Knee Surgery E-Book

James Stannard

• Herausgeber: Thieme Medical Publishers
• Kategorie: Fachliteratur
• Sprache: Englisch

Veröffentlichungsjahr: 2022

Beschreibung

An indispensable step-by-step guide on a full spectrum of open and arthroscopic knee procedures

Knee disorders are among the most common musculoskeletal conditions and, as such, constitute four of the top seven orthopaedic procedures. Currently, 720,000 knee replacements are performed annually in the US, with a projected 3.4 million surgeries by 2030. Knee Surgery: Tricks of the Trade edited by renowned knee surgeons and educators James P. Stannard, Andrew Schmidt, and Mauricio Kfuri features contributions from an impressive cadre of distinguished colleagues. The reader-friendly book fills a gap in the literature with easy-to-follow procedural guidance and pearls from a global who's who of top knee surgeons.

The book is organized in three sections covering trauma, sports medicine, and adult reconstruction. In addition to comprehensive step-by-step procedural techniques, each of the 54 chapters is consistently formatted with succinct sections covering goals, key principles, indications, contraindications, tips and pearls, potential complications, pitfalls, salvage techniques, and postoperative care. A full spectrum of open and arthroscopic knee surgery procedures are included, with discussion of primary and revision approaches. Topics include management of fractures, ligamentous injuries, meniscal pathologies, osteochondral repair, and all types of arthroplasties.

Key Highlights

• Firsthand tips and tricks focus on helping surgeons improve and master techniques
• High-quality drawings and full color operative photographs illustrate important anatomical aspects and salient points
• Thirteen succinct videos feature hands-on steps for performing diverse knee procedures

This quintessential knee surgery resource will help orthopaedic surgeons, knee surgeons, and total joint specialists avoid pitfalls and achieve more optimal patient outcomes.

This book includes complimentary access to a digital copy on https://medone.thieme.com.

Leseprobe

To access the additional media content available with this e-book via Thieme MedOne, please use the code and follow the instructions provided at the back of the e-book.

Knee Surgery

Tricks of the Trade

James P. Stannard, MDMedical DirectorMissouri Orthopaedic Institute; Hansjörg Wyss Distinguished Professor of Orthopaedic Surgery; ChairDepartment of Orthopaedic SurgeryUniversity of MissouriColumbia, Missouri, USA

Andrew Schmidt, MDProfessorDepartment of OrthopaedicsUniversity of Minnesota;ChiefDepartment of Orthopaedic SurgeryHennepin County Medical CenterMinneapolis, Minnesota, USA

Mauricio Kfuri, MD, PhDDirectorOrthopaedic Residency Program;James P. Stannard, MD, and Carolyn A. Stannard Distinguished Professor in Orthopaedic SurgeryUniversity of Missouri;Missouri Orthopaedic InstituteColumbia, Missouri, USA

367 illustrations

ThiemeNew York • Stuttgart • Delhi • Rio de Janeiro

Library of Congress Cataloging-in-Publication Data is available from the publisher.

Illustrations: Stacy Turpin Cheavens, Missouri, USA

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.

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Cover design: © Thieme

Cover Image source: © Thieme/Stacy Turpin Cheavens

Typesetting by TNQ Technologies, India

Printed in USA by King Printing Company, Inc.5 4 3 2 1

ISBN: 978-1-62623-541-0

Also available as e-book:

eISBN (PDF): 978-1-62623-542-7

eISBN (epub): 978-1-63853-481-5

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Contents

Videos

Preface

Acknowledgment

Contributors

Section I: Trauma

1.Unilateral Lateral Tibial Plateau Fractures

David Hubbard

1.1Description

1.2Key Principles

1.3Expectations

1.4Indications

1.5Contraindications

1.6Special Considerations

1.7Special Instructions, Positioning, and Anesthesia

1.8Tips, Pearls, and Lessons Learned

1.8.1Approach

1.8.2Visualization

1.8.3Fracture Reduction

1.8.4Internal Fixation

1.8.5Closure

1.9Difficulties Encountered

1.10Key Procedural Steps

1.11Bailout, Rescue, Salvage Procedures

1.12Pitfalls

2.Unicondylar Medial Tibial Plateau Fractures

Nicholas P. Gannon and Andrew Schmidt

2.1Description

2.2Key Principles

2.3Expectations

2.4Indications

2.5Contraindications

2.6Special Considerations

2.7Special Instructions, Positioning, and Anesthesia

2.8Tips, Pearls, and Lessons Learned

2.9Difficulties Encountered

2.10Key Procedural Steps

2.10.1Straight Medial Approach

2.10.2Lobenhoffer Posteromedial Approach in the Prone or Supine Position

2.11Bailout, Rescue, Salvage Procedures

2.12Pitfalls

3.Bicondylar Tibial Plateau Fractures ..

Mark A. Lee

3.1Description

3.2Key Principles

3.2.1Alignment

3.2.2Buttress

3.2.3Articular Exposure

3.2.4Compression of Articular Segment

3.3Expectations

3.4Indications

3.5Contraindications

3.6Special Considerations

3.7Special Instructions, Position, and Anesthesia

3.8Tips, Pearls, and Lessons Learned

3.9Difficulties Encountered

3.10Key Procedural Steps

3.11Bailout, Rescue, Salvage Procedures

3.12Pitfalls

4.Tibial Plateau Fractures in the Coronal Plane

Yukai Wang and Congfeng Luo

4.1Description

4.2Key Principles

4.3Expectations

4.4Indications

4.5Contraindications

4.6Special Considerations

4.7Special Instructions, Position, and Anesthesia

4.8Tips, Pearls, and Lessons Learned

4.8.1Exposure and Dissection

4.8.2Reduction Principle

4.8.3Intraoperative Fluoroscopy and CT Scans

4.8.4Precontour of the Posterolateral Buttress Plate

4.8.5Evaluation of the Placement of the Posterolateral Buttressing Plate

4.9Difficulties Encountered

4.9.1Reduction of Posterolateral Articular Surface

4.9.2Fracture Pattern

4.10Key Procedural Steps

4.10.1Fracture Reduction and Internal Fixation

4.10.2Treatment of Associated Injuries

4.11Bailout, Rescue, Salvage Procedures

4.12Pitfalls

5.Distal Femur Unicondylar Fracture

Vincenzo Giordano, André Wajnsztejn, and Felipe Serrão de Souza

5.1Description

5.2Key Principles

5.3Expectations

5.4Indications

5.5Contraindications

5.6Special Considerations

5.7Special Instructions, Position, and Anesthesia

5.8Tips, Pearls, and Lessons learned

5.8.1Closed Reduction

5.8.2Open Reduction

5.9Difficulties Encountered

5.10Key Procedural Steps

5.10.1Patient Positioning

5.10.2Approaches for ORIF

5.10.3Fixation

5.11Bailout, Rescue, and Salvage Procedures

5.12Pitfalls

6.Distal Femur Fractures—Bicondylar .

Brett D. Crist

6.1Description

6.2Key Principles

6.3Expectations

6.4Indications

6.5Contraindications

6.6Special Considerations

6.6.1Geriatric and Osteoporotic Fractures

6.6.2Open Fractures

6.6.3Chondral Damage or Loss

6.7Special Instructions, Position, and Anesthesia

6.8Tips, Pearls, and Lessons Learned

6.8.1Preoperative Plan

6.8.2Surgical Exposures

6.8.3Common Reduction Instruments

6.8.4Reduction Aids that Facilitate the Reduction

6.8.5Implants

6.8.6Reduction Tips

6.8.7Fixation Tips

6.9Difficulties Encountered

6.10Key Procedural Steps

6.10.1Choosing the Correct Surgical Exposure

6.10.2Articular Reduction and Fixation

6.10.3Metadiaphyseal Reduction

6.10.4Fixation Strategy

6.10.5Closure

6.11Bailout, Rescue, Salvage Procedures

6.12Pitfalls

7.Distal Femur Fracture in the Coronal Plane—Hoffa Fracture

Robinson Esteves Pires, Richard S. Yoon, and Frank A. Liporace

7.1Description

7.2Key Principles

7.3Expectations

7.4Indications

7.5Contraindications

7.6Special Considerations

7.7Special Instructions, Positioning, and Anesthesia

7.8Tips, Pearls, and Lessons Learned

7.8.1Posterolateral Approach

7.8.2Anterolateral Approach

7.8.3Medial Approaches

7.9Difficulties Encountered

7.10Key Procedural Steps

7.11Bailout, Rescue, and Salvage Procedures

7.12Pitfalls

8.Distal Femur Periprosthetic Fracture—Internal Fixation with Plate

Sven Märdian and Michael Schuetz

8.1Description

8.2Key Principles

8.3Expectations

8.4Indications

8.5Contraindications

8.6Special Considerations

8.7Special Instructions, Position, and Anesthesia

8.8Tips, Pearls, and Lessons Learned

8.9Difficulties Encountered

8.10Key Procedural Steps

8.11Bailout, Rescue, and Salvage Procedures

8.12Pitfalls

9.Retrograde Nailing of Distal Femur Periprosthetic Fractures

Matthew Stillwagon and George Hanson

9.1Description

9.2Key Principles

9.3Expectations

9.4Indications

9.5Contraindications

9.6Special Considerations

9.7Special Instructions, Positioning, and Anesthesia

9.8Tips, Pearls, and Lessons Learned

9.9Difficulties Encountered

9.10Key Procedural Steps

9.11Bailout, Rescue, and Salvage Procedures

9.12Pitfalls

10.Nail-Plate Combination and Double Plating for Complex Distal Femur Fractures (Native or Periprosthetic)

Robinson Esteves Pires and Vincenzo Giordano

10.1Description

10.2Key Principles

10.3Expectations

10.4Indications

10.5Contraindications

10.6Special Considerations

10.7Special Instructions, Positioning, and Anesthesia

10.8Tips, Pearls, and Lessons Learned

10.9Difficulties Encountered

10.10Key Procedural Steps

10.11Bailout, Rescue, and Salvage Procedures

10.12Pitfalls

11.Distal Femur Periprosthetic Fracture: ORIF and Revision Arthroplasty

Idemar Monteiro da Palma and Rodrigo Satamini Pires e Albuquerque

11.1Description

11.2Key Principles

11.3Expectations

11.4Indications

11.5Contraindications

11.6Special Considerations

11.7Special Instructions, Positioning, and Anesthesia

11.8Tips, Pearls, and Lessons Learned

11.9Difficulties Encountered

11.10Key Procedural Steps

11.11Bailout, Rescue, and Salvage Procedures

11.12Pitfalls

12.Patellar Fracture—Simple Transverse Pattern

Suthorn Bavonratanavech and Chatchanin Mayurasakorn

12.1Description

12.2Key Principles

12.3Expectations

12.4Indications and Contraindications

12.4.1Nonoperative Treatment

12.4.2Operative Treatment

12.5Special Considerations

12.6Special Instructions, Position, and Anesthesia

12.7Tips, Pearls, and Lessons Learned

12.8Difficulties Encountered

12.9Key Procedural Steps

12.10Bailout, Rescue, and Salvage Procedures

12.11Pitfalls

12.11.1Indication for Treatment Issue

12.11.2Technical Consideration

13.Patellar Fractures—Comminuted Pattern

Mauricio Kfuri, Juan Manuel Concha, and Igor A. Escalante Elguezabal

13.1Description

13.2Key Principles

13.3Expectations

13.4Indications

13.5Contraindications

13.6Special Considerations

13.7Special Instructions, Positioning, and Anesthesia

13.8Tips, Pearls, and Lessons Learned

13.9Difficulties Encountered

13.10Key Procedural Steps

13.11Bailout, Rescue, and Salvage Procedures

13.12Pitfalls

14.Patellar Tendon Repair with Ipsilateral Semitendinosus Autograft Augmentation

Vishal S. Desai and Michael J. Stuart

14.1Description

14.2Key Principles

14.3Expectations

14.4Indications

14.5Contraindications

14.6Special Considerations

14.7Special Instructions, Position, and Anesthesia

14.8Tips, Pearls, and Lessons Learned

14.9Difficulties Encountered

14.10Key Procedural Steps

14.11Bailout, Rescue, Salvage Procedures

14.12Pitfalls

15.Quadriceps Tendon Rupture

Fabricio Fogagnolo and Mauricio Kfuri

15.1Description

15.2Key Principles

15.3Expectations

15.4Indications

15.5Contraindications

15.6Special Considerations

15.7Special Instructions, Positioning, and Anesthesia

15.8Tips, Pearls, and Lessons Learned

15.9Difficulties Encountered

15.10Key Procedural Steps

15.10.1Preparation

15.10.2Incision and Exposure

15.10.3Tendon Repair

15.11Bailout, Rescue, and Salvage Procedures

15.12Pitfalls

16.Knee Dislocation—Acute Management

John D. Adams Jr

16.1Description

16.2Key Principles

16.3Expectations

16.4Indications for External Fixation

16.5Contraindications to External Fixation

16.6Special Considerations

16.6.1Intimal Tears Resulting in Vascular Occlusion

16.6.2External Fixation in the Polytrauma and/or Obese Patient

16.7Special Instructions, Position, and Anesthesia

16.7.1Reduction

16.7.2Vascular Exam

16.7.3Serial Examinations

16.7.4External Fixation

16.8Tips, Pearls, and Lessons Learned

16.8.1External Fixation—Pin Placement

16.8.2External Fixation for Open Dislocations

16.8.3Tips

16.9Difficulties Encountered

16.10Key Procedural Steps

16.10.1External Fixation

16.11Bailout, Rescue, Salvage Procedures

16.12Pitfalls

17.Correction of a Periarticular Knee Deformity with External Fixation

J. Spence Reid

17.1Description

17.2Key Principles

17.3Expectations

17.4Indications

17.5Contraindications

17.6Special Considerations

17.7Special Instructions, Position, and Anesthesia

17.7.1Preoperative Evaluation

17.7.2Positioning

17.7.3Anesthesia

17.7.4Postoperative Deformity Correction

17.8Tips, Pearls, and Lessons Learned

17.9Difficulties Encountered

17.10Key Procedural Steps

17.11Bailout, Rescue, Salvage Procedures

17.12Pitfalls

18.Floating Knee Injuries

Christian Krettek

18.1Description

18.2Key Principles

18.3Expectations

18.4Indications

18.5Contraindications

18.6Special Considerations

18.7Special Instructions, Positioning, and Anesthesia

18.8Tips, Pearls, and Lessons Learned

18.8.1Alignment References

18.8.2Type I Injuries

18.8.3Type IIA and IIB Injuries

18.8.4Type IIC Injuries

18.9Key Procedural Steps

18.10Bailout, Rescue, Salvage Procedures

18.11Pitfalls

19.Open Knee Fractures: The Use of Rotational Flaps

David Volgas

19.1Description

19.2Key Principles

19.3Expectations

19.4Indications

19.5Contraindications

19.6Special Considerations

19.7Special Instructions, Position, and Anesthesia

19.8Tips, Pearls, and Lessons Learned

19.9Difficulties Encountered

19.10Key Procedural Steps

19.10.1Medial Gastrocnemius Flap

19.10.2Lateral Gastrocnemius Flap

19.10.3Aftercare

19.11Bailout, Rescue, Salvage Procedures

19.12Pitfalls

20.Tibial Plateau Revision Surgery

Peter Kloen and Mauricio Kfuri

20.1Description

20.2Key Principles

20.3Expectations

20.4Indications

20.5Contraindications

20.6Special Considerations

20.7Special Instructions, Positioning, and Anesthesia

20.8Tips, Pearls, and Lessons Learned

20.9Difficulties Encountered

20.10Key Procedural Steps

20.10.1Unicondylar Angulation

20.10.2Widened Tibial Plateau

20.11Bailout, Rescue, and Salvage Procedures

20.12Pitfalls

Section II: Sports Medicine

21.Quadriceps Autograft: All-Inside Anterior Cruciate Ligament Reconstruction

Patrick A. Smith, Jordan A. Bley, and Corey Cook

21.1Description

21.2Key Principles

21.3Expectations

21.4Indications

21.5Contraindications

21.6Special Considerations

21.7Special Instructions, Position, and Anesthesia

21.8Tips, Pearls, and Lessons Learned

21.9Difficulties Encountered

21.10Key Procedural Steps

21.11Bailout, Rescue, Salvage Procedures

21.12Pitfalls

22.Anterior Cruciate Ligament Reconstruction: Hamstrings Autograft

John Byron

22.1Description

22.2Key Principles

22.3Expectations

22.4Indications

22.5Contraindications

22.6Special Considerations

22.7Special Instructions, Position, and Anesthesia

22.8Tips, Pearls, and Lessons Learned

22.9Difficulties Encountered

22.10Key Procedural Steps

22.10.1Tendon Harvesting

22.10.2Graft Preparation

22.10.3Portals

22.10.4Femoral Tunnel Preparation

22.10.5Tibial Tunnel

22.10.6ACL Graft Passage

22.10.7Femoral Fixation

22.10.8Graft Prestressing

22.10.9Tibial Tunnel Graft Tension and Fixation

22.10.10Final Checking and Wound Closure

22.10.11Postoperative Care

22.11Bailout, Rescue, Salvage Procedures

22.12Pitfalls

23.Anterior Cruciate Reconstruction—Patellar Tendon Autograft

Marcio Albers and Freddie Fu

23.1Description

23.2Key Principles

23.3Expectations

23.4Indications

23.5Contraindications

23.6Special Considerations

23.7Special Instructions, Positioning, and Anesthesia

23.8Tips, Pearls, and Lessons Learned

23.9Difficulties Encountered

23.10Key Procedural Steps

23.11Bailout, Rescue, and Salvage Procedures

23.12Pitfalls

24.Anterior Cruciate Ligament Reconstruction—Pediatric Patient

Diego da Costa Astur and Moises Cohen

24.1Description

24.2Key Principles

24.3Expectations

24.4Indications

24.5Contraindications

24.6Special Considerations

24.7Special Instructions, Positioning, and Anesthesia

24.8Tips, Pearls, and Lessons Learned

24.9Difficulties Encountered

24.10Key Procedural Steps

24.11Bailout, Rescue, Salvage Procedures

24.12Pitfalls

25.Anterior Cruciate Ligament—Tibial Avulsion

Elizabeth C. Truelove, Conor I. Murphy, Jeremy M. Burnham, Jan S. Grudziak, Volker Musahl, Joshua Pratt, and Rory McHardy

25.1Description

25.2Key Principles

25.3Expectations

25.4Indications

25.5Contraindications

25.6Special Considerations

25.7Special Instructions, Position, and Anesthesia

25.8Tips, Pearls, and Lessons Learned

25.9Difficulties Encountered

25.10Key Procedural Steps

25.10.1Arthroscopic Technique

25.10.2Open Reduction Internal Fixation

25.10.3Suture Fixation

25.10.4Screw Fixation

25.10.5Hybrid Fixation

25.11Bailout, Rescue, Salvage Procedures

25.12Pitfalls

26.Posterior Cruciate Ligament Reconstruction: Achilles Tendon Allograft

James P. Stannard

26.1Description

26.2Key Principles

26.3Expectations

26.4Indications

26.5Contraindications

26.6Special Considerations

26.7Special Instructions, Position, and Anesthesia

26.8Tips, Pearls, and Lessons Learned

26.8.1Tibial Inlay

26.8.2Transtibial PCL

26.9Difficulties Encountered

26.10Key Procedural Steps

26.10.1Common Steps—Femoral Socket Preparation

26.10.2Transtibial Tibia Socket Preparation

26.10.3Inlay Tibial Preparation

26.11Bailout, Rescue, and Salvage Procedures

26.12Pitfalls

27.Posterior Cruciate Ligament (PCL) Reconstruction—Autograft

Christopher D. Harner, Ryan J. Warth, and Jacob Worsham

27.1Introduction

27.2Description

27.3Key Principles

27.4Surgical Indications

27.5Contraindications

27.6Special Considerations

27.6.1Quadriceps Tendon-Bone Autograft Harvest

27.6.2Hamstring Tendon Autograft

27.7Special Instructions, Position, and Anesthesia

27.8Tips, Pearls and Lessons Learned

27.9Difficulties Encountered

27.10Key Procedural Steps

27.10.1Diagnostic Knee Arthroscopy and Tunnel Preparation

27.10.2Drilling the Femoral Tunnel (Inside Out)

27.10.3Graft Passage and Fixation

27.11Bailout, Rescue, Salvage Procedures

27.12Pitfalls

28.Posterior Cruciate Ligament—Tibial Avulsion

Rodrigo Salim

28.1Description

28.2Key Principles

28.3Expectations

28.4Indications

28.5Contraindications

28.6Special Considerations

28.7Special Instructions, Positioning, and

28.7.1Open Surgical Technique

28.7.2Arthroscopic Technique

28.8Tips, Pearls, and Lessons Learned

28.8.1Open Surgical Technique

28.8.2Arthroscopic Technique

28.9Difficulties Encountered

28.10Key Procedural Steps

28.11Bailout, Rescue, and Salvage Procedures

29.Posteromedial Corner Knee Reconstruction

Robert Longstaffe and Alan Getgood

29.1Description

29.2Key Principles

29.3Expectations

29.4Indications

29.5Contraindications

29.6Special Considerations

29.7Special Instructions, Position, and Anesthesia

29.8Tips, Pearls, and Lessons Learned

29.9Difficulties Encountered

29.10Key Procedural Steps

29.11Bailout, Rescue, and Salvage Procedures

29.12Pitfalls

30.Posterolateral Corner Reconstruction

Robert F. LaPrade and Samantha L. LaPrade

30.1Description

30.2Key Principles

30.3Expectations

30.4Indications

30.5Contraindications

30.6Special Considerations

30.7Special Instructions, Position, and Anesthesia

30.8Tips, Pearls, and Lessons Learned

30.9Difficulties Encountered

30.10Key Procedural Steps

30.11Bailout, Rescue, and Salvage Procedures

30.12Pitfalls

31.Knee Dislocation: Reconstruction

Gregory C. Fanelli and Matthew G. Fanelli

31.1Description

31.2Key Principles

31.3Expectations

31.4Indications

31.5Contraindications

31.6Special Considerations

31.7Special Instructions, Positioning, and Anesthesia

31.8Tips, Pearls, Lessons Learned

31.8.1Posteromedial Safety Incision (PMSI)

31.8.2PCL Tibial Tunnel

31.8.3PCL Femoral Tunnel

31.8.4Single- and Double-Bundle PCL Reconstruction

31.8.5Transtibial ACL Reconstruction

31.8.6Mechanical Graft Tensioning

31.8.7Posterolateral Reconstruction (PLR)

31.8.8Posteromedial Reconstruction (PMR)

31.9Difficulties Encountered

31.9.1Fractures

31.9.2External Fixation

31.10Key Procedural Steps

31.10.1Posterior Cruciate Ligament Reconstruction (PCLR)

31.10.2Anterior Cruciate Ligament (ACL) Reconstruction

31.10.3Fibular Head-Based Posterolateral Reconstruction

31.10.4Two-Tailed Posterolateral

Reconstruction

31.10.5Posteromedial Reconstruction (Posteromedial Capsular Shift)

31.10.6Posteromedial Reconstruction (Free Graft)

31.11Bailout, Rescue, and Salvage Procedures

31.12Pitfalls

32.Patellofemoral Instability—Medial Patellofemoral Ligament Reconstruction

Gilberto Luis Camanho and Marco Kawamura Demange

32.1Description

32.2Key Principles

32.3Expectations

32.4Indications

32.5Contraindications

32.6Special Considerations

32.7Special Instructions, Position, and Anesthesia

32.8Tips, Pearls, and Lessons Learned

32.9Difficulties Encountered

32.10Key Procedural Steps

32.11Bailout, Rescue, and Salvage Procedures

32.12Pitfalls

33.Proximal Realignment: Lateral Retinaculum Lengthening

Andrew J. Garrone, Betina B. Hinckel, Riccardo Gobbi, and Seth L. Sherman

33.1Description

33.2Key Principles

33.3Expectations

33.4Indications

33.5Contraindications

33.6Special Considerations

33.7Special Instructions, Position, and Anesthesia

33.8Tips, Pearls, and Lessons Learned

33.8.1Hemostasis

33.8.2Medial and Lateral Balance

33.9Pitfalls

33.9.1Identification of the Layers

33.9.2Hemostasis

33.9.3Medial and Lateral Balance

33.10Difficulties Encountered

33.11Key Procedural Steps

33.12Bailout, Rescue, and Salvage Procedures

34.Recurrent Patellofemoral Dislocation—Distal Realignment

Richard Ma and Seth L. Sherman

34.1Description

34.2Key Principles in Tibial Tubercle Osteotomy for Recurrent Patellofemoral Dislocation

34.3Expectations

34.4Indications

34.5Contraindications

34.6Special Considerations

34.7Special Instructions, Positioning, and Anesthesia

34.8Tips, Pearl, and Lessons Learned

34.9Difficulties Encountered

34.10Key Procedural Steps

34.11Bailout, Rescue, and Salvage Procedures

34.12Pitfalls

35.Meniscal Tears and Principles of Partial Meniscectomy

Wilson Mello Jr. and Marco Kawamura Demange

35.1Description

35.2Key Principles

35.3Expectations

35.4Indications

35.5Contraindications

35.6Special Considerations

35.7Special Instructions, Position, and Anesthesia

35.8Tips, Pearls, and Lessons Learned

35.9Difficulties Encountered

35.10Key Procedural Steps

35.11Bailout, Rescue, Salvage Procedures

35.12Pitfalls

36.Meniscus Repair

Carlos Eduardo Franciozi, Sheila J. McNeill Ingham, and Rene Jorge Abdalla

36.1Description

36.2Key Principles

36.3Expectations

36.4Indications

36.5Contraindications

36.6Special Considerations

36.7Special Instructions, Position, and Anesthesia

36.7.1Medial Meniscus Inside-Out Technique

36.7.2Lateral Meniscus Inside-Out Technique

36.7.3Biologic Augmentation

36.8Tips, Pearls, and Lessons Learned

36.9Difficulties Encountered

36.10Key Procedural Steps

36.11Bailout, Rescue, and Salvage Procedures

36.12Pitfalls

37.Meniscus Repair—Root Tears

Patrick A. Smith

37.1Description

37.2Key Principles

37.3Expectations

37.4Indications

37.5Contraindications

37.6Special Considerations

37.7Special Instructions, Position, and Anesthesia

37.8Tips, Pearls, and Lessons Learned

37.9Difficulties Encountered

37.10Key Procedural Steps: Lateral Root Tear

37.11Key Procedural Steps: Medial Root Tear

37.12Bailout, Rescue, and Salvage Procedures

37.13Pitfalls

38.Meniscal Allograft Transplantation (Medial and Lateral)

Jacob Worsham and Walter R. Lowe

38.1Description

38.2Key Principles

38.3Surgical Indications

38.4Contraindications

38.5Special Considerations

38.5.1Medial Meniscal Graft Preparation

38.5.2Lateral Meniscal Graft Preparation

38.6Special Instructions, Position and Anesthesia

38.7Tips, Pearls, and Lessons Learned

38.8Difficulties Encountered

38.9Key Procedural Steps

38.9.1Medial Meniscal Allograft Transplant

38.9.2Lateral Meniscal Allograft Transplant

38.10Bailout, Rescue, and Salvage Procedures

38.11Pitfalls

39.Anterolateral Ligament Reconstruction

Patrick A. Smith

39.1Description

39.2Key Principles

39.3Expectations

39.4Indications

39.5Contraindications

39.6Special Considerations

39.7Special Instructions, Position, and Anesthesia

39.8Tips, Pearls, and Lessons Learned

39.9Difficulties Encountered

39.10Key Procedural Steps

39.11Bailout, Rescue, and Salvage Procedures

39.12Pitfalls

Section III: Adult Reconstruction

40.OpeningWedge High Tibia Osteotomy—Varus Knee

40.1Description

40.2Key Principles

40.3Expectations

40.4Indications

40.5Contraindications

40.6Special Considerations

40.7Special Instructions, Position, and Anesthesia

40.7.1Patient Positioning and Preliminary Steps

40.8Tips, Pearls, and Lessons Learned

40.8.1Lateral Hinge

40.8.2Overcorrection

40.8.3Unintended Increase of Tibial Slope

40.9Difficulties Encountered

40.10Key Procedural Steps

40.10.1Surgical Exposure

40.10.2MCL Release

40.10.3Guidewire Placement

40.10.4Osteotomy

40.10.5Opening of the Osteotomy

40.10.6“Fine-tuning” the Correction

40.10.7Fixation of the Osteotomy

40.11Bailout, Rescue, and Salvage Procedures

40.11.1Hinge Fractures

40.11.2Arterial Bleeding

40.11.3Pseudarthrosis

40.12Pitfalls

40.12.1Lateral Hinge

40.12.2Overcorrection

40.12.3Unintended Increase of Tibial Slope

41.Lateral Closing-Wedge High Tibia Osteotomy (LCW HTO) in Varus Knee

Jörg Harrer, Felix Hüttner, and Wolf Strecker

41.1Description

41.2Key Principles

41.3Expectations

41.4Indications

41.5Contraindications

41.6Special Considerations

41.7Special Instructions, Position, and Anesthesia

41.8Tips, Pearls, and Lessons Learned

41.9Difficulties Encountered

41.10Key Procedural Steps

41.11Bailout, Rescue, and Salvage Procedures

41.12Pitfalls

42.Opening Wedge Distal Femur Osteotomy—Valgus Knee

Mitchell I. Kennedy, Zachary S. Aman, Connor Ziegler, Robert F. LaPrade, and Lars Engebretsen

42.1Description

42.2Key Principles

42.3Expectations

42.4Indications

42.5Contraindications

42.6Special Considerations

42.7Special Instructions, Position, and Anesthesia

42.8Tips, Pearls, and Lessons Learned

42.9Difficulties Encountered

42.10Key Procedural Steps

42.11Bailout, Rescue, and Salvage Procedures

42.12Pitfalls

43.Closing Wedge Femur Osteotomy—Valgus Knee

Philipp Lobenhoffer

43.1Description

43.2Key Principles

43.3Expectations

43.4Indications

43.5Contraindications

43.6Special Considerations

43.7Special Instructions, Position, and Anesthesia

43.8Tips, Pearls, and Lessons Learned

43.9Difficulties Encountered

43.10Key Procedural Steps

43.11Bailout, Rescue, and Salvage Procedures

43.12Pitfalls

44.Unicompartmental Knee Replacement—Medial Compartment

Douglas D.R. Naudie

44.1Description

44.2Key Principles

44.3Expectations

44.4Indications

44.5Contraindications

44.6Special Considerations

44.7Special Instructions, Position, and Anesthesia

44.8Tips, Pearls, and Lessons Learned

44.9Difficulties Encountered

44.10Key Procedural Steps

44.10.1Exposure

44.10.2Tibial Preparation

44.10.3Femoral Preparation

44.10.4Balance, Trialing, and Insertion

44.10.5Postoperative Management

44.11Bailout, Rescue, and Salvage Procedures

44.12Pitfalls

45.Unicompartmental Arthroplasty—Lateral Compartment

Eli Kamara and Stefano A. Bini

45.1Description

45.2Key Principles

45.3Expectations

45.4Indications

45.5Contraindications

45.6Special Considerations

45.7Special Instructions, Position, and Anesthesia

45.8Tips, Pearls, and Lessons Learned

45.9Difficulties Encountered

45.10Key Procedural Steps

45.10.1Surgical Approach

45.10.2Femoral Preparation

45.10.3Tibial Preparation

45.10.4Soft Tissue Balancing and Trialing

45.10.5Component Insertion

45.10.6Postoperative Care

45.11Bailout, Rescue, and Salvage Procedures

45.12Pitfalls

46.Unicompartmental Knee Replacement—Patellofemoral Compartment

Patrick Horst and Elizabeth A. Arendt

46.1Description

46.2Key Principles

46.3Expectations

46.4Indications

46.5Contraindications

46.6Special Considerations

46.7Special Instructions, Position, and Anesthesia

46.8Tips, Pearls, and Lessons Learned

46.9Difficulties Encountered

46.10Key Procedural Steps

46.10.1Choosing a Prosthesis

46.10.2Operative Approach

46.10.3Femoral Component Positioning

46.10.4Patellar Resection and Positioning

46.10.5Trial Component Evaluation

46.10.6Cementation and Closure

46.11Bailout, Rescue, and Salvage Procedures

46.12Pitfalls

47.Cruciate-Retaining Total Knee Arthroplasty

James Keeney

47.1Description

47.2Key Principles

47.3Expectations

47.4Indications

47.5Contraindications

47.6Special Considerations

47.7Special Instructions, Position, and Anesthesia

47.8Tips, Pearls, and Lessons Learned

47.9Difficulties Encountered

47.9.1Intramedullary Alignment Guides

47.9.2Visualization

47.9.3Patellar Maltracking

47.9.4Flexion-Extension Imbalance

47.9.5Tibial Slope

47.9.6Asymmetric Femoral Bone Resection

47.9.7Varus-Valgus Laxity

47.10Key Procedural Steps

47.11Bailout, Rescue, and Salvage Procedures

47.12Pitfalls

48.Primary Total Knee Replacement: Posterior Stabilized

Ajay Aggarwal

48.1Description

48.2Key Principles

48.3Expectations

48.4Indications

48.5Contraindications

48.6Special Considerations

48.7Special Instructions, Position, and Anesthesia

48.8Tips, Pearls, and Lessons Learned

48.9Difficulties Encountered

48.10Key Procedural Steps

48.11Bailout, Rescue, and Salvage Procedures

48.12Pitfalls

49.Primary Total Knee Replacement using Navigation

Dominique Saragaglia

49.1Description

49.2Key Principles

49.3Expectations

49.4Indications

49.5Contraindications

49.6Special Considerations

49.7Special Instructions, Positioning, and Anesthesia

49.8Tips, Pearls, and Lessons Learned

49.9Difficulties Encountered

49.10Key Procedural Steps

49.10.1Navigation of the Femorotibial Mechanical Angle

49.10.2Navigation of the Bone Cuts

49.10.3Implanting the Prosthetic Trial

49.10.4Rotation of the Femoral Implant

49.10.5Ligament Balance

49.10.6Implanting the Final Prosthesis

49.11Bailout, Rescue, and Salvage Procedures

49.12Pitfalls

50.Revision Total Knee Arthroplasty: Femoral and Tibial Components

Steven F. Harwin and Julio César Palacio-Villegas

50.1Description

50.2Key Principles

50.3Expectations

50.4Indications

50.5Contraindications

50.6Special Considerations

50.6.1Diagnosis

50.7Special Instructions, Position, Anesthesia

50.8Tips, Pearls, and Lessons Learned

50.8.1Have all Prosthetic Options Available

50.8.2Consider the Possibility of Infection in All Revisions

50.9Difficulties Encountered

50.10Key Procedural Steps

50.10.1Obtain Adequate Exposure

50.10.2Remove the Implants Carefully with Minimal Bone Loss

50.10.3Femoral Component Removal

50.10.4Tibial Component Removal

50.10.5Debride the Knee, Assess Residual Defects, and Determine the Management Strategy

50.10.6Preparation of the Femur and Tibia

50.10.7Apply the Trials and Assess Stability and Kinematics

50.10.8Deflate the Tourniquet, Achieve Hemostasis, Prepare the Bone Ends, and Cement the Implants

50.10.9Close the Wound Securely

50.10.10Wound Healing Must Supersede Rehabilitation

50.11Bailout, Rescue, and Salvage Procedures

50.12Pitfalls

51.Revision Total Knee Replacement—Patellar Component

Benjamin Hansen

51.1Description

51.2Key Principles

51.3Expectations

51.4Indications

51.5Contraindications

51.6Special Considerations

51.7Special Instructions, Position, and Anesthesia

51.8Tips, Pearls, and Lessons Learned

51.9Difficulties Encountered

51.10Key Procedural Steps

51.11Bailout, Rescue, and Salvage Procedures

51.12Pitfalls

52.Extensor Mechanism Reconstruction—Synthetic Mesh

Kevin I. Perry and Arlen D. Hanssen

52.1Description

52.2Key Principles

52.3Expectations

52.4Indications and Contraindications

52.5Special Instructions, Position, and Anesthesia

52.6Tips, Pearls, and Lessons Learned

52.7Difficulties Encountered

52.8Key Procedural Steps

52.9Bailout, Rescue, and Salvage Procedures

52.10Pitfalls

53.Unipolar Osteochondral Femoral Replacement

Luis Eduardo Passarelli Tirico and William D. Bugbee

53.1Description

53.2Key Principles

53.3Expectations

53.4Indications

53.4.1Cartilage Repair

53.4.2Complex Reconstruction

53.5Contraindications

53.6Special Considerations

53.7Special Instructions, Position, and Anesthesia

53.8Tips, Pearls, and Lessons Learned

53.9Difficulties Encountered

53.10Key Procedural Steps

53.10.1Dowel Technique

53.10.2Shell Technique

53.11Bailout, Rescue, and Salvage Procedures

53.12Pitfalls

54.Patellofemoral Osteochondral Replacement

James P. Stannard

54.1Description

54.2Key Principles

54.3Expectations

54.4Indications

54.5Contraindications

54.6Special Considerations

54.7Special Instructions, Position, and Anesthesia

54.8Tips, Pearls, and Lessons Learned

54.9Difficulties Encountered

54.10Key Procedural Steps

54.10.1Trochlea

54.10.2Patella

54.11Bailout, Rescue, and Salvage Procedures

54.12Pitfalls

Index

Videos

Video 4.1: Tibial plateau fractures case in the coronal plane

Video 22.1: Quadriceps tendon ACL reconstruction including graft harvest

Video 27.1: Preparation of the antero-lateral (AL) PCL femoral tunnel insertion site. Note that the meniscofemoral ligament (MPFL) has been preserved

Video 27.2: Final preparation and marking for the k-wire for the AL femoral tunnel drilling. Note the proximity of the medial femoral articular cartilage to the AL insertion site

Video 27.3: Graft passage has occurred. This is the view of the quad tendon autograft insertion into the AL PCL insertion site

Video 27.4: The postero-medial portal is established (viewed with 70 degree arthroscope from the antero-lateral portal). This is followed by placing a 30-degree arthroscope into the posterior medial portal. The insertion site is to your right an angled PCL curette is used to further mark the PCL tibial insertion site approximately 102 cm below the medial joint line (to be confirmed with intra op fluoroscopy)

Video 27.5: PCL tibial tunnel insertion site is identified, and the PCL tibial guide is brought from the antero-medial portal. Note the location of the posterior horn of the medial meniscus to the right. The guide is placed well distal to the body of the medial meniscus

Video 27.6: The PCL tibial tunnel is marked with a k wire and intra op fluoroscopy is obtained to check the position on a lateral x-ray. If acceptable the tunnel is drilled, and a protective PCL guide is used to protect the posterior neurovascular structures.

Video 30.1: Posterolateral corner reconstruction

Video 33.1: Lateral lengthening

Video 38.1: Medial meniscus transplant

Video 38.2: Lateral meniscus transplant

Video 38.1: Opening wedge distal femur osteotomy – valgus knee

Preface

Knee Surgery: Tricks of the Trade is a book designed to help orthopaedic surgeons in the operating room. It is a concise book that presents expert opinions and surgical tips from a superb international group of authors. It is not designed to have references or detailed history of treatment, but rather to provide expert guidance on successful surgical treatment of a wide variety of knee problems, spanning the disciplines of trauma, sports medicine, and arthroplasty/reconstruction.

We hope the readers will find this a helpful book of surgical tips and tricks that they can look at prior to heading into the operating room to treat their patients.

James P. Stannard, MD

Andrew Schmidt, MD

Mauricio Kfuri, MD, PhD

Acknowledgment

I would like to thank my wonderful wife Carolyn and our children for putting up with me doing yet another book project. Their patience, love, and support are what keep me going. This is the last one—I promise!

James P. Stannard, MD

I dedicate this book first to my wife Jamie and my children, Michael and Katherine, whose love, support, and friendship mean more than anything to me, and secondly I would like to acknowledge my partners at Hennepin Healthcare for their dedication to their patients, their resilience, and their teamwork. It is an honor and a privilege to work with such incredible people. I would also like to thank the Thieme staff who assisted us in the development and production of this book.

Andrew Schmidt, MD

I dedicate this book to you, who is passionate about the knee and interested in understanding the multiple facets of this complex joint. At first, I would like to thank and especially acknowledge my wife, Glaucia, and our children, Pedro and Julia, whose love and support allowed me to commit time to this project. You are phenomenal and the main drive to all my actions. I have been inspired by my mentors, Cleber Paccola and Joseph Schatzker, and by my residents and fellows, who probably have offered me more than they received in return. Finally, I dedicate this book to my patients, individuals that have honored me with their trust and whom I feel privileged to serve.

Mauricio Kfuri, MD, PhD

Contributors

Rene Jorge Abdalla, MD, PhD

Full Professor;

Head of the Knee Institute – Hcor;

Professor of the Translational Surgery Post-Graduation Program;

Department of Orthopedics and Traumatology

Paulista School of Medicine - Federal University of São Paulo

São Paulo, Brazil

John D. Adams Jr, MD

Orthopaedic Surgeon

Prisma Health

University of South Carolina SOM- Greenville

Greenville, South Carolina, USA

Ajay Aggarwal, MD

Orthopaedic Surgeon

Department of Orthopedic Surgery

University of Missouri

Columbia, Missouri, USA

Marcio Albers, MD

Orthopedic Surgeon;

Resident Physician

Department of Radiology

University of Pittsburgh

Pittsburgh, Pennsylvania, USA

Rodrigo Satamini Pires E Albuquerque, MD, PhD

Orthopaedic Surgeon

Department of General and Specialized Surgery

Fluminense Federal University (UFF)

Niterói, Brazil;

National Institute of Traumatology and Orthopedics

Rio de Janeiro, Brazil

Zachary S. Aman, MD

Medical Student

Sidney Kimmel Medical College

Philadelphia, Pennsylvania, USA

Elizabeth A. Arendt, MD

Professor and Vice Chair

Department of Orthopedic Surgery

University of Minnesota

Minneapolis, Minnesota, USA

Diego da Costa Astur, MD

Affiliated Professor and Post-Doctorate in Translational Surgery

Department of Orthopedics and Traumatology

Escola Paulista de Medicina / Federal University of São Paulo;

Head

Knee Group of the Discipline of Sports Medicine

Department of Orthopedics and Traumatology

EPM/UNIFESP

São Paulo, Brazil

Suthorn Bavonratanavech, MD

Chief of Orthopedic and Trauma Network;

Senior Director

Bangkok Orthopedic Center

Bangkok International Hospital

Huaykwang, Bangkok, Thailand

Stefano A. Bini, MD

Professor of Clinical Orthopaedics;

Chief Technology Officer

Department of Orthopaedic Surgery

University of California San Francisco (UCSF);

Founder and Chair, UCSF Digital Orthopedics Conference (DOCSF)

San Francisco, California, USA

Jordan A. Bley, MPH

Department of Orthopaedic Surgery

Vanderbilt University

Nashville, Tennessee, USA

William D. Bugbee, MD

Department of Orthopaedic Surgery

Scripps Clinic

La Jolla, California, USA

Jeremy M. Burnham, MD

Orthopedic and Sports Medicine Surgeon;

Medical Director of Sports Medicine;

Orthopedic Surgery Department HeadOchsner Health – Baton RougeBaton Rouge, Louisiana, USA

John Byron, DO

Orthopedic Spine Surgeon

Florida Orthopedic Institute

Florida, Miami, USA

Gilberto Luis Camanho, MD, PhD

Full Professor

Department of Orthopedics and Traumatology

University of São Paulo School of Medicine

São Paulo, Brazil

Moises Cohen, MD

Full Professor of Orthopedics, Traumatology and Sports Medicine

Federal University of São Paulo- Brazil;

Head of Cohen Orthopedic and Sports Medicine Institute

Hospital Israelita Albert Einstein

São Paulo, Brazil

Juan Manuel Concha, MD

Professor of Orthopedics and Traumatology

University of Cauca;

Susana López Hospital in Valencia

Popayán, Colombia, Bogotá

Corey Cook, MA

Clinical Research Coordinator

Columbia Orthopaedic Group

Columbia, Missouri, USA

Brett D. Crist, MD, FAAOS, FACS, FAOA

Professor

Vice-Chairman of Business Development;

Director Orthopaedic Trauma Service;

Director Orthopaedic Trauma Fellowship;

Co-Director Limb Preservation Center;

Surgery of the Hip and Orthopaedic Trauma

Department of Orthopaedic Surgery

University of Missouri

Columbia, Missouri, USA

Marco Kawamura Demange MD, PhD

Associate Professor

Department of Orthopedics and Traumatology

University of São Paulo School of Medicine

São Paulo, Brazil

Vishal S. Desai, MD

Resident Physician

Department of Orthopedic Surgery

State University of New York Upstate

Syracuse, New York, USA

Lars Engebretsen, MD, PhD

Professor

Division of Orthopedic Surgery

University of Oslo

Oslo, Norway

Igor A. Escalante Elguezabal, MD

Attending professor of Orthopaedic Surgery

Universidad Central de Venezuela

Hospital Universitario de Caracas

Caracas, Venezuela

George C. Fanelli, MD

Orthopaedic Surgeon

Geisinger Woodbine - Orthopaedics and Sports Medicine

Danville, Pennsylvania, USA

Matthew G. Fanelli, MD

Orthopaedic Surgeon

Geisinger Woodbine - Orthopaedics and Sports Medicine

Danville, Pennsylvania, USA

Fabricio Fogagnolo, MD

Head of Knee Surgery and Orthopaedic Trauma

Department of Orthopaedics and Anesthesiology

Hospital das Clínicas

University of São Paulo

São Paulo, Brazil

Carlos Eduardo Franciozi, MD, PhD

Affiliate Professor;

Head of the Orthopedic Surgery Residency Program;

Professor of the Post-Graduation Orthopedics - Radiology Program;

Department of Orthopedics and Traumatology

Paulista School of Medicine - Federal University of São Paulo

Knee Institute - HCor

São Paulo, Brazil

Freddie Fu, MD

Chair

Department of Orthopaedic Surgery;

David Silver Professor of Orthopaedic Surgery

University of Pittsburgh School of MedicinePittsburgh, Pennsylvania, USA

Nicholas P. Gannon, MD

Orthopedic Surgeon Resident

Department of Orthopaedic Surgery

University of Minnesota

Minneapolis, Minnesota, USA

Andrew J. Garrone, MD

Professor

Department of Orthopaedics

The Ohio State University

Columbus, Ohio, USA

Alan Getgood, MD, FRCS (Tr and Orth), Dip SEM

Assistant Professor

Schulich School of Medicine & Dentistry;

Fowler Kennedy Sport Medicine Clinic

3M Centre, University of Western Ontario

London, Ontario, Canada

Vincenzo Giordano, MD, PhD, FBCS

Orthopaedic Trauma Surgeon

Orthopedics and Traumatology Service Professor

Nova Monteiro

Miguel Couto Municipal Hospital;

Orthopaedic Trauma Surgeon

Clínica São Vicente

Rio de Janeiro, Brazil

Riccardo Gobbi, MD, PhD

Associate Professor

Hospital das Clínicas

Institute of Orthopedics and Traumatology

Faculty of Medicine

University of São Paulo

São Paulo, Brazil

Jan S. Grudziak, MD, PhD

Assistant Professor

Department of Orthopaedic Surgery

University of Pittsburgh

Pittsburgh, Pennsylvania, USA

Benjamin Hansen, MD

Orthopaedic Surgeon

Department of Orthopedic Surgery

Kirk Kerkorian School of Medicine

University of Nevada Las VegasLas Vegas, Nevada, USA

George Hanson, MD

George Hanson, MD

Orthopaedic Surgeon

Hennepin Healthcare System

Minneapolis, Minnesota, USA

Arlen D. Hanssen, MD

Orthopedic Surgeon

Department of Orthopedic Surgery

Mayo Clinic

Rochester, Minnesota, USA

Christopher D. Harner, MD, FAOA, FAAOS

Orthopaedic Surgeon

Pittsburgh, Pennsylvania, USA

Jörg Harrer

Orthopaedic Surgeon

Department of Orthopedics and Traumatology

Regiomed Klinikum Lichtenfels

Lichtenfels, Germany

Steven F. Harwin, MD, FAAOS

Chief of Advanced Technology of Total Hip and Knee Arthroplasty

Mount Sinai West;

Professor of Orthopaedic Surgery

Icahn School of Medicine at Mount Sinai

New York, New York, USA

Betina B Hinckel, MD, PhD

Assistant Professor

Oakland University

Rochester, Minnesota, USA;

Department of Orthopaedic Surgery

William Beaumont Hospital

Royal Oak, Michigan, USA

Patrick Horst, MD

Assistant Professor

Department of Orthopedic Surgery

Medical School, University of Minnesota

Minneapolis, Minnesota, USA

David Hubbard, MD

Chief

Orthopaedic Trauma Service;

Professor

Department of Orthopaedics

School of Medicine

West Virginia University

Morgantown, West Virginia, USA

Felix Hüttner, MD

Orthopaedic Surgeon

Department of Orthopaedics and Traumatology

Regiomed Klinikum Lichtenfels

Lichtenfels, Germany

Sheila J. McNeill Ingham, MD, PhD

Affiliate

Department of Orthopedics and Traumatology

Escola Paulista de Medicina - Universidade Federal de São Paulo

São Paulo, Brazil

Eli Kamara, MD

Assistant Professor of Orthopaedic Surgery

Albert Einstein College of Medicine

Bronx, New York, USA

James Keeney

Chief, Adult Reconstruction Service;

Associate Professor

Department of Orthopaedic Surgery

University of Missouri

Columbia, Missouri, USA

Mitchell I. Kennedy, MD

Research Coordinator II

Eastside Research Associates

Seattle, Washington, USA

Peter Kloen, MD, PhD

Professor of Orthopaedic Traumatology

Amsterdam University Medical Center

Amsterdam, The Netherlands

Christian Krettek, FRACS, FRCSEd

Professor

Medizinische Hochschule Hannover (MHH)

Hannover, Germany

Robert F. LaPrade MD, PhD

Complex Knee and Sports Medicine Surgeon

Twin Cities Orthopedics;

Adjunct Professor

Department of Orthopaedic Surgery

University of Minnesota

Minneapolis, Minnesota, USA

Samantha L. LaPrade MD

Resident Physician

Department of Otolaryngology

Medical College of Wisconsin

Milwaukee, Wisconsin, USA

Mark A. Lee, MD, FACS

Professor and Vice Chair of Education;

Chief, Orthopaedic Trauma Service;

Director, Orthopaedic Trauma Fellowship

Department of Orthopaedic Surgery

UC Davis Health

Sacramento, California, USA

Frank A. Liporace, M.D.

Chief

Division of Orthopaedic Trauma & Adult Reconstruction

Department of Orthopaedic Surgery

Saint Barnabas Medical Center

Livingston, New Jersey, USA

Robert Longstaffe, MD, FRCSC

Fowler Kennedy Sport Medicine Clinic

3M Centre, University of Western Ontario

London, Ontario

Philipp Lobenhoffer, MD, PhD

Professor, Orthopedic and Trauma Surgery

Go: h Joint Surgery Orthopedics Hanover

Lobenhoffer, Agneskirchner, Tröger GbR

Hanover, Germany

Walter R. Lowe, MD

Ed T Smith Professor and Chair

University of Texas McGovern Medical School

Houston, Texas, USA

Congfeng Luo, MD

Orthopaedic Surgeon

Department of Orthopaedic Surgery

Shanghai Sixth People’s hospital

Shanghai Jiaotong University

Shanghai, China

Richard Ma, MD

Gregory L. and Ann L. Hummel Distinguished Professor

Department of Orthopaedic Surgery;

Chief, Division of Sports Medicine

Missouri Orthopaedic Institute

University of Missouri – Columbia

Columbia, Missouri, USA

Sven Märdian, MD

Chief Senior Physician

Head of the Traumatology and Musculoskeletal Tumor Surgery Section

Center for Musculoskeletal Surgery (CMSC)

Campus Virchow Klinikum

Charité - University Medicine Berlin

Berlin, Germany

Chatchanin Mayurasakorn, MD

Orthopaedic Trauma Surgeon

Bangkok International Hospital

Bangkok, Thailand

Wilson Mello Jr, MD

Research and Study Center

Wilson Mello Institute;

Pontifical Catholic University Hospital of Campinas

Campinas, Brazil

Rory McHardy, ATC

Program Director - Ochsner Sports

Medicine Institute SMA Residency

Ochsner Health – Baton Rouge

Baton Rouge, Louisiana, USA

Conor I. Murphy, MD

Orthopedic Surgeon

Department of Orthopaedic Surgery

University of Pittsburgh

Pittsburgh, Pennsylvania, USA

Volker Musahl, MD

Department of Orthopaedic Surgery

UPMC Freddie Fu Sports Medicine Center

University of Pittsburgh

Pittsburgh, Pennsylvania, USA

Douglas D.R. Naudie, MD, FRCSC

Professor

Department of Surgery (Division of Orthopaedic Surgery)

Schulich School of Medicine

Western University;

Consultant Orthopaedic Surgeon

London Health Sciences Center

Joint Replacement Institute

University Hospital

London, Ontario, Canada

Julio César Palacio-Villegas, MD

Professor of Orthopaedic Surgery

Javeriana University;

Chief of the Hip and Knee Reconstruction Group;

Coordinator of The Fellowship Program in Hip and

Knee Reconstruction Surgery

Clínica Imbanaco Grupo QuirónSalud.

Cali, Colombia, Bogotá

Idemar Monteiro da Palma, MD

Orthopaedic Surgeon

Montese Medical Center

Resende - RJ

Rios D’Or Hospital

Rio de Janeiro, Brazil

Kevin I. Perry, M.D.

Orthopedic Surgeon

Department of Orthopedic Surgery

Mayo Clinic

Rochester, Minnesota, USA

Robinson Esteves Pires, MD, PhD

Professor of Orthopaedic Surgery;

Chief of the Department of the Locomotor Apparatus

Federal University of Minas Gerais;

Director of the Orthopaedic Trauma Division

Felicio Rocho Hospital and Orizonti Institute

Belo Horizonte, Minas Gerais, Brazil

Joshua Pratt, MS, LAT, ATC, OTC, PES

Sports Medicine Assistant Resident

Ochsner Health – Baton Rouge

Baton Rouge, Louisiana, USA

J. Spence Reid, MD

Orthopaedic Surgeon

Penn State University College of Medicine

Milton S. Hershey Medical Center

Hershey, Pennsylvania, USA

Rodrigo Salim, MD, PhD

Knee Surgeon Orthopedist

Foundation for Support of Teaching, Research and Assistance

HCFMRP;

Clinical Hospital of the Faculty of Medicine of Ribeirão Preto

Ribeirão Preto, Brazil

Dominique Saragaglia, MD

Professor Emeritus

Orthopaedic Unit

Grenoble-Alpes-Voiron University Hospital

Voiron, France

Michael Schuetz, FRACS, FaOrth

Director

Jamieson Trauma Institute;

Professor & Chair of Trauma

Queensland University of Technology;

Department of Orthoapedics and Trauma Service

Royal Brisbane and Women’s Hospital

Brisbane, Australia

Seth L. Sherman, MD

Associate Professor of Orthopedic Surgery

Stanford University California, USA

Patrick A. Smith, MD

Columbia Orthopaedic Group

Adjunct Professor of Orthopaedic Surgery;

Co-Director of Sports Medicine Fellowship;

Team Physician

University of Missouri

Columbia, Missouri, USA

Felipe Serrão de Souza, MD

Orthopaedic Trauma Surgeon

Orthopedics and Traumatology Service Professor

Nova Monteiro

Miguel Couto Municipal Hospital;

Rio de Janeiro, Brazil

Matthew Stillwagon, MD

Orthopaedic Surgeon

Mission Hospital

Asheville, North Carolina, USA

Wolf Strecker, MD

Orthopaedic Surgeon

Department of Orthopedics and Traumatology

Klinikum Bamberg

Bamberg, Germany

Michael J. Stuart, MD

Professor

Department of Orthopedic Surgery

Mayo Clinic

Rochester, Minnesota, USA

Luis Eduardo Passarelli Tirico, MD

Knee Surgeon

Orthopedic and Traumatology Institute

Hospital das Clinicas;

Assistant Professor

University of São Paulo Medical School;

São Paulo, Brazil

Elizabeth C. Truelove, MD

Orthopedist

University of Chicago Medical Center

University of Chicago

Chicago, Illinois, USA

David Volgas, MD

Orthopaedic Surgeon

Department of Orthopedic Surgery

University of Missouri Health Care

Columbia, Missouri, USA

André Wajnsztejn, MD, MBA, PhD

Orthopaedic Surgeon

Hospital Israelita Albert Einstein

São Paulo, Brazil

Yukai Wang, MD

Orthopaedic Surgeon

Department of Orthopaedic Surgery

Shanghai Sixth People’s hospital

Shanghai Jiaotong University

Shanghai, China

Ryan J. Warth, MD

Director of Operations

REDCap Cloud

Houston, Texas, USA

Jacob Worsham, MD

Assistant Professor

Orthopaedic Surgery - Sports Medicine

University of Texas at Houston

Houston, Texas, USA

Richard S. Yoon, MD

Director of Orthopaedic Research

Department of Orthopaedic Surgery

Division of Orthopaedic Trauma & Adult Reconstruction

Saint Barnabas Medical Center

Livingston, New Jersey, USA

Connor G. Ziegler, MD

Orthopedic Shoulder, Elbow, Hip, and Knee Specialist

New England Orthopedic Surgeons,

Springfield, Massachusetts, USA

Section I

Trauma

1Unilateral Lateral Tibial Plateau Fractures

2Unicondylar Medial Tibial Plateau Fractures

3Bicondylar Tibial Plateau Fractures

4Tibial Plateau Fractures in the Coronal Plane

5Distal Femur Unicondylar Fracture

6Distal Femur Fractures—Bicondylar

7Distal Femur Fracture in the Coronal Plane—Hoffa Fracture

8Distal Femur Periprosthetic Fracture—Internal Fixation with Plate

9Retrograde Nailing of Distal Femur Periprosthetic Fractures

10Nail-Plate Combination and Double Plating for Complex Distal Femur Fractures (Native or Periprosthetic)

11Distal Femur Periprosthetic Fracture: ORIF and Revision Arthroplasty

12Patellar Fracture—Simple Transverse Pattern

13Patellar Fractures—Comminuted Pattern

14Patellar Tendon Repair with Ipsilateral Semitendinosus Autograft Augmentation

15Quadriceps Tendon Rupture

16Knee Dislocation—Acute Management

17Correction of a Periarticular Knee Deformity with External Fixation

18Floating Knee Injuries

19Open Knee Fractures: The Use of Rotational Flaps

20Tibial Plateau Revision Surgery

1 Unilateral Lateral Tibial Plateau Fractures

David Hubbard

1.1 Description

This procedure is intended for use in isolated lateral tibial plateau fractures, which typically are associated with cortical disruption (the split component) and articular impaction (the depression component) (Fig. 1.1). The articular surface is reduced, and fixation applied.

Fig. 1.1 Illustration of a typical split-depression fracture of the lateral tibial plateau.

1.2 Key Principles

The lateral tibial plateau is exposed using an extensile lateral surgical approach with direct visualization of the articular surface (if needed) under the lateral meniscus through a submeniscal arthrotomy (Fig. 1.2). This allows evaluation of the lateral meniscus and repair as necessary. Depressed articular fragments are elevated. Metaphyseal defects are filled with bone graft or bone graft substitute (Fig. 1.3). Compression of the intra-articular fracture lines is applied. A buttressing-type implant is applied. This is usually a nonlocking implant. There is no indication for a locking implant other than severe osteoporosis. Many implant companies have specific proximal tibial implants.

Fig. 1.2 Illustration of the use of a submeniscal arthrotomy to improve intraoperative visualization of the articular fracture.

Fig. 1.3(a,b) Bone graft (in this case cancellous allograft chips) are placed in the metaphyseal defect that is present after elevation of the articular surface.

1.3 Expectations

The technique provides good visualization of the anterior and central articular surface, but repair of posterior articular impaction is more difficult. Outcomes are generally good when knee alignment and stability are restored, even if there is some residual articular incongruity. The goal is an articular reduction that is stepped off less than 2 millimeters. Despite the high likelihood of associated soft tissue injury to knee ligaments or menisci, late surgery is uncommon, and the risk of posttraumatic arthritis is low.

1.4 Indications

General indications for surgical treatment of a lateral tibial plateau fracture include articular surface step-off and/or depression, joint instability, and/or widening of the proximal tibia relative to the contralateral side.

1.5 Contraindications

Contraindications include soft tissue injury that precludes a safe surgical approach or a medically unstable patient. For example, fracture blisters and/or abrasions should be allowed to resolve, and skin “wrinkles” should be present.

1.6 Special Considerations

Prior to surgery, the three-dimensional anatomy must be completely understood. Most surgeons use computed tomography (CT) to better understand the fracture pattern; however, recently, some surgeons are advocating magnetic resonance imaging (MRI). The other important consideration is the state of the soft tissues. Significant swelling must be allowed to decrease prior to surgery and fracture blisters should be resolved.

Compartment syndrome provides another challenge. Fasciotomies should be performed when indicated. The lateral fasciotomy incision can be aligned such that it is a continuation of the lateral approach incision. Before definitive fixation, the fasciotomy incision should be closed or closeable at that time.

1.7 Special Instructions, Positioning, and Anesthesia

The patient is positioned in the supine position. A bump is placed under the ipsilateral hip to slightly internally rotate the leg. A tourniquet is applied. A foam ramp or stack of blankets is placed under the leg to elevate it above the contralateral leg to make lateral fluoroscopy easier. The C-arm is brought in from the opposite side of the operative field and should be free to rotate between an anteroposterior (AP) view and lateral view. Anesthetic of choice is used but muscle paralysis is necessary (Fig. 1.4).

Fig. 1.4 Photo showing intraoperative positioning for surgical repair of a lateral tibial plateau fracture.

1.8 Tips, Pearls, and Lessons Learned

1.8.1 Approach

After the skin incision is made, the fascia over the tibialis anterior muscle and the iliotibial band are divided to create one long continuous incision. The tibialis anterior is released off of the tibia as needed for plate fixation, and the iliotibial band may need to be released off of Gerdy tubercle. A submeniscal arthrotomy is then performed between the meniscus and the tibia. Sutures are then placed to provide superior retraction of the meniscus.

1.8.2 Visualization

Use of a universal or femoral distractor allows “opening” of the lateral joint, which is further facilitated by applying varus stress (Fig. 1.5). Use of a headlight allows light to be directed into the wound for better visualization. The anterior horn of the lateral meniscus can be divided and later repaired to further improve visualization.

Fig. 1.5 Photo demonstrating the application of a distractor to assist in opening the lateral knee joint in order to facilitate fracture reduction.

1.8.3 Fracture Reduction

How the fracture is reduced is dictated by whether it is a pure split fracture with no depression vs. a split/depression pattern. A pure split fracture pattern needs compression. After the joint surface is exposed, a large pelvic clamp or a specific periarticular clamp is used to squeeze the fragments together (Fig. 1.6). The joint is visualized throughout the reduction. Once the joint is reduced anatomically, provisional K-wires are placed to maintain the reduction temporarily. This is then replaced by the definitive implant.

Fig. 1.6 Use of a “c-shaped” periarticular reduction clamp to provide external compression across the reduced metaphysis.

A split/depression pattern is reduced in a different fashion. One of two methods is used: the “containment method” or the “open book” method. In the containment method, the depressed area is elevated through a cortical window created with an osteotome (Fig. 1.7). The split component is left until the articular surface is reestablished. This elevation is performed with a tamp or an impactor. The defect is filled with bone graft or bone graft substitute. The articular surface is supported with subchondral K-wires. The articular surface is then compressed with a clamp as above. In the open book method, the split component is hinged open anteriorly. This allows direct visualization of the depressed fragment(s) which is(are) then directly manipulated and reduced to either the lateral fragment or the medial intact joint surface. The defect is again filled with bone graft or substitute (Fig. 1.3). The lateral fragment is then rotated to reduce it while visualizing the joint surface. This is then compressed with a clamp.

Fig. 1.7 Illustration of the use of a cylindrical bone tamp to elevated depressed articular fragments.

In all cases, the reduction is checked visually and with fluoroscopy.

1.8.4 Internal Fixation

By definition, lateral-sided-only tibia plateau fractures need a plate that functions in a buttressing mode. The only exception is a purely depressed fracture which only needs subchondral support. For this reason, the most commonly used plates are nonlocking plates. Locked plates would only be used in the case of poor bone quality. There are many commercially available “proximal tibial” plates. These can be large or small fragment implants.

In the case of a simple split fracture, a buttressing plate is applied after reduction as described above. The plate is positioned laterally; the first screw is placed just distal to the most distal extension of the fracture. Slight overcontouring of the plate will provide compression. Additional screws can then be placed more distally to secure diaphyseal fixation. Next, subchondral lag screws are applied to compress the joint (Fig. 1.8).

Fig. 1.8(a,b) Radiographs of a split-depression fracture with large articular fragments stabilized with a precontoured nonlocking lateral tibial buttress plate.

In the case of a split/depression fracture, a similar plating technique is used to compress the joint as well. If the fragments are small, K-wires or small diameter screws may be used or left in position to support these fragments. So-called subchondral “raft screws” may also be applied to compress and support these previously depressed fragments (Fig. 1.9).

Fig. 1.9(a,b) Radiographs of a split-depression fracture with comminuted articular fragments stabilized with two subchondral “raft” screws placed proximal to a precontoured lateral tibial buttress plate. In this case, because of fracture orientation, the raft screws are oriented from anterior to posterior in the lateral plateau.

Ideally, the plate length in any of these cases should allow for three to four screws distal to the most distal extent of the fracture laterally.

1.8.5 Closure

Wound closure is started by closing the submeniscal arthrotomy. The soft tissue on the proximal tibia is often either absent or of poor quality. Some plates provide holes for proximal suture fixation; however, the sutures can also be tied around the plate and/or the screw heads. The skin is closed with atraumatic technique.

1.9 Difficulties Encountered

If the area of articular injury and/or depression is posterior, visualization and fixation may be difficult. Exposure can be increased either by performing a fibular head osteotomy or a lateral epicondyle of the femur osteotomy. Identifying and reducing all impacted fracture fragments is important and facilitated by careful study of preoperative imaging including CT reconstructions. Sometimes, if the split portion of the fracture is incomplete, the vertical fracture can be completed to allow “opening of the book” to better see the metaphyseal cancellous bone. Skin closure problems should be anticipated, and soft tissues handled carefully. Incisions should be carefully planned over fracture lines to minimize the need for skin retraction.

1.10 Key Procedural Steps

●Exposure performed. The meniscus is retracted superiorly.

●Visualization adjuncts are applied as necessary. Reduction is judged by both direct visual inspection and fluoroscopy.

●Articular surface is reduced and provisionally held with K-wires. If the fracture pattern is a split/depression, the actual approach for articular reduction can be accomplished in one of two ways: The “containment” method where a cortical window is made and the articular depression is elevated from below with an impactor (Fig. 1.7). The other method is by “opening the book.” The split component is hinged open on its posterior aspect and the depressed segment is either reduced to the lateral fragment or the medial fragment and then the “book is closed” (Fig. 1.3). If the posterior aspect is depressed, it can be elevated by a bone impactor and visualized from the anterior aspect. It is difficult to place implants more posterior unless a fibular head osteotomy is used to increase the exposure.

●Any residual bone void is filled with bone graft or bone graft substitute.

Articular fracture lines are compressed and a buttress plate is applied.

1.11 Bailout, Rescue, Salvage Procedures

The surgeon should be aware of methods to increase surgical exposure when needed, such as submeniscal arthrotomy, transection and repair of the anterior horn of the lateral meniscus, epicondylar osteotomy. The use of a joint distractor is rarely needed for lateral plateau fractures but could be of benefit in rare cases. In cases of postop compartment syndrome, immediate fasciotomy is warranted. Early plastic surgery referral for consideration of a gastrocnemius rotation flap should be considered in any case of wound breakdown or infection.

1.12 Pitfalls

One pitfall is failure to recognize or realize the position of a torn lateral meniscus. A tear of the lateral meniscus is almost always a peripheral tear that is seen upon creating the submeniscal arthrotomy. This is easily repaired during closure. However, the meniscus may not be seen in cases of split/depression fractures with severe depression. This is because the torn meniscus is trapped in the fracture site and must be retrieved before reduction can occur.

Another pitfall is failure to recreate the patient’s previous alignment because of failure to completely elevate the depressed joint surface. This can be checked by comparing radiographs or fluoroscopic views of the opposite normal knee. You must compare axial alignment as well as the posterior slope of the lateral joint surface.

Finally, joint stability must be checked once fixation and joint closure are complete. This can be performed and visualized with fluoroscopy. Valgus stress is applied to the knee in full extension to check for medial joint line gapping. The posterior and anterior cruciate ligaments should also be checked manually.