Knee arthroscopy is used as a diagnostic and interventional tool in a wide variety of conditions. Because of advances in other imaging modalities, particularly magnetic resonance imaging (MRI), it is becoming less common for arthroscopy to be used for diagnosis alone. The frequent indications include:

Meniscal tears
Cruciate ligament injury
Chondral defects
Removal of loose bodies
Washout of sepsis
Synovectomy, including cases of pigmented villonodular synovitis
Patella realignment procedures
Intra-articular knee fracture assessment and reduction

Contraindications
Infection – particularly cellulitis over the potential portal sites
Ankylosis of the knee
Rupture of the joint capsule (allows extravasation of the irrigation fluid)

Consent and risks

Venous thromboembolism: Less than 1%
Septic arthritis: Less than 1%
Superficial wound infection: Less than 1%
Neurapraxia (secondary to tourniquet use): Less than 1%
Effusion: Virtually universal and can last for several months

Operative planning

Any preoperative imaging should be available. Appropriate instrumentation should be available and checked by the surgeon, including the arthroscope, camera, light lead, arthroscopic instruments, irrigation fluid pump and the ‘stack’, which must include a functioning light source and monitor. The arthroscope used for knee arthroscopy has a 4 mm diameter and 30° viewing angle.

Anaesthesia and positioning

Anaesthesia is usually general, though regional anaesthesia is acceptable. The position is supine. A side support can be used, at the level of the upper- to mid-thigh, to provide a lever when opening up the medial compartment.

Tilting the patient toward the operative side, either by tilting the table or placing a sandbag under the contralateral buttock, reduces internal rotation when applying a valgus stress and allows better opening of the medial compartment in more extended positions when visualising the posterior part of the meniscus.

An appropriately padded tourniquet is applied and inflated at the level of the upper thigh. If the patient is hirsute, the anterior knee is shaved. The surgical field is prepared with a germicidal solution. Waterproof drapes are used with adhesive edges to provide a seal to the skin. Specific arthroscopy drapes with fluid collection pouches and suction ports can help to reduce flooding the operating theatre floor. The foot and lower leg are covered with a stockinette. The arthroscope is connected to the camera and light source. With the arthroscope applied against a clean white swab, the white balance button is pushed to prevent colour casts (unwanted colour tints affecting the picture) during the arthroscopy.

Surgical technique

Examination under anaesthesia

The first stage of any arthroscopy is vital and occurs before any incision is made. The knee is assessed for its full range of movement (which includes any hyperextension) and stability of its ligaments. The patella height and tracking are noted.

Landmarks

The patella, patellar tendon, medial and lateral joint lines are palpated carefully with the knee in around 70° of flexion.

Portals

All arthroscopy requires at least two portals with by far the most common two being the anterolateral and anteromedial portals (Figure 12.1). The anterolateral portal is almost always created first and other portals can be created under direct vision. The following is a general description of portal placement for diagnostic arthroscopy, but the precise location may be adapted to reach specific pathology or perform specific procedures anticipated from the clinical features and imaging. Similarly, it may be necessary to switch viewing and working portals to perform specific tasks.

Figure 12.1 The three common knee arthroscopy portals.

The anterolateral portal is created 1 cm above the lateral joint line and 1 cm lateral to the lateral border of the patellar tendon. This corresponds to a level just below the inferior pole of the patella. It can be palpated by pushing a thumb against the angle between the lateral border of the patella and the anterolateral border of the upper tibia. If the thumb is left on the upper tibial border, the incision can be made just above the thumb to guide the surgeon to the correct position. It is best done with a pointed, rather than curved, blade, with the blade facing away from the patella tendon. A vertical incision or horizontal incision is acceptable. If using a horizontal incision, once the skin is breached the blade is turned to face vertically upwards to perform the capsulotomy. This reduces the risk of damaging the lateral meniscus.

The anteromedial portal is created under direct vision with the arthroscope viewing the medial compartment. It lies 1 cm above the medial joint line and 1 cm medial to the medial border of the patellar tendon. A 16G needle is inserted at this point, facing slightly downwards towards the tibia. This can be visualised directly to ensure that it exits just above the medial meniscus and is directed appropriately to perform any subsequent procedures. If not, it can be withdrawn and

replaced correctly. Once the correct entry point has been identified, the needle is withdrawn and the scalpel used to enlarge the portal in the same fashion as the anterolateral portal.

The superior portals are made with the knee in extension. The superomedial portal is 2 cm above the superior pole of the patella, in line with the medial border of the patella. It was historically used for an outflow cannula. These are rarely used now, as modern pumps obviate their use.

The superolateral portal is 2 cm above the superior pole of the patella, in line with the lateral border of the patella. It can be used in suprapatellar synovectomy, for visualisation of the patellofemoral joint such as in surgery for patellar maltracking, or to visualise the patellar tendon and infrapatellar fat pad.

The posteromedial portal is 1 cm above the posteromedial joint line, in line with the medial border of the medial femoral condyle. This represents the ‘soft spot’ between the tendon of semimembranosus, the medial head of gastrocnemius and the medial collateral ligament (MCL). The portal is created under direct vision with the knee in 90° flexion, allowing the saphenous nerve to fall out of the surgical field. It can be used to visualise the posterior cruciate ligament (PCL) or posterior horn of the medial meniscus, in total synovectomy of the knee, or for removal of loose bodies. It utilises a longitudinal skin incision to avoid neurovascular damage. Following skin incision, an artery clip is used to dissect down to and through the capsule.

Structures at risk

Sartorial branch of the saphenous nerve
Long saphenous vein: Can be transilluminated by the arthroscope to help its identification These structures pass together, approximately 1 cm behind the portal incision.

The posterolateral portal is placed in a soft point between the lateral head of gastrocnemius, the lateral collateral ligament (LCL) and the posterolateral tibial plateau. It is very infrequently used, but it can be used to visualise the posterior horn of the lateral meniscus or to retrieve a loose body from the posterior compartment of the knee. Again, a longitudinal incision is used. The portal is placed under direct vision in a similar fashion to the posteromedial portal. Remaining anterior to the biceps femoris tendon helps to reduce the risk to the common peroneal nerve, which lies posteriorly.

Structures at risk

Common peroneal nerve, running lateral to the lateral head of gastrocnemius, 15 mm below the portal
Lateral superior and inferior geniculate arteries, passing just below and above the

incision site, respectively

A transpatellar tendon portal can be placed to access centrally or for passing additional grasping instruments into the knee. A longitudinal incision is made in line with the fibres of the patellar tendon approximately 1 cm below the inferior pole of the patella.

Insertion of the arthroscope

Structures at risk

Articular cartilage
Anterior horn of lateral meniscus

This is the only step of arthroscopy which must be carried out blind: it must be done with great care to prevent gouging of the articular surfaces. The anterolateral portal is created as described earlier. The trochar and sleeve are inserted at 70° of knee flexion. Firm, gradual pressure is applied until there is a reduction in resistance, indicating that the trochar has passed through the joint capsule. At this point the knee is extended to around 20° of flexion and the trochar advanced, passing through the patellofemoral joint. Its intra-articular position can be confirmed by sweeping the arthroscope gently from side to side – it can be felt to be beneath the patella. If it is outside the knee joint, it will not sweep from side to side. The position of the arthroscope should be confirmed before removing the trochar, introducing the camera and turning on the saline inflow.

Arthroscopic inspection of the knee

It is good practice to follow the same ‘route’ around the knee as this helps to prevent any omissions. It is the authors’ practice to address any pathology as it is located, rather than to proceed with a full inspection before beginning intervention. Table 12.1 gives a suggested route, which many surgeons find the most effective one.

Closure

The portals are closed with either single sutures or adhesive paper stitches. Adhesive dressings, then wool and crepe, are applied before the tourniquet is deflated.

Postoperative care

The specific rehabilitation will depend on procedures performed, but for a simple diagnostic arthroscopy or meniscectomy weightbearing mobilisation is begun early, together with range-of-motion exercises. Anti-thromboembolism stockings are recommended for 6 weeks. The wool and crepe are removed 24 hours after surgery, to increase mobility. Sutures are removed at 10–14 days after surgery.

Recommended references

Jaureguito JW, Greenwald AE, Wilcox JF et al. The incidence of deep venous thrombosis after arthroscopic knee surgery. Am J Sports Med. 1999;27:707–710.

Kim SJ, Kim HJ. High portal: Practical philosophy for positioning portals in knee arthroscopy. Arthroscopy.

2001;17:333–337.

Kramer DE, Bahk MS, Cascio BM et al. Posterior knee arthroscopy: Anatomy, technique, application.

J Bone Joint Surg Am. 2006;88:110–121.

Moseley JB, O’Malley K, Petersen NJ et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347:81–88.

326

Table 12.1 Arthroscopic inspection of the knee

Step	Area of inspection	Position of knee	Position of arthroscope	Structures to inspect	Technical notes
1	Suprapatellar pouch	20° flexion	Upright/upside down	Synovium; loose bodies	Turning the arthroscope through all angles allows visualisation of the synovium throughout the whole cavity.
2	Lateral gutter	20° flexion	Upright	Loose bodies	Best inspected at this stage so that it is not forgotten after tibiofemoral joint inspection.
3	Patellofemoral joint	20° flexion	Upright/upside down	Medial + lateral patella facets; synovial plica; trochlea; patellar tracking	The arthroscope is turned upside down to inspect the patellar cartilage and kept upright to view the trochlea. It must be withdrawn to just inferior to the patella to view tracking.
4	Medial gutter	20° flexion	Upright	Loose bodies
5	Medial compartment	90° flexion initially 30° flexion to view the posterior horn	Normal/viewing laterally to improve visualisation of the posterior horn	Medial femoral condyle; medial tibial plateau; medial meniscus; loose bodies; creation of medial portal	Viewing the posterior horn is easier with the knee straighter and with the arthroscope swung to look laterally.

12 Soft Tissue Surgery of the Knee

(Continued )

Knee arthroscopy

327

Table 12.1 (Continued ) Arthroscopic inspection of the knee

Step

Area of inspection

Position of knee

Position of arthroscope

Structures to inspect

Technical notes

Intercondylar notch

90° flexion

Upright

Anterior cruciate ligament (ACL); posterior cruciate ligament; loose bodies; both posterior horns

In ACL surgery, the portals are created a little closer to the patella tendon to improve access to the notch.

The posteromedial and posterolateral compartments can be visualised by driving the arthroscope

through the notch between the cruciate ligament and respective femoral condyle. The posteromedial compartment is best accessed with the arthroscope in the anterolateral portal, then switching to the anteromedial portal to access posterolaterally.

Lateral compartment

Figure-four position

Upright/viewing medially

Lateral femoral condyle; lateral tibial plateau; lateral meniscus; loose bodies; popliteus tendon

Move the knee into the figure-four position with the arthroscope in the notch (Figure 12.2). Drive into the lateral compartment as it opens and comes into view.

Figure 12.2 The figure-four position for lateral compartment viewing.

Arthroscopic meniscal knee surgery

Preoperative planning

See ‘Knee arthroscopy’ (p. 321) for further details of consent and operative planning, as well as postoperative care.

Indications

Acute tears of the meniscus: Radial, longitudinal, complex and bucket-handle forms (Figure 12.3)
Degenerative tears of the meniscus (commonly posterior horn of medial meniscus): If fails conservative management or there are clear mechanical symptoms
Meniscal repair: In non-degenerative, longitudinal tears within 3 mm of the periphery (i.e. within the vascular zone of the meniscus)

Figure 12.3 The common forms of acute meniscal tear.

Surgical technique

Partial meniscectomy

Partial meniscectomy is the most common procedure performed by trainees throughout the developed world and is considered a required skill by trainers and programme directors. It must be part of a full diagnostic arthroscopy, as described in the previous section.

Initial inspection of the meniscus can often reveal the presence, though not extent, of a tear. The smooth outline of the meniscus will be lost. The first stage is to probe the meniscus with an arthroscopic probe. The probe is inserted under the meniscus and the hook turned to point upwards, into the meniscus; the probe is withdrawn and will catch any inferior tear that was not previously visible.

Large posterior horn tears and even displaced bucket-handle tears can flip into the intercondylar notch and will not be seen unless specifically looked for in the posterior part of the notch. Using the probe, the surgeon can determine the extent of the tear and decide on the boundary between unstable, torn meniscal remnants and well-fixed, stable meniscal rim (Figure 12.4).

Figure 12.4 Use of an arthroscopic probe to show a meniscal tear.

The meniscus can be resected using a number of instruments. The author prefers to use simple punches for the majority of the resection and an arthroscopic shaver to smooth over the final remnant. An ‘upbiter’ is very useful during resection of very posterior tears, particularly of the medial meniscus (Figure 12.5).

The resection should be careful and methodical, leaving all stable meniscus behind. After resection, the meniscus must be probed again to ascertain that all remaining meniscus is stable.

Figure 12.5 An ‘upbiter’ is useful in posterior horn resection.

Bucket-handle tear surgery

A bucket-handle tear is a large, longitudinal tear in which the internal portion is mobile and can flip over and become stuck in the intercondylar notch. It is three times as common in the medial as the lateral meniscus. The following discussion uses the medial meniscus as an example, though the principles are transferrable to the lateral meniscus.

Entry of the arthroscope into the medial compartment can be difficult. Careful creation of an anteromedial portal, as described, is recommended, followed by use of a probe through this portal to gently push the displaced fragment medially. This will usually afford a good view. Assessment can be made as to whether the tear is repairable (see the following section).

A probe is used to define the attachments of the tear, both posteriorly and anteriorly (Figure 12.6). If the fragment is found to be irreparable then a punch is used to detach 90% of the tear at its posterior origin. It is easiest to do this with an upbiter curved to the left for a left medial meniscus and to the right for a right medial meniscus. A straight punch or side-biter is used to resect completely through the anterior attachment. A strong, locking arthroscopic grasper is introduced through the medial portal and locked onto the middle of the torn remnant. The remnant is removed with a ‘crocodile roll’ – the graspers are rolled over several times while carefully watching with the arthroscope.

Figure 12.6 Resection points of a bucket-handle medial meniscal tear.

Once the meniscal remnant has been freed, it is removed through the medial portal. In large tears, this portal often requires enlargement. Careful inspection of the meniscal remnant is carried out, with debridement of any further unstable tissue.

Meniscal repair

Repair is possible if the tear is within 5 mm of the periphery, but more commonly undertaken if the tear is within 3 mm of the periphery, i.e. within the vascular zone. In order to be worthy of repair, the tear should be between 8 and 30 mm long.

The results of meniscal repair are better in patients with a concurrent anterior cruciate ligament (ACL) reconstruction than in repair alone. Repair should not be undertaken in a knee with ligament injury that has not been addressed. A variety of methods are described

including outside-in, inside-out and all-inside suturing (Figure 12.7). In addition, meniscal darts can be used. The details of this surgery are beyond the scope of this book. Sutures are placed, usually vertically, about 3–4 mm apart from each other.

Figure 12.7 Meniscal repair: (a) outside-in, (b) inside-out and (c) all-inside technique.

Most surgeons recommend avoidance of weightbearing for around 4 weeks after surgery, particularly avoiding weightbearing in flexion.

Discoid meniscus surgery

Discoid malformation more frequently affects the lateral meniscus and is bilateral in one-fifth of cases. The majority are stable (i.e. have peripheral attachments to the rim). These are treated by partial meniscectomy, if symptomatic, to create a more normal meniscus.

If a discoid meniscus becomes suddenly painful, it is likely that it is torn and should be examined and treated as such. The rarer unstable, or Wrisberg variant, discoid meniscus is hypermobile due to absent peripheral attachments. These are usually treated by complete excision as there is no stable rim to leave in situ.

Postoperative care

See ‘Knee arthroscopy’ (p. 321).

Meniscal repair has a more controversial rehabilitation regimen. The author uses a brace, limited to 0°–60° range for 1 month then full range of motion within the brace for a further 2 months. Return to sports is gradual following the initial 3 months in the knee brace.

Recommended references

Fabricant PD, Jokl P. Surgical outcomes after arthroscopic partial meniscectomy. J Am Acad Orthop Surg.

2007;15:647–653.

Min S, Kim J, Kim LM et al. Correlation between type of discoid lateral menisci and tear pattern. Knee Surg Sports Traumatol Arthrose. 2004;10:218–222.

Rankin CC, Lintner DM, Noble PC et al. A biomechanical analysis of meniscal repair techniques. Am J Sports Med. 2002;30:492–497.

Lateral patellar retinaculum release ‌

Preoperative planning

Indications

Lateral release of the patella is indicated in patients with a tight lateral patellar retinaculum who meet the following criteria:

Anterior knee pain
Positive patella tilt test, less than 5°
Failure of conservative measures, including physiotherapy specifically, to strengthen the quadriceps and hamstrings

Associated conditions that may worsen the symptoms include chondromalacia patellae, patella alta, abnormal Q angle and trochlear hypoplasia, but these alone are not sufficient to perform a lateral release. In cases of malalignment, it may need to be combined with more advanced procedures, including osteotomy or tibial tubercle transfer. It can also be performed in conjunction with medial patellofemoral ligament reconstruction and vastus medialis advancement.

Contraindications

Lateral release is not indicated in patients with generalised hypermobility or patellar hypermobility – it will worsen the symptoms.

Operative planning

Very careful history and examination are required to elucidate the features. Plain radiography, including patella views, is essential. If malalignment is suspected, reconstruction in computed tomography is useful.

Anaesthesia and positioning

See ‘Knee arthroscopy’ (p. 321).

Consent and risks
- The complications are essentially those of any knee surgery: bleeding, infection, thrombosis and numbness, whether carried out open or arthroscopically
- Mention of haemarthrosis should be made in particular as it is very common and can be
  
  major
- Medial subluxation is a rare, late complication
Surgical technique Open lateral release Landmarks
Lateral border of the patella
Gerdy’s tubercle (insertion of the iliotibial band on the lateral tibia)

Incision

A straight incision is created 1 cm from the lateral border of the patella, running from the level of the superior pole of the patella to 1 cm above Gerdy’s tubercle. The incision is carried down to the lateral retinaculum.

Technique

The superficial lateral retinaculum is incised in line with the skin incision. The deeper fibres and synovium are not incised. The surgeon now assesses whether the release has been sufficient. If the patella is now able to be tilted 45° or more laterally, it is sufficient.

If the release is insufficient, the superficial retinaculum is dissected off the deep retinaculum for 2 cm on the lateral side of the incision. The deep retinaculum can now be incised parallel to the superficial retinacular incision but 2 cm further lateral. If this is required, the lateral portion of the superficial retinaculum is sutured to the medial edge of the deep retinaculum – this helps to lessen haemarthrosis.

Closure

The subcutaneous fat is opposed with interrupted sutures and the skin closed with the surgeon’s chosen method. Occlusive dressing and heavy wool and crepe bandages are applied.

Arthroscopic lateral release

Technique

A complete arthroscopy is carried out first – the lateral release is done last as it causes bleeding. A tourniquet is not used as it interferes with patellar tracking and causes more bleeding postoperatively.

A horizontal line is drawn laterally from the superior pole of the patella and another line 1 cm away from the lateral border of the patella. A needle is inserted into the knee joint at the level where these lines cross.

Structures at risk

The superior geniculate artery

The needle serves as a proximal limit of the release to prevent damage to the artery and subsequent bleeding that cannot be controlled arthroscopically.

Release is carried out, with cautery, running from the needle to the anterolateral portal; it is continued until subcutaneous fat is seen from within the knee.

Closure

The portals are closed with either single nylon sutures or adhesive paper stitches. Adhesive dressings, then wool and crepe, are applied.

Postoperative care and instructions

Weightbearing is begun immediately. The wool and crepe are removed after 24–36 hours and range-of-motion exercises are begun early (to prevent lateral adhesions within the knee). The patient is referred to physiotherapy to reinstate medial quadriceps exercises.

Recommended references

Kolowich PA, Paulos LE, Rosenberg TD et al. Lateral release of the patella: Indications and contraindications. Am J Sports Med. 1990;18:359–365.

Mulford JS, Wakeley CJ, Eldridge JD. Assessment and management of chronic patellofemoral instability.

J Bone Joint Surg Br. 2007;89:709–716.

Patellofemoral instability ‌

A careful assessment of patients with recurrent patellar instability is required to identify the underlying pathoanatomy and confirm the surgical target. The mainstays of surgical treatment, which are discussed here, are medial patellofemoral ligament (MPFL) reconstruction and tibial tubercle transfer, but other abnormalities that should be sought and may require surgical correction include trochlear dysplasia, coronal malalignment and torsional malalignment. Combined procedures may be warranted. The problem may be compounded by generalised hypermobility disorders. Additionally, poor strength of the quadriceps, glutei and core muscles leads to dynamic alignment problems, particularly evident on attempted single-leg squatting, that should be targeted with intensive physiotherapy. Isolated lateral release is not indicated for patellar instability and may even exacerbate the problem.

Medial patellofemoral ligament reconstruction

Preoperative planning

Indications

Recurrent patellar instability with MPFL deficiency. May require combined procedures if other pathoanatomical features are identified. The MPFL is the primary restraint to lateral patella displacement from full extension to 20°–30° of flexion, at which point the patella should engage in the trochlea. Apprehension in extension is typical of MPFL deficiency, whereas apprehension beyond 30° of flexion is suggestive of additional abnormalities.

Consent and risks

Increased contact pressures, pain and degeneration
Patella fracture
Stiffness
Rerupture, recurrent or persistent instability

Operative planning

Various graft options and reconstruction techniques have been described. Regardless of the technique chosen, accurate graft positioning and avoidance of over-tensioning are important in optimising outcome. Intraoperative fluoroscopy may be used to confirm the femoral attachment site.

The need for additional procedures will be dictated by the presence and severity of other risk factors for instability. This may include tibial tubercle transfer for lateralisation or patella alta, trochleoplasty for dysplasia or osteotomies to correct torsional or coronal abnormalities.

Anaesthesia and positioning

The patient is positioned supine under general or regional anaesthesia. Antibiotic prophylaxis is administered on induction of anaesthesia according to local protocols. A thigh tourniquet is used, the skin is shaved as required and standard skin antisepsis with adhesive sterile drapes are used to create a sterile surgical field.

Surgical technique

Landmarks

Superior and medial patellar borders
Medial epicondyle
Adductor tubercle

Incision and approach

Arthroscopy can be performed to identify and address any additional lesions. Visualisation through the superolateral portal provides a good assessment of patellar tracking, which can be compared before and after the procedure.

Three incisions are made for the MPFL reconstruction. The reconstruction is performed with an autologous gracilis graft, harvested through an incision over the medial proximal tibia and whip-stitched with number 1 suture for 10 mm at each end (see section ‘Hamstring graft’, p. 348). An 18 cm length of graft is required.

A 2 cm longitudinal incision is made in line with the proximal half of the medial border of the patella. Access is required from the superomedial corner to the centre of the medial edge of the patella. Dissection is continued through layer 1 of the medial tissues; soft tissue is cleared from the upper half of the medial patella while remaining extra-articular.

The third incision is a 1–2 cm longitudinal incision placed between the medial epicondyle and adductor tubercle. Fluoroscopy can be used to help identify the correct position for femoral tunnel placement. The radiographic landmark (Schoettle point) is 1 mm anterior to a line extending distally from the posterior femoral cortex, 2.5 mm distal to the superior margin of the posterior articular border of the medial femoral condyle, and proximal to the posterior end of Blumensaat’s line (Figure 12.8). Dissection is continued down to the bone where the femoral tunnel will be placed.

Figure 12.8 Schoettle point: radiographic landmark for femoral tunnel placement in MPFL reconstruction.

Procedure

Two parallel 2.4 mm guide wires are placed transversely across the patella. They are positioned so that both are in the upper half of the patella and separated by approximately 15 mm. The two guide pins are over-drilled with a 4.5 mm cannulated drill to a depth of 25 mm. The two whip-stitched ends of the gracilis graft are secured in the patella with

4.75 mm knotless anchors to leave a central loop of graft that will be secured to the femur.

The femoral insertion point is identified between the medial epicondyle and adductor tubercle (confirmed radiographically if desired). A Beath pin guide wire is inserted and directed to exit the lateral femoral cortex and advanced out through the skin of the lateral thigh. The femoral tunnel is created by over-drilling the Beath pin to a diameter of 6–7 mm. The Beath pin is left in place for passage of the graft.

Blunt dissection is performed deep to the fascia of layer 1, remaining extra-articular, to connect the two incisions at the medial patella and medial epicondyle. A loop of heavy suture is passed around the central loop of the graft and passed through the track created from the incision at the medial patella to the medial epicondyle. The loop of graft is pulled down through the same channel and out through the incision at the medial epicondyle. The free ends of the suture looped around the graft are then passed through the eye of the Beath pin and pulled into the femoral tunnel and out through the skin of the lateral thigh. The loop of graft can then be pulled into the femoral tunnel with the suture, ensuring equal

tension on both limbs of the graft. It is tensioned to align the lateral patella facet with the lateral femoral condyle in 30° of flexion. Over-tensioning must be avoided; approximately 1 cm of lateral displacement should be possible in full extension. The graft is secured in the femoral tunnel with an interference screw.

Closure

The suture used to pull the graft into the femoral tunnel can be pulled out through the lateral thigh, and the free ends of the whip-stitches are cut short. The skin is closed with the surgeon’s preferred method.

Postoperative care and instructions

A hinged knee brace allowing motion between 0° and 90° is worn for the first 6 weeks. Weightbearing is protected with crutches for the first 2 weeks, which are then weaned off as tolerated. Full range-of-motion and light exercise are allowed after 6 weeks, aiming for return to full activity after 12 weeks.

Tibial tubercle transfer Preoperative planning Indications

In the context of patellar instability, tibial tubercle osteotomy is indicated in the presence

of patella alta or a laterally placed tibial tubercle, represented by high tibial tubercle–trochlear groove (TT-TG) distance. The precise thresholds used for these parameters are variable in the literature, but TT-TG greater than 20 mm and Caton-Deschamps ratio greater than 1:1.4 are definitely abnormal. Tibial tubercle transfer is often combined with MPFL reconstruction. Apprehension present at 30°–60° of knee flexion is typical of tibial tubercle abnormalities, while apprehension persisting in deeper flexion typically represents more significant coronal or torsional malalignment issues.

Consent and risks

Over-medialisation, increased contact pressures, pain and degeneration
Non-union: Approximately 1%
Tubercle fracture: More common with shallow cuts of insufficient length
Tibial fracture: Approximately 1% – more common with deeper and more oblique cuts
Recurrent instability: Approximately 10%
Hardware irritation: May require later removal

Operative planning

A number of different tibial tubercle transfers are described. Medialisation alone (Elmslie-Trillat) may increase contact pressures, pain and degeneration, particularly in the presence of pre-existing patellofemoral degeneration. In such cases an anteromedialisation (Fulkerson) is preferred. The extent of the transfer is dependent on the preoperative

abnormality and aims to correct TT-TG to 12 mm and Caton-Deschamps ratio to 1:1.1. If anteromedialisation is performed then the length of transfer in the plane of the osteotomy (which will be measured intraoperatively) can be calculated from the required medialisation in the coronal plane and the planned angle of the osteotomy using trigonometry (Figure 12.9).

Figure 12.9 Tibial tubercle anteromedialisation. The length of medialisation is related to the measured length of displacement in the plane of the osteotomy by A = Bcosθ.

Anaesthesia and positioning

This is the same as for MPFL reconstruction.

Surgical technique

Landmarks

Patella tendon
Tibial tubercle

Incision and approach

A 6 cm longitudinal incision is made over the tibial tubercle. Full-thickness flaps are elevated to expose the medial and lateral attachments of the patella tendon to the tubercle and continued for a distance 5 cm distal to the attachment for full exposure of the planned osteotomy site. The anterior compartment muscles are elevated off the anterolateral tibial cortex.

Procedure

The line of the planned osteotomy cut is marked on the periosteum with diathermy. A minimum thickness of 5 mm at the point of tendon attachment is required, tapered distally to produce a 5–6 cm osteotomy length. Larger transfers require thicker cuts. Medialisation alone is achieved with a medial-to-lateral cut in the coronal plane. For anteromedialisation the cut is from anteromedial to posterolateral. Parallel guide wires can be placed in the plane of the cut and used as a saw guide. The longitudinal cut is made in the required plane with an oscillating saw. A distal hinge is left intact if possible. The proximal transverse cut is made with an osteotome, proximal to the tendon attachment. The tubercle is freed with an osteotome and rotated on the distal hinge to medialise it by the planned distance, measured with a ruler at the level of the tendon attachment.

If distalisation is also required then the distal hinge is cut to free the fragment fully. The length of bone equivalent to the planned distalisation distance is removed from the distal end of the osteotomised tubercle fragment, which is then pulled distally to align flush with the distal osteotomy cut.

When the desired transfer has been achieved the fragment is provisionally held in place with two 1.2 mm K-wires. Patella tracking through the range of movement is confirmed, and the fragment can then be definitively fixed with two or three countersunk 3.5 mm cortical screws using a lag technique.

Closure

Debris is washed out of the surgical field and layered closure is performed using the surgeon’s preferred technique.

Postoperative care and instructions

Mobilisation is non-weightbearing with a hinged knee brace locked in extension for the first 6 weeks. Passive range-of-motion exercises are allowed initially from 0° to 30°, increasing by 30° every 2 weeks. Provided radiographs at 6 weeks are satisfactory, weightbearing and range of motion can be progressed from 6 to 12 weeks, with resumption of full range of motion and full weightbearing thereafter. Strengthening and light exercise can resume after full range and weightbearing are achieved, with return to full sport after 6 months.

Recommended references

Grimm NL, Lazarides AL, Amendola A. Tibial tubercle osteotomies: A review of a treatment for recurrent patellar instability. Curr Rev Musculoskelet Med. 2018;11:266–271.

Koh JL, Stewart C. Patellar instability. Orthop Clin N Am. 2015;46:147–157.

Rhee S-J, Pavlou G, Oakley J et al. Modern management of patellar instability. International Orthopaedics (SICOT). 2012;36:2447–2456.

Cartilage reconstruction surgery ‌

Preoperative planning

Indications
Articular cartilage injury (most common on the medial femoral condyle).
Osteochondritis dissecans (most common on the lateral part of the medial femoral condyle).
Atraumatic osteonecrosis of the knee.
The National Institute for Health and Care Excellence (NICE) supports the use of autologous chondrocyte implantation for symptomatic defects greater than 2 cm2 failing conservative management provided it is the primary surgical procedure, there is minimal osteoarthritis and it is performed in a tertiary centre.

Contraindications
Degenerative knee changes: None of the techniques developed to date are successful on osteoarthritic lesions.
Age over 55 years: Poor cartilage regeneration and may be more suitable for arthroplasty techniques.
Active infection.

Consent and risks
- Same as for ‘Knee arthroscopy’ (p. 321)
- Unpredictable outcome (worse if long-standing injury or high body mass index)
- Donor site morbidity (mosaicplasty and autologous chondrocytes transplants [autologous chondrocyte implantation, ACI])
- Need for second procedure (ACI)
Operative planning

Details of previous imaging and surgery should be available. Suitable equipment for the chosen technique of chondroplasty consists of:
Microfracture picks/K-wire (microfracture)
Plug harvest and implant equipment (mosaicplasty)
Chondrocytes (ACI)

Anaesthesia and positioning

See ‘Knee arthroscopy’ (p. 321).

Surgical technique

Debridement
Simple removal of loose chondral material and smoothing of the damaged edges.
‘Roughening’ of the underlying, subchondral bone may allow clot formation and encourage fibrocartilage formation.
May be suitable for small lesions.

Microfracture

Following debridement, an awl is inserted into the ipsilateral arthroscope portal and used to create microfractures in the subchondral bone at the defect (Figure 12.10). The microfractures are 5 mm apart and approximately 5 mm deep. This allows penetration of the tidemark and the release of pluripotential cells from the cancellous bone. This produces a more pronounced and longer-lasting healing response than abrasion alone and increases the prospect of fibrocartilage formation at the defect.

Mosaicplasty

Small plug grafts are taken from a non-weightbearing area of the knee, typically the peripheral areas of the superior trochlea, and grafted into the defect until it is filled. Grafts are taken with a core drill and are 4–8 mm in diameter and 20 mm deep. Matching cores are removed from the defect and the graft plugs impacted in a mosaic pattern (Figure 12.11).

Figure 12.10 Microfracture of a chondral injury of the medial femoral condyle.

Figure 12.11 Femoral condylar defect treated with mosaicplasty medial femoral condyle.

Care must be taken to leave the graft plugs flush with the surrounding cartilage. The defects between the plugs fill in with fibrocartilage. Results are variable and highly dependent on the skill of the surgeon. There are questions over their use in defects over 4 cm2.

Autologous chondrocyte implantation

Autologous chondrocyte implantation is performed as a two-stage procedure. The first stage is arthroscopic and includes a diagnostic arthroscopy and debridement of any chondral flaps around the area of chondral damage. This should be done to provide a rim of stable or healthy cartilage all around the lesion and is essential for attachment of the graft. At the end of the first-stage arthroscopy, small segments of healthy cartilage are harvested

from the outer border of the anterosuperior femur, usually on the medial side of the trochlea. This is performed with a small gouge to loosen the segment and rongeurs to retrieve it. A venous blood sample is taken to screen for infectious diseases.

The chondrocytes can be prepared in a number of ways and can be provided suspended in solution or can be implanted onto a membranous matrix. This usually takes 3–6 weeks. The steps of preparation are similar in each technique: collagenases dissolve the matrix to leave the chondrocytes, then the cells are washed and put in a culture medium derived from the patient’s serum. The cells adhere to a culture surface and proliferate to provide a large number of healthy chondrocytes.

The second procedure is carried out once the chondrocytes have been grown and returned. This is a larger procedure and is performed open. The incision is dependent on the site: for example, a medial femoral condyle defect requires an 8 cm medial parapatellar incision. The defect is exposed and any further loose material is debrided. The defect is then covered with an appropriately shaped membrane that is stitched or glued in place. If the cells are embedded on the membrane, this is the final stage; if the cells are in suspension, the liquid is injected under the membrane. The wound is closed in layers.

Postoperative care and instructions

Movement encourages chondrocyte growth, so after ACI or mosaicplasty, the patient is rested for up to 2 weeks, in either a bulky dressing or a cylinder plaster, then passive mobilisation is begun. In all cases, the patient is allowed to toe touch weightbear for 6–8 weeks, to reduce the force on the grafts. Running is not allowed for 6 months and contact sports for 12 months after ACI or mosaicplasty.

Recommended references

Briggs TWR, Mahroof S, David LA et al. Histological evaluation of chondral defects after autologous chondrocyte implantation of the knee. J Bone Joint Surg Br. 2003;85:1077–1083.

Hangody L, Kish G, Karpati Z et al. Mosaicplasty for the treatment of articular cartilage defects: Application in clinical practice. Orthopaedics. 1998;21:751–756.

Steadman JR, Briggs KK, Rodrigo JJ et al. Outcomes of microfracture for traumatic chondral defects of the knee: Average 11-year follow-up. Arthroscopy. 2003;19:477–484.

Anterior cruciate ligament reconstruction ‌

Preoperative planning

Indications

ACL reconstruction is indicated in patients with symptomatic instability of the knee with a proven ACL rupture. Specific indications include:
High-level athlete (consider early reconstruction, without rehabilitation phase)
Inability to return to sports, particularly those which involve twisting on a planted foot (e.g. rugby, football, racquet sports)
Ongoing instability, giving way and pain resistant to a dedicated ACL rehabilitation physiotherapy programme

Consent and risks
- Knee stiffness (due to arthrofibrosis, inaccurate tunnel placement or insufficient notchplasty)
- Arthrofibrosis: More common if early reconstruction used rather than delayed
- Knee pain
- Kneeling difficulty (higher risk if bone–patellar tendon–bone (B-T-B) technique is used)
- Ongoing instability (11%–25% symptomatic, 60%–89% asymptomatic)
- Failure to return to previous level of sport (up to 30%)
- Graft failure: Impingement or enlargement of the tunnel with time (typically 2 years)
- Degeneration: Found in 75% of patients beyond 10 years after surgery
Operative planning

Careful examination and judicious use of investigations are essential, both to confirm the presence of ACL rupture and to search for associated injuries, particularly associated ligament injury.

The operation notes from prior surgery should be available, along with results of previous MRIs or other imaging. If there is an associated meniscal tear, consideration should be given to concurrent repair, as the results are improved in conjunction with ACL reconstruction.

Anaesthesia and positioning

General or regional anaesthesia is used. Prophylactic antibiotics are given. The patient is positioned supine with a side support or leg holder to hold the knee in supported flexion.

Surgical technique

There are multiple options and a number of controversies surrounding the technique of ACL reconstruction. Graft choice will fall into autograft, allograft or synthetic categories. There are a number of autograft options but those available may depend on previous surgery or injuries. Synthetic grafts are generally not preferred for ACL reconstruction due to historically high failure rates, recurrent or persistent instability, debris generation leading to synovitis and chronic effusions, accelerated osteoarthritis development and possible distant effects of particulate debris. Double-bundle grafts, separately reconstructing both the anteromedial and posterolateral bundles of the native ACL, have shown mixed results when compared with single-bundle reconstruction and are not in widespread use.

Tunnel positions within the femur and tibia have been the subject of much debate. There has been a move toward more anatomical reconstruction, with tunnels being placed within the footprints of the native ACL, aiming to restore improved stability and more normal biomechanics. Fibres of the anteromedial bundle have been shown to be dominant in controlling both anterior translation and rotation, as well as remaining closer to isometric through the range of movement. Transtibial positioning of the femoral tunnel (i.e. through the tibial tunnel) risks compromising the positions of both tunnels: a non-anatomical high femoral tunnel that tends to be placed too anteriorly and risks impingement of the

graft on the notch in full extension, mitigated by placing the tibial tunnel too posteriorly, resulting in a vertically oriented graft that is unable to control rotational instability. Placing the tunnels independently helps to avoid these problems. There are many devices and techniques for fixation of the graft either within the tunnel aperture itself or distant from it, again with much surrounding debate about their relative advantages and disadvantages. Here we describe two widely used techniques but accept that many variations are in clinical use.

The two common methods of reconstruction are with a B-T-B graft or a hamstring tendon graft. The harvesting of both grafts is described, along with the method of reconstruction via an arthroscopic technique. Open techniques are now uncommonly performed.

As always, careful examination under anaesthesia is essential. The technique of the arthroscopy is in common with that described in the previous sections. The anterolateral portal is placed slightly more centrally (adjacent to the patellar tendon) and higher to facilitate access to the notch. Depending on the technique used, the anteromedial portal may also need to be moved, and/or an accessory anteromedial portal created, to facilitate tunnel placement. It is wise to carefully inspect the PCL and popliteus tendon in case of associated PCL or posterolateral corner injury. Failure to address a concomitant posterolateral corner injury is associated with higher rates of ACL graft failure.

Bone–patellar tendon–bone graft

Landmarks
Midline: Superior pole of the patella, tibial tuberosity

Incision and dissection

A midline incision is created from the superior pole of the patella to just below the tibial tuberosity. Dissection is continued to reveal the paratenon, which is then incised to expose the whole of the patella tendon. The central portion (usually 10 mm unless it is a narrow tendon, in which case use one-third of its width) of the tendon is dissected free for its entire length between the patella and the tibial tuberosity.

This dissection is continued across the patella for 30 mm proximally and the tibial tuberosity 30 mm distally. These incisions mark the sites of bone cuts for harvesting of proximal and distal blocks (Figure 12.12).

Structures at risk

Anterior horns of the medial and lateral menisci, just posterior to the fat pad
Medial femoral chondral surface: At risk as the femoral tunnel drill is passed

Procedure

With a 2 mm drill, drill two holes around 10 mm deep, in the centre of each area of bone between the dissected margins – these will be used to pass sutures for control of the graft at insertion. Using a narrow oscillating saw and then an osteotome (8–10 mm wide), dissect a block from the patella of 25 mm length. The osteotomes are directed 45° towards the

Figure 12.12 Bone–patellar tendon–bone graft harvest.

Figure 12.13 The harvested bone–patellar tendon–bone graft.

midline when performing the cuts, in order to create a trapezoidal graft shape. Care must be taken to avoid a graft which is too deep, risking subsequent patella fracture, or too thin, risking failure of fixation of the graft. The aim is creation of a block 25 mm long, 8 mm wide and 5–8 mm deep. The bone block is trimmed to a uniform size and two heavy sutures are passed through the previously drilled holes.

The same technique is used to create two holes in and harvest the tuberosity bone block, which should be of a similar size and shape. It is again trimmed and one heavy suture is passed through one of the drilled holes (Figure 12.13).

The graft is sized with a tunnel sizer, aiming for a snug but not too tight fit. If the grafts are of significantly different sizes, different tunnel widths can be used for the reconstruction; if this is done the tibial tunnel must be the larger one. The length of the entire graft and width of the two bone blocks should be written down and the graft wrapped in gauze presoaked in 5 mg/mL vancomycin solution for 10–15 minutes.

The ACL remnant, if present, is excised. It may be adherent to the PCL and care must be taken to avoid damage to the PCL when it is dissected free. The lateral wall is cleared of any further soft tissues and the back of the lateral wall indentified with a hook.

The femoral footprint of the ACL is identified on the lateral wall. The entire footprint is below and posterior to the lateral intercondylar (resident’s) ridge; the anteromedial (AM) bundle attaches above and behind the bifurcate ridge (Figure 12.14a). A Beath pin guide

Figure 12.14 Native femoral ACL footprint position on the lateral wall of the notch (a) and position of femoral tunnel placement (b). AM, anteromedial bundle; PL, posterolateral bundle.

wire is placed through the anteromedial portal and, with the knee hyperflexed, positioned toward the AM bundle position but so the full tunnel diameter remains within the native footprint (Figure 12.14b). If desired, a better view of the lateral wall to confirm the tunnel position may be obtained by visualising with the scope through the anteromedial portal; an accessory anteromedial portal may be used to place the Beath pin. The Beath pin is advanced so the tip emerges through the skin of the anterolateral thigh.

The femoral tunnel is drilled with the appropriate-sized tunnel drill passing over the guide wire. The length of the tunnel should be just over the length of the bone plug to be used in the tunnel – this is usually 35 mm. The reamings are saved to graft the patellar defect from the graft harvest at the end of the procedure. A tunnel rasp is used to smooth any sharp bone edges. A heavy looped suture is passed through the eye of the Beath pin, which is pulled up through the femoral tunnel so the free ends are retrieved through the anterolateral thigh and the loop remains out of the anteromedial portal. The free suture ends can be passed through the loop and clipped to the drapes to prevent accidental displacement during tibial tunnel preparation.

To prepare the proximal tibia for tunnel creation, the area of tibia medial to the patella tendon is exposed. Using subperiosteal dissection, good bone exposure is obtained so that the tunnel jig will not slip. The ACL tibial tunnel jig is set at 50° and the aiming device

Figure 12.15 Site of the tibial tunnel for anterior cruciate ligament reconstruction. PCL, posterior cruciate ligament; AM, anteromedial; PL, posterolateral.

placed toward the anteromedial part of the tibial footprint, while allowing the full tunnel diameter to remain within the native footprint (Figure 12.15). Small adjustments can be made to the angle of the jig to change the tibial tunnel length, depending on the measured length of the graft, allowing the bone block at the tibial end of the graft to be pulled fully into the tunnel when the graft is in place.

An ACL guide wire is drilled, through the jig, entering the knee just in front of the medial tibial spine. The guide wire is over-drilled with the tunnel drill of appropriate size for the graft. Again, any reamings are saved and any sharp edges present at the joint surface are

Figure 12.16 Suture loop being retrieved through tibial tunnel.

smoothed with a tunnel rasp. The previously placed suture loop is retrieved through the tibial tunnel so the loop now passes through both tunnels and the free ends remain outside the skin of the anterolateral thigh (Figure 12.16). This loop will be used to shuttle the graft sutures through the tunnels.

Returning to the graft, the junction of bone and tendon of the femoral block is marked with a surgical pen – the femoral block should be the smaller of the two. The two strong sutures in the femoral block are passed through the loop of the shuttle suture within the tunnels, which is then pulled up so the graft suture passes through both tibial and femoral tunnels and is retrieved through the anterolateral thigh. A second suture is passed through the tibial bone block – this should be either a strong, braided non-absorbable suture or a steel wire.

The graft is firmly, but smoothly, pulled through into position. Inspection within the knee will reveal when the marking on the femoral plug has reached the margin of the femoral tunnel. An interference screw guide wire is passed anterior to the graft within the femoral tunnel to a depth of at least 25 mm. An interference screw of appropriate size is then passed over the guide wire to secure the graft within the femur. The position and security are checked by cycling the knee through flexion and extension several times.

While the graft is tensioned, a further interference screw is inserted to secure the graft in the tibia. Securing the graft in or near full extension will reduce the risk of developing postoperative fixed flexion. The abolition of the pivot shift phenomenon can be checked at this stage. The graft saved from the tunnels is packed into the defect in the patella. Additional cancellous bone can be obtained from the harvest site of the tibial tubercle bone block to fill the patellar defect if required.

Closure

The paratenon is closed with interrupted, absorbable sutures over the tendon. The tendon itself is not closed as this would shorten the patella tendon. Adhesive dressings, then a wool and crepe dressing, are applied.

Hamstring graft

Landmarks

Tibial tuberosity
Patellar tendon

Incision and dissection

Structure at risk

The infrapatellar branch of the saphenous nerve can often be seen traversing the wound at the site of graft harvesting – it should be preserved if possible. Oblique incisions at the level of the pes anserinus may reduce this risk but need to be positioned carefully to allow access to both the tendons and tibial tunnel.

A diagnostic arthroscopy is carried out to identify and treat associated injuries. The anteromedial portal is kept anterior, close to the patella tendon, in order to allow good

visualisation of the notch. The lateral wall is cleared with an arthroscopic shaver or a small curette. An arthroscopy hook is used to carefully identify the posterior wall.

Figure 12.17 Anatomy of the pes anserinus.

A 50 mm incision, parallel with the patellar tendon, is created 20 mm medial to the tibial tuberosity. It should begin 60 mm below the joint line. Fat and deep fascia are dissected to reveal the tendons of the pes anserinus (Figure 12.17).

An incision is created over the upper border of the tendons, taking care not to damage the tendons themselves. The tendons are adherent to the deep surface of the sartorial fascia. Dissecting scissors are used to develop the planes between the gracilis and semitendinosus tendons, the underlying MCL and the overlying sartorial fascia.

Procedure

The tendons are then pulled forward with the scissors and a tendon hook is passed over them in turn. It is recommended that a length of surgical tape be passed over semitendinosus, which is then released but freely rediscovered via pulling on the tape.

The tendons of gracilis and semitendinosus are dissected free of soft tissue attachments in turn. The tendons are harvested in turn with a tendon stripper. The gracilis tendon is held taught and the stripper carefully pushed over it, keeping the stripper parallel to the tendon. It is advanced until the tendon is released from its muscle belly, and then the same method is used to release the tendon of semitendinosus.

The tendons can then be dissected free of the pes medially, carefully preserving as much graft length as possible. This will give a graft of two tendons, which are joined at one end and free at the other. Alternatively, the graft can be prepared in situ. Muscle tissue is scraped off the tendons. Each tendon is sutured, using a whip-stitch, for 30 mm at either end. The two tendons are then passed through the loop of a cortical suspensory button device and folded in half to create a four-strand single bundle graft (Figure 12.18). The graft is then tensioned, in order to prevent stretching in situ. If a tensiometer is available, it is usually tensioned to 80 N (20 lb) for 10 minutes. Next, the graft is measured: most are 8–10 mm, with 7 mm being a minimum acceptable diameter.

Figure 12.18 Four-strand hamstring graft prepared over a cortical suspensory button.

The femoral tunnel position is identified as for B-T-B grafts, and the guide wire is inserted through the (accessory) anteromedial portal with the knee hyperflexed in a similar fashion. The tunnel is first drilled with a 4.5 mm drill through the anterolateral femoral cortex to allow passage of the femoral cortical suspensory button. The tunnel length is noted and the femoral socket then drilled to the appropriate diameter for the graft up to, but not through, the femoral cortex. The length of graft within the femoral tunnel will be the difference between the tunnel length (total length to the outer surface of the femoral cortex) and the loop length of the suspension device, plus the thickness of the graft looped through the device (Figure 12.19a). A socket that ends sufficiently close to the cortex to allow the button to clear the femur and flip is required; the minimum required depth of the socket to allow this ‘turning circle’ will depend on the size of the button, length of the loop and thickness of the graft through the loop (Figure 12.19b), but drilling the socket as close as possible up to the femoral cortex will usually be sufficient. A shuttle suture loop is passed through the femoral tunnel as for B-T-B grafts.

The knee is positioned in 90° of flexion. The tibial jig is passed through the medial portal and positioned as for B-T-B reconstruction, with its aiming device passing through the previously created graft harvest incision. With the arthroscope in the anterolateral portal, the tibial tunnel guide wire is inserted and its entry point into the knee confirmed to be within the anteromedial portion of the tibial stump on the tibial surface. The tibial tunnel is then drilled and any debris at its entrance into the knee cleared with an arthroscopic shaver. Any sharp bone edges are smoothed with a tunnel rasp. The shuttle suture loop is retrieved through the tibial tunnel. The lead and flipping sutures of the suspension device are passed through the shuttle loop and pulled up through both tibial and femoral tunnels to be retrieved through the skin of the anterolateral thigh. The suspensory button and attached graft are firmly pulled through into position, the button is flipped and the graft is tensioned by pulling on the whip-stitches at the tibial end.

(

Figure 12.19 Relationship between femoral tunnel length, suspensory loop length and graft length within femoral tunnel (a) and minimum socket depth required to allow button to flip (b).‌

The position of the graft is checked arthroscopically and the graft fixed with a screw in the tibial tunnel as described in the section ‘Bone–patellar tendon–bone graft’ (p. 344).

Closure

Closure of wounds is with a combination of interrupted, absorbable deep sutures and the surgeon’s chosen skin closure. The arthroscopy portals and exit wounds of guide wires can be closed with adhesive paper closure sutures alone. Adhesive dressings and a wool and crepe dressing are applied.

Postoperative care and instructions

ACL reconstruction is often performed as a day-case procedure. Full weightbearing is allowed with crutches until quadriceps function returns. The patient is not put into a brace; rather, early supervised range-of-motion exercises are begun. After 24 hours the bulky dressing is removed, leaving adhesive dressings over the wounds. With the aid of a physiotherapist, range-of-motion exercises are begun; the focus in the initial 1–2 weeks is restoration of range of motion, particularly extension, swelling control by icing and gentle quadriceps activation with leg extension activity. The wounds are inspected and sutures removed at 2 weeks after surgery.

A goal-based rehabilitation regime, with progression determined by meeting specific clinical and functional targets, is preferred over one with activities allowed at specific times. Regaining single-leg balance and muscle strength is started with simple body-weight

exercises such as lunges and squats, progressing to a gym-based regime. Running, jumping, hopping and agility activities can commence when strength and balance goals are achieved, followed by a return to sport-specific exercises and training tailored to the individual. Return to sport is typically a minimum of 9 months postoperatively, provided the functional goals are achieved. It is recommended that athletes participate in an injury prevention programme for as long as they continue to participate in sport. There are a number of prevention programmes available, but they should incorporate plyometric, balance and strengthening exercises and be performed for at least 10 minutes before every sport session.

Anterolateral reconstruction

The anterolateral structures of the knee are a subject of much debate. It is recognised that intra-articular ACL reconstruction may be inadequate to control the rotary instability seen during the pivot shift manoeuvre in all cases, and additional anterolateral extra-articular stabilisation may address this. It is hoped that addition of anterolateral extra-articular stabilisation may also reduce ACL graft rupture. Historically, however, such procedures were thought to be associated with over-constraint, stiffness and lateral osteoarthritis. These problems may have been due to excessive tensioning, postoperative cast immobilisation and co-existing chondral or meniscal injuries and seem not to be relevant to modern techniques. Nonetheless, anterolateral procedures are not currently recommended routinely. Indeed, the indications are yet to be fully defined but may include conditions associated with high graft failure or residual rotational instability rates:

Participation in pivoting/contact sports
High-grade pivot shift
Hyperlaxity
Revision ACL reconstruction
Young patients
Medial meniscectomy
Injury to anterolateral structures/Segond fracture

With the recent interest in the description of an anterolateral ligament as a discrete structure, anterolateral ligament reconstructions are now performed by some surgeons in an attempt to address these issues. The authors’ preferred approach, however, is to perform a modified lateral extra-articular tenodesis, which has been shown to be biomechanically superior. This is achieved through a lateral incision by using a 1 cm wide central strip of iliotibial band, approximately 10 cm in length. It is detached proximally but left attached to Gerdy’s tubercle distally. The proximal end is tunnelled deep to the LCL. It is secured to the lateral distal femur proximal and posterior to the lateral epicondyle with a ligament staple, with the knee held at 30° flexion and neutral rotation, and with light tension, approximately 20N. The remaining free proximal end is then folded back distally superficial to the LCL and sutured to itself. The defect in the iliotibial band is closed.

Recommended references

Burnham JM, Malempati CS, Carpiaux A et al. Anatomic femoral and tibial tunnel placement during anterior cruciate ligament reconstruction: Anteromedial portal all-inside and outside-in techniques. Arthroscopy Techniques. 2017;6:275–282.

Frank CB, Jackson DW. Current concepts review – The science of reconstruction of the anterior cruciate ligament. J Bone Joint Surg Am. 1997;79:1556–1576.

Lutz C. Role of anterolateral reconstruction in patients undergoing anterior cruciate ligament reconstruction. Orthopaedics & Traumatology: Surgery & Research. 2018;104:S47–S53.

Salmon LJ, Russell VJ, Refshauge K et al. Long-term outcome of endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med. 2006;34:721–732.

Williams A, Ball S, Stephen J et al. The scientific rationale for lateral tenodesis augmentation of intra-articular ACL reconstruction using a modified ‘Lemaire’ procedure. Knee Surg Sports Traumatol Arthrosc. 2017;25:1339–1344.

Williams RJ, Hyman J, Petrigliano F et al. Anterior cruciate ligament reconstruction with a four-strand hamstring tendon autograft. J Bone Joint Surg Am. 2004;86:225–232.

Woo SL, Kanamori A, Zeminski J et al. The effectiveness of reconstruction of the anterior cruciate ligament with hamstrings and patellar tendon: A cadaveric study comparing anterior tibial and rotational loads. J Bone Joint Surg Am. 2002;84:907–914.

Posterolateral corner reconstruction ‌

Preoperative planning

Indications

Isolated posterolateral corner injuries are uncommon. Low-grade isolated injuries can often be managed non-operatively. However, high-grade isolated injuries, as well as the more commonly seen combined injuries with cruciate ruptures, and those failing conservative management, require surgical treatment. Primary repair may be possible if treated within the first 3 weeks following injury, but results are often improved if augmented with reconstruction.

Consent and risks
- Approximately 10% persistent varus instability
- Common peroneal nerve: Approximately 25% overall, but usually a result of the injury rather than surgery
Operative planning

A number of construct and graft options are described. Consensus is lacking about the optimal technique. The fibular-based technique using a free semitendinosus autograft described later, a modification of that described by Larson, is one that is commonly used and appears to produce comparable outcomes to more complex constructs.

Careful clinical examination is essential, both to ensure that posterolateral corner injury is not missed and to identify other associated injuries. Graft availability may be influenced by the requirement to perform additional reconstructions, or those performed previously.

Anaesthesia and positioning

These are the same as for ACL reconstruction.

Surgical technique

Landmarks
Lateral epicondyle
Gerdy’s tubercle
Fibular head

Incision and approach

The semitendinosus tendon is harvested as described for ACL reconstruction, noting that contralateral harvest may be required in the case of combined injuries.

The procedure can be performed through two small incisions, over the fibular head and lateral epicondyle, but the full approach is described here. A lateral longitudinal incision is made from the lateral epicondyle proximally, to midway between Gerdy’s tubercle and the fibular head distally. Dissection is continued down to the iliotibial band. Three windows are created to expose the deep structures: the common peroneal nerve is exposed and released posterior to the biceps femoris tendon and protected throughout the remainder of the procedure; the tip of the fibula is exposed between the biceps tendon and iliotibial band and the femoral attachments of the LCL and popliteus tendon are exposed through a split in the iliotibial band centred on the lateral epicondyle.

Procedure

The free semitendinosus tendon is whip-stitched at both ends with heavy suture as for ACL reconstruction. A graft of length at least 16–19 cm is required.

A guide wire is inserted from anterolateral to posteromedial through the widest part of the fibular head, approximately 1–1.5 cm below the tip, and over-drilled to a diameter of 4–5 mm to accommodate the single hamstring tendon. The tendon is passed through the fibular tunnel so that the central portion is within the tunnel.

Two Beath pin guide wires are inserted into the lateral femoral condyle and directed anteromedially through the medial femur and skin of the medial thigh, one at the insertion of the LCL on the lateral epicondyle and the second at the insertion of the popliteus, which is found 18.5 mm anterior and distal to the former (Figure 12.20). It is important to direct the wires to avoid interference with the femoral tunnel of an associated ACL reconstruction. Inserting all femoral guide wires, to see their positions and avoid any clashes, before completing the reconstruction, may help with this. The femoral tunnels are then drilled to accommodate the free ends of the graft.

The end of the tendon exiting from the anterior end of the fibular tunnel will reconstruct the LCL while the posterior end will reconstruct the popliteus/popliteo-fibular ligament (Figure 12.21). The popliteo-fibular end of the reconstruction is secured first: it is passed deep to the iliotibial band and retrieved through the window at the femoral epicondyle, the whip-stitches are shuttled through the femoral tunnel at the popliteus insertion by pulling the Beath pin out through the medial thigh and the free end of the graft can then be pulled into the tunnel, aiming for at least 15 mm to be within the tunnel. It is secured with an interference screw in the femoral tunnel then tensioned to 10N by pulling on the remaining free end of the graft at 90° flexion and neutral rotation and secured with a screw from anterior

Figure 12.20 Landmarks for femoral attachments of LCL and popliteus on lateral condyle.

to posterior in the fibular tunnel. The remaining free end exiting the fibula anteriorly is then passed deep to the iliotibial band but superficial to the already secured popliteo-fibular part of the reconstruction and passed into the femoral tunnel at the LCL attachment in a similar fashion, thereby reconstructing the LCL. It is tensioned to 10N with the knee in extension and neutral rotation and secured in the femoral tunnel with an interference screw. The popliteofibular part of the graft should be tighter in flexion, while the LCL part tightens in extension.

Closure

The free whip-stitch ends are cut flush to the medial thigh skin and buried. The iliotibial band is closed with absorbable suture followed by the surgeon’s chosen skin closure.

Postoperative care and instructions

Rehabilitation will often need to be tailored to the particular combination of injuries being addressed. In general, a period of protected weightbearing with the knee braced in extension for 6 weeks is employed. Passive range of motion from 0° to 90° can begin early, progressing to full flexion after 2–4 weeks. Quads exercises can start early, but hamstring activity should be avoided for the first 6 weeks. Progression to normal activity and sports will then follow a similar principle to ACL rehabilitation.

Figure 12.21 Modified Larson posterolateral corner reconstruction.

Recommended references

Crespo B, James EW, Metsavaht L et al. Injuries to posterolateral corner of the knee: A comprehensive review from anatomy to surgical treatment. Rev Bras Ortop. 2015;50:363–370.

Djian P. Posterolateral knee reconstruction. Orthopaedics & Traumatology: Surgery & Research.

2015;101:S159–S170.

Niki Y, Matsumoto H, Otani T et al. A modified Larson’s method of posterolateral corner reconstruction of the knee reproducing the physiological tensioning pattern of the lateral collateral and popliteofibular ligaments. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology. 2012;4:21.

Posterior cruciate ligament reconstruction

Preoperative planning

Indications

Many isolated PCL ruptures will be successfully managed conservatively, particularly low-grade injuries; surgical reconstruction is indicated for persistent symptomatic instability (e.g. deceleration and slope/stair descent) despite conservative management and rehabilitation. Other surgical indications are combined injuries and refractory patellofemoral pain resulting from increased patellofemoral forces with posterior tibial translation.

Consent and risks

Popliteal artery injury
Posterior meniscal root injury – during placement of tibial tunnel
Residual posterior laxity grade II or greater approximately 25%
Osteoarthritis approximately 60% at 9 years

Operative planning

As with other ligament reconstructions around the knee, there are many options and controversies surrounding the optimal graft choice, construct and fixation. Both single- and double-bundle techniques can be used but the relative benefits of each continue to be debated. Single-bundle techniques typically aim to restore the larger anterolateral bundle. Graft choice may depend on previous surgery or combined injuries; autograft and allograft have both been used successfully. Later we describe the use of quadrupled hamstring graft, similar to that for ACL reconstruction, but consideration needs to be given to ensuring sufficient length of graft, which is longer than that for ACL reconstruction. Grafts with bone blocks may present challenges with graft passage because of the angle the graft needs to turn on exiting the tibial tunnel. For those reasons some surgeons will routinely use allograft as their primary graft choice.

Surgical technique

Incision

The procedure described next is performed arthroscopically. A posteromedial portal is placed to access the tibial attachment of the PCL. An accessory anterolateral portal may be used to position the femoral tunnel.

An incision over the medial proximal tibia is created as for hamstring harvest. If the hamstrings are being harvested this will be performed at the same time; if not then the anteromedial tibia is exposed to place the tunnel for PCL reconstruction.

Procedure

The free hamstring graft is harvested and prepared as for ACL reconstruction.

Following full diagnostic arthroscopy and treatment of any associated meniscal lesions, the femoral tunnel is created. The location of the femoral attachment on the medial wall of the notch is identified while visualising through the anterolateral portal. The larger anterolateral bundle is high on the medial wall and adjacent to the chondral surface of the medial femoral condyle. A point is marked at the intended guide wire insertion point so that when the tunnel is placed, matching the diameter of the graft, its edge will be adjacent to the chondral margin within the native femoral footprint (Figure 12.22). A Beath pin is inserted from the anterolateral portal and directed out through the anteromedial femur and thigh skin. The femoral tunnel is created in the same manner as described for hamstring ACL reconstruction: first drilled with a 4.5 mm drill to accommodate the suspensory button device, then over-drilled to match the graft diameter up to, but not through, the femoral cortex. A shuttle suture is pulled up through the tunnel and out the medial thigh using the Beath pin.

Figure 12.22 PCL footprint on medial wall of the notch, and position of femoral tunnel for single bundle reconstruction.

A posteromedial portal and arthroscopic cannula are placed. An arthroscopic shaver is used via the posteromedial portal, while visualising through the notch, to expose the tibial attachment of the PCL, taking care to face the shaver blade anteriorly to reduce risks to the popliteal neurovascular bundle. The tibial footprint is then visualised through the posteromedial portal while a guide wire is passed from the anteromedial tibia, approximately 6 cm below and at an angle of 50° to the tibial plateau, to exit at the planned tibial tunnel site. The tunnel is positioned at a ridge between the attachments of the anterolateral and posteromedial bundles, just proximal to the so-called ‘champagne-glass drop-off’ at the upper border of popliteus, and below the shiny white fibres at the posterior meniscal root attachment, which can be damaged if the tunnel is placed too high (Figure 12.23). Care must be taken to avoid posterior soft tissue penetration of the guide wire and risk to the popliteal neurovascular bundle; it must be directly visualised to penetrate the posterior cortex, and PCL-specific guides are available with protection devices to prevent over-penetration of the wire. The guide wire position can be confirmed with fluoroscopy. The tibial tunnel is drilled over the guide wire to match the diameter of the graft. Again, the tip of the guide wire must be visualised to prevent over-penetration with the drill; a curette placed in the posteromedial portal is used to cover the tip of the guide wire during drilling.

A rasp is used to smooth the proximal edge of the tibial tunnel aperture on the posterior cortex, to reduce graft abrasion at the tibial ‘killer angle’. A second shuttle suture is passed into the knee through the tibial tunnel and retrieved through the anterolateral portal in order to pass the femoral shuttle suture back through the tibial tunnel. The suspensory button and attached graft are pulled up through the tibial and femoral tunnels. Passage of the graft around the

Figure 12.23 Tibial attachment of the PCL. The guide wire is positioned to exit at the bundle ridge.

angle of the tibial tunnel may be difficult; a trocar placed through the posteromedial portal can help to lever the graft out through the tunnel and work it around the angle toward the femoral tunnel. When passed out through the medial femoral cortex the suspensory button is flipped. The graft is tensioned at 90° flexion and with an anterior drawer applied to reduce the posterior tibial sag and secured in the tibial tunnel with an interference screw.

Postoperative care and instructions

PCL graft healing takes about double the length of time of ACL healing. Although individual surgeons may have their own preferred programmes and the precise rehabilitation may need to be tailored to associated injuries, the principles are for initial limited weightbearing, prevention of posterior tibial subluxation, focus on quadriceps strengthening and limitation of hamstring activity.

The patient remains non-weightbearing for the first 6 weeks, gradually increasing to full weightbearing thereafter. A static PCL brace (with a bolster behind the calf) in extension is used for the first 2 weeks before transitioning to a dynamic PCL brace to be worn at all times initially. Isometric quads activity is allowed immediately, and prone passive flexion is allowed once in the dynamic brace, limited to 90° for the first 6 weeks. From 6 to 12 weeks

full passive range of motion is allowed, along with more intense quads strengthening, but weightbearing flexion remains restricted to 70°. After 12 weeks weightbearing flexion can increase and the brace can be weaned off, aiming for removal after about 4 months. Strengthening continues, allowing isolated hamstring activity at this time, followed by running and agility exercises after 5–6 months and a goal-directed sports-specific exercise programme with eventual return to sport after about 9 months.

Recommended references

Pache S, Aman ZS, Kennedy M et al. Posterior cruciate ligament: Current concepts review. Arch Bone Jt Surg. 2018;6:8–18.

Vaquero-Picado A, Rodríguez-Merchán EC. Isolated posterior cruciate ligament tears: An update of management. EFORT Open Rev. 2017;2:89–96.

Medial collateral ligament reconstruction ‌

Preoperative planning

Indications

MCL injuries are common but will often be managed conservatively; a careful bracing regime may negate the need for reconstruction even after high-grade injuries. Reconstruction is indicated in multi-ligament or other combination injuries requiring surgical repair, in chronic instability which has failed conservative management and rarely following debridement of a Pellegrini-Stieda lesion. Occasionally, the ruptured end of the ligament may be incarcerated within the joint or displaced superficial to the pes (analogous to a Stener lesion) and will not be expected to heal without surgery. Primary repair is often possible if performed early but may need to be augmented depending on the quality of the repair and tissues.

Consent and risks

Arthrofibrosis
Saphenous nerve and its infrapatellar branch
Recurrent instability/graft failure

Operative planning

Autograft, allograft and synthetics are all options for medial reconstruction. The main consideration when comparing different constructs is whether the posterior oblique ligament (POL) is also reconstructed. Careful examination for posteromedial corner injury, looking specifically for valgus laxity in full extension (also associated with cruciate injury) and increased external rotation due to excess anteromedial translation (in contrast to posterolateral injury where increased external rotation is due to posterolateral translation), may guide the need to include POL reconstruction, although whether this is included routinely remains a subject of discussion. The following description does include a limb to reconstruct the POL, although it is accepted that this may not necessarily be performed in all cases and there are other methods described to achieve this.

Surgical technique

Landmarks

Medial epicondyle
Medial proximal tibia
Semimembranosus tendon

Incision and approach

The procedure can be performed through multiple smaller incisions but the full approach is described here. A curved medial longitudinal incision is made from the medial epicondyle to medial tibia about 6–7 cm below the joint line. Dissection is continued down to the sartorial fascia, which is incised in line with the skin incision, taking care not to damage the hamstring tendons. The semitendinosus tendon is harvested as per ACL reconstruction. The remaining native MCL is identified deep to the sartorial fascia and pes anserinus.

Procedure

The free semitendinosus tendon is whip-stitched at both ends with heavy suture as for ACL reconstruction. The tendon is looped over a suture or nylon tape and the diameter of the doubled graft measured. One limb of the graft will reconstruct the superficial MCL (sMCL) while the other will reconstruct the POL, in this case from a single femoral tunnel, although techniques with separate femoral tunnels are described.

The tibial attachments of the sMCL are identified (Figure 12.24). There are two sites of tibial attachment: the distal site is located approximately 6 cm below the joint line, deep to the pes anserinus, just anterior to the posterior tibial border; the proximal tibial attachment is located 12 mm below the joint line, in line with the semimembranosus attachment. A Beath pin is inserted at the distal site to exit the anterolateral tibia. It is positioned towards the posterior tibial border but so there is sufficient bone for a tunnel to be drilled without blowout of the posterior cortex.

The tibial attachment of the POL is identified 1–1.5 cm below the joint line at the posteromedial corner of the tibia (Figure 12.24), adjacent to the semimembranosus attachment. A second Beath pin is inserted aiming to exit the anterolateral tibia at Gerdy’s tubercle.

The femoral tunnel site is identified next. The sMCL attachment is reported to be 3.2 mm proximal and 4.8 mm posterior to the medial epicondyle (Figure 12.24). A Beath pin is inserted at this point, directed anterolaterally to exit the femur and skin of the anterolateral thigh, being careful to avoid entering the intercondylar notch. Isometry is now checked by wrapping sutures around the Beath pins to connect the femoral and tibial guide pins in the proposed positions of the sMCL and POL reconstructions and putting the knee through a range of motion to assess the change in tension on the sutures. The sMCL should be isometric throughout, while the POL is lax in flexion but tightens in extension. The femoral pin position can be moved to improve isometry if necessary.

When the positions are confirmed, a tunnel to accommodate the looped end of the graft is drilled in the femur in the same way as for ACL reconstruction, for fixation with a cortical suspensory button device. A suspensory button with a loop length to place 2–2.5 cm of graft within the tunnel is selected. The graft is looped through the suspensory button device and

Figure 12.24 Landmarks on the medial side of the knee and attachment of the MCL.

pulled into the femoral tunnel via the Beath pin, and the button is flipped. After ensuring sufficient length on each end of the graft to perform the sMCL and POL reconstructions, with 2–2.5 cm of graft in each tunnel, the femoral end is secured with an interference screw.

The tibial tunnels are then drilled to an appropriate diameter and depth to accommodate the ends of the graft. One limb of the graft can then be pulled into the POL tunnel and the other into the sMCL tunnel via the whip-stitches and Beath pins. The POL reconstruction is tensioned at full extension and secured with an interference screw. The sMCL reconstruction is tensioned at 20° flexion with slight varus and secured at its distal attachment with an interference screw. The proximal tibial attachment site of the sMCL is finally secured with a ligament staple (Figure 12.25). Any lax and redundant posteromedial capsule can be tightened by suturing it to the POL reconstruction in full extension. The knee is put through a range of motion to determine a safe range for initial rehabilitation without placing undue tension on any repaired or reconstructed tissue.

Closure

The free whip-stitch ends are cut flush to the skin and buried. The cortical button’s lead and flipping sutures are removed. The skin is closed in a standard fashion and a wool and crepe bandage applied.

Figure 12.25 Completed MCL reconstruction.

Postoperative care and instructions

The patient mobilises non-weightbearing in a hinged brace for the first 6 weeks. Initial range of motion during the first 2 weeks is determined by the safe zone defined intraoperatively; this can be increased after 2 weeks. Simple quads exercises are started immediately. Weightbearing is gradually increased from 6 to 12 weeks. Further strengthening is allowed when gait has returned without significant limp, and eventual return to sport follows a goal-based regime.

Recommended references

Andrews K, Lu A, Mckean L et al. Review: Medial collateral ligament injuries. J Orthop. 2017;14:550–554. DeLong JM, Waterman BR. Surgical techniques for the reconstruction of medial collateral ligament and posteromedial corner injuries of the knee: A systematic review. Arthroscopy. 2015;31:2258–2272.

Wijdicks CA, Griffith CJ, Johansen S et al. Injuries to the medial collateral ligament and associated medial structures of the knee. J Bone Joint Surg Am. 2010;92:1266–1280.

Multi-ligament injuries

The full details of multi-ligament knee injuries are beyond the scope of this book. As with all soft tissue knee surgery there are many controversies, but some reconstructive principles are worth noting here. These injuries are often high energy and associated with polytrauma; any life- or limb-threatening injuries must be identified and treated. If the knee is dislocated then it must be reduced urgently, and associated neurovascular injuries must also be identified and treated. A range-of-motion brace will usually be sufficient to maintain reduction. Care must be taken to identify the extent of the injury by thorough clinical examination, under anaesthesia if necessary, especially in cases where the knee has

reduced spontaneously and plain radiographs may look normal. Definitive reconstructive procedures can then be planned.

The timing of definitive reconstruction remains a matter of debate. Some surgeons will routinely perform early reconstruction (within 3 weeks, second week is optimal) but indications for early reconstruction otherwise are irreducible dislocations, neurovascular injuries, posterolateral corner injury and associated fractures. Open surgery will be required in early cases because capsular injury will lead to arthroscopic fluid leak. Early repair of the medial and lateral/posterolateral structures is possible, especially avulsions, but improved outcomes are seen if augmented with reconstruction, particularly in mid-substance tears. The alternative approach is for delayed reconstruction (after 3 months) in the absence of indications for early reconstruction. A period of appropriate bracing can effectively downgrade the extent of the injury, allowing healing of the PCL and MCL in particular, and simplifying later reconstruction based on residual instability.

Whether the full reconstruction is performed in a single operation or a staged strategy is used largely depends on the experience of the surgeon and what the surgeon feels confident with, given the constraints of tourniquet time in these potentially long and demanding procedures. Either way, careful planning of the sequence in which the various steps of the reconstruction are performed is crucial, and the PCL, if being reconstructed, must be tensioned and secured before other reconstructions are completed in order to reduce the tibia under the femur (can be confirmed with fluoroscopy) and prevent fixed posterior translation that will occur if the ACL is tensioned without the restraint of a competent PCL.

Consideration will need to be given to the choice of grafts. Autograft, allograft and synthetics may all have their place, and harvest from the contralateral limb is common. It is widely accepted that synthetic grafts are a reasonable option for extra-articular reconstructions, and they may also be used for PCL reconstruction, although their use in ACL reconstruction is generally avoided for the reasons given earlier. Tunnels need to be positioned to avoid clashes. Placing the multiple required guide wires, which can then be checked with fluoroscopy prior to completing tunnel preparation, can be helpful in this regard.

Full range of motion must be confirmed at the end of the procedure. Rehabilitation depends on the specific injury pattern but a period of protected weightbearing and early passive restoration of motion in a hinged brace is preferable.

Recommended references

Buyukdogan K, Laidlaw MS, Miller MD. Surgical management of the multiple-ligament knee injury.

Arthrosc Tech. 2018;7:e147–e164.

Lachman JR, Rehman S, Pipitone PS. Traumatic knee dislocations: Evaluation, management, and surgical treatment. Orthop Clin North Am. 2015;46:479–493.

Moatshe G, LaPrade RF, Engebretsen L. How to avoid tunnel convergence in a multiligament injured knee. Ann Joint. 2018;3:93.

Osteotomy and soft tissue surgery of the knee

Although the technical aspects of osteotomy about the knee are considered elsewhere, and the full details of this topic are beyond the scope of this book, it is worth noting the

relevance of such techniques in the context of soft tissue reconstruction. Malalignment and abnormal tibial slope are known to be risk factors for failure of ligament reconstruction. Indeed, in chronic instability, particularly in the presence of degenerative changes, corrective osteotomy may be the operation of choice to address the instability with or without additional ligament reconstruction.

Similarly, both correct alignment and stability are required for optimal outcomes of both meniscal repair/allograft transplantation and chondral regenerative procedures. Furthermore, an intact and functional meniscus is required for successful chondral surgery. This has led to the concept of a reconstructive ladder of knee joint preservation surgery, requiring alignment, stability, meniscus and chondral surfaces all be addressed to optimise outcomes. An assessment of these is especially important in failed reconstructive surgery; an osteotomy may be required before embarking on any further soft tissue procedures to avoid repeat failures.

Recommended references

Cantin O, Magnussen RA, Corbi F et al. The role of high tibial osteotomy in the treatment of knee laxity: A comprehensive review. Knee Surg Sports Traumatol Arthrosc. 2015;23:3026–3037.

Harris JD, Cavo M, Brophy R et al. Biological knee reconstruction: A systematic review of combined meniscal allograft transplantation and cartilage repair or restoration. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2011;27:409–418.

Tischer T, Paul J, Pape D et al. The impact of osseous malalignment and realignment procedures in knee ligament surgery: A systematic review of the clinical evidence. Orthop J Sports Med. 2017;5:2325967117697287.

Viva questions‌

What equipment is required to perform a diagnostic arthroscopy?
Define the anatomy of the posterior knee arthroscopy portals.
Which structures are at risk in the posterior portals for knee arthroscopy?
What are the indications for meniscal repair?
Which techniques do you know for meniscal repair?
How are discoid lateral menisci classified?
What treatment do you use for a discoid lateral meniscus?
Which associated anatomical findings worsen a tight lateral retinaculum?
What are the advantages and disadvantages of arthroscopic over open lateral release?
What are the common indications for cartilage reconstruction surgery?
Describe the procedure of microplasty to the medial femoral condyle.
What are the advantages of autologous chondrocyte implantation over microplasty?
How are the cells provided for autologous chondrocyte implantation?
What risks do you describe to a patient consenting to ACL reconstruction?

Describe the anatomy of the pes anserinus.
How are the hamstrings harvested for an ACL graft?
What is the minimal acceptable graft thickness for ACL reconstruction?
Where are the isometric points for the origin of insertion of an ACL graft?
What position is the knee held in while an ACL graft is tensioned and fixed?
Describe your postoperative regimen after an ACL reconstruction.

الأستاذ الدكتور محمد هطيف نائب عميد كلية الطب والعلوم الصحية، جامعة صنعاء،مشرف الدكتوراه في جراحة العظام والمفاصل

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Soft Tissue Surgery of the Knee

Soft Tissue Surgery of the Knee

including outside-in, inside-out and all-inside suturing (Figure 12.7). In addition, meniscal darts can be used. The details of this surgery are beyond the scope of this book. Sutures are placed, usually vertically, about 3–4 mm apart from each other.

This dissection is continued across the patella for 30 mm proximally and the tibial tuberosity 30 mm distally. These incisions mark the sites of bone cuts for harvesting of proximal and distal blocks (Figure 12.12).

The same technique is used to create two holes in and harvest the tuberosity bone block, which should be of a similar size and shape. It is again trimmed and one heavy suture is passed through one of the drilled holes (Figure 12.13).

The femoral footprint of the ACL is identified on the lateral wall. The entire footprint is below and posterior to the lateral intercondylar (resident’s) ridge; the anteromedial (AM) bundle attaches above and behind the bifurcate ridge (Figure 12.14a). A Beath pin guide

A 50 mm incision, parallel with the patellar tendon, is created 20 mm medial to the tibial tuberosity. It should begin 60 mm below the joint line. Fat and deep fascia are dissected to reveal the tendons of the pes anserinus (Figure 12.17).

The tibial attachment of the POL is identified 1–1.5 cm below the joint line at the posteromedial corner of the tibia (Figure 12.24), adjacent to the semimembranosus attachment. A second Beath pin is inserted aiming to exit the anterolateral tibia at Gerdy’s tubercle.

Soft Tissue Surgery of the Knee

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Soft Tissue Surgery of the Knee

including outside-in, inside-out and all-inside suturing (Figure 12.7). In addition, meniscal darts can be used. The details of this surgery are beyond the scope of this book. Sutures are placed, usually vertically, about 3–4 mm apart from each other.

This dissection is continued across the patella for 30 mm proximally and the tibial tuberosity 30 mm distally. These incisions mark the sites of bone cuts for harvesting of proximal and distal blocks (Figure 12.12).

The same technique is used to create two holes in and harvest the tuberosity bone block, which should be of a similar size and shape. It is again trimmed and one heavy suture is passed through one of the drilled holes (Figure 12.13).

The femoral footprint of the ACL is identified on the lateral wall. The entire footprint is below and posterior to the lateral intercondylar (resident’s) ridge; the anteromedial (AM) bundle attaches above and behind the bifurcate ridge (Figure 12.14a). A Beath pin guide

A 50 mm incision, parallel with the patellar tendon, is created 20 mm medial to the tibial tuberosity. It should begin 60 mm below the joint line. Fat and deep fascia are dissected to reveal the tendons of the pes anserinus (Figure 12.17).

The tibial attachment of the POL is identified 1–1.5 cm below the joint line at the posteromedial corner of the tibia (Figure 12.24), adjacent to the semimembranosus attachment. A second Beath pin is inserted aiming to exit the anterolateral tibia at Gerdy’s tubercle.