Arthroscopy of the Lower Extremity

Arthroscopy of the Lower Extremity

Barry B. Phillips Chapter 48

Knee ......................................... 2811 Basic diagnostic techniques ...... 2812 General principles .......................... 2812 Patient positioning .......................... 2813 Portal placement ............................ 2813 Insertion of scope ........................... 2816 Arthroscopic examination of the knee ................................ 2817 Suprapatellar pouch and patellofemoral joint ........................................ 2817 Medial gutter ................................ 2817 Medial compartment ....................... 2817 Intercondylar notch ......................... 2820 Posteromedial compartment ............... 2821 Lateral compartment ....................... 2821 Lateral gutter and posterolateral compartment .............................. 2822 Arthroscopic surgery of the meniscus ................................ 2823 Classifi cation of meniscal tears .......... 2823 Types of meniscal excisions .............. 2824 General principles .......................... 2825 Surgery for specifi c meniscal tears ....... 2825 Discoid lateral meniscus ................... 2830 Meniscal cyst ................................. 2831

Arthroscopic repair of torn menisci ...... 2832 Arthroscopic surgery for other disorders ................................ 2845 Loose bodies in the knee joint ........... 2845 Synovial plicae of the knee ............... 2846 Osteochondritis dissecans of the femoral condyles and patella .................... 2848 Cruciate ligament reconstruction ......... 2855 Chondromalacia of the patella syndrome .................................. 2886 Other applications of arthroscopy of the knee ........ 2891 Arthroscopy in fractures around the knee ........................................ 2891 Arthrofi brosis ................................. 2892 Evaluation before proximal tibial osteotomies ................................ 2892 Débridement of osteoarthrosis and abrasion arthroplasty ................... 2893 Complications ........................... 2893

Ankle ....................................... 2894 Arthroscopic portal placement and examination ................... 2894 Anterior portals ............................. 2894

Posterior portals ............................. 2894 Transmalleolar portals ..................... 2895 Soft-tissue procedures ............... 2898 Synovectomy ................................. 2899 Débridement for septic arthritis .......... 2899 Reconstruction for ligamentous ankle injuries ..................................... 2899 Bony procedures ....................... 2900 Drilling, excision, pinning, or osteochondral transfer for osteochondritis dissecans and traumatic chondral lesions ............. 2900 Removal of osteophytes for anterior impingement syndrome ................. 2901 Ankle arthrodesis ........................... 2901 Arthroscopy of the subtalar joint ....................................... 2904 Complications ........................... 2904

Hip ........................................... 2905 Indications ................................ 2905 General setup ............................ 2905 Labral injuries ........................... 2909 Complications ........................... 2911

KNEE

The knee is the joint in which arthroscopy has its greatest diagnostic and intraarticular surgical application. The usefulness of arthroscopic techniques in diagnosis and treatment of intraarticular pathology has been well documented. Arthroscopy has allowed evaluation of the accuracy of clinical examination, laboratory tests, radiographs, MRI, and other diagnostic tools in knee problems. Johnson compared clinical impressions with arthroscopic diagnoses and found a signifi cant number of additional diagnoses, including some completely different from the clinical impression, in a large percentage of patients. In a study of 229 patients presumed to have a torn medial meniscus, arthroscopy confi rmed an isolated diagnosis in only 21%. Additional pathology was found in 23%, and a completely different diagnosis was made in 56%. An unsuspected lateral meniscal tear was noted in 5% of the knees diagnosed as having a torn medial meniscus. Only 10% of Johnson’s patients with a torn anterior cruciate ligament had no other identifi able lesion. In 70% of all patients with anterior cruciate ligament tears, an accompanying tear of a meniscus was found. Curran and Woodward studied 396 knee arthroscopies and found that the total clinical accuracy rate was only 71%. Diagnostic arthroscopy increased their accuracy to 97%. Noyes et al. reported some degree of anterior cruciate ligament disruption in 72% of knees undergoing arthroscopy for acute, traumatic hemarthrosis; many of these knees had negative or equivocal stress tests. DeHaven and Gillquist and Hagberg also documented a high frequency of torn anterior cruciate ligaments and other internal derangements in patients with acute traumatic hemarthrosis in whom arthroscopy was done early in the evaluation process. Arthroscopy should be considered a diagnostic aid used in conjunction with a good history, complete physical examination, and appropriate radiographs. It should serve as an adjunct to, not as a replacement for, a thorough clinical evaluation. With increased profi ciency in examination of extremities and more accurate adjuvant tests, including MRI, we rarely perform simple “diagnostic arthroscopy.” Surgical alternatives are discussed thoroughly with the patient before the procedure, and the defi nitive surgical procedure is performed at the time of a thorough arthroscopic examination. The general principles, instrumentation, indications, contraindications, and complications of arthroscopy are discussed in Chapter 47.

Basic Diagnostic Techniques

General Principles Arthroscopy of the knee can be done as a purely diagnostic procedure, as the essential initial step before proceeding to operative arthroscopy, or before an open arthrotomy. Anesthesia can be local, spinal, or general. If the procedure is uncomplicated and of short duration, it can be done using local anesthesia in cooperative patients, especially if the surgeon is experienced in arthroscopy. If local anesthesia is to be used, we prefer intravenous sedation for portal injection with 1% lidocaine and an intraarticular bolus of 30 mL of bupivacaine and 15 mL of lidocaine 20 minutes before starting the procedure. Diagnostic arthroscopy before arthrotomy or major intraarticular surgery generally is best done with the patient under general anesthesia, unless this type of anesthesia is contraindicated. If spinal anesthesia is selected for a long procedure ( > 1 hour) in which a tourniquet is used, discomfort from the tourniquet can be a problem; especially early in one’s experience, general anesthesia probably is best, unless it is specifi cally contraindicated. The procedure is performed in the operating room under strict sterile conditions. The seriousness of this surgical procedure must not be minimized. Although complications such as infection are infrequent ( < 1%), carelessness in surgical scrubbing, preparation, or draping or careless handling of the irrigating solutions, arthroscopes, and instruments can result in intraarticular infections just as devastating as those after arthrotomy. Sterilization of arthroscopy equipment and waterproof arthroscopy gowns and drapes are essential. Sealing the extremity proximal and distal to the arthroscopy site and use of a durable skin preparation (DuraPrep) and iodine-impregnated drape at the surgical site can help to minimize infections.

The scrub nurse uses a large table for instruments. This is positioned for the nurse’s convenience, usually on the same side as the knee having surgery. A Mayo stand is placed over the operating table at the upper part of the patient’s thighs, and the more commonly used instruments are placed on it. Power cords and light cables are attached to the appropriate sources and are placed on a side table. Irrigation bags are suspended from an intravenous stand at the head of the table and are raised approximately 4 to 5 feet above the level of the patient. The use of an arthroscopic pump for infl ow through the arthroscope sheath or a separate sheath helps keep fl ow and pressure constant. The pump may eliminate the need for a tourniquet, making arthroscopy using local anesthesia feasible. Advocates also claim that the pumps reduce the volume of irrigant fl uid used because pressure sensors allow only that amount of fl ow that is required to keep the joint distended. A tourniquet is placed around the thigh, but is not infl ated in diagnostic arthroscopy unless troublesome bleeding occurs. Infl ation of the tourniquet blanches the synovium and other vascularized tissue and makes diagnostic evaluation of these structures more diffi cult. Meniscal vascularity and healing potential should be evaluated with the tourniquet defl ated and the intraarticular hydrostatic pressure low. The tourniquet usually is infl ated after exsanguination of the limb in acute traumatic disorders, or if the surgeon anticipates anything other than the simplest intraarticular surgical procedure. Tourniquet time should be minimized and not exceed 90 minutes for routine procedures to prevent possible deep vein thrombosis. For major complicated procedures, tourniquet times of 2 hours can be used, but times longer than this should be avoided to prevent ischemic neurovascular changes. Stressing the knee to open up the various compartments is necessary for diagnostic or operative procedures. This can be accomplished by using an assistant, a padded lateral post, or a commercial leg-holding device (Fig. 48-1). The use of an assistant to stress the joint probably is the least effi cient method because of fatigue and the inconsistent amounts of stress that result, among other factors. The use of a padded lateral post attached to the edge of the operating table can be effective for valgus stressing in or near full extension, but it does not control rotation. The commercial thigh holders are most effective, but some of their potential dangers must be kept in mind. Although the use of a legholding device makes stressing and opening the compartments easier, especially the posterior compartment, these devices do get in the way when one is working through the superior portals in the patellofemoral joint. Also, the potential tourniquet effect of the leg-holding devices must be appreciated. In osteoporotic bone, excessive stress can result in fracture to the rigidly held extremity. We have had no problems with the commercial leg holder and believe that the advantages of being able to control and stress the joint outweigh potential disadvantages. contamination. The patient can be placed supine with the prepared and draped limb angled off the lateral aspect of the table. The use of a leg holder or a lateral post allows the surgeon to stand on the inside of the abducted leg, placing the patient’s foot and ankle on the surgeon’s hip and iliac crest area. Placing the surgeon’s outside foot on a small platform often helps maintain the patient’s foot in the correct position. This position frees both of the surgeon’s hands, and the surgeon can stress the leg into valgus by simply leaning against the leg in the leg holder. This maneuver opens up the medial compartment for examination and probing. When the patient is supine, examination of the lateral compartment requires the assistant to hold the leg in a fi gure-four position. The table-fl at position can be used with the surgeon and assistant standing at the side of the table (Fig. 48-3). The patient also can be placed supine on a standard operating table with the knee joint positioned slightly past the distal break point of the table. The end of the table is dropped so that both limbs dangle at 90 degrees. The opposite limb should be well padded to prevent potential pressure problems. Flexing the middle of the table and placing a padded bolster also fl exes the hips to take the stretch off the femoral nerve and simultaneously fl attens the lumbar spine. The use of a well-leg support for the uninvolved limb is another excellent technique. With either technique, it is recommended to wrap the uninvolved extremity with an elastic wrap or to use an elastic stocking to minimize venostasis (Fig. 48-4).

Portal Placement Among the keys to success in arthroscopy are adequate light and distention of the joint and precise localization of the portals of entry for the arthroscope and accessory instruments. Without adequate illumination, clear vision is

Fig. 48-1 Commercial leg holder that mounts to side rail of standard operating room table. With this particular commercial leg holder, pneumatic tourniquet is placed inside leg-holding device.

Fig. 48-2 Waterproof outer drape with central rubberized opening seals unsterile proximal thigh from operative fi eld.

Patient Positioning When the patient is anesthetized, and a tourniquet and leg holder are applied if desired, the limb from the ankle to the tourniquet is thoroughly scrubbed and surgically prepared, just as for an open arthrotomy. Excellent commercial arthroscopy and draping systems are available that isolate the foot and lower leg and the distal thigh just below the tourniquet and leg holder (Fig. 48-2). Waterproof gowns also are imperative for the surgeon and assistant to prevent

Fig. 48-3 Technique of table-fl at position. Surgeon and assistant stand at side of table.

instrument damage, and other problems. Adequate illumination is ensured by proper care of the arthroscope and fi beroptic light cables, changing the light source bulbs when required, cleansing the arthroscope lens of fi lm from frequent disinfectant soakings, and maintaining a clear irrigation medium. Any damage to the arthroscope tip, whether from motorized instrumentation or careless handling, can result in uneven light regulation and inability to focus the arthroscope properly. Distention is ensured by elevating the irrigation fl uid bag 4 to 5 feet above the patient or using a pump and regulating the outfl ow. Precise entry portal location can be ensured best by carefully drawing the joint lines and soft-tissue and bony landmarks with a skin-marking pen before joint distention. All standard and optional portals are marked. Typically, the outlines of the patella and patellar tendon are drawn, medial and lateral joint lines are palpated with the fi ngertip and drawn, and the posterior contours of the medial and lateral femoral condyles are marked (Fig. 48-5). The surgeon should recheck these outlines after distention to ensure proper placement. When the portals are carefully marked, a small outfl ow, needle-type cannula may be placed superomedially or superolaterally with infl ow through the arthroscope. This generally is necessary for large procedures, such as anterior cruciate ligament reconstruction when hemarthrosis is present. For smaller procedures, such as a meniscectomy, an outfl ow cannula might not always be necessary. Avoiding

A B C

Fig. 48-4 Placement of lateral post and saline bag taped to table allow ease of leg positioning and full range of motion during ligament reconstruction.

Fig. 48-5 Landmarks drawn on knee before distention. A, Anterior view of knee showing standard and optional portal sites and landmarks. Standard portals are anteromedial, anterolateral, and superolateral. Optional portals are transpatellar tendon (central) and midpatellar medial and lateral. B, Medial view of knee showing medial skin portal sites and landmarks. C, Lateral view of knee showing lateral portal sites and landmarks. STC, surgeon’s initials for “sign your site” program to avoid surgery at wrong site. impossible; without adequate distention of the joint, the fat pad, synovium, and other soft tissues obliterate the view; and without precise location of the portals of entry, one would be unable to see adequately or to maneuver within all parts of the joint. Attempts to force a poorly placed arthroscope or instrument can result in articular scuffi ng, going through the vastus medialis obliquus may help to accelerate rehabilitation, as has been shown by Stetson and Templin. In their study, rehabilitation in patients with three portals took approximately twice as long as in patients who had two portals that avoided going through the vastus medialis obliquus. Infl ow through the arthroscope does seem to give the best view with fl uid management being at the site of visualization. In the two-portal system, the outfl ow is managed by the arthroscopic shaver.

Standard Portals The standard portals for diagnostic arthroscopy are the anterolateral, anteromedial, posteromedial, and superolateral.

Anterolateral Portal If allowed only one approach for diagnostic arthroscopy of the knee joint, most arthroscopic surgeons would choose the anterolateral portal. With the use of a 4-mm-diameter, 30-degree oblique forelens arthroscope through the anterolateral portal, almost all of the structures within the knee joint can be seen. Through this portal, the posterior cruciate ligament, the anterior portion of the lateral meniscus, and, in tight knees, the periphery of the posterior horn of the medial meniscus cannot be viewed adequately, however. This portal is located approximately 1 cm above the lateral joint line and approximately 1 cm lateral to the margin of the patellar tendon. Palpation of the inferior pole of the patella helps to ensure that the anterior portals are not placed too high; the portal should be approximately 1 cm inferior to the patella. If the portal is placed too near the joint line, the anterior horn of the lateral meniscus can be lacerated or otherwise damaged. Also, an arthroscope inserted through such a portal can pass either through or beneath the anterior horn of the lateral meniscus, resulting in damage to the anterior horn or diffi culty in maneuvering the arthroscope within the joint because it is bound down by the overlying meniscus. A portal placement too superior to the joint line allows the arthroscope to enter the space between the femoral and tibial condyles and prevents viewing of the posterior horns of the menisci and other posterior structures (Fig. 48-6). An arthroscope placed immediately adjacent to the edge of the patellar tendon can penetrate the fat pad, causing diffi culty in viewing and in maneuvering the arthroscope within the joint.

Anteromedial Portal The anteromedial portal is most commonly used for additional viewing of the lateral compartment and for insertion of a probe for palpation of the medial and lateral compartment structures. This portal is located similarly to the anterolateral portal: 1 cm above the medial joint line, 1 cm inferior to the tip of the patella, and 1 cm medial to the edge of the patellar tendon (see Fig. 48-5A).

Posteromedial Portal The posteromedial portal is located in a small triangular soft spot formed by the posteromedial edge of the femoral condyle and the posteromedial edge of the tibia. Before distention of the joint, this small triangle can be palpated easily with the knee fl exed to 90 degrees. The landmarks shown in Figure 48-5B should be drawn on the skin before beginning the diagnostic arthroscopy. The posteromedial compartment is small, but any arthroscope can be inserted into it with proper care and technique. In this portal, a 30-degree angled arthroscope offers optimal viewing of all the structures in the posteromedial compartment. Three guidelines aid in the establishment of this portal: (1) The knee must be maximally distended with irrigating solution so that the posteromedial compartment balloons out like a bubble when the knee is fl exed to 90 degrees; (2) the knee must be fl exed as close to 90 degrees as possible; and (3) the bony landmarks must be drawn before the joint is distended. The location of the portals should be approximately 1 cm above the posteromedial joint line and approximately 1 cm posterior to the posteromedial margin of the femoral condyle. This portal is useful for repair or removal of displaced posterior horn meniscal tears and for removal of posterior loose bodies that cannot be displaced into the medial compartment and removed through an anterior portal.

A

B

Fig. 48-6 Placement of anterolateral portal. Arthroscope introduced through portal placed high above joint line (A) has advantages of avoiding fat pad and being easy to manipulate. It is diffi cult to reach posterior aspect of joint, however, where most meniscal pathology is located. With low portal placement (B) , posterior access is easier because femoral condyle does not get in way, but instrumentation through fat pad is more diffi cult. Compromise should be made depending on location of intraarticular pathology and tightness of joint. (From Zarins B: Technique of arthroscopic medial meniscectomy, Contemp Orthop 6:19, 1983.)

Superolateral Portal The superolateral portal is most useful diagnostically for viewing the dynamics of the patellofemoral articulation. It also is the best approach for excision of medial plicae. This portal is located just lateral to the quadriceps tendon and about 2.5 cm superior to the superolateral corner of the patella. With the arthroscope in this portal, the patellofemoral joint can be viewed with a 30or 70-degree arthroscope, allowing evaluation of patella tracking, patellar congruity, and lateral overhang of the patella as the knee is carried from extension into varying degrees of fl exion (see Fig. 48-5A).

Optional Portals Posterolateral Portal The knee should be fl exed to 90 degrees, and the joint should be maximally distended. The landmark for the posterolateral portal is at the point where a line drawn along the posterior margin of the femoral shaft intersects a line drawn along the posterior aspect of the fi bula. This is about 2 cm above the posterolateral joint line at the posterior edge of the iliotibial band and the anterior edge of the biceps femoris tendon (see Fig. 48-5C). A 6-mm skin incision is made, and the distended posterior capsule is penetrated using the arthroscope sheath and a sharp trocar. The posterior edge of the femoral condyle is palpated with a trocar, slipping off the posterior condyle parallel to it. Directed slightly inferiorly, the sheath enters the posterolateral compartment. Care must be taken not to damage the articular surface of the posterior femoral condyle with this maneuver. Also, plunging in with a sharp trocar through the capsule and into the popliteal space must be avoided for fear of damaging neurovascular structures. The outfl ow of irrigation solution on removal of the sharp trocar confi rms entry into the joint. This portal is useful for assisting with repair of lateral meniscal tears.

Proximal Midpatellar Medial and Lateral Portals The optional midpatellar portal designations should not be confused with a central transpatellar tendon portal popularized by Gillquist (see later). These optional portals were described by Patel to improve the viewing of the anterior compartment structures, the lateral meniscocapsular structures, and the popliteus tunnel and to minimize accessory instrument crowding with the arthroscope during procedures requiring triangulation of several instruments into these compartments. Viewing of the posterior horns of the menisci and the tibial attachment of the posterior cruciate ligament may be diffi cult through these portals. These portals are located just off the medial and lateral edges of the midpatella at the broadest portion of the patella. The selection of the site is crucial. A site that is too far superior or inferior can jeopardize proper viewing. A 30-degree oblique arthroscope is ideal here. These are our preferred accessory portals for anterior compartment procedures.

Accessory Far Medial and Lateral Portals These inferior optional portals often are used for triangulation of accessory instruments into the knee during operative arthroscopic procedures. They are located approximately 2.5 cm medial or lateral to the standard anteromedial and anterolateral portals (see Fig. 48-5B). Medially, these portals are near the anterior edge of the tibial collateral ligament; laterally, they should be well anterior to the fi bular collateral ligament and popliteus tendon. An excellent technique is to insert a spinal needle through the skin and capsule and into the compartment under direct vision with the arthroscope. The needle should enter the joint above the superior surface of the meniscus, which would allow passage to its desired location. After the needle is directed to the desired location within the joint, the accessory instrument can be passed to this location with ease. If the needle cannot pass to the desired location, its point of entry is adjusted carefully before the portal incision is made. The margin for error is less through these accessory medial and lateral portals; the meniscus or the collateral ligament can be lacerated, or the articular margin of the femoral condyle can be damaged.

Central Transpatellar Tendon (Gillquist) Portal The central transpatellar tendon portal is located approximately 1 cm inferior to the lower pole of the patella in the midline of the joint through the patellar tendon. With the patella in higher or lower locations than normal, or if the patellar tendon is located entirely lateral to the midline of the joint, adjustments in portal location must be made (see Fig. 48-5A). We fi nd this portal most helpful in anterior cruciate ligament reconstruction procedures after graft harvest has been completed, avoiding tendon damage. If a transpatellar tendon portal is necessary for posterior compartment evaluation or anterior compartment triangulation, it is made with the knee in 90 degrees of fl exion to keep the tendon under tension. A 6to 7-mm vertical incision is made sharply with a No. 11 blade through the skin and subcutaneous tissues and the patellar tendon, approximately 1 cm from the inferior pole of the patella. In the case of fi xation of osteochondritis dissecans fragments, in which a more distal portal might be necessary, a spinal needle should be used to localize the portal before making an incision. We do not advocate routine use of this portal because of patellar tendon damage from the incision and instrumentation through the tendon. In certain cases, this portal would allow better instrumentation of an anterior articular joint surface and can complement the standard arthroscopic portals.

Insertion of Scope If the tourniquet is not to be infl ated unless troublesome bleeding occurs, the portal sites should be infi ltrated with

4 to 5 mL of a local anesthetic agent mixed with epinephrine, which reduces bleeding and postoperative pain. The use of more than 4 to 5 mL is not advised because a larger bolus, especially in the anterolateral and anteromedial portals, can distend the fat pads suffi ciently to make viewing diffi cult. If infl ation of the tourniquet is planned, the portals usually are not infi ltrated.

Arthroscopic Examination of the Knee

The key to successful, accurate, and complete diagnosis of lesions within the knee joint is a systematic approach to viewing. A methodical sequence of examination should be developed, progressing from one compartment to another and systematically carrying out this sequence in every knee. The exact sequence is not crucial, but it is important to develop the habit of following it every time. Failure to do so could compromise diagnostic accuracy and completeness. The knee should be divided routinely into the following compartments for arthroscopic examination:

1. Suprapatellar pouch and patellofemoral joint 2. Medial gutter 3. Medial compartment 4. Intercondylar notch 5. Posteromedial compartment 6. Lateral compartment 7. Lateral gutter and posterolateral compartment

The posteromedial compartment can be examined by passing the scope posteriorly through the intercondylar notch or through a separate posteromedial portal. The posterolateral compartment usually can be examined adequately from an anterior portal, but if this compartment is incompletely viewed, a direct posterolateral portal should be chosen.

Suprapatellar Pouch and Patellofemoral Joint With the arthroscope in the distended suprapatellar pouch and the knee in extension, the surgeon systematically examines the synovium, patella, trochlear notch of the femur, synovial plicae, adhesions, and quadriceps tendon. With the oblique forelens of the arthroscope directed superiorly, the undersurface of the quadriceps tendon can be inspected. The synovium usually is quite thin in this area. By rotating the arthroscopic lens alternately to the right and left, the synovium, suprapatellar plicae, adhesions, and other structures within the superior part of the pouch can be seen. The character of the synovial villi, their vascularity, signs of infl ammation, and crystalline deposition can be evaluated. Suprapatellar plicae and mild adhesions rarely are of pathological importance. By sweeping the arthroscope from side to side and by moving it inward and outward, one can focus carefully on the individual structures. By slowly withdrawing the arthroscope with the forelens looking upward, the undersurface of the patella can be examined (Fig. 48-7A). With the suprapatellar pouch maximally distended and the knee in full extension, the arthroscope can sweep across the patellofemoral joint easily. The central ridge and medial and lateral facets of the patella are carefully inspected. Manipulation of the patella, depressing or tilting each edge, allows inspection of its entire articular surface, the condition of which should be noted. Rotating the lens so that it is facing inferiorly allows similar inspection of the surface of the trochlear notch of the femur. The congruity of the patella in the patellofemoral joint and its dynamics in fl exion and extension are best viewed from a superolateral portal. If a superomedial portal has been made for infl ow, the outfl ow can be switched to one of the anterior portals, and the scope can be passed down the previously placed superomedial infl ow cannula. Patellar tracking and congruency also can be evaluated from the anterolateral portal with the scope withdrawn distal to the inferior pole of the patella and turned toward the patella (Fig. 48-7B). The arthroscope is rotated to point toward the medial peripatellar region. In about 40% of knees, a medial synovial plica running slightly medial and distal to the patella can be identifi ed (Fig. 48-7C). This synovial and fi brous band usually originates medially from the side wall of the suprapatellar bursa and inserts into the fat pad distally. It may be responsible for anterior knee pain, popping, and chondromalacic changes on the medial femoral condyle when it is thickened and fi brotic from trauma or chronic synovitis. Occasionally, a large medial plica impedes the sweep of the arthroscope inferiorly toward the medial compartment. If this occurs, the arthroscope must be partially withdrawn so that it is disengaged from the plica.

Medial Gutter With the arthroscope lens facing downward and the horizon of the medial femoral condyle in view, the arthroscope is swept along the medial femoral condyle and down into the anteromedial compartment until the meniscosynovial junction is seen. The lens is rotated to view the posterior extent of the gutter and the medial capsule, allowing the surgeon to look for loose bodies, synovitis, or traumatic disruption of the capsule. Palpation of the posteromedial knee may express previously hidden loose bodies into view. The knee is fl exed to 30 degrees, a valgus stress is applied, and the arthroscope is moved into the anteromedial compartment.

Medial Compartment When the arthroscope has been brought into the anteromedial compartment, the free edge of the medial meniscus orients the viewer (see Fig. 48-7F). The knee is positioned

Popliteal tendon

A

B

I

J

H

G

F

E

D

C

Fig. 48-7 A, Suprapatellar pouch with view of undersurface of articularis genu. B, Tangential view of patellofemoral articulation. C, Normal medial parapatellar plica. D, Posteromedial compartment is seen by passing arthroscope through intercondylar notch after viewing medial compartment. E, Posteromedial compartment is seen through posteromedial portal, which is made after completion of routine examination if complete posteromedial view is unsatisfactory. F, Medial meniscus and medial compartment. G, Cruciate ligaments with fatty synovium covering posterior cruciate ligament. H, View of lateral meniscus and lateral compartment. I, View of posterior horn of lateral meniscus and popliteal tendon through hiatus. J, Posterolateral view of knee with arthroscope in anterolateral portal showing popliteal tendon insertion into femur in popliteal hiatus. in 10 to 30 degrees of fl exion, a valgus stress is applied, and the tibia is externally rotated. For a systematic examination of the medial meniscus, the meniscus is divided into regions—posterior, middle, and anterior thirds. The arthroscope is allowed to slip between the medial femoral condyle and medial tibial plateau articular surfaces. It should be allowed to slide into a space that has been previously opened up by applying stress to the joint. The arthroscope should never be forced between the condyles because severe scuffi ng and gouging may result. The arthroscope should be retracted from between the articular surfaces before releasing any of the stress. If the stress is released fi rst, the sharp edge at the tip of the arthroscope would gouge the articular surface as the arthroscope is retracted. The lens is directed anteriorly to view the anteromedial capsule, while establishing the anteromedial portal. The anteromedial portal is located 1 cm superior to the medial joint line and 1 cm medial to the border of the patellar tendon. Under arthroscopic observation, an 18-gauge spinal needle can be inserted through the planned portal site, and satisfactory position is confi rmed. The spinal needle should be free of the fat pad and safely superior to the medial meniscus. Under arthroscopic observation, the needle can be passed into the medial compartment to ensure that it has the proper location and plane to pass between the medial femoral condyle and tibial plateau. The needle is removed, and a skin incision is made with a No. 11 blade. With the arthroscope, the tip of the knife blade can be observed as the portal is created, protecting the articular cartilage of the medial femoral condyle. A probe is inserted through this portal. With the lens directed posteriorly, the inner free edge of the posterior third of the medial meniscus can be viewed from its intercondylar tibial attachment to the posteromedial corner of the knee (Fig. 48-7D). Only in a lax knee can the posterior meniscosynovial and capsular attachments be viewed from this anterolateral portal. Examination of the meniscus is made easier by inserting a probe through an anteromedial portal. The probe is used to lift, to depress, or to retract the meniscus gently. Frequently, tears through the surface of the meniscus, not noted by simple visual inspection, can be shown by probing. Examination of the meniscus is never complete until the entire meniscus is probed. The instrument should be used gently for this because the meniscus can be torn by too vigorous probing, especially when the tip of the probe is used. The posterior horn of the meniscus should be viewed with the knee fl exed (10 to 30 degrees) and externally rotated and by internally and externally rotating the tibia on the femur. If a small rim of the medial meniscus is seen instead of a meniscus of normal size, the knee may have had a prior medial meniscectomy or a displaced bucket-handle tear of the medial meniscus, with a major portion of meniscus displaced into the intercondylar notch or a meniscal fl ap behind the femoral condyle or rolled under the intact portion of the meniscus. Often a torn, displaced meniscus in the intercondylar notch fi lls the space between the medial femoral condyle and tibial plateau anteriorly, blocking the arthroscope’s access to the medial compartment. Peripheral detachments of the medial meniscus, although not directly viewed, may be suspected if abnormal meniscal movements are present, such as wrinkling. Viewing of the peripheral portion of the posterior third of the medial meniscus and its attachments usually can best be accomplished through a posteromedial portal or with a 70-degree angled arthroscope passed through the intercondylar notch and into the posteromedial compartment (Fig. 48-7E). The arthroscope should be withdrawn slightly and the lens rotated directly medially to view the middle third of the medial meniscus. The superior and inferior surfaces and the stability of the meniscus should be observed under probing. The meniscosynovial refl ection at the periphery, the synovial covering, and the midmedial capsular and posterior oblique portions of the medial collateral ligament complex (Fig. 48-8) should be evaluated. The peripheral attachment of the middle third of the medial meniscus can be seen clearly. The arthroscope can be moved back into the anteromedial compartment and the lens rotated further anteriorly to examine the anterior horn of the meniscus. The fat pad may obliterate the view of its most anterior portion. Further distention of the knee by closing the irrigation outfl ow may push the fat pad away a few millimeters so that this area can be viewed. If viewing still is impossible, redirecting the arthroscope, inserting a probe through an anteromedial portal to retract the fat pad, resecting a portion of the fat pad, or moving the arthroscope to a midpatellar portal may allow viewing of this area. The articular surfaces of the femoral and tibial condyles should be examined systematically for defects indicating chondromalacia or other abnormalities. Flexing the knee

Torn medial meniscus

A B

Fig. 48-8 A, Grade I medial capsular sprain in patient with torn anterior cruciate ligament. B, Grade II sprain of medial collateral ligament, with some mild laxity of meniscotibial ligament as evidenced by abnormal elevation of meniscus off tibial articular surface when valgus stress is applied. brings greater areas of the femoral condyle into view. Early articular wear on the medial femoral condyle is located slightly posteriorly. This area is brought into view by fl exing the knee 45 to 60 degrees. With the arthroscope lens directed superiorly and laterally, the horizon of the medial femoral condyle can be followed into the intercondylar notch.

Intercondylar Notch The anatomical structures to be examined in the intercondylar notch are the anterior cruciate ligament, ligamentum mucosum, fat pad, posterior cruciate ligament, meniscofemoral ligaments, and intrameniscal ligament. With a cruciate ligament injury, it is crucial to observe the architecture and width of the notch with the knee fl exed 30 degrees (see Fig. 48-7G). An open, inverted U –shaped notch may increase the risk of disruption of the anterior cruciate ligament. As the arthroscope follows the horizon of the medial femoral condyle into the intercondylar notch and superiorly to the top of the intercondylar notch, the femoral origin of the ligamentum mucosum is seen. The ligamentum mucosum runs from the superior intercondylar notch down to the fat pad. It may be a thin, narrow band of synovium or a complete septum dividing the medial and lateral compartments. Diffi culty in passing the arthroscope from the lateral to the medial compartment and vice versa may be caused by an enlarged ligamentum mucosum or a complete septum. More commonly, the cause is a narrow synovial membrane superior and anterior to the anterior cruciate ligament. The cruciate ligaments within the intercondylar notch are best viewed with the knee fl exed 45 to 90 degrees. The femoral insertion of the posterior cruciate ligament should be inspected; it usually is covered by synovial tissue. Occasionally, the fi bers of the posterior cruciate ligament can be viewed and probed; hemorrhage or tearing of this synovial covering can be observed in posterior cruciate ligament avulsions. The anterior cruciate ligament is the most imposing structure in the intercondylar notch (see Fig. 48-7G). The tibial insertion and most of the ligament can be viewed adequately from this anterolateral portal. Viewing and exploration of the femoral attachment of the anterior cruciate ligament can be done best with the arthroscope through an anteromedial portal. The appearance of the anterior cruciate ligament varies from patient to patient, depending on its anatomy, the presence or absence of injury, and the synovial covering. Occasionally, the various anatomical bands of the anterior cruciate ligament appear as distinct bundles. In a normal anterior cruciate ligament, the synovial covering usually is thin, with small capillaries coursing on the surface that are obvious with close examination. If considerable synovitis is present, retraction of the ligamentum mucosum and other synovial tissues may be required to observe the underlying anterior cruciate ligament. With complete rupture of the anterior cruciate ligament, considerable hemorrhage within the synovial tissues is evident (Fig. 489A). If the synovial covering also has been ruptured, the collagen bundles of the anterior cruciate ligament are apparent as white “mop end” structures. In other instances, the synovial covering may be intact but hemorrhagic. Careful probing and opening of the synovial sheath often show disrupted anterior cruciate ligament bundles not evident during initial inspection. Probing the anterior cruciate ligament, opening its synovial sheath, and checking its tension with the probe are just as important as probing the menisci. A normal anterior cruciate ligament feels taut or “hard” when hooked with a probing instrument. A torn anterior cruciate ligament feels mushy, without tension.

A B

C D

E F

Torn lateral meniscus

Débridement of torn meniscus

Fig. 48-9 A, Complete tear of anterior cruciate ligament. B, Horizontal tear of degenerative lateral meniscus. C, Oblique tear of posterior horn of lateral meniscus. D, Incomplete radial tear of lateral meniscus. E, Degenerative tear of lateral meniscus. F, Resection of tear of lateral meniscus. Remaining tissue shows fatty degeneration.

The assistant can perform a drawer or a Lachman test while the anterior cruciate ligament is directly viewed. If torn, the ligament can be seen to provide no functional stability to anteroposterior translation of the tibia on the femur. Likewise, the posterior cruciate ligament should be examined and probed to confi rm integrity.

Posteromedial Compartment The posteromedial compartment can be viewed either through a posteromedial portal, as described previously, or with a 30or 70-degree oblique arthroscope passed through the intercondylar notch from the anterolateral or transpatellar tendon portal. Use of a 30-degree oblique arthroscope is optimal if viewing is done through a posteromedial portal. Structures examined from these approaches are the peripheral attachment of the posterior horn of the medial meniscus, the posterior meniscus synovial refl ection, the distal half of the posterior cruciate ligament, the posterior femoral condyle, and the confi nes of the posteromedial capsular and synovial compartment, to which free loose bodies and meniscal fragments tend to gravitate. When this compartment is viewed through an anterior portal through the intercondylar notch, the arthroscope passes between the posterior cruciate ligament and the medial femoral condyle (see Fig. 48-7D). This passage usually requires a slight degree of knee fl exion and valgus stress. When viewed through an anterior portal, the posterior cruciate ligament and posterior horn of the medial meniscus can be probed by inserting the probing instrument through a posteromedial accessory portal. If a 70-degree arthroscope is placed through the intercondylar notch, the leg can be positioned so that there is a slight hip fl exion, external rotation, and abduction and knee fl exion, to allow the posteromedial compartment to billow out. An accessory posteromedial instrumentation portal can be established under direct vision if necessary. A spinal needle can be inserted under direct vision to locate the optimal portal site accurately. Alternatively, a 30-degree arthroscope can be introduced through a posteromedial portal for viewing the posteromedial compartment (see Fig. 48-7E). With the knee placed in a fl exed, abducted, externally rotated position, the posteromedial compartment is maximally distended. An 18-gauge spinal needle can be used to identify the soft spot safely. The location of the portal should be about 1 cm above the posteromedial joint line and at the posteromedial margin of the femoral condyle. To protect the nearby saphenous vein, only the skin should be incised. A sheath and sharp trocar are passed through the skin and subcutaneous tissue down onto the posterior aspect of the medial femoral condyle. The sharp tip of the trocar should be used to engage the capsule, then the trocar is slid posteriorly off the condyle, and the capsule is penetrated. Without engaging a portion of the capsule with the tip of the trocar, the trocar can sometimes glance off the capsule posteriorly instead of penetrating it. Excessive pressure should not be applied against the posteromedial femoral condyle as the trocar is introduced because this could gouge the articular cartilage. Removal of the trocar from the sheath results in escape of irrigating solution when the sheath is in the proper position. The arthroscope is introduced, and after the camera has been righted, the lens should be turned anteriorly to face the posterior aspect of the medial femoral condyle. This is the landmark that orients the surgeon. When this is identifi ed, the lens can be turned inferiorly to view the meniscocapsular junction of the posterior third of the medial meniscus. In the depths of the posteromedial compartment, the posterior cruciate ligament can be seen. A probe can be inserted through the anterolateral portal and passed between the posterior cruciate ligament and the medial femoral condyle to enter the posteromedial compartment. The probe can be used to probe the posterior third of the medial meniscus and the posterior cruciate ligament.

Lateral Compartment The lateral compartment of the knee can be viewed with the arthroscope through the anterolateral or anteromedial portal. The knee is placed in a fi gure-four position by fl exing and abducting the hip, fl exing the knee, and resting the heel and foot on the opposite leg. The leg holder encircling the thigh makes achieving this position more diffi cult, but usually the thigh and hip externally rotate enough to allow it. Downward pressure by an assistant on the thigh just above the knee results in a varus and internal rotational opening of the lateral compartment. If a constricting leg holder is being used, the alternative to the fi gure-four position is placing stress on the slightly fl exed knee to achieve a varus position with internal rotation of the tibia. When the anterolateral portal is being used, the arthroscope’s entrance into the lateral compartment is immediately over the anterior horn of the lateral meniscus adjacent to the intercondylar notch. The arthroscope is introduced through this “doorway” and swept laterally into the lateral compartment. A probe can be introduced into the anteromedial portal. Occasionally, using this confi guration, probing the posterior third of the lateral meniscus is diffi cult. In this situation, a prominent intercondylar eminence forces the probe superiorly over the lateral meniscus and does not allow it to be directed inferiorly. The anterior and middle thirds of the lateral meniscus usually are not a problem. If this diffi culty in probing is encountered, the arthroscope can be switched to the anteromedial portal, and the probe can be placed in the anterolateral portal. Usually, the entire lateral compartment and lateral meniscus can be examined with the arthroscope in the anteromedial portal. As the arthroscope is passed posterior to the fat pad and beneath the ligamentum mucosum, diffi culty occasionally is encountered entering the lateral compartment from this anteromedial portal because of the presence of the intercondylar attachment of the anterior horn of the lateral meniscus. Because the lateral meniscus has a more circular orientation than the medial meniscus, the anterior horn comes well posterior into the intercondylar notch, and the arthroscope directed from an anteromedial portal must pass over this portion of the anterior third of the meniscus before it enters the lateral compartment. A displaced bucket-handle tear of the lateral meniscus incarcerated within the intercondylar notch also can make it diffi cult to enter the anterolateral compartment. Whether the anteromedial or anterolateral portal is used for the arthroscope, the obliquely angled forelens is directed posteriorly, and the posterior third of the lateral meniscus is examined fi rst (see Fig. 48-7H). Dividing the lateral meniscus into regions or thirds and systematically examining each third ensures complete examination. With the leg in the fi gure-four position, the entire posterior third of the lateral meniscus usually can be viewed. The lateral meniscus tends to ride up off the lateral tibial condylar surface, and the inferior surface and the superior surface of the meniscus can be viewed and probed. The intercondylar attachment of the posterior horn of the lateral meniscus is located much further anteriorly than its medial meniscal counterpart. The meniscosynovial attachment of the posterior horn of the lateral meniscus should be carefully probed to detect any posterior peripheral tears. At the posterolateral corner of the lateral compartment, the obliquely coursing popliteus tendon can be easily seen (see Fig. 48-7I). By lifting up the meniscus with the probe, the continuation of the popliteus tendon inferiorly toward the back of the tibia can be seen for a short distance. The tendon usually comes into view when the angled forelens is rotated slightly to a more lateral position. The popliteus tendon usually appears as a brighter whitish color than the meniscus, which is a more whitish yellow color. The hiatus in the coronary ligament attachment between the edge of the meniscus and capsule should not be confused with a peripheral tear in the meniscus. Careful probing of the anterior and posterior ligaments of the hiatal opening, superior and inferior to the meniscus, shows a smooth synovial refl ection, which, on closer inspection, can be differentiated from the more ragged tear in the coronary ligament attachment of the lateral meniscus. This opening for the popliteus tendon frequently hides small loose bodies. As the lens of the arthroscope is rotated to look laterally, and the arthroscope is slowly retracted, the middle third of the meniscus can be viewed and probed. Further rotation of the obliquely angled forelens to view anteriorly provides a good view of the anterior horn of the meniscus with the scope in either portal. Sometimes the anterior horn of the lateral meniscus is diffi cult to view with the arthroscope in the anterolateral portal, and simply moving the arthroscope to the anteromedial portal can remedy this problem.

Occasionally, a hypertrophic, edematous fat pad can block the view of the most anteromedial attachment of the anterior horn of the lateral meniscus, and this may be managed by releasing the ligamentum mucosum and partially resecting the fat pad as necessary. The articular surfaces of the femoral and tibial condyles should be examined visually and probed for chondromalacia and other changes. After examination of the lateral compartment, attention should be turned to the lateral gutter. The knee is brought out of the fi gure-four position, and a slight valgus stress is applied to relax the soft tissues on the lateral aspect of the knee. The arthroscope is swept laterally into the space created. The popliteus tendon can be seen entering its hiatus (see Fig. 48-7J). The popliteal hiatus should be palpated to see if any hidden loose bodies are delivered. Sweeping superiorly in the lateral gutter brings the arthroscope back up into the suprapatellar pouch.

Lateral Gutter and Posterolateral Compartment Structures viewed in the posterolateral compartment are the posterior horn of the lateral meniscus, the meniscosynovial capsular refl ection, the popliteus tendon, the posterior limits of the popliteal hiatus, the confi nes of the posterolateral synovial and capsular compartments, and the posterior articular surface of the lateral femoral condyle. An excellent view of the lateral gutter and posterolateral structures can be obtained by placing the 30-degree arthroscope through the anterior internal portal. The knee is fl exed 30 degrees, and valgus stress is applied. The arthroscope lens is turned to view the lateral condyle and meniscosynovial junction as the scope is advanced posteriorly. When the popliteal hiatus is seen, the knee is carefully fl exed to 70 degrees, while maintaining valgus stress, providing an excellent view of the popliteal tendon and its femoral insertion. Some natural laxity to the lateral compartment usually allows passage of the arthroscope through the intercondylar notch and into the posterolateral compartment. Occasionally, the arthroscope can be passed from the anterolateral portal, but usually passage must come from the anteromedial or transpatellar tendon portal. The arthroscope passes between the anterior cruciate ligament and the lateral femoral condyle. From these anterior portals, a 70-degree oblique arthroscope may provide better viewing. As with an accessory posteromedial portal, establishment of an accessory posterolateral portal can be done under arthroscopic guidance. The knee should be fl exed to 90 degrees, and the joint should be maximally distended. An 18-gauge spinal needle can be used to identify the appropriate position fi rst. The portal is located about 2 cm above the posterolateral joint line at the posterior edge of the iliotibial band and the anterior edge of the biceps femoris tendon. A probe or operating instrument can be introduced as needed. If the arthroscope is placed through the posterolateral portal, a 30-degree oblique arthroscope should be used.

The horizon for orientation in the posterolateral compartment is the posterior edge of the lateral femoral condyle. When it is clearly viewed, this horizon is kept in view and followed inferiorly to the capsular and synovial attachments of the posterior horn of the lateral meniscus. Directing the oblique lens of the arthroscope inferiorly and anteriorly allows examination of the posterior limits of the popliteal hiatus and the posterior aspects of the popliteus tendon coursing through the hiatus. Frequently, loose bodies not seen from the standard anterior portals may be located in the posterolateral compartment and the popliteal hiatus.

Arthroscopic Surgery of the Meniscus

Classifi cation of Meniscal Tears Classifi cation of the types of meniscal tears encountered during diagnostic arthroscopy of the knee is essential in planning the subsequent arthroscopic resection or repair. Although numerous classifi cations of meniscal tears exist, the following, proposed by O’Connor, has proved useful. O’Connor classifi ed the patterns of meniscal tears into the following categories: (1) longitudinal tears; (2) horizontal tears; (3) oblique tears; (4) radial tears (Fig. 48-10); and (5) variations, which include fl ap tears, complex tears, and degenerative meniscal tears. Longitudinal tears most commonly occur as a result of trauma to a reasonably normal meniscus. The tear usually is vertically oriented and may extend completely through the thickness of the meniscus or may extend only partially or incompletely through it. The tear is oriented parallel to the edge of the meniscus, and if the tear is complete, a displaceable inner fragment frequently is produced. When the inner fragment displaces over into the intercondylar notch, it commonly is referred to as a bucket-handle tear (Fig. 48-11). If the tear is near the meniscocapsular attachment of the meniscus, it commonly is referred to as a peripheral

I

II

IV III

Fig. 48-10 Four basic patterns of meniscal tears: I, longitudinal; II, horizontal; III, oblique; and IV, radial. (Redrawn from Shahriaree H: O’Connor’s textbook of arthroscopic surgery, Philadelphia, 1984, Lippincott.)

Fig. 48-11 Bucket-handle tear, displaced centrally. (Redrawn from Shahriaree H: O’Connor’s textbook of arthroscopic surgery, Philadelphia, 1984, Lippincott.)

0 III II I III II I 0 Medial Lateral

Anterior

Posterior A

B

C D

E

F

Fig. 48-12 Zone classifi cation of meniscus (modifi ed from Cooper et al.). Most anterior zone of medial meniscus is labeled C, whereas most anterior zone of lateral meniscus is labeled D . 0 is meniscosynovial junction; I is outer third, II is middle third, and III is inner third of each meniscus. (Redrawn from Newman AP, Daniels AU, Burks RT: Principles and decision making in meniscal surgery, Arthroscopy 9:33, 1993.) tear. A peripheral vertical tear in zone I, referred to as a red-red tear, and a tear between zone I and II, referred to as a red-white tear, are in the vascularized portion of the meniscus (Fig. 48-12). These peripheral tears should be repaired when feasible. Horizontal tears tend to be more common in older patients, with the horizontal cleavage plane occurring from shear, which divides the superior and inferior surfaces of the meniscus (see Fig. 48-9B). These are more commonly seen in the posterior half of the medial meniscus or the midsegment of the lateral meniscus. Many fl ap tears and complex tears begin with a horizontal cleavage component.

Oblique tears are full-thickness tears running obliquely from the inner edge of the meniscus out into the body of the meniscus. If the base of the tear is posterior, it is referred to as a posterior oblique tear (see Fig. 48-9C); the base of an anterior oblique tear is in the anterior horn of the meniscus (Fig. 48-13). Radial tears, similar to oblique tears, are vertically oriented, extending from the inner edge of the meniscus toward its periphery, and can be complete or incomplete (see Fig. 48-9D), depending on the extent of involvement. These probably are similar in pathogenesis to oblique tears (Fig. 48-14). The possible variations include fl ap tears, complex tears, and degenerative meniscal tears. Flap tears are similar to oblique tears, but usually have a horizontal cleavage element, rather than being purely vertical in orientation. Tears containing a horizontal element often are referred to as superior or inferior fl ap tears, depending on where the fl ap is based on the surface of the meniscus. Complex tears may contain elements of all of the abovementioned types of tears and are more common in chronic meniscal lesions or in older degenerative menisci. These generally are caused by chronic, long-standing, altered mechanics of the meniscus, and the initial tear occurring in the meniscus may not be identifi able after several different planes of tearing have resulted. Degenerative tears often refer to complex tears. These present with marked irregularity and complex tearing within the meniscus (see Fig. 48-9E and F). These are most often seen in older patients.

Types of Meniscal Excisions O’Connor separated meniscal excisions into three categories depending on the amount of meniscal tissue to be removed (Fig. 48-15).

A

B

Fig. 48-13 A, Posterior oblique tear. B, Anterior oblique tear. (Redrawn from Shahriaree H: O’Connor’s textbook of arthroscopic surgery, Philadelphia, 1984, Lippincott.)

C

B

A

Fig. 48-14 Radial tears. A, Incomplete radial tear involves part of width of meniscus. B, Complete radial tear extends to periphery. C, Incomplete tear extending posteriorly or anteriorly is called “parrot beak” tear. (Redrawn from Shahriaree H: O’Connor’s textbook of arthroscopic surgery, Philadelphia, 1984, Lippincott.)

B

A

C

Fig. 48-15 Types of meniscal excision. A, Partial meniscectomy. B, Subtotal meniscectomy. C, Total meniscectomy. (Redrawn from Shahriaree H: O’Connor’s textbook of arthroscopic surgery, Philadelphia, 1984, Lippincott.)

Partial Meniscectomy In this type of meniscal excision, only the loose, unstable meniscal fragments are excised, such as the displaceable inner edge in bucket-handle tears, the fl aps in fl ap tears, or the fl aps in oblique tears. In partial meniscectomies, a stable and balanced peripheral rim of healthy meniscal tissue is preserved.

Subtotal Meniscectomy In this type of meniscectomy, the type and extent of the tear require excision of a portion of the peripheral rim of the meniscus. This is most commonly required in complex or degenerative tears of the posterior horn of either meniscus. Resection of the involved portion by necessity extends out to and includes the peripheral rim of the meniscus. It is termed subtotal because in most cases most of the anterior horn and a portion of the middle third of the meniscus are not resected.

Total Meniscectomy Total removal of the meniscus is required when it is detached from its peripheral meniscosynovial attachment, and intrameniscal damage and tears are extensive. If the body of the peripherally detached meniscus is salvageable, total meniscectomy is not warranted, and meniscal suture should be considered.

General Principles Partial meniscectomy is always preferable to subtotal or total meniscectomy. Leaving an intact, balanced, peripheral rim of meniscus aids in the stability of the joint and protects the articular surfaces by its load-bearing functions. Total meniscectomy removes all of the actual load-bearing protection and reduces stability of the joint, especially if a concomitant ligamentous relaxation already exists. Partial meniscectomy, although desirable, is not always possible if the tear extends to the periphery of the meniscus. In such cases, subtotal excision is preferable to complete excision, even though the contoured anterior meniscal tissue left may be subject to subsequent tears or degeneration. To determine accurately the type of meniscectomy required, the meniscal lesion must be carefully probed and classifi ed. Failure to classify, probe, and explore accurately and thoroughly the extent and various planes of the tear before proceeding with the meniscal resection often results in needlessly sacrifi cing healthy meniscal tissue. When the meniscal tear has been probed and classifi ed, the surgeon should mentally formulate the methods and steps required to excise the necessary portion of the meniscus. The surgeon should be able to visualize the tissues to be removed and the subsequent contour of the peripheral meniscal rim. The objective is to remove the torn, mobile meniscal fragment and contour the peripheral rim, leaving a balanced, stable rim of meniscal tissue. Excision of the pathological tissue can be done either with en bloc resection of the mobile fragment or by morcellization of the fragments and subsequent removal. Sharp excision of the major mobile fragments usually is preferable to morcellization to minimize the potential debris within the joint. When the tear has been removed, the remaining peripheral rim must be carefully probed to ensure that there are no additional tears and that the rim is balanced and stable. When a contoured, balanced, stable peripheral rim is present, the joint should be thoroughly lavaged and suctioned to remove any small meniscal fragments or debris that may have dropped into the joint as a result of the resection.

Surgery for Specifi c Meniscal Tears As discussed earlier, tears of the menisci can be (1) longitudinal, either intrameniscal or peripheral, complete or incomplete, displaced (bucket-handle) or nondisplaced;

(2) horizontal; (3) oblique; (4) radial; (5) fl ap; (6) complex; or (7) degenerative. No standard technique can be used in every case. The following techniques are useful in dealing with each of these types of tears through the anteroinferior portals. Even partial meniscectomy has been shown to increase joint wear; reasonable judgment must be used in planning meniscal surgery to preserve functional meniscal tissue. Planning begins in the preoperative period, ensuring the patient is fully informed as to the possibility of a partial meniscectomy versus meniscal repair and the postoperative course involved with each. Also, having the appropriate equipment and a thorough understanding of the incision and repair techniques are imperative. As a whole, tears of the lateral meniscus are less common than tears of the medial meniscus. The radial tear confi guration is almost unique to the lateral meniscus, occurring rarely in the medial meniscus. Also, the occasional discoid meniscus rarely is encountered in the medial compartment. Most lateral meniscal excisions or repairs are done with the knee in the fi gure-four position (Fig. 48-16), that is, with the hip slightly fl exed, abducted, and externally rotated; the knee fl exed at 30 to 90 degrees; and the tibia internally rotated. This position can be achieved with the foot of the table extended or fl exed. With the end of the table extended, the ankle is placed on the table surface or on the opposite lower leg. In this position, the hip falls into external rotation, and a varus stress can be applied by pushing downward on the fl exed knee. The fi gure-four position also can reduce overall joint distention by collapsing the suprapatellar pouch, making viewing and the use of suction and motorized cutters and trimmers in the lateral compartment more diffi cult. Infl ow through the arthroscopic sheath allows for best visualization.

Fig. 48-16 Figure-four position, used to apply varus force to fl exed knee to widen lateral compartment.

Vertical Longitudinal (Bucket-Handle) Tears This common tear usually occurs in young patients as a result of signifi cant trauma. It frequently is associated with an anterior cruciate ligament injury, and the medial side is more commonly involved than the lateral side (approximately 3:1). Long tears that extend at least two thirds of the circumference of the meniscus produce an unstable fragment that locks into the joint by displacing in toward the notch (Fig. 48-17). The patient typically has episodes of locking in which the knee can be neither fully extended nor fl exed. The fragment may displace and reduce with an audible and palpable clunk. There is associated pain and effusion. Occasionally, the bucket-handle fragment permanently displaces into the intercondylar notch. In these situations, the patient is gradually able to resume most activities, but knows that something is wrong with the knee. The fragment may become distorted and fi xed in place. Other bucket-handle tears divide in their central portion, creating two separate fl aps, one based anteriorly and the other posteriorly. A patient with a suspected bucket-handle tear who may be a candidate for meniscal repair should have this possibility discussed before arthroscopy. The most common criteria for meniscal repair include (1) a vertical longitudinal tear more than 1 cm in length located within the vascular zone, (2) a tear that is unstable and displaceable into the joint (Fig. 48-18A), (3) an informed and cooperative patient who is active and younger than 40 years old, (4) a knee that either is stable or would be stabilized with a ligamentous reconstruction simultaneously, and (5) a bucket-handle portion and remaining meniscal rim that are in good condition. Chronically deformed or degenerative menisci are not good candidates for repair. Rubman, Noyes, and Barber-Westin evaluated 198 surgical repairs, a major portion of which were in the avascular region. At 18month follow-up, 80% were asymptomatic, and 20% had repeat surgery. Of the 91 repairs that were reevaluated

A B

Bucket handle tear

A B C

Fig. 48-17 A, Bucket-handle tear of medial meniscus that has fl ipped into intercondylar notch; in this position, meniscus may cause intermittent symptoms. B, Locked buckethandle tear of medial meniscus. arthroscopically, 25% were healed, 38% were partially healed, and 36% had failed. Most investigators report that only 10% to 15% of meniscal tears are reparable, and that most such repairs are done in association with an anterior cruciate ligament reconstruction. Bucket-handle tears that are not reparable can be treated with partial meniscectomy. Early reports suggest that preserving a meniscal rim eventually would lead to better long-term results, particularly in stable joints with a normal weight bearing axis. Schimmer et al. reported 92% goodto-excellent results at 4-year follow-up and 78% at 12-year follow-up after arthroscopic partial meniscectomy in 119 patients. Articular cartilage damage was the main determinant of long-term function. Sixty-two percent of patients had good-to-excellent results if chondral damage was present; 95% had good-to-excellent results if normal articular cartilage was present at the time of arthroscopic surgery. Partially displaceable tears usually are shorter and confi ned to the posterior half of the meniscus. Often, these

Fig. 48-18 A, Unstable 2-cm peripheral tear of meniscus. Meniscus is being repaired with stacked vertical mattress suture. B, Incomplete undersurface tear of medial meniscus; this can be treated with abrasion to stimulate local healing followed by placement of one or two sutures. C, Complete 2-cm tear in avascular zone of meniscus; this type of tear generally is treated with excision, but if repair is attempted, use of fi brin clot and other local stimuli should be considered. shorter tears are located peripherally and can be repaired. Tears that are less than 5 to 7 mm in length and stable to probing during which the tear does not displace more than 1 mm can have the edges and perimeniscal synovium freshened with a meniscal rasp. Talley and Grana noted a 21% failure rate at short-term follow-up of 19 patients with stable partial-thickness medial meniscal tears that were treated with perimeniscal rasping. For lateral tears, 4% failed. These authors recommended repair of partial-thickness medial tears. We also believe that an aggressive treatment approach should be used for medial meniscal tears. When the decision has been made to perform a partial meniscectomy, the choice must be made as to whether to use a two-portal or three-portal technique. If the meniscal fragment has displaced into the notch, it should be reduced using either a probe or a blunt trocar. If the meniscal fragment is large or chronic, the medial compartment may have to be opened with fl exion and a valgus stress to permit reduction of the fragment. The technique for resecting a displaced bucket-handle tear and the technique for resecting a nondisplaced, short, vertical, longitudinal tear are essentially the same. In each situation, a probe should be introduced, and the tear should be examined with the probe to determine the anterior and posterior extents. The probe also can be used to plan the subsequent cuts. This examination usually is most easily conducted with the arthroscope in the anterior portal contralateral to the tear and the probe in the ipsilateral portal.

Resection of Bucket-Handle Tear TECHNIQUE 48-1

• For reduction of the meniscal fragment, use a probe or a blunt trocar to reduce the fragment to its normal position.

• Begin the technique (Fig. 48-19A) with partial division of the posterior attachment of the meniscal fragment. This can be done with basket forceps, scissors, or an arthroscopic knife. Attempt to cut almost completely through the posterior attachment of the mobile fragment at its junction with the remaining normal meniscal rim (Fig. 48-19B). This cut should not be done blindly to prevent harm to the normal meniscus or articular cartilage or both. Exposure can be aided by passing the arthroscope through the intercondylar notch to look down onto the posterior horn of the meniscus while cutting, or a posteromedial portal can be made if necessary to look directly down onto the meniscus for visualization or to pass through the posterior compartment for cutting of the meniscus.

• Leave a small tag of meniscal tissue intact posteriorly to prevent the meniscus from fl oating freely in the posterior compartment after anterior release.

• Divide the anterior horn attachment with angled scissors, basket forceps, or an arthroscopic knife. Make the release of the anterior attachment fl ush with the intact anterior rim so that no stump or “dog ear” remains (Fig. 48-19C). If the approach is diffi cult from the ipsilateral portal, changing portal sites and approaching from the contralateral portal with the operating instrument often facilitates making this cut. Rarely, a midpatellar portal is necessary so that both anterior portals can be used for instrumentation.

• Use a hemostat to dilate the capsular incision before attempting meniscal removal.

• Insert a grasping clamp through the ipsilateral portal, and grasp the meniscal fragment as close to its remaining posterior attachment as possible. Keep the meniscal fragment in view, and twist and rotate the grasping forceps at least two revolutions while applying traction to avulse the small bridge previously created.

• If the meniscal fragment does not come loose as planned, use a grasper through the lateral portal for traction on the meniscus, and pass arthroscopic scissors through the same portal to complete the resection posteriorly. If it is still diffi cult with this technique, make an accessory portal, 1 cm from the anterior portal using the spinal needle. The other option is to make an accessory midpatellar portal for the arthroscope and use the two anterior portals for instrumentation.

• Observe the fragment as it exits the joint to ensure complete removal (Fig. 48-19D).

• Occasionally, the fragment is so large that it lodges within the subcutaneous tissues. In these circumstances, the skin incision may have to be enlarged to deliver the fragment. Additional longitudinal tears can be treated as previously described.

• If there are no further tears, use a motorized meniscal shaver to smooth the remaining rim.

• Before the procedure is completed, examine the posterior compartment with either a 30or 70-degree arthroscope inserted through the intercondylar notch or a 30-degree oblique arthroscope inserted through the corresponding posterior portal.

Longitudinal Incomplete Intrameniscal Tears Longitudinal incomplete intrameniscal tears may extend from the superior surface into the body of the meniscus or may enter from the inferior surface. These often are extremely diffi cult to view and treat. This type of tear is commonly located in the posterior horn of the meniscus and may be only a few millimeters long. By the time such a tear extends more than 1 or 2 cm, it usually becomes complete and often displaceable. Usually a signifi cant amount of stress must be applied to the knee to open up the appropriate compartment to view small tears. The fi rst sign of such a tear may be a wrinkled or buckled inner meniscal border. If the incomplete tear begins from the superior surface, the probe tip passes into it, but not through to the inferior surface. Inferior incomplete tears are even more diffi cult to view and explore, especially in a tight knee. The tip of the

A B

C D

Fig. 48-19 Two-portal technique for bucket-handle tears of lateral meniscus. A, Displaced bucket-handle tear of lateral meniscus probed. B, After reduction of displaced bucket-handle tear, posterior attachment is partially released with scissors. C, Anterior attachment is released with scissors. D, Tenuous remaining posterior attachment is avulsed with grasper and extracted. probe passes into the inferior tear, but not through to the superior surface of the meniscus. Vigorous attempts to hook the probe into an unseen inferior tear should be avoided for danger of extending the tear. If such a tear exists, gentle probing can make the inner border of the meniscus buckle and evert (see Fig. 48-18B). Stable peripheral one-third tears in relatively healthy menisci should be treated by abrasion of the tear site and meniscal synovial tissue to stimulate healing, preserving meniscal function. If stability is in question, suturing may be indicated for most medial meniscal tears (see “Arthroscopic Surgery of the Meniscus” earlier).

🔪 Surgical Technique 48-2

• Use a 15-degree upbiting low-profi le basket to make removal of a posterior horn tear easier.

• Carry the resection out through the ipsilateral portal, trimming back to a stable contoured peripheral rim (Fig. 48-20).

Horizontal, Oblique, Radial, and Complex Tears In evaluating horizontal, oblique, radial, and complex tears, it is imperative to evaluate and remove only damaged tissue, while maintaining functional, healthy meniscal tissue.

21). Complete radial tears that go to the meniscosynovial junction are diffi cult problems. Some authors believe that horizontal mattress repair of the peripheral portion of the meniscus is indicated because resection would result in loss of the functional protective mechanism of the meniscus. This is discussed further in the section on meniscal repairs.

A B C

Fig. 48-20 Technique for longitudinal incomplete intrameniscal tears. A, Probing longitudinal intrameniscal incomplete inferior surface tear. B, Fragment is removed bit by bit with basket forceps. C, Rim is smoothed and contoured with motorized trimmer.

With horizontal tears of long-term duration, a meniscal cyst may be present. This generally is evident on preoperative MRI and should be looked for during the arthroscopic examination. In most instances, the superior and the inferior leaves are resected back to relatively normal stable tissue. The cleft should be probed, and if there is a meniscal cyst present, a small curved curet may be placed through the cleft aimed toward the surgeon’s fi nger on the exterior extent of the meniscal cyst. This can be opened with a small curet, and the cyst can be drained into the knee. A shaver or suction without running the shaver also can be used to open and decompress the cyst. Localization also can be aided with the use of a spinal needle placed exteriorly to enter the cyst. When evaluating fl ap tears, one must probe the meniscus in the tear site carefully. Often a fl ap can be rolled up under the normal portion of the meniscus, and its size and contour are not apparent. Likewise, the fl ap can be posterior to the femoral condyle, and careful examination of the posterior compartments is necessary to evaluate these meniscal tears fully. Resection in the case of a fl ap tear or a complex tear generally is accomplished with a basket forceps to morcellize the tear, and careful probing is done to ensure that the meniscal tissue remaining is of relatively normal contour with a smooth transition at its edges. Radial tears can be divided into partial and complete. A partial-depth tear of the meniscus is treated with saucerization, balancing, and contouring of the edges (Fig. 48-

🔪 Surgical Technique 48-3

• Examine the tear through the contralateral portal, and probe it through the ipsilateral portal.

• Evaluate the extent of the tear.

• Use basket forceps or scissors to resect the torn and degenerative portion of the meniscus.

• Probe the stable meniscal rim to ensure there is no additional fl ap that is inverted under the meniscus or inverted behind the condyle. Horizontal-type tears should be resected back to a stable rim.

• If a meniscal cyst has been noted on MRI before surgery, open this area with a small curved curet passed from the contralateral portal, dilate the opening, and decompress the cyst. Localization can be accomplished with a spinal needle.

• Contour the meniscal fragment with a shaver after resection, and remove small morcellized meniscal fragments.

A B C

Fig. 48-21 Balancing meniscal resection. A, With radial tear. B, With longitudinal tear. C, With fl ap tear. (Redrawn from Newman AP, Daniels AU, Burks RT: Principles and decision making in meniscal surgery, Arthroscopy 9:33, 1993.)

Discoid Lateral Meniscus Most discoid menisci are lateral; compared with other meniscal pathological entities, discoid lateral meniscus is exceedingly rare. In a cadaver study, Casscells estimated the incidence to be 5%. In a review of more than 7000 knee arthroscopies, Albertsson and Gillquist reported a 0.4% incidence of discoid lateral meniscus with no Wrisberg types. Neuschwander et al. reported a 0.8% incidence of discoid meniscus with a 0.2% incidence of the Wrisberg variant. Bilateral discoid menisci generally are reported in less than 10% of patients. Discoid medial meniscus is reported to be present in less than 0.3% of knee arthroscopies. A discoid lateral meniscus may be discovered during a systematic examination of the knee in which another abnormality may be producing symptoms. The abnormality accounting for the symptoms should be appropriately corrected, and the discoid lateral meniscus should be left intact unless torn or degenerative. Careful evaluation of the superior and the inferior surfaces of the meniscus is necessary to rule out a meniscal tear. The most common method of classifi cation of discoid lateral meniscus is that of Wantanabe et al., who described three types—complete or incomplete, based on the degree of coverage of the lateral tibial plateau, and the Wrisberg variant with absent or abnormal posterior meniscal tibial attachment. The current recommended treatment of a discoid lateral meniscus is based on this system of classifi cation. Complete and incomplete lesions with tears of the discoid component are partially resected to a stable peripheral rim of lateral meniscus 6 to 8 mm wide. When healthy meniscal tissue is present, repair of the Wrisberg-type lateral meniscus is performed as advocated initially by Rosenberg and later by Neuschwander et al., who published a series of standard-type lateral repairs of Wrisbergtype menisci.

Vandermeer and Cunningham reported a 55% incidence of good and excellent results in 25 knees that had a partial central meniscectomy or “saucerization.” Factors that tended to be associated with an unsatisfactory rating at follow-up included preexisting degenerative changes, female gender, and age older than 20 years. Bellier et al. reported excellent results in 18 of 19 arthroscopic partial meniscectomies, with disappearance of the snapping with knee fl exion. At 10to 15-year follow-up, we found that a signifi cant percentage of patients had lateral joint symptoms after partial central meniscectomy. We try to preserve, contour, balance, and repair healthy meniscal tissue. Smith et al. found similar results in 43 knees. They had 40% fair-to-poor results at 6.5 years after meniscectomy or partial meniscectomy.

Partial Excision of the Discoid Meniscus

The objective of partial excision of the discoid meniscus generally is to remove the central portion, leaving a balanced rim of meniscus about the width of the normal lateral meniscus. The width is dictated, however, by the location and extent of the tear within the meniscus. If the free inner edge of the meniscus is not noted in the systematic diagnostic arthroscopy of the lateral compartment, a discoid lateral meniscus may be responsible. The tibial plateau may be completely covered by the meniscus, and the lateral compartment may appear to be devoid of a lateral meniscus; alternatively, varying portions may be covered. If a discoid meniscus is suspected, careful exploration should be focused more centrally in the lateral compartment or over near the intercondylar eminence for a meniscal edge.

Meniscal Cyst Meniscal cysts may develop from chronic medial or lateral degenerative meniscal tears; they most commonly involve the lateral meniscus. The site of the cyst usually can be differentiated intraarticularly by probing the meniscal tear fragments and opening the horizontal split in the meniscus with a small curved curet and passing it through the meniscal body into the central portion of the cyst. The cyst is curetted, and external digital palpation of the cyst is used to free up the cyst and decompress it into the joint. Suction may be used to remove the contents further. The meniscal fragments are removed and are cleaned up to relatively stable healthy meniscus. Seger and Woods reported seven lateral meniscal cysts treated arthroscopically. All had a meniscal lesion at the time of surgery (fi ve fl ap tears and two radial tears). A partial arthroscopic meniscectomy was performed, and the contents of the cyst were manipulated into the joint in six of the patients. There were no cyst recurrences at an average follow-up of 28 months. Most required complete excision of the meniscus to bleeding peripheral tissue at the location of the cyst. Metcalf also recommended arthroscopic resection of the meniscal tear and noted that the resection usually requires removing most of the meniscus because of the fragmented, multiplaned nature of the tear. If the cyst decompresses during the meniscectomy, no further treatment is needed for the cyst. If the cyst does not spontaneously decompress, it can be percutaneously aspirated and

A B C

🔪 Surgical Technique 48-4

• In young patients with small knees, use a 2.7-mm arthroscope and small joint instruments. In older individuals, use a medial midpatellar portal for the arthroscope and standard anteromedial and lateral portals for instrumentation.

• With direct vision of the meniscus, plan the resection so that a healthy peripheral meniscus of approximately 8 mm in width remains.

• With the knee in a fi gure-four position, use basket forceps to start the central resection of the discoid tissue (Fig. 48-22A and B).

• When the bulk has been resected, place arthroscopic scissors through the anterolateral portal to make a posterior, radially directed cut extending to the outer 8 mm of the meniscal tissue (Fig. 48-22C).

• From a lateral peripatellar portal, place a curved arthroscopic knife into the outer extent of the radial cut. Direct the incision anteriorly in a semicircular manner, preserving a peripheral rim of 6 to 8 mm of tissue. Complete the cut by changing the knife or scissors to the medial portal.

• When the desired amount of meniscal tissue has been removed, and the rim is balanced, the thickness of the inner edge is much greater than that after routine partial meniscus excision.

• Thoroughly lavage and suction the joint.

Fig. 48-22 Technique for discoid lateral meniscus. A, Anterior portion of discoid lateral meniscus is removed with rotary basket forceps. B, Further contouring of anterior rim with 90-degree rotary basket forceps. C, Posterior discoid fragment is removed with basket forceps. does not require open excision. Lopez reported arthroscopic management of 17 cysts of the lateral meniscus. The patients were treated arthroscopically with partial meniscectomy to the peripheral vascular zone, curettage of synovium to stimulate a synovial reaction, and arthroscopic evacuation of the cyst. In all of his patients, a defect in the capsule was noted that communicated with the cyst. Follow-up averaged 22 months, and only one cyst recurred. In a series of 72 patients, Glasgow et al. reported 89% good-toexcellent results with arthroscopic partial meniscectomy and cyst decompression.

Arthroscopic Repair of Torn Menisci Although partial meniscectomy has yielded functionally better results than total meniscectomy, the ultimate outcome for partial meniscectomy remains suboptimal. Lynch et al. studied the long-term results based on the appearance of Fairbanks changes for four types of treatment—total meniscectomy, partial meniscectomy, meniscal repair, and no treatment (stable tears)—in knees that had been treated by anterior cruciate ligament reconstruction and were considered stable. Fairbanks changes after partial and total meniscectomy were seven times more frequent than after meniscal repair. In a retrospective study of 32 knees in 31 patients who had undergone partial lateral meniscectomy in otherwise stable knees, Jaureguito et al. found signifi cant functional deterioration at a mean followup of 8 years. Multiple authors have found that joint deterioration after meniscectomy is accelerated with concomitant conditions of femoral and tibial chondromalacia, grade II or III anterior cruciate ligament instability, or tibiofemoral malalignment at the time of the initial meniscectomy. Partial lateral meniscectomies tend to do worse than partial medial meniscectomies. The lateral meniscus bears approximately 70% of the weight in that compartment, whereas the medial meniscus bears 50% of the weight in the medial compartment. Ikeuchi performed the fi rst arthroscopic meniscal repair in Tokyo in 1979. In the 1970s, DeHaven and others began to perform open meniscal repair through a posterior arthrotomy, usually in conjunction with ligament repairs and reconstructions. In 1980, Henning performed the fi rst arthroscopic meniscal repair in the United States. Since the 1990s, several investigators have reported series of meniscal repairs, documenting the feasibility and success of this procedure. Many of these series have been small and have had short follow-up periods. In addition, the criteria for determining successful healing vary, and the types of tears and associated intraarticular abnormalities and methods of repair have varied. Most investigators estimate that only 10% to 15% of meniscal tears are reparable, and these usually are seen in association with anterior cruciate ligament injuries. Scott, Jolly, and Henning reported the largest series to date, with follow-up on 178 repairs in 167 patients. The results of the repairs were classifi ed as 61.8% healed, 16.9% incompletely healed, and 21.3% not healed. Arthrography was used to determine the healing status of the medial meniscus, and repeat arthroscopy was performed to assess healing of the lateral meniscus. The authors also evaluated 11 factors that might affect the rate of meniscal healing. The only positive correlations with healing were found in patients who had a narrow peripheral meniscal rim (0 to 2 mm) and patients who had a meniscal repair along with a reconstruction of the anterior cruciate ligament. Cannon reported a series of 210 meniscal repairs, 79 of which were associated with anterior cruciate ligament reconstruction. A total of 112 patients had a second-look arthroscopy, and 39 had arthrograms at 6 months. Overall, 72% had healed with a residual cleft of less than 10% of meniscal thickness or had incompletely healed with a cleft of less than 50%. The best results were obtained when anterior cruciate ligament reconstruction was performed concomitantly (79% versus 47%), when the rim width was less than 4 mm, and when the repair was done within 8 weeks of injury. With a rim width of less than 2 mm, the failure rate was 10%; with a width of less than 4 mm, the rate was 26%; and with a width of 4 to 5 mm, the rate was 50%. The length of the tear also was associated with variations in healing capacity. The failure rate was 20% with tears less than 2 cm long. Repairs in tears more than 4 cm long failed to heal 58% of the time. In Cannon’s series, the addition of fi brin clot tended to increase the healing rate, although patient numbers were not signifi cant; the patient’s age did not affect healing. Henning published work stating that the addition of a fi brin clot increased the healing rate in 950 lateral meniscal repairs from 59% to 90%. Arthroscopic repair techniques can be divided into four categories: (1) inside-out repairs; (2) outside-in repairs; (3) all-inside repairs; and (4) hybrid repairs, which combine the previous techniques. The inside-out technique can be done with double-lumen or single-lumen zone-specifi c repair cannulas, with absorbable or nonabsorbable sutures. The technique is rendered safe with the use of an incision for exposure of the capsule and placement of retractors for safe retrieval of suture needles. The outside-in technique, as described by Morgan and Casscells and Johnson, is most suitable for repairs of the midthird and anterior third of the meniscus. The technique can be used to pass single sutures through the superior and inferior surfaces of the meniscus to be retrieved anteriorly and tied in a Mulberry knot. The sutures are tied over the capsule laterally. Preferably, a single-loop suture is passed in a mattress fashion through the meniscus and is tied laterally. Finally, the all-inside technique, as described by Morgan, uses a posterior cannula and Linvatec spectrum suture hook (Largo, Fla) to pass the suture through the posterior horn for tying all inside. This technique is limited to posterior meniscal tears within 2 mm of the joint capsule and can be diffi cult because of the size of the cannula and passing of the needle through the tight joint space. All-inside repair techniques have been simplifi ed by the development of fi rst-generation suture fi xators, such as the meniscal arrow, for securing tears that are 2 to 4 mm from the peripheral attachment. Barber and Herbert reported variable resorption and fragmentation of these fi rst-generation devices and signifi cant chondral grooving produced by the arrowheads. The fi xation provided by these devices is approximately one third that of vertical mattress suture fi xation. The second-generation suture-based fi xation devices seem to provide more secure fi xation with less potential for intraarticular injury. These devices include the RapidLoc (Mitek Surgical Products, Westwood, Mass), which is the easiest to insert and according to Barber provides 43% strength of a vertical mattress suture. The Fast T-Fix (Smith & Nephew, Andover, Mass) is more diffi cult to insert than the RapidLoc. Nevertheless, the strength of fi xation and stability provided by the Fast T-Fix is comparable to the simple suture technique and did not cause any chondral damage in studies with 2to 3-year follow-up periods. Indications for the different repair techniques are listed in Table 48-1. Controversy still exists concerning open arthroscopic meniscoplasty (see Chapter 43) versus the closed technique. Open techniques generally are reserved for posterior third tears of medial or lateral menisci with the tear no more than 2 mm from the meniscosynovial junction. Proponents for open techniques argue that (1) better preparation of the repair site is possible through an arthrotomy; (2) more precise suture placement is possible; (3) the sutures can be placed vertically through the meniscus with open techniques, and these hold better; (4) because an open incision is required to expose the capsule with arthroscopic techniques, these techniques have no advantage over open techniques; and (5) the immobilization required is the same for open and arthroscopic techniques. Proponents for arthroscopic techniques claim that (1) results have been proven to be equal to those of open techniques; (2) certain tears are easier to suture by arthroscopic techniques (posterolateral tears and tears central to the meniscosynovial junction—such tears 2 to 5 mm from the periphery cannot be exposed and sutured by open arthrotomy methods); and (3) morbidity is less after arthroscopic techniques. Regardless of the arthroscopic technique preferred by the surgeon, arthroscopic meniscal repairs consist of three important steps: (1) appropriate patient selection—the patient should have a documented meniscal tear that is able to heal, most often a single vertical longitudinal tear in the outer one third; (2) tear débridement and local synovial, meniscal, and capsular abrasion to stimulate a proliferative fi broblastic healing response; and (3) suture placement to reduce and stabilize the meniscus. Tears can be categorized into (1) tears that can be rasped and left alone, (2) tears that are defi nitely reparable, (3) tears that are reparable under certain circumstances, and (4) tears that should be resected. Weiss et al. showed that peripheral tears of 7 mm or less heal without suture stabilization. Such tears should be probed to ensure less than 3 mm of displacement, and the tear and the meniscal synovium should be rasped to promote healing further, although in their study these researchers showed excellent healing without stimulation. A report by Talley and Grana showed a 21% failure rate with rasping of medial meniscal tears, indicating a probable need to repair all tears except those in the red-red zone. Tears that defi nitely are reparable are single vertical tears in the peripheral vascular portion of the meniscus, the redred zone at the meniscosynovial junction, or the red-white zone within 3 mm of the junction. These tears are displaceable, are more than 1 cm long, and involve minimal damage to the body of the meniscus. Repair should be limited to patients age 40 years or younger. A healing response is stimulated by rasping the tear and the perisynovial tissue. Tears that are reparable under certain circumstances include tears 3 to 5 mm from the meniscosynovial junction. These tears, similar to all reparable tears, should be evaluated with the tourniquet defl ated to determine vascularity. In young, active patients with minimal damage to the meniscal body, suture repair in association with healing enhancement is most likely to be successful when anterior cruciate ligament reconstruction is performed concomitantly. If rasping produces bleeding, potential healing can be considered. Vascular access channels, achieved through meniscal trephination using an 18-gauge spinal needle to penetrate the peripheral meniscus to the synovium, can stimulate bleeding. When isolated tears are to be repaired, addition of fi brin clot should be considered (see Technique 48-11). Resection is necessary for a meniscus with several tears, for

Table 48-1 • Repair Techniques and Indications

Outside-in sutures Anterior horn tears, midthird tears, radial tears, complex tears, reduction of bucket-handle tears Inside-out sutures Posterior horn tears, midthird tears, displaced bucket-handle tears, peripheral capsular tears, meniscal allografts Fixator implants (fi rstPosterior horn tears, tears with generation devices) > 2-3 mm rim width, vertical/ longitudinal tears Suture-based devices Posterior horn tears, midthird tears, (second-generation bucket-handle tears, radial tears devices)

From Sgaglione NA: Instructional course 206. The biological treatment of focal articular cartilage lesions in the knee: future trends? Arthroscopy 19:154, 2003. tears involving damage or deformation of the body, and for tears that are defi nitely in an avascular area (see Fig. 48-18C). Although complete radial tears are uncommon, they present particularly perplexing problems. When within the meniscal body, these tears disrupt all circumferential fi bers. Even if healing should occur, there has been no evidence that the normal hoop stress provided by a functional meniscus can be regained. Cannon and Shelbourne have shown that radial tears near the origin of the posterior horn of the lateral meniscus can heal. Although the biomechanical functionality of these repairs is in doubt, the long-term results of repair may be better than those of a subtotal meniscectomy, especially in a young patient (Table 48-2). We often combine two or three basic arthroscopic techniques (a second-generation suture-based meniscal fi xator, inside-to-outside cannula technique, and outside-to-inside needle technique). If a large bucket-handle tear of the medial meniscus is suitable for repair, an initial stabilizing horizontal mattress suture can be inserted with a singlecannula or double-cannula technique in the midpoint of the tear near the posteromedial corner. Additional sutures can be placed posteriorly using the cannula technique from inside to outside or with a second-generation suture-based fi xation device. The anterior portion of the tear, especially if this extends into the anterior half of the meniscus, is often best approached with an outside-to-inside technique. In the anterior half of the meniscus, it is diffi cult to have the sutures approach the meniscus perpendicular to its capsular attachment using an inside-to-outside technique. It is easier to approach the tear in a perpendicular fashion with an outside-to-inside technique.

If a patient has an unstable knee caused by an anterior cruciate ligament defi ciency and a reparable meniscal lesion, we believe that generally a ligament reconstruction and a meniscal repair should be done at the same time. The risk of a retear is much greater if no ligament-stabilizing procedure is done.

Table 48-2 • Meniscal Repair versus Resection*

L —Location from capsule < 2 mm 0 2-3 mm 1 4-5 mm 2 A —Age < 20 0 20-30 y 1 > 30 y 2 S —Size ≤ 2 cm 0 2-4 cm 1 > 4 cm 2 T —Tissue quality Excellent 0 Good 1 Fair 2 Qualifi ers Unstable 2 Malalignment 1 Chondromalacia grade III 1 Radial tear 2 ACL reconstruction or fi brin clot − 1

*Repair indicated for score of ≤ 4. ACL, anterior cruciate ligament.

Inside-to-Outside Technique TECHNIQUE 48-5

• Perform a systematic and complete diagnostic arthroscopy.

• If a reparable meniscal lesion is noted after thorough probing to ensure that no additional meniscal damage is present, exsanguinate the extremity and infl ate the tourniquet.

• Have a leg holder in place for stressing the knee. This opens up the compartment to make viewing of the periphery of the meniscus possible.

• For repair of the medial meniscus, insert the 30-degree viewing arthroscope through the anterolateral portal, and view and probe the extent of the tear.

• If the tear is acute and within the vascular red zone of the periphery of the meniscus, minimally prepare the rim before suturing. If the tear is clearly within the vascular red zone, do not resect that part peripheral to the tear. Resection of this material decompresses the meniscus from the peripheral side and has an effect similar to that of partial meniscectomy by narrowing the meniscus.

• If the tear is chronic, freshen and débride the torn surfaces, especially peripherally. Limit the excision to no more than about 0.5 mm of meniscal tissue if possible. This débridement and preparation of the torn surfaces can be accomplished with basket forceps, a shaver, curved meniscal knives, or small angled rasps introduced through the anteromedial, accessory medial, or posteromedial portal, while the tear is viewed with the arthroscope through the anterolateral portal. A small rasp is preferred for excoriating and abrading the meniscal surfaces (Fig. 48-23) and the superior and inferior parameniscal synovium.

• Specifi c cannulas are made to allow for the best approach to meniscal tears based on the location. Place the cannula in such a position to angle the needle away from the posterior midline structures and to place the needle perpendicular to the tear site.

• If a peripheral tear is beyond the posteromedial corner of the knee, use an all-inside meniscus fi xation device, or repair the meniscus using the inside-out technique.

• For the inside-out technique, fi rst make a 5to 7-cm incision over the posteromedial aspect of the knee, dissecting through the subcutaneous tissue down to the posteromedial corner of the knee.

• Identify the interval between the medial head of the gastrocnemius and the posterior capsule of the joint, and retract

Fig. 48-23 Preparation of meniscocapsular tear of medial meniscus through accessory posteromedial portal. (Redrawn from Rosenberg TD, Scott SM, Coward DB, et al: Arthroscopic meniscal repair evaluated with repeat arthroscopy, Arthroscopy 2:14, 1986.)

Gracilis tendon

Semitendinosus tendon

Sartorius muscle

Nerve

Semimembranosus muscle

Needle

Popliteal retractor

Medial tear

M L

Fig. 48-24 Top view of joint with arthroscope, needle cannula, and popliteal retractor in place for medial meniscal repair. (Redrawn from Rubman MH, Lindenfeld TN: Arthroscopic meniscus repair: inside-out technique. In Craig EV, ed: Clinical orthopaedics, Philadelphia, 1999, Williams & Wilkins.) the medial head of the gastrocnemius posteriorly off the posterior capsule.

• Place a popliteal retractor in this interval to protect the popliteal vessels and to aid in capturing the needles (Fig. 48-24).

• Pass the cannula of the suturing instrumentation through the anterolateral portal, and place its tip near the posterior limit of the tear (see Fig. 48-24).

• Remove the needle cradle, and have an assistant load the cradle with the fi rst needle.

• Pass the needle through the cannula to enter the meniscus 3 to 4 mm from the edge, aiming the needle in a slightly vertical direction so as to exit at or above the center of the torn edge. Observe the needle as it is advanced through the outer portion of the tear. Use the needle to align the meniscus anatomically before advancing through the outer rim. If good positioning is obtained, use the needle driver to advance the needle 1 cm more (Fig. 48-25).

• Pass the second needle to enter the meniscus or meniscosynovial junction peripheral to the fi rst needle, forming a stacked vertical mattress or oblique mattress suture (Fig. 48-26).

• Pass the needles out through the capsule with the knee fl exed 15 to 20 degrees, while retracting the pes anserinus and saphenous nerve posteriorly.

• Clamp the paired sutures together with a hemostat.

• Vertical mattress sutures are placed from both surfaces of the meniscus in an alternating fashion every 3 to 4 mm. If it is diffi cult to maintain reduction of a bucket-handle tear, place the fi rst mattress suture anteriorly to help hold the meniscus in place while subsequent sutures are passed.

• The choice of suture material has been varied. Some surgeons fear that all absorbable sutures would degrade before adequate healing and may cause an infl ammatory reaction around the knot. Other surgeons are concerned that nonabsorbable sutures would remain as stress risers within the meniscus or cause abrasive wear to the articular surface of the femur or tibia or penetrate and capture the medial collateral ligament. To date, no studies have shown any deleterious effects of using absorbable sutures with a long tensile life or nonabsorbable sutures. We prefer nonabsorbable sutures for larger, more centrally located tears because of the prolonged healing time.

• If the tear involves mainly the middle third of the medial meniscus, and the capsule has not been opened posteriorly to protect the neurovascular elements, make an incision over the medial joint line, while pushing the initial needle through the capsule and into the subcutaneous tissue.

• Expose the capsule parallel to the peripheral tear of the meniscus and throughout its length. Exposing this area before passing the sutures through the capsule lessens the likelihood of cutting the sutures in making the exposure.

• When all sutures are passed into this medial incision, tie them over the capsule. It is important to view the meniscus as the sutures are tied to ensure reduction of the tear site without deformation.

A

B

Fig. 48-25 A, Most posterior sutures are placed with cannula in ipsilateral portal. B, Anterolateral and midmedial sutures are inserted with cannula through contralateral portal. Stacked vertical or oblique mattress sutures provide better holding strength than depicted horizontal mattress sutures. (From Rosenberg TD, Scott SM, Coward DB, et al: Arthroscopic meniscal repair evaluated with repeat arthroscopy, Arthroscopy 2:14, 1986.)

Inside-to-Outside Technique TECHNIQUE 48-5—cont’d

• The safest position of the knee for suture of lateral meniscus tears is near 90 degrees of fl exion. The peroneal nerve drops more inferiorly with fl exion and is protected.

• If the posterior extent of the tear is near the midline, protect the popliteal vessels before bringing the needles through the capsule by placing a wide metallic retractor between them and the posterior capsule. The common peroneal nerve lies slightly posterior to the posterior aspect of the biceps femoris tendon, so the needles must always exit anterior to the biceps tendon. It is much better, however, to make the posterior skin incision and expose the area of the posterior capsule and peroneal nerve before bringing the sutures through the posterior aspect of the capsule.

• Make a 4to 5-cm posterolateral skin incision, extending distally just anterior to the tip of the fi bula with two thirds of the incision extending distal to the joint line.

• Develop the interval between the iliotibial band and biceps, and retract the biceps posteriorly. Use careful dissection to refl ect the lateral gastrocnemius head off the posterior capsule. Place a hip skid or needle defl ector between the capsule and the gastrocnemius head (see Fig. 48-24).

AFTERTREATMENT There is no universally accepted method of immediate postoperative management of meniscal repairs. Currently, after an isolated meniscal repair, we place the extremity in an immobilizer for 7 to 10 days. Range-of-motion exercises (20 to 80 degrees) are begun immediately for 20 minutes four times daily. Touch-down weight bearing is allowed for the fi rst 2 weeks, partial weight bearing for 2 to 4 weeks, and full weight bearing at 4 to 6 weeks. Jogging is allowed at 3 months, and squatting and return to sports are allowed at 6 months. If the meniscal repair is performed in conjunction with an anterior cruciate ligament reconstruction, we prefer to treat the ligament primarily. This involves placing the knee in full extension immediately and allowing early full range of motion. Touch-down weight bearing on crutches is continued for the fi rst 6 weeks. When stable repair in the red-red zone has been obtained, we allow the patient to return to sports at approximately 3 months, provided that complete return of function has been obtained.

Fig. 48-26 Meniscal repair with oblique mattress sutures, which are “stacked” to obtain most secure fi xation in meniscal tissue.

Outside-to-Inside Technique

Morgan and Casscells and Warren have described a technique for arthroscopic meniscal repair in which a suture is introduced through a spinal needle that is inserted from outside to inside. They advocate this technique as a safe approach to the posterior meniscal horns. We have found this technique most appropriate and safest for tears located in the anterior aspect of either meniscus. Three different techniques are available for outside-in repair of the meniscus. The fi rst technique described was that of Morgan and Casscells using a Mulberry knot technique, in which an absorbable suture is passed through a spinal needle and taken out anteriorly through a cannula, and a triple knot is tied (Fig. 48-27). The suture is pulled back through the meniscus, and the knot is used to reduce the meniscus. This can be done tying one superiorly and one inferiorly to obtain a stack-type repair (Fig. 48-28). The Mulberry knot technique gives a repair comparable to a horizontal mattress suture. A more secure repair may be obtained by using a suture shuttle technique in which absorbable sutures are passed through the needles and through the meniscus and pulled out through a cannula. A nonabsorbable suture is tied to the previously passed sutures and pulled out through the capsule, forming a vertical or oblique mattress suture repair. The third technique is the suture retrieval technique described by Johnson, in which a suture is passed through the spinal needle, and a second needle is passed through the meniscus in a vertical mattress confi guration. A wire loop is used to retrieve the fi rst suture and pull it back through the meniscus, forming a mattress repair (Figs. 48-29 and 48-30). This also may be altered by passing the needle with a wire loop through the meniscus; passing a nonabsorbable suture through the anterior cannula through the wire loop; and then passing it a second time through the meniscus, retrieving the suture again and passing it in a mattress confi guration. With these techniques, use of a nonabsorbable suture probably gives

2 mm

Fig. 48-27 Mulberry knot-end technique. (Redrawn from Kohn D, Siebert W: Meniscus suture techniques: a comparative biomechanical cadaver study, Arthroscopy 5:324, 1989.)

Capsule

Femur

Tibia

Meniscus

Fig. 48-28 With this orientation of needles, sutures can be placed superiorly and inferiorly on meniscal surface. (Redrawn by Rodeo SA: Arthroscopic meniscal repair with use of the outside-in technique, Instr Course Lect 49:195, 2000.)

Anterior portal

Fig. 48-29 Permanent suture brought in through anterior portal and placed into wire cable loop. (Redrawn from Johnson LL: Meniscus repair: the outside-in technique. In Jackson DW, ed: Reconstructive knee surgery, New York, 1995, Raven Press.) better fi xation. Use of a vertical mattress technique has been shown to give more stable fi xation than a horizontal mattress technique or the Mulberry knot technique. With each of these techniques, certain points are emphasized. For posteromedial repairs, the knee should be fl exed about 10 to 20 degrees for the incision and for passing the

Tear

Suture

B

A

Fig. 48-30 A, Second suture is pulled through to complete suture attachment. B, Sutures are brought into place after needles and cable loops have been removed. (Redrawn from Johnson LL: Meniscus repair: the outside-in technique. In Jackson DW, ed: Reconstructive knee surgery, New York, 1995, Raven Press.) needles to allow the sartorial nerve to lie anterior to the repair site. For anteromedial repairs, the knee should be in 40 to 50 degrees of fl exion for the incision and repair to allow the sartorial nerve to lie posterior to the repair site. For lateral repairs, the knee should be fl exed 90 degrees to allow the nerve to be posterior to the repair site. The meniscus and parameniscal tissue must be prepared with a rasp before the repair. A small, 5to 6-mm working cannula should be placed in the ipsilateral side for suture management.

🔪 Surgical Technique 48-6

• Make a small skin incision and extend it through the subcutaneous tissue down to the capsule opposite the site of the meniscal tear.

• Under arthroscopic observation, introduce the needle from outside to inside, penetrating the meniscal rim and the meniscal fragment.

• Remove the stylet, and pass a specially designed suture passer down through the needle and into the joint.

• Deliver the end of the suture into the joint using a special grasping instrument passed through an anterior portal. Place the suture through the wire loop of the suture passer. Withdraw the needle and suture passer simultaneously, bringing one end of the suture with them out through the capsule.

• Repeat the process, placing another needle 3 to 4 mm from the fi rst one. Insert a suture passer through the needle, and again bring the remaining free end of the suture into the joint through the anterior portal, and deliver it through the wire loop. When this needle and the suture passer are retracted, both ends of the suture are now on the outside of the capsule, and a horizontal mattress suture has been placed.

• Tie down the suture over the capsule, and repeat the process as often as necessary to stabilize the meniscal tear securely (Fig. 48-31).

• For large peripheral lesions on the medial side, such as a displaced peripheral bucket-handle tear, a combination of insideto-outside and outside-to-inside methods can be used.

• Place a single horizontal mattress suture, using a cannulated technique, into the midportion of the tear anterior to the posteromedial corner. This suture provides the necessary stability to the large bucket-handle fragment and prevents gross displacement when the spinal needle loaded with suture material is placed through the posterior and anterior horn regions of the fragment (Fig. 48-32).

Suture Shuttle Technique TECHNIQUE 48-7

• Pass a spinal needle through the body of the meniscus, the peripheral meniscal tear, and up through the medial fragment.

• Pass a Prolene suture (Ethicon, Johnson & Johnson, Piscataway, NJ) through the needle and out anteriorly through the cannula (Fig. 48-33A).

• Pass a second needle in a similar fashion through the body of the meniscus and up through the meniscus to form a vertical mattress suture (Fig. 48-33B). Pass this suture likewise anteriorly through the working cannula using a grasper.

• These sutures are used as suture shuttles to a nonabsorbable 2-0 suture.

• Tie a single-throw polydioxanone suture (PDS) around each end of a nonabsorbable suture, and pull the suture construct back into the knee and out through the capsule by pulling the sutures that are left exterior to the joint (Fig. 48-33C).

A

C D E

B

Fig. 48-31 Outside-to-inside technique for suture of medial meniscus. A, Curved needle shown penetrating posterior horn tear. Wire loop passes through needle and is viewed in joint. B, Suture is passed through loop with miniature ligature holder. C, Loop is pulled out of needle, bringing suture to outside. D, Second needle penetrates meniscus tear; suture procedure is repeated. E, Suture is tied over capsule. (Redrawn from Johnson L: Meniscus mender, technique brochure, Instrument Makar, Okemos, Mich.)

Mulberry Knot Technique TECHNIQUE 48-8 Morgan and Casscells (see Fig. 48-27)

• Pass a spinal needle through the peripheral tear into the body of the meniscus, about 3 mm from the tear site.

• Take the PDS out anteriorly through a cannula, and tie a triple knot in the suture.

• Pull the suture tail to snug the knot to the meniscal body.

• Place one knot in the superior surface and one in the inferior surface, and tie these together over the capsule. Place sutures every 3 to 4 mm apart and, as previously mentioned, approximately 3 mm from the tear site.

Fig. 48-32 Suture placement in midportion of large buckethandle tear using curved double-cannula technique.

Lateral Meniscal Suturing TECHNIQUE 48-9

• The technique for suture placement on the lateral side is similar to that described for the medial side, with the common peroneal nerve most at risk when suturing the posterior horn of the lateral meniscus.

• Keep the knee near 90 degrees of fl exion when suturing the posterior horn of the lateral meniscus because in this position the nerve falls well below the joint line posterolaterally. With the knee in nearly 90 degrees of fl exion or in the fi gure-four position, posterior and posterolateral suturing involves little risk of injury to the peroneal nerve if the needles enter and exit the capsule superior to the palpable biceps femoris tendon.

• Sutures can be placed inside-out or outside-in, in a stacked vertical mattress confi guration. Place the sutures approximately 3 mm from the edge and space every 4 to 5 mm.

• If approximation and stability have been achieved, tie the sutures to each other over appropriate bridges of the posterolateral capsule. Tie the sutures with the knee in full extension.

• Immobilize the knee in a plaster splint or a commercial knee immobilizer with the knee in extension.

Saphenous nerve

Pes anserinus tendon

A B C

Fig. 48-33 All-inside technique. A, Proper posteromedial cannula placement begins outside and above medial hamstring tendons, above and behind posteromedial joint line, toward center of joint with knee fl exed 90 degrees. B, Suture placement through posterior operative cannula with suture hook while viewing with 70-degree arthroscope through intercondylar notch. C, Knot tying is accomplished with arthroscopic knot pusher, which advances sequential throws through posterior cannula while viewing with 70-degree arthroscope through intercondylar notch. (Redrawn from Morgan CD: Technical note. The “all-inside” meniscus repair, Op Tech Sports Med 2:201, 1994.)

AFTERTREATMENT Postoperative partial weight bearing on crutches is maintained for 4 to 6 weeks, depending on the stability of the tear and the distance of the tear from the peripheral blood supply.

All-Inside Technique

Morgan described an all-inside arthroscopic technique for meniscal repair that allows access to areas of the posterior aspect of the posterior horn and the posterocentral aspect near the root attachment. The new arthroscopic instrumentation allows placement of vertically oriented sutures across the meniscal tear and intraarticular tying of sutures. This posterior horn repair approximates the meniscotibial and meniscofemoral portions of the coronary ligament complex to the meniscus without repairing the posterior capsule. Morgan recommended this method for suturing mobile, single, vertical tears of the posterior horn located at or within 3 mm of the meniscocapsular junction. He did not recommend this technique for tears anterior to the posterior meniscal corners and suggested using another suture technique to repair the anterior portion when the posterior horn tear extends anteriorly (e.g., in peripheral bucket-handle tears).

🔪 Surgical Technique 48-10

• Position the patient supine on a standard operating table with the table fl exed at midthigh level approximately 120 degrees.

• Prepare and drape the extremity from midthigh to midcalf, and allow the knee to fl ex 90 degrees over the break in the table. A leg holder is not required.

• After confi rming the presence of a peripheral posterior horn tear with standard diagnostic arthroscopy, place a 70-degree arthroscope through the intercondylar notch from either the anteromedial or the anterolateral portal. To make placement of the arthroscope through the notch easier, the anteromedial and anterolateral portals should be made close to the anteromedial and anterolateral margins of the patellar tendon.

• When advancing the arthroscope into the posteromedial compartment, begin at the anterolateral portal, and pass under the posterior cruciate ligament. When advancing into the posterolateral compartment, begin from an anteromedial portal, and pass under the anterior cruciate ligament, using an arthroscope sheath loaded with a semiblunt obturator.

• After the sheath is positioned, exchange the obturator for the 70-degree arthroscope lens. Position the lens in the desired posterior compartment, and rotate 90 degrees so that the posterior horn can be viewed across the posterior compartment.

• Place an 8-mm-diameter operative cannula posteriorly into the posterior compartment.

• On the lateral side, place the cannula through a portal made in the soft spot above the palpable biceps femoris tendon behind and above the joint line.

• Advance and aim for the center of the joint, while observing the cannula’s entrance through the posterior capsule. The knee should be in 90 degrees of fl exion to enlarge the posterior capsular recess and to avoid injury to the peroneal nerve.

• With the knee in 90 degrees of fl exion, place the cannula into the posteromedial compartment beginning in the soft spot above the palpable medial hamstring tendons behind and above the joint line (Fig. 48-33A). Avoid the saphenous nerve on the medial side by placing the operative portal above the medial hamstring tendons with the knee fl exed 90 degrees.

• When the operative cannula is in place, débride both sides of the tear site of any hypovascular abortive healing response, and excoriate the local synovium with a rasp to stimulate local bleeding to obtain a vascular fi brous response after surgery.

• For tear preparation, place a rasp through the posterior cannula, while viewing through the notch the meniscofemoral portion of the tear. Place the rasp anteriorly, while viewing anteriorly for the meniscotibial portion of the tear.

• Place the sutures using a meniscal repair suture hook through the posterior operative cannula. The suture hook is a cannulated, 16-gauge needle with a hook-shaped end attached to a shaft and handle with a roller device that feeds suture through the lumen of its cannulated length. Suture hooks are produced with three types of terminal angular designs to accommodate variable angles of approach and tear anatomy: straight hook, 45-degree right and left hook, and right and left corkscrew. In general, tears with any degree of separation at the tear site are best spanned using the straight or 45-degree angled hooks, whereas anatomically reduced tears can be readily sutured with the corkscrew, straight, or 45-degree hook designs.

• By hand, manipulating the hook so that the sharp tip penetrates the posteroinferior stable rim fi rst, advance across the tear into the mobile fragment from inferior to superior (Fig. 48-33B).

• After the hook has spanned both sides of the meniscal tear, advance 12 to 14 inches of monofi lament suture (0-0 or 1-0 PDS) into the posterior compartment, and withdraw the tool out of the tear and up the posterior cannula, leaving suture across the tear in a vertical orientation.

• Grasp the free end of the suture in the posterior compartment, and bring it up the posterior cannula so that both ends of the suture are out of the cannula.

• Advance four sequential half-hitched throws down the posterior cannula with a double-holed knot pusher to produce a double “stacked” square knot that apposes the meniscal tear at the suture site (Fig. 48-33C).

• After tying the knot, cut the suture tails intraarticularly, and repeat the process as many times as necessary to stabilize the tear. Usually, only three sutures are required to stabilize a large posterior horn tear.

AFTERTREATMENT For isolated meniscal repairs in cruciate-stable knees, immobilize the knee in full extension for 7 to 10 days and allow weight bearing with crutches. When a meniscal repair is done in combination with an anterior cruciate ligament reconstruction (bone–patellar tendon–bone autograft), the knee is immobilized for 2 weeks in full extension with immediate weight bearing. Active range of motion from 0 to 90 degrees of fl exion twice daily for 20 minutes can be started immediately postoperatively. After 2 weeks, progressive range of motion, bicycling, and thigh-strengthening exercises are begun. Weight bearing and range of motion should not be done at the same time, however, until about 4 weeks after surgery.

Preparation of Fibrin Clot

Although the exact role of fi brin clot on meniscal healing is unknown, many authors recommend its use when repairing isolated meniscal tears that are 3 to 5 mm from the periphery. When anterior cruciate ligament reconstruction is done concomitantly, fi brin clot probably is unnecessary because of the hemarthrosis associated with the reconstruction.

🔪 Surgical Technique 48-11

• Using venipuncture, obtain an aliquot of 5 to 10 mL of whole blood, and transfer to a 20or 60-mL plastic syringe to form a shorter, thicker clot or to a 10-mL syringe for a longer, thinner clot.

• Using a 4-mm frosted glass stirring rod, gently stir the blood, avoiding contact with the outer wall of the syringe, which would cause premature sloughing of the forming clot from the glass rod. A roughened glass rod also can be used and prepared by abrading a smooth glass rod with fi ne-grit corundum paper. Wash the glass rod thoroughly before use. This clot formation technique requires stirring in small circles. Use the nonstirring hand to encircle the syringe to provide warmth to help speed coagulation. Place the fi fth digit over the end of the syringe to avoid loss of blood from the tip.

• Within 3 to 5 minutes, a change in the consistency of the blood indicates that the clot has begun to form around the rod. At this point, gently bring the rod to the wall of the syringe, and allow the clot to contact the plastic wall.

• Apply gentle, radial-directed force, while continuing to make small circles to tighten the forming clot.

• After 1 to 2 more minutes, remove the rod with the clot around it.

• Slide the clot off the rod onto a gauze sponge, and blot to remove the serum. The clot can be placed surgically or stored in a saline-soaked gauze.

• The clot can be stretched, manipulated, and squeezed with reasonable force without losing its integrity and is capable of holding sutures.

• Place the clot between the torn edges of the meniscus by using a plastic tube and pusher, or inserting it through a syringe and large-bore 14-gauge spinal needle.

• Alternatively, place 0-0 PDS in each end of the clot, and use meniscal repair needles to pass these sutures down a cannula under the body of the meniscus and out through the capsule, one suture being placed in the anterior portion of the tear and the second in the posterior portion of the tear.

• Gently tease the clot into place between the torn edges of the meniscus using the sutures.

• During clot placement by any of these means, turn off the infl ow, and drain the knee to prevent disruption of the clot.

• After the clot is placed between the torn edges, secure it by reapproximating the meniscal edges with the previously placed mattress repair sutures.

Meniscal Replacement Meniscal replacement continues to evolve using bone plug techniques and with better defi ned indications and more asymptomatic results. Yoldas, Harner, and Sekiya et al. have shown more than 90% symptomatic improvement at 3-year follow-up of large patient numbers. The question remains how much chondroprotective function a transplanted meniscus produces. Stollsteimer et al. and Noyes and Barber-Westin showed a 40% graft shrinkage or failure in 60% of the grafts. Wirth et al. had a 36% meniscal tear rate at 5.4 years, and Van Arkel had a 21% failure rate. Verdonk et al. at 7.2-year follow-up of 100 procedures found that one third had additional surgery for meniscal tears or impingement, and 70% of the patients maintained asymptomatic relief with the meniscal transplant. The functional relief provided by meniscal transplant is clouded further by the fact that many of the patients had concomitant procedures for realignment, stabilization, or osteochondral transplant at the time of the meniscal transplant. In a study by Sgaglione et al., cryopreserved menisci performed similar to fresh frozen menisci and had similar risks, in particular that of acquired immunodefi ciency syndrome (AIDS) (1 in 1.6 million). Investigational studies of biological tissue scaffolds for partial or complete meniscal replacement are in progress. These grafts may provide more acceptable replacements in the future, but at this time results are short-term and limited in number. Noyes noted that meniscal allograft is indicated in a patient who has had a previous meniscectomy, who is age 50 years or younger, and who has symptoms localized to the tibiofemoral compartment and no advanced arthrosis as evidenced by fl attening of the condyles or excessive osteophyte formation. He stated that on a standing 45-degree posteroanterior view that a joint space of 2 mm or greater is necessary. Contraindications listed by Noyes and others include malalignment, instability that the patient does not wish to have corrected, chondromalacia greater than grade III, and previous joint infection. A meniscal replacement is indicated in a patient who meets the aforementioned criteria, who is motivated, well informed, and willing to decrease impact loading activities. When deciding whether a fresh frozen or a cryopreserved meniscus is to be used, one should be familiar with the allograft procurement and ensure that a quality, young, healthy graft is secured. Best results are obtained with a meniscal allograft that has a bone block or a bone bridge attached. Sizing is best done on anteroposterior radiographs, and MRI may be used to determine meniscal coverage. A technique used at the University of Pittsburgh is described. The technique is divided into four parts: graft preparation, tunnel placement, graft insertion, and graft fi xation.

🔪 Surgical Technique 48-12

GRAFT PREPARATION

• After patient positioning, diagnostic arthroscopy, and bed preparation, obtain a true lateral radiograph of the involved knee.

• Measure the anteroposterior diameter of the appropriate tibial plateau, taking into account any magnifi cation factor.

• Thaw the fresh frozen meniscal allograft at a temperature of less than 40ºF to prevent denaturing of the collagen.

• Prepare each meniscal horn bony insertion site to cylindrical 7-mm bone plugs (Fig. 48-34A).

• Place nonabsorbable sutures through the roots of each meniscal horn and respective bone plugs to allow for meniscal insertion, passage, and fi xation into osseous tunnels (Fig. 48-34B).

• Demarcate the meniscus-bone interface with a sterile marking pen for accurate assessment of complete graft seating to the level of the bone–meniscal tunnel junction.

TUNNEL PLACEMENT

• Place the arthroscope and arthroscopic guide in the anterolateral and anteromedial portals to provide optimal exposure and tunnel placement for both lateral meniscal bony insertion sites. The anterior and posterior horn insertion sites of the medial meniscus are best seen with the arthroscope in the anteromedial and posteromedial portals. Placement of the arthroscopic guide in the contralateral anterior portal is optimal for each medial meniscal horn insertion site.

• After determining that the intraarticular placement of the arthroscopic guide is appropriate, place the extraarticular exit over the contralateral portion of the tibial metaphysis at the level of the fi bular head midway between the tibial tubercle and the posteromedial or posterolateral border of the tibia. The advantage of drilling tunnels from the contralateral metaphysis is that tunnel divergence would be greater, providing a larger bony bridge between the two tunnels (i.e., less chance of tunnel “blowout”).

• Make a 3-cm longitudinal incision in the skin, and elevate the periosteal fl aps. Enough exposure is needed for parallel placement of two 7-mm osseous tunnels with a 1-cm bone bridge between them.

• Drill the tibial tunnels under arthroscopic guidance.

• Insert a tibial drill guide through the appropriate anterior portal, and seat it in the “footprint” of the meniscal horn bony insertion site.

• Drill a guidewire through the tibial jig.

• Remove the guide, and confi rm the position of the guidewire before creating the tibial tunnel.

• Overdrill the tibial guide pin with a 7-mm cannulated reamer.

• Débride the tibial tunnel of all soft tissue, chamfer, and smooth with an arthroscopic rasp to facilitate bone plug insertion and prevent graft abrasion at the plateau-tunnel interface.

GRAFT INSERTION

• Make an accessory 3-cm incision at the posteromedial or lateral corner as would be done if performing an inside-out meniscal repair.

• With careful dissection, expose the posterior border of the lateral collateral ligament laterally or the junction of the posterior border of the medial collateral ligament and the posterior oblique ligament medially.

• Make a 1.5-cm arthrotomy at the posterior border of the lateral collateral ligament and medial collateral ligament for lateral and medial meniscal allograft insertion.

• Using the arthroscope, pass a looped 18-gauge malleable wire retrograde through the posterior tibial tunnel to outside the knee through the vertical capsular incision located at the posterolateral-medial border.

• Pull the sutures that were placed in the posterior horn and bone plug of the meniscal allograft through the posterior tibial tunnel with the use of the looped wire.

• Apply tension through these sutures to seat the posterior bone plug of the medial and lateral meniscal allograft.

• To avoid potential fracture of the anterior bone plug, a two-step process is used for anterior horn insertion and seating.

A B

C D

Fig. 48-34 Double bone plug technique. A and B, Graft preparation. C, Insertion of graft, including reduction suture. D, Appearance on completion. (Redrawn from Cole BJ, Carter TR, Rodeo SA: Allograft meniscal transplantation: background, techniques, and results, J Bone Joint Surg 84A:1235, 2002.)

🔪 Surgical Technique 48-12

• Introduce the looped 18-gauge wire through the ipsilateral anterior portal, and bring it outside the knee through the posterior capsular incision (Fig. 48-34C).

• Pull the sutures that anchor the anterior portion of the allograft out the ipsilateral anterior portal, guiding the anterior bone plug into the front half of the knee via the medial or lateral gutter.

• Carefully pass the anterior bone block along the gutter, and take care to avoid fracturing the bone plug.

• Pass the malleable wire retrograde through the anterior tibial tunnel into the knee, and bring it out of the ipsilateral anterior portal to accompany the sutures anchored to the anterior bone plug.

• Pass the sutures through the looped wire, and guide them through the anterior tibial tunnel out the front of the knee.

• Reduce the anterior bone plug into the respective osseous tunnel under arthroscopy. This seats the meniscal allograft in its anatomical position with the anterior and posterior bone plugs in their respective osseous tunnels.

GRAFT FIXATION

• Place 2-0 Ethibond (Ethicon, Inc., Somerville, NJ) nonabsorbable sutures in a vertical or horizontal mattress fashion.

• Insert the sutures from the upper and lower meniscal surfaces to approximate the meniscus and capsule completely.

• When all the sutures have been passed, but before tying, apply tension to the peripheral, meniscal root and bone plug– anchoring sutures, while moving the knee through a complete range of motion.

• Closely observe meniscal kinematics while probing to assess stability and reduction. Tie the peripheral sutures over the capsule.

• Tie the sutures anchoring the tibial bone plugs over the bone bridge separating the tunnels (Fig. 48-34D).

• Perform a standard layered closure for each incision.

AFTERTREATMENT The operated extremity is placed in a long-leg hinged knee brace. Knee range of motion from 0 to 90 degrees is begun immediately postoperatively. The patient is permitted crutch-assisted partial weight bearing with the brace locked in full extension for the fi rst 6 weeks. At 6 weeks, the brace is removed, and the patient is progressed to full weight bearing. Closed chain exercises are emphasized, and deep fl exion is avoided for the fi rst 6 months. Bicycling, swimming, and straight-ahead jogging at half speed are allowed at 3 to 6 months. Hard running, agility maneuvers, and full squats are prohibited until after 6 months. Competitive sports are prohibited until 9 to 12 months postoperatively.

Arthroscopic Surgery for Other Disorders

Loose Bodies in the Knee Joint Removal of loose bodies from the knee joint is especially suitable for arthroscopic techniques. A loose body may be a singular isolated problem, or multiple loose bodies may indicate the presence of a more complex pathological process, such as synovial chondromatosis. Every attempt should be made to identify the underlying process to manage the condition correctly. Loose bodies can be classifi ed into the following types:

1. Osteocartilaginous. These loose bodies are composed of bone and cartilage and are detectable radiographically. Osteocartilaginous loose bodies may originate from several sources, the most common being osteochondritis dissecans, osteochondral fractures, osteophytes, and synovial osteochondromatosis. 2. Cartilaginous. These radiolucent loose bodies usually are traumatic and originate from the articular surfaces of the patella or the femoral or tibial condyle. 3. Fibrous. These radiolucent loose bodies occur less frequently and result from hyalinized reactions originating usually from the synovium secondary to trauma or, more commonly, from chronic infl ammatory conditions. Synovial villi become thickened and fi brotic, may become pedunculated, and may detach and fall into the joint as loose bodies. Chronic infl ammations, such as tuberculosis, may produce multiple fi brinous loose bodies known as “rice bodies.” 4. Others. Intraarticular tumors, such as lipomas, and localized nodular synovitis may be pedunculated and by palpation feel like loose bodies or, in rare instances, drop free into the joint. Bullets, needles, and broken arthroscopic instruments also may appear as foreign loose bodies within the knee.

🔪 Surgical Technique 48-13

• Two techniques generally are used, based on the problem facing the surgeon: (1) small loose bodies are removed from the knee joint by suction and lavage of the joint and (2) larger loose bodies are removed using triangulation techniques.

• Insert the 30-degree viewing arthroscope through the anterolateral portal. Rarely is bleeding a problem in loose body removal; infl ating the tourniquet usually is unnecessary.

• Perform a complete systematic diagnostic arthroscopy, moving sequentially and systematically through the joint. If the loose body is large and radiopaque, preoperative radiographs give an indication of its location; however, it may have moved since the radiograph was taken.

• Search the joint systematically for additional loose bodies, including the suprapatellar pouch, the medial and lateral gutters, the medial and lateral compartments, the popliteal hiatus, the intercondylar notch, and the posterior compartments.

• If the loose body is in the suprapatellar pouch, it may fl oat away from the arthroscope or grasping instrument. In addition, the slightest turbulence in the irrigation fl uids or the slightest touching with the grasper frequently makes it move away. This can be reduced by turning off the outfl ow of irrigating solution and inserting a small suction tip. Frequently, the loose body is drawn to the suction tip, where it can be held until a third instrument is brought into the knee to grasp it.

Fig. 48-36 Loose body in posteromedial compartment. Complete knee arthroscopy should always include examination of posteromedial compartment.

Fig. 48-35 Removal of loose body. Loose body is impaled with needle, and grasper is inserted through superolateral portal.

🔪 Surgical Technique 48-13

• The loose body also can be trapped or stabilized by triangulating a spinal needle to it, piercing it with the needle, and holding it in place until a grasper is inserted, usually through a superolateral or superomedial portal (Fig. 48-35).

• When it is within the jaws of the grasper, slowly withdraw the loose body to the portal entrance.

• If necessary, enlarge the entrance so that the loose body can be extracted. It is better to enlarge the portal than to have the loose body slip from the grasper and become free again within the joint.

• If multiple loose bodies are present, remove the smaller ones fi rst. Removal of the largest ones fi rst may require enlargement of the portal and can result in signifi cant leakage of irrigation solutions from the joint.

• When all loose bodies that can be seen have been removed, suction the joint, especially the posterior compartments and the intercondylar notch. Occasionally, this pulls small, previously unseen loose bodies into view.

• Try to identify, if possible, the pathological process producing the loose bodies, and treat it appropriately (i.e., by biopsy, synovectomy, or chondroplasty).

• Loose bodies that gravitate into the posterior compartment can be seen with the viewing arthroscope through a posteromedial or a posterolateral portal or a central portal using a 70-degree oblique viewing arthroscope (Fig. 48-36).

• Triangulating a grasping instrument into the posteromedial or posterolateral compartment, with the arthroscope also through a posteromedial or posterolateral portal, can be diffi cult because of crowding and collision of instruments.

• Pass the 70-degree oblique viewing arthroscope through the intercondylar notch and into the appropriate posterior compartment, locate the loose body, and triangulate a grasping instrument through a posteromedial or posterolateral portal to remove it.

• Loose bodies also can be diffi cult to fi nd in the anterior compartment around the fat pad under the anterior horns of the menisci. If it is diffi cult to fi nd an anterior loose body, add a midpatellar portal to view the area, and allow instrumentation and probing through both of the anterior portals.

• Loose bodies large enough to require a major incision for removal can be removed in smaller fragments by morcellization if desired. Do not use the delicate basket forceps or other arthroscopic instruments for this purpose, or severe damage to the instrument would result. It is better to use a Kerrison rongeur or an arthroscopic burr to break up larger loose bodies for removal.

• Remove pedunculated “loose bodies,” caused by disorders such as nodular synovitis, using standard triangulation techniques after the restraining pedicle is cut with scissors.

• Instrument breakage during arthroscopic procedures may occur, and portions of broken instruments can drop into the joint. Under these circumstances, remain calm, turn off the irrigating solution, move the knee as little as possible, and always keep the fragment in view. Do not proceed with the intended surgical procedure until the instrument part is removed. The broken part can be stabilized using a small magnet (Dyonics Golden Retriever) inserted through an appropriate portal until it can be secured by a grasping instrument and removed.

Synovial Plicae of the Knee Embryologically, the knee joint forms from three synovial compartments. Normally, these fuse into a single synovial cavity with the intervening synovial partitions resolving.

The important synovial plicae of the knee represent unresolved remnants of these partitions. These plicae are synovial folds, usually classifi ed according to their anatomical relationship to the patella: suprapatellar, infrapatellar, medial patellar, and lateral patellar plicae. They vary in frequency, size, thickness, and clinical signifi cance. Jackson, Marshall, and Fujisawa suggested that the term plica or shelf be reserved to describe a normal synovial fold, and if the plica is believed to be contributing to the patient’s symptoms, it should be referred to as a pathological plica. The infrapatellar plica, or ligamentum mucosum, probably never produces symptoms, but can make it diffi cult to pass the arthroscope from one compartment to the other; if it is prominent, viewing of the anterior cruciate ligament can be diffi cult. It can vary in size from a thin band of synovium running from the back side of the fat pad into the intercondylar notch to a nearly complete synovial partition separating the medial and lateral compartments. The suprapatellar plica is superior to the patella and partially divides the suprapatellar pouch into two compartments. Rarely does it cause symptoms in the knee. A lateral patellar shelf or plica has been described, but is exceedingly rare. The most common of these plicae to be of clinical signifi cance is the medial patellar plica. Its incidence has been reported to range from 10% to more than 50% in normal knees. The frequency of the medial patellar plica and its possible role in the cause of anterior knee pain have been more greatly appreciated as diagnostic arthroscopy has developed. The medial patellar plica begins just superior to the patella and sometimes continues with the distal extent of the suprapatellar plica, running distally along the medial side wall of the joint and over the medial femoral condyle to insert onto the fat pad. This structure causes symptoms only if it becomes thickened and inelastic from trauma or chronic infl ammation. A common precipitating cause is a direct blow to the anteromedial knee region, traumatizing the plica. This results in swelling and infl ammatory changes. Repetitive knee fl exion and extension in such instances may cause thickening and hyalinization within the plica, leading to loss of elasticity. If this is accompanied by increased activities, the narrow, noncompliant structure may act as an abrasive band, rubbing across the medial femoral condyle instead of smoothly gliding over it. This abrasive action with time may result in chondromalacia of the medial femoral condyle. Pathological medial patellar plica has a fairly thickened, rounded, fi brotic, and white inner border. As the knee is moved from extension to 90 degrees of fl exion, this pathological plica makes fi rm contact with the underlying femoral condyle at approximately 30 to 40 degrees of fl exion. Either a softened area of articular cartilage on the edge of the medial femoral condyle or a pannus of synovium growing over the edge of the condyle from the medial gutter is an additional clue that the plica may be pathological and responsible for the patient’s symptoms, provided that the examination and symptom complex are consistent. Clinically, the patient usually describes striking the anteromedial aspect of the knee on a hard object, a fall on the anterior aspect of the knee, or some direct blow to this region. This is followed by a chronic, aching discomfort in the anterior aspect of the knee, which is made worse by activities. The patient also may sense a clicking sensation during fl exion and extension of the joint. Effusion rarely is noted. On examination, a locally tender area well above the joint line on the anteromedial aspect of the knee usually is found. Occasionally, with active fl exion and extension of the joint, a popping of the plica over the medial femoral condyle may be noted, more commonly at about 30 to 40 degrees of fl exion. Sometimes this thickened fi brotic plica is palpable along the medial border of the patella. The initial treatment of pathological medial plica should be conservative. Modifi cation of activities to reduce repetitive fl exion and extension movements of the knee should be advised. The patient should avoid keeping the knee fl exed for prolonged periods, and quadriceps exercises consisting of isometric and stiff-legged exercises are advised, along with a short course of antiinfl ammatory medications. Occasional immobilization of the knee in extension for a few days or a local injection may be benefi cial. Progressive resistive exercises of the quadriceps should be avoided because these repetitive fl exion and extension movements of the knee aggravate the plica. Conservative measures usually are benefi cial in medial plica syndromes of short duration. If the symptoms are chronic, and conservative measures have failed, arthroscopic examination of the knee and resection of the pathological plica may be required.

🔪 Surgical Technique 48-14

• Perform a complete and systematic diagnostic arthroscopy to rule out other intraarticular pathological conditions. If a thickened, inelastic, rounded, and whitish plica is noted, arthroscopic resection of the plica should relieve the symptoms.

• Examine the medial patellar plica with the 30-degree viewing arthroscope in the standard anterolateral portal.

• Confi rm the pathological nature of the plica further by viewing its superior aspect through a superolateral portal.

• If the plica is found to be pathological, it is better to resect a large portion of it, rather than simply to cut it. With the viewing arthroscope in the anterolateral portal, insert scissors or basket forceps through a superolateral portal (or side-biting baskets can be used through the anteromedial portal), advance the scissors or forceps to the medial side wall, and, beginning at the superior aspect of the plica, excise 1 to 2 cm of it. A saucerization of the plica down to the synovial side wall should be the goal of treatment.

Osteochondritis Dissecans of the Femoral Condyles and Patella Osteochondritis dissecans of the knee is a common disorder with an unknown cause. It is thought to result from ischemia of a localized area of subchondral bone, precipitated by infarction, trauma, or other causes. An area of subchondral bone becomes avascular, with subsequent changes occurring in the overlying articular cartilage. Osteochondritis dissecans must be differentiated from true osteochondral fractures and irregular ossifi cation within the femoral condyles. Although it is well established that undisplaced lesions in skeletally immature children heal if immobilized, surgery often is indicated for osteochondritis dissecans in mature or almost mature patients and for patients who have partially or completely detached fragments. Osteochondritis dissecans of the femoral condyles has been classifi ed radiographically, depending on the size and location of the lesion (Fig. 48-37A). Lesions of the medial femoral condyle have been described as central, laterocentral, and inferocentral (Fig. 48-37B). Lesions of the lateral femoral condyle usually are inferocentral and posterior. More than standard anteroposterior and lateral radiographs of the knee are required to evaluate these lesions accurately. Tunnel views, weight bearing lateral views, and patellofemoral joint views are helpful. Radiographs of the opposite knee also are necessary to evaluate for potential contralateral lesions. Bone age fi lms to determine actual skeletal maturity are useful. Bone scans have been advocated, but their usefulness is not well defi ned. MRI is an effective way to evaluate the size and integrity of osteochondritic lesions and may be necessary to determine healing of a lesion. Lesions of osteochondritis dissecans are classifi ed according to their arthroscopic appearance (described subsequently). Guhl and others recommended use of this classifi cation as a basis for treatment. Symptomatic lesions in skeletally immature patients are treated by immobilization for 3 months, the duration being determined by the age of the patient, the size of the lesion, and whether it involves a weight bearing area. Small lesions in non–weight bearing areas can be treated with restriction of activities. Lesions 1 cm or larger in a weight bearing area

A B

Fig. 48-37 Locations of lesions of osteochondritis dissecans. A, Locations of lesions of medial femoral condyle (central, laterocentral, or inferocentral) and of lateral femoral condyle (inferocentral and often posterior). B, Lateral view of medial femoral condyle showing common location of lesions. (From Shahriaree H: O’Connor’s textbook of arthroscopic surgery, Philadelphia, 1984, Lippincott.)

🔪 Surgical Technique 48-14

• Often, the initial division of the plica is accompanied by a snapping apart of the structure and a wide separation of its cut ends, indicating that the plica was under considerable tension. If necessary, insert the motorized shaver or synovial resector through the superolateral portal, and remove the remaining tags of synovium and plica. Avoid overly aggressive synovial resection to reduce postoperative synovitis.

• Thoroughly lavage and suction the joint to remove any remaining debris. are immobilized, and partial weight bearing is allowed until some healing is noted on subsequent radiographs. Lesions destined to heal show some signs of healing over a 3-month period. The immobilizer is discarded after 4 to 6 weeks if symptoms permit. Partial weight bearing is progressed over the subsequent 4 to 8 weeks as healing progresses. Lesions showing no evidence of healing are considered for open or arthroscopic surgical treatment. Early surgical intervention should be considered in lesions that remain symptomatic (effusion and joint line pain) despite a conservative program. This is especially true in children approaching physeal closure. Incidental fi ndings of an asymptomatic osteochondral lesion should be followed by repeat radiographs every 4 to 6 months until the lesion has healed or until skeletal maturity is reached. If after that time the lesion is still asymptomatic, and radiographic fi ndings are benign, follow-up should be on an as-needed basis. Arthroscopic evaluation and treatment are indicated in all patients who are 12 years old or older as determined by bone age radiographs, and who have lesions larger than 1 cm in diameter located primarily in a weight bearing area. Lesions that are massive ( > 3 cm in diameter), lesions having large or multiple loose bodies that are thought to be replaceable, or lesions that are inaccessible to arthroscopic techniques are best treated by open arthrotomy. Treatment of the lesion is based on the arthroscopic examination. The lesions are classifi ed into one of the following groups: (1) intact lesions, (2) lesions showing signs of early separation, (3) partially detached lesions, and (4) craters with loose bodies (salvageable or unsalvageable). An intact lesion presents only a minor irregularity of the articular surface, with no break in the continuity of the surface. This is determined by careful palpation and probing with the arthroscope probe. These lesions are treated by drilling multiple holes through the articular surface and into the subchondral fragment and underlying vascular bone. Because the articular surface viewed arthroscopically may show little or no surface irregularity, palpation of the softened defect is the best means for identifying the lesion. Having preoperative images available and using an image intensifi er during this process may assist in locating the site for drilling. An early separated lesion presents an essentially intact smooth articular surface, but with greater irregularity than that of an intact lesion. The articular surface at some point shows a break in a small portion of the periphery of the lesion, and the fragment moves signifi cantly when probed. These lesions should be treated by débridement and smoothing of the break in the articular surface followed by fragment stabilization. The fragment can be secured with a bioabsorbable pin or screw or by arthroscopic insertion of cannulated screws. Screws have the advantage of fragment compression, which may be helpful in larger lesions. The disadvantages of screws are the technical diffi culty in proper insertion and often the need for removal. Cannulated screws or bioabsorbable screws generally are reserved for larger defects or lesions in weight bearing regions, and non–weight bearing is necessary for approximately 6 weeks after surgery. Most metal screws need to be removed. A partially detached lesion presents a greater disruption in the articular surface and, with probing, the lesion can be displaced or hinged on one edge. These lesions should be hinged open and the crater débrided to remove fi brous tissue and stimulate petechial bone bleeding. Occasionally, cancellous bone grafting in the crater base is required. When viewed arthroscopically, lesions that already have developed a loose body and a crater are treated by reconstruction of the crater, that is, by curettage and débridement to bleeding bone, and by contouring and smoothing the edges and walls of the crater. If the loose body has detached recently, as indicated by hemorrhage or a little fi brous material within the crater, and the loose body can be replaced congruously, it is secured back in the crater and stabilized. Most loose bodies cannot be replaced congruously, however, and require removal and reconstruction of the crater base. Ewing and Voto reported 29 patients who had drilling of the crater after excision of the fragment, with satisfactory results in 72%. Steadman et al. reported good results using a microfracture technique with an arthroscopic awl to make small osseous fractures every 3 to 4 mm. Long-term results are best when larger weight bearing defects, 1 to 2.5 cm in size, are fi lled with autogenous osteochondral graft in active individuals. Osteochondritis dissecans of the patella may occur on the medial or lateral facet and the central ridge or the medial or lateral aspect of the trochlea. Peters and McLean described 37 patients they treated with débridement, and some also had lateral releases. Of these patients, most were improved, but had persistent patellofemoral crepitance and discomfort with activities. In the case of localized lesions, microfracture is the fi rst line of treatment. For persistent mechanical symptoms with swelling and pain that does not respond to conservative treatment or microfracture, a second line of treatment in a mature individual with these lesions would be anterior medialization of the tibial tuberosity and autogenous osteochondral transplant as an open procedure if indicated (see Chapter 43). When reviewing the literature with articles by Cole et al., Peterson et al., Knutsen et al., Bentley et al., and others, it is important to note that the condition of the surrounding cartilage, viability of the meniscus, stability of the knee, and alignment of the extremity weighed greatly on the long-term results of these lesions. Primary procedures as noted are usually microfracture or autogenous osteochondral transfer for lesions that are less than 2.5 cm. Cole et al. recommended osteochondral transfer for more active individuals, although one must recognize that transfer of a cartilage from one area to another does in itself produce the potential for further joint symptoms. Larger lesions, in which the fragment can be fi xed back to its bed, generally should fi xed with bioabsorbable or metal screws using an open technique. In larger lesions, requiring cartilage transfer, the options are microfracture, autogenous chondrocyte implants, or allograft use. For lesions larger than 2.5 cm in size, results vary, but if realignment procedures are performed, and the joint is stabilized, the autogenous chondrocyte implant and allograft procedures tend to have about 80% good results. These techniques are discussed in Chapter 43.

Arthroscopic Drilling of an Intact Lesion of the Femoral Condyle TECHNIQUE 48-15

• Perform a complete and systematic diagnostic arthroscopy with the 30-degree viewing arthroscope in the anterolateral portal.

• Inspect carefully the articular surface of the medial femoral condyle, varying the degree of fl exion of the knee between 20 and 90 degrees to view the posterior extent of the lesion. The articular surfaces appear smooth except for a slightly raised irregularity at the borders of the lesion.

• Insert a probe through the anteromedial portal, and carefully probe this irregular line to ensure there is no break in the articular surface with the lesion. Use of crutches with partial weight bearing is encouraged until early healing is noted radiographically. Four to six weeks of immobilization for young patients is common, whereas older patients with larger lesions should continue the immobilization and avoid weight bearing until defi nite radiographic evidence of healing is noted. Range-of-motion exercises should be performed for 15 to 20 minutes two to three times daily.

Arthroscopic Screw Fixation for Osteochondritis Dissecans Lesions in the Medial Femoral Condyle

For small ( < 2.5 cm), relatively stable lesions, we generally prefer the use of an absorbable fi xation device. We have had good results with the Bionx nail (Bionx Implants, Blue Bell, Pa).

🔪 Surgical Technique 48-16

• Expose the area around the fragment. Preserve all major arteries and nerves by careful dissection.

• Screw the SmartNail arthroscopic tip into place on the threaded front of the arthroscopic handle, and tighten the tip with the wrench. Insert the tip into the joint on top of the fragment.

• Obtain alignment of the fracture, and fi x with 1.5-mm Kirschner wires.

• With the help of the side holes on the handle, fasten the tip in the desired position, using Kirschner wires of 1.5 mm diameter (Fig. 48-39A).

• Drill a hole through the fragment and into the solid bone using a 1.5-mm-diameter SmartNail arthroscopic drill. The drill has three sizing depth marks, indicating the length in millimeters.

• Advance the drill until the desired depth mark aligns with the side holes in the rear portion of the handle (Fig. 48-39B). The SmartNail arthroscopic tip has a window to allow viewing of the SmartNail on insertion.

• Insert a SmartNail of desired length into the rear of the introducer, applying gentle pressure with the fi ngers (Fig. 48-39C).

• Insert the SmartNail arthroscopic piston into the distal end of the arthroscopic housing and screw it into place on the rear part of the handle. Turn approximately two revolutions to seat the rear part tightly into the handle (Fig. 48-39D).

• Lightly tap the proximal end of the SmartNail arthroscopic piston with a hammer. An etching on the rear of the piston indicates when the piston is in the fi nal position (Fig. 48-39E).

Arthroscopic Drilling of an Intact Lesion of the Femoral Condyle TECHNIQUE 48-15—cont’d continuity of the articular surface overlying the subchondral bone lesion.

• If the lesion is intact, perforate it with multiple holes using a 0.062-inch Kirschner wire. Position the Kirschner wire perpendicular to the articular surface, with the soft tissues protected by a sleeve or cannula over the wire (Fig. 48-38). Access for drilling inferocentral lesions of the medial femoral condyle usually is through the anteromedial portal; laterocentral lesions may be approached better by bringing the Kirschner wire through the anterolateral portal, while viewing through the anteromedial portal. Large lesions may require some drilling through anteromedial and anterolateral portals. Penetrate the articular surface, the subchondral lesion, and the underlying bone to a depth of 1 to 1.5 cm to ensure vascular access to the lesion. If the patient is not fully skeletally mature, and the physis is open, take care not to penetrate too deeply and injure the physis.

• Thoroughly lavage and suction the joint, and remove the instruments.

AFTERTREATMENT Postoperative management consists of immobilization in a restricted motion brace, with the arc of motion controlled to prevent contact of the tibial

Fig. 48-38 Technique for drilling intact lesion of osteochondritis dissecans. Multiple perforations of lesion of medial femoral condyle are made using Kirschner wire through anteromedial portal.

3 depth marks

Side holes

25 20 16

Window

Housing

Piston

Window

Etching

Kirschner wire

A B C

D F E

Fig. 48-39 A, View of fragment with arthroscopic tip inserted into joint. B, Hole drilled through fragment. Inset shows close-up of depth marker. C, Screw inserted into rear of introducer. Tip has window to visualize SmartNail on insertion. D, Piston screwed into place. E, Mark on rear of piston indicates fi nal positioning. F, Inserting screws at angle secures fi xation. (Redrawn from SmartNail surgical technique manual, Bionx Implants, 2000, Blue Bell, Pa.)

🔪 Surgical Technique 48-17

• Two surgical approaches can be used, internal and external.

• Use radiographs or image intensifi cation to confi rm the correct location of the screw, especially if multiple fragments are present.

• Place the knee at an angle, depending on the location of the osteochondritic lesion. Insert the Herbert screw guide, and make a perforation through it.

• Measure the length of the screw, and insert it. Depending on the size and fragmentation of the lesion, use one or more screws as needed.

• After placing the screws, make multiple perforations with a 2mm bit. If only one screw is required, use absorbable pins to increase rotational stability.

• In type 2B lesions, in which the crater is covered with a thin layer of fi brous tissue, clean and abrade the crater to reposition the fragment.

• In type 3 lesions, with loose fragments, use an arthroscopic burr to freshen the crater and basal side of the fragment, and insert four Herbert screws.

• Do not abrade too much because the fragment can sink and cause articular incongruency. free within the joint usually are not suitable for reduction and fi xation or bone grafting. Only a recently detached loose body with viable cartilage and bone and a fresh crater base is suitable for replacement and fi xation. More often the loose body or bodies become rounded off and cannot be made to fi t congruously back within the crater by either open or closed methods. In these instances, the loose bodies should be extracted from the joint, the base of the crater cleared of fi brous debris, the underlying eburnated and sclerotic bone perforated with multiple drill holes or abraded to bleeding cancellous bone, and the edges and walls of the crater contoured and smoothed without removing additional healthy articular cartilage. Postoperatively, immediate motion and weight bearing are allowed. Prolonged protection in these circumstances does not seem to improve coverage of the base of the crater with fi brocartilaginous tissue. Constant passive motion for 6 weeks has proved effective. Larger defects (1 to 2.5 cm) in a weight bearing portion with a wall of intact cartilage surrounding the defect are preferably treated by use of an osteochondral autograft transfer (OATS) type of graft to plug the defect.

Osteochondral Autografts The fi rst reports of osteochondral autograft transfer were by Yamashita et al. in 1985. They reported the successful transfer of autograft osteochondral fragments in two adult patients with osteochondritis dissecans of the knee. In 1992, Fabbriciani et al. reported 12 osteochondral transfers for osteochondritis dissecans. Joint surfaces at the donor transfer sites appeared normal or near-normal at 2to 3-year follow-up. Repair of osteochondral defects by allograft transfer was fi rst described by Lexer in 1908. McDermott et al. published an extensive report of 100 patients treated with allograft transfers in 1985. They obtained good or excellent results in 75% of their patients at 5-year follow-up and in 69% at 10-year follow-up. In 1986, Garrett reported improved clinical results in 10 patients at 2to 4-year follow-up after osteochondral allograft transfer. Beaver had a 75% success rate in 92 patients at 5-year follow-up and 63% at 14-year follow-up. The osteochondral transfer method for autogenous material has developed into two similar procedures. One method, advocated by Bobic and Morgan from the United Kingdom, was developed by the Arthrex Corporation and involves the use of individual donor cores 5 to 10 mm in size. Smith & Nephew, in conjunction with Hangody, from Hungary, developed the transfer system using smaller plugs, ranging from 2.7 to 8.5 mm. They believe that smaller plugs cause less trauma to the donor site and can be plugged into the recipient site to restore an area about 2 cm in diameter. The Arthrex system uses a larger graft, which proponents believe fi lls the recipient site with more cartilage and can be used in defects ranging from 1 to 2.5 cm. Many

🔪 Surgical Technique 48-16

• Built into the instrumentation is a countersink, allowing the SmartNail to penetrate totally beneath the surface of the cartilage. If necessary, the procedure is repeated for more fi xation.

• Secure the fi xation by inserting the second SmartNail at an angle and not parallel to the fi rst SmartNail (Fig. 48-39F).

Arthroscopic Screw Fixation for Large Osteochondritis Dissecans ( > 2.5 cm)

For larger osteochondritis dissecans lesions with a fi rm crater, we prefer screw fi xation, either with the Accutrac screw or with Herbert metal screws, with the LactoSorb (Biomet, Inc., Warsaw, Ind) absorbable screw for open stabilization. These devices allow compression and better stabilization of the lesion than the absorbable pin fi xation.

AFTERTREATMENT Immobilization is unnecessary. Isometric exercises can be started the same day. A period of 10 weeks of non–weight bearing for the affected limb is advised.

Osteochondritic Loose Bodies Osteochondritic loose bodies that are already completely detached and fl oating researchers think that the most advantageous size graft is 4.5 to 6.5 mm. When multiple grafts are used (mosaicplasty), Hangody et al. suggests using an open technique to enable ideal restoration of the articular cartilage surface. When multiple grafts are taken, the defect is thought to fi ll with about 60% to 80% of hyaline cartilage. To maximize cartilage transfer, a cartilage bone paste can be used to fi ll the small defects between the cartilage surfaces. Osteochondral autograft transfer is indicated for patients who are younger than age 45 years and have a sharply defi ned defect with normal-appearing hyaline cartilage surrounding the borders of the defect. Lesions should be unipolar and generally no more than 2 to 2.5 cm. Relative contraindications to the procedure are patient age older than 45 years and obvious chondromalacia of the articular cartilage surrounding the defect. For best long-term results, normal mechanical alignment and a stable knee are necessary.

🔪 Surgical Technique 48-18

• Inspect the osteochondral defect arthroscopically, and measure the size of the lesion. Use a set of OATS sizer/tamps with heads of 5 to 10 mm to determine precisely the diameter of the defect. The color-coded tamps correspond in size with the diameter of the tube harvesters (Fig. 48-40A).

• Assemble the tube harvester driver/extractor.

• Load the donor tube harvester with the collared pin into the base of the driver, and tighten the chuck. Screw a cartilage protector cap onto the back of the driver. When seated, the collared pin protrudes a few millimeters past the sharp cutting tip of the harvester to protect articular surfaces (Fig. 48-40B).

• When an acceptable position is established, drive the donor harvester with a mallet into subchondral bone or to a depth of approximately 15 mm. Avoid rotating the harvester during impaction.

• Remove the harvester and bone core by axially loading the harvester and rotating the driver 90 degrees clockwise, then 90 degrees counterclockwise (Fig. 48-40C).

• Fully insert the recipient harvester into the driver, and insert the protector caps in a similar fashion. During socket creation, maintain a 90-degree angle to the articular surface to end up with a fl ush transfer. Rotate the harvester so that the depth markings are seen. Maintain a constant knee fl exion angle during harvesting (Fig. 48-40D).

• After using a mallet to drive the tube harvester into subchondral bone to a depth of approximately 13 mm (2 mm less than the length of the donor core), extract the recipient bone core in the same manner as the donor bone core, and measure and record the depth of the core (Fig. 48-40E).

• Use the calibrated OATS alignment stick of the appropriate diameter to measure the recipient socket depth and align the angle of the recipient socket correctly in relation to the position of the insertion portal when using an arthroscopic approach (Fig. 48-40F).

• Reinsert the donor harvester, collared pin, and autograft core into the driver. Unscrew the cap and remove the T -handled midsection. This exposes the end of the collared pin that is used to advance the bone into the recipient socket.

• Insert the pin calibrator over the guide pin, and press into the open back of the driver (Fig. 48-40G). Insert the donor tube harvester’s beveled edge fully into the recipient socket. Stabilize the harvester during autograft impaction. Use a mallet to tap the end of the collared pin lightly and drive the bone core into the recipient socket (Fig. 48-40H).

• Maintain a stable knee fl exion angle and position of the harvester during this step. Carefully advance the collared pin until the end of the pin is fl ush with the pin calibrator on the back of the driver/extractor. This provides exact mechanical control to ensure proper bone core insertion depth. The predetermined length of the collared pin is designed to advance the bone core so that 1 mm of graft is exposed from the recipient socket when the pin is driven fl ush with the end of the pin calibrator. One can see the core insertion as it is occurring by viewing the core and the collared pin advancement through the slots in the side of the harvester.

• Alternatively, the core extruder is an option to using the mallet to insert the bone core into the recipient socket. Place the donor harvester into the chuck of the fully assembled tube harvester driver/extractor. As described previously, insert the beveled edge of the donor tube harvester into the recipient socket. While keeping the donor tube harvester fi rmly in position, slowly screw the core extruder into the rear of the fully assembled driver/ extractor. Advance the core extruder by turning it in a clockwise motion, forcing the bone core from the donor tube harvester into the recipient socket. When the core extruder is fully seated, the bone core should remain slightly proud.

• Remove the donor tube harvester, and position a sizer tamp, measuring at least 1 mm in diameter larger than the diameter of the bone core, over the bone core. Final seating of the bone core fl ush with surrounding cartilage is achieved by tapping the tamp lightly with the mallet (Fig. 48-40I).

• When multiple cores of various diameters are elected to be harvested and transferred into specifi c quadrants of the defect, each core transfer should be completed before proceeding with further recipient socket creation. This prevents potential recipient tunnel wall fracture and allows subsequent cores to be placed directly adjacent to previously inserted bone cores (Fig. 48-40J).

Bone Grafting Cancellous bone grafts can be packed into the base of the crater in partially detached lesions before reduction and fi xation to obliterate step-off. A cancellous graft can be obtained from the proximal tibia, using a trephine coring needle or similar device to obtain the harvest.

Recipient

5 10 15 20

10 15 20

Alignment stick

Donor

E D F

B A C

90°

Donor

5 10 15 20

5 10 15 20

Fig. 48-40 A, Size of defect determined. B, Harvester driver extractor assembled with tube harvester and collared pin loaded. C, Harvester driven into subchondral bone. D and E, Harvesting of graft. F, Calibrated OATS alignment stick of appropriate diameter used to measure recipient socket depth and align angle of recipient socket correctly to position of insertion portal.

This is placed arthroscopically or by open technique behind the osteochondritis dissecans lesion, packing it to a smooth surface before fi xation with a cannulated screw. Sgaglione described treatment alternatives for osteochondritis dissecans and localized osteochondral fractures (Fig. 48-41). We prefer local transfer of osteochondral grafts or, for large lesions, allograft plugs or autologous chondrocyte implantation. For successful repair of these lesions, the technique must be followed closely. The overall indications must be present without contraindications as listed in Figure 48-41, and the patient must understand that these procedures are relatively new and do not have extended long-term follow-up at this time. Autogenous chondrocyte implantation of the osteochondritis dissecans

H G

J I

Fig. 48-40, cont’d G, Donor harvester, collared pin, and autograft core reinserted into driver. H, Donor tube harvester inserted into recipient socket. I, Sizer tamp, measuring 1 mm in diameter larger than bone core, positioned over bone core. J, Harvested and transferred cores. (Redrawn from Bobic V, Morgan CD: Osteochondral autograft transfer surgical technique manual, Arthrex, 2000, Naples, Fla.)

lesions should be contained and should have a depth of bone loss of less than 8 mm. Bone loss of more than 8 mm should be bone grafted, and a staged procedure should be performed 6 to 12 months later. These techniques are discussed further in Chapter 43.

Cruciate Ligament Reconstruction Arthroscopic techniques have been advanced and refi ned to assist in the reconstruction of the anterior and posterior cruciate ligaments. The arthroscopically aided approach has the advantages of smaller skin and capsular incisions, less

Contained

MCS

*Overall indications: symptomatic, unipolar, nonarthritic, compliant, aligned, no patholaxity, more than two thirds of meniscus intact, age younger than 55 years, body mass index less than 30, no rheumatoid arthritis or cardiovascular disease. ACI , Autologous chondrocyte implantation; TKR , total knee replacement; MCS , mesenchymal cell transplantation; OAT , osteochondral autograft transplantation.

10 cm 2

Femoral Condyle/ Trochlea Focal Lesions Overall indications satisfied * Size as determined on fast spin-echo MR or diagnostic arthroscopy

Patient not willing to tolerate extended recovery

Patient willing to tolerate extended recovery

Low demand

Low demand High demand

High demand

ACI or allograft plugs Debride

Debride

Contained

MCS MCS

Failure

Noncontained

MCS OAT ACI

Salvage cases Posttrauma defect Bone defects

Fresh allograft or TKR

Bone defect

Graft ACI allograft plug TKR

Intact bone

ACI

2.5 – 10 cm 2 2 – 2.5 cm 2

Fig. 48-41 Clinical algorithm for treatment of articular cartilage lesion. (From Sgaglione NA, Miniaci A, Gillogly SD, et al: Update on advanced surgical techniques in the treatment of traumatic focal articular cartilage lesions in the knee, Arthroscopy 18[2 suppl 1]:9, 2002.) extensor mechanism trauma, improved viewing of the intercondylar notch for placement of the tunnel and attachment sites, less postoperative pain, fewer adhesions, earlier motion, and easier rehabilitation. General principles for anterior and posterior cruciate ligament reconstructions are discussed in Chapter 47, and only pertinent portions of the arthroscopic technique are described here. The selection of grafts depends on the surgeon’s preference and the tissues available. Among the autogenous tissues currently available, the most commonly used are central one-third patellar tendon, quadrupled hamstrings, and, less commonly, quadriceps tendon grafts. Each of these grafts has been shown to have suffi cient load-tofailure strength and stiffness to replace the cruciate ligament (Table 48-3). Another important consideration in selecting an appropriate graft is graft creep or stress relax- ation of the graft over time, the occurrence of which may be more frequent with hamstring tendons than with ligaments, such as the patella or quadriceps ligament. Fixation strength, including pull-out strength, graft slippage, and bony ingrowth, also is important. Fixation with interference screws, if performed properly, provides suffi cient strength with bone–patellar tendon–bone grafts. Use of the Bioscrew for fi xation of soft-tissue grafts is enhanced by tunnel compaction and secondary fi xation. The problem with soft-tissue grafting is the increased propensity for slippage with cyclic loading, which has been shown by Rosenberg, Brand et al., and others. Also, the “bungee cord effect” caused by EndoButton (Smith & Nephew Endoscopy, Acufex, Andover, Mass.) linear fi xation away from the joint line may allow for greater graft excursion and possibly for inferior fi brous ingrowth.

The time of graft incorporation into bone varies considerably from study to study, ranging from 3 weeks for bone plugs to more than 3 months for soft tissues. Generally, bone plug graft incorporation into the tunnel occurs at around 6 weeks, with soft-tissue grafts taking 2 to 3 weeks longer. Donor morbidity and cosmesis also must be considered when choosing a graft. Bone–patellar tendon–bone harvest is associated with increased risk for patellar tendinitis, especially if larger grafts are harvested. Acute and delayed stress fractures of the patella resulting from taking too deep of a graft also have been reported. The weakness from harvesting the hamstring is in itself insignifi cant, but injury to the saphenous nerve from graft harvest can be detrimental. The ideal graft and graft fi xation techniques are still being developed. At this time, the patellar tendon and hamstring grafts when fi xed at the joint line with secondary fi xation on the tibia have almost equal results. Wagner found slightly better results with a hamstring, but most studies show comparable results with newer fi xation techniques. A graft with low morbidity; excellent cosmesis, strength, and stiffness; and secure early fi xation and incorporation near the joint line are the ultimate goals of anterior cruciate ligament surgery. At this time, there are approximately 100,000 anterior cruciate ligament reconstructions done yearly, with the number increasing. Also, the number of allografts being used for primary and revision procedures is increasing. The advantages of using allografts are decreased postoperative morbidity, improved cosmesis, decreased operating time, and preservation of the extensor mechanism, which may eliminate some postoperative symptoms of tendinitis or chondromalacia. Arguments against using allografts are that the length of time for allograft maturation and the percentage of incorporation of the graft into the ligamentous structure vary. The potential for infection is low, including bacterial infection and hepatitis. The possibility of AIDS transmission is approximately 1 in 1.5 million. The cost and availability of good, young allografts of appropriate length also is an issue. The increased use of allografts in primary procedures is making it more diffi cult

Table 48-3 • Ultimate Load to Failure and Stiffness of Current Graft Selections in Cruciate Ligament Surgery

Graft Selection Ultimate Strength to Failure (N) Stiffness (N/mm)

Native ACL (Woo et al.) 2160 242 Native PCL (Race, Amis) 1867 Patellar tendon (Cooper et al.) 2977 455 Quadruple hamstring tendon (semitendinosus and gracilis) (Hamner et al.) 4140 807 Quadriceps tendon (Stäubli et al.) 2353 326

ACL, anterior cruciate ligament; PCL, posterior cruciate ligament. From Brand J, Weiler A, Caborn DNM, et al: Graft fi xation in cruciate ligament reconstruction, Am J Sports Med 28:761, 2000. to obtain these for revision or for multiple ligament procedures. The use of allografts in our opinion is best reserved for revision surgery in patients who do not wish to have the patellar tendon harvested from the contralateral leg and for patients with multiple ligamentous injuries in whom morbidity may be increased from harvesting a graft in an already severely injured knee. Noyes and others have shown allografts to have a slower incorporation rate and a higher propensity for elongation over time than autografts. At this time, most authors show some increased propensity for laxity and for failures with allografts compared with the primary autografts. In revision surgery, results from Johnson et al., Noyes and Barber-Westin, and Uribe et al. show failure rates ranging from 27% to 46%. The best results are obtained with the use of autografts. The fi rst attempt at anterior cruciate ligament reconstruction should be the best attempt. At present, Delay et al. found that approximately 85% of anterior cruciate ligament reconstructions involved oneincision endoscopic technique, with about 12% being twoincision and 3% being mini open techniques. Hamstrings probably have increased in popularity but still are used less than the patellar tendon. Woo et al. studied the use of hamstrings and patellar tendons in a cadaver model and found that although both decreased translation, neither hamstrings nor patellar tendons consistently eliminated pivot shift. Their study in a laboratory model suggested that a double-bundle anterior cruciate ligament reconstruction gave superior results to single-bundle techniques. Studies by Hamada et al. and Adachi et al. found no differences in stability produced by a double-bundle technique compared with a single-bundle anterior cruciate ligament reconstruction technique. Tasaki found that with a doublebundle anterior cruciate ligament reconstruction, there was some evidence of partial disruption of one of the bundles at follow-up arthroscopy. There is a theoretical advantage to the double-bundle reconstruction, but in reality with the increased diffi culty of the procedure and the problem with getting both bundles in a secure, nonimpinged position and the potential for signifi cant problems with any later revisions this procedure should be done in a few centers to determine if the benefi ts outweigh the risks. The keys to surgical success are ample mental preparation, knowledge of recent literature, and proper patient evaluation, including assessment of potential stresses, ligamentous defi ciencies, and ultimate goals of the patient. This evaluation should help to determine what to correct and how and when to proceed with surgery. Finally, prioritizing the surgical approach is necessary as far as alignment, instability, articulation, and meniscus are concerned. Preparation also includes knowledge of potential complications and the ability to recognize and resolve them (Figs. 48-42 and 48-43).

Anterior Cruciate Ligament Reconstruction For pathological laxity of the anterior cruciate ligament in an active, healthy individual who wishes to remain active, our preferred treatment is endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft. Surgery is performed as an outpatient or 23-hour admission after the acute infl ammatory reaction has resolved. We use physical therapy to regain muscle tone and motion before the surgical procedure, which usually takes 10 to 21 days before surgery.

Ingrowth (maximize contact) (minimize motion)

Bungee effect (endobutton)

Bone mineral index (dilation)

Screw divergence  15 ° Pull-out (15-mm fixation)

Screw size–gap size  5

Graft–tunnel length mismatch

Slippage

Harvest morbidity Tendinitis Patellar fracture Neuropathy Strength Stiffness Creep (pretension)

Delayed maturation

Immune response

Fixation Impingement Unrestricted rehabilitation

Untreated instabilities (posterolateral corner)

Malalignment

Excessive graft stress

Surgical limitations Resistant organisms Location Autograft Allograft

Joint proximity Physiometric Impingement free

(Postoperative infection) Chondral/meniscal damage Graft rejection Healing response Arthrofibrosis RSD

Bone–Patellar Tendon–Bone Graft: Endoscopic Technique TECHNIQUE 48-19

• Place the patient supine on the operating table.

• After general endotracheal anesthesia has been administered, examine the uninjured knee to obtain a reference examination for ligamentous laxity. Examine the injured knee and record Lachman and pivot shift instability.

• Apply a tourniquet around the upper thigh, and use a wellpadded lateral post. Secure a 5-L intravenous saline bag to the table to act as a stop to maintain 90 degrees of knee fl exion (Fig. 48-44A).

• Prepare and drape the extremity with standard arthroscopy drapes, and use an Esmarch wrap for exsanguination. Infl ate the tourniquet to 100 mm Hg above the patient’s systolic pressure.

• If preoperative examination revealed signifi cant laxity, proceed with patellar tendon harvesting.

• Arthroscopic joint portals can be made through this initial skin incision. If the status of the anterior cruciate ligament is in question (Fig. 48-45) or if more than 90 minutes of tourniquet time is anticipated for completion of the procedure, standard

Fig. 48-42 Causes of complications of anterior cruciate ligament reconstruction.

Preparation • Analyze (patient, literature, failures) • Simplify • Prioritize

Performance • Knowledge and skill • Adherence to details • Avoidance, recognition • Early intervention in complications

Implementation • Correct and refine techniques • If it isn’t working, fix it

Evaluation • Honest assessment of surgical results • Radiographs, examination, KT-1000

Fig. 48-43 Keys to surgical success. arthroscopy portals should be made for joint evaluation and notch débridement before infl ating the tourniquet and making the skin incision for harvest of the patellar tendon.

• Inject the portals with lidocaine and epinephrine to help control bleeding and maintain hypotensive anesthesia. An arthroscopy pump can be used to maintain proper joint distention and to reduce bone bleeding.

• Unless contraindicated, administer ketorolac (Toradol) before tourniquet infl ation and antibiotics (30 mg intravenously in patients younger than 65 years; 15 mg in patients older than 65 years or in those weighing less than 50 kg). Two additional doses can be given postoperatively, not to exceed 120 mg or 60 mg, respectively.

GRAFT HARVEST

• With the knee held in 90 degrees of fl exion, make a 6-cm medial parapatellar incision starting inferior to the patella and extending distally medial to the tibial tuberosity. The length of this incision depends on the size of the patient.

• Expose the patella and tendon by subcutaneous dissection.

• Make a straight midline incision through the peritenon, and dissect the peritenon from the patellar tendon, taking the fl aps medially and laterally.

• With the knee held fl exed to maintain some tension on the patellar tendon, measure the width of the tendon.

• Harvest a 10-mm-wide graft or one third of the tendon, whichever is smaller, from the central portion of the tendon, extending distally from the palpable inferior tip of the patella. Maintain straight, single-fi ber plane incisions while harvesting the tendon.

• Use an oscillating saw with a 1-cm-wide blade to make the bone cuts. Run the saw blade 15 degrees oblique to a line perpendicular to the anterior cortex of the patella, keeping 2 mm of the saw blade visible, to make a cut 8 mm in depth. This cut should be about 10 mm wide × 20 mm long measured from the bony tip of the patella.

• Make 25-mm-long cuts distally, and free the tibial graft with a curved osteotome.

• Flip the plug, and place it back into the harvest site. Drill a 2-mm hole, 3 mm from the distal tip of the plug, and pass a No. 5 Tevdek suture (Deknatel OSP, Fall River, Mass.). An assistant should hold this at all times to ensure that the graft is not contaminated.

• Complete the patellar cut with the saw or an osteotome placed at the inferior pole of the patella, 7 to 8 mm deep and parallel to the anterior cortex.

GRAFT PREPARATION

• Secure the graft to the top drape on a previously prepared table that holds appropriate-sized bone plug trials, rongeurs, a 2-mm drill bit, a Silastic block, a skin marker, No. 5 Tevdek sutures on Keith needles, and an 18-gauge steel wire.

• Commercially available graft preparation boards make tensioning and graft preparation much easier (Fig. 48-44B).

• Contour the graft with the rongeurs so that it fi ts through the 10-mm trial, ensuring that the complete graft would pass through the trial.

• Drill a single hole in the patellar plug about 3 mm from the end.

• Round the end of the bone plug to make passage easier.

• Drill a hole in the tibial bone plug.

• Place a No. 5 nonabsorbable suture through the better bone plug to be placed into the femoral tunnel and an 18-gauge wire through the other plug, which is placed into the tibial tunnel. The use of a wire prevents suture failure before fi rm fi xation is obtained.

• Maintain tension on the graft (with the help of a tension board or an assistant).

• Use a 2-0 absorbable suture to roll the graft edges together with a running suture through only the anterior fi bers of the graft.

• Mark the bone-tendon junction on the cancellous side of the graft at both ends with a methylene blue pencil, and measure the total graft length.

NOTCH PREPARATION

• Use electrocautery to make an inverted L –shaped fl ap through the tibial periosteum, starting about 2.5 cm distal to the joint line and extending distally 1 cm medial to the tibial tuberosity.

A B

C D

E F

50° 30°

3 cm

5 cm

1-2 mm posterior wall Slope of medial tibial spine

Edge of lateral meniscus

Fig. 48-44 A, Saline arthroscopy bag is secured to table to assist in maintaining knee fl exion. B, Prepared graft with No. 5 suture and bone plug. C, Complete resection of soft tissue to back of notch for clear viewing of over-the-top spot. D, Increase in tibial guide angle. Length of tunnel can be increased. E, Tibial guide is positioned so that Kirschner wire enters joint at base of medial tibial spine just medial to center of intercondylar notch. F, Three reference points—inner edge of lateral meniscus, base of medial spine, and posterior cruciate ligament— are used for tibial guidewire.

G H

K

L

35°

A B

J I

Fig. 48-44, cont’d G, Tibial tunnel should be posterior to roof of altered intercondylar notch to prevent graft impingement in knee extension. H, Use of 7-mm femoral offset guide to assist with femoral guidewire placement. I, Derotation slot at 12-o’clock position on femoral tunnel to allow guidewire placement and viewing of recessed graft and to prevent posterior migration of interference screw. J, Use of probe to guide graft into femoral tunnel, with cancellous portion of graft directly anterior. K, With knee fl exed more than 100 degrees, guidewire is placed up femoral tunnel through middle cannula. Interference screw is passed, ensuring that guidewire and traction suture is a straight line and ensuring minimal divergence between screw and bone plug. L, Use of sheath to protect graft and to assist in placing screw parallel to graft.

A B

Fig. 48-45 A, Calcifi ed stump of anterior cruciate ligament after chronic tear. B, Empty lateral wall sign indicating anterior cruciate ligament–defi cient knee; anterior cruciate ligament can be attached to posterior cruciate ligament, giving false indication of functional ligament.

Bone–Patellar Tendon–Bone Graft: Endoscopic Technique TECHNIQUE 48-19—cont’d

• Refl ect the fl ap medially with a periosteal elevator to expose the proximal tibia for later placement of the tibial tunnel.

• Make standard anteromedial and anterolateral arthroscopy portals, taking care not to damage the remaining portion of the patellar tendon. If a separate infl ow is being used for the arthroscopy pump, make a portal just medial to the inferior pole of the patella so that the cannula can be placed just superior to the notch for an unobstructed fl ow.

• Systematically examine the knee, and evaluate and treat any associated intraarticular pathological condition.

• Perform meniscal suturing before securing the anterior cruciate ligament graft.

• Tie the meniscal sutures after completing the anterior cruciate ligament reconstruction.

• With the arthroscope in the anterolateral portal and a 5.5-mm full-radius resector in the anteromedial portal, release the ligamentum mucosum and partially resect the fat pad to allow full exposure of the joint during the procedure.

• Resect the soft tissue from the intercondylar notch and from the tibial stump by sliding the resector between the remaining stump of the anterior cruciate ligament and the posterior cruciate ligament. The opening of the blade should always be pointed superiorly or laterally to avoid damage to the posterior cruciate ligament (see Fig. 48-45).

• Leave the outline of the tibial footprint intact as a reference guide.

• Avoid damaging the intermeniscal ligament just anterior to the tibial stump.

• Completely resect the femoral stump posteriorly to allow full exposure of the over-the-top position (Fig. 48-44C).

• With the knee in 30 degrees of fl exion to expose the opening of the notch, evaluate the available space between the posterior cruciate ligament and lateral wall and the architecture of the roof. Use a 5.5-mm burr to enlarge the notch as indicated. The notch should be opened to look like an inverted “U.” Do not extend the notchplasty too far medially or superiorly, which would interfere with the patellofemoral articulation. Often, the opening needs to be enlarged only 2 to 3 mm superiorly and laterally. The burr can be placed in reverse to remove the articular fringe and smooth the initial notchplasty.

• As the notchplasty proceeds posteriorly, fl ex the knee from 45 to 60 degrees; when the notchplasty is complete, the knee should be at 90 degrees of fl exion. Use controlled strokes with the burr from posterior to anterior. Posteriorly, open the notch enough to accommodate the 10-mm endoscopic reamer. Smooth the edges of the tunnel by placing the burr in reverse or by using an arthroscopic rasp.

• With a curved curet, make a femoral pilot hole about 7 mm anterior to the over-the-top spot at approximately the 10:30o’clock position on the right knee or the 1:30-o’clock position on the left knee. The knee must be fl exed at least 90 degrees to allow viewing of the over-the-top spot (see Fig. 48-44C).

TIBIAL TUNNEL PREPARATION AND DETERMINING APPROPRIATE LENGTH

• When placing the tibial guide, be aware of the intended tunnel length and direction so that the graft can be secured in a physiometric, impingement-free position. Proper length and direction of the tunnel require a starting point approximately 1 cm proximal to the pes anserinus and about 1.5 cm medial to the tibial tuberosity to form a 30to 40-degree angle with the shaft of the tibia. One should see this wire being directed to approach the femoral pilot hole (see Fig. 48-44D). Intraarticular reference points that can serve as guides include the anterior cruciate ligament stump, the inner edge of the anterior horn of the lateral meniscus, the medial tibial spine, and the posterior cruciate ligament.

• When evaluating pin placement in a two-dimensional picture, in the anteroposterior plane, ensure that the guidewire approximates a reference line extended medially from the inner

Table 48-4 • General Guidelines for Tunnel Preparation

Tendon Length Guide Setting Tips (mm) (degrees)

35-40 55 Adjust tibial guide setting so that tunnel length approximates tendon length 40-50 60 Recess femoral plug and externally rotate graft up to 360 degrees. Secure graft at femoral aperture using biointerference screw. > 50 45-50 Trim (7 × 20 mm) and fl ip bone plug 180 degrees back on tendon, usually cancellous away from tendon. Tibial tunnel length approximately equal to new graft length minus 50 mm. Tunnel diameter approximately equal to 11 mm. Bioscrew fi xation. edge of the lateral meniscus. This point should be approximately 7 mm anterior to the posterior cruciate ligament and about 2 to 3 mm anterior to the peak of the medial spine just posterior to the center of the anterior cruciate ligament footprint (see Fig. 48-44E). In the mediolateral plane, ensure that the wire enters at the base of the medial spine in the center or just slightly medial to the center of the anterior cruciate ligament footprint and centered in the notch opening (see Fig. 48-44F).

• The unaltered roof of the intercondylar notch normally forms an angle of 35 to 40 degrees with the long axis of the femur (see Fig. 48-44G). To prevent impingement, an internal notchplasty, as previously described, is necessary, as is appropriate tunnel placement. Use the tibial and femoral landmarks described earlier, and place the guide at 55 to 60 degrees to the tibial plateau surface to obtain suffi cient tunnel length and an angle that allows the graft angle to approximate that of the original. Measure the tibial tunnel length directly off the guide calibrations, and approximate the length of the tendinous portion of the graft. The tunnel length should be suffi cient to allow at least 20 mm of bone to be secured in the tibial tunnel for stable fi xation (Table 48-4).

• If the tendinous portion of the graft is 50 mm long or less, increase the guide angle to produce a longer tibial tunnel. The tunnel can be easily increased to 45 to 50 mm long to accommodate the longer graft, and the graft itself can be rotated 360 degrees or more to take up additional slack. Slightly recessing the graft into the femoral tunnel 2 or 3 mm would take up more slack. For a long ( > 50 mm) tendinous graft and a relatively small tibia, take care not to make the tunnel too distal and too vertical. Focus on correct guidewire alignment (i.e., toward the femoral pilot hole) and correct position in the anterior cruciate ligament footprint. Recess the graft as necessary in the femoral tunnel, and fi x the tunnel aperture with a biointerference screw.

• Using the guide, advance the wire approximately 20 mm into the knee while observing through the arthroscope.

• Move the knee through a range of motion to ensure that the wire passes within 2 mm of the posterior cruciate ligament and does not impinge on the medial or lateral walls or roof of the intercondylar notch. Make small corrections in position to prevent impingement and to allow the wire to be aimed close to the previously chosen pilot hole on the femoral condyle with the knee in 70 to 90 degrees of fl exion. Making small corrections at this point can make femoral tunnel reaming and graft passage much easier in the later steps of the procedure.

• Place a curet over the intraarticular end of the Kirschner wire to prevent advancement. Ream over the wire with an 8-mm reamer.

• Leave the protruding end of the reamer in the tunnel, and examine the tunnel for appropriate impingement-free position as the knee is moved through a full range of motion.

• Make necessary adjustments with the 8-mm reamer.

• Prevent bowstringing of the anterior cruciate ligament graft over the posterior cruciate ligament by leaving a 2-mm posterior wall between the tibial tunnel and the posterior cruciate ligament. By directing the tunnel just lateral to the posterior cruciate ligament, the graft lies on the posterior cruciate ligament without bowing around the ligament.

• Ream the tunnel with the 10-mm reamer, and use the fullradius resector to contour the edges of the tunnel and resect any remaining soft tissue that might block extension.

• Place a rasp through the tunnel to complete contouring and ensure that the external portion of the tunnel is free of soft tissue.

FEMORAL TUNNEL PREPARATION

• With the knee fl exed approximately 90 degrees, confi rm the previously chosen femoral pilot hole with an Arthrex 7-mm offset femoral guide passed through the tibial tunnel. Ensure that 1 to 2 mm of bone remains as a posterior wall. The starting point is at the 10:30-o’clock position on the right knee (1:30-o’clock position on the left knee) approximately 8 mm lateral to the posterior cruciate ligament (Fig. 48-44H).

• Maintain correct visual orientation by keeping the tibia vertical and the knee fl exed 90 degrees.

• Advance a long guidewire through the guide to the chosen physiometric point on the posterolateral portion of the femoral condyle. Advance the wire so that it exits the distal anterolateral femoral cortex. Use wire plier handles to stabilize the skin and soft tissues so that the wire advances externally and does not traverse the thigh more proximally.

Bone–Patellar Tendon–Bone Graft: Endoscopic Technique TECHNIQUE 48-19—cont’d

• Pass a 10-mm endoscopic reamer over the previously placed wire.

• With the knee in 80 to 90 degrees of fl exion to avoid reaming out of the posterior wall, advance the reamer to make a slight print at the entry point in the femoral condyle. If the reamer print cannot be seen, remove any debris with a shaver. If the print is adequately posterior, leaving a 1to 2-mm posterior wall, advance the reamer to 30 mm, or suffi cient distance to seat the graft (5-mm increment marks on the reamer can be seen arthroscopically).

• Carefully retract the reamer, and remove it from the joint, being careful not to enlarge the tunnel and ream out the posterior wall of the femur. During the reaming of the femoral tunnel, a bone wax plug placed around the reamer at the external mouth of the tibial tunnel helps maintain joint distention and improves vision.

• Smooth the edges of the femoral tunnel with a full-radius resector.

• Use the tunnel notcher to make a 25-mm-long slot at the 1-o’clock position (right knee) in the femoral tunnel. This derotation slot allows for appropriate placement of the screw guidewire to allow the screw to push the graft posteriorly and laterally (Fig. 48-44I).

GRAFT PASSAGE

• Use the eyelet guidewire to pass the patellar bone plug guide suture up through the femoral tunnel and out through the lateral thigh.

• With the suture, pull the graft up into the knee, and use a probe to help guide the graft up into the femoral tunnel with the cancellous portion of the graft pointing directly anteriorly (Fig. 48-44J). If diffi culty is encountered in passing the graft, use an Allis clamp to grab the graft and assist it up into the tunnel. If the graft is still diffi cult to pass, resize it, and ensure that no soft tissue impedes the passage.

• When the graft is about halfway into the femoral tunnel, pass a fl exible guidewire through the medial portal, or make a central fat pad portal, whichever makes the most parallel line with the femoral tunnel. Place the wire anterior to the graft, and, with the wire parallel to the graft, advance both up into the tunnel. Ensure that at least 2 cm of bone plug remains in the tibial tunnel for later fi xation; if necessary, recess the graft in the femoral tunnel 3 mm or farther if a biointerference screw is used to fi x the graft at the femoral aperture.

GRAFT FIXATION

• Place an 8-mm cannula with a cannulated screw with noncutting threads through the medial portal or central patellar portal.

• Flex the knee to about 110 degrees.

• Lever the cannula inferiorly, and make a straight line with the femoral tunnel (Fig. 48-44K and L). Close observation is necessary during this step and is made possible by placing the arthroscope above the graft and looking down at the graft during placement of the screw.

• For secure fi xation, the screw should not diverge from the line of the tunnel or bone plug by more than 15 degrees.

• Advance the screw into the tunnel, and place the screw head even with the bone plug, verifying its position with observation and palpation with the screwdriver. Use the distal sutures to tug on the graft to ensure that it is securely fastened in the femoral tunnel.

• Move the knee through a range of motion while holding tension distally on the graft to ensure that there is no impingement or pistoning of the graft. If the graft tightens more than 2 mm with knee fl exion, remove the graft, and move the femoral tunnel, or both tunnels, slightly posterior using a convex arthroscopic rasp. Slight tightening during knee extension is normal.

• Rotate the cancellous portion of the tibial bone plug so that it points laterally to reproduce the 90-degree rotation of the anterior cruciate ligament. This rotation also helps to move the graft away from the lateral wall and adds some strength through fi ber tensioning. The graft can be rotated 360 degrees or more if necessary to decrease the overall length.

• If no graft pistoning or impingement is evident, hold the tension on the graft for approximately 3 minutes while cycling the knee to allow for collagen fi ber stress relaxation. If the graft tends to impinge in one direction, use the screw to push the bone graft in the opposite direction.

• Tension the graft with about 8 to 10 lb of pull. Overtensioning of the graft can cause failure because of joint capture or graft necrosis.

• Secure the graft with a screw equal to the gap size plus 5 mm.

• If the tendon is so long that the bone plug is completely out of the tibial tunnel, as may be the case with an allograft mismatch, use an osteotome and a punch to make a trough distal to the tunnel, and secure it with two barbed staples (Box 48-1).

• Move the knee through a full range of motion, and ensure there is no evidence of capture of the knee joint. Observe and probe the graft arthroscopically to ensure that it is taut. The graft should be slightly tighter than a normal anterior cruciate ligament. Also ensure that there is no impingement and that no bone or screw protrudes into the joint from the tibial or femoral tunnel.

• Check the stability of the knee by Lachman and pivot shift maneuvers. The knee should be just slightly tighter than the uninjured knee.

Box 48-1 • Methods for Accommodating Excessive Graft Length

Increase tibial tunnel length Recess graft in femoral tunnel, secure at aperture Rotate graft 360 degrees Trim and fl ip graft 180 degrees back on itself Secure bone plug in trough distal to tibial tunnel

• If fi xation is secure, remove the 18-gauge wire and the tension sutures.

CLOSURE

• Loosely approximate the patellar tendon with simple interrupted absorbable sutures through the anterior portion of the fi ber of the tendon.

• Place bone saved from contouring of the bone plugs into the patellar defect, and close the peritenon.

• Remove the sutures from the thigh proximally (femoral bone plug) and from the tibial bone plug distally.

• Remove any protruding bone, leaving a smooth surface distally.

• Close the periosteal fl ap back over the tunnel.

• Close the subcutaneous tissues with interrupted 2-0 Vicryl suture, and approximate the skin with a running subcuticular 4-0 Monocryl suture.

• Apply adhesive strips loosely over the closure, and apply a sterile dressing, a cooling sleeve, and an elastic wrap.

AFTERTREATMENT For the anterior cruciate ligament rehabilitation protocol, see Box 48-2.

Bone–Patellar Tendon–Bone Graft: Two-Incision Technique TECHNIQUE 48-20

• Place the patient supine on the operating table, and apply a tourniquet around the upper thigh and use a lateral post.

• Tape a 5-L saline bag to the table to maintain the knee in 90 degrees of fl exion.

• Use waterproof arthroscopy drapes for standard draping.

GRAFT HARVEST

• Graft harvest is performed as described in Technique 48-19.

GRAFT PREPARATION

• At a separate table, have an assistant contour the graft until it fi ts through a 10-mm trial without diffi culty.

• Secure the graft to the top table drape while preparing.

• Contour the ends of the bone plugs in a bullet-type fashion, drill three holes in each bone plug, and place a 5-0 nonabsorbable suture through each drill hole; the fi rst drill hole in each plug should be approximately 3 mm from the end of the graft. Roll the graft with a running 2-0 Vicryl suture while maintaining the graft under tension.

• Mark the tendon-bone interface with a methylene blue pencil.

NOTCH PREPARATION

• With electrocautery, make an inverted “L” incision starting 2.5 cm below the joint line and extending distally 2 cm, approximately 1.5 cm medial to the tibial crest.

• Use a periosteal elevator to raise the periosteal fl ap.

• Place an infl ow cannula medial to the inferior pole of the patella.

• Make medial and lateral parapatellar arthroscopic portals for observation and instrumentation.

• Examine the knee thoroughly to evaluate all damaged structures.

• Place meniscal sutures as indicated to be tied at the end of the procedure.

• Use a 5.5-mm full-radius resector to resect the soft tissue from the intercondylar notch and resect the tibial stump, leaving a visible footprint.

• Flex the knee to 90 degrees to see clearly the over-the-top position and complete the resection of the posterior fringe of the anterior cruciate ligament femoral stump.

• Extend the knee to 30 degrees, and identify the notch architecture. Use a 5.5-mm burr to open the notch to an inverted “U” shape if there is evidence of stenosis of the opening. Superiorly and laterally, 2 to 3 mm of bone usually is removed.

• Place the burr in reverse to smooth the edges of the resected fringe. Increase the fl exion of the knee, and, working posteriorly, use controlled posterior-to-anterior strokes to widen the roof and lateral wall.

• Flex the knee to 90 degrees so that the over-the-top position is clearly visible, and complete the notchplasty.

• For the rear-entry technique, taper the notch posteriorly; do not remove excessive bone in the posterior part of the notch.

• Use a full-radius resector or an arthroscopic rasp for fi nal smoothing of the roof and wall of the notch.

• While viewing the femoral notch architecture, use a curved curet to make a pilot hole about 6 mm anterior to the overthe-top spot at the 10:30-o’clock position on the right knee (approximately 8 mm lateral to the posterior cruciate ligament).

Box 48-2 • Anterior Cruciate Ligament Rehabilitation Protocol

Stage I: 0 to 2 Weeks Patellar mobilizations (emphasize superior/inferior glides) MCB 0 to 90 degrees Quadriceps sets/SLR all planes (emphasize SLR without extension lag) Prone/standing hamstring curls Passive extension (emphasize full extension) Prone hangs Pillow under heel Passive, active, and active-assisted ROM knee fl exion Wall slides Sitting slides Prone towel pulls Edema control—compression pump Electrical stimulation for muscle reeducation if poor QS PWB 50% to 75% with crutches or WBTT without crutches if MCB locked in full extension Sleep in brace locked in extension

GOALS Full knee extension ROM 90-degree knee fl exion ROM Good QS Emphasize normal gait pattern

Stage II: 2 to 4 Weeks MCB full ROM Progress ROM to 120 degrees by week 4 Progress SLR and prone/standing hamstring curls with weights Bike for ROM, begin low-resistance program when ROM adequate Stool scoots FWB with crutches; discontinue crutches when ambulating without limp Begin double leg BAPS, progress to single leg Begin double leg press with light weight/high repetitions Wall sits at 45-degree angle with tibia vertical, progress time Lateral step-ups (4 inches) when able to perform single leg quarter squat Hip machine and hamstring machine when able to perform SLR with 10 lb Treadmill (forward and backward) with emphasis on normal gait Knee extension 90 to 60 degrees (submaximal) with manual resistance by therapist

GOALS ROM 0 to 120 degrees FWB without crutches, no limp

Stage II: 4 to 6 Weeks Progress to full ROM by 6 weeks Begin Kin-Com isokinetic hamstring progression (isotonic/ isokinetic) Begin Kin-Com dynamometer quadriceps work 90 to 40 degrees isotonics with antishear pad Stairmaster (forward and backward) Progress closed chain exercises At 6 weeks, begin Kin-Com dynamometer quadriceps work 90 to 40 degrees isokinetics (start with higher speed and work on endurance) Aquatic exercises

Stage II: 8 to 10 Weeks Progress above-listed exercises Slow-form running with sport cord (forward and backward) Isokinetic quadriceps work at different speeds (60, 90, 120 degrees per second) Begin lunges At 10 weeks, begin Fitter, slide board

Stage III: 12 to 16 Weeks Full range isotonics on Kin-Com dynamometer (begin moving antishear pad down) Knee extension machine with low weight/high repetitions Lateral sport cord drills (slow, controlled) Kin-Com dynamometer test hamstrings, discontinue isokinetic hamstrings if 90% Progress isokinetic quadriceps to full extension by 16 weeks

Stage IV: 16 to 18 Weeks Kin-Com dynamometer test for quadriceps, retest hamstrings if necessary Begin plyometric program with shuttle, minitrampoline, jump rope if quadriceps strength 65%, no effusion, full ROM, stable knee Begin jogging program if quadriceps strength is 65%

Stage V: 5 to 6 Months Agility training Sport-specifi c drills (e.g., carioca, 45 cutting, fi gure-of-eight) Retest quadriceps if necessary

Stage VI: 6 Months Return to sport if: Motion > 130 degrees Hamstrings > 90% Quadriceps > 85% Sport-specifi c agility training completed Maintenance exercises 2 to 3 times per week

BAPS, Biomechanical Ankle Platform System; FWB, full weight bearing; MCB, motion control brace; PWB, partial weight bearing; QS, quadriceps setting; ROM, range of motion; SLR, straight leg raises; WBTT, weight bearing to tolerance.

Bone–Patellar Tendon–Bone Graft: Two-Incision Technique TECHNIQUE 48-20—cont’d

TIBIAL TUNNEL PREPARATION

• With a tibial guide, place a Kirschner wire at least 4 cm distal to the joint line and 1.5 cm medial to the tibial crest. The wire should enter the joint just posterior to the center of the anterior cruciate ligament footprint approximately 2 mm anterior to the peak of the medial tibial spine, which is approximately 7 mm anterior to the posterior cruciate ligament. A third reference point in the anteroposterior plane is that of the inner edge of the anterior horn of the lateral meniscus. A line extended medially from the inner edge of the meniscus should approximate the guidewire. In the mediolateral plane, the wire should enter at the base of the medial tibial spine (see Fig. 4844D and E).

• Advance the guidewire into the joint, and carefully identify its direction of passage just lateral to the posterior cruciate ligament in the general direction of the previously chosen femoral starting portal. The guidewire should not impinge on the roof or the walls of the notch during range of knee motion.

LATERAL EXPOSURE

• Make a 4-cm lateral incision starting 1.5 cm proximal to the fl are of the lateral condyle and centered directly over the iliotibial band. Carry the dissection down to the iliotibial band, and expose it with wide subcutaneous dissection.

• Divide the iliotibial band in its midline, and extend it proximally and distally from the skin incision. The lower edge of the distal portion of the vastus lateralis can be felt by sweeping a fi nger along the intermuscular septum.

• Slide a periosteal elevator under the edge of the vastus lateralis, and lift the muscle anteriorly over the lateral part of the femur without injuring the muscle belly.

• Place a Z-retractor over the femur to hold the vastus lateralis superiorly.

• Use electrocautery to make a longitudinal incision through the periosteum just proximal to the fl are of the condyle, and extend it proximally for about 2.5 cm. Use a periosteal elevator to expose the bone and the over-the-top spot where the fl are of the condyle and the metaphysis of the femur meet. Coagulate the lateral genicular vessels in this area.

FEMORAL TUNNEL PREPARATION

• With the arthroscope in the anteromedial portal, pass the gaff for the rear-entry guide through the anterolateral portal. Ensure that the gaff does not hook the posterior cruciate ligament and that it passes directly over the over-the-top spot, hugging the posterior edge of the condyle. This opening may have to be enlarged with a periosteal elevator to ease the passage of the rear-entry guide.

• Hook the appropriate side (right or left) guide through the eyelet in the graft. While holding slight tension on the rear-entry guide, use the gaff to bring the guide into the knee, and release the gaff from the guide without any twisting motion that might break the tip of the gaff (Fig. 48-46A).

• Place the guide in the previously chosen pilot hole on the femoral condyle 6 mm anterior to the over-the-top spot in approximately the 11-o’clock position on the right knee or the 1o’clock position on the left knee. This point should coincide with the junction of the arch of the roof and the lateral wall of the condyle approximately 8 mm lateral to the posterior cruciate ligament (Fig. 48-46B).

• The pilot hole should be deep enough to be seen when trying to place the guide but not deep enough to allow more than a 2mm recession of the tip of the guide into the bone. If the guide is recessed too far into the bone, the guidewire passes the tip of the guide and enters the joint anterior to the desired location. The external landmark for the guide is the midportion of the femur approximately 3 cm proximal to the over-the-top spot. The angle of the wire should be approximately 45 degrees to the femur and should be as close as possible to the plane of the previously placed tibial guidewire.

• Ensure that at least 2 cm of lateral cortex remains posterior to the wire to prevent “blowing out” the posterior wall of the condyle (Fig. 48-46C).

• Verify placement of the wire with the arthroscope in the anterolateral or central patellar portal.

• Use a curved 4-mm curet to palpate the placement of the wire, ensuring that it is 6 mm anterior to the over-the-top spot. It is important to have the knee fl exed 90 degrees to observe the posterior position of the guidewire.

• When accurate wire placement is confi rmed with observation and palpation, begin the femoral tunnel with an 8-mm reamer, make any necessary alterations with the 8-mm reamer, and complete the tunnel with a 10-mm reamer after checking the isometry if desired (see later).

• Prevent guidewire advancement during reaming with the open end of the full-radius resector or with a Kelly clamp.

• After reaming and smoothing the edges of the tunnel with a full-radius resector and an arthroscopic rasp, place a plastic plug in the femoral tunnel.

TIBIAL TUNNEL PREPARATION

• Ream over the previously placed tibial wire with the 8-mm reamer.

• Place the reamer tip in the joint, and leave it there while the knee is moved through a range of motion. Look for potential impingement on the roof or walls.

• Make necessary corrections to the tunnels with an 8-mm reamer before overreaming with a 10-mm reamer. Most

B

A

C

Fig. 48-46 A, Gaff passed along femoral condyle to pull rear-entry guide into knee. B, Rear-entry guide is placed in pilot hole in 11o’clock position on right knee 6 to 7 mm anterior to over-the-top spot. C, External view of guide, ensuring it is at least 1.5 to 2 cm anterior to posterior femoral cortex.

Bone–Patellar Tendon–Bone Graft: Two-Incision Technique TECHNIQUE 48-20—cont’d corrections are necessary because the tunnels are too far anterior, resulting in graft tightening during knee fl exion. If this is a problem, the femoral tunnel can be widened posteriorly or inferiorly in the notch; likewise, the tibial tunnel can be moved posteriorly if indicated.

• Contour the edges of the tunnels with a rasp to prevent graft abrasion.

GRAFT FIXATION

• Make a slight (15-degree) bend in a suture passer, and pass it proximally through the tibial and femoral tunnels.

• Grasp the sutures in the end of the graft with the suture passer and pull the graft through the femoral and tibial tunnels. As it is passed distally from the femoral tunnel out through the tibial tunnel, the cancellous portion of the bone in the femoral tunnel should point anteriorly to maximize posterior placement of the graft; the cancellous portion in the tibial tunnel should point laterally to reproduce the 90-degree fi ber rotation of the normal anterior cruciate ligament. This rotation has been shown to increase graft strength by fi ber recruitment.

• Secure the graft with an appropriate-sized interference screw placed anterior to the graft in the femur, pushing the graft posteriorly (see Technique 48-19).

• Move the knee through a range of motion to ensure that there is no pistoning or impingement of the graft. If the graft tightens more than 2 mm with knee fl exion, remove the graft, and use a convex arthroscopic rasp to enlarge the femoral tunnel posteriorly or inferiorly in the notch if the tunnel is as far posterior as possible. If the tunnel is moved after having been reamed with the 10-mm reamer, a larger interference screw or a bone grafting technique may be necessary.

• Place the knee in extension, and maintain tension on the graft for approximately 3 minutes to allow for stress relaxation.

• Secure it to the tibia with an interference screw. This screw usually is placed medial to the graft in the tunnel, but can be placed laterally if this would center the graft better in the notch. If less than 2 cm of bone plug remains in the tunnel, use a bicortical screw and washer post for distal fi xation.

• Observe the graft arthroscopically, and probe it to ensure that it is adequately tight and that no screw or bone is left protruding.

• Check the stability of the knee by Lachman and pivot shift maneuvers. The knee should be just slightly tighter than the uninjured knee.

• Place a suction drain intraarticularly into the suprapatellar pouch, ensuring that it does not curl on itself.

• Place a drain laterally before closure of the iliotibial band. Place bone from contouring of the bone plugs or tunnel reaming into the patellar defect, and approximate the patellar tendon loosely with interrupted 0-0 Vicryl sutures, closing just the anterior fi bers.

• Close the paratenon with 2-0 Vicryl suture, and close the skin with a running 3-0 Prolene subcuticular suture.

• Apply adhesive strips and a sterile dressing.

Endoscopic Quadruple Hamstring Graft TECHNIQUE 48-21

• Place the patient supine on the operating table, and apply a tourniquet around the upper thigh; use a padded lateral post.

• Tape a 5-L saline bag to the table to use as a foot stop to maintain the knee in 90 degrees of fl exion during the procedure (see Fig. 48-44A). Exposure is easier with the extremity placed in a fi gure-four position (Fig. 48-47A).

GRAFT HARVEST

• Make a 4-cm incision anteromedially on the tibia starting approximately 4 cm distal to the joint line and 3 cm medial to the tibial tuberosity (Fig. 48-47B).

• Expose the pes anserinus insertion with subcutaneous dissection.

• Palpate the upper and lower borders of the sartorius tendon, and identify the palpable gracilis and semitendinosus tendons 3 to 4 cm medial to the tendinous insertion (Fig. 48-47C).

• Make a short incision in line with the upper border of the gracilis tendon, and carry the incision just through the fi rst layer, taking care not to injure the underlying medial collateral ligament.

• With Metzenbaum scissors, carry the dissection proximally up the thigh. Stay in the same plane, and maintain adequate exposure by using properly placed retractors. Careful observation of structures is necessary to avoid injuring the saphenous vein or nerve by straying from the plane of dissection.

• With a curved hemostat, dissect the gracilis and semitendinosus tendons from the surrounding soft tissues about 3 cm medial to their insertion onto the tibia.

• After carefully identifying each tendon, place a Penrose drain around the gracilis tendon, and release its fi brous extensions to the gastrocnemius and semimembranosus muscles (Fig. 48-47D). These fi brous extensions come off the hamstring tendons at approximately 6 to 7 cm proximal to their distal attachment.

• Palpate all sides of the tendon to ensure there are no fi brous extensions before releasing it with an open-end tendon stripper. If fi rm resistance is felt, redissect around the tendons with a periosteal elevator and Metzenbaum scissors. Release the tendon proximally by controlled tension on the tendon, while advancing the stripper proximally. The muscle should slide off the tendon as the stripper is advanced proximally.

• Use the same procedure to release the semitendinosus tendon.

• Subperiosteally dissect the tendons medially to the insertion, and release them sharply. Do not damage or release the sartorius tendon.

• At a separate table, separate the muscle from the tendon with a No. 10 blade.

• Place a double Krackow-type whipstitch in both ends of each tendon with 2-0 nonabsorbable sutures (Fig. 48-48E). Fold both tendons in half to form four strands of tendon.

• Place a No. 5 nonabsorbable suture through the loop end of both tendons.

• Place a running, interlocking No. 2 nonabsorbable Krackowtype whipstitch in each end of each hamstring so that the graft can be passed as a single quadruple graft; use a No. 0 Vicryl running stitch to suture the terminal 2.5 cm of the looped end (femoral side) together to prevent the graft (Fig. 48-47E) from wrapping around the interference screw.

• Place a free No. 5 polyester suture through each loop end to pull the graft into the femoral tunnel.

• Perform notchplasty and tunnel placement as described for the endoscopic bone-tendon-bone technique (Technique 48-19).

• Ream the tibial tunnel at 50 degrees to the tibial articular surface. The tunnel is reamed 2 mm smaller than the graft size

B A

Fncision

C

E D

F

Fig. 48-47 A, Extremity is placed in fi gure-four position to assist in hamstring harvest. B, A 3-cm incision is made over pes anserinus tendons. C, Inferior retraction of sartorius tendon, exposing gracilis and semitendinosus tendons. D, Placement of Penrose drain around hamstring tendon to be harvested. E, Two running, interlocking (Krackow) sutures. F, Fixation technique for quadruple hamstring graft.

Endoscopic Quadruple Hamstring Graft TECHNIQUE 48-21—cont’d and serially dilated to produce a snug fi t. Cain and Phillips have shown that dilating the tibial tunnel signifi cantly increases the pull-out strength. The tunnel length should be 30 to 35 mm to allow fi xation near the articular surface.

• Ream the femoral tunnel to a depth of approximately 30 mm. Determine the size of the femoral tunnel by measuring the graft with the sizer sleeve. A snug fi t of the graft is essential for earlier healing.

• Choose an acorn reamer with approximately the size (diameter) of the quadruple graft.

• Use an offset guide that would allow a 1to 2-mm posterior wall to pass the guidewire at the 10:30-o’clock position on the femoral condyle (right knee).

• Make a 30-mm-long notch at the 1-o’clock position, and pass the graft 25 to 30 mm up into the femoral tunnel. By placing the notch at the 1-o’clock position, the screw when placed would push the graft posterior and lateral in the tunnel.

• Fixation in the femoral tunnel is accomplished with a bioscrew interference fi xation technique using a screw equal to the diameter of the femoral tunnel. Ensure, however, that this screw does not wrap the graft.

• Hold tension at both ends, and watch the graft during placement of the screw.

• Maintain 10 lb of tension for 3 minutes while cycling the knee before securing fi xation distally with a bioscrew 1 mm larger than the tibial tunnel size.

• Use the 28-mm screw to fi x the graft securely near the joint surface, allowing for stiffer fi xation and less chance for graft motion. The best pull-out is obtained when the head is sunk to the level of the cortical bone.

• Secondary fi xation is indicated to prevent slippage. Use a screw and soft-tissue washer, or a screw and washer as a post, or a soft-tissue staple and a unicortical drill hole 2 cm distal to the tunnel for secondary fi xation. When using the unicortical drill hole, one suture from each end of the graft is passed through the hole and tied to its accompanying suture over the bony bridge formed between the drill hole and the femoral tunnel.

• Pass one suture from each graft through the drill hole, and tie each to its accompanying suture end over the bone bridge as described by Stähelin, Südkamp, and Weiler.

Two-Bundle Anterior Cruciate Ligament Reconstruction with EndoButtons

At this time, there is some debate as to the merit of a two-tunnel anterior cruciate ligament reconstruction. In the laboratory, as previously mentioned, some increased success has been shown in biomechanical evaluation, but clinical reports on two-tunnel series have not shown any advantage. Nonetheless, this procedure has been included for completeness at this time. Semitendinosus and gracilis grafts are in a multistrand-bundle fashion. Gracilis tendon is harvested only when the semitendinosus is less than 22 cm in length or very thick.

🔪 Surgical Technique 48-22

• Make a 3-cm-long incision in the anteromedial portion of the tibia 2 cm below the tibial tuberosity. Use a tendon stripper to harvest the tendons.

• After thorough arthroscopic examination of the knee joint, position the grafts using an arthroscopically assisted inside-out technique with the Multitrac system (Smith & Nephew Endoscopy, Acufex, Andover, Mass) and for femoral-side fi xation.

• Set the angle of the tibial drill guide for the anteromedial bundle at 55 degrees and the angle for the posterolateral bundle at 50 degrees.

• Position the tibial guidewire for the anteromedial bundle in the center of the natural anterior cruciate ligament insertion and for the posterolateral bundle about 3 mm posterior to the anteromedial guidewire; position the wire for the posterolateral bundle in an anteromedial-to-posterolateral direction. The tibial guidewires make an angle between 20 and 30 degrees.

• Determine the tibial guidewire position based on anatomical landmarks on an intraoperative two-directional radiograph with the knee in hyperextension (Fig. 48-48A and B). If the guidewire position is unacceptable, use a parallel guide to change the wire position.

• Separate two tibial guidewires anteriorly and posteriorly within the normal tibial anterior cruciate ligament insertion between the dome of the intercondylar notch (Blumensaat line) and the anterior edge of the lateral intercondylar tubercle in the lateral view.

• Perform minimal anterior notchplasty only in patients with an extremely narrow notch, especially in the upper portion.

• Before determining the femoral drill guide position, probe the posterior edge of the intercondylar notch cautiously. If the posterior wall of the intercondylar notch is thick, remove a suffi cient amount of bone using an arthroscopic shaver system to put the Isotac in the aiming position. Position the Isotac for the femoral drill guide 5 mm anterior to the posterior edge of the intercondylar notch, then measure the isometry of each

AFTERTREATMENT See Box 48-2 for postoperative anterior cruciate ligament rehabilitation. We generally proceed more slowly with rehabilitation when a hamstring graft has been used. The patient generally is allowed to return to full activity at around 9 months.

A B C

🔪 Surgical Technique 48-22

reconstruction route using the Isometric Positioner with a folded No. 2 suture.

• Drill femoral holes medially and laterally.

• Position the anteromedial bundle just adjacent to the posterior cruciate ligament, and position the posterolateral bundle lateral to the anteromedial bundle in the direction of the over-the-top route.

• Position the anteromedial bundle around the 12:30-o’clock position and the posterolateral bundle around the 1:30-o’clock position of the intercondylar space in the case of a left knee.

• Make two double-strand grafts by cutting a harvested semitendinosus tendon in half and folding it in a double-strand fashion. Use a glove-suture technique with two No. 2 braided sutures with one No. 5 polyester suture added.

• Measure the diameter and length of each bundle (usually 6 to 7 mm in diameter).

• Make both femoral drill holes for the anteromedial and posterolateral bundles using the inside-out technique with a guidewire and a cannulated drill. The length of each femoral drill hole is determined by adding 8 mm to the planned graft length in the femoral bony socket.

• A 4.5-mm-diameter cannulated drill (EndoButton Drill; Smith & Nephew Endoscopy, Acufex) is used along the guidewire by inside-out technique to connect between the outlet of the intercondylar space and the femoral cortical bone surface. The length of each femoral drill hole is measured using a probe (Depth Probe; Smith & Nephew Endoscopy, Acufex).

• Suture the EndoButton at the femoral end in the position of the measured length between the outlet of the intercondylar space and the surface of the femoral bone of each bundle on

Fig. 48-48 Intraoperative two-directional radiography of knee in hyperextension. Tibial drill guide position determined with intraoperative two-directional radiograph in hyperextension and based on radiographic anatomical landmarks. A, Two tibial guidewires were separated anteroposteriorly within normal tibial anterior cruciate ligament insertion between dome of intercondylar notch (Blumensaat line) and anterior edge of lateral intercondylar tubercle in lateral view. B, In anteroposterior view, both drill guides positioned around tip of medial intercondylar tubercle. Tibial guidewires made angle between 20 and 30 degrees (to right). C, Postoperative two-directional radiography of knee in hyperextension. Two EndoButtons on femoral cortex and one post screw in tibia anteroposterior view (left) and lateral view (right). Anterior margin of drill hole of anteromedial bundle is on line of dome of intercondylar notch in lateral view. In two-bundle reconstruction, enlargement of drill holes has not occurred as in this photograph, although drill hole position is not easily seen. (From Muneta T, Sekiya I, Yagishita K, et al: Twobundle reconstruction of the anterior cruciate ligament using semitendinosus tendon with EndoButtons: operative technique and preliminary results, Arthroscopy 15:618, 1999.) viduals with mild-to-moderate instability, reduction of activity level may be all that is necessary until they have had an appropriate growth spurt and maturing of the physes. In active, young boys, sometimes this is quite hard to accomplish. In these children when there is a meniscal tear or recurrent giving way, a physeal-preserving, softtissue graft procedure is best. A small central tunnel made in the tibia just above the physis and preserving the physis in the femur seems to be a safe procedure. The benefi t of stabilizing the knee seems to outweigh the small potential for growth disturbance if these procedures are done correctly. It is necessary to use a soft-tissue graft to avoid bone or fi xation across the physis. The tunnel and the tibia can be drilled above the physis, or a small central tunnel through the physis probably is acceptable, particularly in Tanner stage II, III, and IV patients. In younger patients, a procedure going around the physis or an over-the-top procedure as described by Anderson and Kocher, Garg, and Micheli is recommended (Fig. 48-49).

Transepiphyseal Replacement of Anterior Cruciate Ligament Using Quadruple Hamstring Grafts

The transepiphyseal replacement of anterior cruciate ligament using quadruple hamstring grafts procedure described by Anderson is indicated in patients in Tanner stage I, II, or III of development. The procedure is contraindicated in patients in Tanner stage IV of development, who can have conventional anterior cruciate ligament reconstruction. Pitfalls of this procedure are summarized in Box 48-3. the graft preparation table (GraftMaster; Smith & Nephew Endoscopy, Acufex).

• Introduce the graft for the posterolateral bundle fi rst through the joint into the femoral drill hole using a Passing Pin (Smith & Nephew Endoscopy, Acufex).

• Flip the EndoButton, and fi x it onto the femoral cortical surface. Fix the graft for the anteromedial bundle in the same manner. Do not allow the Passing Pin to interfere with the posterolateral bundle when the anteromedial bundle is introduced into the joint. The introduced posterolateral bundle should be kept tensioned during the introduction and fi xation of the anteromedial bundle.

• Place the knee in 30 degrees of fl exion, and fi x the graft to the tibial screw post with maximal manual pulling, fi rst fi xing the suture of the posterolateral bundle to the post screw and then fi xing the anteromedial bundle (Fig. 48-48C).

AFTERTREATMENT Postoperatively, a simple knee brace is used for knee immobilization. Range of motion of the knee and weight bearing exercises are begun 3 to 4 days after surgery and are gradually progressed so as not to leave a more than 5 degree extension loss within 2 weeks after surgery. Knee fl exion of more than 95 degrees and full weight bearing using double crutches can be expected at least 2 weeks after surgery. Isometric knee muscle exercises are started the day after surgery and progressed. Halfsquatting exercise, standing-bike, and swimming are allowed from 1 month after surgery. Jogging is encouraged after 3 months if the patient recovers knee extension strength of more than 65% of the uninjured knee. Various sporting activities are practiced step by step, and desired sporting activities are allowed 6 months after surgery if the patient achieves at least 80% of knee extension strength compared with the uninjured leg.

Quadriceps Tendon Graft Fulkerson and Langeland, Shelton, and others have described anterior cruciate ligament reconstruction using a 10-mm-wide quadriceps tendon with an attached piece of patellar bone. We have rarely used this as a revision technique.

Anterior Cruciate Ligament Injuries in Skeletally Immature Individuals With athletic activities becoming more competitive at a younger age, the incidence of anterior cruciate ligament injuries in skeletally immature individuals has rapidly increased over the last decades. These injuries present a particularly perplexing problem with the potential for physeal injury with reaming of tunnels that is counterbalanced by the potential for meniscal damage from recurrent giving way in these individuals. Two principles must be followed: (1) preserve menisci if possible, and (2) prevent recurrent giving way. In some less active indi-

🔪 Surgical Technique 48-23

• Place the injured lower limb in an arthroscopic leg holder with the hip fl exed to 20 degrees to facilitate C-arm fl uoroscopic viewing of the knee in the lateral plane.

• Position the C-arm on the side of the table opposite the injured knee, and place the monitor at the head of the table. View the tibial and femoral physes in the anteroposterior and lateral planes before the limb is prepared and draped. When the distal part of the femur is viewed, adjust the C-arm so that the medial and lateral femoral condyles line up perfectly with the lateral plane. Rotate the C-arm to see the extension of the tibial physis into the tibial tubercle on the lateral view of the tibia.

• Make an oblique 4-cm incision over the semitendinosus and gracilis tendons. Dissect these tendons free, and transect at the musculotendinous junction with use of a standard tendon stripper, and detach distally.

• Double the tendons, and place a No. 5 FiberWire suture (Arthrex, Naples, Fla) in the ends of the tendons with a whipstitch.

Conservative treatment

Preadolescent (  12 years) Adolescent

Chronic with recurrent giving way

Functionally stable Functional instability*

Unstable with ADL

Consider • Laxity • Activity level • Future aspirations

*Functional instability indicates repeat episodes of complete or partial giving way

• No athletics • Rehabilitate and educate • Reconstruct BTB when above criteria are met

• 1 laxity • Compliant • No additional pathology

Conservative treatment Reconstruction

• Reparable meniscus • Level I or Level II competitive • Noncompliant

• Rehabilitate • Repair menisci • Reduce activity • No Level I sports • Level II recreational if no functional instability

• Physes wide open • Tanner 1 or 2 • No growth spurt •
2˝ shorter than sibs • Girls  14 years • Boys  15 years

• Physes closing • Tanner 3 or 4 • growth spurt •  2˝ shorter than sibs • Girls
14 years • Boys
15 years

• Rehabilitate • Repair menisci • Level II recreational sports

• Stop athletics, brace

• Hamstrings intra-articular through center of tibial physis, over-the-top on femur

Fig. 48-49 Treatment algorithm for anterior cruciate ligament injuries in children and adolescents. ADL, activities of daily living; BTB, bone-patellar tendon-bone. (From Phillips B: Anterior cruciate ligament injuries. In Andrews JR, Timmerman LA, eds: Diagnostic and operative arthroscopy, Philadelphia, 1997, Saunders.)

Box 48-3 • Pitfalls of Transepiphyseal Replacement of the Anterior Cruciate Ligament Using Quadruple Hamstring Grafts in Skeletally Immature Patients

Suboptimal Graft Placement Optimal graft placement is essential to restore normal knee kinematics and avoid physeal injuries Avoid placing the femoral or tibial drill hole anterior; correct positioning of the drill hole is crucial in preventing graft impingement Surgery should not proceed without clearly seeing the physes on anteroposterior and lateral planes using C-arm Guidewires should be inserted under real-time C-arm viewing Confi rm arthroscopically that the guidewires enter the joint in the center of the footprint of the anterior cruciate ligament on the femur and in the posterior footprint of the anterior cruciate ligament on the tibia

Incorrect Diameter of Transepiphyseal Drill Holes A drill bit corresponding to the smallest size through which tendon would easily pass should be used to make transepiphyseal holes A small diameter drill bit is less likely to damage the physes, and a snug fi t promotes healing of the graft to bone

Graft passage can be eased by chamfering the femoral hole and pushing the graft into the hole using a blunt instrument through an anteromedial portal, while pulling a No. 5 FiberWire suture tied to an EndoButton

Failure of Fixation Load to failure in this technique exceeds normal tensile loads on the anterior cruciate ligament In the early phase of healing, failure can lead to instability Check the femoral side fi xation with C-arm to confi rm that EndoButton washer is fl ush on lateral femoral condyle

Graft Slippage Associated with Suture Postfi xation Minimize slippage by meticulous placement of whipstitches in tendon ends with tight loops placed in close proximity Pretension graft using Graftmaster (Smith & Nephew Endoscopy, Andover, Mass) When tendon graft extends through the tibial hole, augment the tibial fi xation by suturing the tendons through the periosteum

• Use tendon sizers to measure the diameter of the quadruple tendon graft (which typically is 6 to 8 mm). A tight fi t is important; consequently, use the smallest appropriate drill to ream over both guidewires.

• Chamfer the edge of the femoral hole intraarticularly, and measure the width of the lateral femoral condyle. Choose the appropriate EndoButton continuous loop (Acufex-Smith Nephew, Memphis, Tenn) (2 to 3 cm) so that approximately 2 cm of the quadruple hamstring tendon graft remains within the lateral femoral condyle.

• Pass the EndoButton continuous loop around the middle of the double tendons, and loop inside of itself to secure the tendons proximally (Fig. 48-50C). Alternatively, the tendons can be placed through the continuous loop before the tendon ends are sutured together. That requires drilling and measuring the length of the femoral hole before graft preparation, however. Otherwise, it is diffi cult to determine the appropriate length of the EndoButton continuous loop necessary to leave 2 cm of the tendon graft within the lateral femoral condyle.

• Place a No. 5 FiberWire suture in one end of the EndoButton, and pass a suture passer from anterior to posterior through the tibia and out the lateral femoral condyle (Fig. 48-50D). Pull the EndoButton and tendons up through the tibia and out the femoral hole with the use of the No. 5 suture.

• Place an EndoButton washer (Smith & Nephew, Memphis, Tenn), 3 to 4 mm larger than the femoral hole, over the EndoButton. Apply tension to the tendons distally, pulling the EndoButton and washer to the surface of the lateral femoral condyle (Fig. 48-50E). The washer is necessary to anchor the graft proximally because the hole in the femoral condyle is larger than the EndoButton.

• Place the graft under tension, and extend the knee to determine arthroscopically if there is impingement of the graft on the intercondylar notch.

• An anterior notchplasty usually is unnecessary when this technique is used; however, if the anterior outlet of the intercondylar notch touches or indents the graft in terminal extension, remove a small portion of the anterior outlet.

• With the knee in 10 degrees of fl exion, secure the quadruple hamstring graft distally by tying the No. 5 FiberWire sutures over a tibial screw and post that is placed medial to the tibial tubercle apophysis and distal to the proximal tibial physis (Fig. 48-50F and G).

• If the tendon graft extends through the tibial drill hole, secure it to the periosteum of the anterior tibia with multiple No. 1 Ethibond sutures with use of fi gure-of-eight stitches (see Fig. 4850F). Close the subcutaneous tissue and skin in a routine fashion, and apply a hinged brace.

🔪 Surgical Technique 48-23

• Place the doubled tendons under 4.5 kg (10 lb) of tension on the back table with the use of the Graftmaster device (AcufexSmith Nephew, Andover, Mass).

• Insert the arthroscope into the anterolateral portal, and insert a probe through the anteromedial portal.

• Perform intraarticular examination in the usual manner.

• Remove debris in the intercondylar notch, and perform a notchplasty to see the anatomical footprint of the anterior cruciate ligament on the femur.

• Repair any substantial meniscal tears found.

• With the C-arm in the lateral position, adjust the limb to show a perfect lateral view.

• Place the point of the guidewire over the lateral femoral condyle, corresponding with the location of the footprint of the anterior cruciate ligament on the femur. This point is approximately one fourth of the distance from posterior to anterior along Blumensaat line and one fourth of the distance down from Blumensaat line (Fig. 48-50A). Make a 2-cm lateral incision at this point.

• Incise the iliotibial tract longitudinally, and strip the periosteum from a small area of the lateral femoral condyle.

• Use the C-arm to view the entry point of the guidewire in the anteroposterior and the lateral planes. With the C-arm in the lateral plane and with the use of a free-hand technique, introduce the point of the guidewire 2 to 3 mm into the femoral epiphysis. Do not angulate the pin anteriorly or posteriorly, but rather keep it perpendicular to the femur in the coronal plane. Rotate the C-arm to the anteroposterior plane to ensure that the guidewire is not angulated superiorly or inferiorly.

• Drive the guidewire across the femoral epiphysis, perpendicular to the femur and distal to the physis (see Fig. 48-50A). Through the arthroscope, view the entrance of the guidewire into the intercondylar notch. The guidewire should enter the joint 1 mm posterior and superior to the center of the anatomical footprint of the anterior cruciate ligament on the femur.

• Leave the femoral guidewire in place, and insert a second guidewire into the anteromedial aspect of the tibia, through the epiphysis, with the aid of a tibial drill guide. From the direct lateral position, rotate the C-arm externally approximately 30 degrees to show the physis clearly extending into the tibial tubercle. Drill the guidewire into the tibial epiphysis under realtime fl uoroscopic imaging (Fig. 48-50B). The handle of the drill guide must be lifted for the wire to clear the anterior part of the tibial physis. The wire should enter the joint at the level of the free edge of the lateral meniscus and in the posterior footprint of the anterior cruciate ligament on the tibia.

• Arthroscopically confi rm the appropriate position of both guidewires at this point.

A

B

E F G

C D

Physeal-Sparing Reconstruction of the Anterior Cruciate Ligament

The procedure of Kocher, Garg, and Micheli consists of arthroscopically assisted, physeal-sparing, combined intraarticular and extraarticular reconstruction of the anterior cruciate ligament with use of an autogenous iliotibial band graft. It is a modifi cation of the combined intraarticular and extraarticular reconstruction described by MacIntosh and Darby. Modifi cations include application in skeletally immature patients, arthroscopic assistance, graft fi xation, and accelerated rehabilitation. Rehabilitation must be geared to the age of the young patient.

🔪 Surgical Technique 48-24

• The procedure is done with the patient under general anesthesia as an overnight observation procedure.

• Position the child supine on the operating table with a pneumatic tourniquet around the proximal aspect of the thigh.

• With the patient under anesthesia, confi rm anterior cruciate ligament insuffi ciency.

• Make an incision of approximately 6 cm obliquely from the lateral joint line to the superior border of the iliotibial band (Fig. 48-51A). Separate the iliotibial band proximally from the subcutaneous tissue with the use of a periosteal elevator under the skin of the lateral part of the thigh.

• Incise the anterior and posterior borders of the iliotibial band, and carry the incisions proximally under the skin with the use of a curved meniscotome.

• Detach the iliotibial band proximally under the skin with the use of a curved meniscotome or an open tendon stripper.

• Leave the iliotibial band attached distally at Gerdy tubercle.

• Dissect distally to separate the iliotibial band from the joint capsule and from the lateral patellar retinaculum (Fig. 48-51B).

• Tubularize the free proximal end of the iliotibial band with a whipstitch using a No. 5 Ethibond suture (Ethicon, Johnson & Johnson, Somerville, NJ).

• Examine the knee with the arthroscope through standard anterolateral and anteromedial portals, treat any meniscal injury or chondral injury, and excise the anterior cruciate ligament remnant.

• Identify the over-the-top position on the femur and the overthe-front position under the intermeniscal ligament.

• Perform a minimal notchplasty to avoid iatrogenic injury to the perichondrial ring of the distal femoral physis, which is in close proximity to the over-the-top position.

• Bring the free end of the iliotibial band graft through the overthe-top position with the use of a full-length clamp (Fig. 48-51C and D) or a two-incision, rear-entry guide and out through the anteromedial portal.

• Make a second incision of approximately 4.5 cm over the proximal medial aspect of the tibia in the region of the pes anserinus. Carry the dissection through the subcutaneous tissue to the periosteum.

• Place a curved clamp from this incision into the joint under the intermeniscal ligament (Fig. 48-51E).

• Make a small groove in the anteromedial aspect of the proximal tibial epiphysis under the intermeniscal ligament with the use of a curved rat-tail rasp to bring the tibial graft placement more posterior.

• Bring the free end of the graft through the joint (Fig. 48-51F), under the intermeniscal ligament in the anteromedial epiphyseal groove, and out through the medial tibial incision (Fig. 48-51G).

• Place the knee in 90 degrees of fl exion and 15 degrees of external rotation. For extraarticular reconstruction, fi x the graft on the femoral side through the lateral incision using mattress sutures on the lateral femoral condyle at the insertion of the lateral intermuscular septum.

• Fix the tibial side through the medial incision with the knee fl exed 20 degrees and tension applied to the graft.

• Make a periosteal incision distal to the proximal tibial physis as confi rmed fl uoroscopically.

• Make a trough in the proximal medial tibial metaphyseal cortex, and suture the graft to the periosteum at the rough margins with mattress sutures (Fig. 48-51H).

AFTERTREATMENT Postoperatively, the patient is permitted touch-down weight bearing for 6 weeks. Immediate mobilization from 0 to 90 degrees is allowed for the fi rst 2 weeks, followed by progression to full range of motion. Continuous passive motion from 0 to 90 degrees is used for the fi rst 2 weeks postoperatively to initiate motion and overcome the anxiety associated with postoperative movement in young children. A protective hinged knee brace is used for 6 weeks after surgery with motion limits of 0 to 90 degrees for the fi rst 2 weeks. Progressive rehabilitation consists of range-of-motion exercises, patellar mobilization, electrical stimulation, pool therapy (if available), proprioception exercises, and closed chain strengthening exercises during the fi rst 3 months postoperatively followed by straight-line jogging, plyometric exercises, sport cord exercises, and sport-specifi c exercises. Return to full activity, including sports that involve cutting, usually is allowed 6 months postoperatively. A custom-made knee brace is used routinely during cutting and pivoting activities for the fi rst 2 years after return to sports.

A B

C

D E

Fig. 48-51 A, Technique of physeal-sparing, combined intraarticular and extraarticular reconstruction of anterior cruciate ligament with use of autogenous iliotibial bone graft. A, Iliotibial band harvested through oblique lateral knee incision. B, Iliotibial band graft detached proximally, left attached distally, and dissected free from lateral patellar retinaculum. C, Iliotibial band graft brought through knee with use of full-length clamp placed from anteromedial portal through over-top position into lateral incision. D, Graft brought through over-top position. E, Clamp is placed from proximal medial incision in leg under intermeniscal ligament, and groove is made in anteromedial tibial epiphysis with use of rasp.

G

F

H

Fig. 48-51, cont’d F, Graft is brought through knee in over-top position and under intermeniscal ligament. G, Graft is brought out of proximal medial incision in leg. It is sutured to intermuscular septum and periosteum of lateral femoral condyle through lateral knee incision, and it is sutured in trough to periosteum of proximal medial tibial metaphysis. H, Schematic appearance of combined intraarticular and extraarticular reconstruction. ( A-G from and H redrawn from Kocher MS, Garg S, Micheli LJ: Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents, J Bone Joint Surg 87A:2371, 2005.)

Complications of Anterior Cruciate Ligament Reconstruction Five-year follow-up studies of anterior cruciate ligament reconstruction using autograft bone–patellar tendon–bone grafts and hamstring grafts show similar results as far as stability and failure rates are concerned. Stiffness and strength tend to be slightly better with bone–patellar tendon–bone grafts, but overall results are comparable. Allograft studies at 5and 7-year follow-up are similar to those with autograft, especially since the incidence of effu- sions and apparent graft rejection has decreased, and graft procurement and sterilization techniques have improved. Failure rates seem to have stabilized at about 7% to 8% at 5-year follow-up when graft failure is the cause of the poor outcome. Other studies measure failure by KT-1000 testing, giving way of the knee, or failure of the patient to return to a previous sporting activity. If these parameters are used to measure surgical failure, the percentage ranges from 5% to 52%. Although the failure rate has stabilized, the number of revision surgeries continues to increase, probably because of better follow-up protocols; higher patient demands, expectations, and activity levels; and the earlier age at which these procedures are being performed. Economically speaking, the cost of failure can be high. Additional procedures and rehabilitation, loss of work for the patient, and the potential loss of a college scholarship for a high school athlete can be fi nancially burdensome. Anterior cruciate ligament failure also may take an emotional toll on the patient. Psychological trauma from additional surgery, frustration over prolonged rehabilitation, loss of motivation, and displaced anger may result. Physiological consequences include additional surgical trauma from harvesting the graft, possible articular damage, and additional chondral or meniscal damage from chronic instability because many patients wait some time before revision surgery. Meniscal damage has been shown to occur in approximately 40% at 1 year, 60% at 5 years, and approximately 80% at 10 years, which is the same incidence as degenerative joint disease seen at 10 years. The causes of anterior cruciate ligament reconstruction complications can be outlined by the failures as depicted in Fig. 48-42. Most failures can be prevented by careful surgical planning and preparation, adherence to technique, attention to detail, and careful postoperative follow-up with early recognition and intervention for complications. Surgeons should be knowledgeable about the current literature and potential complications. If one is to advance on a surgical learning curve and decrease the number of complications, assessment of surgical results, radiographic evaluation of tunnels and screw placements, and careful, unbiased physical and KT-1000 examinations are necessary. Complications can be divided into preoperative, intraoperative, and postoperative categories. Preoperative radiographic evaluation can eliminate most problems of excessive patellar tendon length, tuberosity ossicles, or aberrancy of the patella. Intraoperative complications can result from graft, fi xation, or tunnel problems and are avoidable by attention to details. Methods for avoiding these complications are discussed subsequently. Less common or signifi cant problems are noted in Figure 48-42. Surgical failure can be caused by nonphysiometric tunnel placement, graft impingement, a weak graft, or weak graft fi xation. Careful observation of the landmarks and correct placement of tunnels are essential to prevent excessive graft stress or impingement. We generally like to ream the tunnels initially with a reamer that is approximately 2 mm smaller than the defi nitive tunnel so that minor adjustments can be made easily. Use of a rasp or eccentric reaming to move a tunnel to an appropriate place is easily accomplished. Stress on the patella can be decreased greatly by carefully harvesting the patellar tendon graft. It is important to make straight cuts in line with the fi bers and to ensure that the bone cuts are not too deep, especially in the patella, and that the length of the cut is about 20 to

23 mm. Cuts should be slightly angled, and the patella should be bone grafted on completion to avoid late stress fractures. At the time of the procedure, an internal notchplasty and careful viewing of the guidewire to ensure that it does not impinge on the roof or the wall of the tunnel with fl exion and extension is essential. Also, one should ensure that it is not too far posterior, where it would impinge on the posterior cruciate ligament. After placement and alterations have been made, the graft should be fully observed again, particularly in knee extension. Postoperative problems include arthrofi brosis, which should be treated with nonsteroidal anti-infl ammatory drugs and supervised therapy. Therapy to rebuild muscular tone initially should be attempted to try to regain full knee extension. Supervised therapy is instituted three times a week with the patient working on range of motion three times daily, stressing prone hangs to regain full extension. If motion fails to progress over 4 to 6 weeks of therapy, and the patient has less than 90 degrees fl exion after 6 weeks of supervised physical therapy, gentle manipulation and possibly arthroscopic evaluation should be considered. Postoperative radiographs are reviewed to ensure that the tunnels are correctly placed, and that an obvious impingement is not demonstrable. Loss of full extension, persistent effusion, anterior knee pain, or clicking or popping in the anterior part of the knee that is painful with terminal extension may indicate impingement. A lateral radiograph should be obtained with the knee in extension to ensure the tibial tunnel is posterior to the foot of the intercondylar notch and that screw placement in the femur is in the posterior aspect of the intercondylar notch. Postoperative infections are uncommon with arthroscopic anterior cruciate ligament reconstructions, but persistence or recurrence of fever 5 to 6 days after the procedure with increased pain, loss of knee motion, and heat or erythema at the knee site may indicate early infection and must be treated appropriately and aggressively. If a knee aspiration shows a white blood cell count to be elevated (often in the range of ≥ 20,000/ µ L), arthroscopic irrigation and evaluation of the graft should be performed. If the graft is still intact and in good condition, it should be left in place, but the joint should be thoroughly irrigated, and repeat irrigation and débridement should be done at 48 to 72 hours if symptoms are not drastically improving. A combination of antibiotics intravenously for 2 to 3 weeks followed by oral antibiotics to complete a 6-week course of organism-specifi c antibiotic treatment is necessary. In any postoperative infection, fi nding the source is crucial to prevent additional infections. Equipment sterilization procedures, preparation and draping techniques, handling of the graft by operating room personnel, and surgical techniques should be evaluated carefully. The surgical site of arthroscopy should always be prepared with a waterproof antibiotic solution and draped and sealed proximal and distal to the site of surgery.

Posterior Cruciate Ligament Reconstruction The posterior cruciate ligament consists of three components: an anteromedial band, a posterolateral band, and the meniscofemoral ligaments. The posterolateral band is approximately 150% the strength and stiffness of the anteromedial band and is tight in knee fl exion. The entire ligament has 1.5 to 2 times the strength of the anterior cruciate ligament, and the broadness of its femoral footprint is approximately 3 cm 2 . The large insertion site of the dual ligaments makes physiometric reconstruction diffi cult. Fanelli et al. found that in the traumatic setting, approximately 85% of posterior cruciate ligament injuries had an associated ligamentous injury, most commonly the posterolateral corner. Fowler and Messieh found that hyperfl exion was the most common cause for posterior cruciate ligament injuries in athletes. This hyperfl exion injury sometimes resulted in a partial posterior cruciate ligament injury, with 1 + to sometimes 2 + posterior laxity. Shelbourne and Muthukaruppan reported good clinical outcomes when these injuries were treated conservatively initially, consisting of knee extension and a protective rehabilitation program with no active hamstring strengthening. Longterm results did not correlate with the initial degree of instability in these isolated injuries. Subjective scores did not deteriorate with time. For more signifi cant posterior cruciate ligament injuries with associated posterior and posterolateral laxity, reconstruction has become the treatment of choice for active, younger individuals. Physical examination of these posterior cruciate ligament injuries reveals a 1-cm posterior drawer that does not improve with internal rotation and may reveal a 10-degree increase in external rotation at 30 and 90 degrees indicative of associated posterior labral injury. The choice of techniques varies and is still being debated. The original one-tunnel posterior cruciate ligament technique in itself does not seem to stabilize satisfactorily many of these conditions. Nonetheless, when the one-tunnel posterior cruciate ligament reconstruction is performed, and posterolateral reconstruction is used to stabilize the posterolateral component, Fanelli has shown that excellent results increase from 48% to greater than 70%. More recently, two additional techniques for posterior cruciate ligament reconstruction have gained popularity. Enthusiasm has increased for the posterior cruciate ligament inlay technique as described by Burks and Schaffer and later by Miller et al. Its popularity can be attributed to the fact that fi xation is solid near the joint line, and that the “killer curve” is removed by placing the graft in a tibial trough at the posterior cruciate ligament footprint. The disadvantage of this technique is the diffi culty with patient positioning and using posterior and anterior incisions.

At present, for isolated posterior cruciate ligament reconstruction, we agree with Miller, Noyes et al., Bergfeld et al., and Cooper and Stewart, who prefer the tibial inlay technique as described by Burks et al. For most highimpact trauma injuries, we perform a posterolateral corner repair or reconstruction using a fi gure-of-eight tendon reconstruction technique. A posterior tibial tendon is placed through the fi bular head and secured in a 25-mm deep tunnel at the femoral epicondyle using a biotenodesis screw. The femoral tunnel may be single or double, with Harner et al. and Noyes et al. believing that the double-tunnel technique practically and biomechanically gives the best stability. The posterior cruciate ligament inlay technique is described in Chapter 43. The two-tunnel technique has been shown in clinical studies to have increased stability and physiometric placement of a posterior cruciate ligament graft. Mannor et al., Harner et al., and Clancy and Bisson have performed this technique in a laboratory and have reported early results in patients. No long-term follow-up studies of the procedure are available at this time, however, and from early results it is still diffi cult to tell whether it has more benefi t than the combined procedure of single-tunnel posterior cruciate ligament and posterolateral corner reconstruction. The single-tunnel technique, which we use mostly for reconstruction of multiple knee ligaments in knee dislocations, is described subsequently. The two-tunnel technique is used primarily in isolated posterior cruciate ligament reconstruction. An Achilles tendon allograft (transtibial or inlay) is our preferred graft source for posterior cruciate ligament reconstruction.

Single-Tunnel Reconstruction TECHNIQUE 48-25

• Place the patient supine, and apply a tourniquet high around the thigh. Use a padded lateral post to assist with valgus stress. Tape a 3-L saline bag to the table before draping to use as a foot bolster to help maintain 80 to 90 degrees of knee fl exion during the procedure.

• Perform a routine systematic arthroscopic examination of the knee, and repair any associated intraarticular abnormalities as necessary. If a meniscal repair is performed, the sutures should be tied after the ligament reconstruction is completed.

• Using standard anterolateral and anteromedial portals, débride the soft tissue and remaining cruciate ligament from the intercondylar notch.

• Perform an internal bony notchplasty as necessary.

• Viewing of the tibial attachment site of the posterior cruciate ligament is improved by using a 70-degree viewing arthroscope in the anterolateral portal or by placing the 30-degree viewing arthroscope through a posteromedial portal.

Single-Tunnel Reconstruction TECHNIQUE 48-25—cont’d

• Using a full-radius resector, remove the remaining stump of the posterior cruciate ligament. Specially designed back-cutting knives, curets, and rasps also are available to assist in removing the remnants.

• Elevate the posterior capsule from its attachment to the posterior fl at spot on the tibia using a curved curet or periosteal elevator passed through the intercondylar notch or the posteromedial portal.

• Contour an Achilles tendon allograft to make a bone plug 11 mm wide × 20 mm long.

• Place the tendinous part of the graft under tension, and roll the graft with a running Vicryl suture. Place a No. 5 tension suture in the distal 5 cm of the graft, using a running interlocking suture. Place the graft on a graft tension board, maintained with 10 lb of tension for 15 minutes.

• If an autogenous patellar tendon is chosen as a graft, make a 7-cm midline incision, starting at the inferior patella and extending distally over the tibial tuberosity.

• Later the femoral tunnel can be reamed through a separate 3-cm incision centered over the medial epicondyle. If preferred, these exposures can be incorporated into a single medial parapatellar hockey-stick incision that allows extension of the exposure and posteromedial capsular exposure, if necessary, for reaming and graft passage.

• Harvest the central third of the patellar tendon—10 to 11 mm wide and 25 mm long—with 8-mm-thick bone plugs.

• Contour the graft to pass through a 10or 11-mm trial. The bone plug to be secured in the femoral tunnel should be shortened to approximately 20 mm to make intraarticular passage easier.

• Place three drill holes and three No. 5 Tevdek sutures in each bone plug, and roll the tendon graft with a running 2-0 Vicryl suture while the graft is maintained under tension.

• If an Achilles allograft is selected, make a 3-cm incision at the level of the tibial tuberosity or approximately 5 cm distal to the joint line.

• Make a corresponding 3-cm longitudinal incision over the medial femoral condyle to expose the femoral cortex midway between the articular margin of the medial femoral condyle and the medial epicondyle.

• Retract the vastus medialis obliquus anteriorly.

• For making the tibial tunnel, we prefer to use the Arthrex drill guide system. With the arthroscope in the anterolateral portal, insert the guide through the anteromedial portal, and pass it through the notch.

• Place the guide tip 10 to 12 mm below the joint line in the posterior cruciate ligament facet.

• Orient the drill guide approximately 60 degrees to the articular surface of the tibia, starting just inferior and medial to the tibial tuberosity (Fig. 48-52A). A more perpendicular angle would create too much of an acute angle at the posterior tibia that may abrade the graft. A tibial tunnel that is started too distally may ream out the posterior tibial shelf. The simultaneous use of image intensifi cation and arthroscopy aids in proper positioning of the drill guide before and during drilling. Calibrations on the tibial guide accurately measure the distance from the anterior tibial cortex to the tip of the guide.

• Adjust the guide pin so that it is protruding from the tip of the drill 1 cm less than the distance measured on the guide system to help prevent overdrilling (see Fig. 48-52A). The guide pin should exit posteriorly at the physeal scar area.

• Tap the pin in the fi nal 1 cm to help prevent penetration. While tapping the pin in, place a 5.5-cm shaver through the posteromedial portal to protect the neurovascular structures from pin penetration during advancement and reaming. If adequate soft-tissue débridement has been performed, the guide pin can be observed arthroscopically as it exits the tibia. As experience is gained, the use of the image intensifi er can be discontinued, but proper placement of the guidewire should be alternatively confi rmed with anteroposterior and lateral radiographs.

• The femoral physiometric point is 8 mm proximal to the articular cartilage at the 1-o’clock position on the right knee and at the 11-o’clock position on the left knee (Fig. 48-52B). Place the tip of the posterior cruciate ligament femoral guide through the anteromedial portal while viewing with the arthroscope in the anterolateral portal.

• Expose the femoral cortex through the 3-cm longitudinal incision, and elevate the vastus medialis obliquus superiorly.

• Insert the guide pin midway between the articular margin of the medial femoral condyle and the medial epicondyle.

• Use the appropriate size reamer for the available graft, leaving 1 to 2 mm of distal bone at the articular margin.

• Rasp the internal and external apertures. While reaming the tibial tunnel, use the shaver in the posteromedial portal to cover the wire tip. Ream just distal to the posterior wall, and then complete the reaming by hand or proceed at very slow revolutions.

• Pass a double 18-gauge wire or an Arthrex worm with a suture loop up through the tibial tunnel into the joint (Fig. 4852C). Pull the wire or suture through a central fat pad portal. Use this suture to pull a Gore smoother through the tibial tunnel into the joint. The smoother is used to smooth and remove the posterior soft-tissue remnants. Do not enlarge the tibial tunnel excessively.

• When the smoother passes without undue resistance, attach the graft to the end of the smoother, and pull the graft sutures and bone plug into the joint.

A

B

C

Fig. 48-52 Posterior ligament reconstruction. A, Arthrex Popliteal Drill Stop prevents advancement of guide pin past tip of marking hook during drilling. B, Millimeter markings on Arthrex PCL Femoral Marking Hook allow determination of distance of femoral tunnel from margin of articular cartilage. C, Arthrex “Worm” Curving Suture Passer facilitates passing of graft sutures through tibial tunnel into intercondylar notch. (From Terry GC, Renstrom PA, Fu F, et al: Transtibial arthroscopic PCL reconstruction, surgical technique, Arthrex, Naples, Fla.)

• Extreme fl exion of the knee sometimes aids passage of the patellar bone plug from the posterior tibial aperture into the joint. Placing a switching stick through the posteromedial portal allows the guide sutures to be redirected over the stick to assist in passing the graft.

• Place a grasper through the femoral tunnel to grab the sutures. Use a probe or Allis clamp to assist the graft into the femoral tunnel.

• Place the cancellous portion of the bone plug posteriorly to reduce graft abrasion.

• Before tibial fi xation, ensure that the femoral bone plug would fi t appropriately at the aperture of the femoral tunnel.

• Put the knee through a range of motion, and ensure there is no more than 3 mm of graft pistoning through range of motion

Single-Tunnel Reconstruction TECHNIQUE 48-25—cont’d from 0 to 100 degrees. If excessive pistoning is encountered, rasp the femoral tunnel proximal wall.

• Secure the femoral bone plug with a metal interference screw.

• Maintain graft tension and put the knee through a range of motion for 20 cycles to allow stress relaxation of the graft.

• Secure the Achilles allograft over a post distal to the femoral tunnel, while maintaining an anterior drawer on the knee and 10 to 15 lb of tension on the graft.

• Double fi xation of the graft is necessary to ensure best results, and this is done by using a biointerference screw placed anterior to the graft and seated at the posterior aperture of the tibial tunnel. To accomplish this, use the arthroscope in the posterior portal, obtain a radiographic image, or premeasure the tunnel length.

• If an autogenous or allograft patellar tendon is used, place a bone plug with its cancellous portion anteriorly, and secure it with an interference screw at the posterior aperture of the tibial tunnel.

AFTERTREATMENT Rehabilitation depends on the graft material selected, the size of the patient, and any other surgery done. After isolated posterior cruciate ligament reconstruction, the knee can be immobilized in extension in a removable knee immobilizer for 4 weeks. Early rangeof-motion and quadriceps exercises are encouraged, but fl exion is limited to 90 degrees for the fi rst 4 weeks. Hamstring strengthening is begun at 3 months. During motion and strengthening therapy, care is taken to prevent posterior tibial stress. Return to sports is allowed at 9 months.

Double-Tunnel Posterior Cruciate Ligament Reconstruction TECHNIQUE 48-26 Clancy and Bisson

• Harvest a patellar tendon bone plug 10 mm wide × 10 to 20 mm long from the patella and tibial tubercle or a quadriceps tendon through a separate small incision above the patella (8 mm wide × 10 to 20 mm long).

• Place three No. 5 Ethibond sutures in each end of the graft for later fi xation.

• Alternatively, the semitendinosus tendon can be harvested through the inferior incision and doubled over itself to form a double-strength graft.

• After débridement of the posterior cruciate ligament remnant from the femur and débridement of the tibial insertion side of the posterior cruciate ligament, create the tibial tunnel.

• When the site of insertion of the posterior cruciate ligament has been fully identifi ed, drive a guide pin from the anterior tibia (approximately 12 to 15 mm distal to the site of graft harvest from the tibial tubercle) into the center of the insertion of the posterior cruciate ligament. The entry point of the guide pin into the tibia is important because it creates a vertical tunnel (which eases graft passage into the tibia and facilitates tensioning of the graft) and avoids creating an oblique hole at the exit site of the tunnel in the fovea. Drilling a hole that enters medial or lateral to the tibial tubercle creates an oblique exit hole in the tibial fovea and can result in excessive medial or lateral placement of the graft.

• Drive a 10-mm reamer over the guidewire and then a 12-mm reamer. Leave the arthroscope in the posteromedial portal to ensure that neither the guide pin nor the reamers penetrate the knee joint during reaming.

• When the tibial tunnel has been reamed, débride the foveal site of any remaining tissue.

• Pass a No. 5 Ethibond suture through the tibial drill hole and out the central fat pad portal. This suture is used during passage of the graft into the tibial tunnel.

• To create the femoral tunnels, use the remaining fi bers of the posterior cruciate ligament on the medial femoral condyle as a guide.

• Drill a 10-mm anterior proximal tunnel and an 8-mm posterior distal tunnel, keeping them separated by a 3to 4-mm bony bridge.

• A small (00) curet is used to make marks in the medial femoral condyle at the desired tunnel sites. The anterior proximal tunnel guide pin should enter the intracondylar notch at the 10:30o’clock position in the left knee (1:30-o’clock position in the right knee) approximately 6 mm posterior to the articular surface of the medial femoral condyle (Fig. 48-53).

• Place the posterior distal tunnel approximately 5 mm posterior and 5 mm distal to the anterior proximal tunnel, ascertaining that the tunnel sites remain within the anatomical site of origin of the posterior cruciate ligament, and that both tunnels are entirely anterior to the ridge in the medial femoral condyle. Noyes suggested 1-o’clock and 3-o’clock positions and 6 mm and 8 mm off the articular surface. He uses a two-limb quadriceps graft.

• Make an incision over the vastus medialis muscle at the level of the adductor tubercle, and elevate the fi bers of the vastus medialis anteriorly.

• Use a vector guide to place a pin from the region of the adductor tubercle into the desired position of the anterior proximal tunnel and drive a 10-mm reamer over this guide.

• Drive a second guide pin from a separate site in the medial femoral condyle into the desired site of the posterior distal

Fig. 48-53 Ideal sites for positions of femoral tunnels as viewed from side of left knee with lateral femoral condyle removed. (Redrawn from Bisson L, Clancy W: Isolated PCL injury and posterolateral laxity. In Chapman MW, Szabo RM, Marder RA, et al, eds: Operative orthopaedics, 3rd ed, Philadelphia, 2000, Lippincott Williams & Wilkins.)

tunnel, and drive an 8-mm reamer over this guide pin. Ensure that an adequate bony bridge separates these two tunnels.

• Pass two No. 5 Ethibond sutures, which will be used later for graft passage, through these tunnels, and exit out the central fat pad portal.

• If using the endoscopic technique, a specially designed custom guide, fl exible guide pins, and reamers are used to ream the two tunnels from the inside of the notch.

• Each tunnel is reamed to a depth of 25 to 30 mm with the appropriate-sized reamer, and a 4.5-mm drill is used to drill out the medial femoral cortex.

• The grafts are fi xed using an EndoButton device, allowing an entirely endoscopic reconstruction.

• Pass the grafts into the femoral tunnels using the previously placed sutures through the central fat pad portal and the femoral tunnels.

• Place the quadriceps or semitendinosus graft fi rst, and fi x it at the medial femoral condyle using either a simple button (open technique) or an EndoButton (endoscopic technique).

• After femoral fi xation of this graft, pass the patellar tendon into the femur, and fi x in a similar fashion.

• When both grafts have been fi xed at the medial femoral condyle, pass them through the central fat pad portal and into the tibia using the previously placed suture through the tibial tunnel. This step can be facilitated with the use of a specialized graft passer, which encloses the grafts and provides a smooth surface to slide through the tibial tunnel. The application of an anterior drawer maneuver at the time of graft passage into the tibia helps the graft to turn the corner at the proximal part of the tibial tunnel.

• The fi nal step in the procedure is fi xation of the grafts to the tibia.

• Fix the patellar tendon graft fi rst, and tension it at 90 degrees of fl exion with an anterior drawer maneuver.

• Tie the sutures from the patellar bone plug over a screw and washer, and tighten at the end of the procedure.

• Tighten the quadriceps or hamstring graft at 30 degrees of fl exion, and tie these sutures over the same screw as those from the patellar tendon graft. Irrigate the wounds, and close in routine fashion.

AFTERTREATMENT The rehabilitation protocol should begin on the fi rst postoperative day. In the immediate postoperative phase, the patient is encouraged to bear 50% of weight as tolerated, using two crutches to do ankle and hip exercises and to perform knee extensions from 60 to 0 degrees. Full weight bearing is allowed 2 to 6 weeks after surgery; multiangle quadriceps and isometric exercises at 60, 40, and 20 degrees are performed. Leg presses and squats from 0 to 60 degrees are introduced, and well-leg bicycling is performed. By week 4, range of motion should be to 90 degrees, and bicycling can be encouraged for range of motion and endurance. Exercises in the pool are initiated at week 5. Swimming, closed kinetic chain rehabilitation, and a stretching program are begun at 6 to 12 weeks to increase quadriceps strength. By week 12, the patient can begin lateral step-ups, cycling for endurance (30 minutes), hamstring curls from 0 to 60 degrees with low weight, and a walking program. These exercises should be continued to week 16. By 5 to 6 months after surgery, the patient should be performing plyometric exercises and agility and balance drills. The patient can return to sports when KT-2000, isokinetic testing, and functional testing yield satisfactory results.

Inlay Technique Interest is increasing in techniques that allow direct fi xation of a tibial bone plug to the posterior aspect of the tibia. This technique, originally described by Verdonk in the European literature and later by Burks and Schaffer, allows direct fi xation of a bone plug to a tibial trough in the anatomical insertion of the posterior cruciate ligament along the posterior tibia. Although no large series reports of this technique are available, it seems promising because of the advantage of eliminating acute graft angle changes. This technique allows secure direct fi xation to the posterior tibia. The approach described by Burks and Schaffer allows safe exposure of this area. The disadvantage of this technique is that access to the anterior and the posterior knee is necessary during the surgical procedure. Miller et al. described a technique of placing the patient in the lateral decubitus position with the injured side up. The hip can be externally rotated for the arthroscopic part of the procedure, and then the knee can be straightened and placed on a padded Mayo stand for the posterior exposure. This is our preferred technique and is performed in the manner as described in Chapter 43. Jung et al. described a posteromedial incision to expose the posterior cruciate ligament footprint. The patient is placed supine, secured, and held on the table with the end of the table lowered. The table is tilted 30 degrees down on the affected side when the posterior incision is made. Jung et al. suggested a double-bundle technique if the posterior cruciate ligament is thin and defi cient with tunnels placed at the 1o’clock and 3-o’clock positions. When the posterior cruciate ligament is lax but substantiated, Jung recesses the posterior cruciate ligament insertion and reconstructs the anterolateral bundle (Fig. 48-54).

Chondromalacia of the Patella Syndrome Chondromalacia, which means softening of the articular cartilage, has multiple causes (Fig. 48-55). Cartilage changes can be classifi ed from an arthroscopic standpoint based on the modifi ed Outerbridge (Insall) classifi cation: grade I, softening and swelling of the cartilage; grade II, fragmentation and fi ssuring in an area 0.5 inch or less in diameter; grade III, more severe fragmentation and fi ssuring involving an area of more than 0.5 inch in diameter; and grade IV, erosion of cartilage down to bone. Chondromalacia can be treated conservatively in most patients with an emphasis on maximizing fl exibility of the musculature and strengthening the vastus medialis obliquus muscle. Closed chain exercises are recommended, and some studies showed that taping and bracing were advantageous. Carefully evaluating lower extremity alignment, particularly for hyperpronation that can be corrected with orthotics, also can decrease patellofemoral stress. If prolonged, conservative treatment fails, surgical intervention may be necessary. Careful evaluation of the individual, including alignment, associated articular changes, ligamentous laxity, future goals, and rehabilitation potential, is necessary to obtain a good surgical result. In the case of chondromalacia with no signifi cant malalignment and grade II or early grade III changes, arthroscopic débridement of the patellofemoral joint and reevaluation of the exercise program may be all that is necessary. Arthroscopic débridement of the articular surface can be done safely with mechanical instrumentation (i.e., baskets and arthroscopic shavers). Some early results involving thermal chondroplasty, using either laser or radiofrequency devices, have been reported. We do not use these devices at this time and believe that the potential for additional chondral or osseous damage outweighs the benefi ts. Lateral release procedures have been performed for years by open or arthroscopic technique. The enthusiasm for release procedures has decreased, and the indications have become more specifi c, although they still are evolving, and the current literature often is contradictory. Lateral release procedures should not be applied to every disorder producing anterior knee pain but should be reserved for disorders with a defi nite clinical, radiographic, or arthroscopic abnormality of tracking or dynamics of the patella. Disorders for which it may be useful include lateral subluxation and dislocation; lateral tracking abnormalities, in which the patella cannot be proved to subluxate but is laterally riding and tilted on patellofemoral radiographs; and the lateral compression syndrome described by Ficat and Hungerford. Routine lateral retinacular release for undefi ned disorders of the anterior region of the knee should be discouraged. Lateral release for patellar instability associated with a hypermobile patella or with an excessive Q angle approaching 20 degrees or more should be combined with a realignment procedure, as described in Chapter 43. At this time, we prefer open realignment procedures, which allow more control over soft-tissue tightening. Some early reports of arthroscopic realignment procedures have shown good results in small groups of patients. Initial reports advocated the use of lateral retinacular release primarily for patellar instability. Schonholtz et al. reported 35 lateral retinacular releases performed through minimal lateral incisions. Twenty-two knees were available for an average 4-year follow-up. The patients were divided into three groups based on their preoperative diagnosis. Group 1 patients (eight knees) had a history of patellar dislocations, group 2 (seven knees) had recurrent patellar subluxations, and group 3 (seven knees) had patellar pain without any history of patellar instability. In groups 1 and 2 (patients with a history of patellar dislocation or subluxation), 67% improved after lateral retinacular release. In group 3 (patients with patellar pain, but no instability), only one of seven patients had a satisfactory result. Sherman et al. reported 45 patients with a history of recurrent patellar subluxations or dislocations, who were treated by arthroscopic lateral release using electrosurgery. At an average 28-month follow-up, 11.1% of the knees had excellent results, 64.4% were improved, and 24.5% had poor results. The knees with recurrent dislocations had poor results more frequently than the knees with subluxations. Aglietti et al. reported 45 arthroscopic lateral releases. At an average 4-year follow-up, 60% of patients undergoing surgery because of patellar pain had satisfactory results; 68.5% of patients with instability had satisfactory results. Aglietti et al. noted that unfavorable prognostic factors were an incomplete release with insuffi cient postoperative passive patellar tilt in the group with pain and more than fi ve preoperative dislocations in the group with instability. In a report of 117 lateral releases, Kolowich et al. concluded that the best results were obtained in patients with a preoperative diagnosis of lateral patellar compression syn-

Anterior

Posterior

Proximal

Distal

A

C D

B 5-6 mm

Semimembranosus muscle

Medial head of gastrocnemius muscle

Fig. 48-55 Degenerative medial compartment with grade III chondromalacia of femoral condyle, degenerative meniscal tear, and small area of grade IV chondromalacia of tibial articular surface just below probe.

+15°

b a

A B

Fig. 48-56 A, Passive patellar tilt test. Lateral edge of patella is lifted from lateral femoral condyle (b). Patella should remain in trochlea and not be allowed lateral subluxation. Excessively tight lateral restraint is shown by neutral or negative angle to horizontal (a). B, Patellar glide test in 30 degrees of fl exion. (Redrawn from Kolowich PA, Paulos LE, Rosenberg TD, et al: Lateral release of the patella: indications and contraindications, Am J Sports Med 18:359, 1990.) drome. Surgery for patellar instability was not as predictable. Their results indicate that the most predictable criterion for success is a negative passive patellar tilt. Additional criteria include a medial and lateral patellar glide of two quadrants or less and a normal tubercle-sulcus angle with the knee at 90 degrees of fl exion. The passive patellar tilt test is performed with the patient supine, the knee extended, and the quadriceps relaxed. The examiner lifts the lateral edge of the patella from the lateral femoral condyle. The patella should remain in the trochlea. An excessively tight lateral restraint is shown by a neutral or negative angle to the horizontal (Fig. 48-56A). The patellar glide test determines medial or lateral retinacular tightness (Fig. 48-56B). This test is performed with the knee fl exed 20 to 30 degrees and the quadriceps relaxed. This position can be accomplished by placing a small pillow beneath the knee. The patella is divided into longitudinal quadrants, and an attempt is made to displace the patella medially and laterally. A lateral patellar glide of three quadrants or more suggests an incompetent medial restraint. A medial glide of one quadrant is consistent with a tight lateral restraint, and a glide of three or more quadrants suggests a hypermobile patella. The tuberosity-sulcus angle is determined by measuring the Q angle with the knee at 90 degrees of fl exion. The angle is formed by a line drawn from the center of the patella to the center of the tibial tuberosity and a line drawn from the center of the patella and passing perpendicular to the transepicondylar axis. This angle should be 0 degrees, and more than 10 degrees is defi nitely abnormal. The traditional Q angle measured from the tibial tuberosity to the center of the patella and extending to the anterior superior iliac spine likewise is a valuable measurement that should be evaluated when contemplating surgical procedures for the patella. Anteroposterior, 45-degree lateral, and 45-degree Merchant view radiographs are helpful in determining patellar tilt, subluxation, and Insall ratio, as described in Chapter 45. Kolowich et al. recommend that lateral release extend only to the vastus lateralis and not include this structure. Of 43 unsatisfactory results, 16 knees required vastus lateralis repair for overrelease of the lateral structures. All these patients showed persistent quadriceps weakness with associated patellar pain. The procedure can be done as an arthroscopic intraarticular procedure or by a percutaneous method. In the former method, the synovium, capsule, and retinacular structures from near the tibial plateau along the lateral side of the patella and proximally to the muscular fi bers of the vastus lateralis are cut with arthroscopic knives or by electrocautery techniques. Use of an electrocautery-coated tip allows release without changing the electrolyte irrigation solution. Through electrocautery, many of the small vessels and the superior lateral genicular vessel can be coagulated, reducing postoperative complications of hemarthrosis.

A B

Trochlea

Fig. 48-57 Patellofemoral articulation view from anterolateral portal. A, Lateral tracking of patella is evident, as is grade II chondromalacia of lateral facet. B, Grade IV chondromalacia of trochlea with bare bone exposed.

Lateral Retinacular Release TECHNIQUE 48-27

• View the patellofemoral joint with a 30-degree viewing arthroscope in the inferior or superior portal; either is adequate. With the arthroscope in the standard anterolateral portal and advanced into the patellofemoral joint, rotate the lens upward and downward alternately to view the articular surfaces of the patella and the trochlear groove of the distal femur (Fig. 48-57).

• Manually manipulate the patella with the thumb and index fi nger for complete viewing of the entire surface of the patella. The tracking of the patella and the dynamics of the patella and the patellofemoral joint can be viewed better from a superior portal (Fig. 48-58). The patella naturally rides laterally with the knee in extension, and observation of it in this position does not confi rm that the patella is subluxable or riding laterally. As the knee is moved from full extension into 30 to 40 degrees of

Fig. 48-58 Patellofemoral joint view from superolateral portal; lateral subluxation of patella is evident.

fl exion, the patella enters the trochlear groove and should become congruous and centered at this degree of fl exion. Persistent lateral tilt or overhang of the lateral facet over the edge of the lateral femoral condyle with the knee in this position suggests a lateral tracking phenomenon. Note the various degrees of chondromalacia of the patellar and trochlear articular surfaces, and record them (Fig. 48-59).

• Before performing the lateral retinacular release, carry out a complete and systematic examination of the knee for other pathological entities, and trim and shave severe patellar articular surface chondromalacic changes where appropriate. Extensive shaving of chondromalacic areas on the patellar or trochlear surface probably has only short-term effects; shaving should be kept to a minimum, emphasizing removal of only degenerative fi brillated material. The objective is restoration of the proper dynamics of the extensor mechanism.

• When a complete arthroscopic examination has been done, and any chondroplastic areas have been shaved, remove the arthroscopic instruments from the joint, and evacuate the irrigating fl uids.

• Attempt to palpate the inferior edge of the vastus lateralis tendon, and mark this junction at its insertion into the patella with an 18-gauge spinal needle at the superior pole of the patella. If the edge of the tendon cannot be palpated, simply insert the needle at the superolateral corner of the patella.

• Insert the arthroscope through the superolateral or the anteromedial portal. Initially, insert the electrocautery into the anterolateral portal.

Fig. 48-59 Grade III chondromalacia of patella involving central ridge and lateral facet.

Vastus lateralis Vastus medialis

Rectus femoris and vastus intermedius

Line of incision for lateral release

Incision curves slightly medial at superolateral border of patella to cut across insertion of vastus lateralis

Fig. 48-60 Line of deep incision for lateral patellar release of right knee. (Redrawn from Metcalf RW: Operative arthroscopy of the knee, Instr Course Lect 30:357, 1981.)

Lateral Retinacular Release TECHNIQUE 48-27—cont’d

• Under arthroscopic guidance, divide the synovium and lateral retinaculum from the superolateral corner of the patella marked by the spinal needle to the inferior extent of the lateral border of the patellar tendon. Occasionally, the electrocautery must be placed in a superomedial or superolateral portal to complete the most inferior portion of the release. The release can be extended proximally along the lateral border of the vastus lateralis tendon.

• If a percutaneous method is chosen, the joint can be redistended or left defl ated. Through a 1-cm incision at the lateral border of the patella, or through the anterolateral portal, undermine the skin and subcutaneous tissue along the entire lateral border of the patella, along the lateral retinacular area, distally along the lateral border of the patellar tendon, and proximally to the insertion of the vastus lateralis muscle into the superolateral pole of the patella (Fig. 48-60).

• Place one tine of a curved Mayo scissors into this retinacular and capsular defect, and push the scissors superiorly along the lateral edge of the patella to the vastus lateralis. At this point, they can be turned to follow the lateral border of the vastus lateralis for a short distance.

• Repeat this maneuver distally along the lateral border of the patella and the patellar tendon to the level of the lateral tibial plateau.

• When these structures have been released proximally and distally, remove the scissors and, with the knee in full extension, grasp the patella between thumb and index fi nger and tilt it 90 degrees to the plane of the trochlear surface.

• If the patella cannot be tilted, carefully inspect the release, and carry it further if necessary or consider a medial plication.

• Place a thick sponge-rubber pad over the superolateral aspect of the distal thigh just proximal to the patellar tendon to serve as a pressure pad over the cut superolateral geniculate vessels. This has reduced the incidence of troublesome hemarthrosis after release.

• A drain can be placed intraarticularly and removed after several hours.

AFTERTREATMENT The knee is maintained in an immobile, extended position for 48 hours, and then gentle rangeof-motion exercises are begun. Immobilization of the knee in extension for longer than 72 hours may allow the edges of the lateral retinacular release to adhere and become ineffective. Early range of motion tends to spread the release. Quadriceps isometric and stiff-leg exercises are encouraged. Weight bearing is allowed as tolerated.

Arthroscopic Medial Parapatellar Plication

Arthroscopic plication of the medial retinaculum has been described for patellar instability. The procedure described by Halbrecht uses a 17-gauge Tuohy epidural needle to pass a No. 1 PDS near the medial edge of the patella. The edge of the suture is retrieved out of a superolateral portal. The needle is backed up slightly to remain under the subcutaneous tissue and advanced posteriorly about 2 cm. The needle is passed back through the retinaculum, and the resulting loop of the PDS is pulled out superiorly, taking both tails out superiorly. After passage of four to fi ve sutures, they are tied arthroscopically through the anteromedial portal. An arthroscopic lateral release is performed. We do not do this procedure and believe that the same technique can be performed more adequately with nonabsorbable sutures and better imbrication through a small medial parapatellar incision.

Synovectomy

Arthroscopic synovectomy in rheumatoid disease and other chronic infl ammatory conditions and in hemophilia has been reported to produce less morbidity, shorter hospitalization, and more rapid return of function to the joint. Ogilvie-Harris and Basinski reported 96 arthroscopic synovectomies performed for rheumatoid arthritis without major complications. Pain and synovitis were signifi cantly decreased at 4-year follow-up, and the range of motion was maintained. Smiley and Wasilewski reported 25 arthroscopic synovectomies. At 6-month follow-up, 96% of the knees showed good results; 90% had good results at 2 years, and 57% had good results at 4 years.

AFTERTREATMENT Before discharge, the drain is removed. Weight bearing to tolerance with crutches is allowed, and range-of-motion and quadriceps-strengthening exercises are begun immediately.

Drainage and Débridement in Pyarthrosis

Arthroscopic débridement and lavage in pyarthrosis offer the advantages of reduced morbidity and shortened hospitalization. With the arthroscope, the knee can be lavaged with large volumes of fl uid, and any fi brinoid material and infected debris can be removed. Smith reported 30 patients treated by arthroscopic decompression and lavage, combined with parenteral or oral antibiotics; in 28 of these patients, arthroscopy was performed within 72 hours of the onset of symptoms, and surgery was performed in all

🔪 Surgical Technique 48-28

• Five or six portals, including the posteromedial and posterolateral portals, are used routinely. Approach the posterior compartment with a 70-degree viewing arthroscope placed through the intercondylar notch, and place a full-radius resector through the corresponding posteromedial or posterolateral portal.

• Preserving the menisci, resect the synovial proliferation inferior to the menisci and around the cruciate ligaments, preserving the underlying structures (Fig. 48-61).

• Carefully strip the synovial proliferation in the medial and lateral aspects of the knee off the junction of the synovium and the articular cartilage. Frequent repositioning of the arthroscope and motorized shavers is necessary to avoid damage to the articular cartilage and to reach all synovial recesses.

• After synovectomy, insert a drain in the knee, and connect it to suction. Place the knee in a modifi ed Jones dressing.

A B

Fig. 48-61 A, Localized nodular synovitis of posteromedial compartment of knee. B, Arthroscopic excision of localized nodular synovitis with arthroscope in posteromedial portal and probe through intercondylar notch to palpate posterior cruciate ligament. Synovial attachment of nodular synovitis is just superior and posterior to probe.

patients within 24 hours of presentation. Postoperatively, patients usually were given parenteral antibiotics for 48 to 72 hours and then were given oral antibiotics. The drain usually was removed on the second postoperative day. Crutches were used for 2 weeks to rest the joint, but active range of motion was encouraged. Smith reported 28 excellent results and 2 good results in 30 patients. There were no poor results or recurrences and no cases of osteomyelitis. With the advent of more resistant organisms, the use of appropriate cultures and initial use of broad-spectrum antibiotic coverage, including coverage for methicillin-resistant Staphylococcus aureus, is indicated. When the cultures are complete, antibiotics specifi c to the organism should be used.

🔪 Surgical Technique 48-29

• The standard arthroscopic setup is used for arthroscopic débridement. Do not exsanguinate the extremity. Use a largebore cannula or arthroscopic pump for irrigation.

• Make anteromedial and anterolateral portals to examine and débride fi brinoid exudate as indicated. Take appropriate bacterial cultures.

• Thoroughly lavage all compartments—anterior, posterior, and suprapatellar—and the medial and lateral gutters, using 9 to 10 L of fl uid.

• Place suction drain tubes in the medial and lateral gutters through the arthroscopic cannula, and then withdraw the cannula over the drain. Loosely approximate the portals with absorbable sutures.

AFTERTREATMENT A Jones-type dressing is applied to immobilize the knee for 36 to 48 hours while appropriate antibiotics are administered. At 48 hours, the drains are removed, and range of motion is begun. If the infection fails to respond to treatment, repeat débridement is considered at 72 hours.

Other Applications of Arthroscopy of the Knee

The following are additional, less frequent, applications for arthroscopy of the knee. Several are refi nements of principles and techniques previously described in this chapter, and most should be attempted only by surgeons with considerable arthroscopic experience. Many of these techniques have not been suffi ciently evaluated to determine the longterm results and are not described in detail.

Arthroscopy in Fractures around the Knee Arthroscopic techniques have been used to evaluate fractures of the anterior intercondylar eminence of the tibia, to reduce such fractures, and, after reduction, to fi x the eminence with percutaneously inserted internal fi xation. In addition, arthroscopy has been advocated to assess the degree of articular surface depression and the adequacy of reduction after tibial plateau fractures. Caspari et al., Fowble et al., Guanche and Maekman, Müezzinoglu et al., and others have reported good results with arthroscopically assisted fracture reduction and percutaneous fi xation. Fracture patterns that are appropriate for arthroscopic management are those that can be internally fi xed with a cancellous screw and do not require a major reduction or use of a buttress plate. Better fracture evaluation, reduced operative time and morbidity, shorter hospitalization, and quicker recovery have been cited as advantages to the arthroscopically assisted technique. after arthroscopic procedures. He found that arthroscopic methods were more successful in increasing fl exion than in increasing extension. If extensive infrapatellar contracture syndrome develops, as evidenced by peripatellar induration, restricted patellar mobility, and loss of knee motion, conservative means should be used to reduce infl ammation and regain muscle tone and knee extension. An open technique, including lateral release and excision of the fat pad, as described by Paulos et al., may be necessary after the acute reaction has subsided.

🔪 Surgical Technique 48-30

• Make a small transverse incision in the skin 3 to 4 cm below the joint line, and drill holes through the anterior cortex.

• With the use of an image intensifi er and under arthroscopic guidance, insert a 0.25-inch osteotome through the cortical window, and drive it under the fracture to elevate the fragments. By manipulating the osteotome and using the anterior cortex as a fulcrum, elevate the fragments under arthroscopic guidance. Caspari et al. have termed this “indirect triangulation.” They recommend overelevation of the fragments.

• Remove the stress from the knee, and move it through a range of motion. The femoral condyle serves to mold the surface of the tibial plateau back into its anatomical confi guration. If necessary, insert a bone graft under the fracture through the cortical window.

• Obtain internal fi xation by percutaneous or open technique.

• Fowble et al., Müezzinoglu et al., and others have described using an arthroscopic anterior cruciate ligament guide to place a guidewire into the fracture site. A reamer is used to make the cortical window and a tamp to elevate the fragments. Müezzinoglu et al. described using a 15-mm Arthrex “coring” reamer, preserving local bone graft. Image intensifi cation is used to place percutaneous cannulated screws.

🔪 Surgical Technique 48-31

• Insert an arthroscopic sheath and blunt trocar through standard anterolateral and anteromedial portals.

• Pass the blunt trocar carefully beneath the patella and into the suprapatellar pouch. Use the trocar to disrupt bluntly any adhesions in the suprapatellar pouch and in the medial and lateral gutters.

• Insert the arthroscope, and inspect the joint in a routine manner. If the adhesions are dense, the patellofemoral joint usually is spared.

• Begin the débridement in the peripatellar region, and extend it outward.

• When the suprapatellar pouch has been restored, insert an infl ow cannula through a superior portal.

• Continue the dissection down into the medial and lateral gutters and compartments and fi nally into the intercondylar area. Avoid damage to the cruciate ligaments.

• Occasionally, proliferation of fi brous tissue is present within the intercondylar notch and anterior regions; this should be removed because it may limit extension. Some investigators recommend a lateral retinacular release as part of the procedure if patellar mobility is restricted after the arthroscopic release. Avoid iatrogenic fracture caused by excessive manipulation.

• After the systematic lysis of adhesions, perform a gentle manipulation. If any further adhesions are disrupted, débride these further arthroscopically.

• Thoroughly irrigate the joint, insert a suction drain, and apply a bulky compressive dressing.

AFTERTREATMENT Postoperative management is tailored to the specifi c injury and the adequacy of reduction and fi xation. If the fracture is stable, with rigid internal fi xation, early controlled range of motion is begun.

Arthrofi brosis Arthroscopic techniques for lysis and excision of postoperative adhesions have been reported. The arthroscopic procedure usually is combined with a gentle manipulation after the release. Sprague reported a mean gain of fl exion of 28 degrees and improvement of extension of 6 degrees

AFTERTREATMENT We have found it helpful to perform this procedure with the patient under continuous epidural anesthesia, which is maintained for 2 to 3 days after surgery. The patient is placed in a continuous passive motion machine immediately after surgery and the suction drain is removed at 2 days.

Evaluation before Proximal Tibial Osteotomies There have been confl icting reports concerning the merits of arthroscopic examination to assess the quality of the articular surfaces before proximal tibial osteotomies. Some surgeons recommend its routine use, whereas others report that the condition of the articular surface in the contralateral compartment has no bearing on the eventual outcome after proximal tibial osteotomy.

Débridement of Osteoarthrosis and Abrasion Arthroplasty Numerous reports have indicated that arthroscopic resection of mobile portions of degenerative menisci, resection of excessive synovial fronds, shaving of severe chondromalacic changes, and removal of loose bodies have a place in the management of degenerative arthritis of the knee. The best results can be expected when symptoms are relatively acute in onset. Patients with chronic, progressive changes and patients with advanced degenerative changes (evident on standing 45-degree posteroanterior radiographs) are not likely to have signifi cant improvement with arthroscopic surgery. Symptoms from grade IV chondromalacia isolated to a 1 cm or less area of the condyle can be improved by stimulating fi brocartilage healing with superfi cial abrasion, drilling, or microfracture techniques. These procedures are used to stimulate a vascular response, which should be evident when the tourniquet is defl ated and the intraarticular fl uid pressure is reduced. Healing of chondral defects can be enhanced by protective weight bearing and constant passive motion for 6 to 8 hours a day for 6 weeks; however, the cost-benefi t ratio for extended use of continued passive motion is still questionable. Larger lesions associated with osteoarthritis generally should just be lightly débrided. Microfracture techniques, osteochondral transfers, and autogenous chondrocyte implantation are not indicated in patients with extensive degenerative arthritis.

Complications

Large series on complications associated with knee arthroscopy were published in the late 1980s. In 1986, Small presented a report from the Committee on Complications of the Arthroscopy Association of North America. In 375,069 knee arthroscopies, there were 239 infections, 12 vascular injuries, and 683 cases of thrombophlebitis. In addition, refl ex sympathetic dystrophy developed in 190 patients. The complication rate in meniscal repair was 2.4%, including 30 saphenous nerve injuries, six peroneal nerve injuries, 22 infections, three vascular injuries, and four cases of thrombophlebitis. With anterior cruciate ligament procedures, the complication rate was 1.8%, including seven stiff knees, one infection, two neurological injuries, and 12 loose or poorly placed staples. In 1988, Small reported a second study of complications from the Arthroscopy Association of North America. In this series of 8741 knee arthroscopies, the highest overall rate of infection was 7% for lateral retinacular release. Of the complications, 65% were hemarthroses. With improve- ments in technique and added experience, the complication rate for meniscal repair had decreased to 1.29%. This was even lower than the complication rate for medial meniscectomy, which was 1.78%. Only one neurological injury was recorded—a saphenous nerve injury during a medial meniscal repair. The complication rate for anterior cruciate ligament surgery was only 2%, and no neurological or vascular injuries were reported. Overall, the complication rate for knee arthroscopy in this selected series of surgeons was 1.8%. At this time, complications associated with knee arthroscopy continue to occur at a rate similar to that reported by Small in 1986 and 1988. Complications increase with the diffi culty of the case, and saphenous and peroneal nerve injuries are still being reported with arthroscopic repairs. The incidence of arthrofi brosis associated with anterior cruciate ligament reconstruction is increased when meniscal repair is performed. Likewise, the incidence of infection associated with anterior cruciate ligament reconstructions is slightly increased when the reconstruction is performed in conjunction with meniscal repair. Additional exposure, surgical time, and potential for joint contamination during the passing and retrieving of needles are probably the reasons. Surgical complications related to ligamentous reconstruction are associated with multiple factors that have been reported (see Figs. 48-42 and 48-43). Most of these causes of failures have been discussed in the technique section. Careful attention to detail during surgery, including proper sterilization techniques, handling of the graft, and appropriate preparation and draping, can help to prevent postoperative infections. If a graft is contaminated by dropping it on the fl oor, the surgeon has two choices: change graft sources (i.e., a different autogenous graft source) or attempt sterilization of the dropped graft. Molina et al. reported the results of sterilization of dropped grafts in one of three solutions: (1) a 1-mL vial containing 40 mg of neomycin and polymyxin in 1000 mL of sterile saline, (2) 10% povidone-iodine solution, or (3) 4% chlorhexidine gluconate solution. Their results after a 90-second soak showed that one of 50 of the contaminated grafts that were soaked in chlorhexidine remained positive, three of 50 soaked in antibiotic remained positive, and 12 of 50 soaked in the povidone-iodine solution remained positive. With this in mind, it should be reasonable to retrieve the graft immediately from the fl oor, rinse it using sterile technique with a large volume of sterile saline, soak it in 4% chlorhexidine gluconate solution for at least 90 seconds and then in the neomycin and polymyxin B solution for at least another 90 seconds, and fi nally rinse it thoroughly. In a survey by Izquierdo et al., 196 sports-trained surgeons responded to a questionnaire on anterior cruciate ligament graft contamination (from a variety of sources). Forty-nine surgeons had experienced a total of 57 contaminations, 75% of which were treated with graft cleansing and proceeding with the reconstruction. In 18% of contaminations, the surgeon harvested a different graft, and in 7% an allograft was used. There were no reported infections. Sixty-fi ve of the 147 surgeons with no graft contaminations responded with hypothetical treatments: 58% would cleanse the graft, 34% would harvest a different graft, and 8% would use an allograft. When postoperative knee infections occur, early, thorough arthroscopic irrigation and débridement are indicated with repeat irrigation and débridement at 48 to 72 hours if the symptoms have not resolved. Anterior cruciate ligament grafts can be left in place, provided that no extensive deterioration of the graft is present at the time of initial irrigation. The appropriate intravenous antibiotics generally are prescribed for 2 to 3 weeks, followed by oral antibiotics to complete a 6-week course of antibiotic treatment. Abnormal healing reactions, arthrofi brosis, refl ex sympathetic dystrophy, and failure of graft incorporation fall under the category of surgical limitations, as do chondral or meniscal injuries. Surgical control over these conditions often is limited, but sometimes skill in surgical planning and timing can have an effect. Early surgical intervention for ligamentous injuries before regaining muscular tone and motion is associated with arthrofi brosis, as are surgical procedures, such as medial collateral ligament repair on the femoral side and meniscal repair. Shelbourne et al. showed that allowing motion and allowing the knee to calm before surgery greatly decreases the incidence of postoperative stiffness and arthrofi brosis. Refl ex sympathetic dystrophy is a poorly understood condition that possibly could be decreased by better patient selection, decreased operating time, and early physical therapy. Early reports stated that overtightening of the anterior cruciate ligament graft might result in failure of graft maturation, but more recent studies by D’Amato and Safran have not supported this conclusion.