid placing
stress on the transplanted area. Patients with tibial or femoral grafts are restricted to toe-touch
weightbearing for 6 weeks. Patients with patellofemoral grafts are permitted weightbearing
as tolerated in extension but are limited to between 30 and 45 degrees of active f lexion. In
addition to passive- and active-assisted knee ROM, exercises include stretching and isometric
strengthening of the quadriceps, hamstrings, and gluteus muscles. Although knee braces are not
required, they may be useful for patients with patellofemoral grafts by limiting knee f lexion to
less than 45 degrees.18 For patients with bipolar knee lesions, an unloader brace may be useful
as they progress to full weightbearing.
Osteochondral Allograft Transplantation 253
Potential Complications
Early Complications
Use of a limited arthrotomy and emphasis on early motion is advised to avoid arthrofibrosis.
Superficial and deep surgical site infections may occur and must be distinguished based on labora-
tory markers, physical examination, and joint aspiration. The risk of surgical site infection is low as
long as the graft is processed and handled properly and graft lavage and appropriate perioperative
antibiotics are used. Allograft-related complications, such as disease transmission, infection, and
immunogenic reaction, are rare but may arise.20-23 Occasionally, patients may develop recurrent
sterile effusions related to overuse or an immune-mediated synovitis. These symptoms typically
resolve with symptomatic management (ie, aspiration, rest, ice, compression) without requiring
graft removal. Graft failure with fragmentation and collapse may occur. Delayed or nonunion
of the allograft is extremely rare but may occur with use of larger allografts or in patients with
compromised subchondral bone.24
Late Complications
Late graft failure may be characterized by fracture of the graft, incomplete remodeling of the
graft-bone interface, and/or resorption of allograft tissue. Graft fragmentation and collapse may
result from incomplete healing with host bone due to limited revascularization.25 Progression of
the underlying disease process (ie, additional chondral lesions, osteoarthritis, avascular necrosis)
may result in recurrent or persistent symptoms independent of graft status.
254 Chapter 18
References
1. Heir S, Nerhus TK, Røtterud JH, et al. Focal cartilage defects in the knee impair quality of life as much
as severe osteoarthritis: a comparison of knee injury and osteoarthritis outcome score in 4 patient cat-
egories scheduled for knee surgery. Am J Sports Med. 2010;38(2):231-237.
2. Moran CJ, Pascual-Garrido C, Chubinskaya S, et al. Restoration of articular cartilage. J Bone Joint Surg
Am. 2014;96(4):336-344.
3. Raz G, Safir OA, Backstein DJ, Lee PT, Gross AE. Distal femoral fresh osteochondral allografts: follow-
up at a mean of twenty-two years. J Bone Joint Surg Am. 2014;96(13):1101-1107.
4. Yu J, Bugbee WD. Osteochondral allograft transplantation. In: Williams RJ III, ed. Cartilage Repair
Strategies. Totowa, NJ: Humana Press Inc; 2007:167-191.
5. Horton MT, Pulido PA, McCauley JC, Bugbee WD. Revision osteochondral allograft transplantations:
do they work? Am J Sports Med. 2013;41(11):2507-2511.
6. Behery O, Siston RA, Harris JD, Flanigan DC. Treatment of cartilage defects of the knee: expanding on
the existing algorithm. Clin J Sport Med. 2014;24(1):21-30.
7. Sharma L, Dunlop DD, Cahue S, Song J, Hayes KW. Quadriceps strength and osteoarthritis progression
in malaligned and lax knees. Ann Intern Med. 2003;138(8):613-619.
8. Highgenboten CL, Jackson A, Aschliman M, Meske NB. The estimation of femoral condyle size. An
important component in osteochondral allografts. Clin Orthop Relat Res. 1989;(246):225-233.
9. Latterman C, Romine SE. Osteochondral allografts: state of the art. Clin Sports Med. 2009;28(2):281-301.
10. Campbell AB, Knopp MV, Kolovich GP, et al. Preoperative MRI underestimates articular cartilage
defect size compared with findings at arthroscopic knee surgery. Am J Sports Med. 2013;41(3):590-595.
11. Mucha A, Dordevic M, Hirschmann A, et al. Effect of high tibial osteotomy on joint loading in symp-
tomatic patients with varus aligned knees: a study using SPECT/CT [published online ahead of print
May 11, 2014]. Knee Surg Sports Traumatol Arthrosc.
12. Arthrex. Allograft OATS (Osteochondral Autograft Transfer System) Surgical Technique. Available at:
http://jrfortho.org/images/prod-files/Allograft_OATS%C2%AE_(Osteochondral_Autograft_Transfer_
System).pdf. Accessed on July 30, 2015.
13. Minzlaff P, Feucht MJ, Saier T, et al. Osteochondral autologous transfer combined with valgus high
tibial osteotomy: long-term results and survivorship analysis. Am J Sports Med. 2013;41(10):2325-2332.
Osteochondral Allograft Transplantation 255
14. Pascual-Garrido C, Slabaugh MA, L’Heureux DR, Friel NA, Cole BJ. Recommendations and treatment
outcomes for patellofemoral articular cartilage defects with autologous chondrocyte implantation: pro-
spective evaluation at average 4-year follow-up. Am J Sports Med. 2009;37(suppl 1):33S-41S.
15. Harris JD, Cavo M, Brophy R, Siston R, Flanigan D. Biological knee reconstruction: a systematic
review of combined meniscal allograft transplantation and cartilage repair or restoration. Arthroscopy.
2011;27(3):409-418.
16. Hunt HE, Sadr K, Deyoung AJ, Gortz S, Bugbee WD. The role of immunologic response in fresh osteo-
chondral allografting of the knee. Am J Sports Med. 2014;42(4):886-891.
17. Koh JL, Wirsing K, Lautenschlager E, Zhang LO. The effect of graft height mismatch on contact pres-
sure following osteochondral grafting: a biomechanical study. Am J Sports Med. 2004;32(2):317-320.
18. Cole BJ, Pascual-Garrido C, Grumet RC. Surgical management of articular cartilage defects in the knee.
Instr Course Lect. 2010;59:181-204.
19. Krych AJ, Robertson CM, Williams RJ III; Cartilage Study Group. Return to athletic activity after osteo-
chondral allograft transplantation in the knee. Am J Sports Med. 2012;40(5):1053-1059.
20. Kainer MA, Linden JV, Whaley DN, et al. Clostridium infections associated with musculoskeletal-tissue
allografts. N Engl J Med. 2004;350(25):2564-2571.
21. American Association of Tissue Banks. Standards for tissue banking. Available at: http://www.aatb.org/.
Accessed July 16, 2014.
22. Centers for Disease Control and Prevention (CDC). Update: allograft-associated bacterial infections—
United States, 2002. MMWR Morb Mortal Wkly Rep. 2002;51(10):207-210.
23. Tugwell BD, Patel PR, Williams IT, et al. Transmission of hepatitis C virus to several organ and tissue
recipients from an antibody-negative donor. Ann Intern Med. 2005;143(9):648-654.
24. Ball ST, Amiel D, Williams SK, et al. The effects of storage on fresh human osteochondral allografts.
Clin Orthop Relat Res. 2004;(418):246-252.
25. Oakeshott RD, Farine I, Pritzker KP, Langer F, Gross AE. A clinical and histologic analysis of failed
fresh osteochondral allografts. Clin Orthop Relat Res. 1988;(233):283-294.
Introduction
Chondral defects of the patellofemoral joint can be caused by overuse, traumatic injury, and
pathoanatomy. As such, the patellofemoral joint remains the most common location for articular
cartilage defects of the knee.1 Most of these lesions are asymptomatic and found incidentally at
the time of knee arthroscopy, but some may be symptomatic. The key to proper management is
to sort through the multiple potential etiologies of the patient’s patellofemoral pain and assign a
component to the cartilage defect. This is a diagnosis by exclusion because the aneural chondral
defect contributes to the pain through its effect on the sensory nerves in the bone, capsule, and
synovium. For patients with chondral lesions that have been assigned as a contributing component
to the overall patellofemoral pain, a spectrum of treatment may be indicated based on the size and
location of the defect in addition to patient-related and anatomic factors. These treatments include
arthroscopic and open procedures and combinations of both. This chapter focuses on providing
a framework for the surgical management of symptomatic chondral defects of the patellofemoral
joint via an algorithmic approach.
Indications
▶ Failed thorough comprehensive nonoperative management
▶ Pain is directly attributed to the documented chondrosis by imaging and/or arthroscopy (no
atypical or global pain)
▶ Chondral lesion is grade III or IV modified Outerbridge (International Cartilage Repair
Society grades IIIA, IIIB, IIIC, IIID, IVA, or IVB, noting the environment is optimized for
patellofemoral force/contact area, tracking, and stability
▶ Lesion size appropriate for considered treatment (< 3 cm 2 in diameter osteochondral autograft
transfer; > 3 cm 2 in diameter osteochondral allograft transplant or cell therapy)2
Controversial Indications
▶ Bipolar lesions
▶ Marrow stimulation of patellar lesions3
▶ Autologous chondrocyte implantation (ACI) after prior microfracture/marrow stimulation4,5
▶ When age and lesion size would allow consideration of patellofemoral arthroplasty
▶ Worker’s compensation cases6
▶ Open growth plates
▶ Elevated body mass index (BMI; > 35 kg/m 2 or > 40 kg/m 2)6
▶ Cell therapy alone in the presence of marked bone marrow lesion(s)
Contraindications
▶ Atypical pain (complex regional pain syndrome)
▶ Pain not directly attributable to the chondrosis
▶ Patient not willing to follow the rehabilitation program and/or future activity modification
Nonoperative Management
Initial nonoperative management is to educate the patient on why he or she is having pain. For
example, is the primary problem structural, inadequate muscle/soft tissue balance, or overuse?
Patients need to understand their personal “envelope of function” and that all patients are unique
and must stay within their own body limits. Physical therapy is key and should include a com-
prehensive “core to floor” program that is similar in some aspects to an anterior cruciate ligament
prevention program. Attention is focused on quadriceps, core, abductor, and gluteal strengthening
in addition to flexibility, patellar mobilizations, and physiotaping. Anti-inflammatory drugs and/
or cortisone injections may aid in symptom control while the patient undergoes physical therapy.
A patellar stabilizing brace may be useful if the patient has a history of patellar instability. This
aggressive nonsurgical regimen should continue for a minimum of 6 weeks and should be pursued
until muscle strength and flexibility defects are improved, which can require up to 6 months in
some patients. Surgery should be considered in the patient who remains symptomatic despite
regaining near full ROM and near normal strength. Such patients should also have a chondral
defect that is logically contributing to the majority of their symptoms.
Pertinent Imagining
X-Rays
▶ Standing anteroposterior, posteroanterior, flexion weightbearing and hip-to-ankle alignment
view if coronal plane malalignment is suspected
▶ True lateral x-ray to evaluate trochlear dysplasia and patellar tilt.9 Patellar height is most com-
monly reported as a ratio using the Caton-Deschamps or Blackburne-Peel method.
▶ Low flexion angle axial view, such as the Merchant view, to assess patellar position in relation
to the trochlea and for identifying the subluxation. (In most patients, this view assesses the
distal aspect of the trochlea and will underestimate patellofemoral chondral wear that occurs
in the mid aspect.)
Computed Tomography
▶ Allows for quad active view of alignment and patellar positioning through ROM
▶ Alternative measurement for tuberosity distances
▶ Assesses bone quality, especially if there are regions of deficiency
Equipment
▶ Arthroscopic debridement
▷ 3.5- or 4.5-mm high-speed shaver
▷ Curved shaver
▶ Marrow stimulation: Microfracture awls with a variety of curves
▷ K-wires
▷ Power drill
▷ Ring curettes
▷ Arthroscopic scalpel
▶ Osteochondral autograft
▷ Osteochondral plug harvest set from company of surgeon’s choice
▷ Donor plug harvester
▷ Cannulated reamer or tubular chisel
▷ Calibrated ruler
▷ Donor plug inserter or bone tamp
▶ Osteochondral allograft
▷ Allograft set from a company of the surgeon’s choice
▷ Cannulated circular reamers
▷ Calibrated ruler
▷ Coring reamer
▷ Pulsatile lavage
▷ Oversized bone tamp
▶ ACI
▷ Harvesting awl for initial biopsy
▷ Ring curettes
▷ 6-0 suture
▷ Periosteal patch or collagen membrane
▷ Fibrin glue
▷ Small angiocatheter and syringe
▷ Sterile saline
▷ Autologous chondrocytes in vials
Approach to Chondral Damage in the Patellofemoral Joint 261
Marrow Stimulation
Microfracture of patellar defects generally leads to less promising results than those
obtained when the procedure is performed for symptomatic defects on the femoral condyles.17
Microfracture may be performed via open or arthroscopic means. If open access is required, a
laterally based arthrotomy allows avoidance of the vastus medialis obliquus. The incision extends
from the superior pole of the patella to the patellar tendon and may be extended further distally to
expose the entire tibial crest if a tibial tubercle osteotomy is being performed concomitantly with
the patellofemoral cartilage procedure. Lesions are debrided down to sharp margins with stable,
vertical walls of healthy articular cartilage surrounding the defect. A curette or arthroscopic
scalpel removes the calcified cartilage layer from the defect without penetrating the subchondral
bone. Multiple perforations are then made 2 to 3 mm apart in the subchondral bone by starting at
the periphery and moving toward the center of the defect (Figure 19-1). This can be done with a
262 Chapter 19
microfracture awl, K-wire, or drill with care taken to not fracture the subchondral bone between
perforations. Drilling with saline irrigation may be specifically useful on the patella where the
subchondral bone is thicker because awls with a 90-degree curve may still skive.
Osteochondral Autograft
Osteochondral autograft plug harvest and implantation may be performed via arthroscopic or
open means. If performed arthroscopically, accessory portals may be required to achieve perpen-
dicular access to the donor and recipient sites and should be confirmed with spinal needle local-
ization. Once the lesion has been debrided to a stable base, a sizing tool is placed arthroscopically
through the appropriate portal or through a mini-arthrotomy to determine the size of the defect
and the number of donor plugs required to fill the lesion. Graft harvest is then performed from the
intercondylar notch, the trochlea, or just proximal to the sulcus terminalis. Using a plug harvester
placed directly perpendicular to the donor site, an osteochondral plug of 6 to 11 mm in diameter
and 8 to 12 mm long is taken from a location of the surgeon’s choice. Multiple plugs may be har-
vested if needed and should be inspected for length and slope after removal. The recipient site is
then prepared with a tubular chisel placed perpendicular to the defect or by placing a guide pin
into the center of the defect and reaming over it with a cannulated circular reamer. A calibrated
measuring device is used to measure the recipient socket at the 3, 6, 9, and 12 o’clock positions to
ensure that the donor graft(s) can be oriented in the correct position to match slope before implan-
tation in a press-fit fashion. It is imperative that articular congruency be maintained, but it is
preferable to have the graft slightly recessed rather than proud if congruency cannot be achieved.18
Osteochondral Allograft
A standard parapatellar arthrotomy is performed, and the patella is everted to expose the chondral
defect. A cylindrical guide is placed over the defect to perform appropriate sizing, and the 12 o’clock
position is marked. A guide pin is placed through the center of the guide to a depth of 2 cm, and
the guide is removed. A cannulated reamer is placed over the guide pin, and the defect is reamed to
a depth of 6 to 8 mm. The depth of the recipient site is then measured at the 3, 6, 9, and 12 o’clock
positions with a small ruler to allow precise allograft preparation and to minimize the chances of the
Approach to Chondral Damage in the Patellofemoral Joint 263
graft being proud or recessed. The donor graft is prepared using a coring reamer of appropriate size
with adjustments being made to the depth based on the recipient site measurements. The donor plug
is irrigated using pulsatile lavage to wash out marrow elements and is inserted into the recipient site
in a press-fit manner with gentle use of an oversized tamp (Figure 19-2).
Figure 19-4. The margins of the defect are sharply debrided, and the calcified cartilage is removed.
Approach to Chondral Damage in the Patellofemoral Joint 265
recessed because there is a tendency for the cells to grow upward and outward. The mixture should
be allowed to set before closure and may be sealed with a fibrin glue seal around the margins of
the defect or sewing a collagen membrane in place (Figure 19-7).
Postoperative Protocol
If arthroscopic debridement alone is performed, patients are allowed full weightbearing and full
knee ROM. However, weightbearing is only allowed in extension for 4 to 6 weeks if microfrac-
ture, cartilage transplantation, or ACI is performed so as to not unduly load the patellofemoral
joint with flexion weightbearing. In addition, weightbearing is protected for 6 weeks if a tibial
tubercle osteotomy is performed in conjunction with the patellofemoral cartilage. Continuous pas-
sive motion is started immediately postoperatively and is typically used for 6 to 8 hours per day.
ROM is set from 0 to 30 degrees and is increased by 5 to 10 degrees daily so that patients have
nearly full flexion by 6 to 8 weeks postoperatively. A brace is worn locked in extension for the first
week postoperatively but can be removed for continuous passive motion and exercises. The brace
is then gradually opened in 20-degree increments per week and can be discontinued when active
quadriceps control is achieved to the extent that a straight leg raise can be performed with extensor
lag. Microfracture patients generally may be ready to return to strenuous activities by 6 months
Approach to Chondral Damage in the Patellofemoral Joint 267
postoperatively, whereas patients undergoing cartilage transplantation or ACI may require as long
as 12 months to return to impact activities and as long as 18 months to reach maximum medical
improvement.
Potential Complications
Standard postoperative complications, such as infection, wound complications, complex region-
al pain syndrome, and deep venous thrombosis, may be encountered with all procedures. Patients
undergoing microfracture may undergo intralesional osseous overgrowth within the treated defect,
and research is currently ongoing to confirm whether microfracture may reduce the potential
efficacy of any future cell-based therapies for the treated lesion. Patch overgrowth may occur in
patients treated with cell-based therapies, such as ACI and PJAC, and osteochondral allograft
treatment carries with it risks of disease transmission and graft resorption along with the potential
to delaminate or collapse. Osteochondral autografts may lead to development of postoperative pain
due to donor site morbidity and cyst formation.
References
1. Curl WW, Krome J, Gordon ES, Rushing J, Smith BP, Poehling GG. Cartilage injuries: a review of 31,516
knee arthroscopies. Arthroscopy. 1997;13(4):456-460.
2. Hangody L, Füles P. Autologous osteochondral mosaicplasty for the treatment of full-thickness defects
of weight-bearing joints: ten years of experimental and clinical experience. J Bone Joint Surg Am.
2003;85(suppl 2):25-32.
3. Kreuz PC, Steinwachs MR, Erggelet C, et al. Results after microfracture of full-thickness chondral
defects in different compartments in the knee. Osteoarthritis Cartilage. 2006;14(11):1119-1125.
4. Minas T, Von Keudell A, Bryant T, Gomoll AH. The John Insall Award: a minimum 10-year outcome
study of autologous chondrocyte implantation. Clin Orthop Relat Res. 2014;472(1):41-51.
268 Chapter 19
5. Pestka JM, Bode G, Salzmann G, Südkamp NP, Niemeyer P. Clinical outcome of autologous chondro-
cyte implantation for failed microfracture treatment of full-thickness cartilage defects of the knee joint.
Am J Sports Med. 2012;40(2):325-331.
6. Ding C, Cicuttini F, Scott F, Cooley H, Boon C, Jones G. Natural history of knee cartilage defects and
factors affecting change. Arch Intern Med. 2006;166(6):651-658.
7. Crossley KM, Cowan SM, Bennell KL, McConnell J. Knee flexion during stair ambulation is altered in
individuals with patellofemoral pain. J Orthop Res. 2004;22(2):267-274.
8. Post WR, Fulkerson J. Knee pain diagrams: correlation with physical examination findings in patients
with anterior knee pain. Arthroscopy. 1994;10(6):618-623.
9. Malghem J, Maldague B. Depth insufficiency of the proximal trochlear groove on lateral radiographs of
the knee: relation to patellar dislocation. Radiology. 1989;170(2):507-510.
10. Potter HG, Linklater JM, Allen AA, Hannafin JA, Haas SB. Magnetic resonance imaging of articu-
lar cartilage in the knee. An evaluation with use of fast-spin-echo imaging. J Bone Joint Surg Am.
1998;80(9):1276-1284.
11. Shindle MK, Foo LF, Kelly BT, et al. Magnetic resonance imaging of cartilage in the athlete: current
techniques and spectrum of disease. J Bone Joint Surg Am. 2006;88(suppl 4):27-46.
12. Dejour H, Walch G, Nove-Josserand L, Guier C. Factors of patellar instability: an anatomic radiographic
study. Knee Surg Sports Traumatol Arthrosc. 1994;2(1):19-26.
13. Camp CL, Stuart MJ, Krych AJ, et al. CT and MRI measurements of tibial tubercle-trochlear groove
distances are not equivalent in patients with patellar instability. Am J Sports Med. 2013;41(8):1835-1840.
14. Federico DJ, Reider B. Results of isolated patellar debridement for patellofemoral pain in patients with
normal patellar alignment. Am J Sports Med. 1997;25(5):663-669.
15. Edwards RB III, Lu Y, Uthamanthil RK, et al. Comparison of mechanical debridement and radio-
frequency energy for chondroplasty in an in vivo equine model of partial thickness cartilage injury.
Osteoarthritis Cartilage. 2007;15(2):169-178.
16. Ryan A, Bertone AL, Kaeding CC, Backstrom KC, Weisbrode SE. The effects of radiofrequency
energy treatment on chondrocytes and matrix of fibrillated articular cartilage. Am J Sports Med.
2003;31(3):386-391.
17. Mithoefer K, Williams RJ III, Warren RF, et al. The microfracture technique for the treatment of articu-
lar cartilage lesions in the knee. A prospective cohort study. J Bone Joint Surg Am. 2005;87(9):1911-1920.
18. Koh JL, Wirsing K, Lautenschlager E, Zhang LO. The effect of graft height mismatch on contact pres-
sure following osteochondral grafting: a biomechanical study. Am J Sports Med. 2004;32(2):317-320.
Introduction
Articular cartilage implantation or transplant, first described by Brittberg et al1 in 1994, has
been performed in the United States since 1996. The literature is now replete with a plethora of
reports, including more than 15- to 20-year follow-up for the treatment of focal chondral defects
in the knee.2-6 Its first and current Food and Drug Administration (FDA)-approved use is as a
second-line treatment for previous failed chondral debridement, microfracture, or osteoarticular
autograft treatment of a focal articular cartilage defect in the medial, lateral, or trochlear femoral
condyle. Recent experience has shown it to be effective in knees with deep osteochondral defects,
osteochondritis dissecans,7 primary treatment of large chondral defects up to 7 cm 2 , and in
multiple lesions.8 Patellofemoral lesions have also been successfully treated when effectively com-
bined with patellar realignment.9 Despite these excellent medium- and long-term peer-reviewed
reports, its widespread use in the United States remains limited, and the procedure is most often
performed in specialty centers. Most recent data estimate that approximately 11,000 implants are
performed worldwide annually, mostly in the United States and Europe, with a small number in
Asia. Relative contraindications include kissing lesions, presence of uncorrected malalignment,
meniscal deficiency, and ligament instability. Presence of infection or synovial inflammatory dis-
ease is also a contraindication.
Over the past decade, several technical improvements have been published regarding the
technique and have been put into popular use as off-label uses of this technology. In addition,
rehabilitation protocols have progressed to allow earlier load bearing while protecting the nascent
cartilage. Lastly, newer cellular technologies with collagen matrix and hyaluronan seeding, plus
collagen gel and atelocollagen-based cell transport vehicles, have been reported in other countries
and approved for use.
Indications
▶ Focal chondral post-traumatic defects of the medial, lateral, and trochlear femoral condyles.
Although well-contained lesions are preferable, partially uncontained lesions can be addressed
with specific techniques
▶ Age range 15 to 55 years
▶ Osteochondritis dissecans
▶ Knee must have or the surgeon must provide adequate ligament stability, limb alignment, and
adequate meniscal function.
Controversial Indications
▶ Multiple lesions in the same knee, including kissing lesions of the opposite condyle
▶ Patellar lesions with or without concomitant instability or malalignment. Issues of malalign-
ment or instability must be addressed at the time of implantation for good results.
▶ Lesions in patients with concomitant varus or valgus malalignment and degenerative lesions.
Must address alignment with high tibial or distal femoral osteotomy as well.
▶ Chronologically older active patients with focal defects and younger teenagers prior to physeal
closure
Pertinent Imaging
▶ Weightbearing anteroposterior, lateral, Rosenberg, and patellofemoral x-rays
▶ Long-leg alignment scanogram from hip to ankle to evaluate alignment and the need for
concomitant osteotomy
Articular Cartilage Transplantation 271
Patient Counseling
These procedures are significant undertakings for patients, their families, and the surgeon.
The cost and postoperative requirements are considerable; therefore, it is essential that the sur-
geon offer a comprehensive teaching and counseling program and effectively help these patients
make a truly informed consent about these complex surgical choices. Often, these decisions may
occur over more than one visit. Patients should be made aware not only of the existing research
and potential success rates, along with the typical discussion of surgical risks, but should also be
instructed in the considerable postoperative precautions and rehabilitation needed to truly make
this procedure a success. Educating patients about the maturation phases of cartilage is important
for them to understand the protective weightbearing phases postoperatively and restrictions from
work and daily activities that will be important to ensure success. In addition, a discussion of
the patient’s expectations at 1 and 2 years postoperatively from a work and athletic perspective is
essential. The physician should discuss what actual change in lifestyle and sports participation is
possible. It is also essential to stress that these are salvage procedures and often may be performed
with multiple concomitant procedures. Therefore, the patient should expect some secondary small
procedures to maximize results, which may include lysis of adhesions, excision of a thickened fat
pad or plica, or partial patch detachment and/or hardware removal if applicable. These secondary
surgical procedures are not failures but should be considered essential to returning the patient
to the best function possible for the longest period of time. If these issues are discussed upfront,
patients are cooperative and sanguine about their progress. If these complications occur postop-
eratively but they were not effectively discussed prior to primary surgery, it may have a negative
effect on the surgeon-patient relationship later on and lead to poorer prognosis.
Arthroscopic Diagnosis/
Final Decision Making and Cell Harvest
Once the patient has decided to move forward with the evaluation, a first-stage, outpatient
arthroscopic procedure is scheduled. Simple diagnostic arthroscopy is performed and minimal
concomitant pathology may be addressed simultaneously with partial meniscectomy, plica resec-
tion, or chondral debridement of partial-thickness defects. The meniscal volume and ligament
integrity can be confirmed and any kissing lesions noted. The joint is also evaluated in regard to
the character of the lesion (ie, single, multiple, or well contained or not). In addition, the thickness
or health of the surrounding cartilage can help determine if this patient is not presenting with a
traumatic chondral injury but perhaps a knee that is heading for arthritis and happened to have
a traumatic event prior to presentation. The latter patients with diffuse disease are poorer candi-
dates for joint restoration procedures and may be better candidates for metallic joint resurfacing
or osteotomy.
If the patient meets the final criteria for cartilage transplant, the cell harvest is performed at
this time. Approximately 300 to 400 mg of normal cartilage is required. This amount is estimated
as 3 Tic Tac–sized biopsies of full-thickness cartilage from a nonweightbearing area, including a
272 Chapter 20
small amount of subchondral bone. The author’s preferred safe location is the intercondylar notch
near where notchplasty was performed in the earlier days of anterior cruciate ligament reconstruc-
tion. Medial trochlear areas away from the articulating patellofemoral joint are also available
as in osteochondral autograft transfer system procedures; however, some mechanical symptoms
may occur from fibrous infill here. An angled or ring curette is used to harvest the full-thickness
biopsy. The cells closest to the lamina splendens may be the best for growth, so it is important
to get to the basal area of cartilage by the bone interface. Cells are then placed in the provided
commercial medium and sent for culture. The cell company will isolate and culture chondrocytes
and can return between and 4 and 12 million chondrocytes for transplant on the day of surgery
within 3 to 4 weeks.
should flatten these with a burr. These central osteophytes usually do not bleed because they are
quite sclerotic. Minas et al14 showed that placing cells and patches over these may often lead to
cell transplant failure if not addressed.
Once debridement and preparation are complete, the lesion is measured, and a patch will be
taken to fit the exact size. In the standard FDA-approved protocol, a patch is taken from the
proximal tibial or distal femoral periosteum. Distal femoral periosteum is usually reserved for older
patients with thin to nonexistent tibial periosteum because it is often too thick in younger subjects.
The tibial periosteum is harvested from just distal to the pes anserine bursa to a size 2 mm larger
in diameter than the lesion to be covered because the periosteum often shrinks during harvest.
Care to remove the full depth of the periosteum down to the bone is important because the layer
closest to the bone has some progenitor cells, which may aid in the repair. The cambium layer
side of the periosteum is then placed down toward the lesion and sewn into place with 6-0 or
5-0 Vicryl suture.
The repair is then checked to see if it is water tight with the application of 0.3 cc of saline
delivered by a tuberculin syringe under the patch via the superior corner where the final suture is
left unplaced. Once placed, if there is no leak, the saline is removed with the tuberculin syringe
so as not to dilute the ultimate chondrocyte suspension. Fibrin glue (Tisseal; Baxter) is then
added to the periphery of the repair, and the final superior stitch remains open. The cultured
chondrocytes are then drawn up using appropriate Carticel (Vericel Inc) technique and delivered
under the patch by a similar tuberculin syringe after which the final stitch is placed and followed
by fibrin glue (Figure 20-2).
Articular Cartilage Transplantation 275
Equipment
▶ Standard open knee tray with at least 2 “Z” retractors
▶ Small pads soaked in 1% epinephrine and thrombin to decrease intralesional bleeding and
gel-soaked thrombin pads
▶ Narrow sharp periosteal elevator
▶ 5-0 and 6-0 Vicryl suture (preferably dyed purple)
of cancellous bone to place in to fill the defect to the normal anatomic subchondral bone plate
level (Figure 20-5). A collagen or periosteal patch is then sewn with a rough or cambium layer
face up over the bone graft to prevent blood infusion into the chondrocyte implant. A second
collagen patch is then sewn on top with the rough side facing down as usual, and the cells can be
placed between the 2 membranes using the usual proper Carticel technique (Figure 20-6). If these
278 Chapter 20
lesions are poorly contained, strict nonweightbearing might be appropriate for 4 weeks and then
progress along the original Carticel guidelines. However, if the lesion is well contained, minimal
partial weightbearing may be begun postoperatively with foot flat as with usual articular cartilage
implantation.
Postoperative Protocol
Patients are placed in a knee immobilizer or off-the-shelf T-ROM brace locked in extension
for the first 6 hours postoperatively. At 6 hours postoperatively, the brace is unlocked, or the
immobilizer removed, and continuous passive motion is begun continuously for the first 24 hours.
After that, many surgeons recommend continuous passive motion or some low-load cyclic loading
6 hours per day for the first week. The patient’s weightbearing is restricted to foot flat 15- to 20-lb
partial weightbearing with 2 crutches for at least 6 to 8 weeks. Although protection of the cell
transplant is important to avoid shear stress and too much longitudinal load, some load at the cell-
bone interface and cyclic motion is useful for stimulating chondrocyte growth and maturation. For
poorly contained lesions, nonweightbearing may be needed for a few weeks, but most patients may
begin partial weightbearing immediately. The amount of weightbearing also varies based on the
location of the lesion. If the lesion is in the central weightbearing area of medial or lateral femoral
condyle, the load is more slowly applied; however, trochlear lesions and lesions more posterior in
the condyle can accept more rapid partial weightbearing as tolerated because they are not loaded
in the normal gait cycle. Immediate weightbearing for patellofemoral lesions is appropriate once
quadriceps recovery allows, but active open chain extension must be avoided for the first month
in these patients to avoid the shear stresses in this area that would most likely affect the implant
in this region.
Cyclic loading is appropriate once ROM allows, and early pool exercises, once the incision is
effectively sealed, can allow earlier low-load functional activity.
Protocols have been previously published for the appropriate progression to full weightbearing
and progressive resistance exercises,23 and in recent years, surgeons and therapists have begun
to accelerate the full weightbearing process from an average of 10 to 12 weeks to 6 to 8 weeks.
No untoward effects have been noted in early studies to date of these accelerated rehabilitation
programs; however, it is important for sports medicine surgeons to note that these accelerated
programs allow for stress protection early up to 6 weeks and are not as aggressive as usual ligament
reconstruction protocols.24
Concomitant meniscal transplant or ligament reconstruction will also affect rehabilitation pro-
tocols; however, osteotomy, which used to delay weightbearing when open-wedge osteotomy was
performed with weaker implants, can now tolerate rapid weightbearing if larger, stronger implants
or newer weightbearing bone or bone substitute wedges are used.
Potential Complications
The most common complications reported with open articular cartilage implantation include
patch hypertrophy, partial patch detachment, and adhesions. These complications most often
show up in the first 4 to 6 months postoperatively and may need to be addressed with arthroscopic
evaluation and surgery. In the early prospective studies of the use of articular cartilage implanta-
tion for second-line treatment, these complications were reported as commonly as 30% to 49%
but once addressed had no effect on the ultimate success rate.3 Since the use of CACI and cell
seeded–articular cartilage implantation, these complications rates have significantly decreased to
less than 5% to 10%.18 Therefore, the need for secondary surgical procedures has significantly
Articular Cartilage Transplantation 279
decreased. Rarer complications include infection and deep venous thrombosis, which are both less
than 1% to 2% but have been reported, as with most limb surgeries.3
Although these are complex surgeries with long postoperative recuperative periods, significant
serious adverse events are rare if good surgical and postoperative protocols are followed.
(Carticel) is the sole provider of cultured chondrocytes in the United States, throughout most of
Europe, the only product available is Chondroselect (formerly Tigenix), which is now marketed
exclusively by Sobi.
In England, Shetty reported on a collagen gel–based articular cartilage implantation, originally
described with Kim in Korea, that can be performed arthroscopically or open and distributes the
chondrocytes evenly within a collagen gel with thrombin and fibrinogen. After standard defect
preparation as previously described in this chapter, this gel product can be easily applied to fill
these defects arthroscopically under gas insufflation. For this purpose, he uses the same double
injector the authors use for fibrin glue in the standard procedure.26,27 In Japan, authors have
similarly worked to decrease the variability in the fluid injection of cells under membrane by sus-
pending cells in a matrix of atelocollagen, with good to excellent results in prospective studies.27,28
Although these newer techniques have many potential technical and biologic benefits to creating
a stable cartilage repair, longer-term studies are needed to see if these new constructs yield a more
durable repair than existing techniques.
References
1. Brittberg M, Lindahl A, Nilsson A, Ohlsson C, Isaksson O, Peterson L. Treatment of deep cartilage
defects in the knee with autologous chondrocyte transplantation. N Engl J Med. 1994;331(14):889-895.
2. Mandelbaum BR, Browne JE, Fu F, et al. Articular cartilage lesions of the knee. Am J Sports Med.
2000;26(6):853-861.
3. Zaslav K, Cole B, Brewster R, et al. A prospective study of autologous chondrocyte transplantation in
patients with failed prior treatment for articular cartilage defect of the knee: results of the Study of
Articular Repair (STAR) clinical trial. Am J Sports Med. 2009;37(1):42-55.
4. Peterson L, Brittberg M, Kiviranta I, Akerlund EL, Lindahl A. Autologous chondrocyte transplantation.
Biomechanics and long-term durability. Am J Sports Med. 2002;30(1):2-12
5. Peterson L, Vasiliadis HS, Brittberg M, Lindahl A. Autologous chondrocyte implantation: a long-term
follow-up. Am J Sports Med. 2010;38(6):1117-1124.
Articular Cartilage Transplantation 281
6. Biant LC, Bentley G, Vijayan S, Skinner JA, Carrngton RW. Long-term results of autologous chon-
drocyte implantation in the knee for chronic chondral and osteochondral defects. Am J Sports Med.
2014;42(9):7-11.
7. Cole BJ, DeBerardino T, Brewster R, et al. Outcomes of autologous chondrocyte implantation in Study
of the Treatment of Articular Repair (STAR) patients with osteochondritis dissecans. Am J Sports Med.
2012;40(9):2015-2022.
8. Minas T, Gomoll AH, Solhpour S, Rosenberger R, Probst C, Bryant T. Auotologous chondrocyte
implantation for joint preservation in early osteoarthritis. Clin Orthop Related Res. 2010;468(1):147-157.
9. Gillogly SD, Arnold RM. Autologous chondrocyte implantation and anteromedialization for isolated
patellar cartilage lesions: 5- to 11-year follow-up. Am J Sports Med. 2014;42(4):912-920.
10. Farr J. Specific considerations for patellofemoral chondral disease. In: Cole BJ, Gomoll AH, eds. Biologic
Joint Reconstruction. Thorofare, NJ: SLACK Incorporated; 2009:187-201.
11. Minas T. A Primer in Cartilage Repair and Joint Preservation of the Knee. Philadelphia, PA: Elsevier;
2011.
12. Buckwalter JA. Evaluating methods of restoring cartilaginous articular surfaces. Clin Orthop Rel Res.
1999;(367 suppl):S224-S238.
13. Mithoefer K, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR. Clinical efficacy of the microfrac-
ture technique for articular cartilage repair in the knee: an evidence-based systematic analysis. Am J
Sports Med. 2009;37(10):2053-2063.
14. Minas T, Gomoll AH, Rosenberger R, Royce RO, Bryant T. Increased failure rate of autologous chon-
drocyte implantation after previous treatment with marrow stimulation techniques. Am J Sports Med.
2009;37(5):902-908.
15. Pugh JW, Radin EL, Rose RM. Quantitative studies of subchondral cancellous bone. Its relationship to
the state of its overlying cartilage. J Bone Joint Surg Am. 1974;56(2):313-321.
16. Richardson JB. Sub-chondral bone: current concepts. In: Brittberg M, Imhoff A, Madry H, Mandelbaum
B, eds. Cartilage Repair: Current Concepts. Surrey, UK: DJO Publications; 2010.
17. Gooding CR, Bartlett W, Bentley G, Skinner JA, Carrington R, Flanagan A. A prospective, randomized
study comparing two techniques of autologous chondrocyte implantation for osteochondral defects of
the knee: periosteum covered versus type I/III collagen covered. Knee. 2006;13(3):203-210.
18. Gomoll AH, Probst C, Farr J, Cole BJ, Minas T. Use of a type I/III collagen membrane decreases reop-
eration rates for symptomatic hypertrophy after autologous chondrocyte implantation. Am J Sports
Med. 2009;37(suppl 1):20S-23S.
19. Neimeyer P, Lenz P, Kreuz PC, et al. Chondrocyte-seeded type I/III collagen membrane for autologous
chondrocyte transplantation: prospective 2-year results in patients with cartilage defects of the knee.
Arthroscopy. 2010;26(8):1074-1082.
20. Saris D, Price A, Widuchowski W, et al. Matrix-applied characterized autologous cultured chondro-
cytes versus microfracture: two-year follow-up of a prospective randomized trial. Am J Sports Med.
2014;42(6):1384-1394.
21. Zak L, Albrecht C, Wondrasch B, et al. Results 2 years after matrix-associated autologous chondrocyte
transplantation using the Novocart 3D scaffold: an analysis of clinical and radiological data. Am J Sports
Med. 2014;42(7):1618-1627.
22. Peterson L, Minas T, Brittberg M, Lindahl A. Treatment of osteochondritis dissecans of the knee
with autologous chondrocyte transplantation: results at two to ten years. J Bone Joint Surg Am.
2003;85(suppl 2);17-24.
23. Hambly K, Bobic V, Wondrasch B, Van Assche D, Marlovits S. Autologous chondrocyte implantation
postoperative care and rehabilitation: science and practice. Am J Sports Med. 2006;34(6):1020-1038.
24. Edwards PK, Ackland TR, Ebert JR. Accelerated weightbearing rehabilitation after matrix-induced
articular chondrocyte implantation in the tibiofemoral joint: early clinical and radiological outcomes.
Am J Sports Med. 2014;41(10):2314-2324.
25. Kon E, Gobbi A, Filardo G, Delcogliano M, Zaffagnini S, Maracci M. Arthroscopic second-generation
autologous chondrocyte implantation compared with microfracture for chondral lesions of the knee:
prospective nonrandomized study at 5 years. Am J Sports Med. 2009;37(1):33-41.
26. Choi NY, Kim BW, Yeo WJ, et al. Gel-type autologous chondrocyte implantation (Chondron)
implantation for treatment of articular cartilage defects of the knee. BMC Musculoskelet Disord.
2010;11:103.
282 Chapter 20
27. Gomoll AH, Kamei G, Ochi M, Shetty AA, Zaslav K. Technical enhancements and update on chondro-
cyte implantation. Oper Tech Orthop. 2014;24:35-47.
28. Katsube K, Ochi M, Uchio Y, et al. Repair of articular defects with cultured chondrocytes in
Atellocollagen gel. Comparison with cultured chondrocytes in suspension. Arch Orthop Trauma Surg.
2000;120(3-4):121-127.
Introduction
DeNovo NT (Zimmer) is minced (1-mm cubes) juvenile allograft cartilage delivered with
fibrin glue indicated for the treatment of chondral defects with minimal to no bone loss. One
benefit of DeNovo NT is the use of juvenile tissue, which has been shown to have a consider-
ably greater ability to produce proteoglycans and stimulate matrix production compared to adult
sources of chondrocytes.1,2 An additional feature is that juvenile cells are less immunogenic than
their adult counterparts.1 Because DeNovo NT supplies viable cells, it has a shelf-life of 44 days
from the date it was harvested and typically needs to be ordered prior to surgery, similar to an
osteochondral allograft. The technique can be applied in an open or arthroscopic fashion; how-
ever, the arthroscopic method is significantly more demanding.
Outcomes for DeNovo NT have only recently been reported. Tompkins et al 3 reported on
patellar defects (2.4 ± 1.2 cm 2) at 28 months using a density of 1 unit per 1.3 cm 2. This is twice
the density recommended by the manufacturer. In this setting, there was an 89% mean defect fill
on magnetic resonance imaging (MRI), and 2 of 15 patients required a debridement for hypertro-
phy. Farr et al4 reported on a similar patient population and reported no reoperations at 2 years in
25 patients; the study also demonstrated statistically significant improvements over baseline levels
for multiple measures of pain, symptoms, activities of daily living, and sports and recreation.
Indications
▶ In general, the indications for DeNovo NT mirror that of autologous chondrocyte implanta-
tion (ACI).
Sgaglione NA, Lubowitz JH, Provencher MT, eds. The Knee:
- 283 - AANA Advanced Arthroscopic Surgical Techniques (pp 283-296).
© 2016 AANA.
284 Chapter 21
▶ International Cartilage Repair Society grade III cartilage lesion (cartilage defect > 50%
cartilage depth but with minimal bone loss, possibly extending down to but not through the
subchondral bone)
▶ Lesion size > 2 cm 2 after debridement
▶ Minimal to no bone loss
▷ Can possibly be performed in conjunction with bone grafting as described in ACI,
although there are no data to support this technique
▶ Preferentially used in the patellofemoral joint
▶ Body mass index less than 30 to 34 kg/m 2
Relative Contraindications
▶ Bipolar lesion
▶ Significant subchondral bone edema
▶ > 5 mm of untreated bone loss (osteochondritis dissecans)
▶ Unaddressed meniscectomy or malalignment
▶ Potentially decreased outcomes in the setting of prior microfracture based on ACI data 5,6
Pertinent Imaging
▶ X-rays
▷ Anteroposterior standing: Anterior tibiofemoral arthritis
▷ Posteroanterior flexion weightbearing: Posterior tibiofemoral arthritis
▷ Lateral: Patellar alta/baja
▷ Merchant: Patellofemoral joint space narrowing, tilt, and tracking
▶ MRI (necessary for all patients to evaluate the following)
▷ Cartilage integrity
▷ Cartilage quality (delayed gadolinium-enhanced MRI of cartilage, fast-spin echo, or other
cartilage-specific sequences)
▷ Subchondral bone edema
Novel Techniques in Articular Cartilage Restoration 285
▷ Associated pathology
• Meniscus status
• Ligament status
• Tibial tubercle to trochlear groove (TT-TG) distance
▶ Computed tomography (CT)
▷ Considered for patients with significant bone loss, cystic change, or as an alternative
to measure the TT-TG distance in the setting of concomitant planned tibial tubercle
osteotomy
Equipment
▶ DeNovo NT needs to be requested prior to surgery because it is viable tissue that is not gener-
ally made available as an on-the-shelf option.
▶ The manufacturer recommends 1 package per 2.5-cm 2 defect.
▶ Arthroscopy setup is based on surgeon preference.
▶ Small curettes and ring curette if available
Arthrotomy
▶ The authors prefer performing an arthrotomy to access the cartilage defect. The location
of the incision depends on the location of the defect, with a lateral arthrotomy preferred for
a patellofemoral or lateral femoral condyle defect and a medial vastus-sparing approach for
other defects.
Defect Preparation
▶ Similar to any cartilage procedure, the defect should be debrided to stable healthy walls that
are vertical in nature.
286 Chapter 21
▶ The bed of the defect should be free of any diseased tissue, and care should be taken to
attempt removal of the calcified cartilage layer without gaining access to the subchondral
bone elements.
▶ Measure the defect to ensure the size is as expected (Figure 21-1).
Figure 21-5. The implant is lifted from the foil using an elevator and is placed into the defect
after fibrin has been placed in the base of the defect.
▶ Finally, set the pre-prepared DeNovo implant into the defect bed and ensure stability with
knee range of motion (ROM) (Figure 21-6).
▶ ROM: Continuous passive motion (CPM) is performed out of the brace for 6 hours per day
from 0 to 45 degrees for 3 weeks and is then increased by 5 to 10 degrees per day until it
reaches 90 degrees by 6 weeks. Discontinue it thereafter.
▶ Exercises: At weeks 1 to 4, perform quadriceps sets and straight leg raises with hamstring
isometrics. At weeks 4 to 10, perform isometric closed chain exercises with balance and bike at
8 weeks. At 6 to 8 months, perform fast walking on a treadmill and light plyometric activity.
High-impact activities thereafter are limited and advanced as tolerated as long as symptoms
do not recur.
Potential Complications
▶ Lack of integration/graft displacement
▶ Graft hypertrophy
▶ Risk of infection/allograft transmission
▶ Chondrocytes have not been shown to stimulate proliferation of allogeneic or xenogeneic
lymphocytes or promote graft rejection immune responses
290 Chapter 21
Introduction
Although microfracture is not considered an emerging technology, the augmentation of micro-
fracture continues to evolve. BioCartilage (Arthrex) is one such product that acts as a clot stabi-
lizer that also involves autogenous growth factor delivery. Using micronized hypothermic dehy-
drated allograft articular cartilage that is 100 to 300 microns in size, this is mixed in equal parts
of an autologous blood solution, such as platelet-rich plasma (PRP). This mixture can be delivered
arthroscopically or through an open technique. After placement, fibrin glue is used to maintain
the graft in the defect site. BioCartilage does not contain a viable cell source and has a shelf-life
of 5 years. Although comparing it to microfracture is favorable in clinical use and basic science in
vivo large animal models, no clinical outcomes regarding BioCartilage have been reported.
Indications7,8
▶ In general, the indications for BioCartilage mirror that of microfracture alone.
▶ Grade III/IV cartilage lesion
▶ Lesion size < 2 to 4 cm 2 after debridement
▶ No bone loss
▶ Preferentially used on the femoral condyle, trochlea, tibia, and hard-to-reach locations
▶ Body mass index < 30 to 34 kg/m 2
▶ No prior cartilage repair surgery
▶ Better outcomes if Tegner score is > 4 and symptoms last for < 12 months
Relative Contraindications
▶ Bipolar lesion
▶ Significant subchondral bone edema
Novel Techniques in Articular Cartilage Restoration 291
Pertinent Imaging
X-rays
▶ Anteroposterior standing: Anterior tibiofemoral arthritis
▶ Posteroanterior flexion weightbearing: Posterior tibiofemoral arthritis
▶ Lateral: Patellar alta/baja
▶ Merchant: Patellofemoral joint space narrowing, tilt, and tracking
MRI (necessary for all patients to evaluate the following)
▶ Cartilage integrity
▶ Cartilage quality (delayed gadolinium-enhanced MRI of cartilage, fast-spin echo, or other
cartilage-specific sequences)
▶ Subchondral bone edema
▶ Associated pathology
▷ Meniscus status
▷ Ligament status
▷ TT-TG distance
CT
▶ A consideration for patients with significant bone loss, cystic change, or as an alternative to
measure the TT-TG distance in the setting of concomitant planned tibial tubercle osteotomy
Equipment
▶ Arthroscopy setup based on surgeon preference
▶ Small curettes and ring curette if available
▶ Microfracture awls and/or powered device to create subchondral access
▶ BioCartilage comes in 1-cc packages that are to be mixed with 1 cc of PRP or less; this typi-
cally is enough volume to cover any indicated lesion.
292 Chapter 21
Potential Complications
▶ Microfracture site pain
▶ Osseous overgrowth at the site of microfracture
▶ Subchondral cyst formation
296 Chapter 21
References
1. Adkisson HD, Gillis MP, Davis EC, Maloney W, Hruska KA. In vitro generation of scaffold independent
neocartilage. Clin Orthop Relat Res. 2001;(391 suppl):S280-S294.
2. Bonasia DE, Martin JA, Marmotti A, et al. Cocultures of adult and juvenile chondrocytes com-
pared with adult and juvenile chondral fragments: in vitro matrix production. Am J Sports Med.
2011;39(11):2355-2361.
3. Tompkins M, Hamann JC, Diduch DR, et al. Preliminary results of a novel single-stage cartilage resto-
ration technique: particulated juvenile articular cartilage allograft for chondral defects of the patella.
Arthroscopy. 2013;29(10):1661-1670.
4. Farr J, Tabet SK, Margerrison E, Cole BJ. Clinical, radiographic, and histological outcomes after carti-
lage repair with particulated juvenile articular cartilage: a 2-year prospective study. Am J Sports Med.
2014;42(6):1417-1425.
5. Minas T, Gomoll AH, Rosenberger R, Royce RO, Bryant T. Increased failure rate of autologous chon-
drocyte implantation after previous treatment with marrow stimulation techniques. Am J Sports Med.
2009;37(5):902-908.
6. Pestka JM, Bode G, Salzmann G, Südkamp NP, Niemeyer P. Clinical outcome of autologous chondro-
cyte implantation for failed microfracture treatment of full-thickness cartilage defects of the knee joint.
Am J Sports Med. 2012;40(2):325-331.
7. Mithoefer K, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR. Clinical efficacy of the microfrac-
ture technique for articular cartilage repair in the knee: an evidence-based systematic analysis. Am J
Sports Med. 2009;37(10):2053-2063.
8. Kreuz PC, Steinwachs MR, Erggelet C, et al. Results after microfracture of full-thickness chondral
defects in different compartments in the knee. Osteoarthritis Cartilage. 2006;14(11):1119-1125.
Introduction
High tibial osteotomy (HTO) for the treatment of varus gonarthrosis isolated to the medial
compartment of the knee was first described by Jackson et al in 19581 and popularized by
Coventry.2 Valgus-producing HTO for medial joint gonarthrosis has evolved from a lateral clos-
ing wedge to a medial opening wedge, and both techniques are recognized as joint-preserving
alternatives to unicompartmental and total knee arthroplasty, specifically in younger patients.3,4
Many studies have shown good patient-reported outcomes and survivorship following limb
realignment with an HTO for medial joint gonarthrosis.5,6 A varus-producing distal femoral
osteotomy (DFO) can be performed to unload the lateral compartment with valgus malalignment,
which also provides good results.7
The use of HTO and DFO for the treatment of gonarthrosis follows the theory of limb realign-
ment in the coronal plane in order to unload the affected knee compartment and transfer the
weightbearing forces through the healthy knee compartment.5,8 Valgus-producing osteotomies to
unload the medial compartment are typically performed with an HTO (medial opening wedge
or lateral closing wedge), whereas varus producing-osteotomies to unload the lateral compartment
are performed with a DFO (medial opening wedge or lateral closing wedge) or lateral opening
wedge HTO.
Osteotomies can also be used in the treatment of ligamentous instability in the setting of
malalignment. Coronal plane realignment can be used to protect ligamentous reconstructions.9-12
In addition, altering the tibial slope on the sagittal plane can be performed to treat posterior
(PCL) or anterior cruciate ligament (ACL) insufficiency.13,14 Corrections to the tibial slope can
be performed with a direct anterior wedge osteotomy or through a medial or lateral wedge biplanar
osteotomy (to address coronal and sagittal alignment).13
Multiple HTO and DFO techniques have been described in the literature for a variety of
conditions, both gonarthrosis and ligamentous instability. This chapter describes the authors’
technique of a medial opening wedge HTO for medial gonarthrosis and medial closing wedge
DFO for lateral gonarthrosis.
Indications
High Tibial Osteotomy (Medial Opening Wedge)
▶ Gonarthrosis isolated to the medial compartment with varus malalignment
▶ Age younger than 60 years
▶ Good range of motion (ROM)
▶ Ligamentous knee stability5 (but it is indicated in some ACL-/PCL-deficient patients)
▶ Associated with meniscal or osteochondral transplantation
Controversial Indications
▶ Knee with significant motion loss
▶ Inflammatory arthritis
▶ Associated patellofemoral or low-grade contralateral compartment arthritis (compartment
that the mechanical axis is shifting to needs to be relatively well preserved)
▶ Advanced age5,6,15
▶ Obesity5
▶ Relative contraindications include smoking and diabetes mellitus given the increased rate of
complications in these patient populations.
Contraindications
▶ Contraindications for a DFO include advanced age, stiffness, tricompartmental disease, and
inflammatory arthritis.7,18,19
Figure 22-1. Draw the mechani- Figure 22-2. From the center
cal axis of the leg from the center of the hip, draw a line to the
of the hip to the center of the desired correction point in the
ankle. lateral compartment and a line
to that point from the center of
the ankle.
Pertinent Imaging
▶ Bilateral weightbearing
▶ Anteroposterior (AP) in full extension
▶ Rosenberg or tunnel view (AP in 30 to 45 degrees of flexion)
▶ Lateral
▶ Skyline views
▶ Weightbearing hips-to-ankles AP x-ray to assess weightbearing axis and calculate correction 20
When unloading the medial compartment with a valgus-producing osteotomy, most authors
aim to correct the weightbearing line to intersect in the lateral compartment at Fujisawa’s point,
62.5% along the medial to lateral width of the tibia.15,21 However, correction to Fujisawa’s point
is largely arbitrary, as this has never been validated.22 The authors believe that correction to the
midpoint of the lateral tibial spine downslope is sufficient. Studies in the authors’ gait analysis
laboratory suggest that this reduces the adduction moment during the gait cycle by 50% on aver-
age (unpublished data). The method for calculating the degree of correction in a medial opening
wedge HTO is shown in Figures 22-1 through 22-3. Calculations for the varus-producing oste-
otomy are similar; however, when performing a varus-producing osteotomy, it is largely accepted
to correct the alignment to neutral.7
300 Chapter 22
Figure 22-3. Draw line A, which represents the osteotomy; this line
stops 7 to 10 mm inside the lateral cortex of the tibia. Draw line B, which
is identical in length to line A. Distance C represents the amount the
osteotomy will need to be opened for the desired mechanical axis to be
achieved.
Equipment
▶ Fluoroscopy
▶ Radiolucent operating room table
▶ Positioning bundle
▶ Large curved blunt Hohmann retractor (Figure 22-4) for posterior retraction
▶ Narrow curved retractor (see Figure 22-4) for anterior retraction
▶ Calibrated pin (or break-away pins)
▶ Oscillating saw
▶ Wide and narrow flexible osteotomes (Figure 22-5)
▶ Opening wedge (Figure 22-6A)
▶ Laminar spreader (optional) (Figure 22-6B)
▶ Plate fixation (TomoFix, Puddu plate, Contourlock, iBalance)
▶ Bone graft, synthetic or allograft (optional)
Figure 22-5. (A-C) Thin, sharp osteotomes are useful following a limited saw cut followed by a
calibrated osteotome to ensure the lateral hinge is maintained.
B
302 Chapter 22
A B
Figure 22-7. (A, B) A break-away calibrated guide pin is inserted immediately above the
proposed plane of the osteotomy under fluoroscopic guidance. It is best to bring the C-arm
from the operative side and perform the surgery from the medial position.
Anesthetic Considerations
The standard at the authors’ institution is a general anesthetic with or without a supplementary
regional block at the discretion of the anesthetic team. The exception to this is when a tibial tubercle
osteotomy or biplanar cut is anticipated, which would violate the anterior compartment of the lower
leg; it is best to avoid a regional block for fear of masking a potential compartment syndrome. This
is not an issue with standard medial opening tibial wedge HTO (MOWHTO) or DFO.
Positioning
Fluoroscopic guidance is essential to perform an osteotomy; therefore, one will need to use
a radiolucent operating table. The author uses a trauma table or, more frequently, a radiolucent
extension on a standard operating table. One may consider a small bolster, such as a 3-L saline bag,
under the operative hip, to avoid excessive external hip rotation. If arthroscopy is being considered,
lateral posts can be easily added to the setup. A pneumatic tourniquet is applied to the proximal
thigh and can be inflated at the surgeon’s discretion; once a surgeon is experienced, tourniquet
times are routinely less than an hour. Plan to have a full-sized C-arm fluoroscopy unit enter the
surgical field from the same side as the operative leg with the surgeon operating from the opposite
side (Figure 22-7). The C-arm will move in and out as needed by having it move from a proximal
position over the hip to a more distal position over the knee when required. The C-arm should be
draped, and appropriate drapes should be available for the image intensifier to come to the lateral
position. After standard draping with an extremity drape or U-drapes (for distal femoral access),
Proximal Tibial and Distal Femoral Osteotomy 303
the operative side can be elevated above the nonoperative side using a positioning pack (sterile
sheets or towels); this places the knee in slight flexion and makes it easier to retract and to get a
lateral x-ray when needed.
Figure 22-9. Following dissection through the skin and subcutaneous tissue, the sartorius fascia
is opened just above the gracilis tendon and the pes anserinus is released off the tibia for 1 cm
distally.
Figure 22-10. The pes anserinus tendons are retracted distally, the posteromedial edge of the
tibia is identified, and the attachment of the popliteus muscle is elevated off the flare of the
tibia. A Cobb elevator can be gently inserted directly on the posterior tibial cortex and a blunt
Hohmann retractor slid across the posterior tibia. This is a key step in protecting neurovascular
structures posteriorly.
allowed to fall back over the osteotomy at the end of the procedure. A small oscillating saw blade
is chosen (45 mm long), and the cut is made staying perfectly inline and below the guide pin.
Commit to the plane of the cut, especially anterior to the pin, so that the surgeon does not wander
more proximally toward the joint than desired. Once the initial cut is made with the saw, thin
osteotomes can be used. Keep a 10-mm bridge of bone on the lateral side and use the C-arm to
follow each step. During cutting, the retractors should remain in the same plane as the saw or
osteotome for safety. Once the surgeon feels he or she has completed the desired cut, a wide, firm
osteotome can be inserted, and mobility of the osteotomy can be assessed by gently levering on
this instrument. Usually, if minimal movement is noted, the posterior cortex needs to be cut a little
further. To open the osteotomy, you can use stacked osteotomes or wedges to open to the desired
amount. The authors like to use the equipment from the original Puddu set along with laminar
Proximal Tibial and Distal Femoral Osteotomy 305
Figure 22-11. The osteotomy is planned out from a point anteriorly just at the patellar tendon
attachment on the tibial tubercle to a point angling posteriorly and distally. The superficial MCL
can be elevated up or cut directly in line with the proposed osteotomy. This does not destabilize
the medial side of the knee.
Figure 22-12. Upon completion of the osteotomy, a calibrated wedge or laminar spreader is
used to open the osteotomy. Be sure to keep the wedge to the very posterior aspect to avoid
increasing tibial slope and also to stay out of the way of plate positioning.
spreaders as needed. Gauge the amount of opening off the posteromedial aspect of the osteotomy;
to keep the slope neutral, do not use a wedge more anteriorly because this will open the front and
increase the slope (this can be desirable in cases of PCL insufficiency but not in cases of ACL
insufficiency or medial arthrosis; Figure 22-12). It is important to try to maintain the integrity of
the lateral column of bone to prevent translation and maintain stability. The tip of the osteotomy
on the lateral side should always be closer to the lateral cortex than to the lateral joint line; this
will avoid intra-articular fractures (Figure 22-13).
Once the osteotomy is complete and is held open with a wedge or laminar spreader to the desired
amount, one can then apply hardware to maintain the correction. The authors prefer a locking plate
to maintain axial and rotational stability during the consolidation period. The plate is placed on top
of the fascial layer using spacer screws to hold the plate slightly off the bone (Figure 22-14). While
306 Chapter 22
Figure 22-14. A locking plate is then inserted subcutaneously superficial to the pes anserinus,
minimizing any periosteal stripping. Spacer screws can help hold the plate from compressing
the soft tissues as it is fixed. A small stab wound facilitates distal fixation. Grafting the defect can
be performed with autograft, allograft, or bone graft substitutes.
inserting screws using the C-arm to confirm safe positioning, one can usually place 4 locking screws
proximal and distal to the osteotomy with proper plate position. Check the lateral fluoroscopic
view to ensure that screws are not extending beyond the posterior cortex. After one is satisfied with
the fixation, one may consider filling the defect with bone graft or a bone graft substitute (Figure
22-15). The authors prefer allograft cancellous chips combined with 1 g of vancomycin for correc-
tions of greater than 8 mm; no graft is used for smaller corrections. The wound is closed over a one-
eighth-in suction drain that is removed the following day. One may chose an icing sleeve and/or a
hinged knee brace for added comfort.
Proximal Tibial and Distal Femoral Osteotomy 307
A B
Figure 22-16. Medial femoral closing wedge Figure 22-17. On the lateral
osteotomy to correct valgus deformity. Two view, an optional biplane cut is
pins are inserted equal distance A, converg- demonstrated (arrow).
ing upon point B, which is just above the
trochlea and 10 mm medial to the cortex.
on the medial femur with fluoroscopic guidance. The authors prefer to use the Medial TomoFix
Plate (DePuy Synthes). The plate is lined up with the anterior aspect of the plate flush with the
anterior cortex of the femur. There is room for 4 screws above and below the osteotomy. The lower
cut of the osteotomy should be approximately 10 mm above the superior extent of the trochlea;
a small arthrotomy may be necessary to palpate this landmark. The proposed osteotomy is then
marked using electrocautery on the medial cortex perpendicular to the long axis of the femur. To
make the osteotomy close with cortical contact, one should have both limbs of the osteotomy of
equal length with the apex 10 mm medial to the lateral cortex (Figure 22-16). The apex should
be below the level of the medial epicondyle because the MCL will provide additional restraint to
translation of the osteotomy (Figure 22-16, blue dot). K-wires can be used as cutting guides, being
sure to account for the thickness of the saw blade when planning the wedge. While using the saw,
use plenty of irrigation to avoid heat build-up on the blade. The posterior Hohmann retractor
should be right in line with the saw at all times. A series of osteotomes can be used to complete
the cuts as needed. The bone wedge is then removed. A biplanar cut can be performed as an
option to increase the stability and surface area of the osteotomy (Figure 22-17). Fixation is then
achieved using standard fracture fixation techniques to achieve compression across the osteotomy
site (Figures 22-18 through 22-20).
Postoperative Protocol
Patients are kept overnight in most situations, although with healthy younger patients with
good perioperative pain management, one can consider outpatient surgery. Prophylactic antibiot-
ics and anticoagulation can be given per the surgeon’s preference. The brace is locked at 0 degrees
overnight then unlocked after a dressing change and drain removal the following morning.
The brace is set at 0 to 90 degrees. During the first 2 weeks, the patient is on crutches and is
Proximal Tibial and Distal Femoral Osteotomy 309
A B
Figure 22-20. (A, B) A medial closing wedge femoral osteotomy is secured with a locking plate.
If performed as described, this is a very stable construct that will tolerate early weightbearing
and motion.
feather-touch weightbearing. The patient is reassessed for wound healing at this stage and is then
allowed to put as much weight as tolerated through the operative leg so long as no complications
with the fixation are noted on x-rays. In general, it takes another 3 or 4 weeks of crutch usage
before patients can walk without aids. The brace is removed for therapy, and full ROM and iso-
metric quadriceps and hamstring exercises are encouraged. The use of a stationary bike without
310 Chapter 22
resistance and water therapy are allowed when the wound is well healed. After 6 weeks, the brace
is discontinued, and progressive closed chain strengthening is used. Patients are followed routinely
at 2, 6, 12, 26, and 52 weeks. It is not uncommon for the osteotomy to take a full 6 months to
unite and 1 year to remodel.
Potential Complications
Complications can be looked at in 3 classes. Class 1 includes complications considered minor
that do not require treatment and do not affect outcome. Class 2 complications require nonopera-
tive medical treatment. Class 3 complications are more severe and required surgical management
and/or long-term medical treatment. A review of complications on 323 osteotomies performed in
the authors’ center was performed.23 The incidence of complications is multifactorial and is influ-
enced by the following factors: body mass index, systemic illness (diabetes mellitus), size of the
correction, hardware system used, and how and when one defines delayed union.
Class 1 complications included undisplaced lateral cortex breach (20%), displaced lateral corti-
cal breach 2 mm or greater (6%), delayed wound healing (6%), undisplaced tibial plateau fracture
(3%), hematoma (3%), and increased tibial slope (1%). Class 2 complications included delayed
union after 3 months that resolved by 6 months (12%), cellulitis (10%), limited hardware failure
(broken screw; 4%), stiffness (1%), deep vein thrombosis (1%), and chronic regional pain syndrome
(1%). Class 3 complications included aseptic nonunion (3%), deep infection (2%), chronic regional
pain syndrome (1%), gross hardware failure and correction loss (1%), and additional surgery (3%).
These complications can be minimized by careful patient selection (avoid insulin-dependent
diabetics) and meticulous technique (avoid penetrating the lateral cortex or cutting proximally
toward the plateau), including wound closure. Use a locking plate system to minimize mechanical
failure during bone healing. If these issues are avoided, the important class 3 complication rate is
low (3% reoperation rate). One additional issue is the need for hardware removal; in the authors’
experience, this is necessary 30% to 40% of the time.
References
1. Jackson JP, Waugh W, Green JP. High tibial osteotomy for osteoarthritis of the knee. J Bone Joint Surg Br.
1969;51(1):88-94.
2. Coventry MB. Osteotomy of the upper portion of the tibia for degenerative arthritis of the knee. A prelimi-
nary report. J Bone Joint Surg Am. 1965;47:984-990.
3. Smith TO, Sexton D, Mitchell P, Hing CB. Opening- or closing-wedged high tibial osteotomy: a meta-
analysis of clinical and radiological outcomes. Knee. 2011;18(6):361-368.
4. Hoell S, Suttmoeller J, Stoll V, Fuchs S, Gosheger G. The high tibial osteotomy, open versus closed wedge, a
comparison of methods in 108 patients. Arch Orthop Trauma Surg. 2005;125(9):638-643.
5. Amendola A, Bonasia DE. Results of high tibial osteotomy: review of the literature. Int Orthop.
2010;34(2):155-160.
6. Floerkemeier S, Staubli AE, Schroeter S, Goldhahn S, Lobenhoffer P. Outcome after high tibial open-
wedge osteotomy: a retrospective evaluation of 533 patients. Knee Surg Sports Traumatol Arthrosc.
2013;21(1):170-180.
7. Puddu G, Cipolla M, Cerullo G, Franco V, Gianni E. Osteotomies: the surgical treatment of the valgus knee.
Sports Med Arthrosc. 2007;15(1):15-22.
8. Saithna A, Kundra R, Modi CS, Getgood A, Spalding T. Distal femoral varus osteotomy for lateral compart-
ment osteoarthritis in the valgus knee. A systematic review of the literature. Open Orthop J. 2012;6:313-319.
9. Noyes FR, Barber SD, Simon R. High tibial osteotomy and ligament reconstruction in varus angu-
lated, anterior cruciate ligament-deficient knees. A two- to seven-year follow-up study. Am J Sports Med.
1993;21(1):2-12.
10. Noyes FR, Barber-Westin SD, Hewett TE. High tibial osteotomy and ligament reconstruction for varus
angulated anterior cruciate ligament-deficient knees. Am J Sports Med. 2000;28(3):282-296.
11. Dejour H, Neyret P, Boileau P, Donell ST. Anterior cruciate reconstruction combined with valgus tibial
osteotomy. Clin Orthop Relat Res. 1994;(299):220-228.
12. Trojani C, Elhor H, Carles M, Boileau P. Anterior cruciate ligament reconstruction combined with valgus
high tibial osteotomy allows return to sports. Orthop Traumatol Surg Res. 2014;100(2):209-212.
13. Giffin JR, Shannon FJ. The role of the high tibial osteotomy in the unstable knee. Sports Med Arthrosc.
2007;15(1):23-31.
14. McNamara I, Birmingham TB, Fowler PJ, Giffin JR. High tibial osteotomy: evolution of research and clini-
cal applications—a Canadian experience. Knee Surg Sports Traumatol Arthrosc. 2013;21(1):23-31.
15. Rossi R, Bonasia DE, Amendola A. The role of high tibial osteotomy in the varus knee. J Am Acad Orthop
Surg. 2011;19(10):590-599.
16. Collins B, Getgood A, Alomar AZ, et al. A case series of lateral opening wedge high tibial osteotomy for
valgus malalignment. Knee Surg Sports Traumatol Arthrosc. 2013;21(1):152-160.
17. Healy WL, Anglen JO, Wasilewski SA, Krackow KA. Distal femoral varus osteotomy. J Bone Joint Surg Am.
1988;70(1):102-109.
18. Stahelin T, Hardegger F, Ward JC. Supracondylar osteotomy of the femur with use of compression.
Osteosynthesis with a malleable implant. J Bone Joint Surg Am. 2000;82(5):712-722.
19. Wang JW, Hsu CC. Distal femoral varus osteotomy for osteoarthritis of the knee. Surgical technique. J Bone
Joint Surg Am. 2006;88(suppl 1 pt 1):100-108.
20. Dugdale TW, Noyes FR, Styer D. Preoperative planning for high tibial osteotomy. The effect of lateral tibio-
femoral separation and tibiofemoral length. Clin Orthop Relat Res. 1992;(274):248-264.
21. Fujisawa Y, Masuhara K, Shiomi S. The effect of high tibial osteotomy on osteoarthritis of the knee. An
arthroscopic study of 54 knee joints. Orthop Clin North Am. 1979;10(3):585-608.
22. Amis AA. Biomechanics of high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2013;21(1):197-205.
23. Martin R, Birmingham TB, Willits K, Litchfield R, Lebel ME, Giffin JR. Adverse event rates and classifica-
tions in medial opening wedge high tibial osteotomy. Am J Sports Med. 2014;42(5):1118-1126.
Introduction
The anatomy of the cruciate ligaments has been described as far back as the Egyptians in
3000 BC. Around 170 AD, Galen first described the anterior cruciate ligament (ACL) as a sup-
portive structure of the knee that prevented abnormal knee motion.1,2 Through the 1800s, the
understanding of the ACL evolved, and near the turn of the 20th century, the first case reports
of repair of the ACL emerged.3,4 An estimated 175,000 ACL reconstructions are performed
each year, with revision rates reported from 1.5% to 20%.5-8 In the 1970s, reports of primary
ACL repair with or without augmentation were successful in approximately 70% of cases with
higher success in proximal tears. This overall 20% to 30% failure rate led to the abandonment
of ACL repair in most cases.9-14 The trouble with interpretation of early studies was that these
studies included many midsubstance tears, which have clearly shown a lesser potential for heal-
ing. However, Marshall et al12 reported a series of ACL repairs, including 56 of 70 patients with
midsubstance, mop-end tears. Using a multiple-looped, varying-depth suture repair, the group
overall achieved a 90% return to sports with 68% at preinjury level of function.12 Higgins and
Steadman15 reported a series of elite downhill skiers who underwent primary ACL repair with
iliotibial band tenodesis. They had an average return to competitive skiing at 9.1 months in all but
3 skiers, pain-free function in 78%, and a normal pivot shift in 85% of patients.15 The belief that
the ACL lacked the potential to heal was widely held,16,17 despite several studies showing definite
healing of a torn ACL.18-20 Arthroscopic reconstruction techniques improved, and a rapid shift to
ligament reconstruction took place.
Recent advances in orthobiologics have demonstrated promising results of primary ACL repair
in human and animal studies.21-29 The addition of collagen scaffolds into the repair has enhanced
healing, 24,26,27 and a renewed interest in ACL repair has emerged. Microfracture of the ligament
insertion site provides the local environment with growth factors and enhances ligament heal-
ing.21 With an estimated 175,000 ACL reconstructions performed each year in the United States,
future research will focus on ACL repair and preservation. In summary, of the available literature,
proximal ligament avulsions can be repaired primarily with multiple-looped, varying-depth suture
repair using soft tissue graft augmentation. This maintains the native ligament’s propriocep-
tive function, minimizes donor site morbidity, and can produce acceptable outcomes in properly
selected patients.
Indications
▶ Indications include proximal or “off-the-wall” tears with good-quality tissue remaining.
Controversial Indications
▶ Controversial indications include midsubstance ruptures and distal ligament avulsions.
Pertinent Imaging
▶ Plain x-rays
▷ Standing anteroposterior in extension and at 30 degrees of flexion
▷ Lateral view
▷ Sunrise patella view
▶ Magnetic resonance imaging (MRI) is especially helpful in potential ligament repair situa-
tions to evaluate the location of the tear and tissue quality (Figure 23-1).
Arthroscopic Anterior Cruciate Ligament Repair 317
Equipment
In addition to standard arthroscopic tools, ACL repair requires additional instruments. Suture
passage can be performed with a suture punch (Figure 23-2). A cannula through one of the portals
aids in preventing capsular tissue from being inadvertently captured by the sutures. A rear-entry,
outside-in ACL drill guide (Figure 23-3) is useful to prevent damage to the remaining ACL tissue
by the drill tip. A large curved introducer or rear-entry hook used to position the outside-in drill
guide is also helpful in passing sutures over the top of the lateral femoral condyle (Figure 23-4).
Varying-sized drills and ACL guides are necessary for tunnels. Drills for graft tunnels are usually
smaller (6 to 8 mm) compared to standard reconstruction tunnels (9 to 11 mm). A bone pick or awl
can be used to microfracture the footprint.21 Graft fixation is completed with absorbable interfer-
ence screws in the femoral and tibial tunnels to avoid cutting sutures in the tunnel.
and sutures from inside out, and the foot of the bed is lowered. Alternatively, the foot of the bed
can remain elevated, and the leg can be abducted over the side of the bed with a lateral post placed
to apply valgus stress.
through the bone tunnel using a looped suture or a wire. Pulling these 2 groups of sutures tight
will pull the ligament back up to the femoral attachment, restore the footprint, and recreate the
natural torsion between the 2 bundles (Figure 23-7). With the ligament pulled tight, a standard
ACL guide is placed in the posterior lateral edge of the tibial footprint, and a 7-mm tunnel is
reamed from outside-in. Care must be taken at this point not to disrupt an excessive amount of
ACL fibers or sutures with the reamer as it pierces the tibial cortex. The previously harvested
7-mm graft is then passed through the tibial tunnel and into the femoral tunnel. The native
ACL usually has to be held to the side while the graft is teased through the knee. With the knee
reduced, the ACL sutures are tensioned and tied over the femoral condyle. The graft is secured in
the femoral tunnel with a 7-mm interference screw. An absorbable, nonmetallic screw is used to
avoid cutting the sutures in the femoral tunnel. The tibial side is then secured with an interference
screw in the tibial tunnel with appropriate tension applied to the graft. The knee is carried through
a full ROM to ensure there is no impingement of the graft and that the tension is appropriate
(Figure 23-8). After routine closure, a sterile dressing and hinged knee brace are applied.
Postoperative Protocol
Using this technique of solid repair with augmentation, standard postoperative ACL protocols
can be used. Early weightbearing and active ROM are safe. Our current protocol involves frequent
icing with active straight leg leg lifts for the first 48 hours. A knee immobilizer is used for comfort.
320 Chapter 23
The patient is seen in the clinic 48 hours after surgery, and large effusions can be aspirated. Active
ROM is then initiated with weightbearing as tolerated using 2 crutches for the first 3 weeks.
During weeks 4 to 6, the patient transitions to using a single crutch in the opposite hand once able
to do a straight leg lift with no extensor lag. Stretching and strengthening are also initiated. Full
weightbearing is begun at 6 weeks without crutches. Straight-line running on smooth surfaces is
begun at 3 months, and cutting activities are started at 6 months.
Potential Complications
As in all extremity surgeries, complications such as bleeding, infection, or deep venous
thrombosis are a small risk but may occur. Specific to this procedure, sutures may pull out from
the ACL, the augmentation graft may fail, or the ligament may not heal back to the insertion.
These would lead to graft failure, and persistent instability could result. If any concomitant inju-
ries go unrecognized, stability may be affected, or further surgery may be required to address
the symptomatic knee. Donor site morbidity can be significant, and graft choice must be patient
dependent.
References
1. Snook GA. A short history of the anterior cruciate ligament and the treatment of tears. Clin Orthop
Relat Res. 1983;(172):11-13.
2. Davarinos N, O’Neill BJ, Curtin W. A brief history of anterior cruciate ligament reconstruction.
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3. Battle WH. Suture of the crucial ligaments. Br Med J. 1902;2(2189):1879.
4. Robson AW. Ruptured crucial ligaments and their repair by operation. Ann Surg. 1903;37(5):716-718.
5. Chahal J, Lee A, Heard W, Bach B. A retrospective review of anterior cruciate ligament reconstruction
using patellar tendon: 25 years of experience. Orthop J Sports Med. 2013;1(3):1-7.
6. Lyman S, Koulouvaris P, Sherman S, Do H, Mandl LA, Marx RG. Epidemiology of anterior cruciate
ligament reconstruction: trends, readmissions, and subsequent knee surgery. J Bone Joint Surg Am.
2009;91(10):2321-2328.
Arthroscopic Anterior Cruciate Ligament Repair 321
7. Lind M, Menhert F, Pedersen AB. Incidence and outcome after revision anterior cruciate ligament
reconstruction: results from the Danish registry for knee ligament reconstructions. Am J Sports Med.
2012;40(7):1551-1557.
8. Barrett AM, Craft JA, Replogle WH, Hydrick JM, Barrett GR. Anterior cruciate ligament graft failure: a
comparison of graft type based on age and Tegner activity level. Am J Sports Med. 2011;39(10):2194-2198.
9. Feagin JA Jr, Curl WW. Isolated tear of the anterior cruciate ligament: 5 year follow-up study. Am J
Sports Med. 1976;4(3):95-100.
10. Strand T, Mølster A, Hordvik M, Krukhaug Y. Long-term follow-up after primary repair of the anterior
cruciate ligament: clinical and radiological evaluation 15-23 years postoperatively. Arch Orthop Trauma
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11. Taylor DC, Posner M, Curl WW, Feagin JA. Isolated tears of the anterior cruciate ligament: over 30-year
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12. Marshall JL, Warren RF, Wickiewicz TL. Primary surgical treatment of anterior cruciate ligament
lesions. Am J Sports Med. 1982;10(2):103-107.
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cruciate ligament repair. Defining a rationale for augmentation. Am J Sports Med. 1991;19(3):243-255.
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ment. [Invited Editorial, electronic]. J Bone Joint Surgery (Am). August 2001.
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injuries—conservative treatment using an extension block soft brace without anterior stabilization.
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19. Andersson C, Odensten M, Gillquist J. Knee function after surgical or nonsurgical treatment of acute
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injuries to the ligaments of the knee. A prospective randomized study. J Bone Joint Surg Am.
1987;69(8):1120-1126.
21. Gobbi A, Bathan L, Boldrini L. Primary repair combined with bone marrow stimulation in acute ante-
rior cruciate ligament lesions: results in a group of athletes. Am J Sports Med. 2009;37(3):571-578.
22. Joshi SM, Mastrangelo AN, Magarian EM, Fleming BC, Murray MM. Collagen-platelet composite
enhances biomechanical and histologic healing of the porcine anterior cruciate ligament. Am J Sports
Med. 2009;37(12):2401-2410.
23. Vavken P, Fleming BC, Mastrangelo AN, Machan JT, Murray MM. Biomechanical outcomes after bio-
enhanced anterior cruciate ligament repair and anterior cruciate ligament reconstruction are equal in a
porcine model. Arthroscopy. 2012;28(5):672-680.
24. Murray MM, Spindler KP, Ballard P, Welch TP, Zurakowski D, Nanney LB. Enhanced histologic repair
in a central wound in the anterior cruciate ligament with a collagen-platelet-rich plasma scaffold.
J Orthop Res. 2007;25(8):1007-1017.
25. Murray MM, Spindler KP, Abreu E, et al. Collagen-platelet rich plasma hydrogel enhances primary
repair of the porcine anterior cruciate ligament. J Orthop Res. 2007;25(1):81-91.
26. Murray MM, Spindler KP, Devin C, et al. Use of a collagen-platelet rich plasma scaffold to stimulate
healing of a central defect in the canine ACL. J Orthop Res. 2006;24(4):820-830.
27. Murray MM, Fleming BC. Use of a bioactive scaffold to stimulate anterior cruciate ligament healing
also minimizes posttraumatic osteoarthritis after surgery. Am J Sports Med. 2013;41(8):1762-1770.
28. Konda E, Yasuda K, Yamanaka M, Minami A, Tohyama H. Effects of administration of exogenous
growth factors on biomechanical properties of the elongation-type anterior cruciate ligament injury
with partial laceration. Am J Sports Med. 2005;33(2):188-196.
322 Chapter 23
29. Pascher A, Steinert AF, Palmer GD, et al. Enhanced repair of the anterior cruciate ligament by in situ
gene transfer: evaluation in an in vitro model. Mol Ther. 2004;10(2):327-336.
30. Katz JW, Fingeroth RJ. The diagnostic accuracy of ruptures of the anterior cruciate ligament comparing
the Lachman test, the anterior drawer sign, and the pivot shift test in acute and chronic knee injuries.
Am J Sports Med. 1986;14(1):88-91.
Indications
The goal of anterior cruciate ligament (ACL) reconstruction is to produce a stable, functional
knee that allows the patient to return to his or her preinjury level of activity while minimizing
comorbidities and postinjury arthritis. Over the past 2 decades, multiple reports have compared
various graft choices and outcomes.1-8 The heterogeneity of surgical techniques (ie, tunnel place-
ment, graft fixation, and rehabilitation protocol) makes comparison of the outcomes of the differ-
ent graft choices difficult.
In addition, numerous variables and factors contribute to the success and outcome of ACL
reconstruction, namely additional injuries at the time of ACL (ie, chondral, meniscal, or multilig-
amentous) injury, patient anatomy (ie, constitutional varus, narrow notch, small ACL footprint),
surgical technique, graft fixation, rehabilitation protocol, and time of release to sport activities.9-13
Therefore, not all ACL injuries or reconstructions are the same.
The ideal graft choice in ACL reconstruction remains elusive. Grafts can be autograft or
allograft tissue. For autografts, the 3 prevalent choices include bone patellar tendon bone (BPTB),
hamstring tendons (HT), or quadriceps tendon (QT; with or without a patellar bone plug).
Allograft tissue can be procured from the BPTB, hamstring, tibialis anterior, Achilles, or poste-
rior tibialis, as well.
Autografts are the most widely used method for ACL reconstructions worldwide. Maletis et
al14 reported 57.6% use of autografts in primary ACL reconstructions in a community-based reg-
istry. Globally, it seems that hamstring autograft is the most widely used autograft. The Danish
Registry reports usage of the hamstring autograft 85% of the time.15 In Sweden, 96.1% of ACL
reconstructions in 2011 used hamstring autograft.16 The Norwegian Registry documented 76.7%
usage of hamstring autograft for ACL reconstructions in 2012.17
Hamstring autografts seem to be preferred to obviate the comorbidities associated with BPTB
harvest, such as anterior knee pain, kneeling pain, loss of extension, quadriceps weakness, and
the development of osteoarthritis.5,18-20 The evolution of fixation of the hamstring tendon on the
femoral and tibial sides has made analyzing the literature difficult. Several studies have suggested
a higher revision rate with hamstring autograft; however, when graft fixation and technique are
the same, the results—subjective and objective—appear similar.9,18,21-23 Taylor et al 23 reported
similar results in army cadets with 2-year follow-ups using HT and patellar tendon (PT) auto-
grafts. Laxdal et al 20 compared PT to 3- and 4-stranded HT with interference fixation on the
femoral and tibial sides and found no difference in functional outcome or knee laxity; the HT
group had less pain with knee-walking. However, Lidén et al 24 reported no difference in objec-
tive or subjective outcomes, including kneeling pain, with 7-year follow-up. Pinczewski et al 21
reported excellent results with PT and HT autografts at 10-year follow-up; however, there were
decreased donor-site symptoms and less radiographic osteoarthritis in the HT group. Aglietti et
al9 also reported no difference at 2 year follow-up between HT and PT when technique and fixa-
tion methods were identical. Several meta-analyses have sought to independently analyze the lit-
erature. The 2011 Cochrane review found no difference between the 2 graft choices for long-term
functional outcome; however, they found that PT grafts were more likely to result in statically
stable knees but were also more likely to develop anterior knee pain.7
QT autograft has recently been advocated as a viable alternative to HT and PT. The tendon can
be harvested with or without a patellar bone plug. There is versatility with respect to the length
and diameter of the tendon that is harvested. Sasaki et al 25 demonstrated that the QT restores
knee kinematics under cadaveric testing conditions. Lund et al 26 compared QT to BPTB in a pro-
spective randomized study. They reported similar anterior knee stability and subjective outcomes
in both groups; however, there was less donor site morbidity in the QT group.26
Allograft tissue is widely used because its availability has increased over the past decade.
Allografts potentially eliminate the comorbidities associated with autograft harvest and decrease
surgical time. However, concern remains about delayed graft incorporation, disease transmis-
sion, and the integrity of the mechanical properties based on the sterilization methods used.27-30
In analyzing the survivorship of allograft tissue, it is imperative to understand the procurement
technique and sterilization method used. Krych et al 29 found no significant difference in graft
failure rate, postoperative laxity, or patient-reported outcomes in comparing nonirradiated ACL
reconstruction to autografts in a systemic review. Park et al31 also found superior results compar-
ing nonirradiated allografts to those using low-dose (< 2.5 Mrad) irradiated allografts. Krych
et al 29 performed a meta-analysis of PT autograft vs allograft. When irradiated and chemically
processed grafts were excluded, no significant differences were found. These studies suggest that
the use of nonirradiated allografts are equivalent to autografts and are appropriate alternatives.
Graft choice depends on several factors. The authors tend to favor autografts for younger
patients because the growing literature suggests fewer long-term failures when using one’s own tis-
sue. For athletes who participate in contact and collision sports, the authors’ bias has been toward
using PT autografts. For people who tend to kneel or crawl for a living (such as plumbers or carpet
installers), the authors typically steer these patients toward HT autografts. There is a growing
trend toward using QT autografts, although the authors have little experience with this option. If
a surgeon is doing fewer than 20 ACLs per year, it is probably best to stick to one autograft only.
The authors tend to favor fresh-frozen allografts for multiligament cases, revisions, and in patients
older than 40 years.
Controversial Indications
Two variables may explain the increased early failure rate of HT autografts, including the size
of the graft and timing of return to play. The size of the quadrupled hamstring has been reported
to effect outcome. Mariscalco et al 32 found that HT autografts greater than 8 mm in diameter
had a 0.0% revision rate at 2 years compared to 7.0% with grafts 8 mm in diameter or smaller.
This suggests that HT autografts less than 8 mm in diameter may need to be augmented with
nonirradiated allograft tissue to increase the diameter of the graft size. However, the Norwegian
Registry data found no correlation between graft size and failure.17
Anterior Cruciate Ligament Graft Choices and Harvest Techniques 325
The results from the Danish Registry found a 3.8-fold increased relative risk of revision 1 year
after ACL reconstruction using HTs compared to BPTB. However, patient-reported outcome
measures, the Tegner score, and Knee Injury and Osteoarthritis Outcome Score subscores of
sports and activities of daily living were higher for HT grafts 1 year postoperatively compared to
BPTB.33 This suggests that consideration should be given to delaying return to sport with HT
autografts. Furthermore, Taylor et al 23 found that 75% of their hamstring reruptures were in the
first year. The combination of patients subjectively feeling better sooner after hamstring ACL
reconstruction and the documented weakness of knee flexion after hamstring harvest may cor-
relate with early graft rerupture if patients return to sports too soon.
In addition, if an anatomic ACL reconstruction is performed through an independent (ie, low
medial portal) femoral tunnel, there can be an increased incidence of graft tunnel mismatch with
BPTB autograft. The total length from the femoral tunnel to the tibial tunnel is reduced with an
anatomic ACL technique; therefore, surgeons should be prepared to fix the bone plug outside of
the tibial tunnel (ie, staples).
ACL surgeons need to be comfortable with the various graft choices and surgical techniques
and should individualize the surgery based on patient needs and expectations. Graft choice should
be considered in the context of surgeon preference, patient anatomy, patient age (ie, open growth
plates), prior surgical procedures, donor site morbidity, graft incorporation, and patient choice.
Consideration should be given to augmenting hamstring autografts less than 8 mm and prolong-
ing return to play based on the graft choice and/or fixation methods.
In the authors’ practice, if the HT graft is less than 8 mm, they augment the autograft tis-
sue with gracilis or semitendinosus nonirradiated allograft tissue. Furthermore, they try to delay
return to sports for at least 9 months with anatomic ACL reconstructions.
Harvest Techniques
Hamstring Tendon Autograft
Equipment
▶ #5 Ethibond suture x2 to secure tendon ends
▶ Hemostat
▶ HT graft harvester; open or closed
The leg is exsanguinated, and the tourniquet is inflated. A 3-cm longitudinal incision is made
about 1 cm medial to the tibial tubercle (Figure 24-2). The soft tissue is dissected down to the
sartorial fascia. A sponge can be used to sweep posteromedially to bluntly dissect and further
expose the fascia. Typically, the semitendinosus and gracilis tendons can be easily palpated digi-
tally. Forceps are used to grab the tendons with the sartorial fascia to try and elevate them off the
superficial medial collateral ligament (MCL) which lies just beneath the 2 tendons (Figure 24-3).
The tendons are sharply dissected off their insertion on the tibia. Again, care is used to protect
the superficial MCL. A Metzenbaum scissor is then used to separate the sartorial fascia from the
2 tendons. The fascia is splint longitudinally.
The tendons can now be visualized on their posterior surfaces and distinguished from each
other. The Metzenbaum scissors are used to split the 2 tendons. The 2 tendons can then be indi-
vidually sutured with a #2 Ethibond suture (Figure 24-4). Once the 2 tendons are secured, they
Anterior Cruciate Ligament Graft Choices and Harvest Techniques 327
need to be separated and released of their proximal adhesions. This is a critical step; if the tendons
are prematurely harvested before the extraneous strands of tendon are released, they could easily be
amputated prematurely. A simple test is to pull on the individual tendons; if there is any dimpling
of the calf, additional calf adhesions need to be released. Releasing the adhesions can be done
digitally or cut under direct visualization with scissors. Sometimes it is necessary to blindly insert
a curved hemostat to retrieve a posterior calf adhesion and deliver it into the wound. The adhesion
can then be sharply cut with a scalpel over the hemostat.
Once all the proximal adhesions are released and there is no further dimpling around the
posterior calf with pulling on the tendons, the hamstrings are ready for harvest. The leg is flexed
90 degrees to protect the saphenous nerve. A closed-loop harvester is placed over the tendon, and
a hemostat is wrapped around the suture. A push-pull technique is used and the hamstrings are
sequentially harvested (Figure 24-5).
328 Chapter 24
Figure 24-4.
The 2 tendons
are individually
secured with
nonabsorbable
suture.
B
Anterior Cruciate Ligament Graft Choices and Harvest Techniques 329
The tourniquet is deflated after the hamstrings have been successfully harvested. The grafts
are brought to the back table and prepared. The muscle is removed from the tendon sharply or
bluntly with the back end of a metal ruler or Cobb elevator (Figure 24-6). The hamstrings are each
folded over a #5 Ethibond suture and passed through a tunnel sizer to determine the appropriate
tunnel diameter for the quadrupled HT graft. If the graft diameter is less than 8 mm, the authors
consider augmenting with nonirradiated allograft tissue. The tibial footprint is measured with an
arthroscopic ruler, and if the diameter of the quadrupled autograft tendons is less than 60% of the
tibial footprint, allograft is also considered to augment the graft construct.
The graft ends are then whip stitched with #5 Ethibond suture for a length of 30 mm on each
end. A Krackow- or Bunnel-type stitch is typically used (Figure 24-7). Once the tendon ends have
been sutured, they are placed under tension with a graft harvester, and a moist sponge is wrapped
around the tendons until they are needed for graft passage.
Once the tibial bone plug has been successfully harvested, the PT is freed of the fat pad, which
is typically most adherent closer to its proximal insertion. A towel clamp is placed on the tibial
bone plug to pull the patella into the mobile window while retracting proximally. The patel-
lar bone plug is outlined with electrocautery. A triangular graft may be taken starting on either
side and moving proximally. The saw can be used to free the bone proximally. A small curved
osteotome can be used to release the bone plug. A mallet should be avoided to prevent articular
cartilage damage to the patella. Alternatively, the circular oscillating saw can be used to harvest
the patellar bone plug.
With the BPTB graft free, it is prepared on the back table (Figure 24-9). A rongeur is used to
size the bone plugs to the desired diameter. All bone should be saved for later bone grafting of the
patellar defect. The femoral bone plug is made 20 mm, and the tip is bulleted to facilitate passage
into the femoral tunnel, particularly if a low medial portal is used for femoral tunnel creation.
When preparing the graft, it is best to trim the bone rather than the soft tissue to make it slide
through the desired tunnel diameter spacer.
A single drill hole is placed close to the tip, and a #2 Ethibond suture is passed with a Keith
needle. The bone-tendon junction is marked with a marking pen, and an additional vertical mark
is placed on the cancellous side of the bone plug to help with orientation during arthroscopic
implantation.
Three drill holes—oriented at different angles—are made in the tibial bone plug. High-
strength #2 Ethibond suture is again passed with a Keith needle (Figure 24-10).
The graft is then placed under tension on the graft board, and a moist sponge is wrapped
around the graft for the duration of the case.
332 Chapter 24
exposed. Army Navy retractors can be placed, and the soft tissue window is easily mobilized to
obtain visualization proximally and distally. A 9- or 10-mm-wide graft can be obtained from the
central third of the QT. The tendon can be measured with a ruler in a proximal to distal direction
to ensure at least a length of 80 mm can be obtained. With the QT exposed, the medial side of
the quadriceps is typically incised first; this can be started proximally and extended to the superior
pole of the patella. Care must be taken to avoid penetration of the scalpel into the suprapatellar
pouch (Figure 24-11). This is typically avoided medially and will allow the surgeon to get a sense
of the depth of the QT thickness. If the suprapatellar pouch is violated, it can be sutured closed to
prevent extravasation of fluid during the arthroscopic portion of the procedure.
Once the medial incision is made, a ruler is used to measure a 10-mm width to mark the start-
ing point of the lateral incision. A transverse incision is made in the QT, starting at the proximal
extent of the medial incision and connecting to the starting point of the lateral extent of the ten-
don. Forceps are used to stabilize the tendon proximally, and the lateral incision is made extending
distally. Care is taken to avoid penetration of the suprapatellar pouch.
At this point, depending on the length of the tendinous portion and surgical preference, the ten-
don harvest can be amputated from the superior pole of the patella if only a soft tissue graft is desired.
Alternatively, a bone plug from the superior pole of the patella can be obtained from the cen-
tral portion of the patella. This is typically 10 mm in width and 20 mm in length. The patella is
marked and sharply outlined with a scalpel. A small oscillating saw is used to a depth of 10 mm.
A small one-quarter-inch osteotome can be used to liberate the bone plug. Care is taken to avoid
entrance into the suprapatellar pouch.
With the graft harvested, with or without a bone plug, it is prepared on the back table. The soft
tissue ends are divided into 2 limbs; this is between the vastus intermedius and the rectus femoris.
This is a consistent finding, with a fatty stripe defining the 2 tendinosis limbs. These limbs can be
used for a double-bundle reconstruction or, more commonly, for a single-bundle reconstruction. If
a single-bundle technique is used, leave a total of 50 mm of the tendon intact (if there is no bone
plug harvested) or 30 mm of the tendon (plus an additional 20-mm bone plug). This accounts for
the femoral and the intra-articular portion of the graft (Figure 24-12).
334 Chapter 24
The 2 limbs of the graft are then whip stitched with nonabsorbable suture. If a bone plug is
obtained, a drill hole is made in the mid-aspect of the bone plug to pass a nonabsorbable suture
for graft passage.
Please refer to Table 24-1 to compare the pros and cons of the various graft choices.
References
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9. Aglietti P, Giron F, Buzzi R, Biddau F, Sasso F. Anterior cruciate ligament reconstruction: bone-patellar
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10. Andernord D, Björnsson H, Petzold M, et al. Surgical predictors of early revision surgery after anterior
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ligament graft failure: a case-control study. Am J Sports Med. 2009;37(12):2362-2367.
13. Maletis GB, Inacio MC, Desmond JL, Funahashi TT. Reconstruction of the anterior cruciate ligament:
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14. Maletis GB, Inacio MC, Funahashi TT. Analysis of 16,192 anterior cruciate ligament reconstructions
from a community-based registry. Am J Sports Med. 2013;41(9):2090-2098.
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18. Aune AK, Holm I, Risberg MA, Jensen HK, Steen H. Four-strand hamstring tendon autograft compared
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19. Ibrahim SA, Al-Kussary IM, Al-Misfer AR, Al-Mutairi HQ, Ghafar SA, El Noor TA. Clinical evaluation
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21. Pinczewski LA, Lyman J, Salmon LJ, Russell VJ, Roe J, Linklater J. A 10-year comparison of anterior
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24. Lidén M, Ejerhed L, Sernert N, Laxdal G, Kartus J. Patellar tendon or semitendinosus tendon autografts
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Anterior Cruciate Ligament Graft Choices and Harvest Techniques 337
26. Lund B, Nielsen T, Faunø P, Christiansen SE, Lind M. Is quadriceps tendon a better graft choice than
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29. Krych AJ, Jackson JD, Hoskin TL, Dahm DL. A meta-analysis of patellar tendon autograft versus patel-
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32. Mariscalco MW, Flanigan DC, Mitchell J, et al. The influence of hamstring autograft size on patient-
reported outcomes and risk of revision after anterior cruciate ligament reconstruction: a Multicenter
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33. Rahr-Wagner L, Thillemann TM, Pedersen AB, Lind M. Comparison of hamstring tendon and patel-
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Introduction
In the 1970s and early 1980s, anterior cruciate ligament (ACL) reconstruction was performed
with open surgical techniques. The development of the arthroscope and its widespread adoption led
to the evolution of the arthroscopically assisted ACL reconstruction and, subsequently, the trans-
tibial endoscopic technique. Transtibial drilling of the femoral socket for ACL reconstruction can
result in suboptimal placement of the femoral socket. Suboptimal placement puts the ACL graft in a
sagittal plane within the joint, which may not fully eliminate rotatory instability of the knee. Howell
et al1 recognized and described this graft placement as a clinical problem. They demonstrated that
the ACL needs to be in the coronal plane of the knee and described the coronal angle in the fron-
tal plane, which is the angle described by the axis of the joint line and the axis of the tibial tunnel
(Figure 25-1). If this coronal angle is more than 75 degrees, it results in a more vertical graft and
has a higher incidence of laxity and/or graft failure. The authors described a tibial start point for the
tibial tunnel, which reproducibly produces a coronal angle less than 70 degrees.2
Use of the medial portal, as a technique to more accurately place the femoral socket within the
femoral footprint of the ACL, has returned to current reconstructive techniques. Independent
drilling of the femoral socket, not constrained by the tibial tunnel, can also be facilitated by using
outside-in instrumentation in which placement of the guide or starter pin is done through an
additional portal or incision placed superolaterally. Use of the medial portal technique requires
positioning the knee so it can be flexed to 120 degrees in order to ensure an adequate length of
the femoral socket (Figure 25-2). It is also facilitated by having flexible reamers and/or guide pins
available to assist in placement of the instrumentation in such a way to avoid injury to the medial
femoral condyle articular surface. Using an outside-in technique also requires specialized instru-
mentation to facilitate performance.
With the transtibial technique, the external start point of the guide pin into the tibia influences
the locations where the femoral socket can be placed. Attention to the start point is a key step if
one undertakes a transtibial technique. The definition of a reproducible start point has been identi-
fied as the intersection between the anterior edge of the medial collateral ligament (MCL) and the
superior border of the sartorius fascia or gracilis tendon. In the authors’ study, this start point repro-
ducibly yielded a coronal angle of 70 degrees or less, allowing the surgeon to consistently place the
femoral socket within the ACL footprint.2 Nevertheless, it tends to lead to a socket that is slightly
more proximally placed within the femoral footprint compared to independent drilling techniques.
Consequently, the authors only use this technique for bone patellar tendon bone (BPTB) grafts. The
transtibial technique results in a femoral socket that is typically longer. This increased tunnel length
allows the bone block to be recessed within the femoral socket, therefore reducing the chance of
developing a graft-tunnel-length mismatch on the tibia. In order to use the transtibial technique for
BPTB grafts, one must rotate the graft such that the tendinous portion is in the more distal region
of the femoral socket and the screw is placed in the most proximal region of the socket, resulting in
a graft that is well centered within the femoral footprint.
The choice of graft material in ACL reconstruction has potential significance. Autograft tis-
sues are most commonly used. Allograft tendons are also reasonable alternatives. Recently, some
information has been presented that irradiated allografts lead to inferior results, particularly in
younger athletes.3 The most commonly used autografts are BPTB and hamstring tendons (qua-
druple semitendinosus and gracilis). Quadriceps tendon is less commonly used but is a reasonable
graft choice. Each graft material has potential advantages and disadvantages. Meta-analyses com-
paring autologous patellar tendon to hamstrings demonstrated that there are distinct differences
in the outcomes. BPTB tendon grafts have been demonstrated to result in a higher percentage
of clinically stable knees and a greater likelihood of athletes returning to preinjury athletic per-
formance.4-6 This outcome difference is not without cost because there is a greater incidence of
Single-Bundle Anterior Cruciate Ligament Reconstruction 341
GRAFT INDICATIONS
Bone-tendon-bone High-demand young athletes (high school, college, professional)
autograft Revision of failed soft tissue grafts
Quadrupled Recreational athletes younger than 40 years
hamstring autograft High-demand young athletes with patellar tendon problems
Quadriceps tendon High-demand young athletes with inadequate patellar tendons and
autograft hamstring tendons
Allograft tendons Recreational athletes older than 40 years
Multiligament-injured knees
Augment smaller hamstring autografts
anterior knee pain and quadriceps weakness in the patellar tendon group. One of the potential
issues with hamstring grafts is the diameter of the graft. Recent data suggest that grafts that are
8 mm or less in diameter have a higher failure rate than larger grafts.7 There is no single way to
predict the potential graft diameter preoperatively that is completely reproducible. The patient’s
height can be used as a preoperative predictor of potential hamstring graft diameter.8 For patients
who end up with a graft diameter of 8 mm or less, the authors have recently started augmenting
the autograft tissue with an additional allograft hamstring tendon to bring the diameter up to
9 mm or greater. To date, no data confirm whether this will improve results.
One variable that has been defined in the use of allografts is whether the tissue has been irradi-
ated. Nonirradiated or low-dose irradiated grafts that are not treated with harsh chemicals prob-
ably give the best results.9 Any surgeon using allograft tissues for ACL reconstruction should be
cognizant of the processing techniques of the available allografts in his or her institution prior to
selecting allograft tissue for use in ACL reconstruction.
The authors developed an algorithm that they use for graft selection based on the patient’s age
and athletic demands (Table 25-1). Autologous BPTB graft remains the authors’ preference for
younger, high-demand athletes. This includes competitive high school, intercollegiate, and profes-
sional athletes. For less-demanding athletes, the authors prefer a quadrupled hamstring autograft.
This would typically be for recreational athletes younger than 40 years. It also includes younger,
more athletic patients if their patellar tendons are so long as to result in a graft–tunnel mismatch.
Tendon length can be determined by the preoperative magnetic resonance imaging (MRI) scan.
As previously noted, the authors augment these hamstrings with an additional hamstring allograft
if the diameter is less than 8 mm in females and 8 mm or less in males. Finally, allograft as an
isolated tissue in the authors’ practice is reserved for patients older than 40 years old or special
situations (revision, multiligament injuries, or patient preference).
Indications
▶ Functional instability in an ACL-deficient knee
▶ Acute ACL tear in a young, active athlete
▶ Multiligament-injured knee with an ACL tear
342 Chapter 25
Controversial Indications
No consensus exists as to the optimal technique or graft selection for ACL reconstruction.
Single-bundle ACL reconstruction remains the most widely used technique, but double-bundle
techniques have been proposed, potentially resulting in better fill of the ACL footprints on
the femur and tibia and as a means of having a more anatomic configuration of the graft.
Biomechanical analyses and comparative clinical outcome studies evaluating single- vs double-
bundle techniques have been inconsistent. Due to the added complexity and cost of double-bundle
techniques, single-bundle ACL reconstruction is currently the most widely performed.
Pertinent Imaging
▶ Plain x-rays (anteroposterior and lateral)
▶ MRI
Plain x-rays are an appropriate imaging modality to start the evaluation of the acute or chronic
sports-injured knee. Although an ACL injury cannot be seen with this modality, a fracture, par-
ticularly a tibial spine avulsion or a Segond fracture, may be identified. The imaging modality
Single-Bundle Anterior Cruciate Ligament Reconstruction 343
of choice for identifying an ACL injury is MRI. This modality, if the patient is appropriately
positioned, will identify subtle damage to the ACL. MRI has the additional benefit of being able
to identify bone bruising in an acute injury. The typical bruise pattern of posterolateral tibia and
anterolateral femur is highly suggestive of a complete ACL tear. MRI is also beneficial in identify-
ing associated injuries, such as meniscal tears and additional ligament damage.
Preoperative Planning
It has become routine to delay treatment of the acute ACL tear until that time when the patient
has regained full extension, near full flexion, and resolution of the acute hemarthrosis. There is no
specific time frame for this, but early reconstruction in a joint that lacks full motion is associated
with risk of postoperative stiffness requiring additional surgery. Early physical therapy post injury,
to assist in the reduction of swelling and regaining motion while maintaining muscle strength,
is appropriate and encouraged. This therapy period allows the surgeon and patient to select a
surgery date and technique that is appropriate. For younger student athletes, delaying the surgery
to a period of vacation has been associated with better performance in school for that semester.10
Surgical timing should be discussed with the patient and the parents because a rush to reconstruct
may facilitate a quicker return to sports but may compromise the student athlete’s ability to get
into the college of his or her choice if his or her grades suffer.
ACL reconstruction is readily accomplished in an outpatient surgery center. A potential reason
to do this type of procedure in a full-service hospital is for a medical comorbidity. Although spinal
or general anesthesia can be used, supplementation with peripheral nerve blocks (typically femoral
nerve) assists with postoperative pain management.
Equipment
A multitude of orthopedic equipment manufacturers have ACL reconstruction trays that
contain the instruments necessary to complete the procedure. There are subtle differences in the
design of these, and the surgeon should be familiar with the equipment available at the selected
surgery center and should be comfortable that he or she can perform the procedure as planned
with the available equipment. The use of flexible instrumentation for medial portal techniques
facilitates the procedure and can be protective of the articular cartilage. The use of a leg holder
or positioning posts is beneficial. Medial portal techniques often require that the knee be flexed
more than 110 degrees.
Figure 25-3. Soft tissue allograft after preparation being kept under tension on the back table, prior to
insertion. The Roman sandal weave is to the right.
commencing the surgery. The authors prefer to harvest autograft tendons prior to arthroscopic
examination of the joint if a complete ACL tear can be established based on the MRI scan and
the presence of a pivot shift under anesthesia. If the pivot shift cannot be identified and the MRI
did not clearly demonstrate a complete ACL tear, then the authors routinely arthroscope the joint
to confirm that there is a complete ACL tear prior to harvesting the graft. In any case, the authors
prefer to have the graft prepared on the back table while simultaneously preparing the joint. There
are a myriad of fixation techniques for soft tissue ACL grafts. They generally fall into the cat-
egory of suspensory (where the fixation is on the cortex) or aperture (where the fixation is within
the tunnel). Although there is no consensus within the literature as to which is preferable, it has
been the authors’ practice to use interference-type intratunnel fixation for soft tissue allografts.
The authors’ preference for interference devices is to use a permanent material so that there is no
potential issue with breakdown products from an absorbable interference screw and for formation
of a cavitary lesion as the screws resorb. Therefore, the senior author (JCR) uses femoral and tibial
Intrafix devices (DePuy Mitek). These devices are made out of permanent medical grade plastics,
are exceedingly inert, and facilitate compression of the graft to the largest circumference of the
socket.
Simultaneous graft preparation on the back table is accomplished with a preparation board that
maintains the graft under tension while the various sutures are applied. With the authors’ tech-
nique using femoral Intrafix, they use a “Roman sandal” suture that is passed around the middle
of the graft while baseball sutures are placed in the ends of the graft. The resulting construct is
shown in Figure 25-3. Sizing of the graft is done very early after the autologous tendons have
been skeletonized or the allograft has been thawed. If the autologous hamstring tendons are sized
smaller than 8 mm for females or 8 mm or less in males, the authors add an allograft hamstring
tendon to them. The authors always keep the graft under tension on the back table with the hope
of reducing creep in the construct during fixation and tensioning. This tension is maintained for
the entire time once the graft is prepped, prior to insertion.
Complete diagnostic evaluation of the joint is the first arthroscopic portion of the procedure.
Visualizing the popliteus tendon through the lateral gutter is the authors’ start point. The gutters
and the suprapatellar pouch should be carefully inspected for loose bodies. Laxity of the collaterals
should be evaluated while arthroscoping the medial and lateral compartments. Prior to graft inser-
tion, it is important to carefully probe the menisci to identify any potentially unstable meniscal
tear that might need treatment. Once the graft has been inserted and secured, repair or removal of
damaged menisci is more difficult to perform because the laxity prior to reconstruction facilitates
meniscal surgery.
Single-Bundle Anterior Cruciate Ligament Reconstruction 345
Minimal preparation of the notch is required in most acute ACL tear situations. Nevertheless,
one should carefully inspect for a narrow notch, which necessitates performance of a notchplasty
(Video). The authors prefer to preserve remnants of the ACL on the tibia and femur. The femoral
remnant can serve as a landmark for placement of the guide pins on the femur (Figure 25-4), while
the tibial remnant, which the authors often preserve at 8 mm in length, can act as a neurologic
active envelope for the ACL graft, theoretically improving proprioception following ACL recon-
structive surgery.11
Prior to drilling the tibial tunnel, it is essential to resect adequate fat pad such that the fat will
not impinge into the notch and obscure the surgeon’s view (Video). The authors resect the distal
fat pad such that the intrameniscal ligament can be readily visualized. Once the fat pad is removed
and the medial tibial flare has been exposed, the authors select an entry site for the drill guide on
the anteromedial tibial surface that is just at the superior border of the sartorius fascia. When one
is using the medial portal technique, it is not necessary to use the anterior edge of the MCL as an
additional guide for locating the start point, and the authors prefer to use a start point closer to
the tibial tubercle. Use of a commercial tibial ACL guide is encouraged for placing the tibial guide
pin. The guide facilitates accurate placement of the guide pin and can reduce the risk of injury to
the articular surface. The tip of this guide should be placed at the anatomical center of the ACL
on the tibia, which should be midway between the medial and lateral extents of the ACL attach-
ment and located in the anteroposterior plane at the most posterior attachment of the anterior
horn of the lateral meniscus. The accurate position of the guide pin should be ascertained before
overdrilling it. If the guide pin is more than a few millimeters distant from anatomic center of the
ACL, it should be replaced prior to reaming. If the guide pin is within 2 mm of the optimal posi-
tion, it can be slightly moved by initially overdrilling with a smaller cannulated drill. The guide
pin should always be stabilized with a hemostat when it is being overdrilled so that the premature
breakthrough of the drill that occurs anterior to the pin does not result in anterior migration of the
tunnel. If one overdrills the 2.4-mm guide pin with a 4.5-mm cannulated drill, the guide can be
displaced 1 mm in any direction by using the hemostat to push it or pull it to the appropriate posi-
tion intra-articularly. If one overdrills initially with a 6-mm cannulated drill, then one can displace
346 Chapter 25
the guide pin 2 mm in the appropriate direction to center the guide pin in the anatomic tibial
footprint of the ACL. When one is planning to use the tibial Intrafix device for a tibial fixation,
the tibial tunnel should be drilled to the same diameter as the graft. The authors routinely drill
the tibial tunnel prior to the femoral socket so that the tibial tunnel can be used to evacuate the
bone debris from drilling the femoral socket and therefore improve visualization through that step.
Leaving a millimeter of femoral footprint for the ACL in place prior to determining the femo-
ral start point for the guide pin can be beneficial. The authors find that it is most helpful to think
of the knee in the 90-degree flexed position. The footprint is ovoid with the long axis being on the
proximal to distal line of the femur and the shorter axis being in the anterior to posterior line (see
Figure 25-4). Routinely placing the arthroscope through the anteromedial portal to better identify
the ACL footprint is of value. The position of the anteromedial portal for medial portal technique
ACL reconstruction is crucial. Some have described using an accessory, more medial portal. The
authors routinely use an oblique, relatively low, primary anteromedial portal that works well for
the medial portal technique. They localize the position of that portal with a spinal needle before
it is cut. The spinal needle needs to be able to reach back to the ACL femoral attachment with the
knee flexed to 90 degrees while being just off the articular cartilage of the medial femoral condyle.
This portal placement ensures that the guide pin can be placed accurately, resulting in a femoral
socket of adequate length. The medial portal technique is facilitated by having a flexible guide
wire (made from nitinol) and/or flexible drills. The systems that use flexible nitinol guide pins
typically do not require hyperflexion for passage of the guide pin. Because the authors prefer to
pass a rigid guide pin and then immediately substitute a flexible wire for this, they use the 110- to
120-degree hyperflexed position for passage of the pin and drilling of the socket. The hyperflexed
position can be disorienting and may make it difficult to ascertain whether one is in the appropri-
ate position prior to pin passage. The authors usually mark the area in the ACL footprint that is
optimal for pin passage with a shaver and/or microfracture pick prior to bringing the over-the-
back femoral aimer in through the medial portal. Because the paddle of the over-the-back aimer
is on articular cartilage in this position, high-offset (7.5 to 8.0 mm) aimers are optimal. Less than
that will result in a tunnel that is too posterior and often too short.
Once the anatomic start point for the femoral guide pin has been determined at 90 degrees
of flexion and the aimer has been positioned, it is maintained in that position while the knee
is brought into hyperflexion. The guide pin is then drilled out through the lateral condyle and
through the skin and immediately switched out for a flexible 2.4-mm nitinol wire (Video). With
the wire in place, the knee can be moved to any position, and the location of the pin can be care-
fully assessed in relation to the ACL femoral footprint (Figure 25-5). This flexible pin also allows
one to bend the pin away from the medial femoral condyle while the acorn drill is threaded over
it. This should be done in approximately 60 to 70 degrees of flexion to minimize the risk of injury
to the medial femoral condyle articular cartilage. Protection of the medial femoral condyle can
also be facilitated by using a half-fluted cannulated drill or by using an accessory anterolateral
portal and femoral drill guide such that the guide pin is placed into the ACL femoral footprint
from outside in.
Once the cannulated acorn drill has been brought safely into the notch, the knee is brought
back to the hyperflexed position. Any device that had been used to plug the tibial tunnel is then
removed to facilitate drainage of fluid and bone debris from the joint. The authors typically bring
a 4-mm shaver up through the tibial tunnel while drilling the femoral socket so that suction on the
shaver can be used to evacuate the bone debris while drilling and watching the depth. With the
femoral Intrafix system, the femoral socket needs to be a minimum of 27 mm in length, preferably
30 mm in length. In using this system, the socket should be drilled 1 mm greater in diameter than
the graft was measured. Using the 7.5- to 8-mm offset over the back guide routinely generates
adequate tunnel length. After the socket is drilled, all bone debris should be evacuated from the
socket and the back of the joint using the shaver as a suction device. The positioning of the socket
should be critically evaluated to be certain that placement was appropriate (Figure 25-6).
Single-Bundle Anterior Cruciate Ligament Reconstruction 347
The next step is to reinsert the Beath-type femoral guide pin through the medial portal and
out through the femoral socket and skin. A retrieval suture is then brought into the joint and out
though the femoral socket. It can then be brought down through the tibial tunnel to retrieve the
graft into the femur transtibially. This is easily accomplished using the grasper up through the
tibial tunnel. A #5 polyester suture is satisfactory for this step.
The graft is then retrieved transtibially up into the femur. Because the Roman sandal weave
typically results in a 2-bundle construct for the femur, these should be positioned as the graft is
pulled into the femur such that they reproduce the anteromedial and posterolateral bundles of the
native ACL. With use of the femoral Intrafix device, there is a trial inserter, which is brought
up through the medial portal in the hyperflexed position to separate the 2 arms of the graft and
dilate the tunnel to accept the sheath. A small-diameter nitinol wire is inserted through this trial
device before it is removed and acts as a guide wire for the femoral sheath insertion and ultimately
for the femoral screw insertion. The sheath and screw come as a packaged set and should be sized
according to the manufacturer’s recommendations based on the measured diameter of the graft
and the drill recommended for that diameter graft. The screw is then placed into the sheath over
the nitinol wire. It is beneficial to remove the nitinol wire once the screw has been seated approxi-
mately three-quarters of the way so the tip of the wire will not be bent over by the screw.
Once the graft has been fixed on the femur (Figure 25-7), it should be cycled under tension
prior to inserting and securing the tibial fixation device. Kleweno et al12 demonstrated that every
femoral fixation device has the potential for creep with cyclic loading. Trying to remove some of
this creep through cycling the graft under tension prior to tibial fixation makes sense. Perhaps the
least well-understood factor in ACL reconstruction is tensioning the graft and the position of the
knee during tensioning and fixation. The authors identified that applying a maximal pull to the
graft while the knee is in full extension reliably results in a high percentage of stable knees, with
the added assurance that the patient will be able to regain full extension because the graft was
secured in the fully extended position.13
After the graft has been fixed on the tibial side, the joint should be examined for laxity and
range of motion to be sure the tension on the graft is appropriate and full extension and flexion
348 Chapter 25
B
Single-Bundle Anterior Cruciate Ligament Reconstruction 349
are achieved. Finally, the graft should be inspected and probed to be sure there is adequate tension
and no impingement (Figure 25-8). If the tension is inadequate, the tibial fixation device should
be removed and the graft retensioned. If there is impingement of the graft, a notchplasty is needed.
The authors routinely use the transtibial technique when they select bone-tendon-bone auto-
graft (or allograft) for high-demand patients. The transtibial approach results in a longer femoral
socket and allows the bone block, which is harvested from the tibia, to be recessed into the femoral
socket an additional 8 to 10 mm if needed. This graft positioning is beneficial when the tendi-
nous portion of the bone-tendon-bone construct measures more than 40 mm. The authors use the
preoperative MRI scan to measure the patellar tendon length prior to making a decision for graft
choice. If the measured length is more than 50 mm at its shortest length, this excess length may
compromise fixation because the bone block in the tibial socket may project too distally, neces-
sitating a less-than-optimal fixation technique.
If the preoperative MRI measurement of the patellar tendon is longer than 40 mm but less
than 50 mm, the authors harvest an additional 8 to 10 mm of bone from the tibia proximal to the
most proximal patellar tendon fibers (Figure 25-9). This larger harvest will allow the bone block
to be inserted up into the femur an additional 8 to 10 mm; therefore, the block harvested from the
patella will advance that same distance into the tibia tunnel, facilitating a fixation.
As with soft tissue graft, the authors harvest the bone-tendon-bone autograft prior to pre-
paring the joint. The assistant can prepare the graft on the back table simultaneously while the
joint is prepared. The harvest of the bone-tendon-bone graft should be performed carefully. The
width of the proximal patella tendon should be accurately measured prior to the harvest. For
small females, the authors accept a minimum of 8 mm for the width of the graft. On preoperative
evaluation of the MRI scan, if the width of the proximal patellar tendon is less than 24 mm, the
patellar tendon is not an adequate source of graft. In this case, a quadriceps tendon autograft or a
hamstring autograft/allograft composite may be a better choice for the graft source. The authors
use an identical procedure for notch preparation with either technique. A commercial ACL tibial
guide is appropriate for passage of the tibial guide wire. The MCL pes anserinus start point will
350 Chapter 25
give an appropriate angle for this tibial tunnel such that transtibial drilling of the femoral socket
will result in anatomic positioning of the tendinous portion of the bone-tendon-bone graft on the
femur. Because tensioning of the graft relies on easy sliding without resistance of the bone block
within the tibial tunnel, the block should be sized so that it slides easily in the sizer.
Drilling a transtibial tunnel as outlined previously, one can accurately place a femoral Beath
guide pin using a standard commercially available over-the-top–type guide. This guide is selected
so that it is 2 mm more than the radius of the femoral socket that will be created. The diameter
of that socket should be the diameter of the bone block harvested from the tibia measured with a
snug fit. A snug fit in the femoral socket will allow use of a 7-mm cannulated titanium interfer-
ence fit screw to get strong fixation.14 Once the Beath pin has been passed through the femur
and out percutaneously through the lateral thigh, it is immediately removed and replaced with a
2.4-mm nitinol wire. The nitinol wire facilitates passage of the cannulated acorn drill, specifically
allowing the pin to be deformed such that the tibial tunnel is not expanded posteriorly as the drill
is advanced into the joint. With this technique, the femoral socket is routinely drilled to a depth
of 40 mm. This length of tunnel allows the position of the proximal bone block to be adjusted as
needed within the tunnel to bring the distal bone block into the tibial tunnel and avoid a potential
graft–tunnel mismatch.
Once the femoral socket is drilled and all bone debris is removed, the Beath pin is replaced
for retrieval of the graft. The graft is retrieved and rotated such that the tendinous portion lies
in the most distal aspect of the socket. This position is typically in the anatomic center of the
ACL footprint on the femur. The bone block is then proximal within the femoral socket and the
Single-Bundle Anterior Cruciate Ligament Reconstruction 351
interference screw is inserted in the most proximal aspect of the socket. A commercially available
notcher should be used to develop a starting position for the screw. The nitinol guide pin, over
which the screw will be placed, should be inserted up into the femoral socket along with the bone
block to ensure that it is parallel to the tunnel. With a snug fit of the bone block in the socket, a
7-mm diameter by 20- to 25-mm-long screw can be readily inserted, providing excellent fixation.
Because there is no creep between a titanium interference screw and the bone-tendon-bone
graft, cycling the bone-tendon-bone graft prior to tibial fixation is not needed. Again, fixation
of the tibial bone block in full extension is crucial to ensure that full extension will be obtainable
postoperatively. External rotation of the tibial bone block by 90 degrees will reproduce the normal
ACL rotation.15
The authors tension with the knee in full extension (including hyperextension), applying maxi-
mal tension to the graft prior to tibial fixation. Fixation in the tibial tunnel should be done with
an 8- or 9-mm-diameter titanium interference screw. The length of the screw should be selected
so that the tip of the screw on insertion should not impinge on the soft tissue portion of the graft.
The authors routinely place the screw so that the threads abut the cancellous portion of the block
and the wall of the tunnel to reduce the risk of damage to the tendinous portion of the graft.
Postoperative Protocol
Tensioning the graft in full extension facilitates the patient regaining full extension postop-
eratively. The authors stress this early on in the rehabilitation program and require the patient to
be in an adjustable postoperative brace locked in extension for 18 hours daily, removing it only
for 6 hours (in 2-hour increments) of passive motion and other exercises. While using continuous
passive motion (CPM), obtaining full extension is also stressed. This position is facilitated by plac-
ing a rolled towel behind the Achilles tendon. The CPM machine should be set at a minimum of
0 degrees of extension and preferentially to 10 degrees of hyperextension. Motion is begun from
0 to 40 degrees for 2 hours 3 times a day and then increased in 5- to 10-degree daily increments
until the first postoperative visit approximately 10 days postoperatively. Quadriceps setting and
straight leg lifts can be of benefit in maintaining quadriceps tone during this time. It is appropri-
ate to take some precautions to reduce the risk of thrombophlebitis or pulmonary embolism. The
authors routinely use elastic compression socks on both calves for the first 2 days postoperatively
and on the operated calf until the first postoperative visit. Ankle pumps are encouraged. Use of
aspirin or a cyclooxygenase nonsteroidal anti-inflammatory drug may act as a mild chemoprophy-
lactic for thrombophlebitis as well.
At the first postoperative visit, wounds are checked, the calf is examined for signs of phlebitis,
and motion is ascertained. In the authors’ protocol, formal physical therapy routinely begins at
this point, and the brace is used only for ambulation and is locked in extension. The authors use
a protocol that gradually advances strengthening exercises and progressively increases the stress
on the graft. The brace is discontinued 4 weeks after surgery. The graduated rehabilitation pro-
gram for strength and endurance is designed so that unopposed quadriceps contraction early on
(felt to unduly strain the graft) is avoided.16 High-risk activities are delayed until a minimum of
4.5 months after bone-tendon-bone autograft to preferably 6 to 9 months for soft tissue autograft
or allografts.
Potential Complications
▶ Thrombophlebitis/pulmonary embolism
▶ Iatrogenic chondral damage
352 Chapter 25
▶ Pain/stiffness
▶ Motion loss
▶ Infection
▶ Nerve/vascular injury
▶ Fracture
▶ Graft rupture
▶ Tunnel malposition
▶ Graft–tunnel mismatch
References
1. Howell SM, Gittins ME, Gottlieb JE, Traina SM, Zoellner TM. The relationship between the angle of the
tibial tunnel in the coronal plane and loss of flexion and anterior laxity after anterior cruciate ligament
reconstruction. Am J Sports Med. 2001;29(5):567-574.
2. Raffo CS, Pizzarello P, Richmond JC, Pathare N. A reproducible landmark for the tibial tunnel origin
in anterior cruciate ligament reconstruction: avoiding a vertical graft in the coronal plane. Arthroscopy.
2008;24(7):843-845.
3. Pallis M, Svoboda SJ, Cameron KL, Owens BD. Survival comparison of allograft and autograft
anterior cruciate ligament reconstruction at the United States Military Academy. Am J Sports Med.
2012;40(6):1242-1246.
4. Goldblatt JP, Fitzsimmons SE, Balk E, Richmond JC. Reconstruction of the anterior cruciate ligament:
meta-analysis of patellar tendon versus hamstring tendon autograft. Arthroscopy. 2005;21(7):791-803.
5. Yunes M, Richmond JC, Engels EA, Pinczewski LA. Patellar versus hamstring tendons in anterior cruci-
ate ligament reconstruction: a meta-analysis. Arthroscopy. 2001;17(3):248-257.
6. Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach BR Jr. Arthroscopic anterior cruciate ligament
reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J
Sports Med. 2003;31(1):2-11.
7. Conte EJ, Hyatt AE, Gatt CJ Jr, Dhawan A. Hamstring autograft size can be predicted and is a potential
risk factor for anterior cruciate ligament reconstruction failure. Arthroscopy. 2014;30(7):882-890.
8. Tuman JM, Diduch DR, Rubino LJ, Baumfeld JA, Nguyen HS, Hart JM. Predictors for hamstring graft
diameter in anterior cruciate ligament reconstruction. Am J Sports Med. 2007;35(11):1945-1949.
9. Curran AR, Adams DJ, Gill JL, Steiner ME, Scheller AD. The biomechanical effects of low-dose irradia-
tion on bone-patellar tendon-bone allografts. Am J Sports Med. 2004;32(5):1131-1135.
Single-Bundle Anterior Cruciate Ligament Reconstruction 353
10. Trentacosta NE, Vitale MA, Ahmad CS. The effects of timing of pediatric knee ligament surgery on
short-term academic performance in school-aged athletes. Am J Sports Med. 2009;37(9):1684-1691.
11. Lee BI, Kwon SW, Kim JB, Choi HS, Min KD. Comparison of clinical results according to amount of
preserved remnant in arthroscopic anterior cruciate ligament reconstruction using quadrupled ham-
string graft. Arthroscopy. 2008;24(5):560-568.
12. Kleweno CP, Jacir AM, Gardner TR, Ahmad CS, Levine WN. Biomechanical evaluation of anterior
cruciate ligament femoral fixation techniques. Am J Sports Med. 2009;37(2):339-345.
13. Nabors ED, Richmond JC, Vannah WM, McConville OR. Anterior cruciate ligament graft tensioning
in full extension. Am J Sports Med. 1995;23(4):488-492.
14. Hulstyn M, Fadale PD, Abate J, Walsh WR. Biomechanical evaluation of interference screw fixation in
a bovine patellar bone-tendon-bone autograft complex for anterior cruciate ligament reconstruction.
Arthroscopy. 1993;9(4):417-424.
15. Samuelson TS, Drez D Jr, Maletis GB. Anterior cruciate ligament graft rotation. Reproduction of normal
graft rotation. Am J Sports Med. 1996;24(1):67-71.
16. Beynnon BD, Fleming BC, Johnson RJ, Nichols CE, Renström PA, Pope MH. Anterior cruciate ligament
strain behavior during rehabilitation exercises in vivo. Am J Sports Med. 1995;23(1):24-34.
Introduction
Anterior cruciate ligament (ACL) rupture is a common injury worldwide. Estimates suggest
an annual incidence of ACL rupture of 35 per 100,000 people of all ages, with an approximately
2- to 8-times higher risk in female than in male athletes.1-3 Double-bundle ACL reconstruc-
tion originated from the application of research findings to an individualized surgical approach
tailored to patient anatomy. Murawski et al4 recently reported that most studies show no differ-
ences between anatomic single- and double-bundle ACL reconstruction with respect to patient-
reported outcome scores and that double-bundle reconstruction may provide superior knee joint
laxity outcome measurements compared with the single-bundle technique. Double-bundle ACL
reconstruction is based on reconstructing the anteromedial and posterolateral bundle when rup-
tured. Although some studies indicate cartilage protection with ACL reconstruction, there is no
definitive consensus that double-bundle reconstruction effectively prevents the development of
osteoarthritis. However, it is known that the double-bundle technique and concept better restores
native kinematics, and future long-term studies may potentially reveal a difference.
Indications
There are no absolute indications established for double-bundle reconstruction; however, the
important factors that indicate a patient for double-bundle reconstruction include the following:
▶ Tear patterns include a 2-bundle complete tear, partial tears of both bundles with poor tis-
sue integrity or laxity, and 1 bundle completely torn with other bundle partially torn with
incompetent tissue.
▶ Native footprint size: A tibial insertion size greater than 18 mm indicates a patient for double-
bundle reconstruction because, otherwise, single-bundle reconstruction will likely not restore
a sufficient portion of the native ACL.
Controversial Indications
Controversial indications for double-bundle reconstruction may arise when native insertion
site measurements fall between 14 and 18 mm. In this case, double-bundle surgery is indicated
depending on other parameters, such as notch morphology. A narrow notch may provide ideal
drilling only for single-bundle placement, although a notch morphology that can house drilling
sufficient for 2 grafts may provide enough area for double-bundle placement.
Contraindications
Relative contraindications for double-bundle ACL reconstruction include the following5:
▶ ACL tibial insertion size less than 14 mm (better suited for anatomic single-bundle
reconstruction)
▶ Open physes
▶ Severe bone bruising over the lateral femoral condyle due to risk of possible fracture
▶ Narrow (< 14 mm) or shallow notch (< 14 mm) can lead to inability to appropriately drill femo-
ral tunnels and cause impingement, respectively
▶ Severe arthritic changes (grade 3 or greater)
▶ Multiligamentous injuries (due to likely need for other tunnels and risk of tunnel convergence/
overlap and associated fracture risk)
Anatomy
The ACL originates from the medial aspect of the lateral femoral condyle (femoral origin)
and inserts between the medial and lateral tibial spines (tibial insertion site). To remain consis-
tent, this chapter refers to positional relationships with the knee located in the anatomic position
or full knee extension. Arthroscopic evaluation of the ACL typically occurs with the knee f lexed
to 90 degrees (Figure 26-1). For this reason, the anatomically anterior border of the ACL will
appear arthroscopically as the superior border. Similarly, the anatomically posterior extent of
the ACL will appear as the arthroscopic inferior border when the knee is f lexed to 90 degrees
(see Figure 26-1).
Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction 357
The femoral insertion site or ACL origin is located at the posterior aspect of the medial wall
of the lateral femoral condyle. The length of the femoral footprint of the ACL is 17.7 ± 1.2 mm,
and the width is 9.9 ± 0.8 mm. The surface of the origin of the 2 bundles is not flat, and there is
variable slope of each origin. The femoral attachment of the anteromedial bundle forms an angle
with the posterolateral bundle of 27.6 ± 8.8 degrees. The average length of the femoral antero-
medial bundle is 9.8 ± 0.8 mm, and the average length of the femoral posterolateral bundle is
7.3 ± 0.5 mm. The anatomically anterior (arthroscopically superior) border of the femoral origin of
the ACL is defined by an important bony landmark referred to as the lateral intercondylar ridge
(see Figure 26-1). The lateral bifurcate ridge, another important osseous landmark, delineates the
anteromedial and posterolateral insertion areas, with the anteromedial proximal and posterolateral
distal to this landmark. Ferretti et al6 arthroscopically visualized the lateral bifurcate ridge in
81% of patients undergoing ACL reconstruction, with variable prominence of the ridge.
In its midportion, the ACL tapers to a thinner diameter, similar to an hourglass shape. The
cross-sectional area of the insertion sites are 3 to 3.5 times larger than the cross-sectional area
of the ligament’s midsubstance.7 The ACL fibers fan out and insert on the center of the tibial
plateau, between the tibial spines consistent with their 2 given names: anteromedial and postero-
lateral bundles. The length of the tibial insertion site and its area has been described with tremen-
dous variability across studies; the authors feel that is due to varying measurement and dissection
techniques in addition to use of cadaveric specimen of varying ages. The authors recognize that
there is patient-to-patient variability, and they have found the length of the tibial insertion site
to range from 9 to 25 mm, with the majority between 14 and 18 mm.8 It is important to realize
that the course of the anteromedial and posterolateral bundles is distinct. This is evident from the
embryological stage, with fetal anatomical and histological studies demonstrating the 2 bundles
and a septum between the bundles.9 The bundles are parallel near full extension but have different
orientations as the knee approaches 90 degrees of flexion (Figure 26-2).10
Cadaveric study has shown that the length of each bundle changes throughout the arc of
flexion-extension, with the bundles being longer toward extension as opposed to 90 degrees of
flexion (see Figure 26-2). Therefore, avoidance of overconstraint of the knee in reconstruction is
one reason the bundles should be tensioned in 0 and 20 to 30 degrees for the posterolateral and
anteromedial bundles, respectively.
Biomechanics
The anteromedial bundle functions more to limit anteroposterior (AP) translation, and the pos-
terolateral more so facilitates rotation within a controlled range.11 In addition, many studies have
tried to describe the exact functional role of the anteromedial and posterolateral bundles in terms
of AP translation. A recent study evaluated in vivo kinematics of the anteromedial and postero-
lateral bundles. Fifteen knees were examined sequentially during surgery before reconstruction,
after fixation of the posterolateral bundle, and after fixation of the posterolateral and anterome-
dial bundles.12 They discovered that isolated posterolateral bundle reconstruction improved AP
and rotational laxity and that the addition of the anteromedial bundle further improved laxity
parameters.12
The anteromedial and posterolateral bundles do not remain isometric throughout a full func-
tional range of motion (ROM).10 Each bundle of native ACL is exposed to varying degrees of
tension at various flexion angles. The anteromedial bundle is slightly more isometric than the
posterolateral bundle, remaining taut throughout a greater ROM. In contrast, the posterolateral
bundle is taut with the knee in extension and is lax when the knee is flexed. Logically, the contri-
bution of the posterolateral bundle to knee stability becomes increasingly important under greater
degrees of tension or near full extension.13-15
358 Chapter 26
Patient History
Before understanding double-bundle ACL reconstruction indications, a surgeon must know
when to recommend ACL surgery in general. To master the indications, the provider must take a
thorough history and perform a physical examination. It is important for the physician to inquire
about the mechanism of injury and consider all possible associated pathologies. While obtaining
the history and physical examination listen for key words such as pop, pivot, and swelling, which
are commonly reported with ACL rupture.16
Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction 359
Distinguishing acute from chronic ACL injury is important because of the increased likelihood
of associated injuries in the chronic setting. Acute cases typically present with a clear mechanism
of injury and reported symptoms, whereas chronic cases can present with great variability in com-
plaints due to secondary injuries or may present with recurrent instability. Recurrent instability or
giving way associated with pain and/or limitation of activity and sports typically leads to presenta-
tion in chronic cases. Secondary injury in chronic cases may include meniscal tear (usually medial)
or cartilage damage, leading to further pain and complaints.
Different injury mechanisms place varying strains on the anteromedial and posterolateral
bundles that manifest as various, documented rupture patterns (Figure 26-3). Two distinct injury
mechanisms of the ACL have been classically described by Muller et al,17 including hyperexten-
sion trauma with resultant stretch of the ACL over the anterior intercondylar notch roof and mod-
erate extension trauma, during which the anteromedial bundle is taut and a valgus and/or external
rotation force is applied. Based on the variable tension patterns exhibited at different positions of
knee flexion, the authors have seen various 2-bundle injury patterns and isolated anteromedial or
isolated posterolateral bundle injuries. Isolated posterolateral bundle injury occurs when stress is
applied at or near full extension. In greater degrees of flexion (30 to 60 degrees), isolated antero-
medial bundle injury can occur (see Figure 26-3).
During surgery, the authors recommend detailed dissection of the remnant ACL as an impor-
tant first step prior to proceeding with the reconstructive portion of ACL surgery due to the prev-
alence of partial tears to the ACL during injury. Zantop et al18 studied 121 consecutive patients
and found that 25% of patients had partial tears, with 12% having no injury to the posterolateral
bundle. The other 75% had complete tears of both bundles. Single-bundle augmentation is per-
formed when appropriate according to the specific injury pattern.19 Preservation of intact native
tissue has distinct advantages, including preservation of the microvasculature and proprioceptive
fibers. Isolated reconstruction of the anteromedial or posterolateral bundle alone requires an
awareness of such injury patterns and more precise pre- and intraoperative diagnostic assessment
of the injury pattern to equip physicians with the proper knowledge to approach surgery.
Pertinent Imaging
X-Rays
▶ The physician should first order plain x-rays.
▶ The authors’ recommended sequence includes flexion weightbearing PA (both knees), flexion
lateral, and Merchant views (both knees) to evaluate for fracture or other osseous abnormality.
▶ In most cases of acute ACL injury, the x-ray will be negative, but it is still necessary to obtain
it.
▶ Plain x-rays allow the surgeon to evaluate for malalignment, joint space narrowing, and other
signs of early degenerative arthritis.
Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction 361
A B
▶ The Segond fracture, or lateral tibial rim avulsion of the meniscotibial ligament, is considered
pathognomonic for ACL injury and should be screened as well.
▶ In the chronic setting or revision cases, long-cassette limb alignment studies are also useful to
determine if any significant malalignment is associated with recurrent instability.
Advanced Imaging
The most important imaging modality is magnetic resonance imaging (MRI), which is highly
sensitive for evaluating tears.
▶ High-resolution MRI with dedicated ACL sequences greatly increases the sensitivity.
▶ Standard MRI protocols consist of sagittal, coronal, and axial T1- and T2-weighted images.
▶ With standard basic protocols, it can be difficult to evaluate both functional bundles, so the
authors recommend using special MRI protocols that also include sagittal oblique and coro-
nal oblique imaging (Figure 26-4). These additional sequences help to clearly delineate both
bundles by viewing them in the plane of the ACL fibers, providing greater detail.20
362 Chapter 26
▶ These sequences improve specificity and sensitivity of evaluating complete and partial tears.21
The surgeon should also evaluate for associated ligament, cartilage, or meniscal injury and
bone bruise patterns.
▶ From the MRI, preparation to individualize the surgery can be achieved by measuring the
ACL insertion site size, ACL length, ACL angle, and the quadriceps and patellar tendon size
for graft possibilities.
▶ The general patient population insertion site size tends to be between 9 and 18 mm.8
▶ Because each patient’s anatomy is different and varies on a spectrum, these measurements
allow the physician to predict the appropriate intraoperative decisions best suited for the ana-
tomically placed ACL and estimate the appropriate graft size.20,22
▶ In revision cases, computed tomography (CT) scan is valuable to help determine tunnel place-
ment and the proper measurements needed for preoperative planning.23,24
▶ The authors also obtain 3-dimensional reconstructions of these CT scans when performed
and find them helpful in planning and explaining findings to the patient (see Figure 26-4).
Equipment
▶ Articulated bed (with foot piece that can flex sufficiently to allow knee flexion to at least
120 degrees)
▶ Well-leg holder and arthroscopic limb holder
▶ Well-padded tourniquet
▶ 30-degree arthroscope
▶ Malleable arthroscopic ruler
▶ Standard knee arthroscopic ACL instrumentation
▶ ACL tip guide
▶ Flexible and straight guide wires and reamers/drills
▶ Heavy braided suture for graft passage
▶ Suspensory fixation devices (EndoButton; Smith & Nephew)
▶ Interference screw fixation devices (Biosure PK screws; Smith & Nephew)
▶ Mini C-arm for intraoperative fluoroscopy
is often better appreciated in the examination under anesthesia because there is no guarding and
it is more sensitive.25
Once examination under anesthesia is performed, the supine patient is brought distally on the
bed to the point where the knees are beyond the articulation in the bed where the foot portion will
be flexed. This facilitates adequate maximal flexion to at least 120 degrees when the foot piece
of the bed is maximally flexed. The nonoperative lower extremity is secured in a padded well-leg
holder in the lithotomy position to safely facilitate access to the operative knee from the medial
side. A well-padded tourniquet is applied in the proximal portion of the thigh of the operative
extremity, and the extremity is secured in an arthroscopic leg holder with the post at the level of
the tourniquet.
tissue is potential inadequate size. The surgeon should be prepared to supplement if necessary with
all soft tissue grafts. The preoperative measurement of quadriceps tendon size, patellar thickness,
and length from the MRI can help avoid that issue with the quadriceps harvest (see Figure 26-5).
Allograft tissue has the advantage of having a predetermined size prior to incision and the pos-
sibility of prep before incision for efficiency. However, drawbacks include delayed vascularization,
potential reaction or disease transmission, increased cost, and lack of availability/variable supply.
The authors do not recommend allograft in younger patients (< 35 years) in high-risk sports with
suitable autograft options.
The authors typically use the EndoButton continuous loop for suspensory femoral fixation
(method detailed in the femoral fixation discussion), but several options are available. For the soft
tissue grafts, the authors prepare both ends of each graft with #2 Ticron whip stitched sutures with
appropriate tensioning throughout suturing. The portion of the graft to go within the femoral
tunnel is sutured and marked at the appropriate depth for full seating and an additional 7 mm to
allow for the EndoButton to totally exit the tunnel and flip. The tunnel must also be drilled to a
depth at least 7 mm beyond the desired length of the graft in the tunnel to allow the EndoButton
to flip. If the authors use a fibrin clot, it is sutured into the graft using resorbable nonbraided clear
suture on the femoral side of the intra-articular portion of the graft.
A B
Figure 26-7. (A) Measurement of AP length of ACL tibial insertion (~ 18 mm in this patient, indicating
double-bundle ACL reconstruction). (B) Measurement of the diameter of the posterolateral tibial insertion
(7 mm in this patient).
measuring the ACL dimensions. The medial portal is created more medially above the joint line
with a direct trajectory of the spinal needle to the ACL femoral origin. The medial portal should
be slightly proximal to the central portal and should allow sufficient clearance of medial femoral
condyle cartilage for passage of instruments to avoid iatrogenic cartilage injury. The medial portal
is used for drilling femoral tunnels and for best viewing of the AP profile of the medial wall of
the lateral femoral condyle. The portal size should also facilitate easy passage of the scope and
necessary equipment without tissue trauma. All 3 knee compartments are examined in diagnostic
arthroscopy to evaluate for associated injuries to cartilage or menisci and pathology addressed as
indicated.
The ACL injury pattern is thoroughly evaluated because there is variability in ACL rupture
patterns,18 and this must be respected in determining reconstruction needs. All 3 portals are
used to evaluate the origin and insertion sites of the ACL. The native femoral origin is best
seen via the central and medial portals. Prior to preparing the medial wall of the lateral femo-
ral condyle, any remaining soft tissue at the origin is carefully probed, and the outline of the
soft tissue is preserved when using the arthroscopic shaver and radiofrequency thermal device
(Arthrocare). The osseous landmarks are also examined and include the lateral intercondylar
ridge and bifurcate ridge. Osseous and soft tissue landmarks are useful for determining the
native origin site.6,28 The tibial insertion site is best seen from the lateral portal, and appreciat-
ing the entire footprint for both bundles is critical to placement of the tunnels. Placing the leg
in a figure-4 position can better demonstrate the posterior extent of the posterolateral bundle
insertion, and a probe can be used when remnant tissue exists to facilitate visualization. When
remnant tissue is present, the surgeon may sharply dissect the tissue to get a good overview of
the entire footprint. The native ACL dimensions are measured with a malleable arthroscopic
ruler (Smith & Nephew) and compared to the MRI measurements (Figure 26-7). The authors
measure the entire ACL origin, insertion footprint, and individual bundles. Notch dimensions
are also critical and are measured because a narrow notch (< 14 mm) will not facilitate drilling of
2 tunnels. The pre- and intraoperative data are used to determine final reconstruction technique
respecting the double-bundle concept.
366 Chapter 26
the distal end is retrieved with a suture retriever through the tibial posterolateral tunnel. The
same is done for the anteromedial tunnel with another looped suture. As an extra precaution, the
authors typically use different colored sutures to facilitate keeping track of tunnels and grafts as a
supplement to direct visualization. The posterolateral graft is the first reconstructed bundle that
is passed and is secured on the femoral side. Once that is examined, the anteromedial bundle is
passed. Appropriate position of the EndoButton fixation devices on the lateral cortex is confirmed
visually by observing intra-articular graft position when tugging on each graft and also fluoro-
scopically to see the button seated on the lateral cortex. The grafts are cycled with tension if no
fibrin clot was used. If a fibrin clot was used, the authors do not cycle the knee to avoid extrusion
of the clot from within the grafts.
The tibial fixation of the posterolateral bundle is performed at 0 degrees, and the anteromedial
bundle fixation is done at 20 to 30 degrees in keeping with their position of maximal tightness
from biomechanical studies. The leg is placed on an adjustable-height Mayo stand for stability
during tibial fixation. Various fixation devices may be used, such as interference screws, suture
post cortical fixation, staples, etc. The authors prefer interference screw fixation for the tibial side
and routinely use nonabsorbable biocompatible interference screws. The screw size should be the
same as the tunnel diameter or 1 mm wider in diameter for good fit. Final arthroscopic inspec-
tion is performed to evaluate graft position, ensure there is no impingement at full extension, and
probe the graft to confirm good tension. This final inspection of the graft uses the same principles
emphasized throughout the case of carefully analyzing the femoral origin and tibial insertion sites
and is done from all 3 portals for the best overview. Sterile dressings are applied after incision
closure. A foot-to-thigh dressing for gentle compression and a cool pack are applied. Finally, a
hinged knee brace locked in extension is applied.
Figure 26-9. (A) View from the medial portal of a single femoral tunnel for bone block and
2 tibial tunnels with dilators in place. (B) Dilator in the anteromedial (AM) tunnel and postero-
lateral (PL) graft already passed. (C) Both bundles passed from the femoral bone block into
their respective tibial tunnels in anatomic double-bundle positions. (B) and (C) are viewed
from lateral portal.
Postoperative Protocol
The rehabilitation protocol for double-bundle ACL reconstruction is the same as for anatom-
ic single-bundle ACL reconstructions. The brace remains locked in extension for the first 7 days
for ambulation with crutches. If no meniscal repair was performed, the patient is allowed to bear
weight with the brace and crutches immediately once the regional nerve block has worn off. The
patient is instructed to perform heel slides and active isometric quadriceps strengthening start-
ing on postoperative day 1. If available, a continuous passive motion machine is also used from
the day of surgery starting at 0 to 45 degrees and is advanced 5 to 10 degrees daily as tolerated.
By approximately 6 weeks, the patient is weaned off of the crutches and brace. Gradual progres-
sion through the phases of rehabilitation continues under the supervision of a therapist over the
next several months. Initial emphasis in the first 3 months is on swelling control, ROM, and
quadriceps strengthening, particularly with closed chain kinetic activities. After 3 months, non-
cutting, higher-intensity activity may commence if appropriate strength and motion are present.
This may include straight-line jogging/running, cycling, and swimming. With good progress,
controlled functional training may ensue with introduction of controlled cutting activities
and more explosive work. Return to sports follows successful completion of functional testing
and sport-specific training, with an emphasis on gradual return to sport activity in controlled
Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction 369
training environments. If the patient successfully completes the aforementioned measures, full
competitive participation is then allowed.
Typically, athletes return at approximately 9 ± 2 months. It can sometimes take up to 1 year
for an athlete to be ready, and the authors emphasize the importance of avoiding premature
return to minimize reinjury risk. An array of information factors into the decision to clear an
athlete for return to sport and includes painless activity with no effusion, ligament stability on
clinical examination, no concerning subjective reports, minimum 85% quadriceps strength vs
the contralateral knee, and passing of the required functional tests. If there is any concern prior
to return to sport or if the time for return to sport is earlier than typical, the authors do not
hesitate to obtain an MRI to evaluate healing. Pertinent to the double-bundle reconstruction,
the posterolateral bundle seems to demonstrate more prolonged increased signal intensity than
the anteromedial bundle, so close attention needs to be given to the 2 bundles because they may
potentially heal at different rates. 24 The clinical examination before clearance must include
evaluation of AP and rotatory ligament integrity to evaluate the anteromedial and posterolateral
bundles, respectively.
Potential Complications
Similar to single-bundle ACL reconstruction, double-bundle ACL reconstruction poses several
risks to the patient. The most common risk is iatrogenic injury due to the provider’s technical
skill, tunnel placement resulting in flexion and extension issues, misdiagnosis, poor fixation,
or mismanagement of preoperative preparation and postoperative protocol. Other less common
complications include saphenous nerve injury, fibrosis, hardware failure, patellar failure, and
wound infection.
Conclusion
Single-bundle reconstruction has served as the mainstay for ACL reconstruction surgery for
decades, but with improved understanding of the native ACL anatomy and biomechanical func-
tion, more sophisticated techniques have been developed to restore normal kinematics and aim to
potentially prevent the development of early osteoarthritis. Anatomic single-bundle reconstruc-
tion is one of these techniques, but in some patients with sufficiently large ACL footprints and
ideal notch morphology, the double-bundle technique is needed to maximally restore the native
anatomy. Although the anatomic double-bundle technique has not been widely adopted, early
clinical and imaging evaluation is promising.23,29,30
To fully comprehend the double-bundle concept and technique, surgeons should have an inti-
mate understanding of the native anatomy and measurements to appropriately understand when
double-bundle ACL reconstruction may be indicated. More prospective randomized controlled
trials are necessary to further evaluate the overall clinical benefit of double-bundle ACL recon-
struction, but currently, early studies suggest improved kinematic function and have motivated
future exploration.31
370 Chapter 26
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Introduction
All-inside anterior cruciate ligament (ACL) reconstruction was first described in 1995 by
Morgan.1 Initially, the procedure was performed using a bone-hamstring-bone composite graft
and was fixated with metal interference screws. Subsequently, in 2006, Lubowitz2 published a
technical note on no-tunnel all-inside ACL reconstruction based on drilling the femoral and
tibial sockets transtibially with use of the RetroCutter (Arthrex). The RetroCutter is a proprietary
device that serves as a retroreamer (Figure 27-1). It consists of a specialized, cannulated guide pin
that is drilled into the joint from a small tibial skin incision capturing the RetroCutter, which is
reverse threaded on its guide. Drilling in forward, the socket is reamed to the desired depth, pre-
serving the tibial cortex. Then, the RetroCutter is brought back in the joint and the drill reversely
engages the RetroCutter back onto the guide for removal from the joint. Fixation with the
Lubowitz technique was accomplished by an absorbable RetroScrew (Arthrex) interference screw
for the femur and an absorbable RetroScrew placed at the aperture of the tibial socket from inside
the joint with the Retro Screwdriver (Arthrex) that was cannulated to allow passage of a suture
to pull the screw onto the driver to then be secured against the graft. In 2007, Smith3 described a
modification of Lubowitz’s technique, drilling the femoral socket through the anteromedial portal
with absorbable TransFix (Arthrex) cross-pin fixation. One inherent advantage of this change for
the single-bundle all-inside approach relates to drilling the femoral socket through the antero-
medial portal because many studies have shown better localization of the femoral socket through
anteromedial portal drilling as opposed to transtibial femoral drilling, particularly to avoid vertical
graft placement.4-7 This procedure was soon modified for a double-bundle construct.8
The next development in the evolution of all-inside ACL reconstruction is related to the
FlipCutter (Arthrex; Figure 27-2). The FlipCutter is a pin and reamer in 1 unit; the 3.5-mm pin
is drilled in the desired center of the socket and, then, with a simple mechanism, is flipped to
become a reamer. After completing the reaming process, it is reflipped for removal and a suture is
passed through the pin tract for later graft passage. In essence, this unique device replicated drill-
ing the femoral socket like a 2-incision outside-in approach.9,10 It also represents an alternative to
drilling the femoral socket from the anteromedial portal, which can be challenging, particularly
because it allows drilling the femoral socket at 90 degrees of knee flexion for easy arthroscopic
visualization.6 The FlipCutter has a special guide sleeve that is malleted 7 mm into the cortex
prior to reaming the socket, which ensures this amount of bone bridge for suspensory cortical
fixation as the reamer is stopped at this point as the socket is retroreamed. The FlipCutter is also
used to create the tibial socket, and specific centering guides (Arthrex) are available for both the
femur and tibia.
The final technological step in facilitating progression of the all-inside technique to the
GraftLink related to the development of the TightRope (Arthrex), which allows for suspensory
cortical fixation (Figure 27-3). The TightRope is an adjustable continuous loop device. It is based
on a proprietary suture loop construct with a #5 polyethylene suture spliced on itself to create
2 shortening strands that, when tightened, provide fixation against a metal button suspended on
the femoral or tibial cortex. The shortening sutures can be threaded either way through the button.
The TightRope Reverse Tensioning (RT) device is preferred; RT refers to the direction the white
shortening sutures are pulled, which can be used on the femur or the tibia. The TightRope button
is 3-by-12 mm in dimension. It passes through a 3.5-mm hole via an attached blue #2 FiberWire
passing suture (Arthrex) and is self-flipping. There is also a TightRope Attachable Button System
(ABS) (Arthrex) construct, which consists of a 2-holed cortical button 12 mm long and 8 mm wide
that can be attached to the loop of a No Button TightRope (Arthrex) to create the TightRope
Arthroscopic All-Inside Anterior Cruciate Ligament Reconstruction 375
mechanism—commonly done on the tibial side—and then the loop is shortened to this button for
fixation. There are 4 points of fixation, including 2 points of friction where the suture is spliced,
2 linked loops that are interconnected, and suture against the eyelet of the button (Figure 27-3).
TightRope suspensory cortical fixation has been studied biomechanically. Petre et al11 showed
that the ultimate failure strength of the TightRope fixation device on the femur was 859 N tested
in porcine bone with 2.74 mm of cyclic displacement after 1000 cycles. They concluded that the
TightRope possessed the necessary biomechanical properties for soft tissue femoral fixation for
ACL reconstruction. Smith and DeBerardino12 compared the strength of the TightRope in a
continuous loop GraftLink construct to interference screw fixation on the tibia in porcine bone.
They found that average ultimate load to failure of tibial suspensory fixation for the all-inside
GraftLink continuous loop construct was 1012 N, which was significantly different compared to
the tibial interference screw group at 612 N (P < .001). The stiffness of the continuous loop con-
struct at 165 N/mm and cyclic displacement of 2.5 mm was not statistically significant compared
to the interference group (193 N/mm and 1.9 mm, respectively).12 They concluded that tibial
fixation of the TightRope was satisfactory for the normal loads placed on the ACL with activities
of daily living.13-17
The GraftLink construct refers to single soft tissue tendon—commonly a semitendinosus
autograft—quadrupled and linked together by sutures on each end of a TightRope loop (Figure
27-4).18 It is created by placing a TightRope RT loop on one end (for the femur) of a graft prep
station and a TightRope RT or a No Button TightRope loop on the other end (for the tibia). A
semitendinosus tendon is passed through the tibial TightRope loop first, and then the 2 free ends
are passed through the TightRope RT loop on the femoral end in opposite directions. The 2 free
ends are then sutured together with a #0 TigerLoop (Arthrex) suture in a SpeedWhip pattern,
and this suture is used to bury the free tissue ends of the graft on the inside of the outer graft
loop on the tibial side to create a quadrupled construct.19 The graft is placed under tension, and
then 4 #0 FiberWire (Arthrex) sutures are placed on each end of the construct passing the needle
through all 4 tendons and then wrapping each suture end around the 4 tendons prior to tying the
knot, thereby securely incorporating all 4 loops for linkage. The author routinely leaves in place
the 2 free 0 TigerLoop sutures on the tibial side used to initially suture the graft ends together so
he can tie them later to the tibial button for backup fixation here. Graft preparation is shown in
the surgery video.
In all-inside ACL reconstruction, it is essential that the depth of socket creation for the femur
and tibia, along with the intra-articular ACL distance, is greater than the final graft length. This
is critical so the graft does not bottom out in the sockets because, otherwise, it would be lax.
The author routinely uses an intra-articular measuring device (Arthrex) to determine the ACL
376 Chapter 27
Figure 27-4. A final GraftLink construct with a TightRope RT loop on one end and a No Button loop on
the other end. Note the two 0 TigerLoop sutures free on the tibial side, which represents the suture that
attached the 2 free tendon ends here to complete the quadrupling of the graft. They will be incorporated
with the tibial button to be tied here for backup fixation.
distance, and the depth of reaming for the femoral and tibial sockets is easily known (Figure
27-5). It is the author’s approach to overream the tibia by 5 mm to allow for adequate graft ten-
sioning, which ensures the graft will not be too long. Typically, his graft lengths are a minimum
of 63 mm and a maximum of 75 mm in length, whereas the intra-articular distance is usually
in the range of 23 to 26 mm. Generally, he then has at least 20 mm of graft in both the femoral
and tibial sockets.
All-Inside Advantages
Less postoperative pain is an evidence-based advantage of all-inside ACL reconstruction. This
was shown first in a Level 1 randomized controlled trial with allograft comparing all-inside recon-
struction to a full tibial tunnel.20 It was then proven again using semitendinosus autograft with
the GraftLink technique.21 Given the trend for outpatient surgery and accelerated rehabilitation
after ACL reconstruction, less postoperative pain is an advantage for patients.
Arthroscopic All-Inside Anterior Cruciate Ligament Reconstruction 377
All-inside ACL reconstruction is suitable for any patient deemed an appropriate surgical candi-
date because it is flexible from the standpoint of graft selection. At this time, the author’s preferred
graft is a semitendinosus autograft harvested through a small popliteal incision.22 A recent study
of 60 of the author’s patients showed an average graft diameter of 9.0 mm and length of 70.3 mm
with this minimally invasive, single-incision, posterior hamstring harvest technique. 23 Analyzed
for sex, average female graft length was 68.1 mm with an average final graft diameter of 8.6 mm
compared to grafts of 71.7 and 9.3 mm, respectively, in males. In both sexes, patient height and
weight were strongly correlated to the final construct diameter (r = 0.60 and r = 0.56) and length
(r = 0.47 and r = 0.44), respectively. Also, in this study, the amount of graft in the femoral socket
averaged 22.4 and 23.7 mm in the tibial socket with the all-inside GraftLink technique.
Alternative grafts are amendable to the all-inside technique. Folding the tibial bone plug and
suturing it to the tendon to shorten the length allows the patellar tendon bone-tendon-bone graft
to be used in an all-inside reconstruction. Quadriceps tendon autografts (with or without bone)
can be used with a technique of securing the tendinous ends to the TightRope loops. Soft tissue
allografts also work well. In this chapter, the outside-in approach with the FlipCutter is described
first with an allograft. The anteromedial portal approach is then done with a semitendinosus
autograft. Instructive videos for both techniques are provided.
Indications
▶ ACL tears in active individuals with functional instability
▶ Any age is suitable because all-epiphyseal GraftLink can be done in children, avoiding the
growth plates
▶ Autograft hamstring with quadrupled semitendinosus
▶ Soft tissue allograft quadrupled semitendinosus or anterior/posterior tibialis for larger graft
▶ Revision cases: Suspensory fixation on the femur and tibia facilitates fixation
▶ Most minimally invasive technique if pain is an issue for the patient
Pertinent Imaging
X-Rays
▶ Bilateral weightbearing anteroposterior views in full extension and posteroanterior Rosenberg
views in flexion
▶ Lateral weightbearing of the affected knee
378 Chapter 27
Equipment
GraftLink Preparation (Video)
▶ Graft Preparation Station to secure TightRope devices
▶ TightRope RT for femoral fixation
▶ TightRope No Button for tibial fixation
▶ 0 FiberLoop suture for free ends of quadrupled graft
▶ 0 FiberWire suture to link graft limbs (4 on each side)
FlipCutter Approach
▶ CaliBlator
▶ FlipCutter for the femoral and tibial sockets
▶ 6-9 femoral guide (Arthrex) for the FlipCutter
▶ #2 FiberStick in a red tube as a femoral shuttling suture
▶ PassPort cannula
▶ Intra-articular measuring device
▶ Tibial guide for the FlipCutter
Arthroscopic All-Inside Anterior Cruciate Ligament Reconstruction 379
A B
C D
Figure 27-8. The FlipCutter guide is oriented for this right knee
A with the tip of the 6-9 guide in the anterolateral portal posi-
tioned on the femur intra-articularly. The angle of the guide is
20 degrees in the transepicondylar axis (A) and 60 degrees in
the coronal plane (B). The knee is at 90 degrees of flexion.
between the native posterolateral and anteromedial ACL bundles, so he favors a bit toward the
anteromedial attachment on the femur by referencing approximately 43% of the distance from the
proximal articular cartilage margin to the distal articular surface margin. After the femoral socket
is drilled, a #2 FiberStick in its red sheath is passed through the 3.5-mm drill hole and is retrieved
on the joint side and docked outside the joint to be the passing suture for the graft into the femoral
socket later on (Figure 27-9).
Prior to creating the tibial socket, the intra-articular distance for the ACL graft is measured
with the intra-articular measuring device. This distance is then added to the depth of the femoral
socket created and referenced to the length of the GraftLink construct to determine the desired
depth of the tibial socket. The next step is reaming the tibial socket. Again, the FlipCutter is used
with the tibial aiming device. The author’s preferred position is just anteromedial to the normal
ACL center. In most cases, there are native ACL fibers from the tibial footprint here still present
that can be used for orientation. The one constant landmark to reference is the anterior horn of
the lateral meniscus, and the author strives for approximately three-quarters of the tibial socket to
be anterior to the posterior margin of the anterior horn attachment point, representing more of an
anteromedial bundle attachment location on the tibia. The CaliBlator can also be used to mark the
desired centering point for the tibial socket to facilitate positioning the tibial aiming device. Just
as with the femur, the tibial intraosseous distance is measured to know the limit of tibial socket
depth. The guide pin is predrilled with the stiffer 3.5-mm pin, and then the guide sleeve is tapped
in 7 mm through the tibial cortex. The FlipCutter pin is drilled in to the joint and flipped to retro-
ream the tibial socket, always leaving a 7-mm bone bridge on the tibial cortex to ensure suspensory
cortical fixation with the TightRope. This tibial socket depth is generally at least 5 mm greater
than the desired graft length in the tibia, which allows for graft tensioning so that the graft does
not bottom out. Final tibial socket position is still well within the tibial footprint, even with this
slightly more anteromedial position (Figure 27-10).
On the tibial side, a #2 TigerStick suture in its red sheath is passed into the joint. Prior to
retrieving this tibial socket suture, the author always places a PassPort cannula in the anteromedial
portal to prevent a soft tissue bridge during graft passage, which can be disruptive to the flow of
the procedure if it were to occur.
Graft passage is straightforward. The FiberStick suture—“F” for femur—is pulled out of the
PassPort cannula, followed by the TigerStick suture—“T” for tibia. First, the TightRope RT
382 Chapter 27
Figure 27-9. The femoral socket is seen with the FiberStick docking suture in place.
This is an arthroscopic view from the anterolateral portal for a right knee at 90 degrees
of flexion. The author’s optimal position is just proximal to the true ACL center, favor-
ing more toward the anteromedial bundle attachment than the posterolateral attach-
ment point in the proximal/distal orientation. The posterior margin of the femoral
socket should ideally be 2 mm from the posterior lateral femoral condyle articular
surface.
sutures are passed in the femoral socket via the blue passing suture on the button, along with the
white shortening sutures. The intraosseous distance is marked on the shortening sutures with
methylene blue as a guide for when the button should flip outside the lateral femoral cortex. It
is usually easy to feel when the button flips. The graft is then hoisted into the femoral socket by
alternatively pulling the 2 shortening sutures until the graft is fully seated to the expected depth
in the femoral socket, again, marked on the graft with methylene blue. At this point, the author
always cycles the knee 20 times and, if necessary, retensions the TightRope femoral sutures to
eliminate any potential cyclic displacement or creep in the fixation here.
On the tibial side, when using the No Button TightRope, which the author finds easier than
the TightRope RT here, it is important to protect the loop during passage. A simple luggage tag–
type suture with a 0 FiberWire is placed at the base of the loop. Then, this suture and the 2 free
suture ends from the tibial side of the GraftLink construct are passed through the TigerWire
loop and pulled out of the small anterior tibial incision. This of course is through the PassPort
cannula also passing the graft into the tibial socket. Now, the shortening strands are delivered
out with the No Button loop, and the 0 FiberWire suture is removed from the loop. The ABS
button (12-by-8 mm) is assembled to the No Button loop to create a regular TightRope, and the
shortening sutures are pulled in an alternating fashion down toward the tibia. Before final seating
of the button down to the bone, the sutures in the tibial end of the graft are passed in the slots of
the button, and the knee is brought to full extension to avoid overconstraining the joint, and the
shortening sutures are secured to the button. The knee is cycled again to eliminate any potential
cyclic displacement with the TightRope, and then the shortening sutures are retightened in full
Arthroscopic All-Inside Anterior Cruciate Ligament Reconstruction 383
Figure 27-10. The final tibial socket for a right knee as viewed from the anterolateral
portal is shown completely within the native tibial footprint. The author’s optimal
position is just anteromedial to the center of the ACL with approximately one-quarter
of the tibial socket behind the anterior horn of the lateral meniscus.
extension and tied down to the button. The tibial graft sutures are then tied to the button for
backup fixation. Final graft position is checked arthroscopically to make sure there is no notch
impingement, especially in hyperextension (Figure 27-11). The author does not routinely perform
a notchplasty because he rarely sees impingement after all-inside ACL reconstruction. Plus, in his
experience of second-look ACL reconstruction after a notchplasty has been done, it always grows
back with fibrocartilage, thereby defeating its purpose.
Anteromedial Portal
This case is a right knee GraftLink ACL reconstruction done with a quadrupled semiten-
dinosus autograft harvested from a single posterior incision. Given the flexibility of the all-
inside technique, drilling the femur through the anteromedial portal works well and is a known
and comfortable approach for many surgeons. This is facilitated by use of low-profile reamers
(Arthrex) to avoid iatrogenic injury to the medial femoral condyle. Furthermore, the author has
found it unnecessary to create an accessory anteromedial portal because a low anteromedial portal
allows for full accessibility of the femoral ACL footprint. Also, as mentioned previously with the
FlipCutter technique, the author rarely performs femoral notchplasty.
The author’s optimal femoral socket location is slightly proximal to the center of the native
anteromedial and posterolateral bundles, which favors a bit toward the anteromedial bundle
attachment. This is consistent with the Piefer meta-analysis study and a center point 43% of the
distance from the proximal femoral articular margin landmark to the distal lateral femoral articu-
lar margin.26 This can easily be determined with a ruler measuring technique, and the CaliBlator
radiofrequency device works well to find this point. The author’s goal is for the most posterior
margin of the femoral socket to be 2 mm from the posterior femoral articular surface margin. An
384 Chapter 27
Figure 27-11. Final ACL graft position. Quadrupled GraftLink soft tissue prefabricated
allograft for a right knee as viewed from the anterolateral portal. Note the native ACL
fibers around the base of the new graft, confirming optimal position within the tibial
footprint.
offset guide (Arthrex) placed through the anteromedial portal also works well to find this point.
It is critical after creating the femoral socket centering point to check its position and view it from
the anteromedial portal to verify proper location.
To create the femoral socket for the GraftLink construct with TightRope suspensory fixation,
it is necessary to measure the femoral intraosseous distance. After determining the femoral socket
centering position as outlined previously, a special spade tip measuring pin (Arthrex) that also acts
like a depth gauge is drilled from the anteromedial portal, usually at approximately 120 degrees
of flexion to allow for easy determination of the femoral intraosseous distance. The low-profile
reamer matching the graft diameter is then passed carefully in a vertical orientation through
the anteromedial portal, avoiding the medial femoral condyle articular surface, and the femoral
socket is reamed to the appropriate depth. This depth is based on the intraosseous distance and
the desired amount of graft in the femoral socket given the length of the GraftLink construct,
with the key being preserving the lateral femoral cortex for the TightRope fixation. Generally,
the author does not have less than 20 mm of graft in the femoral socket with this technique. A
#2 FiberStick suture is then docked here to pull the graft up into the femur later.
The next step is measuring the intra-articular distance from the femoral socket margin to the
proposed tibial socket aperture with the special intra-articular measuring device. Usually, this
distance is in the range of 23 to 26 mm. Now, with the known depth of the created femoral socket,
the intra-articular distance, and the length of the graft, the desired length of the tibial socket is
determined. As with the femur, the tibial intraosseous is measured so as to know the limit of the
tibial socket depth that can be drilled while preserving the tibial cortex for the TightRope fixa-
tion. As described with the FlipCutter technique, the tibial socket depth is generally created 5 mm
longer than the expected graft length in the socket to allow room for graft tensioning.
Arthroscopic All-Inside Anterior Cruciate Ligament Reconstruction 385
The author prefers using the RetroCutter to create the tibial socket because it is so accurate
visually to place the RetroCutter matching the graft diameter right where you want the tibial sock-
et to be, although the FlipCutter also works well. Through a small tibial incision, the RetroCutter
guide sleeve is placed down to the bone, and the cannulated RetroCutter pin is drilled forward
into the joint, capturing the RetroCutter that is reverse threaded on the guide. In forward drilling
mode, the RetroCutter reams the tibial socket to the desired depth. It is then brought back in the
joint and, when reengaging the guide, is switched to reverse to deliver the RetroCutter back onto
the guide for removal. At this time, the small pin within the RetroCutter pin is removed to open
the cannulation, and a passing wire is easily passed into the joint. A PassPort cannula is placed
in the anteromedial portal to retrieve this wire, and then a #2 TigerStick suture is folded in half
and a simple loop knot is created, and one end of this suture is passed out of the small tibial inci-
sion. This suture will be used to shuttle the tibial end of the graft and the No Button TightRope
loop, which the author prefers over the TightRope RT for fixation on the tibial side into the tibial
socket.
The graft is first passed into the femur by retrieving the FiberStick docking suture through
the PassPort cannula. The TightRope RT blue passing and white shortening sutures are passed
through this FiberStick loop and are shuttled out the small lateral pin incision. The shortening
sutures have been marked with the femoral intraosseous distance to facilitate the expected flipping
of the button on the lateral femoral cortex, which can usually be felt. Pulling on the graft outside
the PassPort cannula confirms button flippage with no pullback. Next, the graft is hoisted in the
femoral socket by alternating pulling on the white TightRope shortening sutures. The expected
graft depth in the femoral socket is marked with methylene blue as a guide. After the graft is
seated fully in the femur, the knee is always cycled 20 times at this point to make sure there is no
slippage or creep with the femoral TightRope fixation; if necessary, the femoral shortening sutures
can be retensioned.
To facilitate shuttling of the No Button TightRope loop out the small tibial incision, as
described with the FlipCutter technique, a 0 FiberWire luggage tag–type suture is placed at the
base of the loop. This suture, along with the sutures in the tibial end of the GraftLink construct,
are then passed through the PassPort cannula via the #2 TigerStick with the loop into the tibial
socket pulling the graft in the socket in the process. The No Button loop and shortening sutures
are delivered now out the small tibial incision. The 0 FiberWire suture is removed from the No
Button loop, and the ABS button is attached to convert to a regular TightRope. The 2 sutures in
the tibial end of the graft are passed through the slots in the button, and then the white shortening
sutures are pulled in an alternating fashion to the button for fixation bringing the knee into full
extension so as not to overconstrain the joint. As on the femoral side, the knee is cycled 20 times
to eliminate any potential creep with the tibial fixation, and then the shortening sutures are pulled
taut again and tied to the ABS button and the sutures in the tibial end of the graft are tied to the
button for backup fixation.
Postoperative Protocol
For the FlipCutter technique and the anteromedial portal technique, the author generally
begins early motion with use of a continuous passive motion machine in the recovery room. Formal
outpatient physical therapy is started the next day with the first dressing change, and initiation
of quadriceps exercises with quadriceps sets progressing to straight leg raises when there is no
extensor lag. Patellar mobilization is emphasized to avoid infrapatellar scarring or contraction.
The exercise bicycle is usually started at 10 to 14 days. Weightbearing off crutches is allowed once
the patient demonstrates good leg control, which typically takes 2 weeks or so. Sometimes with a
difficult meniscal repair (ie, in the white-white zone), the author keeps the patient nonweightbear-
ing for the first 3 weeks and limits knee flexion to 90 degrees for the first 2 weeks to minimize
386 Chapter 27
rollback stress on the repair site. Closed chain exercises are initiated once the patient is fully
weightbearing at 3 to 4 weeks. Running is allowed by 3 months, and return to sport is delayed at
least until 6 months postoperatively and is based on functional testing results at that time along
with completion of ACL prevention-type exercises conducted by the physical therapist.
Potential Complications
All-inside ACL reconstruction is a safe and reproducible procedure with a short learning curve.
However, as with any surgery, anything can happen. Potential complications could include a prob-
lem with anesthesia or a postoperative infection. Prophylactic antibiotics are always administered
intravenously right before the incision is made. Deep venous thrombosis can occur and, generally,
any patient felt to be an increased risk for deep venous thrombosis is placed on aspirin 325 mg twice
daily beginning the night of surgery and is continued until the patient is fully weightbearing.28
Relative to the steps of the procedure itself, one potential complication would be if the final
graft length is longer than the sum of the femoral and tibial socket depths and the intra-articular
graft distance. In that circumstance, the graft could not be tensioned and still would be lax. The
bailout would be to remove the tibial ABS button so that the tibial end of the graft could be
pulled out of the tibial socket and out of the PassPort cannula where a new suture could be passed
through the loop of the graft. Then, the FlipCutter or the RetroCutter could be used to create a
full tibial tunnel in the location of the socket. The graft would then be pulled back into the joint
by way of a passing wire or suture to be fixated in the full tibial tunnel with an interference screw
backed up by a distal PushLock (Arthrex) or SwiveLock (Arthrex).
Another possible complication that could occur on the femoral or tibial side would be inad-
vertent creation of a full tunnel by violating the cortex during the reaming process. This could
happen on the femur with the anteromedial portal drilling technique and on the tibia using the
RetroCutter. This would not occur with the FlipCutter technique because the 7-mm depth stop
on the guide sleeve protects the cortical bridge of bone here. The bailout on the femoral side
would be use of an extender button (Arthrex) that allows the TightRope button to fit within it
and, because it is longer at 20 mm, it can span a larger femoral cortical hole while also providing
adequate fixation. On the tibial side, the bailout is the extender button if a regular TightRope is
used here or a larger, circular 14-mm-diameter ABS button to cover the larger cortical hole and
provide suspensory fixation.
A final complication would be securing the TightRope fixation with the knee in flexion
because, in the author’s experience, the TightRope fixation is secure and at time zero on the
operating table; these knees are clinically tight on stress testing with Lachman, pivot shift, and
anterior drawer tests. Therefore, the author always brings the knee out to full extension (or hyper-
extension if present) before final fixation of the graft. His concern would be if the graft was fixed
at 20 degrees of flexion, the knee could be overconstrained and the patient may not achieve full
extension, which would be a definite postoperative complication.
Arthroscopic All-Inside Anterior Cruciate Ligament Reconstruction 387
Acknowledgments
Dr. Smith would like to thank Jordan Bley for his assistance in writing and editing this chapter.
References
1. Morgan CD. The all-inside ACL reconstruction. In: Morgan CD, ed. Operative Technique Manual.
Naples, FL: Arthrex; 1995.
2. Lubowitz JH. No-tunnel anterior cruciate ligament reconstruction: the transtibial all-inside technique.
Arthroscopy. 2006;22(8):900.e1-900.e11.
3. Smith PA. An alternative method for “all-inside” anterior cruciate ligament reconstruction. Arthroscopy.
2007;23(4):451.
4. Alentorn-Geli E, Samitier G, Alvarez P, Steinbacher G, Cugat R. Anteromedial portal versus transtibial
drilling techniques in ACL reconstruction: a blinded cross-sectional study at two- to five-year follow-
up. Int Orthop. 2010;34(5):747-754.
5. Bedi A, Musahl V, Steuber V, et al. Transtibial versus anteromedial portal reaming in anterior cruciate
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6. Lubowitz JH. Anteromedial portal technique for the anterior cruciate ligament femoral socket: pitfalls
and solutions. Arthroscopy. 2009;25(1):95-101.
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ligament double-bundle retroconstruction. Arthroscopy. 2008;24(10):1184-1189.
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18. Lubowitz JH, Ahmad CS, Anderson K. All-inside anterior cruciate ligament graft-link technique: sec-
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Introduction
Over the past few decades, the number of anterior cruciate ligament (ACL) reconstructions
has increased to an estimated 250,000 per year.1,2 Primary ACL reconstruction has been shown
to be successful in restoring knee stability and function. An improved ability to identify, recon-
struct, and rehabilitate these patients has led to a better understanding of the natural history and
functional consequences of an ACL-deficient knee. Although current techniques are successful
in restoring a large percentage of patients to competitive play,3 the authors anticipate an ever-
increasing number of patients who will present with ACL failure. There are 3 main categories of
ACL reconstruction failure, including loss of motion, recurrent instability, and persistent pain.
Loss of motion can result in significant impairment and functional disability. Extension loss
remains a major concern after ACL reconstruction because most patients tolerate mild flexion loss.
Studies have shown that even a 5-degree loss of flexion can result in poor subjective outcomes
in patients.4,5 Multiple factors play into motion loss, and the etiology of this must be under-
stood before proceeding with revision ACL reconstruction. Factors that can cause motion loss
include improper tunnel placement, noncompliance with physical therapy, excessive graft tension,
impingement, and cyclops lesions.6-9
Recurrent instability is most often related to technical errors. It has been estimated that 70% to
80% of ACL failures may be due to improperly placed tunnels.10 Malpositioned tunnels can
lead to excessive graft tensioning, laxity, or impingement. The 2 bony landmarks that define the
femoral location of the ACL femoral insertion are the lateral intercondylar ridge and the lateral
bifurcate ridge. No fibers of the ACL insert superior to the lateral intercondylar ridge. The bifur-
cate ridge separates the anteromedial and the posterolateral bundles of the ACL on the femoral
attachment.11 One recent study demonstrated that the native ACL femoral attachment lies at a
point 50% along a line drawn from the proximal articular cartilage and the distal articular carti-
lage border, parallel to the tibial surface with the knee at 90 degrees of flexion.12 Another study
showed similar results in their systematic review in regard to arthroscopically measurable land-
marks. They determined that the anatomic location of the ACL femoral footprint is 43% of the
distance from the proximal articular margin to the distal articular margins. In addition, they also
showed that a rim of bone of 2.5 mm exists between the posterior ACL fibers and the posterior
articular cartilage margin.13 The tibial footprint, the larger of the 2, is more variable in description
of its anatomic location, and the literature supports this variability. A recent systematic review of
the tibial footprint showed that the ACL tibial footprint is 15 mm anterior to the posterior cruci-
ate ligament (PCL) and two-fifths of the medial-lateral width of the interspinous distance, with
the majority of the ACL fibers attaching anterior to the posterior margin of the lateral meniscus.14
The authors place their tibial tunnel directly across from the midportion of the anterior horn of
the lateral meniscus and as far medial as possible as not to injure the cartilage of the medial tibial
plateau. Previous reports of placing the ACL tibial tunnel 5 to 6 mm anterior to the PCL produced
a nonanatomic tibial ACL tunnel based on the current evidence; this is also based on the senior
author’s experience.15
The objective of anatomic single- or double-bundle reconstruction is to restore a maximum per-
centage of the native ACL insertion, thereby reproducing the native ACL insertion site anatomy
and restoring the normal ACL kinematics and stability. It is imperative that the graft be placed
at the anatomic location of native ACL to prevent clinical failure. To provide the most anatomic
ACL graft placement, the current literature weighs heavily in favor of medial portal reaming,
outside-in, or double-bundle ACL reconstruction.16,17
Recent studies have also looked at the importance of graft size with primary ACL reconstruc-
tion. One study showed that revision was performed in 1.7% of patients with grafts greater than
8 mm in diameter, 6.5% with 7.5- or 8-mm-diameter grafts, and 13.6% with grafts 7 mm or less
in diameter.18 Another study found similar results and noted that a revision was required in no
patients with grafts greater than 8 mm in diameter and 7.0% with grafts 8 mm in diameter or
smaller. Among patients aged 18 years or younger, revision was required in no patients with grafts
greater than 8 mm in diameter and 18.3% with grafts 8 mm in diameter or smaller.19 Thus, when
doing revision ACL reconstruction, the authors believe it is imperative to use larger grafts and
supplement with allograft tissue if needed to increase the overall collagen content of the graft.
The desired level of activity of the patient and the primary graft source must be considered in
revision ACL surgery. It is imperative that surgeons recognize the different incorporation rates
between soft tissue and bone autografts and allografts.20,21 Appropriate rehabilitation for each
graft is important, and a cookbook standard rehabilitation protocol may result in early clinical fail-
ure. Adherence to biologic principles is essential to the success of the primary and revision surgery.
Traumatic failures can occur whenever the graft is exposed to tensile loads that exceed the
biomechanical strength and stiffness of the graft during a particular stage of healing and matu-
ration. Early failures are defined as those that occur during the process of graft incorporation
and remodeling (< 1 year), whereas late failures occur once the graft has matured (after 1 year).7
Overaggressive rehabilitation, premature return to sports, and a significant reinjury can all result
in traumatic failure of the primary ACL reconstruction. Although they are commonly used,
accelerated rehabilitation programs may injure the immature graft or cause fixation loosening and
graft failure.22
ACL injuries often are associated with concomitant injuries approximately 75% of the time.
Failure to recognize associated injuries can result in repeat graft failure. Posterolateral corner
injuries are the most commonly unrecognized concurrent injury and have been reported to be
present 10% to 15% of the time.23 The Multicenter ACL Revision Study group has shown that
approximately 10% of patients have normal menisci/articular cartilage at the time of revision ACL
surgery.24 The medial collateral ligament, posterior horn of the medial meniscus, and posterome-
dial capsule also provide secondary stability to the ACL-deficient knee. In addition, limb align-
ment must be critically analyzed as well, with consideration of osteotomies as needed. Recognition
and management of these concurrent issues is vital to the success of revision ACL reconstruction.
Persistent pain after ACL reconstruction can originate from a plethora of areas. Pain may be
due to recurrent instability, graft site morbidity, and patellofemoral joint pain. Intra-articular
Revision Anterior Cruciate Ligament Reconstruction 391
sources include traumatic arthrosis, osteochondral defects, and meniscal tears. It is important
to understand that if a revision ACL reconstruction is performed for pain only, poor outcomes
should be expected. ACL reconstruction is an instability-reducing procedure, not a pain-reducing
procedure.
Indications
▶ Failed primary ACL reconstruction
▶ Traumatic rerupture
▶ Loss of motion from improperly placed tunnels
▶ Pain only if the pain is secondary to recurrent instability episodes
Controversial Indications
▶ Revision ACL reconstruction in the setting of arthritis
▶ Revision ACL reconstruction for pain alone
Pertinent Imaging
▶ Preoperative x-rays should be obtained, including standing anteroposterior, posteroanterior 45,
lateral, and sunrise views. Alignment films must also be considered to rule out mechanical
axis issues. Degenerative changes should be noted and discussed with the patient because
many revision ACL reconstruction patients have degenerative pathology. Preoperative x-rays
should be use to evaluate the hardware used, tunnel position, and expansion. Previously placed
metal screws do not always need to be removed depending on their locations. If the previously
placed metallic screws do not interfere with revision tunnel location, they should be left to
prevent bone void defects. If hardware removal is necessary, a complete set of implant drivers
and screw removal instruments must be on hand.
392 Chapter 28
▶ Tunnels should be assessed for osteolysis and bone loss. Excessively posterior femoral tunnels
from the original procedure may cause back wall blowout. When the tunnel exceeds 16 to
17 mm, the authors recommend staged bone grafting and returning in 6 months for revision
ACL after the bone graft has incorporated.
▶ Magnetic resonance imaging (MRI) and 3-dimensional computed tomography scan may be
useful tools to fully evaluate tunnel osteolysis and tunnel position. MRI is more useful in
determining integrity of the graft and chondral and meniscal pathology but has limited use
when metallic screws are present due to metallic artifact.
Preoperative Planning
Evaluation
A thorough preoperative evaluation is imperative when presented with a patient with a prior
ACL reconstruction. It is vital to determine the cause of graft failure and what the patient’s
expectations for a revision ACL reconstruction are. The surgeon and the patient should have
realistic expectations for revision ACL reconstruction because it has been shown that success rates
of revision ACL reconstruction do not match that of primary ACL reconstruction.25,26 For many
patients, revision surgery may be considered a salvage procedure. For some patients returning to
activities of daily living without instability, it could be considered a success. Return to sports or
high-level activities may be unlikely and should be stressed preoperatively.27
History
The initial evaluation must include a careful history that addresses the nature of the primary
injury and procedure, postoperative regimen, ability to return to activity, and timing of recurrent
instability. The surgeon must have the operative notes from the primary surgery and, ideally, the
intraoperative images to help guide the revision surgery. Information regarding the original graft,
fixation type and manufacturer, and status of the menisci and articular cartilage is important in
preoperative planning. Symptoms of pain and instability must be clearly differentiated because the
treatment and prognosis may significantly differ. Typically, patients with symptomatic instability
and objective findings of patholaxity have the highest potential for successful outcomes after revi-
sion ACL reconstruction.
Graft Selection
There is no single optimal graft option for revision ACL reconstruction, and each patient
should be individualized in regard to graft choice. Studies have shown no significant difference
in allograft and autograft use in the revision setting.28,29 The authors’ preferred graft choice in
athletes younger than 22 years is autograft tissue, especially patellar tendon autograft. However,
in less-active and lower-demand patients, allograft tissue remains an excellent option. Factors
such as previous graft used, tunnel placement and enlargement, presence of patellofemoral symp-
toms, existing skin incision, other surgical procedures planned as part of the revision, and patient
preference should be taken into account when making this decision. Allograft tissue offers sev-
eral advantages that are relevant in the revision setting. Lack of donor site morbidity, decreased
operative time, and smaller incision are all beneficial to the patient. For the surgeon, variable
graft sizes, ability to create larger bone plugs, and increased tissue availability provides improved
surgical flexibility. Bone patellar tendon bone and Achilles tendon grafts are the most commonly
used allografts in the revision setting; however, slower graft incorporation and the risk of disease
transmission are concerns.
Revision Anterior Cruciate Ligament Reconstruction 393
Equipment
The surgeon must have all necessary equipment ready at the time of surgery. There should
be no question as to what implants were used for the primary surgery and any special equipment
needed for their possible removal. The authors routinely request the following for all revision
surgeries:
▶ ACUFEX PINPOINT Anatomic ACL Guide System (Smith & Nephew)
▶ ACL revision REDUX system for screw removal, including broken screws (Smith & Nephew)
▶ Mini C-arm for localization of hardware
▶ Richards Staple Tray (Smith & Nephew; used in some instances for tibial-sided supplemental
graft fixation in addition to interference screw)
▶ Large fragment set (can be used for femoral fixation in instances of posterior wall blowout of
the lateral post and washer)
▶ Geofit screw and washer set (Mitek; used in some instances for tibial-sided supplemental graft
fixation in addition to interference screw)
▶ ACUFEX ACL/posterior cruciate ligament drill guide system for tibial tunnel reaming
(Smith & Nephew)
▶ Femoral head frozen allograft (if bone grafting)
▶ Graft Master (Smith & Nephew) when soft tissue graft is used
▶ Bone crimpers for shaping bone plugs
▶ Fully fluted reamers, acorn reamers, and single-fluted reamers
▶ Curette set
▶ Bone tamps
▶ Power saw and blade for harvest of patellar tendon graft
▶ Interference screws of surgeon’s preference
▶ Cortical fixation button of surgeon’s choice if soft tissue fixation is used
▶ Any special equipment needed for removal of the previous implant from the primary surgery
(The authors routinely call the sales representative if they are unsure of any hardware needed
for implant removal.)
▶ Zone-specific cannulas for inside-out meniscal repair
▶ Henning retractor or a pediatric half speculum for inside-out meniscal repair
▶ All-inside meniscal repair system of surgeon’s preference
▶ Sterile bowl and frosted pestle for fibrin clot if needed for meniscal repair
needed for accessory medial portal femoral drilling and for complete access to the operative leg for
assistants to hold retractors and perform meniscal repairs, etc (Figure 28-3).
Hardware Removal
The decision to remove or retain hardware can be one of the hardest decisions in revision
ACL reconstruction. The following 2 questions should be asked: (1) Can the hardware be
safely removed? (2) Does the hardware need to be removed? In general, hardware should only be
removed when it interferes with the planned procedure, but the surgeon should be prepared for
hardware removal in all cases. The importance of previous surgical reports and having the appro-
priate instrumentation available cannot be overemphasized.
Tunnel Placement
Previous tunnel position may also affect revision graft integrity and, therefore, the ability to
perform a single-stage revision. For example, a transtibial primary ACL reconstruction commonly
results in a posteriorly placed tibial tunnel and an anteriorly and superiorly placed femoral tunnel.
In this scenario, drilling an anatomic femoral tunnel in native bone is often possible; however, it
is more common that the tibial tunnel necessitates bone grafting and staged surgery. Prior tunnel
Revision Anterior Cruciate Ligament Reconstruction 395
position can be described as anatomically placed (entire tunnel opening is 100% in the native
ACL footprint), nonanatomically placed (commonly seen in transtibial femoral tunnel drilling),
or partially anatomic (overlapping). The greatest variation in tunnel placement is seen on the
femur. When the femoral tunnel is nonanatomically placed, it rarely interferes with the revision
tunnel placement and can be ignored, leaving the previous fixation hardware in place. Partially
overlapping tunnel placement creates the most difficult scenario because the existing and revision
tunnels will create a figure-8 tunnel. Often, redirection of the tunnel (diverging from the exist-
ing tunnel) can address this on the femur, allowing for adequate fixation of the new graft. In the
authors’ experience, outside-in femoral tunnel drilling has proven successful in this situation. A
revision ACL surgeon must be comfortable with multiple techniques to reproduce anatomic tibial
and femoral tunnels.
secondary stabilizers. If there is a medial or lateral drive through sign, this would indicate signifi-
cant medial collateral ligament or posterolateral corner laxity and should be addressed concomi-
tantly at the time of revision ACL reconstruction. The previous ACL graft should be debrided,
and critical arthroscopic analysis of the tunnels should be done. Once all of the above has been
addressed, the appropriate ACUFEX PINPOINT guide size is chosen, with options ranging
from 6 to 10 mm. The scope is placed in the central medial portal, and the outside-in PINPOINT
guide is placed through the anterolateral portal. The intra-articular portion of the guide is placed
on the anatomic position on the medial aspect of the lateral femoral condyle. Next, the trochar
is placed through the handle to mark the skin incision laterally. The starting point for the drill
in general is anterior and proximal to the lateral epicondyle, except for use in skeletally immature
patients. In these patients, the entrance point must be distal to the femoral physis, which is directly
above the epicondyle or femoral attachment of the fibular collateral ligament. Care must be taken
to maintain the intra-articular portion of the guide in the anatomic position.
The trochar is removed once the skin is marked, and a 2- to 3-cm skin incision is made in line
with the iliotibial band. Skin retractors are placed, the trochar is reinserted, the iliotibial band is
incised in line with its fibers, and the trochar is advanced through the guide handle abutting the
lateral femoral condyle. While the guide is held firmly in place, a Beath pin is slowly advanced
through the trochar and visualized with the scope, passing a few millimeters into the intercon-
dylar notch (Figure 28-10). The guide is removed, and retractors are placed deep to the iliotibial
band on each side of the Beath pin to prevent the reamer from injuring the iliotibial band. The
Beath pin is grabbed with a pituitary grabber via the low anteromedial portal. The appropriately
sized, fully f luted reamer is drilled in an outside-in manner while an assistant holds the Beath
pin to prevent advancement. The pin and reamer are removed, the tunnel is debrided, and a plug
is placed into the tunnel to prevent f luid extravasation (Figures 28-11 through 28-13). Drilling
outside-in allows for a new virgin tunnel to be drilled, with tunnel convergence at the notch.
The tibial tunnel is drilled in a standard fashion. If the previously used screw can be avoided,
the screw is left in place. In some cases, the screw is removed, and the tunnel is rereamed to
allow for good bleeding bone. In addition, in some cases, if biocomposite screws were used in
the original case, they are drilled through. It is important to start reaming with small reamers
and progress up in size because previously placed screws can cause def lection of the reamers and
cause nonanatomic tunnels. To pass the graft, a passing suture is looped and grabbed with a
Revision Anterior Cruciate Ligament Reconstruction 399
pituitary grabber. The passing suture is placed in a retrograde fashion through the lateral femo-
ral condyle and passed off to another grabber through the drilled tibial tunnel. The graft can
then be pulled into appropriate position (Figure 28-14). If a bone tendon bone graft is chosen,
the bone plug is fixed on the femoral side with a metal screw placed from outside-in. The guide
wire is placed in a retrograde manner, and the bone plug must be directly observed to prevent
aberrant screw placement. The tibial side is fixed with a metal screw in the standard fashion
(Figure 28-15).
If a hamstring tendon graft is used, the graft is passed in a similar manner; however, a
10-mm EndoButton (Smith & Nephew) with an Xtendobutton (Smith & Nephew) attachment
is used for femoral fixation. A biocomposite screw and a staple or a screw with a spiked washer
are used for tibial fixation (Figure 28-16).
Postoperative Protocol
Standard rehabilitation after revision ACL reconstruction is the same as a primary. The authors
place all of their patients in a telescoping brace locked in full extension for 1 month when ambulat-
ing and weightbearing as tolerated. The brace can be unlocked for sleep at night and is removed
Revision Anterior Cruciate Ligament Reconstruction 401
when the patient is seated, and immediate full range of motion (ROM) is started on postoperative
day 1. Formal physical therapy is started 3 to 5 days from the index procedure. At 1 month, the
telescoping brace is shortened and unlocked. At 2 months, the patient is fitted with a standard
off-the-shelf knee sleeve. Functional ACL braces are used for patients returning to contact sports,
such as football and hockey, for the first year after the reconstruction. Patients are advised to start
immediate full ROM on postoperative day 1 with quadriceps sets and straight leg raises initiated.
Around 1 month, mini-squats and wall slides are started and bicycle is added. The patient in gen-
eral is advised not to jog for 4 months with no running for 5 months. Sport-specific drills are initi-
ated around 6 months, and return to sports after a revision is advised between 9 and 12 months,
depending on quadriceps function. The rehabilitation protocol is adjusted depending on associated
meniscal, cartilage, or alignment procedures performed.
Potential Complications
The following is an abbreviated list of the many complications that can occur with revision
ACL reconstruction:
▶ Arthrofibrosis
▶ Graft rerupture
▶ Inability to return to play
▶ Lateral collateral ligament femoral insertion disruption, from outside-in reaming
▶ Poor graft fixation (if done in a single stage and not bone grafted or if tunnels converge)
402 Chapter 28
Conclusion
As the number of primary ACL reconstructions increases, so will the number of revisions. ACL
failure can be attributed to numerous factors. Loss of motion, chronic pain, and recurrent laxity
are all reasons for patients to present with dissatisfaction with their primary reconstruction. It is
imperative to understand the exact reason why the primary ACL reconstruction failed to ensure a
successful outcome for the revision ACL reconstruction.
Return to play after revision ACL reconstruction is noted to be approximately 60%, and many
of those patients will not be able to return to their previous levels of play.26 The greatest concern
is that more than 50% of patients have early radiographic findings of degenerative changes as
early as 5 years after primary ACL surgery. The authors believe that the use of nonanatomic prin-
ciples combined with failure to recognize associated patholaxity is the primary reason for primary
ACL graft failure. The outside-in technique allows for a predictable method for revision ACL
reconstruction. Adhering to anatomic reconstruction principles and addressing missed injuries to
the secondary stabilizers should restore knee kinematics to as normal as possible and, therefore,
improve overall outcomes. The senior author currently uses the outside-in technique on the major-
ity of his revision ACL reconstructions.
References
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Revision Anterior Cruciate Ligament Reconstruction 403
4. Irrgang JJ, Harner CD. Loss of motion following knee ligament surgery. Sports Med. 1995;19(2):150-159.
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2013;95(22):2035-2042.
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404 Chapter 28
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Introduction
This chapter addresses single- and double-bundle arthroscopic transtibial tunnel posterior
cruciate ligament (PCL) reconstruction. This discussion includes physical examination, imaging
studies, equipment requirements, patient positioning, surgical technique, postoperative program,
potential complications, and the top technical pearls for the procedure. Isolated PCL tears are rare
in the author’s practice, and PCL injuries and reconstruction must always be considered in the
context of the multiple-ligament injured knee.1,2 Recognition and treatment of collateral ligament
instability (posteromedial and posterolateral instability) is essential for successful PCL reconstruc-
tion.3 Other factors that maximize the probability of a successful PCL reconstruction include
strong graft material, accurate tunnel placement approximating anatomic ligament insertion sites,
minimal graft bending, mechanical graft tensioning, secure graft fixation, and the appropriate
postoperative rehabilitation program.4,5 Single- and double-bundle PCL reconstruction surgical
techniques are successful when evaluated with stress radiography, KT 1000 arthrometer measure-
ments, and knee ligament rating scales. Indications for double-bundle PCL reconstruction include
severe hyperextension of the knee and revision PCL reconstruction.6 The author’s long-term post-
surgical results revealed successful PCL reconstruction using the arthroscopic transtibial tunnel
surgical technique.7,8
Indications
▶ PCL-based multiple-ligament injured knee4,9
▶ PCL tears with articular surface and/or meniscal injuries4,9
▶ Isolated chronic PCL tear with functional instability
Controversial Indications
▶ Acute isolated PCL tear
Pertinent Imaging
▶ Plain x-rays
▶ Magnetic resonance imaging
▶ Computed tomography scans for revision surgery evaluation and evaluation of fracture
dislocations
▶ Stress radiography4,9,12,13
Equipment
The Biomet Sports Medicine PCL/ACL System (Biomet Sports Medicine) includes the surgi-
cal instruments that the author uses for this surgical procedure; however, other equipment compa-
nies offer surgical instrumentation. Intraoperative radiography and C-arm image intensifiers may
routinely used for this surgical procedure depending upon surgeon preference.
PCL-based reconstruction procedures are routinely performed in an outpatient setting unless
specific circumstances indicate the necessity of an inpatient environment. The same experienced
surgical teams are assembled for these complex surgical procedures. Experienced and familiar
Arthroscopic Posterior Cruciate Ligament Reconstruction 407
teams provide for a smoother operation, shorter surgical times, enhanced patient care, and a
greater probability of success in these difficult surgical procedures.
incision enables the surgeon to protect the neurovascular structures, confirm the accuracy of the
PCL tibial tunnel, and facilitate the flow of the surgical procedure. The neurovascular structures
of the popliteal fossa are in close proximity to the posterior capsule of the knee joint and are at
risk during transtibial PCL reconstruction. The posteromedial safety incision is important for the
protection of these structures.
The curved over-the-top PCL instruments (Biomet Sports Medicine) are used to sequentially
lyse adhesions in the posterior aspect of the knee and elevate the capsule from the posterior tibial
ridge. This will allow accurate placement of the PCL/ACL drill guide and correct placement of
the tibial tunnel.
The arm of the PCL/ACL guide (Biomet Sports Medicine) is inserted through the inferior
medial patellar portal (Figure 29-2). The tip of the guide is positioned at the inferior lateral aspect
of the PCL anatomic insertion site. This is below the tibial ridge posterior and in the lateral aspect
of the PCL anatomic insertion site. The bullet portion of the guide contacts the anteromedial
surface of the proximal tibia at a point midway between the posteromedial border of the tibia and
the tibial crest anterior at or just below the level of the tibial tubercle. This will provide an angle of
graft orientation such that the graft will turn 2 smooth 45-degree angles on the posterior aspect of
the tibia. The tip of the guide, in the posterior aspect of the tibia, is confirmed with the surgeon’s
finger through the extracapsular, extra-articular posteromedial safety incision. Intraoperative
anteroposterior and lateral x-rays may also be used; however, the author does not routinely use
intraoperative x-rays. When the PCL/ACL guide is positioned in the desired area, a blunt spade-
tipped guide wire is drilled from anterior to posterior. The surgeon’s finger confirms the position
of the guide wire through the posterior medial safety incision.
The appropriately sized standard cannulated reamer is used to create the tibial tunnel. The
surgeon’s finger through the extracapsular, extra-articular posteromedial incision is monitoring
the position of the guide wire. When the drill is engaged in bone, the guide wire is reversed with
the blunt end pointing posterior for additional patient safety. The drill is advanced until it comes
to the posterior cortex of the tibia. The chuck is disengaged from the drill, and completion of the
tibial tunnel is performed by hand.
Arthroscopic Posterior Cruciate Ligament Reconstruction 409
The PCL single- or double-bundle femoral tunnels are made from inside-out using the
double-bundle aimers, or an endoscopic reamer can be used as an aiming device (Biomet Sports
Medicine). The appropriately sized double-bundle aimer or endoscopic reamer is inserted through
a low anterior lateral patellar arthroscopic portal to create the PCL anterior lateral bundle femoral
tunnel with the surgical knee in 90 to 110 degrees of knee flexion (Figure 29-3). The double-
bundle aimer or endoscopic reamer is positioned directly on the footprint of the femoral anterior
lateral bundle PCL insertion site. The appropriately sized guide wire is drilled through the aimer
or endoscopic reamer, through the bone, and out of a small skin incision. Care is taken to prevent
compromise of the articular surface. The double-bundle aimer is removed, and the endoscopic
410 Chapter 29
a b
Figure 29-4. (A) A single-bundle PCL femoral tunnel in the region of the anterolateral bundle of
the PCL. (B) Double-bundle PCL reconstruction tunnels approximating the anatomic insertion
sites of the anterolateral and posteromedial bundles of the PCL. The patient is supine on the fully
extended operating table. A lateral post is used. No leg holder is used. The arthroscope is in the
inferior lateral patellar portal on this right knee.
reamer is used to drill the anterior lateral PCL femoral tunnel from inside to outside. When the
surgeon chooses to perform a double-bundle double femoral tunnel PCL reconstruction, the same
process is repeated for the posterior medial bundle of the PCL. Care must be taken to ensure that
there will be an adequate bone bridge (approximately 5 mm) between the 2 femoral tunnels prior
to drilling. This is accomplished using the calibrated probe and direct arthroscopic visualization
of the PCL femoral anatomic insertion sites (Figure 29-4).
The author prefers the surgical technique of PCL femoral tunnel creation from inside to outside
for 2 reasons. There is a greater distance and margin of safety between the PCL femoral tunnels
and the medial femoral condyle articular surface using the inside to outside method. In addition, a
more accurate placement of the PCL femoral tunnels is possible because one can place the double-
bundle aimer or endoscopic reamer on the anatomic footprint of the anterior lateral or posterior
medial PCL insertion site under direct visualization.
A Magellan suture retriever (Biomet Sports Medicine) is introduced through the tibial tunnel
into the joint and is retrieved through the femoral tunnel. The traction sutures of the graft mate-
rial are attached to the loop of the Magellan suture retriever, and the graft is pulled into position.
The graft material is secured on the femoral side using a bioabsorbable interference screw for
primary aperture opening fixation, and a polyethylene ligament fixation button is used for backup
fixation (Figure 29-5).
The cyclic dynamic method of graft tensioning using the Biomet graft tensioning boot is used
to tension the PCL and ACL grafts.23 Tension is placed on the PCL graft distally using the
Biomet graft-tensioning boot (Biomet Sports Medicine). Tension is gradually applied with the
knee in 0 degrees of flexion (full extension), reducing the tibia on the femur (Figure 29-6). This
restores the anatomic tibial stepoff. The knee is cycled through a full range of motion (ROM)
multiple times to allow pretensioning and settling of the graft. The process is repeated until there
is no further change in the torque setting on the graft tensioner. The knee is placed in 70 to
90 degrees of flexion, and fixation is achieved on the tibial side of the PCL graft with a bioabsorb-
able interference screw and backup fixation with a bicortical screw and spiked ligament washer or
polyethylene ligament fixation button (Figure 29-7).
Arthroscopic Posterior Cruciate Ligament Reconstruction 411
Postoperative Protocol
The knee is maintained in full extension for 3 to 5 weeks nonweightbearing. Progressive ROM
begins during postoperative weeks 3 through 5. Progressive weightbearing occurs at the beginning
of postoperative weeks 3 through 5. Progressive closed kinetic chain strength training, propriocep-
tive training, and continued motion exercises are initiated slowly, beginning at postoperative week
12. Return to sports and heavy labor occurs after the 9th to 12th postoperative month when suf-
ficient strength, ROM, and proprioceptive skills have returned. Functional bracing may be used
at the surgeon’s discretion. It is important to carefully observe these complex knee ligament injury
patients and get a feel for the personality of the knee. The surgeon may need to make adjustments
and individualize the postoperative rehabilitation program as necessary. Careful and gentle ROM
under general anesthesia is a useful tool in the treatment of these complex cases and is used as
necessary. Pre- and postoperative antibiotics are given, and antibiotics are routinely used to help
prevent infection in these time-consuming, difficult, and complex cases.19,24-27
Potential Complications
Potential complications include injury to the posterior neurovascular structures of the knee,
articular surface damage during tunnel creation, osteonecrosis, peroneal nerve injury during pos-
terolateral reconstruction, infection, problematic wound healing, deep venous thrombosis, postop-
erative fracture, arthrofibrosis, persistent laxity, compartment syndrome, and physeal injury.28-30
Conclusion
The goals leading to successful PCL reconstruction include identification and treatment of
associated pathology, such as posterolateral instability, posteromedial instability, and lower-
extremity malalignment. The use of strong graft material, properly placed tunnels as closely as
possible to the approximate PCL insertion sites, and minimization of graft bending also enhance
412 Chapter 29
Figure 29-6. The cyclic dynamic method of graft tensioning using the
Biomet graft tensioning boot is used to tension the PCL graft. Tension is grad-
ually applied with the knee in 0 degrees of flexion (full extension), reducing
the tibia on the femur. This restores the anatomic tibial stepoff. The knee is
cycled through a full ROM multiple times to allow pretensioning and settling
of the graft. The process is repeated until there is no further change in the
torque setting on the graft tensioner. The knee is placed in 70 to 90 degrees
of flexion, and fixation is achieved on the tibial side of the PCL graft with a
bioabsorbable interference screw and backup fixation with a bicortical screw
and spiked ligament washer or polyethylene ligament fixation button. The
patient is supine on the fully extended operating table. A lateral post is used.
No leg holder is used. The arthroscope is in the inferior lateral patellar portal
on this left knee.
a b
Figure 29-7. (A) Single- and (B) double-bundle PCL reconstructions. An Achilles tendon allograft is
used for the anterolateral bundle of the PCL in both reconstructions. A tibialis anterior allograft is
used for the posteromedial bundle PCL reconstruction in double-bundle PCL reconstructions. The
patient is supine on the fully extended operating table. A lateral post is used. No leg holder is used.
The arthroscope is in the inferior lateral patellar portal on this right knee.
Arthroscopic Posterior Cruciate Ligament Reconstruction 413
the probability of PCL reconstruction success. In addition, mechanical graft tensioning, secure
PCL graft fixation, and an appropriate postoperative rehabilitation program are also necessary
ingredients for PCL reconstruction success. Single- and double-bundle PCL reconstruction
surgical techniques are successful when evaluated with stress radiography, KT 1000 arthrometer
measurements, and knee ligament rating scales. Indications for double-bundle PCL reconstruc-
tion include severe hyperextension of the knee and revision PCL reconstruction. The author’s
postsurgical results reveal successful PCL reconstruction using the arthroscopic transtibial tunnel
surgical technique using allograft tissue.5-8,15,17-22
References
1. Fanelli GC. Posterior cruciate ligament injuries in trauma patients. Arthroscopy. 1993;9(3):291-294.
2. Fanelli GC, Edson CJ. Posterior cruciate ligament injuries in trauma patients: part II. Arthroscopy.
1995;11(5):526-529.
3. Noyes FR, Barber-Westin SD. Posterior cruciate ligament revision reconstruction, part 1: causes of sur-
gical failure in 52 consecutive operations. Am J Sports Med. 2005;33(5):646-654.
4. Fanelli GC, Beck JD, Edson CJ. Current concepts review: the posterior cruciate ligament. J Knee Surg.
2010;23(2):61-72.
5. Fanelli GC, Beck JD, Edson CJ. Arthroscopic double-bundle posterior cruciate ligament reconstruction
surgical technique. J Knee Surg. 2010;23(2):89-94.
6. Fanelli GC, Beck JD, Edson CJ. Single compared to double-bundle PCL reconstruction using allograft
tissue. J Knee Surg. 2012;25(1):59-64.
7. Fanelli GC, Edson CJ. Surgical treatment of combined PCL-ACL medial and lateral side injuries (global
laxity): surgical technique and 2- to 18-year results. J Knee Surg. 2012;25(4):307-316.
8. Fanelli GC, Sousa PL, Edson CJ. Long-term followup of surgically treated knee dislocations: stability
restored, but arthritis is common. Clin Orthop Relat Res. 2014;472(9):2712-2717.
9. Fanelli GC, Giannotti BF, Edson CJ. The posterior cruciate ligament arthroscopic evaluation and treat-
ment. Arthroscopy. 1994;10(6):673-688.
10. Fanelli GC, Feldman DD. Management of combined anterior cruciate ligament/posterior cruciate liga-
ment/posterolateral complex injuries of the knee. Oper Tech Sports Med. 1999;7(3):143-149.
11. Fanelli GC, Harris JD. Late medial collateral ligament reconstruction. Tech Knee Surg. 2007;6(2):99-105.
12. Malone JW, Verde F, Weiss D, Fanelli GC. MR imaging of knee instability. Magn Reson Imaging Clin N
Am. 2009;17(4):697-724.
13. Staubli HU. Stress radiography: measurements of knee motion limits. In: Daniel D, ed. Knee Ligaments:
Structure, Function, Injury, and Repair. New York, NY: Raven Press; 1990:461-480.
14. Fanelli GC. Rationale and Surgical Technique for PCL and Multiple Knee Ligament Reconstruction. 3rd
ed. Warsaw, IN: Biomet Sports Medicine; 2012.
414 Chapter 29
15. Fanelli GC. Surgical treatment of combined PCL-ACL medial and lateral side injuries (global lax-
ity): acute and chronic. In: Fanelli GC, ed. The Multiple Ligament Injured Knee. A Practical Guide to
Management. 2nd ed. New York, NY: Springer-Verlag; 2013:281-301.
16. Fanelli GC, Boyd J. How I manage PCL injuries. Oper Tech Sports Med. 2009;17(3):175-193.
17. Fanelli GC, Beck JD, Edson CJ. Double bundle posterior cruciate ligament reconstruction: surgical
technique and results. Sports Med Arthrosc Rev. 2010;18(4):242-248.
18. Fanelli GC, Beck JD, Edson CJ. Arthroscopic double-bundle posterior cruciate ligament reconstruction.
J Knee Surg. 2010,23(2):89-94.
19. Fanelli GC. The multiple ligament injured knee: what I have learned. In: Fanelli GC, ed. The Multiple
Ligament Injured Knee. A Practical Guide to Management. 2nd ed. New York, NY: Springer-Verlag;
2013:3-14.
20. Fanelli GC, Edson CJ. Combined posterior cruciate ligament-posterolateral reconstructions with
Achilles tendon allograft and biceps femoris tendon tenodesis: 2- to 10-year follow-up. Arthroscopy.
2004;20(4):339-345.
21. Fanelli GC, Edson CJ. Arthroscopically assisted combined anterior and posterior cruciate liga-
ment reconstruction in the multiple ligament injured knee: 2- to 10-year follow-up. Arthroscopy.
2002;18(7):703-714.
22. Fanelli GC, Edson CJ, Orcutt DR, Harris JD, Zijerdi D. Treatment of combined anterior-posterior cruci-
ate ligament medial lateral side injuries of the knee. J Knee Surg. 2005;18(3):240-248.
23. Fanelli GC. Mechanical graft tensioning in multiple ligament knee surgery. In: Fanelli GC, ed. The
Multiple Ligament Injured Knee. A Practical Guide to Management. 2nd ed. New York, NY: Springer-
Verlag; 2013:323-330.
24. Fanelli GC. Posterior cruciate ligament rehabilitation: how slow should we go? Arthroscopy.
2008;24(2):234-235.
25. Edson CJ, Fanelli GC, Beck JD. Rehabilitation after multiple-ligament reconstruction of the knee. Sports
Med Arthrosc Rev. 2011;19(2):162-166.
26. Edson CJ, Fanelli GC, Beck JD. Postoperative rehabilitation of the posterior cruciate ligament. Sports
Med Arthrosc Rev. 2010;18(4):275-279.
27. Edson CJ, Fanelli GC. Postoperative rehabilitation of the multiple ligament injured knee. In: Fanelli
GC, ed. The Multiple Ligament Injured Knee. A Practical Guide to Management. 2nd ed. New York, NY:
Springer-Verlag; 2013:437-442.
28. Fanelli GC, Monahan TJ. Complications of posterior cruciate ligament reconstruction. Sports Med
Arthrosc Rev. 1999;7(4):296-302.
29. Fanelli GC, Monahan TJ. Complications in posterior cruciate ligament and posterolateral corner sur-
gery. Oper Tech Sports Med. 2001;9(2);96-99.
30. Fanelli GC, Orcutt DR. Complications posterior cruciate ligament reconstruction. Sports Med Arthrosc
Rev. 2004;12(3):196-201.
Introduction
The primary function of the posterior cruciate ligament (PCL) is to prevent posterior tibial
translation, and a secondary function is to restrict the rotation of the knee.1 Only by understand-
ing the anatomy and function of the PCL is it possible to attempt anatomic reconstruction and
restoration of proper stability and kinematics to the knee. Consequently, significant research has
gone into accurately describing the PCL. Current descriptions of the PCL describe a continuum
of fibers that can be delineated into 2 separate bundles, including the anterolateral and the pos-
teromedial bundles. Tension in these 2 bundles differs during range of motion (ROM), with the
anterolateral bundle experiencing more tension during flexion and the posteromedial bundle expe-
riencing more tension during extension.1-7 However, in normal ROM, Papannagari et al4 demon-
strated synergistic function of the 2 bundles because both experienced an increase in length, with
degrees of flexion ranging from 0 to 120 degrees using dual-orthogonal fluoroscopic imaging.
The femoral and tibial footprints have been described using multiple anatomical references
in an attempt to allow accurate footprint identification and reconstruction. The average femoral
footprint has been measured at 209 ± 33.82 mm 2 (anterolateral, 118 ± 23.95 mm 2; posteromedial
90 ± 16.13 mm 2) and the tibial footprint at 243 ± 38.2 mm 2 (anterolateral, 93.1 ±16.6 mm 2; pos-
teromedial, 150.8 ± 31.0 mm 2).5-7 Specific identification of the centers of the anterolateral and
posteromedial bundles has been extensively studied in reference to local anatomical landmarks to
facilitate accurate reconstruction of the individual bundles.
The tibial insertion of the PCL is predominantly within the posterior PCL or intercondy-
lar facet, which is a relatively flat area bordered anteriorly by the posterior horn of the medial
meniscus and posteriorly by the posterior cortex of the tibia.8 Edwards et al 3 and Takahashi et al9
measured the distance from the medial tibia to the centers of the anterolateral and posteromedial
bundles and reported them as a percentages of the width of the tibial plateau, averaging 48% ± 4%3
and 51%,9 respectively, for the anterolateral bundle and 48% ± 5%3 and 50%9 for the posterome-
dial bundle. The center of the PCL insertion can reproducibly be identified 7 mm anterior to the
posterior cortex of the tibia.8 The anterolateral bundle inserts at the superolateral portion of the
facet, and the posteromedial bundle is upon the inferomedial portion.5
Femoral footprints have shown greater variability than tibial footprints. Femoral tunnel place-
ment during reconstruction has proven to have a significant impact on the function of the PCL,
as demonstrated by multiple investigators.1,6,7,10,11 When varying the femoral tunnel location,
Mannor et al10 demonstrated that the tension of the graft was subsequently altered and the biome-
chanical properties of the knee were changed. Markolf et al11 also investigated the biomechanical
effects of tunnel placement; they used 10 cadaveric knees to test the effect of 5 mm of displace-
ment (medial and lateral) of the femoral footprint and found that the medially displaced graft was
subjected to greater forces at knee flexion angles greater than 5 degrees. These studies underline
the importance of establishing the proper anatomic position for the femoral footprint of the PCL
and have been the focus of multiple studies. Takahashi et al9 measured the distances from the
center of the anterolateral (9.6 mm) and posteromedial (10.6 mm) bundles from the articular
cartilage, using a line drawn parallel to Blumensaat’s line. Conversely, Morgan et al12 measured
the centers of the anterolateral and posteromedial bundles at 13 ± 0.5 mm and 8 ± 0.5 mm, respec-
tively, posterior to the medial articular cartilage-intercondylar wall interface and 13 ± 0.5 mm and
20 ± 0.5 mm, respectively, inferior to the articular cartilage-intercondylar roof interface. Lopes et
al6 coined the term medial intercondylar ridge after identifying an osseous prominence just proximal
to the femoral footprint of the PCL in 18 of 20 (90%) cadaver specimens. In addition, in 8 of
20 (40%) of the specimens, they identified and named an osseous bridge dividing the anterolateral
and posteromedial bundles the medial bifurcate ridge.6 These anatomical landmarks may be of
great utility in proper anatomic intraoperative footprint identification.
Controversy remains in regard to the degree in which function can be restored through vari-
ous surgical techniques. Gill et al13 showed that under normal physiologic loads, single-bundle
reconstruction restores the anteroposterior laxity of the PCL at flexion angles up to 90 degrees. In
addition, Gill et al13 showed a nonstatistically significant reduction of external rotation in single-
bundle repaired knees. However, the success of single-bundle reconstruction in restoring the rota-
tional component of PCL function is a matter of contention. In studies by Race et al,14 Harner et
al,15 and Whiddon et al,16 in vitro double-bundle PCL reconstruction more closely restored the
function of the native PCL. Wijdicks et al17 also demonstrated significantly less internal rotation
with double-bundle repair at angles of 90 degrees or greater. However, Bergfeld et al18 found no
definitive advantage of double-bundle repair.
Indications19-23
▶ Multiligamentous knee injury
▶ Avulsion fractures
▶ Decrease in tibial stepoff greater than 8 mm
▶ Chronic functional instability
▶ Failed conservative management
Controversial Indications23
▶ Grade I and II PCL injuries
▶ Isolated complete PCL injuries
Arthroscopic All-Inside Posterior Cruciate Ligament Reconstruction 417
Pertinent Imaging
▶ Stress x-rays24,25: Obtaining lateral x-rays of the knee while performing a posterior drawer
test allows for direct measurement of the displacement of the tibia from the reduced ante-
rior position and the posterior subluxed position. Posterior displacement of 8 mm indicates
complete PCL disruption, and displacement of greater than 12 mm indicates that additional
structures have been compromised in the posterior lateral corner of the knee.
▶ Magnetic resonance imaging: Can aid when the patient is guarding and evaluate the remain-
ing structures of the knee for concomitant injuries that would need to be addressed concomi-
tantly to produce a stable knee.
Equipment
▶ TightRope Attachable Button System (ABS; Arthrex)
▶ GraftLink
▶ Anatomic Contour PCL Guide (Arthrex)
▶ FlipCutter (Arthrex)
▶ #2 FiberStick (Arthrex)
▶ 30-degree scope
▶ Leg holder
reconstructions by preventing spacing issues between incisions and limiting the additional surgical
trauma of the reconstruction to the already traumatized knee. The all-inside technique allows the
surgeon to avoid a posterior incision and popliteal fossa dissection, the drilling of the tibia is done
using a FlipCutter that allows drill progression/advancement to be directed away from the pos-
terior neurovascular structures, and less bone is removed by creation of a tibial socket as opposed
to the traditional full-length transtibial tunnel. Furthermore, the creation of a tibial socket limits
the potential for graft migration. Lubowitz and Konicek 27 demonstrated that retrograde socket
drilling is more accurate than antegrade drilling in a cadaveric study in which a 3.5-mm tibial
socket drilled in a retrograde fashion was significantly more accurate than a 2.4-mm tibial socket
drilled in an antegrade fashion.
Reconstruction strengths have been found comparable between the all-inside and open inlay
techniques.28,29 In a cadaveric model, Zehms et al 28 demonstrated that arthroscopic double-
bundle PCL inlay reconstruction performed with an all-inside techniques provided comparable
stability to its open counterpart. In addition, Kim and Park 29 demonstrated less than 3 mm of
side-to-side difference in posterior translation after double-bundle PCL reconstruction using an
all-inside inlay technique.
With the open tibial inlay technique, there is concerning evidence that clinical laxity may be
created as a result of the posterior capsulotomy that is required during the open exposure. Using
14 cadaveric knees, Ritchie et al 30 demonstrated that after posteromedial capsular sectioning,
there was an average increase of 0.59 mm of posterior translation. Park et al 31 similarly found that
posterior capsule violation increased posterior translation by 0.97 mm at 0 degrees of flexion and
0.94 mm at 120 degrees of knee flexion. These increases in laxity are relatively small but must be
kept in mind when the goal is to increase restraint and return stability to the PCL-deficient knee.
Visualization is facilitated by usage of the posteromedial portal. With all-inside techniques, the
surgeon has the ability to fully visualize the distal extent of the PCL tibial insertion through the
posteromedial portal while not working around and retracting the posterior neurovascular struc-
tures. This improves visualization and facilitates proper footprint identification and, thus, tunnel
placement for anatomic PCL reconstruction. Although there is no conclusive clinical outcomes
evidence to support the superiority of the all-inside PCL reconstruction technique when compared
to the open counterpart, there are major benefits to the surgeon.
Patient Positioning
The patient is placed supine on the operating table. Once adequate anesthesia is achieved, the
operative leg is prepped and draped (Figure 30-1A). The operative limb is at 90 degrees in an
arthroscopic leg holder. The well leg is placed in a leg holder that keeps the well leg flexed and
abducted to keep it out of the way. This gives the surgeon posteromedial access for the postero-
medial portal (Figures 30-1B and 30-1C.)
A soft tissue graft is prepared by folding the TightRope ABS implant and stitching the tails
together with #2 FiberLoop (Arthrex) after quadrupling the graft (GraftLink Technique Video).
The graft is prepared to the appropriate length, and the ends can be tapered with a stitch to ease
graft passage.
An accessory posteromedial portal may first be localized with a spinal needle. Once estab-
lished, a 2-cm incision is made, and a screw-in cannula is placed under direct visualization in an
outside-in fashion. An alternative approach would be to make use of the knee obturator device
for posterior portals and create the posteromedial portal in an inside-out fashion (Figure 30-2).
The soft tissue remaining on the PCL footprint is gently debrided with a shaver and/or a
radiofrequency ablator device placed through the posteromedial portal to expose the full extent of
the PCL footprint on the tibia (Figure 30-3). Care should be taken to protect the neurovascular
structures that lie just posterior to the capsule by keeping a device facing the posterior tibia.
Arthroscopic All-Inside Posterior Cruciate Ligament Reconstruction 419
Figure 30-1. (A-C) Patient positioning and graft preparation using the TightRope ABS and GraftLink
technique.
The mammillary bodies at the posterior aspect of the tibia can be palpated through the postero-
medial portal to confirm anatomic placement. The PCL should be positioned directly between
these 2 bodies and distal on the tibia. The side-specific Anatomic Contour PCL Guide is placed
420 Chapter 30
C
Arthroscopic All-Inside Posterior Cruciate Ligament Reconstruction 421
over the back of the tibia through the anteromedial portal and positioned between the mammillary
bodies (Figure 30-4). The arthroscope can be placed in the posteromedial portal to best visualize
the footprint. Fluoroscopic guidance may be used to confirm correct positioning of the posterior
guide in the over-the-top position and assist with drill trajectory. When in position, the marking
hook will guide the FlipCutter to the ideal location and angle for transtibial PCL reconstruction
(Figure 30-5). A small 2- to 3-cm incision is made in this location, and the guide is gently tapped
to confirm that it is in cortical bone (Figure 30-6). Before drilling the FlipCutter, note the osseous
length as read by the drill sleeve markings as it enters the guide handle (see Figure 30-6).
Place the FlipCutter into the drill sleeve and move the rubber grommet back to a distance equal
to the interosseous length (Figure 30-7). This will give an indication of drill depth. With the
arthroscope in the posteromedial portal, drill the FlipCutter until it is visualized just in the joint.
Remove the guide and confirm that the FlipCutter is in the center of the PCL footprint (Figure
422 Chapter 30
30-8). Tap in the Stepped Drill Sleeve and slide down the rubber grommet until it is flush with
the drill guide. Flipcut the socket to a depth of at least 20 mm, as indicated by the distance on
the drill sleeve. After completing the socket, unflip the FlipCutter and remove it from the drill
sleeve. Place a #2 FiberStick up the sleeve and into the joint for future graft passage (Figure 30-9).
Retrieve the suture using an arthroscopic grasper through the medial portal.
Place the arthroscope back into the anterolateral portal and visualize the femoral footprint of
the PCL (Figure 30-10). Place the All-Inside PCL Femoral Guide (Arthrex) in the center of the
anterolateral bundle. Drill the FlipCutter from outside-in, and flipcut the socket to a depth of
at least 20 mm as indicated by the distance on the drill sleeve. Place a #2 FiberStick down the
sleeve and into the joint for future graft passage. Alternatively, the femoral socket can be drilled
with a standard reamer from inside-out, and a Beath pin (Arthrex) can be used to pass the suture
retrograde for future graft passage. This technique may be used if interference screw fixation is
chosen on the femoral side.
424 Chapter 30
B
Arthroscopic All-Inside Posterior Cruciate Ligament Reconstruction 425
A B
Figure 30-8. (A, B) Confirm that the FlipCutter is in the center of the PCL footprint before drilling.
A B
Figure 30-9. (A, B) Thread a #2 FiberStick into the joint for use with graft passage.
The #2 FiberStick sutures are retrieved through the anteromedial portal. Care should be
taken to avoid a suture bridge (Figure 30-11). The graft is introduced through the portal, and the
TightRope ABS is passed into the tibia using the passing/safety suture so that the tibial TightRope
is not inadvertently shortened (Figure 30-12). The graft is advanced all the way to the bottom of
the tibial socket by pulling on the inner loop of the implant without shortening the loop (Figure
30-13). The #2 suture with the attached button is next retrieved from the femoral socket, and the
graft is pulled into the femoral socket. The femoral end of the graft can be tensioned with the knee
at 90 degrees of flexion (Figure 30-14). The graft is tensioned on the tibial side at 90 degrees, sup-
porting the foot to eliminate gravity and anterior drawer. The free TightRope button is applied,
and the graft is tensioned (Figure 30-15). Once the femoral and tibial sides are secured and ten-
sioned, a knot may be tied over the button to act as another form of fixation. Alternatively, the
excess suture can be used for further backup fixation or the excess cut for removal.
426 Chapter 30
C D
Arthroscopic All-Inside Posterior Cruciate Ligament Reconstruction 427
A B
B
428 Chapter 30
B
Arthroscopic All-Inside Posterior Cruciate Ligament Reconstruction 429
A B
C D
A cold compressive dressing is placed atop the wound, and the patient is placed in a knee immo-
bilizer until quadriceps function adequately returns. The patient is typically made weightbearing
as tolerated with ROM as tolerated.
Postoperative Protocol
General follow-up intervals are 2 weeks, 6 weeks, 3 months, 6 months, and 1 year. The patient
starts physical therapy immediately after surgery with the goal of providing edema control and
restoration of ROM. Physical therapy progresses to closed chain strengthening of the involved leg
with a focus on quadriceps strength at 6 to 8 weeks. The targeted time frame for sport-specific
rehabilitation is 4 to 5 months, with the addition of more plyometric-based rehabilitation at 6 to
7 months. The goal for return to play varies by sport, with noncontact sports returning around
6 months and contact/collision sports returning around 8 months if functional scores are greater
than 80% of the contralateral uninjured leg.
Potential Complications
Common complications may include knee pain and instability. The saphenous nerve can
be injured with accessory posterior medial portal placement. Li et al 32 reported 1 patient with
anterior knee pain, 2 with parasthesias that resolved in 6 months, and 1 with arthrofibrosis that
required arthroscopic lysis of adhesions and manipulation. Wu et al33 also reported a case of
arthrofibrosis. Zhao et al 34 reported 5 patients with medial knee discomfort with flexion. This
was corrected 1 year postoperatively by removing the tape knots and mini-plate of the femoral
fixation. Hardware removal and complex regional pain syndrome has also been described in a
few patients.33,35,36 Although rare, injury to the popliteal neurovascular structures is possible
when not adhering to meticulous posterior compartment arthroscopic techniques and must be
mentioned for completeness.
Arthroscopic All-Inside Posterior Cruciate Ligament Reconstruction 431
MINIMUM
NO. OF FOLLOW- GRAFT
AUTHOR YEAR PATIENTS UP TENDON IKDC GRADE (%) LYSHOLM
A B C D
Lin et al37 2013 25 36 Q 16 68 16 0 92
34 36 H 35 59 6 0 94
Boutefnouchet
et al35 2013 15 12 H 67 27 6 0 91
Kim et al38 2009 8 24 A — — — — 87
Li et al32 2009 15 24 H 53 20 20 7 85
Zhao and 2007 21 24 H 52 24 19 5 83
Huangfu34 22 24 Ha 64 27 9 0 92
Wu et al33 2007 22 60 Q 23 64 13 0 89
MacGillivray et al39 2006 13 24 Q and A — — — — 81
Seon and Song40 2006 21 24 H — — — — 91
Chan et al36 2006 20 36 H 25 60 10 5 93
A, Achilles; H, hamstring; IKDC, International Knee Documentation Committee; Q, quadriceps.
a7-strand graft.
Outcomes
The degree to which all-inside single-bundle reconstructions can restore proper knee function
is not clearly elucidated in the literature. The results from multiple recent outcome studies on all-
inside, single-bundle PCL reconstruction are summarized in Table 30-1.32-40 In general, when
using Lysholm and International Knee Documentation Committee scores, outcomes are satisfac-
tory and postoperative restoration of function is obtained. Long-term follow-up studies using
Lysholm scores by Wu et al 33 and Boutefnouchet et al 35 found 86% and 93% of patients had good
or excellent scores at a minimum of 60-month follow-up and 4.1 years, respectively. In a system-
atic review of arthroscopic single-bundle transtibial PCL reconstruction, Kim et al41 concluded
that this technique can improve posterior knee laxity by one grade, with 75% of patients reaching
normal or near normal outcomes.
The debate between all-inside, single-, and double-bundle reconstruction in the clinical set-
ting is ongoing. Yoon et al42 found that double-bundle reconstruction using an Achilles tendon
allograft had no subjective difference but yielded a better International Knee Documentation
Committee score and objective stability than single-bundle. In contrast, Wang et al43 found no
difference in clinical outcomes between patients treated with single- vs double-bundle PCL recon-
struction with semitendinosus and gracilis tendon grafts. Similarly, Fanelli et al44 found no differ-
ence between single- and double-bundle reconstruction in regard to Lysholm, Tegner, or Hospital
for Special Surgery ratings. In a study comparing PCL reconstruction via arthroscopic tibial inlay
432 Chapter 30
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8. Moorman CT III, Murphy Zane MS, Bansai S, et al. Tibial insertion of the posterior cruciate
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9. Takahashi M, Matsubara T, Doi M, Suzuki D, Nagano A. Anatomical study of the femoral and tibial
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Arthroscopic All-Inside Posterior Cruciate Ligament Reconstruction 433
11. Markolf KL, McAllister DR, Young CR, McWilliams J, Oakes DA. Biomechanical effects of medial-lateral
tibial tunnel placement in posterior cruciate ligament reconstruction. J Orthop Res. 2003;21(1):177-182.
12. Morgan CD, Kalman VR, Grawl DM. The anatomic origin of the posterior cruciate ligament: where is
it? Reference landmarks for PCL reconstruction. Arthroscopy. 1997;13(3):325-331.
13. Gill TJ, DeFrate LE, Wang C, et al. The biomechanical effect of posterior cruciate ligament recon-
struction on knee joint function. Kinematic response to simulated muscle loads. Am J Sports Med.
2003;31(4):530-536.
14. Race A, Amis AA. PCL reconstruction. In vitro biomechanical comparison of “isometric” versus single
and double-bundled “anatomic” grafts. J Bone Joint Surg Br. 1998;80(1):173-179.
15. Harner CD, Janaushek MA, Kanamori A, Yagi M, Vogrin TM, Woo SL. Biomechanical analysis of a
double-bundle posterior cruciate ligament reconstruction. Am J Sports Med. 2000;28(2):144-151.
16. Whiddon DR, Zehms CT, Miller MD, Quinby JS, Montgomery SL, Sekiya JK. Double compared with
single-bundle open inlay posterior cruciate ligament reconstruction in a cadaver model. J Bone Joint
Surg Am. 2008;90(9):1820-1829.
17. Wijdicks CA, Kennedy NI, Goldsmith MT, et al. Kinematic analysis of the posterior cruciate liga-
ment, part 2: a comparison of anatomic single- versus double-bundle reconstruction. Am J Sports Med.
2013;41(12):2839-2848.
18. Bergfeld JA, Graham SM, Parker RD, Valdevit AD, Kambic HE. A biomechanical comparison of pos-
terior cruciate ligament reconstructions using single- and double-bundle tibial inlay techniques. Am J
Sports Med. 2005;33(7):976-981.
19. Shelbourne KD, Clark M, Gray T. Minimum 10-year follow-up of patients after an acute, isolated poste-
rior cruciate ligament injury treated nonoperatively. Am J Sports Med. 2013;41(7):1526-1533.
20. Parolie JM, Bergfeld JA. Long-term results of nonoperative treatment of isolated posterior cruciate liga-
ment injuries in the athlete. Am J Sports Med. 1986;14(1):35-38.
21. Boynton MD, Tietjens BR. Long-term followup of the untreated isolated posterior cruciate ligament-
deficient knee. Am J Sports Med. 1996;24(3):306-310.
22. Dejour H, Walch G, Peyrot J, Eberhard P. The natural history of rupture of the posterior cruciate liga-
ment [in French]. Rev Chir Orthop Réparatrice Appar Mot. 1988;74(1):35-43.
23. Sekiya JK, Whiddon DR, Zehms CT, Miller MD. A clinically relevant assessment of posterior cruciate
ligament and posterolateral corner injuries. Evaluation of isolated and combined deficiency. J Bone Joint
Surg Am. 2008;90(8):1621-1627.
24. Margheritini F, Mancini L, Mauro CS, Mariani PP. Stress radiography for quantifying posterior cruciate
ligament deficiency. Arthroscopy. 2003;19(7):706-711.
25. Schulz MS, Steenlage ES, Russe K, Strobel MJ. Distribution of posterior tibial displacement in knees
with posterior cruciate ligament tears. J Bone Joint Surg Am. 2007;89(2):332-338.
26. Noyes FR. Noyes’ Knee Disorders: Surgery, Rehabilitation, Clinical Outcomes. Philadelphia, PA: Saunders
Elsevier; 2009.
27. Lubowitz JH, Konicek J. A 3.5-mm-diameter anterior cruciate ligament tibial retrograde socket drilling
pin is more accurate than a 2.4-mm-diameter pin. Arthroscopy. 2011;27(5):666-671.
28. Zehms CT, Whiddon DR, Miller MD, et al. Comparison of a double bundle arthroscopic inlay and
open inlay posterior cruciate ligament reconstruction using clinically relevant tools: a cadaveric study.
Arthroscopy. 2008;24(4):472-480.
29. Kim SJ, Park IS. Arthroscopic reconstruction of the posterior cruciate ligament using tibial-inlay and
double-bundle technique. Arthroscopy. 2005;21(10):1271.
30. Ritchie JR, Bergfeld JA, Kambic H, Manning T. Isolated sectioning of the medial and posteromedial
capsular ligaments in the posterior cruciate ligament-deficient knee. Influence on posterior tibial trans-
lation. Am J Sports Med. 1998;26(3):389-394.
31. Park SE, Stamos BD, DeFrate LE, Gill TJ, Li G. The effect of posterior knee capsulotomy on poste-
rior tibial translation during posterior cruciate ligament tibial inlay reconstruction. Am J Sports Med.
2004;32(6):1514-1519.
32. Li B, Wen Y, Wu H, Qian Q, Wu Y, Lin X. Arthroscopic single-bundle posterior cruciate ligament recon-
struction: retrospective review of hamstring tendon graft versus LARS artificial ligament. Int Orthop.
2009;33(4):991-996.
33. Wu CH, Chen AC, Yuan LJ, et al. Arthroscopic reconstruction of the posterior cruciate ligament by
using a quadriceps tendon autograft: a minimum 5-year follow-up. Arthroscopy. 2007;23(4):420-427.
434 Chapter 30
34. Zhao J, Huangfu X. Arthroscopic single-bundle posterior cruciate ligament reconstruction: retrospec-
tive review of 4- versus 7-strand hamstring tendon graft. Knee. 2007;14(4):301-305.
35. Boutefnouchet T, Bentayeb M, Qadri Q, Ali S. Long-term outcomes following single-bundle transtibial
arthroscopic posterior cruciate ligament reconstruction. Int Orthop. 2013;37(2):337-343.
36. Chan YS, Yang SC, Chang CH, et al. Arthroscopic reconstruction of the posterior cruciate ligament with
use of a quadruple hamstring tendon graft with 3- to 5-year follow-up. Arthroscopy. 2006;22(7):762-770.
37. Lin YC, Chen SK, Liu TH, Cheng YM, Chou PP. Arthroscopic transtibial single-bundle posterior cruci-
ate ligament reconstruction using patellar tendon graft compared with hamstring tendon graft. Arch
Orthop Trauma Surg. 2013;133(4):523-530.
38. Kim SJ, Kim TE, Jo SB, Kung YP. Comparison of the clinical results of three posterior cruciate ligament
reconstruction techniques. J Bone Joint Surg Am. 2009;91(11):2543-2549.
39. MacGillivray JD, Stein BE, Park M, Allen AA, Wickiewicz TL, Warren RF. Comparison of tibial inlay
versus transtibial techniques for isolated posterior cruciate ligament reconstruction: minimum 2-year
follow-up. Arthroscopy. 2006;22(3):320-328.
40. Seon JK, Song EK. Reconstruction of isolated posterior cruciate ligament injuries: a clinical comparison
of the transtibial and tibial inlay techniques. Arthroscopy. 2006;22(1):27-32.
41. Kim YM, Lee CA, Matava MJ. Clinical results of arthroscopic single-bundle transtibial posterior cruci-
ate ligament reconstruction: a systematic review. Am J Sports Med. 2011;39(2):425-434.
42. Yoon KH, Bae DK, Song SJ, Cho HJ, Lee JH. A prospective randomized study comparing arthroscopic
single-bundle and double-bundle posterior cruciate ligament reconstructions preserving remnant
fibers. Am J Sports Med. 2011;39(3):474-480.
43. Wang CJ, Weng LH, Hsu CC, Chan YS. Arthroscopic single- versus double-bundle posterior cruciate
ligament reconstructions using hamstring autograft. Injury. 2004;35(12):1293-1299.
44. Fanelli GC, Beck JD, Edson CJ. Single compared to double-bundle PCL reconstruction using allograft
tissue. J Knee Surg. 2012;25(1):59-64.
45. Kim SJ, Jung M, Moon HK, Kim SG, Chun YM. Anterolateral transtibial posterior cruciate ligament
reconstruction combined with anatomical reconstruction of posterolateral corner insufficiency: com-
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6-year follow-up. Am J Sports Med. 2011;39(3):481-489.
Introduction
The posterior cruciate ligament (PCL) is critical for stability of the knee. The PCL stabilizes
the knee against posterior translation of the tibia with respect to the femur and against external
rotation of the knee.1-8 Insufficiency of the PCL can result in clinically noticeable instability
and pain. However, PCL injuries are relatively infrequent when compared to other soft tissue
injuries in the knee, with PCL injuries accounting for less than 1% to 16% of knee injuries.9-11
Traditionally, PCL injuries have garnered significantly less attention than anterior cruciate liga-
ment (ACL) injuries. Interest in PCL reconstruction has increased recently as surgeons have noted
an increased incidence of unrecognized PCL instability.9,10 Although most patients are able to
tolerate a PCL-deficient knee, interest has increased in the altered biomechanics seen with a PCL-
deficient knee.8,10 Therefore, significant controversy remains with when and how to best address
PCL injuries. The goal of PCL reconstruction is to reduce or eliminate pathologic laxity and the
resultant wear in the medial and patellofemoral compartments.6
In order to understand and treat PCL injuries, a familiarity with the anatomy is necessary. The
PCL originates from the medial femoral condyle and consists of 2 bundles, including an antero-
lateral bundle, which is tight in flexion, and a posteromedial bundle, which is tight in extension.
The PCL inserts on the central, posterior tibia 1.0 to 1.5 cm distal to the joint line.2,8,12-15 The
femoral origin of the PCL is intra-articular, whereas the tibial insertion of the ligament is at the
capsular junction at the proximal tibia. In addition, the meniscofemoral ligaments (ligaments of
Humphrey and Wrisberg) run from the lateral meniscus to the medial femoral condyle, inserting
anterior or posterior to the PCL, respectively, which can remain intact after a PCL injury and
provide minimal residual posterior stability of the knee.
The method of PCL reconstruction has been controversial and has undergone significant
evolution over time. Original techniques for PCL reconstruction involved transosseous tunnels in
the femur and the tibia. This resulted in an anteroinferior to posterosuperior tibial tunnel. This
method is popular today but has been challenged due to concerns resulting from the biomechanics
of the technique. The transtibial tunnel has proven over time to result in difficult graft passage,
requiring the graft to bend over a significant angle around the posterior tibia. This angle, deemed
the killer turn, has also been shown to be a cause of graft failure.8,10,15-17
In the majority of situations, the authors prefer the more recently developed tibial inlay tech-
nique. The tibial inlay technique provides a more anatomic reconstruction of the tibial insertion of
the PCL and avoids the killer turn. Traditionally, the tibial inlay technique has involved an open
approach to the posterior knee but continues to undergo advances, with some authors advocating
an all-arthroscopic technique.10,11,17 Since its introduction, the tibial inlay technique has proven
to be a durable method for PCL reconstruction.8 This technique is discussed in depth in this
chapter.
Indications
Historical treatment for the majority of PCL injuries has been nonoperative with bracing and
early range of motion and quadriceps strengthening. Nonoperative management remains the
mainstay of treatment for isolated grade I and II PCL injuries, both acute and chronic. However,
continued knee instability has been increasingly recognized and has resulted in orthopedic sur-
geons developing broader indications for surgical management of PCL injuries.4-7,18,19 Currently,
there is controversy over the timing of this procedure, but the authors believe that injuries with
concomitant posterolateral corner injuries should be reconstructed within 2 weeks due to improved
ability to identify the anatomy, particularly the peroneal nerve, prior to abundant scar formation.
Indications4-7,18,20
▶ Acute grade III PCL injuries
▶ Chronic grade III PCL injuries with symptomatic instability after a failed nonoperative treat-
ment course
▶ PCL injury in conjunction with bony avulsion injuries and posterolateral corner injuries
▶ PCL injury as part of a multiligamentous injury, specifically a grade II or higher medial col-
lateral ligament injury or an ACL rupture
Relative Indications
▶ Grade II injury in a young, active patient with symptomatic instability after attempted non-
operative management
Contraindications
▶ Patients with a prior history of vascular procedures in the extremity because the relevant
anatomy becomes distorted and unpredictable
Physical Findings4-8,18
▶ Best test: Posterior drawer test (Figure 31-1)
▷ 90% sensitive and 99% specific
▷ Performed with the knee in 90 degrees of flexion
▷ PCL injuries are graded I to III with grade I defined as 5 mm of posterior translation of
the tibia, grade II as 6 to 10 mm, and grade III as greater than 10 mm. This is best accom-
plished by placing the thumbs on the anterior joint line and documenting the translation
of the tibia in reference to the femoral condyles. Grade III PCL injuries are rarely isolated,
and a high suspicion for other ligamentous injuries must be suspected when a grade III
posterior drawer is noted.
▶ Posterior sag test
▶ Godfrey test
▶ Prone drawer test
▶ Quadriceps active test
▶ Dynamic posterior shift
▶ Dial test to assess for posterolateral instability: The dial test should be performed with the
patient prone. Asymmetry of external rotation of the feet should be looked for at 30 and
90 degrees of knee flexion. A positive test at 30 degrees only indicates an isolated posterolat-
eral corner injury, whereas a positive dial test at 30 and 90 degrees indicates combined PCL
and posterolateral corner injuries. Additional maneuvers to diagnose posterolateral instability
include varus laxity, the external rotation recurvatum test, posterolateral and posteromedial
drawer tests, and the reverse pivot shift.18
Pertinent Imaging
Plain X-Rays
▶ Assess for any bony avulsion
▶ Assess for concomitant tibial plateau fracture or fibular head fracture
Stress X-Rays
▶ Quantify the extent of the injury
▶ Performed by the physician in the imaging suite by application of a posteriorly directed force
at the level of the proximal tibia
▶ The authors use the Telos system, which applies 15 decaNewtons (daN) of force, to obtain
stress x-rays. The extent of posterior instability is determined by recording the degree of pos-
terior translation of the tibial plateau in relation to the femoral condyles (Figure 31-2).
▶ The authors also obtain varus stress x-rays to assess the lateral joint opening because increased
widening of the lateral joint has been found to correlate with posterolateral corner injuries.21
438 Chapter 31
Figure 31-1. The posterior drawer test. (A) The knee should be flexed to 90 degrees with the tibia in
neutral rotation and centered under the knee. (B) A posterior force should be applied, and the amount
of translation relative to the femoral condyles should be noted. Grade I injuries will have less than 5 mm,
grade II will have 6 to 10 mm, and grade III will have greater than 10 mm of posterior translation.
Tibial Inlay Posterior Cruciate Ligament Reconstruction 439
Figure 31-2. Telos stress x-rays. Both knees are radiographed with the Telos system
applying 15 daN of force, and the side-to-side difference in posterior tibial translation
is measured. (A) The uninjured knee will have minimal translation, (B) whereas the PCL-
injured leg will have increased translation.
440 Chapter 31
Equipment
Because this is a combined open and arthroscopic procedure, it is important to have standard
equipment for both available. Similar to many relatively complex cases, there are often specific
instruments, implants, and pans that do not necessarily need to be open at the beginning of the
case but should be readily available. It is also important to have a reliable implant technician to
assist with any issues related to equipment or implants.
A standard knee arthroscopy (with 30- and 70-degree arthroscopes) and major orthopedic pan
should be open at the beginning of the case, in addition to the equipment for bone patellar tendon
bone autograft harvest. Solid or cannulated screws should be available for the tibial inlay fixation
(the authors prefer 4.5-mm cannulated screws with washers). Preferred fixation for the femoral
side is a titanium interference screw, but alternative fixation, such as a cortical suspensory device,
should be available. Luque wires can be used to pass the graft. Femoral PCL guides are used for
femoral tunnel placement. Round or oval burrs are used to create the trough in tibia. Several 3/32-
in guide pins should be open and are used for retraction and femoral tunnel placement. A Shantz
pin with a T-handle should be available and is used to apply an anterior drawer on the tibia when
the PCL graft is fixed.
Tibial Inlay Posterior Cruciate Ligament Reconstruction 441
Figure 31-5. Positioning during arthroscopy. The up leg can be placed in a bracketed leg holder and can
be easily positioned for the arthroscopic portion of the case.
Arthroscopy is then performed, and the injured PCL is debrided with a basket and a shaver. If
there are intact fibers (including meniscofemoral ligaments), the authors try to retain them whenever
possible. ACL laxity may be normal, and this pseudolaxity will resolve when an anterior drawer is
applied.28
The femoral tunnel is drilled from outside-in. A subvastus approach is made through an incision
in Langer’s lines, and a guide is used to place a 3/32-in guide pin high in the notch (at approximately
1:30 on the clock face for a right knee) and 6 to 8 mm from the articular surface (Figure 31-6). The
authors have found that the outside-in approach reduces the amount of graft bend into the femoral
tunnel (the critical corner).29-31 The tunnel is overdrilled with the appropriate cannulated drill and
bone graft from the drill flutes is collected for later placement in the patellar harvest site. The pos-
terior aspect of the tunnel is rasped to reduce graft abrasion. A looped 18-gauge Luque wire is then
positioned arthroscopically through the tunnel and into the posterior aspect of the knee.
The authors then place the leg onto a Mayo stand and prepare for the tibial inlay approach.
The surgeon sits on an operative stool and uses a headlight to directly approach the popliteal fossa.
An incision is made in the popliteal crease, and the gastrocnemius fascia is incised. A hockey stick
incision is made in the fascia (but not in the skin as originally described by Burks and Shaffer24).
The medial head of the gastrocnemius is identified and bluntly mobilized. The tendinous portion
of this large muscle is on the deep surface. The medial head of the gastrocnemius is mobile and
can be retracted laterally, past the midline. This muscle can be held in place with 3/32-in pins that
can be bent and used as retractors. The muscle belly of the popliteus is identified, and a posterior
arthrotomy is made at its superior border. This can be enlarged with Mayo scissors, and the pre-
placed Luque wire is retrieved. The PCL fossa is palpated and electrocautery, a rongeur, and a burr
Tibial Inlay Posterior Cruciate Ligament Reconstruction 443
are used to create a trough that matches the dimensions of the graft (Figure 31-7). The graft is then
brought up to the operative field and secured to the drapes (safety net). The patellar portion of the
graft is pulled into the knee (and hopefully directly into the femoral tunnel), and the tibial portion is
inlayed into the trough. The authors secure the graft with 4.5-mm cannulated screws. These screws
are serially drilled, measured, and placed to secure the graft into the trough. It is helpful to clamp
the guide wires at the anterior portion of the tibia prior to drilling to help with screw placement.
The knee is then placed back into the bracketed knee holder, and the graft is arthroscopically
visualized. If the patellar bone block did not get delivered into the femoral tunnel, it is passed at
this point. Sometimes it is necessary to toggle the graft with a right angle clamp to facilitate pas-
sage. Once it is in the tunnel, the knee is cycled to eliminate any kinking, and the graft is fixed
in the femur with a 9-by-20-mm metal interference screw. An anterior drawer force is placed on
the tibia while the graft is fixed. A Shantz pin with a T-handle from the external fixation set can
be useful for this purpose (Figure 31-8). The patient is examined on the table to ensure the pos-
terior tibial laxity has been corrected and the remaining portions of the case are completed prior
to standard closure.
Postoperative Protocol
Initial Postoperative Period
Patients should be placed into an external hinged knee brace that is locked in full extension for
the first 2 weeks. Fifty percent partial weightbearing with crutches should be used for the first
4 to 6 weeks, with subsequent progression to weightbearing as tolerated. Under the direction of
a physical therapist, passive range of motion exercises from 0 to 90 degrees should be started; it
is essential that these ROM exercises be done in the prone position to avoid early stress on the
reconstruction. Quadriceps sets and edema control are also used in the early time period.
444 Chapter 31
Figure 31-7. Tibial inlay trough. A left knee viewed in the lateral position after the posterior approach has
been performed. The posterior tibia is well exposed, with 2 to 3 Steinmann pins acting as self-retainers to
retract the medial head of the gastrocnemius. The trough is placed in the PCL fossa at the superior border
of the popliteus muscle.
Potential Complications
As with any surgical intervention, infection is always a concern. In a lengthy procedure such as
this and with multiple steps and numerous instruments being used, the infection rate is higher than
other arthroscopic procedures. A review of the American Board of Orthopaedic Surgery database
from 2003 to 2009 showed the arthroscopic procedure with the highest complication rate was PCL
reconstruction at 20.1%, with infection being the most common.32 Because there are so many instru-
ments and assistants used in this surgery, the surgeon must be diligent in observing sterile technique
and ensuring the additional operating room staff remain sterile throughout the case.
The most severe, and certainly most dreaded, complication following PCL reconstruction is neu-
rovascular injury. Mastery of the anatomy in the posterior knee is mandatory when performing the
tibial inlay technique. Consider reviewing the anatomy or performing a cadaveric dissection prior to
a PCL reconstruction to help decrease the risk of this complication. The risk of vascular injury can
also be decreased by performing careful dissection during the posterior approach because anomalous
branches of the genicular arteries can result in significant intra- and postoperative bleeding.
Excess pressure can develop in the soft tissue due to extravasation of the arthroscopic fluid,
especially in the setting of a multiligament injury with significant capsular injury. It is important to
manually check the pressure in the thigh and leg with intermittent palpation throughout the case.
Early arthrofibrosis and late laxity can be seen after this procedure. If early loss of motion is
noted, lysis of adhesions and manipulation under anesthesia may be necessary. Late laxity can be
multifactorial but can best be avoided with meticulous surgical technique and treating any con-
comitant ligamentous injuries, especially frequently overlooked posterolateral corner disruptions.
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Introduction
The complex anatomy of static and dynamic stabilizers in the posterolateral corner (PLC) of
the knee creates a diagnostic and treatment challenge. These structures are injured in 5% to 9% of
all knee injuries and up to 16% of all ligamentous knee injuries.1-3 Injuries to the PLC are often
caused by a direct or indirect blow to the anteromedial aspect of the knee, a contact or noncontact
hyperextension injury, or a varus noncontact injury.4,5 Concomitant injuries to the anterior cruci-
ate ligament (ACL) and posterior cruciate ligament (PCL) are frequent, with isolated PLC injuries
accounting for only 16% to 28% of all PLC injuries.3-5 Despite an increased awareness, up to 70%
of PLC injuries are missed acutely, leading to a critical delay in treatment.3 Due to the inherent
bony instability of the lateral compartment, which contributes to a lack of healing, surgical inter-
vention is often required.6-8 Primary repair of injured ligaments and tendons is only possible in
the acute setting, whereas chronic PLC injuries and acute grade III (complete) injuries generally
require surgical reconstruction.9-11 In repair and reconstruction, the goal of surgery is anatomic
restoration of these structures in order to best reproduce the native anatomy and biomechanics of
the knee.
The primary stabilizers of the PLC include the fibular collateral ligament (FCL), popliteus
tendon, and popliteofibular ligament.1,12,13 Anatomic-based surgical reconstruction of these
structures has been developed and validated through biomechanical and clinical outcome studies
(Figure 32-1).9,12,14-17 This chapter provides an overview of the diagnosis and indications for sur-
gery following a PLC knee injury and presents a detailed description of an anatomic-based PLC
surgical reconstruction technique.
Figure 32-1. An anatomic-based PLC reconstruction of the popliteofibular ligament, popliteus tendon,
and FCL.
Indications
There are several indications for surgical reconstruction of the PLC. The recommended treat-
ment for grade I or II PLC knee injuries is generally nonoperative.3,8,18 Operative indications
include the following:
▶ Acute grade III PLC injuries that display significant varus and posterolateral rotary instabil-
ity in the setting of functional instability and/or knee pain necessitate surgical intervention.14
If these injuries are diagnosed acutely, the ligaments are of acceptable quality, and surgery is
planned within the first 1 to 2 weeks after injury, primary repair of injured ligaments may
occasionally be feasible. However, at about 3 weeks after injury, significant scar tissue devel-
ops, making repairs difficult, and reconstruction should be considered. In addition, injury
to the popliteus muscle at the musculotendinous junction precludes repair.10,11 Stannard et
al11 compared acute PLC repair vs surgical reconstruction and found a 28% higher failure
rate with repair. Levy et al10 reported similar results favoring anatomic reconstruction. The
authors recommend anatomic surgical reconstruction for acute grade III PLC injuries in most
instances, especially where tissue and injury pattern are not optimal for a repair.19
Anatomic Reconstruction of the Posterolateral Corner of the Knee 451
▶ Chronic grade III PLC injuries are unlikely to heal with primary repair or nonoperative mea-
sures and require surgical reconstruction.10,11 Therefore, the authors recommend anatomic
surgical reconstruction for chronic grade III PLC injuries.19
▶ Although total PLC reconstruction is indicated in cases of severe injury, isolated injuries to
posterolateral structures, including the FCL, popliteus tendon, and popliteofibular ligament,
are relatively common and must be ruled out before performing a total reconstruction. Isolated
anatomic-based repair or reconstruction procedures may be used in cases of less-extensive
injury.20-22
Controversial Indications
Genu varus in the setting of PLC injury is a difficult problem that creates a treatment chal-
lenge. Due to the stress of PLC structures in genu varus alignment, correction of malalignment
is often necessitated prior to reconstruction. Without correction, there is a high risk of graft
failure.5,19,23,24 In addition, it has been shown that a proximal tibial osteotomy alone will resolve
chronic PLC laxity in patients with genu varus 38% of the time.25 Therefore, in the setting of
genu varus, the authors recommend a 2-staged approach to correct the mechanical axis using a
proximal tibial osteotomy and then to reassess for residual PLC laxity before proceeding with a
PLC reconstruction.
▶ Posterolateral drawer test: This test is best used in assessing the integrity of the poplit-
eus muscle complex. The knee is flexed to 90 degrees, and the foot is externally rotated
15 degrees. A posterior force is applied to the knee, and translation is compared to the
contralateral side.
▶ Anterior and posterior stress examinations: The constellation of examination findings
should be confirmed with increased anterior tibial translation on the Lachman maneuver
and increased posterior tibial translation on the posterior drawer test. These findings can be
present with isolated injury but may also indicate concomitant ACL or PCL injury.
The synergistic results of these tests provide the best clinical utility in diagnosing PLC injury.
All of these tests should be used in the clinic and during the examination under anesthesia to
confirm the findings.
Anatomic Reconstruction of the Posterolateral Corner of the Knee 453
Pertinent Imaging
A combination of basic and advanced imaging modalities is necessary in the diagnosis of PLC
knee injury.
X-Rays
Plain anteroposterior (AP) and varus stress x-rays can be helpful in assessing static and dynamic
varus gapping. On varus stress x-rays at 20 degrees of knee flexion, the mean varus gapping in
isolated FCL injured knees is 2.7 mm, as compared to a 4.0-mm gap in complete PLC-injured
knees (Figure 32-4).27 AP, lateral, sunrise, and tunnel x-rays are also necessary to rule out associ-
ated fracture, fibular head avulsion fractures, and osteoarthritis. Bilateral AP long-leg imaging
is necessary to assess the alignment of the extremities. If genu varus is detected, a proximal tibial
osteotomy is necessary to correct malalignment and to protect the PLC reconstruction.25
Equipment
In preparing for a PLC reconstruction, instruments for an open and arthroscopic procedure
must be readily available. An operating table with removable ends or the ability to flex the end of
the bed is required for proper patient positioning. An arthroscopy tower and arthroscopy equip-
ment are needed to address cruciate and meniscal intra-articular pathology. Tool kits for cruciate
reconstructions, meniscal repair, and microfracture should be readily available. An Adson pointed
hemostat is useful to perform a common peroneal neurolysis. For the PLC reconstruction, a
cruciate-aiming device is needed for placement and reaming of tunnels. A split Achilles allograft
is the authors’ preferred graft material. In addition to standard operating materials, reamers, bio-
absorbable screws, and cannulated screws are needed for graft fixation. It is helpful if the operating
room staff are well versed with these required materials and the flow and pace of the procedure.
454 Chapter 32
peroneal nerve is identified 2 to 3 cm distal to the long head of biceps femoris. When the nerve is
not readily identifiable, it can be palpated 2 cm distal to the fibular head. The peroneal nerve is
decompressed for up to 8 cm to minimize the risk of postoperative palsy secondary to swelling and
to ensure that gentle traction to retract it from the surgical site will not injure the nerve.
Blunt dissection between the planes of the long head of the gastrocnemius and soleus is con-
ducted to better expose the fibular head (Video). Through this interval, the posteromedial aspect
of the fibular head (where the popliteofibular ligament inserts) and the musculotendinous junc-
tion of popliteus muscle can be readily identified. Next, an incision through the anterior arm of
the long head of the biceps femoris proximal to the fibular head is created and extended through
the biceps bursa. Through this incision, the midsubstance of the FCL is identified, as well as its
attachment to the fibular head. A traction stitch is placed in the distal midsubstance of the FCL
to assist with identification of the proximal femoral attachment later in the surgery. The fibular
attachment of the FCL is now subperiosteally dissected off of the fibular head. A saddle should
be identified on the posteromedial aspect of the fibular head, which denotes the insertion of the
popliteofibular ligament on the posteromedial aspect of the fibular head.
With necessary identification and exposure conducted, the fibular head tunnel may now be
drilled. The proper path of the tunnel should begin directly at the attachment of the FCL and
continue through to the posteromedial downslope of the fibular styloid. Using a cruciate-aiming
device, a guide pin is carefully directed along this path. A retractor should be inserted posterior
and medial to the fibular head to prevent intrusion of the guide pin into the posterior neurovascu-
lar structures while drilling. After confirmation of proper guide pin placement, a 7-mm reamer is
used to ream the fibular head tunnel. Finally, a passing suture is placed through the fibular tunnel
to facilitate future graft passage.
The next portion of the procedure is aimed at reaming the tibial tunnel. Meticulous dissec-
tion of the distal attachment of the superficial layer of the iliotibial band is conducted to identify
Gerdy’s tubercle. Immediately distal and medial to Gerdy’s tubercle is a small flat area. This area
is also adjacent to the lateral aspect of the tibial tubercle. Sharp dissection is carried to bone in this
area, and a rongeur is used to free the area of soft tissue. The anterior aperture of the tibial tunnel
will emerge through this site. After the anterior site is prepared, attention is again directed toward
the posterior aspect of the tibia. Through the interval between the gastroc-soleus complex, the
456 Chapter 32
drill to a depth of 25 mm for both the popliteus and FCL tunnel. Passing sutures are then passed
into both tunnels. After the femoral tunnels are completed, any intra-articular pathology, such as
ACL reconstruction, PCL reconstruction, meniscectomy, meniscal repair, or articular cartilage
repair, is conducted. In cruciate ligament reconstructions, the femoral attachments of the grafts
should be fixed, but the tibial attachments should remain free due to risk of a fixed external rota-
tion deformity.29
Although the surgeon is performing the intra-articular portion of the surgery, an assistant
should prepare the PLC reconstruction grafts. The authors prefer to use a split Achilles tendon
graft. The calcaneal portion is split down the middle, and 2 additional 9-by-25-mm bone plugs are
harvested from the calcaneal bone graft for use in the femoral tunnels (Figure 32-8). The distal
aspects of the Achilles tendon are tubularized for graft passing. Although the graft should be eas-
ily passable through a 7-mm tunnel, the initial 70-mm length of the FCL graft and 60 mm of the
popliteus graft should remain thicker to best restore the strength of these ligaments and tendons,
with only the portions passing through bone being slightly trimmed at the time of passing. Passing
sutures are placed in the soft tissue end and bone plugs of the graft.
Once the graft is prepared, it may be passed in a femoral-to-tibial direction. Similar to an endo-
scopic ACL passage, the femoral ends of the graft are placed into the femoral tunnels, and pass-
ing sutures from the bone plugs are placed in the looped passing sutures. The bone plug sutures
are pulled through, and tension is placed on the graft. A tight fit of the graft and bone plugs is
confirmed, and the bone plugs are secured with screw fixation. In this technique, a 7-by-20-mm
cannulated titanium screw is fitted to a handheld drill chuck, with approximately 3 cm of guide
pin protruding past the screw. The guide pin is positioned at the margin between the bone plug
and tunnel edge so that the screw is placed optimally between the bone plug and tunnel wall. After
the screw is tightly fixed, secure purchase of the graft is verified with a firm lateral tug.
After femoral fixation, the popliteus tendon graft is passed distally along the popliteal hiatus
and exits the knee in the interval between the lateral gastrocnemius and the soleus. The FCL graft
is passed distally, medial (deep) to the superficial iliotibial band and lateral aponeurosis of the long
head of the biceps femoris. The FCL graft is then passed through the fibular head tunnel and may
be assisted with a suture or suture passer. If any further graft trimming is necessary to facilitate
passage, this should occur now. If a PCL reconstruction is needed, the tibial graft fixation should
occur prior to fibular or tibial fixation of the PLC grafts and should occur now.
To secure the FCL graft in the fibular tunnel, tension is applied to the graft end by pulling
proximally, and a valgus force is applied to the knee in 20 degrees of knee flexion, with the knee
in neutral rotation. The graft is fixed with a 7-mm bioabsorbable screw. Following fixation, a
458 Chapter 32
physical examination should be performed to ensure correction of varus instability. The remaining
graft ends, which reconstruct the popliteus tendon and the popliteofibular ligament, are passed
from posterior to anterior through the tibia. Each graft must be cycled to ensure no residual laxity
is present and proper tension is being applied. In addition, the posterior entry site of the grafts is
palpated to confirm that there is no bunching of the grafts. With the knee flexed to 60 degrees in
neutral rotation and sufficient tension being applied to the grafts individually, the grafts are fixed
in the tibial tunnel with a 9-mm bioabsorbable screw. A thorough examination under anesthesia,
including the posterolateral drawer and dial test, occurs to make certain that posterolateral insta-
bility has been corrected. A backup staple can be placed over the tibial graft for maximal fixation
in patients with osteopenic bone. Now that the PLC has been corrected, fixation of an ACL graft
to the tibia can occur, and any other procedures can be finished.
Subcutaneous tissues are repaired with absorbable sutures, and a running absorbable suture is
used to close the skin. Loose skin taping is a secondary measure to ensure adequate strength of
closure. Prior to the termination of anesthesia, the patient’s incisions are sterilely dressed, and the
knee is placed in a knee immobilizer. This minimizes the chance of stress on the reconstruction
while the patient awakens.
Postoperative Protocol
Following the procedure, patients should remain nonweightbearing for 6 weeks. For the first
2 weeks, quadriceps contraction sets and straight leg raises may be performed while the knee is
in an immobilizer, and early passive range of motion (ROM) from 0 to 90 degrees is allowed up
to 4 times per day. The goal is to achieve ROM to 90 degrees of knee flexion by 2 weeks. If the
patient is able to perform straight leg raises with no extensor lag at 2 weeks, he or she may per-
form his or her quadriceps sets and straight leg raises out of the knee immobilizer for the rest of
rehabilitation. After 2 weeks, ROM is gradually increased, and active ROM is allowed, with the
goal of attaining maximum knee flexion and extension by 6 weeks. Activities or exercises that may
lead to graft stress, including external rotation or varus gapping, should be avoided for 6 weeks.
After 6 weeks, patients are allowed to progressively wean off crutches and begin weightbearing as
tolerated if limping is absent. Stationary bicycle and low-resistance exercises may be initiated fol-
lowing successful knee flexion of 105 to 110 degrees. At 12 weeks, low-impact exercises, such as
swimming, cycling, walking, and using an elliptical, are permissible, and the goal is full strength
and ROM by 6 months. After 6 months, varus stress x-rays are obtained to assess for attenuation
of the reconstruction grafts. At 7 months for an isolated PLC surgery, or 9 months for a combined
PLC surgery, a full physical examination and assessment by the surgeon occurs, and full return to
contact and pivot activities is allowed if cleared.
Potential Complications
As with all open procedures, infection and wound dehiscence are potential risks. However,
with sterile technique and prophylactic antibiotics, this risk is minimized, and a recent report
showed only 1 surgical site infection among 64 surgeries.9 Common peroneal nerve laceration
and neuropraxia is also a rare, but significant complication. Graft failure or residual posterolateral
knee instability is a concern in any ligamentous reconstruction and has been shown to occur in
approximately 5% of surgeries.9 This is best assessed using varus stress x-rays.
Anatomic Reconstruction of the Posterolateral Corner of the Knee 459
References
1. LaPrade RF. Introduction and incidence of posterolateral knee injuries. In: Posterolateral Knee Injuries:
Anatomy, Evaluation, and Treatment. New York, NY: Thieme; 2006:1-8.
2. LaPrade RF, Wentorf FA, Fritts H, Gundry C, Hightower CD. A prospective magnetic resonance imag-
ing study of the incidence of posterolateral and multiple ligament injuries in acute knee injuries present-
ing with a hemarthrosis. Arthroscopy. 2007;23(12):1341-1347.
3. Pacheco RJ, Ayre CA, Bollen SR. Posterolateral corner injuries of the knee: a serious injury commonly
missed. J Bone Joint Surg Br. 2011;93(2):194-197.
4. Geeslin AG, LaPrade RF. Location of bone bruises and other osseous injuries associated with acute
grade III isolated and combined posterolateral knee injuries. Am J Sports Med. 2010;38(12):2502-2508.
5. LaPrade RF, Terry GC. Injuries to the posterolateral aspect of the knee. Association of anatomic injury
patterns with clinical instability. Am J Sports Med. 1997;25(4):433-438.
6. Baker CL Jr, Norwood LA, Hughston JC. Acute combined posterior cruciate and posterolateral instabil-
ity of the knee. Am J Sports Med. 1984;12(3):204-208.
7. Fleming RE Jr, Blatz DJ, McCarroll JR. Posterior problems in the knee. Posterior cruciate insufficiency
and posterolateral rotatory insufficiency. Am J Sports Med. 1981;9(2):107-113.
8. Hughston JC, Andrews JR, Cross MJ, Moschi A. Classification of knee ligament instabilities. Part II.
The lateral compartment. J Bone Joint Surg Am. 1976;58(2):173-179.
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posterolateral knee reconstruction. J Bone Joint Surg Am. 2010;92(1):16-22.
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10. Levy BA, Dajani KA, Morgan JA, Shah JP, Dahm DL, Stuart MJ. Repair versus reconstruction of the
fibular collateral ligament and posterolateral corner in the multiligament-injured knee. Am J Sports
Med. 2010;38(4):804-809.
11. Stannard JP, Brown SL, Farris RC, McGwin G Jr, Volgas DA. The posterolateral corner of the knee:
repair versus reconstruction. Am J Sports Med. 2005;33(6):881-888.
12. LaPrade RF, Bollom TS, Wentorf FA, Wills NJ, Meister K. Mechanical properties of the posterolateral
structures of the knee. Am J Sports Med. 2005;33(9):1386-1391.
13. LaPrade RF, Ly TV, Wentorf FA, Engebretsen L. The posterolateral attachments of the knee: a qualita-
tive and quantitative morphologic analysis of the fibular collateral ligament, popliteus tendon, popliteo-
fibular ligament, and lateral gastrocnemius tendon. Am J Sports Med. 2003;31(6):854-860.
14. Geeslin AG, LaPrade RF. Outcomes of treatment of acute grade-III isolated and combined pos-
terolateral knee injuries: a prospective case series and surgical technique. J Bone Joint Surg Am.
2011;93(18):1672-1683.
15. LaPrade RF, Johansen S, Engebretsen L. Outcomes of an anatomic posterolateral knee reconstruction:
surgical technique. J Bone Joint Surg Am. 2011;93(1):10-20.
16. LaPrade RF, Johansen S, Wentorf FA, Engebretsen L, Esterberg JL, Tso A. An analysis of an anatomi-
cal posterolateral knee reconstruction: an in vitro biomechanical study and development of a surgical
technique. Am J Sports Med. 2004;32(6):1405-1414.
17. Yoon KH, Bae DK, Ha JH, Park SW. Anatomic reconstructive surgery for posterolateral instability of
the knee. Arthroscopy. 2006;22(2):159-165.
18. American Medical Association. Standard Nomenclature of Athlete Injuries. Chicago, IL: American
Medical Association; 1966.
19. LaPrade RF, Wentorf F. Diagnosis and treatment of posterolateral knee injuries. Clin Orthop Relat Res.
2002;(402):110-121.
20. Horst PK, LaPrade RF. Anatomic reconstruction of chronic symptomatic anterolateral proximal tibio-
fibular joint instability. Knee Surg Sports Traumatol Arthrosc. 2010;18(11):1452-1455.
21. LaPrade RF, Spiridonov SI, Coobs PR, Ruckert PR, Griffith CJ. Fibular collateral ligament anatomical
reconstructions: a prospective outcomes study. Am J Sports Med. 2010;38(10):2005-2011.
22. LaPrade RF, Wozniczka JK, Stellmaker MP, Wijdicks CA. Analysis of the static function of the popliteus
tendon and evaluation of an anatomic reconstruction: the “fifth ligament” of the knee. Am J Sports Med.
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23. Harner CD, Vogrin TM, Höher J, Ma CB, Woo SL. Biomechanical analysis of a posterior cruciate liga-
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24. Neuschwander DC, Drez D Jr, Paine RM. Simultaneous high tibial osteotomy and ACL reconstruction
for combined genu varus and symptomatic ACL tear. Orthopedics. 1993;16(6):679-684.
25. Arthur A, LaPrade RF, Agel J. Proximal tibial opening wedge osteotomy as the initial treatment for
chronic posterolateral corner deficiency in the varus knee: a prospective clinical study. Am J Sports Med.
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26. LaPrade RF, Ly TV, Griffith C. The external rotation recurvatum test revisited: reevaluation of the sagit-
tal plane tibiofemoral relationship. Am J Sports Med. 2008;36(4):709-712.
27. LaPrade RF, Engebretsen L, Johansen S, Wentorf FA, Kurtenbach C. The effect of a proximal tibial
medial opening wedge osteotomy on posterolateral knee instability; a biomechanical study. Am J Sports
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28. Terry GC, LaPrade RF. The posterolateral aspect of the knee. Anatomy and surgical approach. Am J
Sports Med. 1996;24(6):732-739.
29. Wentorf FA, LaPrade RF, Lewis JL, Resig S. The influence of the integrity of posterolateral structures
on tibiofemoral orientation when an anterior cruciate ligament graft is tensioned. Am J Sports Med.
2002;30(6):796-799.
Introduction
Although the majority of medial-sided ligamentous knee injuries are isolated and can be suc-
cessfully managed nonoperatively, reconstruction of the medial collateral ligament (MCL) and
other posteromedial structures of the knee (posterior oblique ligament [POL], posteromedial cap-
sule [PMC], semimembranosus, medial head of gastrocnemius) is indicated for the management
of multiligamentous injured knees. In addition, cases of chronic valgus instability and/or cases of
anteromedial rotatory instability that have failed conservative management may require operative
intervention. The authors’ preferred technique for treatment of medial and posteromedial knee
injuries includes anatomic reconstruction of the MCL1 and anatomic repair of any additional
ligamentous injuries. This chapter describes the technique in detail, along with the preoperative
evaluation and postoperative course.
Indications
▶ Isolated medial-sided insufficiency
▷ Persistent symptomatic instability despite nonoperative treatment
▷ Intra-articular entrapment of the MCL
▷ Stener lesion of the knee: Pes anserine tendons trapped deep to the MCL
▶ Multiligamentous injury
▷ Asymmetric medial joint space opening with valgus stress
In the authors’ practice, the majority of medial-sided reconstructions are performed in the
setting of multiligamentous knee injuries; however, chronic isolated valgus and/or anteromedial
rotatory instability are also potential indications. In the case of isolated, medial-sided insuffi-
ciency, patients are indicated for reconstruction if they have symptomatic instability that persists
despite comprehensive nonsurgical treatment, including bracing. In addition, MCL entrapment
Sgaglione NA, Lubowitz JH, Provencher MT, eds. The Knee:
- 461 - AANA Advanced Arthroscopic Surgical Techniques (pp 461-469).
© 2016 AANA.
462 Chapter 33
within the joint as well as distal MCL disruption with pes anserine tendons trapped deep to the
MCL fiber—the so-called Stener lesion of the knee—are indications for operative management.
In the multiligamentous injury setting, medial-sided reconstruction is indicated in patients with
asymmetric medial joint space opening with valgus stress. If the knee demonstrates greater than
10 degrees of valgus opening in full extension, not only are the MCL and PMC injured, but both
cruciate ligaments are likely disrupted. The decision to reconstruct the medial side may be made
from preoperative stress radiographs; however, equivocal results present a unique circumstance.
In this context, final determination of the need for medial-sided reconstruction is made after
the cruciate ligaments have been reconstructed because the anterior cruciate ligament (ACL) and
posterior cruciate ligament serve as secondary valgus stabilizers.
Controversial Indications
▶ Acute midsubstance MCL injury
▶ Asymmetric valgus laxity less than 3 mm
Many cases do not provide an absolute indication for medial-sided reconstruction. Acute
medial-sided injuries in the multiligamentous setting can be treated with bracing, surgical repair,
or reconstruction. The indication for reconstruction in this setting is based on the perceived
irreparability of the medial-sided injury and/or its inability to heal with bracing. An acute, mid-
substance, irreparable tear of the superficial MCL and POL has been suggested as an indication
for medial-sided reconstruction, 2 although the authors’ practice treats these injuries in a brace,
saving reconstruction for patients for whom bracing fails.
In addition, the amount of asymmetric valgus laxity above which medial-sided reconstruction
should be performed has not been well-delineated. In the setting of a multiligamentous recon-
struction, valgus stability is checked after reconstruction of the cruciates by obtaining stress x-rays.
A decision must be made about whether to proceed with medial-sided reconstruction based on the
result of these stress views. Sectioning studies have shown that an isolated MCL injury will result
in 3.1 mm of asymmetric laxity at 20 degrees of knee flexion, whereas a combined MCL-POL
injury will result in 9.8 mm of asymmetric laxity.3 As a result, the authors typically use asymmetric
laxity greater than 3 mm as a cutoff to proceed with medial-sided reconstruction, 2 especially in
the setting of valgus malalignment because valgus loads are associated with ACL injury and ACL
graft failure.4 Having said that, it is important to recognize that this treatment algorithm has not
been validated clinically.
flexion with the foot fixed and externally rotated 10 to 15 degrees. In this position, an anterome-
dial rotatory force is applied to the proximal tibia, and any anterior subluxation of the medial tibial
plateau relative to the medial femoral condyle is consistent with a PMC injury. It is important to
discern how the tibia plateaus are moving relative to the femoral condyles during this test because
increased tibial external rotation can be caused by increased anteromedial translation of the medial
tibial plateau (anteromedial rotatory instability) or increased posterolateral translation of the lateral
tibial plateau (posterolateral rotatory instability).
Pertinent Imaging
▶ Magnetic resonance imaging (MRI) is the modality of choice for evaluating medial-sided
injuries.
▶ Valgus stress x-rays at 30 degrees help assess the extent of the injury.
Plain x-rays are often unremarkable in patients with medial-sided knee injuries. Full-length
standing x-rays should be obtained when feasible to assess coronal plane alignment because
patients with significant genu valgum may benefit from a varus-producing osteotomy. MRI is the
modality of choice for imaging the medial-sided knee structures,7,8 although MRI evaluation in
the chronic setting can be difficult. For this reason, imaging results must be corroborated with
clinical findings to arrive at an accurate diagnosis.
The authors routinely use valgus stress x-rays at 30 degrees of flexion, especially in the multilig-
amentous injury setting, to evaluate the competency of the MCL prior to surgery. Both knees must
be imaged to provide a side-to-side comparison. LaPrade et al reported that an isolated superficial
MCL injury will result in a side-to-side difference in joint space widening of 3.1 mm, whereas a
complete medial-sided injury (superficial and deep MCL and POL) will result in 9.8 mm of asym-
metric widening (Figure 33-1).3
464 Chapter 33
Equipment
▶ Achilles tendon allograft with calcaneal bone block
▶ Fluoroscopy entering from the ipsilateral side of the table
▶ 9-mm reamer and guide pins
▶ Interference screw, metal or biocomposite, 7 by 20 mm
▶ Large straight hemostat
▶ Several threaded suture anchors, single or double loaded
▶ 4.5-mm cortical screws with 3.2-mm drill bit
▶ 18-mm spiked washer
▶ #2 nonabsorbable sutures
▶ 0 braided absorbable sutures
▶ Mersilene tape (Ethicon)
Figure 33-5. Intraoperative images of the medial side of a right knee (ante-
rior = up; distal = left). During MCL reconstruction, isometry between the femoral
(†) and distal tibial (*) attachments is confirmed in (A) extension and (B) flexion
using Mersilene tape.
medial epicondyle,9 which can be palpated and used as a reference point. It has been shown that
the fluoroscopic and anatomic methods of determining the MCL femoral insertion have similar
accuracy.11 Identification of the femoral MCL insertion will help guide further dissection, which
includes identification of the adductor magnus tendon, adductor tubercle, medial head of the
gastrocnemius, semimembranosus insertion, POL, and PMC. Occasionally, higher-energy injury
mechanisms can cause disruption of the meniscotibial ligaments with resultant meniscal extrusion
on preoperative MRI. In these cases, these ligaments should be exposed as well to facilitate repair.
Disrupted or attenuated tissues are then repaired or imbricated, with the exception of the pos-
teromedial capsule, which is imbricated after MCL reconstruction is complete. Single- or double-
loaded threaded suture anchors are used for repair/imbrication. Meniscotibial ligament anchors
are placed in the proximal tibia, just distal to the articular margin, and sutures are placed in a
mattress configuration to repair the ligament and reduce the meniscus. Medial head of the gas-
trocnemius anchors are placed on the posteromedial distal femur, and semimembranosus anchors
are placed on the posteromedial aspect of the tibial plateau.
Once any injured posteromedial knee structures have been repaired or imbricated, attention is
turned to MCL reconstruction. A longitudinal split is made in the crural fascia at the posterior
border of the native MCL. This is taken down to the bone, dividing the crural fascia and joint cap-
sule. The posterior flap created by this split contains the PMC and the POL. This tissue is com-
monly attenuated or redundant due to valgus instability and will later be imbricated and repaired.
Next, 2.4-mm guide pins are inserted at the femoral and distal tibial MCL insertions. Isometry
between the 2 points is examined by looping Mersilene tape between the 2 guide pins and cycling
the knee in flexion and extension (Figure 33-5). The femoral insertion can be adjusted to achieve
optimal isometry.
Next, a 9-by-25-mm socket is reamed over the femoral guide pin, and a bicortical 3.2-mm drill
hole is made at the site of the distal tibial insertion. Then, 2 suture anchors are placed on the proxi-
mal medial tibia 12 mm distal to the joint line along the proposed course of the reconstructed MCL.
These sutures are set aside to later restore the proximal MCL tibial attachment.
At this point, femoral fixation is obtained by inserting the calcaneal bone plug into the femoral
socket and fixing with a 7-by-20-mm interference screw. Two suture anchors are placed on the pos-
terior margin of the medial femoral condyle, just distal and anterior to the gastrocnemius tubercle at
the femoral insertion of the POL/PMC.9 Mattress sutures are passed into the attenuated capsular
tissue in preparation for capsular imbrication, which will be performed after final graft fixation.
The graft is then tunneled distally beneath the sartorial expansion to the distal tibial insertion
using a large straight hemostat. A 2-cm longitudinal split is made in the graft at the level of the
distal MCL tibial insertion, and a #2 nonabsorbable suture is used to place a locking whip stitch
up and down the graft, 2 to 3 cm proximal to this point. The graft is tensioned by pulling on the
whip stitches with the knee held in varus at 20 degrees of flexion and is fixed at the distal tibial
attachment site with a bicortical 4.5-mm screw and 18-mm spiked ligament washer (Figure 33-6).
Anatomic Reconstruction of the Posteromedial Corner and Medial Collateral Ligament 467
Fluoroscopy is used to confirm that the screw is bicortical. Excess graft is then trimmed, and the
whip stitch suture ends are tied around the screw to achieve double fixation at the distal attach-
ment. The sutures from the proximal tibial suture anchors are then passed through the graft in a
mattress configuration and tied to recreate the proximal MCL tibial attachment. The previously
placed posteromedial capsule sutures are tied to obtain capsular imbrication, and the longitudinal
capsular split is closed with braided 0 absorbable suture. Fluoroscopy is used to confirm appropri-
ate anchor and screw placement (Figure 33-7).
Postoperative Protocol
Postoperative restrictions may vary depending on concomitant injuries and procedures performed.
Typically, the patient is placed into a hinged knee brace with a slight varus mold, which will be
worn for 6 weeks after surgery until a custom, varus-molded knee orthosis is prescribed. The brace
is recommended for the first year after surgery. Toe-touch weightbearing with the brace locked in
extension is prescribed for the first 6 weeks. Range of motion and quadriceps activation exercises
468 Chapter 33
are begun 1 week postoperatively. At 6 weeks, weightbearing and strengthening programs are initi-
ated, with the goal of full motion and normal gait by 12 weeks. Return to sports and other activi-
ties is individualized but is allowed no sooner than 1 year postoperatively after multiligamentous
reconstruction. Chemical venous thromboembolism prophylaxis is indicated in all multiligamentous
reconstruction patients and in isolated MCL reconstruction patients with risk factors.
Potential Complications
Recent reports suggest satisfactory results and a low complication rate after MCL/PMC recon-
struction.1,2,12 In addition to general postoperative complications after lower-extremity surgery
(eg, superficial and deep infection, deep venous thrombosis, etc), there are several specific poten-
tial complications related to MCL/PMC reconstruction (Table 33-1).
References
1. Marx RG, Hetsroni I. Surgical technique: medial collateral ligament reconstruction using Achilles
allograft for combined knee ligament injury. Clin Orthop Relat Res. 2012;470(3):798-805.
2. Laprade RF, Wijdicks CA. Surgical technique: development of an anatomic medial knee reconstruction.
Clin Orthop Relat Res. 2012;470(3):806-814.
3. Laprade RF, Bernhardson AS, Griffith CJ, Macalena JA, Wijdicks CA. Correlation of valgus stress
radiographs with medial knee ligament injuries: an in vitro biomechanical study. Am J Sports Med.
2010;38(2):330-338.
4. Hetsroni I, Lyman S, Pearle AD, Marx RG. The effect of lateral opening wedge distal femoral osteotomy
on medial knee opening: clinical and biomechanical factors. Knee Surg Sports Traumatol Arthrosc.
2014;22(7):1659-1665.
5. Wijdicks CA, Griffith CJ, Johansen S, Engebretsen L, LaPrade RF. Injuries to the medial collateral liga-
ment and associated medial structures of the knee. J Bone Joint Surg Am. 2010;92(5):1266-1280.
6. Sims WF, Jacobson KE. The posteromedial corner of the knee: medial-sided injury patterns revisited.
Am J Sports Med. 2004;32(2):337-345.
7. Stannard JP. Medial and posteromedial instability of the knee: evaluation, treatment, and results. Sports
Med Arthrosc. 2010;18(4):263-268.
8. Tibor LM, Marchant MH Jr, Taylor DC, Hardaker WT Jr, Garrett WE Jr, Sekiya JK. Management of
medial-sided knee injuries, part 2: posteromedial corner. Am J Sports Med. 2011;39(6):1332-1340.
9. LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L. The anatomy of the
medial part of the knee. J Bone Joint Surg Am. 2007;89(9):2000-2010.
10. Wijdicks CA, Griffith CJ, LaPrade RF, et al. Radiographic identification of the primary medial knee
structures. J Bone Joint Surg Am. 2009;91(3):521-529.
11. Leiter JR, Levy BA, Stannard JP, et al. Accuracy and reliability of determining the isometric point of the
knee for multiligament knee reconstruction. Knee Surg Sports Traumatol Arthrosc. 2014;22(9):2187-2193.
12. Kovachevich R, Shah JP, Arens AM, Stuart MJ, Dahm DL, Levy BA. Operative management of the
medial collateral ligament in the multi-ligament injured knee: an evidence-based systematic review.
Knee Surg Sports Traumatol Arthrosc. 2009;17(7):823-829.
Introduction
The multiligament-injured knee is a complicated orthopedic injury that is typically the result
of a high-energy force and often results in a knee dislocation. The mechanism may be from an
athletic injury or from high-energy blunt trauma, such as a motor vehicle collision. The knee may
dislocate or sublux at the time of injury as a result of the impact but frequently reduces prior to
presentation to the treating physician. Even if the knee spontaneously reduces, the damage to the
ligaments and other structures in and around the knee can be significant.1,2
Indications
▶ Any patient with a multiligament- (2 or more of the 4 major ligament complexes) injured knee
who requires knee stability for ambulation or activities of daily living and who may tolerate
potentially prolonged surgery
▶ Patients with 3 or more ligament complexes injured may require staged procedures or place-
ment of a Compass Knee Hinge (Smith & Nephew).
Controversial Indications
▶ Patients with partial ligament complex injuries in conjunction with 1 or 2 complete ligament
ruptures
Pertinent Imaging
▶ Quality magnetic resonance imaging (MRI) of the knee to assess the extent of ligament injury
and to identify other associated injuries, such as meniscal tears or chondral defects
▶ Stress x-rays (varus, valgus, and posterior), with comparison to the contralateral knee, can
frequently be helpful to identify the degree of instability present in the medial and lateral
corners and the PCL.
▶ Intraoperative fluoroscopic stress examinations can help confirm clinical and/or MRI
findings.
Treatment of Multiligament Knee Injuries 473
After adequate imaging has been completed, a plan may be formulated regarding surgical tim-
ing, ligament repair vs reconstruction, the order of ligament reconstruction, and an assessment of
any further surgeries potentially required.9 Appropriate surgical timing and planning are neces-
sary to prevent the poor outcomes that can result from multiligament injuries. Hospital readmis-
sion within 90 days and unplanned repeat surgeries can be as high as 4.8% and 28%, respectively.10
Recurrent instability, arthrofibrosis, and persistent pain are the most frequent complications.11-13
Multiple techniques exist when planning operative treatment of knee dislocations, with stud-
ies demonstrating advantages and disadvantages to repair vs reconstruction and acute vs delayed
management of these injuries. Repair vs reconstruction may be dictated by surgeon preference or
by the degree of injury, but for highly unstable injuries with 3 or 4 ligaments involved, studies
have shown benefit to reconstruction rather than repair, in particular reconstruction of the PMC
and the PLC.9,14-18 There are also times when the native ligaments and soft tissue are extremely
hemorrhagic and difficult to define and, thus, cannot be repaired. When the native ligaments are
identifiable or present, however, the authors prefer to repair the native tissue. Then they perform
the planned reconstructions in addition to the repairs to give the best stability possible using a belt
and suspenders approach.
When performing reconstructions, autograft or allograft may be used. Allograft is most fre-
quently chosen in the multiligament knee to protect as much of the uninjured native anatomy
surrounding the knee joint as possible. Many allograft options exist, including anterior and
posterior tibialis tendons, hamstring tendon, quadriceps tendon, Achilles tendon, and patellar
tendon. The specific grafts used may be dictated by the availability of the grafts, the number
of ligaments being reconstructed, and the planned reconstruction techniques. Some techniques
require different size grafts than others. For example, a 2-tailed PLC reconstruction requires a
graft that will have plenty of length to complete the entire reconstruction. In contrast, a tibial
inlay technique for a PCL reconstruction requires an appropriately sized bone block on one end
of the tendon.
Timing and staging of operative intervention is the topic of some debate and may be influ-
enced by other injuries or comorbidities, but, when possible, many authors prefer early (< 4 weeks)
operative treatment to achieve good ligamentous stability and promote mobilization.9,16,19 Early
stabilization may result in decreased risk of arthrofibrosis, improved range of motion (ROM), and
earlier rehabilitation. Ensuring the patient’s swelling and skin will tolerate multiple incisions is
important to define prior to any operation, because a poor tissue bed could lead to postoperative
wound breakdown or infection.
For patients with a multiligament injury, the authors prefer an initial repair and/or reconstruc-
tion within 2 to 4 weeks of initial injury. Surgeons may choose to repair or reconstruct every liga-
ment in one procedure or may delay one or more of the reconstructions in a staged fashion. In a
3- or 4-ligament injured knee, the authors recommend considering staging 2 separate procedures
for the following reasons:
▶ Performing all reconstructions in a single procedure involves an extensive operation with a
prolonged anesthesia time and a potential increased risk for infection.
▶ Some degree of stiffness may result after reconstructing multiple ligaments, and a planned
return to the operating room allows for a manipulation under anesthesia and/or lysis of any
adhesions that have developed, which aids the patient in his or her postoperative rehabilitation.
▶ By staging the procedures, different rehabilitation techniques can be used at different time
points to maximize the patient’s final ROM and return to function.
The preferred technique of the senior author is an early reconstruction of the PMC, PLC, and
PCL, with a delayed reconstruction of the ACL 6 weeks after the index procedure. In addition, in
the setting of the highly unstable knee, consideration is given to placing a Compass Knee Hinge.
The Compass Knee Hinge consists of 2 carbon fiber rings bolted to multi-hole Rancho Cubes
(Smith & Nephew) that are connected to the Schanz pins placed in the femur and tibia. The rings
474 Chapter 34
are connected by 2 calibrated hinges that align along either side of the knee joint. The rings are
available in numerous sizes based on the size of the patient. The Compass Knee Hinge allows
ROM in the sagittal plane while restricting motion in the coronal and axial planes. This allows
early weightbearing and knee ROM while protecting the newly reconstructed ligaments. Studies
have shown multiple benefits to using the Compass Knee Hinge after multiligament reconstruc-
tions, particularly in decreasing the potential for reconstruction failures vs knee bracing alone.20-23
The Compass Knee Hinge is particularly helpful for 4-ligament knee injuries, multiligament inju-
ries with associated fractures or fracture dislocations, preoperative flexion deformities greater than
15 degrees, or for chronic knee dislocations. When any of these situations are encountered or when
planning multiple simultaneous reconstructions or staged procedures, the authors recommend
considering the Compass Knee Hinge during the preoperative planning process.
Numerous techniques for the timing and specific types of reconstructions for multiligament
knee injuries are available to surgeons. Regardless of the techniques used, with proper planning
and preparation, a successful outcome can frequently be achieved in 1 or 2 operations.
Equipment
The equipment necessary depends on the number of ligaments being reconstructed and the
techniques used by the surgeon. In general, standard arthroscopy equipment with a 30-degree
arthroscope is sufficient for visualization during the arthroscopic portions of the procedure.
For allograft reconstruction, adequately sized grafts and a graft prep station with a tensioning
device are necessary. For a PCL using a tibial inlay technique, the authors prefer an Achilles ten-
don with a bone block at a minimum length of 15 mm, width of 10 mm, and thickness of 10 mm.
The thickness is crucial to avoid cracking the bone block when the screw is tightened. For a PLC
reconstruction using a modified 2-tailed technique, the authors prefer an anterior or posterior tibi-
alis tendon at least 27 cm in length. For a PMC reconstruction using a modified loop technique,
the authors prefer a semitendinosus tendon. Finally, for an ACL reconstruction using a soft tissue,
all-inside technique, the authors prefer a semitendinosus, anterior tibialis, or posterior tibialis graft
with the goal of obtaining a final graft diameter 8.5 mm or greater.24
For the techniques used by the senior surgeon, cannulated drills, reamers, and taps in multiple
sizes are necessary to create bone tunnels or sockets. Guide wires are necessary for screw place-
ment. A nitinol wire is used for tap and screw placement, and a suture passer is necessary for suture
and graft passage. A #2 nonabsorbable suture is used for the ends of the grafts. Cortical screws
with washers, bioabsorbable screws, or suspensory button fixation may all be used for graft fixation
depending on surgeon preference. For the PCL inlay technique, a 4.5-mm cannulated screw and
washer is used to fix the bone block in the tibia, and absorbable interference screws are used to fix
the soft tissue fixation in the femur (Figure 34-1). For the PMC, an absorbable biotenodesis screw
is used to fix the graft in the femur, and a 4.5-mm screw and washer are used to fix the graft in
the tibia. For the PLC, a 7-mm bioabsorbable screw secures the soft tissue graft in the tibia while
a fully threaded 4.5- or 6.5-mm screw and washer secure the graft in the femur.
In addition to the mentioned screw fixation techniques, consideration may be given to recon-
structions using suspensory fixation. This technique incorporates bone sockets instead of full
bone tunnels, meaning more preserved bone stock and less chance of crossing or crowding bone
tunnels during simultaneous reconstructions. It also eliminates the risk of screw cutout or screws
or washers cutting soft tissue grafts. The senior author prefers suspensory fixation for the ACL
reconstruction in the setting of multiligament knee reconstruction and has also begun incorporat-
ing the technique in PMC and PLC reconstructions.
Treatment of Multiligament Knee Injuries 475
Figure 34-1. Intraoperative photograph from a posteromedial view of the posterior aspect of a
right knee depicting screw fixation of a tibial inlay PCL bone block (arrow) with the thigh to the
top and the lower leg to the bottom of the photograph.
described here. Regardless of the techniques used, it is vital for the surgeon to attempt to achieve
anatomic restoration of the ligament complexes being reconstructed. For the PMC, restoration of
the superficial medial collateral ligament, posterior oblique ligament, and direct head of the semi-
membranosus attachment are necessary to restore function. For the PLC, the vital components
are the lateral collateral ligament, popliteus, and popliteofibular ligament. When reconstructing
multiple ligaments simultaneously, it is important to plan each step preoperatively to proceed as
efficiently as possible intraoperatively. The authors recommend performing diagnostic arthroscopy
first to identify and address any intra-articular pathology, such as chondral defects or meniscal
tears, and then proceed with the open reconstructions. Femoral tunnels for the double-bundle
PCL are created arthroscopically. The authors typically perform the posteromedial approach first
and reconstruct the PCL, followed by the PMC reconstruction, then the posterolateral approach,
and finally the PLC reconstruction. All of the reconstructions should be tensioned at the end of
the overall procedure so the exact order can be adjusted based on the number of ligaments being
reconstructed or by surgeon preference. A precise preoperative plan ensures optimal efficiency.
Application of the Compass Knee Hinge is relatively straightforward, but there are some
critical steps required to ensure the Compass Knee Hinge functions appropriately. First, in the
setting of a multiligament knee reconstruction including the PMC and/or the PLC that will also
be combined with Compass Knee Hinge placement, it is necessary to place a centering wire for
positioning of the Compass Knee Hinge and the femoral Schanz pins first prior to PMC or PLC
reconstruction. The centering wire for the Compass Knee Hinge is placed through the isometric
point in the femur where the reconstructions of the corners would also be placed (Figure 34-2).
Positioning the wire frequently takes a number of passes to obtain the perfect position, so placing
the wire after performing the PLC or PMC reconstructions is impossible and would damage the
reconstructions. For this reason, application of the hinge must be completed in 2 phases.
The first step in the application requires finding the isometric point on the femur using
fluoroscopy. To accomplish this, a perfect lateral view of the knee is obtained, with the isometric
point at the intersection of a line drawn along the anterior aspect of the posterior femoral cor-
tex with Blumensaat’s line.29 A long, threaded 2.5-mm wire is then drilled through the cortex
at this point, with the wire appearing as a single dot on the lateral fluoroscopic view (Figure
34-3). Fluoroscopy should be used throughout to ensure exact placement of the wire. When the
wire is well seated and in line, it is then drilled across the femur, parallel to the joint line. This
Treatment of Multiligament Knee Injuries 477
Figure 34-3. Lateral intraoperative fluoroscopic x-ray depicting centering wire placement
across the femur for placement of a Compass Knee Hinge. The centering wire should appear as
a single dot (arrow) at the isometric point of the knee.
placement is confirmed with an anteroposterior view of the knee. If it is not parallel to the joint
line, it should be removed and revised. Precise placement of this centering wire is a critical step to
appropriate placement and subsequent final functioning of the Compass Knee Hinge; it is critical
to take the time to get adequate fluoroscopic views to ensure proper placement. After the wire is
appropriately placed, the 2 femoral pins may then be placed. Construction of the hinge begins by
placing the apparatus on the centering wire with the wire placed through the holes in the middle
of the medial and lateral calibrated hinges (Figure 34-4). Rancho Cubes are then placed in the
most posterior hole on the medial and lateral sides of the proximal side of the femoral carbon fiber
ring, with a 1-hole cube used medially and a 3-hole cube laterally to avoid crossing of the pins in
the femur. Triple trocar guides are then placed through the Rancho Cubes to allow drilling for
the femoral pins. An adequate skin incision is made at the entry point of the trocar, and blunt
dissection is carried out down to bone. A 4-mm drill is used to drill completely across the femur
medially and laterally, and a 6-mm pin is then placed through each guide. A centering sleeve that
is provided in the system is then placed over the pins to lock the Rancho Cube into place. At this
point, the Compass Knee Hinge may be detached from the pins. Leaving the femoral pins and
Rancho Cubes in place, the centering wire is removed, and the Compass Knee Hinge is placed on
a sterile table to allow completion of the corner reconstructions.
478 Chapter 34
After the appropriate reconstructions have been completed, the Compass Knee Hinge is then
remounted on the femoral pins through the same holes as before. Three-, 4-, or 5-hole Rancho
Cubes are then placed on the distal aspect of the tibial ring in lateral, anterior, and anteromedial
locations on the tibia, and the tibial pins are placed in a similar fashion as the femoral pins (Figure
34-5). Centering sleeves are placed over all the pins, and the femoral and tibial sleeves are all tight-
ened to complete the application. The knee is then flexed to 90 degrees to ensure that there is no
skin tension at the pin entry sites. If tension is present, the incisions may be extended to release
the tension. The knee is then taken through a final ROM to ensure all pins and bolts are properly
positioned and tightened and the ROM is adequate (Figure 34-6).
Treatment of Multiligament Knee Injuries 479
Postoperative Protocol
The authors’ postoperative protocol incorporates an early, progressive attempt to regain motion.
Continuous passive motion machines set from 0 to 60 degrees are begun on postoperative day 1,
and patients are allowed to bear weight immediately with a knee brace or the Compass Knee
Hinge locked in extension. A combination of anesthetic epidurals, spinal or femoral blocks, and
patient-controlled analgesia may be used for inpatient postoperative pain control. ROM is pro-
gressed as tolerated as quadriceps strength and function improve. When a Compass Knee Hinge
is used, patients are asked to lock the hinge in full extension and in the maximum tolerable flex-
ion for a least 1 hour every day. At 6 weeks, the Compass Knee Hinge is removed, and the ACL
reconstruction is completed. After this point, the rehabilitation may then be primarily dictated by
the surgeon’s preferred ACL rehabilitation protocol.
Potential Complications
Appropriate preoperative physical examination, imaging, diagnosis, and planning are critical
to avoid the many complications that may arise in the treatment of multiligament knee injuries.
Adequate diagnosis of PMC and PLC injuries preoperatively is imperative because failure to recon-
struct the corners in the setting of a multiligament knee injury can lead to persistent instability and
early failure of ACL and/or PCL reconstruction. Surgical timing must be balanced with associated
injuries and comorbidities because wound breakdown or infection can occur when the skin envelope
and soft tissue swelling around the knee are inappropriate for surgery. Neurovascular injury to the
saphenous nerve and vein, tibial nerve, and popliteal artery and vein can occur with the postero-
medial approach to the knee during a PMC or a PCL reconstruction. Peroneal nerve injury can
occur with the posterolateral approach to the knee during PLC reconstruction. Awareness of the
pertinent anatomy and proper patient positioning are necessary to avoid these major neurovascular
complications. Recurrent instability, arthrofibrosis, and persistent pain are all complications that
may be encountered postoperatively but may be avoided with proper surgical planning, timing, and
technique.
480 Chapter 34
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5. Makhmalbaf H, Moradi A, Ganji S, Omidi-Kashani F. Accuracy of Lachman and anterior drawer tests
for anterior cruciate ligament injuries. Arch Bone Jt Surg. 2013;1(2):94-97.
6. Feltham GT, Albright JP. The diagnosis of PCL injury: literature review and the introduction of two
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7. Jung YB, Lee YS, Jung HJ, Nam CH. Evaluation of posterolateral rotatory knee instability using the dial
test according to tibial positioning. Arthroscopy. 2009;25(3):257-261.
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Phys Ther. 2010;42(3):221-233.
9. Levy BA, Dajani KA, Whelan DB, et al. Decision making in the multiligament-injured knee: an evi-
dence based systemic review. Arthroscopy. 2009;25(4):430-438.
10. Wilson SM, Mehta N, Do HT, Ghomrawi H, Lyman S, Marx RG. Epidemiology of the multiligament
knee reconstruction. Clin Orthop Relat Res. 2014;472(9):2603-2608.
11. Cole BJ, Harner CD. The multiple ligament injured knee. Clin Sports Med. 1999;18(1):241-262.
12. Yeh WL, Tu YK, Su JY, Hsu RW. Knee dislocation: treatment of high-velocity knee dislocation.
J Trauma. 1999;46(4):693-701.
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16. Dwyer T, Marx RG, Whelan D. Outcomes of treatment of multiple ligament knee injuries. J Knee Surg.
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17. Stannard JP, Brown SL, Farris RC, McGwin G Jr, Volgas DA. The posterolateral corner of the knee:
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Dr. David A. Abrutyn has no financial or proprietary interest in the materials presented herein.
Dr. Annunziato Amendola is a consultant for Arthrex, owns stock in Arthrosurface, and
receives royalties from Arthrex, Arthrosurface, and Smith & Nephew.
Dr. Jack Anavian has no financial or proprietary interest in the materials presented herein.
Dr. Jack M. Bert has no financial or proprietary interest in the materials presented herein.
Dr. Andrew J. Blackman has no financial or proprietary interest in the materials presented
herein.
Dr. Trevor Born has no financial or proprietary interest in the materials presented herein.
Dr. Joseph Brunkhorst has no financial or proprietary interest in the materials presented herein.
Dr. William Bugbee is a consultant for and has received research support from Joint Restoration
Foundation.
Dr. James M. Bullock has no financial or proprietary interest in the materials presented herein.
Dr. Joseph Carney has no financial or proprietary interest in the materials presented herein.
- 483 -
484 Financial Disclosures
Dr. Thomas Carter’s financial disclosures are Arthrex (royalties, consultant, fellowship sup-
port), Arthroscopy Association of North America (Board of Directors), Cayenne Medical (fellow-
ship support), Osiris (stock, consultant, research support), Ossur (fellowship support), and RTI
Biologics (consultant, research support).
Dr. Austin Crow has no financial or proprietary interest in the materials presented herein.
Dr. Umer R. Dasti has no financial or proprietary interest in the materials presented herein.
Dr. Julie A. Dodds is an Arthroscopy Association of North America board and committee
member.
Dr. Ryan Dunlay has no financial or proprietary interest in the materials presented herein.
Dr. Neil C. Dunleavy has no financial or proprietary interest in the materials presented herein.
Dr. Paul Fadale has no financial or proprietary interest in the materials presented herein.
Dr. Gregory C. Fanelli has no financial or proprietary interest in the materials presented herein.
Dr. Jack Farr is a consultant for Genzyme, Zimmer, Osiris Therapeutics, Regeneration
Technologies Inc, DePuy Mitek, and Arthrex. Royalties include Arthrex and DePuy Synthes. All
other disclosures are up to date on AAOS.org.
Dr. Donald C. Fithian has no financial or proprietary interest in the materials presented herein.
Dr. Freddie H. Fu’s Department of Orthopaedic Surgery receives research funding from Smith
& Nephew for anatomic ACL reconstruction.
Dr. John P. Fulkerson has no financial or proprietary interest in the materials presented herein.
Dr. Theodore J. Ganley has no financial or proprietary interest in the materials presented herein.
Dr. Brian B. Gilmer has no financial or proprietary interest in the materials presented herein.
Dr. Andrew D. Goodwillie has no financial or proprietary interest in the materials presented
herein.
Financial Disclosures 485
Dr. Vipool K. Goradia has no financial or proprietary interest in the materials presented herein.
Dr. Nathan L. Grimm has no financial or proprietary interest in the materials presented herein.
Dr. Jeffrey Halbrecht has no financial or proprietary interest in the materials presented herein.
Dr. Christopher D. Harner receives education and research support from Smith & Nephew.
Dr. Nathan Jacobson has no financial or proprietary interest in the materials presented herein.
Evan W. James has no financial or proprietary interest in the materials presented herein.
Dr. Adam M. Johannsen has no financial or proprietary interest in the materials presented
herein.
Dr. Lanny L. Johnson has no financial or proprietary interest in the materials presented herein.
Dr. Ethan Kellum has no financial or proprietary interest in the materials presented herein.
Dr. Jason L. Koh has no financial or proprietary interest in the materials presented herein.
Dr. Peter R. Kurzweil is a consultant for Ceterix, Cayenne Medical, Orteq, Parcus, and Pierce
Surgical.
Dr. Robert F. LaPrade is a consultant for Arthrex, Ossur, and Smith & Nephew and has received
a grant from Health East Norway.
Dr. Bruce A. Levy has the following financial or proprietary interests in the materials presented
herein: consultant for Arthrex; royalties from Arthrex and VOT Solutions; research support—
Arthrex, Biomet, and Stryker; editorial board memberships: Clinical Orthopaedics and Related
Research—deputy editor, Arthroscopy—Board of Trustees, Knee Surgery, Sports, Trauma and
Arthroscopy—member.
Dr. Darius Lin has no financial or proprietary interest in the materials presented herein.
Dr. Robert Litchfield receives royalties from Arthrosurface, is on the speaker’s bureau of Zimmer,
and receives research and fellowship support from Smith & Nephew and Arthrex (fellowship).
Dr. James H. Lubowitz has no current consulting or royalty disclosures. (Past consulting or roy-
alties include Arthrex and Smith & Nephew.) Taos Orthopaedic Institute Research Foundation
receives educational grant support from Arthrex, Breg, DonJoy, Smith & Nephew, Stryker, and
Tournier.
Dr. Jonathan R. Maher has no financial or proprietary interest in the materials presented herein.
486 Financial Disclosures
Dr. Randy Mascarenhas has no financial or proprietary interest in the materials presented
herein.
Dr. Taylor Mathis has no financial or proprietary interest in the materials presented herein.
Dr. Owen P. McGonigle has no financial or proprietary interest in the materials presented herein.
Dr. Sanjay Menon has no financial or proprietary interest in the materials presented herein.
David B. Merkow has no financial or proprietary interest in the materials presented herein.
Dr. Ryan Michels has no financial or proprietary interest in the materials presented herein.
Dr. Mark Miller has no financial or proprietary interest in the materials presented herein.
Dr. Kevin R. Myers has no financial or proprietary interest in the materials presented herein.
Dr. Shane J. Nho is a consultant for Stryker, Pivot Medical, and Ossur. Stocks include Pivot, and
he receives research support from Stryker and Allosource.
Dr. Clayton W. Nuelle has no financial or proprietary interest in the materials presented herein.
Dr. Benjamin R. Parker has no financial or proprietary interest in the materials presented herein.
Dr. Leon (Lonnie) Paulos has no financial or proprietary interest in the materials presented
herein.
Dr. Matthew A. Pifer has no financial or proprietary interest in the materials presented herein.
Dr. Matthew T. Provencher is a consultant for Arthrex and Joint Restoration Foundation.
Dr. John C. Richmond is a consultant for Histogenics Corp and DePuy Synthes.
Dr. V. Franklin Sechriest II has no financial or proprietary interest in the materials presented
herein.
Dr. Kevin G. Shea has no financial or proprietary interest in the materials presented herein.
Dr. Walter Shelton has no financial or proprietary interest in the materials presented herein.
Financial Disclosures 487
Dr. Robby Sikka has no financial or proprietary interest in the materials presented herein.
Dr. Paul L. Sousa has no financial or proprietary interest in the materials presented herein.
Dr. Jeffrey T. Spang has no financial or proprietary interest in the materials presented herein.
Dr. James P. Stannard receives institutional research support from Smith & Nephew and
Arthrex Inc and receives royalties from Thieme Publishing. Dr. Stannard is the Editor-in-Chief
of Journal of Knee Surgery. He is also a consultant to Smith & Nephew, Regeneration Technologies
Inc, Ellipse Technologies Inc, and DePuy Synthes. Dr. Stannard is also a board member of the
AO Board of Trustees, the AO Research Review Commission, and the Orthopaedic Trauma
Association. He is receiving support from a US Department of Defense research grant.
Dr. James Starman has no financial or proprietary interest in the materials presented herein.
Alexandra Styhl has no financial or proprietary interest in the materials presented herein.
Dr. Kentaro P. Suzuki has no financial or proprietary interest in the materials presented herein.
Annemarie K. Tilton has no financial or proprietary interest in the materials presented herein.
Dr. Garth N. Walker has no financial or proprietary interest in the materials presented herein.
Dr. Amanda L. Weller has no financial or proprietary interest in the materials presented herein.
Dr. Adam Wilson has no financial or proprietary interest in the materials presented herein.
Dr. Adam B. Yanke receives research funding from NuTech and Arthrex.
Dr. Kenneth R. Zaslav is a consultant for Vericel Inc, Cartiheal Inc, Lifenet Inc, and Aesculap
Inc.